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Archive for November, 2011

Tackling late presentation in bowel cancer

By Paul Finan, Professor of Colorectal Surgery, consultant general and colorectal surgeon and Clinical Lead for the National Bowel Cancer Audit 2011 - 30th November 2011 11:15 am

It’s not the easiest of subjects, but we need to talk about the early detection of bowel cancer.

The annual report from the National Bowel Cancer Audit, published today, shows a continuing high mortality rate of 6 and 11.2% for urgent and emergency surgery for bowel cancer.

Today’s report is based on, for the first time, submissions from 100% of trusts, and reports on the management of over 28,000 cases of bowel cancer during the 12 month period ending July 2010.

While the overall picture of care for bowel cancer patients in England and Wales continues to improve, patients who undergo urgent and emergency surgery are still at a much greater risk of death compared to those who have elective and scheduled procedures.

The real problem is late presentation, which is why the Department of Health’s Bowel Awareness Campaign, starting in January 2012, needs the support of every colorectal surgeon in the country to ensure it has the maximum impact locally.

But it is also about how we manage our cases and the need for:

· prompt and senior involvement with acute cases of bowel cancer; and

· implementation of modern management protocols for those patients presenting acutely.

Many more bowel cancer patient lives could be saved if the NHS made more consultant time available for emergencies and new techniques were more widely used.

An innovation that could help improve care is colonic stenting. This technique enables a bowel blocked by a tumour to be opened by inserting a device. This temporary measure buys vital time for the patient to be stabilised, prepared for surgery and for the expert team to be assembled.

A trial is currently underway to prove the safety and value of this approach - the Royal College of Surgeons (RCS) and Association of Coloproctology of Great Britain and Ireland are encouraging as many hospitals as possible to sign up as participation gives surgeons the back up of training and a support network so the technique can be introduced safely for patients.

The NHS could also be doing a lot more to organise how these very sick patients get the care of a consultant surgeon, consultant anaesthetist and the wider team, and access to high dependency and other facilities, from the moment they arrive at hospital and at any time of the day or night, including weekends. The RCS is encouraging commissioners to ensure their local hospital is following the RCS standards for emergency care.

Read more on the National Bowel Cancer Audit 2011.

Read more on the CREST colonic stenting trial, being run from the University of Birmingham.

Read more on the RCS emergency surgery standards.

See the Department of Health’s campaign on Bowel cancer awareness.

The National Bowel Cancer Audit Project is a collaborative, national clinical audit for bowel cancer run jointly by The NHS Information Centre and the Association of Coloproctology of Great Britain and Ireland.

Tags: Cancer
Posted in Dr Blogs | 1 Comment »

Cancer audit says make time for emergencies

By Mike Broad - 10:55 am

Many more bowel cancer patient lives could be saved if the NHS made more consultant time available for emergencies, say the presidents of the Royal College of Surgeons and Association of Coloproctology of Great Britain and Ireland.

Bowel cancer is frequently only detected at a late stage and a significant number of patients don’t realise they have it until the tumour causes a life-threatening emergency bleed or blockage. These patients are typically in imminent danger and need a quick operation.

The National Bowel Cancer Audit 2011, published today by the NHS Information Centre, shows that while results for planned operations were improving, mortality for emergency patients remained high.

An innovation that could help improve care is colonic stenting. This technique enables a bowel blocked by tumour to be opened by inserting a device. This temporary measure buys vital time for the patient to be stabilised, prepared for surgery and for the expert team to be assembled. A trial is currently underway to prove the safety and value of this approach - and the RCS and ACPGBI encourage as many hospitals as possible to sign up as participation gives surgeons the back up of training and a support network so the technique can be introduced safely for patients.

Professor Norman Williams, president of the Royal College of Surgeons, said: “Last month the RCS produced a report on the failings of the NHS in effectively treating emergency patients and bowel cancer emergencies are a regular situation hospitals face.

“The NHS could be doing a lot more to organise in a way that gets these very sick patients in the care of a consultant surgeon earlier on their arrival at hospital and we would encourage commissioners to find out if their local hospital is following Royal college of Surgeons standards for emergency care.”

Nigel Scott, president of the Association of Coloproctology of Great Britain & Ireland, said: “We fully supports the Department of Health Bowel Awareness Campaign to be launched in January 2012 - in the hope that earlier presentation by patients and more bowel telescopes to find bowel cancer, will boost the success of colorectal cancer treatment further still.”

Read a blog on the issue.

