Katherine Teale

Katherine Teale is a consultant anaesthetist in Greater Manchester

Health inequalities: time to park the Health Bill

By Katherine Teale - 23rd January 2012 11:37 pm

Unless you’ve been hiding under the duvet for the last 18 months, you must be aware of the furore over the Health Bill, which has received a new battering this week from the Health Select Committee.

As a GP friend pointed out during a commissioning meeting, we work in an inner-city area where most residents take home less than the UK median wage (£23,000), and so, under the proposed system,  probably won’t be buying health insurance or ‘top ups‘, or whatever this will be called when the GP commissioners run out of money and decide that they can’t afford to fund procedure X or Y on the NHS. And that therefore if you require an X- or Y-plasty you will have to find alternative funding or just put up with it.

So poverty (or, at least, being unable to afford health insurance) and illness is going to be a bad combination - but if you’re a healthy doctor in the top 5% wage bracket and able to ‘work’ the health system, do you care?

Some do. NHSCA chair Dr Clive Peedell ran six back-to-back marathons this month to draw attention to the dismantling of universal healthcare - that’s what I call putting ‘skin in the game’.

Others, though, are less sympathetic, and take the view that the poor have only themselves to blame. Apparently they should have bothered to get themselves a good education when they were younger, and then they wouldn’t be in this mess. This was my second interesting discussion this week, and came on the back of complaints about our graduated car park charges, whereby a consultant on £90K has to pay about £15 a month more than a support worker on £18K.

“We don’t have to pay more for a pint of milk at Tesco just because we earn more.”  The Tesco argument is one which I’ve heard before, so this is not an isolated view.

I’m no saint when it comes to compassion - I don’t even  buy the Big Issue every week - but where do I start? For one thing, the comparison doesn’t work because, of course, poor people probably do pay less for a pint of milk at Tesco -  they simply avoid the organic or decent locally farmed stuff. Hospital car park charges are quite substantial (I pay over £30 monthly) and a significant burden for low paid workers taking home less than £1,000. Even means tested, it’s still a helluva lot more, proportionately, for them than for us.

My concern with this is that it’s a small step from saying it’s OK to price our poorly paid colleagues out of the car park, to saying that poor people don’t  deserve the same healthcare, because  they obviously didn’t try hard enough at school.

How appropriate that in the bicentenary of Dickens’ birth, we should be hearing about the undeserving poor. Doctors have traditionally stood up for the poor and the sick. As well as getting angry about the theft of our pension funds, we should all be striving to preserve the NHS as a good, universal service for all - even for those who didn’t manage 10 GCSE’s. Please sent an email to your Royal College president asking them to support dropping the Health and Social Care Bill.

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2012: let us concentrate on the important stuff

By Katherine Teale - 3rd January 2012 11:07 am

Perhaps it’s the constant rain, but it’s difficult to look forward to 2012 with anything other than trepidation. The only two glimmers of light are the Olympics, on which we’re spending the last few (billion) pounds in the coffers, and the extra bank holiday for the Queen’s Jubilee. But unless you’re Lord Sebastian Coe, or a member of the Royal Family, I’m afraid it looks like 2012 is going to be about austerity.

And that’s only the good news - there are other possibilities too - war with Iran and another crazy Republican in the White House for instance.

We’re certainly going to have to hang on to our hats, if this week is anything to go by - the flood of directives and criticism  from above is quite bewildering.

First we have news of the lifting of the cap on private income generation to 49% of hospital  budgets. Then we are told by the NHS confederation that 1 in 4 hospital patients could be being treated at home - although by whom and with what isn’t made clear. It didn’t take long for journalists to start asking whether this was to free up beds for the private patients.

Almost simultaneously we have the Daily Telegraph thundering about the “scandal” of  the “soaring” number of patients having to be readmitted as emergencies after being discharged too early. Apparently numbers have increased  by three quarters in a decade. Closer analysis might have revealed that the number of admissions generally has increased by a large proportion in the same period, and that this decade also coincided with it becoming virtually impossible to see a GP out-of-hours.

