Tom Goodfellow

Tom Goodfellow is a consultant radiologist at University Hospitals Coventry and Warwickshire NHS Trust

Why on earth campaign for more scans?

By Tom Goodfellow - 10th April 2014 11:03 am

The Sunday Times loves to run health campaigns, spearheaded by their two health correspondents. But unfortunately they seem to have a bit of an issue with regard to radiology.

Last summer their story was the inability to get ’scans’ during weekends implying that come lunchtime Friday the entire radiology department does a ‘POETS‘ leaving the MRI and CT scanners to gather dust until Monday morning. The story was illustrated by accounts of medical disasters due to patients not being scanned promptly enough.

Now obviously we already know that patients may be managed inappropriately with poorer outcomes at weekends and no one wants to see this. But in my department scanning takes place 24/7 for urgent cases and it is actually easier to get a not-very urgent scan at the weekend than during the week. This is because the weekday lists are totally overbooked with non-urgent patients to ensure they don’t breach the wretched six week scanning target. We also regularly run routine weekend lists to cope with the backlog.

The ST published a letter which I wrote at that time. I pointed out that while radiology departments are under relentless pressure Joe public perceives the service as free and consequently put huge pressure on their GPs for unnecessary and irrelevant scans and X-rays. The “banged finger/toe/knee six weeks ago, still sore, please X-ray” and myriads of similar requests are well known to all radiologists and must cost the NHS £millions per year. If the public want prompt appropriate access diagnostics then they need to use the service more responsibly.

The latest ST campaign relates to poor cancer outcomes in the UK as compared to elsewhere in Europe. The aims of this are laudable and would certainly merit the support of anyone. However yet again they have targeted radiology and the ability of GPs to get rapid access to diagnostics for their patients.

Many trusts, they told us, are breaching the six week target.

So again I wrote to the ST (published 23 March) and pointed out two things. The first is that the problem is not due to inefficient radiology departments. Most will be able to demonstrate significant increases in productivity over the last decade. But we are simply unable to cope with the inexorable rise in demand for diagnostic imaging. The complexity of scans is also increasing as technology improves.

When I was a lad a cranial CT scan would consist of about ten slices, and it would take about 20 minutes to produce the images. Nowadays you can scan from nipples to knees in one breath-hold and hundreds, if not thousands, of images are generated.

However more important is the fact that even if a patient is scanned within the six week target and the box ticked the scan may well sit in a digital queue for a further six weeks waiting to be reported. There is no target for this, consequently it is not measured and is not therefore regarded as a priority by trust managers.

This came as a bit of an eye-opener to the ST journalists who, in line with the majority of the population, think that the output from a scan is a picture whereas it is, in fact, a considered report from an experienced radiologist. But modern scanners can produce images far faster than we can report them.

I was phoned by each of them following my letter. One relayed a conversation she had had with “an exasperated” but anonymous London radiologist who told her that there was also a significant backlog of unreported plain X-ray images, some of which might show significant pathology. She wanted to know if this could possibly be true. And of course it is! In PACS systems up and down the country there are probably now millions of images which have not been formally reported. A recent unofficial straw poll revealed significant reporting backlogs in 81% of trusts.

On Sunday 6 April the ST published a letter from the President of the Royal College of Radiologists, Dr Giles Maskell (a mate of mine) basically confirming what I had said (phew) and pointing out that the UK has one of the lowest ratios of radiologists per head of population in the developed world. There is little point in the ST campaigning for “more scans” when there are simply not enough people to report them as it is.

We have been highlighting this problem for years but the Department of Health has simply stuck its proverbial head up its proverbial backside. Seventy per cent of all patients accessing healthcare need to pass through a radiology department and we are now a significant blockage in the drive for NHS improvement.

I am now off to my PACS workstation for a gruelling reporting session. And what work will I be prioritising - paediatrics or acutely ill medical patients? No I will be reporting the sore fingers/toes/knees because the GPs are now our paymasters and the trust management requires us to prioritise this otherwise they might send their patients elsewhere and our income would plummet.

It’s a funny old world!

Embedding clinical governance into hospitals

By Tom Goodfellow - 26th February 2014 3:32 pm

Mention the words Clinical Governance to a group of doctors and I guarantee that it will only succeed in generating apathy. Most will regard it as on a par with appraisal, revalidation and emptying your bowels – something necessary to do on a regular basis, but not to spend too much time on if possible.