Read more on the National Bowel Cancer Audit.

Tags: Cancer
Posted in Hospital Dr News | No Comments »

Strike “not expected to affect urgent NHS care”

BBC Health - 10:34 am

The NHS is confident emergency and urgent care will be mainly unaffected by the strikes, managers believe.

The walkout will be the biggest in the health service for more than 20 years, with the government expecting a fifth of the workforce to take action.

But contingency measures have been put in place to protect services such as A&E units, cancer treatment and end-of-life care, NHS Employers said.

Routine appointments and non-emergency operations are likely to be hit though.

Health workers who are members of Unison and Unite will take part in the strikes on Wednesday.

Between them they have more than 500,000 health staff, including nurses, health care workers, admin staff, porters and cleaners.

NHS reforms “set to cost 3.4bn pounds” Labour says

Press Association - 29th November 2011 10:10 pm

Coalition reforms of the NHS will cost nearly £3.4 billion, Labour has claimed.

Shadow health secretary Andy Burnham accused the Government of “burying” the true scale of the cost of the reorganisation in papers setting out the technical details of the plans. He claims an order for primary care trusts to hold back 2% of their budgets over two financial years to pay for the overhaul will total £1.69 billion this year and £1.7 billion in 2011/12.

Government estimates put the cost of the shake-up, which includes giving GPs control of health service budgets, at around £1.2-£1.3 billion but academics have predicted the final bill would reach double that.

Mr Burnham said: “This wasteful reorganisation is costing the NHS even more than we first feared. It is scandalous that the Government is spending £3.5 billion on an unnecessary reorganisation when the NHS is facing the biggest financial challenge in its history.

“Before his plans are even through Parliament, the costs of David Cameron’s reorganisation are hitting the NHS hard. On his watch patients are waiting longer for treatment and thousands of nursing jobs are being axed.

“These shocking new figures show that the reality is that patient care is being cut in real terms. If ever a reason was needed to stop this reorganisation, then this is surely it.”

Overpaid GPs, concrete bums, and surgery shockers - it’s Jerry!

By Jerry Nelson - 6:09 pm

GPs??!…HOW MUCH?!!

Can you believe it? The pill-pushers are raking in £750K - that’s nearly half the salary of an orthopod. It’s not right.

It’s not as if they do any training - they go straight from medical school into the cardigan and comfy chair, gazing into the middle distance while self-obsessed patients maunder on about their drab, unsatisfactory lives. Their seven-minute solution? A script for Prozac. I mean, what’s so bloody difficult about that?

Still, you’ve got to hand it to them. I thought God’s own specialty - GENERAL AND HEPATOBILIARY SURGERY - was up there in the money for old rope stakes, but these guys don’t even have to work on their feet like we do (or did, in my case - that’s one good thing about this journalism lark, you can do it sitting down, pissed). Respect, as the young people say.

TAVISTOCK TOSSERS!

It’s almost worth joining the BMA, just so I can resign. First of all they come out with another of their nannying calls to ban something - smoking in cars this time, not boxing or their global campaign on running with scissors - then it turns out that they can’t even get their numbers right.

Mind you, if you wanted an illustration of the fact that the BMA are a bunch of wasters, you only have to note that their rep in the Middle Bit of England Trust was Dweeb Urologist Johnson - the compost loving willy-wrangler, whose most notable contribution to industrial relations during my time there was to ‘negotiate’ an increase in staff parking charges. Not that it mattered much, he was the only one who actually paid up. Prat.

FAKE DOC CUFFED IN CONCRETE ARSE SHOCKER

I’d been congratulating myself that after only a week in my new job, I was already demonstrating a gift for the eye-catching headline, but as you’ll see from the link, I can’t claim credit for this one, which should be in line for some sort of award.

It just has it all, including the constructive and appropriate use of the word ‘arse’ which, as you all know, is a special interest of mine. In fact, the headline is better than the story, which just reports, yet again, how mind-bogglingly stupid the average punter is. Oh well, I suppose if they weren’t, the cosmetic surgeons would all be out of a job, and we wouldn’t want that, would we? Oh…alright, then.

Although, looking at that picture of the woman again, I can’t help wondering if she hasn’t got a contract with infection control at Middle Bit of England NHS Trust…

ADVICE…on drinking?