In case that isn’t enough to be going on with, we are have more edicts from Steve Field, a GP who leads the Future Forum advising the government n the reforms. He’s decided that every contact with a patient by any health professional should include questions and advice on life-style issues such as smoking, obesity, exercise and alcohol - and why stop there - perhaps we should also question them about their book choices to ensure they’re not wasting their free time, and demand five goals and objectives to be completed before the next outpatient appointment. Dr Field can rest assured that time in the anaesthetic room could be used very profitably - I suspect patients will agree to anything when you’re standing over them with a large syringe.

Some of us might start to suspect that the government doesn’t know what it’s doing - or even that it’s trying to distract attention from the intended dismantling of universal health care. But the real problem with this whirlwind of contradictory orders - apart from the fact that it’s evidence-free crap - is it causes massive disruption and really pisses off the staff (and God knows they’re depressed enough already). That’s quite apart from what the patients think, if anyone ever bothered to ask them.

All of us, this year, need to be allowed to concentrate on the really important stuff - which is to  work together to  make this dwindling precious resource work as well as it can, without distraction, obfuscation or confusion.

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It’s worth keeping in mind why we do it

By Katherine Teale - 11th December 2011 10:32 pm

As I get older, I realise there are more and more things I don’t understand - for instance, how to do long division without a calculator, and whether it’s a good or bad thing to be in the EU.

It’s a bit strange, I think, that so many people seem to be absolutely sure about this quite complex economic issue, particularly readers of our tabloid press, although I do think that before being able to participate in any referendum about Europe, voters should have to be able to name at least five countries in it. That would reduce voter numbers substantially. Come to think of it, I would no more trust the view of the man on the street on membership of the EU, than I would ask him to take my appendix out.

Things have got so depressing this week that’s I’ve decided to stop watching the news, and restrict my media contact to Classic FM, nature programmes, and anything by Jane Austen. Even natural history programmes are problematic in our house - we couldn’t watch the Frozen Planet together, as it was too upsetting for my daughter - nature is too grizzly for today’s sanitised youth, I’m afraid.

As far as work goes, I’ve decided to keep my head down and just  do what I can in my own small corner - and very satisfying it is too. Last week I had three patients on my theatre lists with NYHA stage 3 heart failure - there are few things more satisfying than successfully seeing such high risk patients through their surgery, especially when it’s witnessed by a colleague who, when letting me out for a very welcome coffee-break, was visibly impressed by my (for once) spectacularly effective supraclavicular brachial plexus  block.

This week’s gloom was lightened by the successful outcome of two patients who came to theatre with agonising trigeminal neuralgia, and left pain-free.

I do think we sometimes need reminding about how fortunate we are to be doing a job which doesn’t involve sitting at a computer terminal for hours on end. It might be physically demanding and involve too much getting out of bed in the small hours, but the rewards still sometimes bring a tear to my eye. Whatever happens out there in the wider world, to our pensions and salaries, and whether we end up working for Spire, Circle, or United Health, we can still go on doing our best for the patient in front of us.

We won’t always make a difference for the better, and even if we do they won’t always be grateful - but it’s what makes the job worth doing. And when I lose sight of that, will be the time to hang up my laryngoscope. Merry Christmas.

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Obesity: industry prioritised over public health

By Katherine Teale - 21st November 2011 1:17 pm

Our leaders are really super-glued to the idea that ‘the market will fix everything’ - the less regulation, the better.

Perhaps nobody has pointed out that this is exactly what American politicians used to say right up until the fall of ENRON. The Department of Health’s own webpage on obesity predicts that if no action is taken, by 2050 50% of women, 25% of children and 60% of men will be obese. So what do they do? Genius - nothing! Let the market sort it out. If you thought the last government didn’t stand up to the food industry, then this bunch has rolled over, handed over the family silver, and mortgaged the estate.

The ’strategy’ is based on two beliefs: 1. that all those fat people just need to try a bit harder to control themselves, and 2. that markets are capable of self-regulation.

So, do we get regulation of the food industry? Legal limits on fat, sugar or salt contents? Restrictions on fast food advertising? No, we get a talking plate.

Yes, on the news this morning, we were told about a plate (imported from Sweden since we can’t even make our own crockery now).   It weighs the food for us, as it’s too much effort to do it ourselves, and then tells us to eat more slowly in case we’re gobbling impolitely - hopefully not in Swedish, although it would probably be just as effective.

