Sunday, 30 November 2008

NHS Treatment of Patients: the Shotgun approach (Drs) vs the finely honed NHS Manager Sniper. Your life in their hands.

Patient: I am bleeding from my arse I think I have piles . . .

Doctor: You may have piles but after examining you I am concerned you may have cancer. I would like to arrange some more tests to make sure that you haven’t . . .

Manager: you do not have cancer as it costs too much to investigate so we will send you to a complimentary therapist who is an expert in colonic irrigation and can decide if you have a cancer as they have never seen it or operated on one but they are cheap.

NorthernDoc’s scientific team had the misfortune to go to a meeting with certain paid up members of the Party. These were all less qualified and experienced in the field under discussion than NorthernDoc but as a result have power.

One of them repeatedly claimed to be a “clinician” which is defined by the Shorter Oxford Dictionary as “a clinical investigator; now, a doctor having direct contact with and responsibility for patients”.

The alleged “clinician” was in fact a jumped up alternative or complimentary therapist with the title “consultant” which can be obtained faster in non medical professions than a doctor can qualify as it is a cheap meaningless title and used to be termed a “senior” complimentary therapist which is more accurate.

This was to “sell” the local Politburo idea that Drs are expensive and quality health care is cheap especially if the managers organise it. The upshot was that the local comrade commissar managers had seen a statistic and decided to bugger up loads of peoples’ lives based on the bottom line (cost).


When you start in medicine you feel that you know everything and believe that what you are told in medical school for example bleeding from the back passage is something serious. As you get more experience you realise that yes it might well be and you should investigate it thoroughly for you cannot tell that it isn’t something nasty until you have done so.

Medicine is not a snipers rifle it is more often than not a shotgun. As a good doctor you should refer to a specialist in order to exclude this small but life curtailing possibility. This may seem like shooting a shotgun and potentially hitting nothing but you have to fire the gun (refer) in order to chance hitting a target but know that more often than not that you will miss.

Doctors unfortunately (or fortunately?) miss more often than they hit but then that is because they try to be safe. If you do not look then you will not find.

Unfortunately NHS mangers eye sight and general health and ability would disqualify them from any active military or otherwise useful service to the country.

They assume that if out of a 100% of people referred to say a surgeon only 25% need an operation then 75% of the 100% do not need to see (an expensive) surgeon or even be referred in the first place. They need to see an alternative practitioner who based on their less extensive and much cheaper experience (which involves no assessment as to who might, or might not, need an operation as they cannot operate) can save money (but not lives).

NHS managers are therefore the elite snipers of the NHS.

For they “see” what the thick overpaid doctors “miss” namely the result of medical investigation not the clinical suspicion. They are so much better at treating patients as they failed to get anywhere near a medical school. They see that 75% of referrals need no (expensive) treatment and therefore are a waste of time and more importantly money.

Unfortunately like a sniper they miss what is going on outside the snipers sight (the 100% who might just possibly be ill) that some of the patients are actually ill and will be missed by complimentary therapists who have never dealt with ill patients who need surgery.

If you therefore work on the management assumption that 75% of GP referrals are crap then it makes sense to refer all GP (100%) referrals to see the “alternative therapists” as they are cheaper but unfortunately and unbeknown to managers are thicker than themselves and would miss the 25% that need surgery.

Why? Because the alternative therapists have only ever seen the 75% that DON’T need surgery but they have never seen the 25% of people THAT DO NEED SURGERY.

Therefore a thick manager can decide that a patient who has seen a doctor who has decided that there may be a chance (1 in 4) of something nasty that needs to be excluded then the manager who has not seen the person can exclude the 1in 4 possibility of something serious by using the Party Centrals means of control called Choose and Book.

Because all referrals are mandated to be sent via Choose and Book instead of the referral letters being screened by consultants they are now screened by complimentary therapists a few of whom are “consultants”. In other words when a GP in Northernshire asks for a more qualified and experienced opinion (which we used to get when real consultants read the letters) we now get a complimentary therapists’ opinion who has less experience than the referring GP.