More whining in the Sunday Times (link only works if you give money to the needy Murdochs), this time because ministers and civil servants drawing up advice on drinking have had 85 meetings with those magnificent men and women who manufacture alcoholic beverages. Apparently ‘health groups’ are complaining because the industry boys get more access to Whitehall than they do. Well, what do they expect? If I was a senior civil servant and had the choice of meeting half a dozen members of the board of Diageo, or sitting around a table with a bunch of miserable beardies over a carafe of spring water and tofu biscuits, I know what I’d do. For a start, think of the freebies the drinks team would bring along - it would be a right piss-up. Anyway, who needs advice on drinking? Can’t help recalling that quote (was it W C or Gracie Fields?) in response to an unwise journo who asked him about his drink problem: “I drink, I fall down. No problem.” Might try that one with the GMC…

WELL STAY AT HOME AND DIE, then

More whingeing from the Murdoch stable, this time quoting a report from those Dr Foster nerds about ‘botched operations’. (Definitely spent their formative days being bog-washed and wedgied at minor public schools. Get proper jobs…).

It’s the usual bloody complaint about wrong-side surgery. It happened 57 times last year, apparently, so think how many times they removed the intended limb/organ, but no-one gets any thanks for that, do they? And ‘a foreign object’ was left inside the patient on 125 occasions. Garlic bread, Lederhosen? It doesn’t explain but one can surmise it wasn’t an English surgeon who put them there…

Anyway, I bet none of these ‘objects’ were false teeth. I well remember the occasion when the nurses forgot to remove a patient’s dentures before she came down for her cholecystectomy, so Dan the FG took them out when he intubated her and left them on top of his gas machine. Too good to resist I’m afraid, so when his back was turned, I tucked them out of sight in the pelvis and stitched up. A bit naughty I suppose, but I was still feeling skittish after a particularly good mess party the previous evening (remember those?). She didn’t come to any harm, and it made for a really good post-op abdominal x-ray.

Luckily for me, the dozy radiologist saw teeth, and said it must be an ovarian teratoma, so there was no come-back. Happy days!

But to get back to those testosterone-challenged Dr Foster odd-balls, what these people need to understand is that any big building full of sick people and doctors is bound to be a dangerous place. Grow a pair, and deal with it.

Tags: Humour
Posted in Nelson's Column, Bolg, Blog, whatever... | 2 Comments »

Chancellor sets out low pay future for NHS staff

By Mike Broad - 3:09 pm

Chancellor George Osborne says public sector pay rises are to be capped at 1% for two years.

The announcement, delivered during his Autumn Statement, means that NHS doctors will not have had anything like an inflation matching pay rise in six years.

Consultants are currently in the second year of a three year pay freeze, and when that ends will only receive a maximum of 1% salary uplift, if at all, for the ensuing two years.

Pensions are also under review and consultants are likely to have to work longer and make higher contributions for weaker benefits. And there’s still no indication whether this year’s Clinical Excellence Awards programme will be run, as the profession awaits the government’s response to the pay body’s review.

Stephen Campion, chief executive of the HCSA, said: “This announcement reinforces the need for a negotiated settlement on both pay and pensions, although I very much fear that attitudes will harden in the coming weeks. The timing of all this is particularly insensitive coming as it does not only during the pension negotiations but also when the government has been made aware only this week of the need for improved hospital consultant cover at night and weekends.

“Today’s announcement will do little to help the health secretary and NHS Employerswork work with health professionals who will feel even more undervalued than they did before the Chancellor’s announcement.”

Inflation is currently running at around 5%.

The BMA has said it will ballot members on the government’s pension proposals, and is not ruling out an industrial action vote in the future.

Dr Hamish Meldrum, BMA chairman of council, said: “The Chancellor’s decision to bypass the normal pay review process for a further two years and announce another sub-inflationary pay award will come as a bitter blow to all those who work in the NHS.

“Doctors, like their public sector colleagues, are angry at the government’s proposals to slash the value of their pensions. This announcement, coming on top of what will be three years of pay freeze for senior doctors, will further alienate those who are working hard to deliver improvements to patient care.”

Osborne also confirmed that UK economic growth would be lower, and borrowing higher, than was forecast during the Budget in March.

Delivering his Autumn Statement, Osborne told MPs the UK economy was now forecast to grow by 0.9% this year - compared with 1.7% forecast in March and 0.7% next year down from the 2.5% March forecast. This would be followed by 2.1% in 2013, 2.7% in 2014, and 3% in 2015.

The Office for Budget Responsibility has increased its estimate of the public sector jobs expected to go. Previously, the figure was put at around 400,000 - it’s now 710,000.

