Archive for January, 2010

Caution advised over incentive pilot scheme

By Mike Broad - 31st January 2010 9:33 pm

The English NHS should “proceed cautiously” in introducing payment for performance schemes aimed at improving quality, researchers have warned.

This scheme is scheme is called the commissioning for quality and innovation framework (CQUIN) and is being piloted in the NHS North West region.

It’s modelled on a US scheme and offers rewards to trusts - not clinical teams - for meeting clinical targets. Hospitals in the top two performing quartiles are offered 4% and 2% increases in tariff payments and there are no penalties for those with low scores.

CQIUIN follows the introduction of the quality and outcomes framework in primary care, which provided financial incentives to GPs. But, researchers from the University of York believe that the effects of incentive schemes on healthcare systems are still unclear and that the cost of implementing them may not be justified.

They point to possible problems such as its effects on motivation and increasing financial instability in a time of funding constraint in the NHS.

Although early data show good clinical engagement with the scheme in the North West, there is still uncertainty about the impact of rolling out the new scheme for NHS hospitals, they say on bmj.com. The authors argue that evidence of the effectiveness of the US incentive scheme is weak.

Clearly the costs and benefits of using rewards and penalties alone or in combination to induce clinical and organisational performance improvement needs to be evaluated, they write. This should include consideration of the possible problems of bias or gaming, as well as inadequate data collection.

Professor Alan Maynard, director at the department of health sciences, University of York, said: “The lesson learnt from the quality and outcomes framework is that we need to find out what the opportunity costs are of implementing the new scheme.

“If clinicians and hospitals allocate scarce resources to incentive schemes aimed at improving a particular set of conditions, there is a risk that other clinical conditions and procedures will get less attention and their outcomes will not be improved.”

“I shot abortion doctor to protect children”

The Guardian - 29th January 2010 1:22 pm

A born-again Christian who believes abortion is a sin failed yesterday to ­convince a judge that he need not stand trial for murder after he admitted shooting dead an ­abortion doctor.

Scott Roeder, 51, told the court in Wichita, Kansas, that on 30 May 2009, the day before he shot George Tiller, he had bought a .22-calibre gun and bullets and then practised target shooting with his brother. He checked into a motel in Wichita and the next day followed Tiller to the Reformation Lutheran church, where the doctor was an usher.

His defence lawyer asked: “Did you go and shoot Dr Tiller?” Roeder replied: “Yes.”

The fact Roeder was the killer, with a single shot to the head, was not in doubt, but the confession was an attempted defence that he felt forced to act to save the lives of unborn children. He has pleaded not guilty to first-degree murder, and it was the first time in US legal history that an anti-abortionist was allowed to present the jury with his justification for murder.

The judge, Warren Wilbert, dismayed pro-abortionists and doctors this month when he ruled that Roeder could present his justification. They feared that if a jury were to find him guilty of just manslaughter it would encourage more attacks. But after Roeder gave his evidence, Wilbert ruled that the jury could not consider the lesser charge, since abortion, including late-term abortion, is legal in Kansas, and Tiller did not pose an imminent threat.

Tiller had long been a target for anti-abortionists as he was one of few doctors prepared to ­perform legal abortions after 21 weeks of gestation. In 1986 his clinic was bombed and in 1993 he was shot in both arms, but he carried on working.

Read more at The Guardian.

Plans for swingeing managerial cuts revealed

Pulse - 10:59 am

NHS leaders are taking the first step to reversing the huge rise in health service management costs, with a series of PCTs planning deeper than expected cuts as soon as the coming financial year.

Thousands of NHS managers are set to lose their jobs under the plans. Documents reveal PCTs across the country will be asked to reduce their spending on managers by as much as a fifth in the coming financial year, with GPs warning the cuts are a sign of just how bloated trusts have become.

Early findings from Pulse’s pre-election survey, of more than 700 GPs, reveal almost 90% support for sweeping NHS cuts in management costs, as a way of avoiding reductions in front-line services such as those proposed in London last week.

NHS East Midlands plans for all its PCTs to cut management spending by 20% in the next financial year, with further cuts to follow.

Areas affected will include Derby, Nottingham, Lincolnshire and Leicestershire, which will be required to come up with plans for job cuts. The SHA said up to £10m could be saved by contracting out back-office functions alone.

Read more at Pulse.

How do we repair the damage of the MMR debacle?

By Mike Broad - 28th January 2010 5:34 pm

So, it looks like Dr Andrew Wakefield is finally going to be brought to book.