Result? Patients who are ill and need surgery are subjected to unnecessary and painful complimentary therapy while getting worse until usually after weeks the therapist realizes there is something wrong and asks for a surgeon to see them which the GP already had done several weeks earlier, or the patient is so peed off that he comes back and asks for a referral to a real consultant (which we had asked for in the first place).

Ergo management thinks that the scum known as GPs refer 100% of patients in order to only get 25% operated on and so complimentary therapy (which is cheap and thick) is the way forward.

If you are in pain and there is a lasting solution that may be achieved by surgery I suspect that most people in pain would consider the option of surgery.

But this costs and requires an opinion of a surgeon who may be able to help you IF there is an option. Managers who are all wise as organs of the Party know better and so you are denied this option (unless you have private insurance as do those who work for Connecting for Health.)

Once again Praise be to the Party for they are all wise. And NorthenDocs are thick.

1 comment:

cathymiller said...

I understand your frustration- highly trained to heal and preserve life then bad cop manager comes along purely focussed on budgets - aaargh!
It is hard to reconcile these two roles so they can both hear and understand each other.
I have great respect for Drs both personally and professionally - I am a Nurse.
I do think we have to try and find a way to keep an eye on costs as there isn't a bottomless pit of money out there. As a Dr could it be possible there are blinkers put on in med school that keep you focussed on preserving/improving life no matter what the cost? Or could it be the horrendous ethical minefield.
eg I Nursed a patient in intensive care who was in after thier 4 th unsucessful suicide attempt, this type of patient was quite common. The were with us for over 10 days before being transfrerred to the ward. I believe thier care cost in the region of £60,000 per day. As a Nurse it was common to see treatment and think is this really cost effective? As there isn't a bottomless pit of money who will make these difficult decisions as to what care will be provided? Also in infectious diseases I saw HIV+ and Hep C + single drug addicted women who were getting 24hr 1:1 Nursing throughout thier fragile pregnancy so they could give birth to a sick / addicted baby which social services + NHS would have to plough tens of thousands into looking after.
Where does it all end?
I agree the managers could be putting patients at risk and interfering in the workings of the medics which they dont know enough about but if we as medical professionals can also pick up the role of watching the budget and making difficult decisions then they would become redundant. I know it is a lot to ask and may even be a conflict of interests?

I think the real issue is about funding , interference and power but as an aside I would like to also respond to the comp therapies theme.
I have been doing Colonic Hydrotherapy in private practice for over 5 years. Patients have come to me with bowel cancer who were sent home with laxatives by thier GP x2 + A+E x1. I then told them how to present that they would be taken seiously and gave them the understanding and confidence that they had to go back and get seen.I them followed them up to make sure they were now in safe hands and they were operated on.
I also get a lot of patients who were put therough the system of colonoscopies/ barium ememas etc them spat out at the end of the conveyor belt and told ' there is nothing wrong/ nothing we can do for you'.
They have had costly tests and time with consultants because they have symptoms. The vast majority of them are solved when we adress thier diet/ fluids/ lifestyle or explain how to take the medicine they were prescribed. Occasionally we need to encourage them to as for a referral to an IBS/ Motility specialist Consultant which thier GP had not suggested or may not even be aware of.
I thnk that many of them would have not needed the screening and anxiety and tests if they had been to see a specialist Nurse who worked closely with a consultant and had enough time to take a full history/ ask questions/ counsel re meds.
I think the NHS may have made a rod for its own back by sending out FOB home testing kit to everyone over 55 ( I think is the age). Our Bowel Cancer rates in the UK are terrible but is this the best way forward? I am glad to hear they are employing more specialist Nurses to work in this area pre colonoscopy but how will the NHS cope with the increasing need from a population living longer?
Specialist Nurses are low paid and have a lot to offer so could help with cost saving in the NHS if used appropriately.
As a Nurse Colonic Hydrotherapist I could not do the work of Drs but I could help them get through thier caseload quicker and with good results. Also possibly reduce the need for expensive/ unpleasant colonoscopies etc on many patients.

I hope you can embrace what other professional have to bring to the table and get through the frustration of someone interfering with you achieving your admirable goals of preserving life. I think we can channel the energy+ passion into finding cost effective ways of getting good results for our patients which in turn brings job satisfaction.