This Weeks’ News and Comment from Roy Lilley

primary_care_training_the_citadel

Take the best into the future…

In October, 1942 an idealistic, newly qualified doctor, arrived from Scotland, to work in a mining town in South Wales.  Later, he moved on to work as an assistant in the miners’ medical aid scheme.  

The experiences and the travails of this young man and the conflict he experiences between practicing medicine for the working classes and wealthy private practice, are the bones of A.J. Cronin’s book, The Citadel.

Cronin was a doctor.  He worked for the Tredegar Medical Aid Society, which went on to be the inspiration for the National Health Service.

The NHS is far from perfect but I don’t know a healthcare system, anywhere in the world, that is.

That’s the point; ‘a system’.  

In the system we agree to syndicate the risks of our illnesses, disease and accidents.  The costs of our maternity care and the call at the end of our lives.

We share the risk.  We accept the demands on the service from drug addicts, knife criminals, drunks and people whose life is nothing like ours.  The stupid drivers, the careless, the frail, the inadequate.  

The people who are not like us.

The sports fanatics and the mountain climbers with their accidents and injuries.  The obese, the smokers and their inability to cope with life.  The luckless and indigent.  

Until the day when we are careless, make a mistake and misfortune visits us.  The day our luck runs out.  The day when our lifestyle catches up with us.  

The day when we lose our job and the Black Dog is at the door.  

The day when your breath is short, there’s an ache in your chest and arms and you break out in a cold sweat.

When you have a weakness in the face, arm or leg, you’re confused and think… these things don’t happen to me.

When you look at your phone and not the traffic… bang!  These things don’t happen to me.  

I have news for you, they do and they will.

All the times when it is other people and the day, it’s your turn, that’s why the Tredegar Medical Aid Society was started and that’s why the NHS was founded.

The NHS that is infuriating, reduces us to tears, confusion, exasperation, admiration, love and gratitude beyond belief.

An NHS that makes mistakes, errors, is a good employer and a slave driver.  Is good at looking after people and is callous and off hand.

All of this because the NHS is staffed by us… wears our faces, carries our prejudices, our fears.  Tells the lies that we tell and treats people like we treat people.  Uses our skills and our compassion.  Good and bad, the NHS is us.

An NHS that is patient, kind and caring.  An NHS that is rushed, absent minded and cruel.

It cannot be our-NHS, without it being us.  Human, optimistic, fearful and joyful, successful and not.  Full of human failings and human achievement.

You can pay for it how you like.  Look around the world and there are systems aplenty.  

Remember this; take taxes from your left pocket, copayments, insurance and top-ups from your right pocket… it’s still your trousers.

And, whilst you are looking around, can you name another healthcare system?  The German, the French, the Singaporean, anywhere?  I can’t but I can name the NHS.  

The world knows the NHS and frankly, given eight years of flat-line funding, out performs the UK economy, works its socks off and makes creating miracles, routine.

Travel the world and you will find ‘trained in the NHS’ a badge of honour and competence.

Travel the world and you will find dementia, age, obesity, diabetes confounding healthcare systems, everywhere.

Travel the world and you will find a shortage of staff and a medical community that is mobile and international.

Travel the world and you won’t find the transparency we have that shows up our foibles, exposes our failings and mistakes. 

This is the day when we remember the courage and optimism it took to nationalise the health delivery infrastructure and invent a Tredegar Medical Aid Society for everyone. 

It’s OK to be proud of what you do.  

Have fun today… respect the past, take the best of it into the future.

Knowing what not to do…

Last week, I spent two days at the Digital Healthcare Show, in the relentlessly urban Excell Conference Centre.  A cavern of concrete and a cornucopia of digital delights.  

If all the claims, of all the vendors, were deliverable, the accumulated savings would run the NHS free, forever. 

Digital is getting out of hand!

And, I’m a fan! If you can plug it in and has a screen, I want one.  If there’s a dashboard, show me.  If it talks, I’m listening.  If it crunches numbers, builds algorithms, plots a map… bring it on.

… but, there’s a lot of it about.  Maybe it all has a place?  Would be nice to have?  I’m not sure.  It’s complicated.  More important… complicating.

The most useful thing… a waste bin that opens when you say ‘open’.  I get that!  I understand the infection control benefits and who’d use it!

Most of this great software doesn’t solve our fundamental problems.  And that’s my point… there’s stonkingly good stuff out there but do we want it?

I sat through the NHS digital brigade’s ritual conference presentations.  Frankly, I’ve watched the same confusing messages for twenty years.  

‘We must do this, we need to do that… we’re gonna… we should.  If we did this we could get that… avoid disaster, save money… live happily ever after.’

Is it rude to rain on their parade?  We still don’t have ubiquitous wi-fi across the NHS estate.  The guidance was first issued in 2016.  I’m told the job will be finished by Christmas.  I’m not sure which Christmas.  To be honest they might do better looking after our data.  

In the meantime, Babylon is eating Primary Care’s lunch and Amazon will eat the pharmacy for breakfast.  We are being left behind.  We are no longer in control of our digital strategy.

If we allow the agenda to be drawn by the people who make the kit, the strategy to be painted by the people enthral to the stuff, we will end up with a Jackson Pollock policy that no one understands.

IT and the ‘digital thing’ is creating problems.  It’s too complicated.  

Time to stop, regroup and concentrate on four things.  

Do them, they are urgent.  Do them, we can’t afford not to.  Do them and each of them will push the door, that bit wider, on safer, affordable care.  