Now that we’ve got the talking plates, the government has quietly disbanded the expert group on obesity, most of whose members were, strangely, unhappy with Andrew Lansley’s decision to focus his obesity strategy on cosying up to the multi-billion pound food and drinks’ industry.

Evidently the constant criticism was getting too much for him, particularly after he had suffered a stinging rebuke from Jamie Oliver - the “government’s obesity strategy is worthless patronising rubbish. Eight year olds could come up with a better strategy”. I didn’t realise celebrity chefs were so articulate.

Like it or not, history tells us that people don’t change their habits easily. Smoking rates only fell substantially when education policies were combined with legislation which really made smoking inconvenient. The tobacco industry fought every step of the way, in the teeth of the evidence, and the food and drinks industry is no different.

You only have to look at America to see what lobbying can achieve - only this week the US congress, faced with an attempt to make school lunches healthier, fought against a plan to limit the serving of fast food. The move followed intense lobbying from the frozen food industry. I can only imagine what industry lobbying goes on in Whitehall, but it’s obviously effective.

In the futuristic Pixar film Wall-E, humans are portrayed as enormous blobs, carried everywhere because they are too fat to walk. I already see patients like this at work. The longer this government prioritises industry interests before public health, the more I think this really is the way we’re heading.

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Resist the political brainwashing over the NHS

By Kathy Teale - 8th November 2011 11:46 am

Orwell, who explained that to change thinking you first have to change the language, would have recognised how management is implementing the latest fad.

Meetings are peppered with  ‘service line management‘, ‘stragetic business units’  (SBUs), ‘profitability’ and ‘re-engineering‘. Service line management  is the latest solution to everything, heavily endorsed across the NHS by Monitor, so I guess some of you out there have also have been divided in SBU’s and are enjoying the amazing benefits thereof.

While it might be the best thing since ‘lean’ if you’re, say, a cardiac surgeon belonging to a neatly-defined team, for the anaesthetists or radiologists amongst us who provide services in many areas, it’s not quite so positive. We now find our departments deconstructed and parcelled out amongst other business units.

Nevertheless, we are repeatedly told that devolving management responsibility to front-line staff leads to ‘increased staff engagement’ and ‘improved morale’. Not only that, but it also - and I really think there must be some sort of magic power at work here - improves patient safety and outcomes.

Senior managers have been heard to claim that there are people walking around out there who “wouldn’t be here” if it weren’t for service line management. Perhaps they should check the bottom of the garden for fairies, while they’re out and about…I’m afraid I need to hear the mantra a few more times before I’m ready to get on board.

While the NHS is happily occupied with deckchair rearrangements, similar techniques of persuasion are being used at much more elevated levels. Statements which are extremely dubious and, in some cases, clearly contradicted by evidence, become widely accepted and eventually pass unchallenged. A couple of oft-heard examples spring to mind:

1. The NHS is NOT being privatised. And

2. Public sector pensions are an unaffordable burden on the taxpayer.

It works like this - firstly, wheel out a senior minister to repeat the ‘fact’ in a simple soundbite, ridiculing anyone who disagrees. Secondly, blame any problems on a) the last government, b) the public sector or c) Europe. Third, ensure that the media trots out the party line. Lastly, repeat several times a day for at least six months. Result - fiction becomes fact.

The problem lies, I think, in that people naturally want to believe everything’s OK, and health economics is very complicated. Real explanations don’t lend themselves to soundbites or doorstep conversations. How do you convince people that the NHS is being, effectively, privatised when they don’t understand how the NHS works now, and privatisation to them means having to take their cheque book to Casualty. You’ve lost them after the first mention of clinical commissioning groups.

Similarly with pensions, anyone listening to the news would think private sector taxpayers donate their entire wage to our gold-plated pensions while we sit about booking our next holiday in Tuscany. Again, the smokescreen relies on the fact that hardly anyone understands pensions. Unless you’re going to sit down and read about Funded and Unfunded pension schemes and accrual rates (yawn) you’re probably going to simply believe whichever set of politicians happens to have grabbed the mic.  In fact taxpayers (other than ourselves) are NOT funding NHS pensions, nor are they projected to do so.