The very word ‘governancehas a ring of boredom about it and conjures up a picture of men in grey suits, dull meetings, masses of turgid reports and many hours wasted when we could be doing something more useful. Putting the word ‘clinical’ in front of it seems to give it a spurious respectability but the reality is that most doctors think it should be left to the managers and a few geeky clinicians to sort out.

And indeed they do! If you go to the data banks of any trust today you will soon find reams of policies and procedures, governance committees, lines of accountability and individuals with important sounding titles like ‘Governance Lead’ and ‘Head of Patient Safety’. Hours will be spent collecting and collating all sorts of data such as drug errors, trips and falls, hospital acquired infections, clinical adverse events etc. Much of this data collection is a statutory NHS requirement and trust boards are required to review it on a regular basis.

So why is it that many doctors do not appear to take CG more seriously? I think the answer is that although the processes may look good on paper many doctors have little confidence that the system will actually result in organisational change. To give a straightforward example they may discover that the ward staffing levels are unsafe. But when they raise it as a ‘Clinical Adverse Event’ reported through the rather cumbersome DATIX system (which many use) nothing seems to happen and no one takes any notice. We can all think of multiple similar examples throughout the NHS.

The consequence of this is clinical disengagement which was one of the main conclusions of the Francis Report into the Mid Staffs debacle.

Interestingly the recent Kennedy Report highlighted something similar. For the uninitiated, this report is a review of the response of Heart of England NHS Foundation Trust to concerns about Mr Ian Paterson’s surgical practice. Report author Prof Sir Ian Kennedy - who also famously chaired the inquiry into the Bristol heart surgery scandal in the 90s - makes a series of recommendations.

When doctors raised clinical concerns based on robust audit data they were ignored for years. When finally the trust management took action they went down the HR route (personal conduct) rather than the clinical route. Consequently immediately everything to do with the matter was cloaked in confidentiality so that the doctors involved had no idea what, if anything, was happening.

However I believe that Clinical Governance is something that is of fundamental importance and that all doctors should be actively committed to the process. If it doesn’t work then it behooves us to find ways to make work. Ignoring the issue or leaving it to others is simply not an option.

In a recent thoughtful blog Anton Joseph highlighted that there is little confidence that appraisal and revalidation will identify poorly performing doctors. From my own experience I know this to be true. But my contention is that if clinical governance is deeply embedded in the culture of a hospital and that all clinical and managerial staff are committed to it then there is a good chance that bad clinical practice or a poorly performing doctor will be exposed before too much damage is done. Robust data collection from multiple sources will allow a vigilant governance team to triangulate information and highlight concerns.

Here I must declare an interest. I have recently started working (in my own time) as an adviser to the Clinical Governance unit of Capsticks, a large legal firm specialising in health and social care. Working in conjunction with a highly experienced group of associates (medical, managerial and nursing in both primary and secondary care) the unit provides a variety of NHS organisations with assessment, support and training for both corporate and clinical governance issues.

The aim is not just to wag a finger at the clients telling them what they are doing wrong (which they probably already know), but to actively work with them to find solutions. The NHS tends to wait until disaster strikes before acting, but surely it is far better, and ultimately cheaper, to be far more proactive with regard to governance. Fire prevention seems a better way rather than belatedly calling the fire engine once the house is ablaze.

For me, the work I have done so far has been both challenging and highly educative. All good clinical staff have a passion to see things done better, and the quality and governance agendas should go hand in hand together. I can sense a bit of missionary zeal rising in my soul.

The NHS world has changed since Francis and Kennedy. We need to change with it.

Passive smoking should be reserved for midges

By Tom Goodfellow - 20th February 2014 12:44 pm

It was in the mid 1950’s when, as a child, I went with my parents to visit family in Scotland. We went for a drive into the highlands to view the beautiful lochs and the heather-clad mountains. However in the late afternoon we suddenly found ourselves surrounded and attacked by myriads of midges (if you have ever had a similar experience you will understand and sympathise).

We rushed back to the car which was also infested, but my parents had a simple solution. The windows were closed and they both lit up. Soon the car was filled with thick pungent cigarette smoke which had the desired lethal effect on the midges.

