Category Archives: General

I’m in the business of medicine, but do I really want medicine to be a business?

Today is the beginning of a new era in the NHS. For supporters of the Health and Social Care Act it represents the implementation of a necessary shift to cope with rising demand and cost:

“[6] The main aims of the Act are to change how NHS care is commissioned through the greater involvement of clinicians and a new NHS Commissioning Board; to improve accountability and patient voice; to give NHS providers new freedoms to improve quality of care; and to establish a provider regulator to promote economic, efficient and effective provision.” [explanatory notes for Health and Social Care Act]

For its detractors, it is popularly described as the end of the NHS and an entire political party has arisen as a result. The debate has often been extremely heated but generally confined to those already in touch with medical “politics”. Anecdotally  (I have no supporting evidence for this) wondering around the corridors of a random english hospital may not find you many staff with a clear knowledge of the details of what has happened on 1st April 2013.  It is this lack of knowledge that may explain, despite some of the vitriol, why contributions by members voting on the Royal Colleges support for and against the bill last year were not that impressive.

College Total Voting Members Number of Respondents Votes against the Bill Response Rate
RCPL [1] 25,417 8,878 6,092 (69%) 35%
RCPCH [2] 10,289 1,492 1,184 (79.36%) 14.5%
RCGP [3] 33,837 in England nearly 2,600 completed responses 90% support withdrawal of Bill 7.7%

Independents have attempted to explain the detail (this summary from fullfact.org is good). There is also a visual timeline of events via the Kings Fund.

A great many commentators have put their hats into the ring about what will happen in the future. I am neither experienced or wise enough to do this. As a trainee, albeit a relatively senior one, I have been disappointed about the level of information given to the future workforce about the changes. It is is a complex area, the Health Act is a huge piece of legislation with arguments of recent terminology on the section 75 amendment making the area even more confusing.

What is without doubt is new ability to widen opportunity for any “provider” to deliver services for patients. I don’t think I am naive about healthcare as a business. The NHS has always run to accounts, tendered and has paid private companies to deliver operations it was falling behind on. But I am old enough to remember a day when there was one National Rail Service. I don’t know if it was true that ‘nationalisation’ was not providing effecient, cost effective services but rail is now clearly a competitive business, even though the trains are often not competing for the same track. However, as a regular train traveller, I know my experiences between the companies are often very different, that even if they do run on time it is at a cost or comfort detriment and I certainly don’t know who best embodies the rail service.

I ask myself is this really how I want to see the NHS?

References

1. Results of RCP Health and Social Care Bill Survey.

http://www.rcplondon.ac.uk/press-releases/results-rcp-health-and-social-care-bill-survey (last accessed 1st April 2013)

2. RCPCH votes for Government to withdraw the Health and Social Care Bill.

http://www.rcpch.ac.uk/news/rcpch-votes-government-withdraw-health-and-social-care-bill (last accessed 1st April 2013)

3. RCGP members support withdrawal of the Bill, says RCGP survey.

http://www.rcgp.org.uk/news/2012/january/rcgp-members-support-withdrawal-of-the-bill-says-rcgp-survey.aspx (last accessed 1st April 2013)

Why do you do what you do?

This blog actually appeared in its first form on the The-Network Blog site (well worth joining this free initiative if you are interested in quality improvement and health system leadership and management – there are 2000+ other members!). Its posting here was prompted by the following tweet

So writing back in July 2012…..

At the end of last week I attended the International Conference on Emergency Medicine (#icem2012) in Dublin. Like many conferences the benefits of attending (meeting friends and networking) outweighed the costs (exorbitant registration and travel) but resulted in very little practical knowledge gain.

One lecture particularly stuck in my mind and has re-shaped my enthusiasm for medicine. The speaker, from America, was introduced as a giant in the field of Emergency Medicine and an expert in paediatric emergency care. He was speaking on the topic of “Neonatal Emergencies”. About half way he started talking about a 5 day old presenting to the Emergency Department with Jaundice. His slide set finished with the comment – “stopping breast feeding can be used to confirm the diagnosis of Breast Milk Jaundice”. I have rarely been so angry in my entire life. This is not far off saying “to confirm that people get dehydrated don’t let them drink”. Breast milk jaundice is a physiological process which does not need confirming (other causes of jaundice need excluding if you are unable to do this clinically).

In the middle of the lecture I started waving my hand frantically in the air and stopped when I realised people were looking at me strangely (although this is not the first and last time that will happen). I was the first to put my hand up for questions at the end of the talk and politely asked if I had misheard the speaker in their assertion that stopping a normal process to confirm a diagnosis of no practical relevance was a useful medical intervention. The reply included a denial of being in the pay of a formula manufacturer (something I hadn’t been concerned about but now was) and the fact practices varied so discussion with the family should always take place. I remain perplexed that even in America this could be deemed a suitable practice and was relatively reassured by the number of delegates who came up to my afterwards to agree with my concern. I was also equally horrified that a number of non-paediatric emergency physicians were dutifully scribbling down every word.