The man who first suggested a link between the MMR vaccine and autism acted unethically, the GMC found this week. Wakefield’s 1998 study in The Lancet, which was later discredited, caused vaccination rates to plummet and a significant rise in measles.

The GMC ruled that he had acted “dishonestly and irresponsibly” in conducting his research. It found that he had carried out invasive tests on children which were against their best clinical interests, and had even paid children £5 each for blood samples at his son’s birthday party.  

The GMC now has to decide whether Wakefield’s behaviour amounted to serious professional misconduct and, if so, what sanctions should be imposed. He could be struck off the register. But, with Wakefield now being based in America, who knows how far any sanctions will reach in reality.

Wakefield’s legacy in the UK will be a sad one - a lot of children suffering from measles unnecessarily. But, he was aided by the media in spreading fear about the MMR jab.   

His research message was spread by The Lancet and many of the nationals. Have they faced sanctions for their complicity? Of course not.

The other issue that surprises me is the amount of time it’s taken to get to this decision. The hearings have been going on for two-and-a-half years - one of the longest cases in the regulator’s history.

Why should it take so long? How many parents still shun the MMR without realising that both the research and the researcher have now been discredited?

Maybe certain regulators, national papers and academic journals should foot the bill for a public health campaign on the issue…

Academics must protect their jobs from cuts

By Francesca Robinson - 9:22 am

Medical academics are being advised to have proper job plans and regular appraisal in order to protect their jobs from funding cuts.  

“We are anticipating a very tough time ahead for many medical schools and academics because of the current economic crisis,” warned the BMA’s medical academic staff committee co-chair Professor Michael Rees.

At the beginning of January Imperial College London made 21 medical academics redundant as part of a restructuring to tackle a £28m deficit. 

Another 14 academics are currently facing redundancy at the Institute of Psychiatry at King’s College London, which has a £5m hole in its budget.

“There is certainly an increase in the generalised threat to academic employment. I can’t quantify the level of that threat but there certainly is a threat,” said Rees.

A three-pronged funding squeeze is putting a strain on medical school budgets. All university budgets will be affected by a £400m funding cut in 2010-11, announced by business, innovation and skills secretary Lord Mandelson in December. Some medical schools will also lose money because of a redistribution of funds following the Research Assessment Exercise (RAE) and a review of the Multi Professional Education and Training (MPET) levy currently being conducted by the Department of Health.

The MPET review is looking to more fairly distribute funds for clinical training. The MPET levy is likely to be replaced with a tariff-based system where the funding follows the student or the trainee.

The BMA fears that this will not equate to posts following the students and could result in academic jobs being axed. Traditional medical schools, particularly those in London, which employ more staff than the newer medical schools, are likely to suffer most from any reallocation of funds.

“The threatened redundancies at the Institute of Psychiatry at King’s are particularly unfortunate because it’s a high flying department, was shown to be a very productive department in the RAE and is an important site for academic training,” said Rees.

He added that the chances of academics finding work by either moving to other universities or NHS jobs were very slim in the current economic climate.

The BMA is publishing new job planning guidance for academics, which will advise them to ensure they have a job plan which clarifies the work they do. They should undergo regular appraisals and ensure they know exactly where the funding for their joint contracts between universities and the NHS is coming from. They are also being advised to avoid any dubious fixed term contracts and to carefully check terms and conditions before accepting any job.

A spokeswoman for Imperial College said they had now agreed a new structure for their Faculty of Medicine that would safeguard their internationally leading research and education activities, and address a significant projected deficit of 28.7m by 2013/14. The deficit was caused by rising salary costs, a cut in central funding and “the difficult economic climate that universities are now operating in”.

“Staff identified as holding posts that were at risk were fully consulted during the process, and every effort was made to avoid compulsory redundancies. In total, 21 academic members of staff and 27 support staff have regretfully been made redundant,” she said.

Read a blog on the future of medical research sector.

Lib Dems call for test to root out poor EU doctors

BBC Health - 27th January 2010 9:51 am

The Liberal Democrats have called for doctors from other European Union countries working in the UK to be subject to tougher restrictions.

The party has called for exams to root out those with poor language skills and inferior medical training.

It follows the case of an out-of-hours GP from Germany who accidentally gave a patient a fatal overdose.

The Department of Health said primary care trusts were already legally bound to provide safe, high quality care.

Lib Dem health spokesman Norman Lamb said: “I believe patients lives are at risk because standards across Europe are not uniformly good and because doctors can come into this country and practise in the NHS without a test of competence and language.”

Mr Lamb’s party will also press in the Commons for a new criminal offence under which hospital managers could face prosecution if they fail to carry out such tests.