As a young child I was perfectly used to this. Both my parents (Second World War generation) were heavy users of the weed, my father at least 30/day. In those days smoking was socially and medically acceptable and large numbers indulged in the habit. I noticed on a recent TV drama set in the fifties that the hansom doctor was also a smoker.

Our home was always filled with a dense fug and the rooms littered with ashtrays. Cups of tea (we used cups in those days) were always an excuse for a smoke and a gossip, and the saucers would be filled with stubbed-out fag-ends. The memory of this still revolts me.

I was never a very active child and suffered from regular chest infections which would persist for weeks at a time. My mother, while puffing away, would express surprise that I was still coughing and would take me to the GP. Of course in the waiting room at least half the patients would light up while waiting for their appointment. But in those days the connection between childhood chest disease and passive smoking had not been made.

Statistically I should probably have taken up the habit myself, but in fact as I grew older smoking came to revolt me. It was not until I left for medical college, and began to breathe fresh air, that I came to notice the stale stench of old smoke when I returned home to visit. At college I came to learn of the links between smoking and lung cancer, first described in the famous paper by Doll and Hill published in 1950 in the BMJ.

In subsequent years the risks associated with passive smoking became clear and in 2002 the International Agency for Research on Cancer published a report suggesting that regular exposure to passive smoking increased the risk of developing lung cancer by 20 – 30%. As a result of this a ban on smoking in public places was introduced throughout the UK including bars and clubs in 2007.

I remember at that time listening to a discussion on this on Radio 4’s Any Questions programme. I immediately rang the associated programme - Any Answers - and was broadcast having a live discussion with David Dimbleby. My point was that, while I was very sympathetic towards bar staff who had to inhale other people’s smoke, what about the children of smokers? Bar staff had a choice: children did not!

Perhaps someone took note because on February 10 this year Parliament voted to ban smoking in cars if children are present, recognising that smoking is a significant cause of paediatric chest disease, a fact which I have known instinctively since childhood. This vote empowers but does not compel the government to act but at least is a step forward. Although logical it would probably be impossible to ban smoking in the home, but at least parents could be encouraged to pop out into the garden for a drag rather than poisoning their children.

I regularly perform image-guided lung biopsies and am always touched by the gratitude shown to me by the patients who come in terrified at the thought of someone sticking a large needle into their chest, and go out relieved that the procedure was so simple and painless. Nevertheless the results of the biopsy generally determine their fate.

Two years ago a very close family member developed an acutely painful shoulder. She had been a nurse, the largest group of persistent smokers today, and had smoked since starting training. She was treated ineffectively for a frozen shoulder until an x-ray finally revealed a destructive lytic metastasis in her humerus from a small, but highly malignant, lung primary. Her final six months were not pleasant.

I hate smoking!

Baffled by first step on to medical ladder

By Tom Goodfellow - 2nd January 2014 1:06 pm

To this day, I have no idea how I managed to get a place in medical school! I suppose that as a Christian I should claim divine providence, but I am not that super-spiritual being more of a “God helps those who help themselves” type of person.

Now don’t get me wrong – I believe that I was well suited to medicine and have been a good doctor with a happy and successful career behind me. I still get a buzz out of draining a horrendous pelvic collection resulting in a grateful patient and happy surgeons.

I enjoy the expression of relief on the face of a terrified patient who did not actually notice that I had both started and completed the interventional procedure without causing any pain or distress.

But how I got onto the ladder in the first place still baffles me, and the reason for my confusion is simple – I was a grammar school boy and not from a prestigious public school.

Back in the sixties that mattered a lot; more than 80% of my year were public school educated (and only 10% were female). The ability to play rugby was an advantage, and having a father in the profession also counted so I failed to impress in every respect. An individual with these qualifications did not necessarily need to be a high academic achiever and reasonable A-levels were adequate rather than the multiple A*’s which seem to be required today.

(My own grades were less than stunning – not because I was not clever enough but because I did not learn how to learn until I started university.)

But the public school lads had a swagger and confidence about them which carried them through the interview process with ease. They were well coached in the social graces and not afraid to express an opinion. You could almost hear the professors on the interview panel mutter that the candidate may not have been the brightest flower in the forest, but he was the right sort of chap, a good prop forward, “and anyway I was at school with his father”.