Tags: Pay
Posted in Hospital Dr News | No Comments »

Under the influence - guidance for doctors on alcoholic patients

By Dr Yvonne McCombie, MDU medico-legal adviser - 12:12 pm

From drunken revellers staggering around British town centres to more sombre images of jaundiced alcoholic patients lying in hospital beds, the social and health problems caused by alcohol are a regular feature of news and documentaries.

Sensationalist as much of this coverage may appear, there seems little doubt that alcohol-related problems are a growing burden on the health service. According to the latest statistics from the NHS Information Centre, there were more than one million alcohol-related admissions to hospital in 2009/10, an increase of 12% on the previous year.

Alcohol-related deaths in England in 2009 did fall by 3% to 6584 but this was still up by a fifth on the 2001 figure and other alcohol addiction charities estimate the number of alcohol-related deaths to be much higher.

Given the number of health problems associated with alcohol misuse - alcoholic liver disease, malignancies, etc - and the disinhibiting effect of alcohol on behaviour, drunken patients present particular challenges for doctors. In the two-and-a-half years between January 2009 and June 2011, the MDU opened 189 files in response to requests for help from members concerned about an aspect of treating an alcoholic patient, an average of six such cases each month

The primary reason for members to seek our assistance in each case was as follows:

- Coroners’ inquiries 70

- Complaints 44

- Disclosing information 34

- Consent and capacity issues 12

- Other 29

The large proportion of cases relating to coroners’ reports and inquests highlights just how difficult it is to successfully treat alcoholism. For example, it is often difficult to persuade patients to even accept they have a problem, still less ensure their cooperation with treatment. Tragically, at least 13 coroners’ investigations looked into suspected suicides while others followed an overdose, drowning or a fall.

In addition, some conditions can be difficult to diagnose in alcoholic patients because the symptoms can be confused with the effects of heavy drinking. For example, in a handful of cases we reviewed, patients had died from an undiagnosed subdural haemorrhage, a condition for which alcoholism is a risk factor but where many of the symptoms such as headaches, nausea and speech problems are also associated with heavy drinking.

The MDU’s study also revealed:

· The number of files opened over the period was consistent: 79 in 2009, 78 in 2010 and 32 in the first six months of 2011.

· 64% of cases concerned a GP, while 24 related to psychiatrists and nine were doctors in Accident and Emergency Departments.

· Over half of the complaints (24) were made by a third party, usually the patient’s family. This compares with a previous MDU study of complaints received in the year to April 2010 in which 84% of complaints were made by the patient.

· In the 34 cases in which doctors sought advice about disclosing information about a patient’s condition, nine involved reports to social services (usually where a child was at potential risk), eight were reports to the Driver and Vehicle Licensing Agency and four involved reports to the police.

· In seven cases, doctors had been asked to assess the capacity of an alcoholic or drunken patient to consent to treatment, make an advance decision, or make a will.

The following advice, drawn from the MDU’s analysis may help doctors avoid the pitfalls of treating alcoholic patients:

· Ensure appropriate steps are taken to exclude other possible diagnoses within a reasonable time. Include your differential diagnosis and management plan and relevant findings on examination in the patient’s notes.

· It may be that the patient’s alcohol problems means they are unable to complain themselves or that they have died but if you receive a complaint from a third party, check that that person has the necessary authority or is an appropriate person to act on the patient’s behalf. Respect the patient’s expressed wishes concerning the disclosure of information.

· Be aware of and consider the latest authoritative guidance on treating alcoholism such as the national clinical guidelines published by NICE in July 20112.

· Other than when required by law (such as a court order), it is only acceptable to disclose information about a patient without their consent in exceptional situations in the public interest where failure to disclose may expose others to a risk of death or serious harm, such as the risk to a child. You should still seek the patient’s consent unless this is not practicable and any disclosure should be the minimum needed for the purpose.

· The patient’s capacity is likely to fluctuate and may depend on the complexity of the decision they are being asked to make. In each case, you will need to assess their ability to understand and retain the relevant information, use it to make a decision and communicate that decision. Keep a record of the name and contact details of anyone with power of attorney or a court appointed deputy who you can contact if the patient lacks capacity.

Tags: Alcohol
Posted in Guidance | No Comments »

Junior doctor drowned herself over stresses of work

Evening Standard - 28th November 2011 11:22 pm

A promising young doctor drowned herself in the Thames after the pressure of work became too much for her, an inquest heard.

Sumayya Dukes, 24, had been working long night shifts as a junior doctor at St Mary’s Hospital in Paddington when she first went to A&E with stress and exhaustion.