There are almost 20,000 doctors from the EU qualified to work in the UK.

Read more at BBC Health.

How to help the humanitarian effort overseas

By Dr Abi Smith, deputy chair of the BMA's international committee - 9:20 am

I find it difficult to watch the news coming out of Haiti without feeling like I want to use my clinical skills to help. I am not alone in feeling like this as Médecins Sans Frontières has been inundated with calls from doctors wanting to help.

The stark reality is, however, that most of us would be of little help without additional training or experience of working in the developing world in the aftermath of natural disasters. It got me thinking about the humanitarian work carried out by many British doctors, not only at times of crisis but, throughout the year and what organisations like the BMA can do to support them.

The BMA’s international committee runs a humanitarian fund supporting healthcare workers working in projects in the developing world. Looking through the list of projects it supported last year, it is humbling to see how ordinary doctors are using their time to make such a big difference.

In Ghana, for example, a transplant surgeon and nephrologist have worked with local doctors with the long term aim of setting up a kidney transplant service. Kidney dialysis over a long period of time is prohibitively expensive and so it is critical that developing countries like Ghana can offer transplants.

Other projects have involved working in war torn countries like Afghanistan, Sudan, Ethiopia and Mozambique. Some of the projects are quite simple such as training community care workers to improve maternal health and infant mortality or supporting public health education programmes. What they all have in common is that they invest in local people making a sustainable difference long after the project teams have returned the UK.

Applications for this year’s Humanitarian Fund are now open. If you are looking to work on humanitarian projects in the developing world or know of colleagues embarking on this sort of work you should visit the BMA website.

If you want to find out a more about working overseas it is also worth having a look at Broadening Your Horizons, a comprehensive guide for doctors wanting to work overseas. For medical students interesting in getting work experience outside the UK the BMA has recently launched extensive guidance on medical electives.

“A major blow against limiting doctors’ rights”

By Richard Marks, Remedy's head of policy - 26th January 2010 3:25 pm

Remedy is delighted that our legal team has forced the government to delay their plans to exempt deaneries from employment agency legislation.

This is of significant importance to any doctors caught up in the recruitment process, who would have been deprived of many employment rights by these proposals. The legislation governing the conduct of employment agencies was passed by Parliament in order to give protection to vulnerable workers.

A government consultation in early 2009  stated that they ‘consider that [Deaneries] operate as employment agencies within the definition contained in the Act’ and that they wished to introduce an exemption. Their reasons for doing so were unclear.

The Act gives the power to introduce exemptions by regulation, subject to consultation, and a consultation took place in the summer. Both Remedy and the BMA opposed the change, arguing that it was not in the best interest of doctors. But the government announced in November 2009 that the respondents on the issue of postgraduate deaneries ‘mainly comprised a number of Deaneries who were in support of the proposal’. They also stated that they had been presented with  ’evidence that the potential consequences could be to seriously hinder the recruitment and training arrangements for junior doctors with a subsequent impact on both costs and staffing for the NHS’.

Remedy believes that the consultation was not carried out properly. We had no idea what the ‘potential consequences’ were, and we have had no opportunity to comment on them, or on the evidence which is referred to.
Our lawyers sent a Letter Before Action to Lord Peter Mandelson on 11 December, challenging the veracity of the consultation.

In their reply, the government solicitors agreed to re-consult on whether or not to introduce the exemption. They offered  to consult specifically in areas around training and recruitment. No date has been set for this re-consultation.

The status quo has been maintained, and the proposed exemption has been delayed - possibly indefinitely. We are very grateful to our legal team at Blackstones and Leigh Day in securing this result.

This delivers a major blow against a concerted effort by government to limit the employment rights of doctors. We anticipate further attempts in the future and will do everything to resist them if they are unfair.

Doctors should enjoy the same level of protection against abuse as other parts of the workforce.

The government has also agreed to negotiate a code of conduct for deaneries, and Remedy has been asked to join these negotiations alongside the BMA. We have drafted our thoughts on this and are now seeking the views of our supporters.

Our views on the implications of Employment Agency legislation and the issues that we feel need to be addressed can be read on the Remedy website

Government delays deanery reform plans

By Francesca Robinson - 3:05 pm

Lawyers acting for campaign group Remedy have forced the government to put plans to exempt deaneries from employment agency legislation on hold.

But the BMA has warned that this is only a delaying tactic and will not in the longer term prevent the government from declassifying deaneries as employment agencies.

Remedy’s lawyers challenged the way the Department for Business carried out the consultation on the exemption. Both Remedy and the BMA opposed the move, arguing that it would deprive juniors of key employment protection rights.