The first rule of politics - which is what hospital management is morphing into - is  that if you say the same thing often enough for long enough, no matter how wacky or  evidence-lite,  you will eventually be believed. Let’s not be brainwashed.

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Some weighty Health Bill issues come to light

By Kathy Teale - 10th October 2011 10:02 am

One of my patients (let’s call her Beryl) complained to me this week that she had been denied bariatric surgery. She had been unable to lose the percentage of body weight required to demonstrate an ability to adhere to the stringent dietary restrictions patients have to live with following a gastric bypass. She was therefore deemed ‘unsuitable’ by the PCT despite her BMI of approaching 60.

One of the founding principles of the NHS is that services should be free at the point of access, and that the secretary of state for health is responsible for ensuring the delivery of all ‘reasonable’ services. In practice, the only services which the NHS has not generally delivered have been cosmetic surgery, some infertility services, complementary therapies and the long-term nursing care of the elderly. The distressing consequences of the latter for many, who mistakenly believed that the NHS would care for them in their hour of need, are well known to us all.

Currently Beryl can appeal against the PCT’s decision - and if she can demonstrate that they haven’t followed NICE guidance, she has a good chance of winning. She might even choose to  take her appeal to the secretary of state for health. It might also be reassuring for Beryl to know that under the present system staff at the PCT aren’t personally quids-in as a direct result of their refusal. Surgery has almost certainly been refused because A. it’s unlikely to be successful because she can’t stick to a diet, and B. the PCT hasn’t got money to throw away on pointless procedures.

What Beryl, and many like her, don’t  realise is that under the proposed Health and Social Care Bill things will be very different. As we have seen from the behaviour of a Yorkshire GP practice (who have jumped the gun, admittedly, but probably only by a few months), commissioning consortia will be given  the power to decide which procedures are available on the NHS and which are not.

They can do this without any public discussion, and it’s not obvious who to appeal to. The Haxby GPs have also ably demonstrated to the most sceptical observer the potential for massive conflict of interest. The practice wrote to patients  informing them that their procedures were no longer available on the NHS, and offering them a choice of four private providers, one of which just happens to be owned by the very same Haxby group. Under the proposed new rules, as an additional bonus, any money not spent on patients from their NHS-budget  can be divvied up amongst the group. Denying NHS treatment to patients therefore becomes fantastically profitable.

Why hasn’t there been an outcry about this? Possibly because not many of us have read the 700 pages of the Bill sufficiently carefully, or perhaps, with typical British pragmatism, we are just hoping that things won’t turn out  as badly as expected. Let’s hope we’re right.

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Key objective for year - don’t maim or kill anyone

By Kathy Teale - 7th September 2011 4:08 pm

I’m glad I don’t live in London - apart from having to fork out squillions for a flat the size of a small rabbit hutch, many London hospitals seem to be in even more dire financial straits than out here in the provinces and therefore ripe for takeover by private companies.

Hence we read in the papers that officials at the Department of Health have been in talks with German health care company Helios about ‘opportunities’ in London. You have to hand it to this lot - they don’t hang about. Why waste time waiting for your wacky idea to actually become law, when you can just forge ahead ignoring all the leftie nay-sayers.

I’m sure we’d all appreciate a bit of Germanic efficiency in our exec suites - but it would have to extend to more than cutting staff and/or wages.

SPA time, for instance, would doubtless be a thing of the past; anaesthetists would be in theatre 24/7 (in fact they would probably just seal us up in there); at least surgeons would be allowed the occasional glimpse of daylight to go and do a clinic.

Meanwhile back at my own trust, we’re bumbling along in our own quaint British way, and  managing to stick pretty well to the old national terms and conditions, although this year we do have to justify our SPA time. Fair enough.

I had my appraisal recently, at which I had to produce a diary of all SPA activity, with detail to the nearest 20 minutes of how I was spending this time profitably. There was a great temptation to say: “Stuff it, keep your SPAs” - but in the end of course, I complied. I did, however, struggle  to decide which category ‘gossiping around the coffee machine’ comes under (team-building activities, perhaps?).