I, on the other hand, was quiet and rather mousey. I had no great achievements and my only claim to fame was that I once had a leading role in an amateur production on the Edinburgh Festival Fringe. But I passionately wanted to be a doctor from childhood. A favourite uncle was a GP in a small town in Scotland with the surgery attached to the house.

Happy summers were spent exploring the surgery (when not being used), playing with the stethoscopes and sphygmomanometer, and I can still smell today the disinfectant in the jars containing the re-usable needles for suturing.

My own interview was a disaster! I stuttered and mumbled, and was generally very poorly prepared. When asked why I preferred surgery to medicine I remarked naively that I wanted to help people, at which point the whole panel guffawed. I must have seemed hopelessly out of my depth and left the room flushed with embarrassment and a sense of hopelessness.

Nevertheless several weeks later a letter arrived from the university admissions board offering me a place at the London Hospital Medical College to start in autumn 1967 and the rest is history.

Of course it has all changed today and the selection process purports to be much more robust and fair. I read with interest Caroline Whymark’s recent piece on the selection of medical students in Glasgow.

When I started my training I initially felt quite intimidated by and socially inferior to the large cohort of public school lads in my year. But as time went on they became my mates and all differences fell away as together we faced the challenge of the examiners and house jobs. By and large we all made the grade whatever the inequalities of the selection process.

However I have one darker secret to reveal. My mother, a nurse, was acquainted with one of the senior consultants at the London. I do not know for sure but I have a suspicion that she contacted him and asked him to put in a good word for me. If true it would be a quite disgraceful example of inappropriate patronage, but I will never know for sure.

A trip to a CQC-inspected GP practice

By Tom Goodfellow - 12th December 2013 11:32 am

He set out at 5am hoping to be at the front of the queue, but others clearly had the same idea and there were at least a dozen ahead of him. He had requested an appointment over five weeks ago and this was the earliest they could fit him in.

The morning was cold with a bleak easterly wind and slow steady drizzle of rain.

The surgery doors opened at 8.30am by which time the queue stretched round the corner and into the car park where sat the doctor’s gleaming new BMW. The patients pushed and jostled their way into the waiting room, at least those who could get in, the rest huddled under their umbrellas and the occasional bin liner.

When he reached the desk a brisk receptionist stared pointedly at a computer screen for several long minutes before appearing to notice him. “Name?” “No, I am sorry you are not on the doctor’s list. You will have to make an appointment and come back another day.”

He protested that he did have an appointment and produced a ticket to confirm this. The receptionist wrinkled her nose and clattered away on the key board. “We have had a new computer system recently,” she remarked, somehow insinuating that this was his fault, “but I will try to fit you in. The doctor is very busy you know.” He muttered his gratitude.

The waiting room was dirty and the floor littered with empty crisp packets and crushed polystyrene cups, strange since it was clear that the coffee machine did not work. The few chairs were occupied, but fortunately he had brought his own collapsible stool which he perched on in the corner.

This gave him a grandstand view of the consulting room and the adjacent treatment room, neither of which had a door. There were piles of rubbish bags on the treatment room floor some of which were overflowing, and even from where he sat he could detect a faint but rather unpleasant aroma. Despite the chill of the morning a few angry flies were buzzing around the bags.

His attention was quickly drawn to the consulting room where the doctor was loudly questioning an elderly man about his symptoms. “How many times do you have to get up at night and what is your stream like? I am going to have to examine you; lie down on the couch and face the wall”. Fortunately the couch was just out of his range of vision.

Many other consultations came and went, and he was surprised at how mundane were many of the complaints, nothing like the cases he regularly watched on the TV. “So you are feeling a bit low,” boomed the doctor to a young woman with a baby in arms and two other snotty kids hanging on to her skirt. “Has he left you again?”

After what seemed like an eternity his name was called and he gingerly entered the consulting room. He stated that he was sorry to bother the doctor but he wanted a flu jab. The doctor looked surprised and went to a cupboard in the corned. He pulled out a few vials, blew the dust off them and squinted at the fading labels. “This should do the trick,” he muttered, “it’s last years but waste not want not. Bend over the table and drop ‘em”.

The consultation over, he pushed his way through the still crowded waiting room to the door reflecting just how grateful he was for our wonderful NHS, free at the point of delivery.