She wrongly feared her work wasn’t up to scratch and had been upset by a ward sister shouting at her when she asked for help, West London coroner’s court heard. Dr Dukes, from Ealing, who senior doctors described as “high-achieving”, was signed off work with depression for 21 days.

But on the day she was due to return to work, in January last year, passers-by found her body on the shore of the Thames at Mortlake. She was identified by the hospital ID she was wearing around her neck.

GPs forced to abandon industrial action plans

Pulse - 9:44 pm

GPs have been forced to shelve plans to take official ‘industrial action’ on Wednesday’s Day of Action against the government’s pension reforms, after an eleventh-hour intervention from union lawyers who warned that striking could be illegal.

A number of GPs in London had notified the MPU, which is part of the Unite union, of their intention to strike on 30 November and provide a limited service in their practices. MPU members had been part of a Unite ballot on industrial action, but the MPU has now officially declared that its 100 GP members are ‘not being called out’ to join strikes, after advice from lawyers identified complications with issuing ‘intention to strike’ notices to cover GPs.

Stop wasting NHS money on worrying about money

By Caroline Whymark - 10:57 am

So back to the original question: how can the ever spiralling costs of delivering a high quality NHS free-at-the-point-of-use be met? In true political speak, I think if we were to address some tough questions and make some unpopular decisions (and actually follow them through) there would be no need for budgetary panic.

1. Rationing:

Not by postcode or by local practice variations dependent on the prevailing wind direction, but by doing the big things first and then assessing what you are going to spend the left over money on. There is a well known adage about fitting stones in a jar - if the big ones don’t go in first they will never fit. The smaller stones always slot in around them in the little left over spaces. Surgery is like stones. Spend money on all the small frivolities and the budget will fall short for the big essentials. Use the budget with this in mind. Do the emergencies, the cancer, the trauma and forget about questionable cosmetic procedures treating self-esteem issues unless you have money to burn in March.

2. Stop robbing Peter to pay Paul:

Time-wise and budget-wise this repeatedly occurs. Let’s say healthcare costs X amount. Whether time and money is spent in pre-assessment clinics, ward bed days, or increasing day surgery capacity, the work required still costs X regardless of whether it is done by a doctor, a nurse or any number of advanced and extended roles. We often simply redistribute where the time is spent and which budget the money comes from. Stop wasting time, effort and more money trying to find more cost efficient ways of doing things. Savings in one area generally mean increased expenditure and reduced time available in another and false economies prevail.

3. Stop measuring things we already know and/or cannot change:

There must come a point when measuring any variable that the process becomes more costly than any potential savings that could be made from removing inefficiencies. Further, when measuring a load of variables (read theatre start time, end time, in between time) which finds we are actually pretty efficient, the actual process of the measuring is a cost which generates no reciprocal saving. Why keep doing it over and over again? Some systems by their very nature are slow. A trauma list finally deciding on clinical priority at 0830, after taking into account overnight admissions, will not start at 0845. This is not inefficient.

It is a fact of this type of work. Priorities change, theatre readiness of a patient changes. Long gone are the days of the instant orthopaedic patient (read ‘add water when ready to operate’). Measuring the ‘delays’ on this type of list goes no way to reducing them. They are not delays, they are the inherent time required in the system to follow due procedure and carry out repetitive safety checks. Measuring them will not change this.

4. Accept clinical risk is the nature of the beast:

Things don’t always go well and this may be no-one’s fault. Accept that complaints and litigation are more prevalent throughout society and not just in medicine. Stop investigating, escalating, referring and reviewing practice in the light of a complaint. Endless meetings and paperwork result from tiers of investigative staff tasked with determining what went wrong when often nothing did. Medicine is a risky business with no guarantees. Sometimes the outcome is not good. Accept that or get out of healthcare.

5. Staffing:

Approximately 80% of the total budget is spent on staffing. Approximately 50% of these are non clinical. Does 50% of Apple’s staff have nothing to do with producing an i-gadget? I think not. Many managers have necessary roles and do the stuff that someone has to do. But their numbers seem to be escalating and at the end of the day the NHS is in the business of delivering healthcare to patients and that should be the main focus of the organisation.

A high quality service free-at-the-point-of-use, encompassing modern medicine as it evolves is expensive. It would be easier to meet this cost if we stopped wasting money on wondering where the money goes.

Tags: Funding, Managers
Posted in Caroline Whymark | 2 Comments »