Do medicine without frontiers…

In Australia, by Xmas, every citizen who wants it, will have a pin number that they can give to a clinician, allowing access to their medical records.  It’s been achieved in two years. 

Working with paper is dangerous.  Working without audit… reckless.  Managing information without the use of IT… flying blind.

The record and access to it, is the key.  The starting point.  The Oz solution is beautifully simple.  Once data is moved from analogue to digital, everything is possible.

Ask them to help.

Do medicine without stamps…

The unreformed backwater; outpatients… an unlikely starting point.

Send patients a text with a pin number and a web-click.  Log in, chose an appointment time and agree, where it’s appropriate, to the consultation on FaceTime, Skype or over the phone.  It starts the process of familiarity with telemedicine, rolling into an expectation.

Milton Keynes are doing it, saving a million quid on stamps and redefining delivery.  After outpatients, why not A&E triage?

Ask them to help.

Do medicine without people… 

It’s a must.  Globally, we’re short of 7m health workers.  We can’t make that up.   I noticed a news headline; the EU numbers applying to join a professional healthcare register here, has dropped off a 92%, cliff.

There’s a 32% drop in people coming here from outside the EU.

We have to look to Artificial Intelligence… which is based on algorithms… they can only come from population-based health data curation and outcomes analysis and that can only come from our records.  Cerner is working on it.  Babylon is already doing it.

Ask them to help.

Do procurement without the palaver.  

Decide on the stuff you need to deliver this.  Buy it, install it, get on with the day job.  

Ask Sainsbury’s; if they thought store managers buying their own IT was a good idea, they’d do it.  

Ask an airline; if they thought it would be a good idea for captains to chose their own make of plane… they’d do it.  They don’t, it’s a rotten idea.

Four focused things we need to do.  

The best strategy; asking for help and knowing what not to do.

Pure genius…

It was the year of the Maastricht Treaty, three astronauts did a simultaneous space walk, Iraq continued to hamper the efforts of UN weapons Inspectors and the US refused to sign the UN convention on climate change.

It was also the year of a UK General Election; 1992.

John Major was in Number Ten.  Neil Kinnock wanted to be in Number Ten.

Labour ran an election broadcast; the story of  young Jennifer.   She suffered, ‘Glue Ear’…  

… a condition which can result in pain, irritability, discharge and difficulty in hearing.  For school age children, lack of hearing may inhibit their development.

It is treated by antibiotics (over which there is a row) and pain control.  About eighty percent settle by themselves.  Serious cases may need relief by inserting a Tympanostomy Tube, aka… a grommet.

Political commentators became experts on grommets!

In a Labour election broadcast we heard all about Jennifer’s glue ear.  She’d been waiting a year for a fix on the NHS.  Kinnock said it was an example of Tory mismanagement, rationing and underfunding.

The story was denounced as untrue and was overshadowed by a debate over the ethics of involving a young girl in national politics and the efficacy of the treatment.  

Major got back to Number 10.  Kinnock resigned.

Rationing healthcare is toxic and a very stupid thing to meddle with.  For bizarre and unfathomable reasons, in the week of the NHS’ 70th, we are having another go at it.  

NHSE have published a list of stuff we might not do, but on the other hand, we might.  They must have lost their last marble…

From the top of my mountain of ignorance, it seems to me either a patient needs treatment, or they don’t and if they do, only the best will do.  As a shop worker, on their feet all day, denied varicose vein surgery, will tell you.  

As an older person might tell you; struggling to get the lids off bottles and jars, with Carpal tunnel, or Dupuytren’s contracture.  Or, dare I say; juggling hot meals out of a microwave, playing the piano or holding hands with their grandkids.

Breast reduction… ask the women with backache, pain when walking and about the psychology of body image.

Hysterectomy for heavy menstrual bleeding… we hardly do any.  Modern conservative methods are much better.  

In fact, there are few CCGs that commission this stuff routinely.  This is a laundry list of well worn stuff we don’t do anyway and stuff, when we have to, we will still do.  It’s meaningless.  Chalazia removal, tops off the list.  Most GPs will do it in the surgery.

And, frankly, after 70 years, if we can’t decide what to do about shoulder pain… it’s time to call in Bupa.

All of these conditions can be important to someone and where no viable alternative is available… will still be carried out.

This announcement is very stupid.  The BBC and others are on the look out for people whose procedures have been interrupted.  Human interest stories will make great headlines in Birthday week.

Of course; encourage professionals to put a rational behind the use of resources but if we are to be persuaded the NHS, in its 70th year, is ‘putting patients at the centre of all we do’… this is a very dumb way of going about it.

If the idea is to make NHSE look macho… tough on spending and tough on the causes of spending… it doesn’t.  It makes them look kack-handed.

If I was The Maymite, having squeezed the last drop of cash out of the Treasury, for NHS funding, how delighted I would be to see a list of service-rationing splashed all over the morning press.

Whoever is the genius behind this Kamikaze press release… thanks.  

Instead of talking about NHS success, we will, quite unnecessarily, spend the week talking about rationing and listening to patient’s stories about their haemorrhoids.  

Indeed, a huge chunk of Simon Stevens’ interview with Marr on Sunday was distracted by rationing talk. 

What have we got; a prehistoric list of stuff that we have evolved away from but will do if there’s nothing better…  exploding into a high octane list about rationing, feeding scare stories and bad news… just a few days after the headlines; ‘The NHS gets a £20bn Birthday Bung.’ 

Yup… thanks, whoever you are… pure genius.

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Reproduced at TrainingPrimaryCare.com by kind permission of Roy Lilley.