P.S. I wish to emphasis that this does not resemble my own excellent GP surgery in any way!

Am I the only one tiring of Mandelamania?

By Tom Goodfellow - 10th December 2013 11:16 am

Breaking news - ninety-five year old chronically ill man dies and the whole world is in shock and mourning.

I am sorry but this is going to be a bit of a rant!

Please don’t get me wrong; I respect the memory of Nelson Mandela as much as anyone and his achievements will live long after him. But the gross media overkill in reaction to his death is grotesque and vulgar IMHO. It is the Princess Diana syndrome all over again with vicarious grief and false emotions; Mandelamania to coin a phrase!

When the long-expected news of his death was announced it was as if a button had been pressed, and immediately all the news channels switched into Saint Nelson mode. Much, if not all, of the output had clearly been prepared well in advance (well it was hardly unexpected). Since then we have had almost wall to wall, blanket coverage of every single detail. It seems that anyone who ever had a conversation with him or interacted with him in any way merited an interview to tell us just how wonderful a man he was.

World leaders are quoted expressing their great sadness at his departure. The Radio4 Sunday morning church service was re-located to St. Martin’s in the Field in honour of the great man. The ABof C himself delivered the oration, and I was interested to note that it was at least five minutes into the service before God was even given a passing mention.

His life story has been told and re-told again and again. There are endless shots of his cell on Robben Island with various dignitaries peering in and looking sorrowful. His “walk to freedom” has been shown so many time I know it off by heart. Everyone who is, or who has been, anybody has been interviewed hoping that some of the Mandela fairy dust will fall on them.

For me I think the lowest point was reached when Justin Webb on the Radio4 Today Programme suggested to an interviewee that Mandela had been compared by someone to Christ!

But we all already know his story; we have heard it many times before, and a very remarkable story it is too. So why does it need to be told again and again? During his life he was celebrated and feted, given every honour known to man and elevated to super-stardom. All the great and the good were falling over themselves to be photographed with him although to his great credit he managed to keep the common touch.

But what really offends me is his medical management. If he had been my granddad, and clearly as sick and frail as he seemed, I would have wanted him to be tucked up in a warm bed as the family gathered to say farewell.

Instead, because he is Mandela, he is rushed to hospital and put in the intensive care unit where no doubt he would have had the full panoply of modern medical treatment and technology. I don’t know for certain but, given he was in respiratory failure due to chronic chest disease, he would have been ventilated probably with a tracheostomy, all deeply inappropriate given his age and condition.

Rather than allowing him to end his time peacefully, full of years and wisdom, his life is stretched out to the last bitter extreme while his descendents squabble over his legacy and whether or not they can make money out of “brand Mandela”.

The ANC Party which he has left behind is hardly a paragon of political virtue despite their attempts to cloth themselves with the Mandela mantle.

Personally I find the whole spectacle deeply unpleasant. It is as if, with Christmas approaching, the world needs a secular saint to make them feel good about themselves.

And we still have six days of the funeral to endure. Spare us!

Laws and targets will not stop NHS cover ups

By Tom Goodfellow - 26th November 2013 11:12 am

“You must be open and honest with patients if things go wrong. If a patient under your care has suffered harm or distress, you should: A. put matters right if that is possible; B. offer an apology; C. explain fully and promptly what has happened and the likely short-term and long-term effects.” (GMC Good Medical Practice, paragraph 55)

I am very glad that the Secretary of State has listened to reason and dropped plans for doctors to have a legal duty of candour to report poor care.

This requirement is already clearly defined by the GMC in GMP, and further enforced in the guidance, Raising and acting on concerns about patient safety (GMC March 2012). It is incumbent on all doctors to take this very seriously. But inevitably the various campaigning groups are furious preferring a big legal stick to hit us with.

Unfortunately they miss the obvious. If a doctor is behaving professionally then he or she will be conscientious in following the guidance. But if they are not behaving professionally or if there are other external pressures then they are unlikely to comply, even if there is a big legal stick!

When mistakes are made or things go wrong the natural human instinct is to cover up; this is as old as human nature. In the Garden of Eden, after things went wrong with the serpent, the story states that Adam and Eve came suddenly to the realisation that they were naked i.e. exposed. They then proceeded to cover their nakedness with fig leaves to try to hide their shame from God – a rather futile exercise! Whether or not you believe the Bible the psychology is spot on.