There’s no doubt that SPA time is valuable. For instance, this year I’ve learned to do ultrasound guided nerve blocks by going to courses and joining colleagues on their lists in my SPA time. As a consultant it’s the only way to learn new skills.

So far so good (in the appraisal, I mean) but now I’ve got to go and work out my ‘Goals and Objectives’ for this year, so that I can go back for another meeting with my line manager to discuss them. This is where I start to lost patience with it all.

How about the following goals - ‘to go home at the end of each list without having actually killed or maimed anyone, thereby keeping my name out of the headlines’. And then ‘to  keep up with mandatory training and the ever increasing burden of on-call while retaining a grip on sanity until I can afford to retire’. Somehow I don’t think these will cut the mustard, they’re not SMART enough.

OK, my first goal is to remind myself what all the letters in SMART stand for. And it all gives me something to put in my SPA diary…

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Riots are about politics whatever the PM says

By Katherine Teale - 15th August 2011 8:33 am

If you work in the NHS, you know the type. The foul mouthed youth on the trauma list; the woman in A&E who threatens to deck the anaesthetic registrar as he struggles to treat her injured son. Patients to whom violence is a daily event - the first and only solution to every problem, coupled with a strong sense of entitlement. Without a doubt these are the people we saw on our streets this week looting and lobbing stones at the police.

Miles of newsprint have been churned out, but the only point of agreement is that we don’t want it to happen again. Anything and anybody is being blamed, depending on the writer’s standpoint, from feminists to Margaret Thatcher to hip hop. Some politicians are unwilling to discuss reasons - and react to those who do as if they had personally booted in the window of JD sports.

The looting, they claim, was due to pure criminality - “not poverty but culture” according to David Cameron. In other words they are just evil people and nothing to do with politicians. Well, I’m afraid that is simply denying responsibility - riots are always about politics, whether or not the rioters have heard of EMA or cuts to Sure Start. Politics shapes the culture, the way people live and the money they have to spend, the gap between rich and poor, the opportunities available - if politicians don’t accept that, then what on earth are they for? Unless we want to spend more weekends watching shopping centres being torched, we have to look at reasons, and politics has to be part of the solution.

I don’t believe people are born wicked, so what makes them so? Watching the riots on TV, my husband recognised in the crowd one of the mums at his school. She’s a crack addict bringing up her 11-year-old son in between frequent spells inside when grandma steps in as main carer. The boy is doing well at school (he’s just got level 4’s) because he’s clever, has skilled teachers, and there are always consequences for bad behaviour. Out of school it’s a different matter - he’s already known to the police and grandma does her best but can’t control him.

My husband reckons that, away from the nurturing environment of primary school (the only place where he’s ever had consistent boundaries), he’ll last about 4 weeks before he’s expelled. Another life blighted, along almost certainly, with the lives of all those he comes into contact with. What good does gaoling his mother do? (It hasn’t worked so far). What would be achieved by evicting them except the removal of the only stability the child has ever known? It’s difficult to punish people with so little to lose.

This week hasn’t shown us anything new. We’ve just been forcibly reminded of something most people like to ignore. We have a small minority for whom it’s OK to kick in shop windows; OK to scream at nurses; OK to torch buildings while they’re full of people. Why? One commentator said on TV that he felt “we’re in a different country now”. Perhaps - but only if you’ve been going around for the last 20 years with your eyes closed.

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It’s obvious why PCTs are making patients wait

By Katherine Teale - 1st August 2011 10:05 am

You really have to wonder what it’s like in the world of a Tory minister. It’s evidently a place where nobody has to rely on a public service. David Cameron’s gratitude to the NHS for treating his son Ivan, frequently repeated in the run up to the election, seems to have been conveniently forgotten.

First we have Steve Hilton, David Cameron’s director of ‘strategy’ (for which his qualification are…ummm…I’ll have to get back to you on that one), suggesting the abolition of maternity leave, job centres and consumer rights legislation.