They would like juniors to be provided with more information when applying for jobs, such as its location, hours of work and pay, and stop them feeling obliged to accept their first job offer.  

The government has now offered to hold a new consultation and to seek opinions on training and recruitment. It has also invited Remedy to join with the BMA in negotiating a code of conduct for good employment practice by deaneries.

Remedy’s head of policy Dr Richard Marks said the proposed exemption had been
delayed - possibly indefinitely. “This delivers a major blow against a concerted effort by government to limit the employment rights of doctors. We anticipate further attempts in the future and will do everything to resist them if they are unfair,” he said.

Dr Shree Datta, chair of the junior doctors committee, said the decision to hold a new consultation was good news for doctors caught up in this year’s recruitment process.

But she warned there was no indication that the government had abandoned its plans to declassify deaneries as employment agencies. It was still pressing ahead with plans to establish a code of conduct it intended to replace the protection provided by the employment legislation. Two meetings to discuss the code have already been held.

“This is going to be a real battle for the next few months because we will need to make sure we negotiate the best deal for juniors and that the code of practice has teeth. Both Remedy and the BMA will be working to make sure that deaneries will be held to account if they don’t do things correctly,” she said.

A Department for Business spokesman said: “We want to ensure that all interested parties have an opportunity to comment on the issue of medical deaneries and employment agency legislation and that these comments are taken into account before the department reaches the correct decision in the public interest. To ensure this, the department will be consulting again and will notify stakeholders in due course on the timing of this consultation.”
The BMA is asking for any juniors who have suffered from poor employment practice to contact them to help them argue their case for a robust code of conduct.

Read a blog on the issue

“I can’t believe it’s not another health fascist”

By Jerry Nelson - 9:13 am

Arsington bloody arse, with an extra pint of arse for the weekend.

There was I, having awoken in a positive mood, enjoying my favourite breakfast of toast, butter, marmalade, butter, coffee, butter and a cigarette with extra butter, when up pops the health-fascist-of-the-week.

Some ‘leading heart surgeon’ has announced that butter should be banned, an issue that’s so pressing he has abandoned his search for an even vaguely convincing toupée.

Apparently only “radical action” can save growing numbers of young adults from heart attacks and clogged arteries.

Oh gosh, mate, are you sure banning butter is radical enough? Why not tackle the genetic causes of heart disease with eugenic extermination camps? What are you going to do when people start smuggling butter in from France? Jail them? Kill them? Will we need a War on Butter?

Maybe we need a pack of butter sniffer dogs? A heavily-armed Metropolitan Police butter squad? Butter rehabilitation programmes? And when banning butter is shown to have had precisely fuck all effect on the nation’s health will you do the decent thing and shoot yourself in the face with a service revolver, or will you decide that cheese, milk, red meat, and Curlywurlies will have to go too? What would it take for fascists like you to actually arsing well stop?

You know what the real problem is here? Heart surgery! It was always an accident waiting to happen.

You see, not everyone can get into medical school. And not everyone who gets into medical school can be a surgeon. And not every surgeon can make it in a tough discipline like DGH hepatobiliary surgery with an interest in blogging.

So some - generally those who lack the delicate touch to do orthopaedics or the personality to be urologists - end up in the sump of the surgeon’s art: cardiac. And the big problem with cardiac surgery is that it only really involves one and a half different operations, with the difficult bits like vein harvesting done by nurses.

So cardiac surgeons are all, quite simply, bored. And, as Shakespeare said, the devil makes work for bored hands.

Some try to take on different surgical operations which are actually difficult, with disastrous consequences.

Others go in search of other diversions. After a bit of digging I found this article. See what I lengths I go to in order to bring you the truth? I read articles in The Guardian by people called Felicity. I actually feel dirty now.

It would appear from the right royal kicking he’s getting in the Bolgosphere that not only is Mr Leading Heart Surgeon an authoritarian git who thinks he has a god-given right to tell me what I can and can’t eat for my own good, it turns out he knows less about the subject than I do.

And the reason his idiotic ideas have gained such a wide audience is because they were spread (har!) by the PR agency that works for big-assed multinational Unilever. And do you know what Unilever makes? I’ll give you a clue: it’s not butter.

Gosh what a great game! Take a groundless assertion, give it to a corporation who could profit from it and expect everyone to do as they’re told because you’re a self-styled ‘leading surgeon’.

Can I play? “Top Middle Bit of England surgeon says smoking is good for you and should be compulsory”. Has a nice ring to it. I’ll give Philip Morris a ring.