If doctors are found to be covering up, and the MPTS Fitness to Practise panel decision reports make very salutary reading, the consequences may be very severe indeed.

But it is not just individuals who cover up, hospitals can do the same and also other public institutions which are target driven.

I know I am always banging on about targets and how much I hate them but command and control target-driven performance management does not work – it merely drives dysfunction and cheating into the system. And what is the point of putting a numerical value on a system (e.g. the four hour A&E target) when it has no relationship to actual outcomes? “A time measure should only be used where time is critical to the purpose”.* The outcomes for a visit to A&E are many and varied; how long you spend in the place is largely irrelevant to this.

St Paul in his thoughtful and eloquent letter to the Church in Rome sums up the problem perfectly.

In essence he states that a law or target, whether it is human or divine, can define the requirements, boundaries and limits of behaviour. It may also, to some extent, reduce and control wrongdoing. But what it cannot do is make people good; that requires a change of heart. The thirty miles per hour speed limit is a perfect example. We all know what the law states, but which one of us does not regularly exceed this provided there is no speed camera or policeman watching.

In the current NHS climate cover ups will continue, and individuals and organisations will search frantically for fig leaves when they are about to be exposed. Surely there must be a better way?

* J Seddon, Freedom from Command and Control, VanguardConsulting Ltd.

The day I outscored a Welsh rugby legend

By Tom Goodfellow - 4th November 2013 11:44 am

As a radiologist I am obviously an FRCR. However, as it happens, I am double qualified being also an FRCS (England) although not in active membership.

In those days, entrance into the hallowed halls at Lincoln’s Inn Fields as a Fellow depended on passing parts I and II of the entrance exam, each very rigorous with a high failure rate, and many needed multiple attempts to get through. I don’t understand how the system works today or if the same rigour applies. I hope so!

Part I required a detailed knowledge of anatomy and physiology and I was thoroughly prepared for this having attended the private Sloane Stansfield course run by two aged professors, both ex-royal college men. I also spent a couple of terms as an anatomy demonstrator at my alma mater The London Hospital. I don’t think they have anatomy demonstrators any more – I recently sat a medical student in front of a chest x-ray and spent about ten minutes trying to get him to correctly identify the large structure occupying the space between the lungs.

Part II was a different matter consisting of a written paper, an MCQ (I think) and, most challenging of all, the viva voce which included the clinical examination of patients wheeled in for the day.

I did all the theoretical textbook stuff but my main preparation for the written exam was a conscious attempt to make my handwriting legible (sadly a temporary achievement). It obviously worked because I was invited to attend the clinical part of the exam.

On the day we were processed in batches of ten. My team included the Welsh rugby icon J.P.R. Williams easily recognisable by his long sideburns (although I cannot comment on whether or not his socks were round his ankles). We were made to wait our turn in various anterooms marked by the smell of sweat and fear before a fairly savage grilling by the examiners.

But, as with many things in life, success or failure depends on careful attention to detail in small things and I had been given good advice by my tutors.

I was asked to examine a man lying on his belly with his backside exposed. He had a number of complex fistulae opening in the region of his natal cleft. I poked and prodded for a minute or two then the examiner asked me what I thought the diagnosis was. I did not fall into the trap, but asked politely if I could first turn him over and examine his groins. This was obviously the response he was looking for and I was immediately whisked away and told to examine a lady with a lump.

Again I was prepared! I stuck my hands out in front of me like Oliver Twist asking for more, and humbly requested that could I please wash them before examining the lump. The examiner’s smile was positively beatific and he personally led me to the sink and handed me a towel. The other cases have long since vanished from memory, but I was hopeful that these two episodes might just tip the balance in my favour.

At the end of the day all the candidates congregated in the main entrance hall of the college clutching a card recording our individual three figure identity number. After a nerve-jangling wait a college official appeared and read out, one by one in sequence, a list of the numbers of those who had been deemed worthy of higher calling, and omitting those who were not. If your number was called you went forward and were ushered into a reception room. If your number was not called you bowed your head and slinked away.