Then Oliver Letwin claiming public sector workers need more ‘fear and discipline’ (how about a spot of whipping?). Thanks for that, boys - if that’s the direction of travel, we’ll soon be opening workhouses again. Let’s admit this government is devoid of intelligent ideas for deficit reduction, or indeed, any grasp on the realities of life for the majority who don’t have a trust fund and didn’t go to Eton.

Then we have the Cooperation and Competition Panel doing what it was set up to do - clobbering the NHS and cosying up to the private sector. Its report last week claims that PCT’s are unfairly giving work to local hospitals, and restricting access for elective surgery to save money.

Making patients wait for treatment, we’re told, is designed expressly to force those who can afford it to go privately. Not only that - those wicked managers are hoping that many others will tidy themselves off the waiting list by dying before they finally get an op date. With breathtaking hypocrisy, the government piles in with expressions of horror, completely ignoring the reason why PCT’s are so desperate to save money. It’s a shame PCTs are so strapped for cash that they can’t treat CCP members to the same corporate entertainment package that lobbyists from the private healthcare industry recently did, according to a report in The Guardian. It was obviously be money well spent.

What the government also fails to acknowledge, is that this was always the plan - i.e. to  force NHS waiting lists to increase so that the private sector is able to ride in and save the day - patients will either pay privately, or demand an alternative provider. And this is before the Health and Social Care Bill has even become law.

For a politician, political expedience trumps compassion and humanity every time, especially if you yourself have full BUPA coverage. We only need to look at America to see what happens when leaders are desperate to balance the books - states are cutting Medicaid coverage drastically, causing unimaginable suffering. We might almost suspect that our own government cares more about the welfare of private health companies than it does about the welfare of ordinary citizens. What a surprise.

Tories are very fond of lecturing us about reducing the deficit so that our children and grandchildren aren’t burdened by our debts - all very laudable, but at this rate, we’re creating a country so awful that our children, should anyone be able to afford to have them, won’t want to stay here anyway.

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Private not public pensions are the problem

By Katherine Teale - 4th July 2011 4:17 pm

Do you understand all the arguments over public vs private sector pensions? I mean, REALLY understand  them? Me Neither. Nor, it turns out, does our esteemed cabinet minister for pensions, Francis Maude, who appeared on the Today Programme this week without doing his homework.

Unluckily for him, his interviewer had, and pointed out that Maude’s supposed quotations from the Hutton report about public sector pensions being “untenable” were in fact made up. If listening to a Cabinet Minister absolutely flounder will brighten your day, then listen to the last few minutes of this.

Note to self, Mr Maude - the next time you appear on national radio (which may not be for some time) it is generally a good idea to have some idea what you’re talking about.

So argument rages - are public sector workers really getting more than they deserve?  Figures of average public sector pensions are flying around the internet - £5,000 to £6,000 seems to be the consensus - but this may be skewed by the number of part-timers. And there is no comparator from the private sector, since the data is not easily available and there are so many different systems at work - including many people with no pension at all.

What is obvious is that many in the private sector get a very poor deal - since the company final salary schemes were scrapped, employees are often stuck with buying  private pension schemes, frequently with no employer contribution at all. The other major difference is the lack of guaranteed income from private pensions, with the payouts depending entirely on the size of the final pot, and not at all on the salary - final, career average, or otherwise.

The so-called competitive market in pensions is one area, at least, where capitalism hasn’t worked to our advantage. Private employers are free to offer terrible pension rights to their employees, who, in a climate of high unemployment, cannot shop around for a more generously funded job.

Nor do customer choices have any influence here - shoppers have no interest in how much pension workers are receiving - hell, most of them don’t even care that the T-shirt they’re buying is made by 6-year-olds in Thailand as long as it’s dirt cheap.

What we know now is that public sector pensions, which have already been extensively reformed under the labour government, are not unaffordable - in fact according to Hutton and the Public Accounts committee,  their cost as a proportion of GDP is projected to fall over the next 50 years. The problem is whether the government chooses to afford them or not and that is a purely political decision.

There needs to be some honesty about this - come clean and admit that this is all about saving money to  reduce the deficit. That’s fine - I’m sure most of us are only too happy to sacrifice our pensions to bail out the banks.

But here’s a novel idea - how about doing something about the terrible state of private sector pensions - surely if anything needs reforming, it’s that.

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