Recently I have taken on a little too much and my enthusiasm for the clinical side of my work has waned. I have been reflecting on what matters most to me and which direction I should be taking. Clinical credibility has now firmly been planted back into my life plans and I never wish to become so distant from actual clinical practice that I lose sight of fundamental principles.

I am sure I said at some point in my Medical School interview I came into medicine to help people but this also includes helping my colleagues understand bad practice. On reflection this is what I do with my research, representative and leadership roles and is actually what really drives me forward.

Why do you do what you do?

#APEM 2012 Highlights

Thanks to the efforts of Dr. Mark Lyttle (@mdlyttle) APEM 2012 proved to be a resounding success. Here is a selection of some of the hot topics, mainly via the superb tweets of Dr. Natalie May (@_nmay) to fill those in who weren’t there and prompt further discussion and debate. A more detailed twitter feed can be found on my Storify site for Day One and Two and all the presentations will shortly be available via apem.me.uk. The links within the tweets should all work (let me know if not!)

1. Dr. Nick Sargent “Anaphylaxis – an evidence based update

Not something I had really considered and wonder if I have ever missed this. It does appear studies on adrenaline versus salbutamol for acute asthma have taken place fairly recently http://www.ncbi.nlm.nih.gov/pubmed/16490653

Useful to  consider how your local allergy/anaphlaxis pathways ensure suitable follow up?

2. Dr. Anne Frampton “PEM Training Update

Although not directly related to the theme of the talk this is causing a lot of concerned conversations

Has your unit fully implemented toxbase guidance (sorry can’t link as password protected) that children should have bloods at 75mg/kg cut off? This technically means the calpol bottle glugger may need investigations when previously they could have gone home. It’s not entirely clear what consultation occurred before this change but consensus was this will result in unnecessary tests.

3. Dr. Mike Clancy “The future of Emergency Medicine

Mike Clancy emphasised the need for departments to take the bull by the horns in engaging with the new world of commissioning, especially with LETBs . The workforce crisis has been taken on board by the DOH but solutions will not happen overnight.

4. Prof. Ronan O’Sullivan “Paediatric Procedural Sedation – an evidence based approach

Ronan O’Sullivan has sent up an extensive curriculum around paediatric procedural sedation, in which consent must be obtained even for Nitrous Oxide. The reason being that the mindset created around consenting ensures the proper respect is shown to the procedure. It was great to see some anecdote being supported by other APEM delegates

5. Prof. Adam Finn “The impact of new vaccines in Paediatric Emergency Medicine

So a number of vaccines will shortly be available in the UK – rotavirus from next year and a flu vaccine. The effects on Paediatric Emergency Departments potentially may be profound. Add in the addition of Men B (potentially) and you are left wondering what we all might be doing in a decade! Some food for thought…

6.  Dr. Natalie May and Dr. Damian Roland “This house believes paediatric Emergency Medicine in the UK would benefit from more doctors in the UK being active on mainstream Social Media

The against argument is available here

7. Dr. Lisa Munro Davies “Is there a role for ultrasound in Paediatric Emergency Medicine?”

Utilising Ultrasound in Paediatric Emergency Medicine is an inevitable progression as technology advances but the true overall utility has yet to be defined. There was much discussion about the best methods of gaining, developing and maintaining skills. What was clear is the Paediatric Emergency Medicine community would like to be masters of their own destiny in this regard.

Day Two

8. Dr. Anne Kerr ” Should we use Tranexamic Acid in Paediatric Trauma

TXA has a good safety profile in paediatric surgery but despite the large amount of patients in CRASH-2 we don’t have the paediatric data to know when and in which category of patient to most effectively give it. The RCPCH guidance should promote its use.

9. Dr. Catherine Bevan “Paediatric Cervical Spine Injuries – a pain in the neck?

An interesting conundrum – true C-Spine injury astonishingly rare but consequences of missing potentially catastrophic. A sharp mind ad flexible thinking required.

10. Dr. Ffion Davies “Paediatric Trauma Networks: the national picture

It was noticed that whatever national system is put in place there remains not an insignificant number of patients who present with high trauma scores who are brought directly to Emergency Departments by their parents….

11. Dr. Simon Chapman “Simulation in Practice

Simulation continues to expand but the traditional APLS model is increasingly becoming replaced by more immersive scenarios. Key message was importance of debrief and need for role credibility to be maintained i.e. play the role you actually are!

Thanks for reading!