It was a cruel business and I had to watch my good friend Robin slink away with many others. Then finally, with total disbelief on my part, my number came up and I shakily mounted the Elysian steps. Once all were gathered in the reception room, a relatively small number, the examiners arrived and after a short congratulatory speech they applauded us; a nice closing touch to a very stressful day.

Unfortunately I had chosen a job which at that time had a severely bottle-necked career structure. There were just too many middle grade registrars chasing far too few senior registrar posts, and unless you were perfectly placed (i.e. the professor’s blue-eyed boy) then there was no way forward.

I had been doing a research year at The Royal Marsden and worked alongside a cheerful American radiologist. He too had trained as a surgeon and had worked in a MASH in Vietnam. He returned home at the end of his time and decided that he wanted to remain sane, married and alive, and made the decision to retrain as a radiologist. He never regretted this, and I decided to copy his example. After all, to slightly misquote a former RCR President, “interventional radiology is surgery down the tubes.”

I too have never regretted my decision and curiously the RCR has recently relocated to Lincoln’s Inn Fields just across the square from the RCS. Just how uncanny is that.

And, just in case you are wondering, JPR failed to score on that occasion. Perhaps he forgot to wash his hands! But he has more than made up for it since.

Here’s a particularly painful clip for all England fans - Ed.

Mental health: balancing community and hospital

By Tom Goodfellow - 21st October 2013 9:36 am

Many years ago when I was a fresh-faced medical student I did a six month psychiatry attachment. This included a four week residential stay at Claybury Hospital, one of the huge Victorian psychiatric units on the edge of London.

It was a spectacular Victorian building complex with a magnificent water tower which dominated the site, and at its height the hospital housed 2000 pauper “lunatics” (to use the historical terminology).

The main corridor was huge, very wide and more than half a mile long with wards opening off each side. During the day it was thronged with patients (at least those who were allowed to throng) wandering aimlessly up and down. Indeed it was so long that a bicycle was provided for the resident on call psychiatrist to reach the wards at night, although when I was there both its tyres were flat; possible let down by a disconsolate patient.

We were required to fully participate in the therapeutic activities of the ward we were assigned to, and if you have ever watched the film, One flew over the cuckoo’s nest, you will know what I mean.

I remember a group therapy session where we all sat in a circle with the patients and staff. After about 20 minutes of us all sitting around in silence and trying to avoid eye contact the sweet manic depressive lady spoke up and quietly confessed that the previous day she had been propositioned by the hospital chaplain, a fresh faced young curate who was sitting next to her, and had had sex with him in the hospital chapel.

This revelation was received in total silence; nobody reacted in any way including the chaplain. I just stared at the floor. Neither he nor the lady was challenged as to the veracity of her allegation and in those days of my innocence I was sure she was fantasising. But following the many recent revelations of sexual impropriety in the 60’s and 70’s who knows? Not a single word was uttered for the rest of the session, and her confession hung there like a lurid helium balloon whose owner has let go the string!

But the most memorable episode was the drama therapy session. We were put into pairs, and the scenario was that we had to take turns in curling up on the floor in the foetal position. Then your partner had to find ways to “open you up” and restore you to normality (I am sure it was all very therapeutically meaningful).

I was paired with a young woman who was a psychopathic pyromaniac detained on Her Majesty’s pleasure who the psychiatrists were already considering committing long term to Broadmoor. She went first and I spent a fruitless ten minutes trying to open up even a finger as she held herself ridged on the floor.

Then it was my turn. I curled up tight, but was rather worried by the venomous expression on her face. It took me about one nanosecond to decide that having my head (or even more sensitive regions) kicked in by a psychopath was probably not the best therapy for either of us. So I jumped up with a quick “sorry, you win” expression on my face. She was clearly disappointed, and the drama therapist furious presumably at being denied a bit of a spectacle.

Claybury Hospital was finally closed in 1997 and converted into private residential dwellings, unlike most psychiatric hospitals which were either demolished or left to fall into decay. Indeed photography and ghost hunting in such ruins has quite a following.

However the move towards less hospitalisation and care in the community for mental health patients has had both positive and negative consequences. Indeed the reduction in available beds for the very sick has tipped the service into crisis according to Dr Martin Baggaley, Medical Director of the South London and Maudsley Trust.

This means that patients are at risk of harm themselves, but also that the public are at risk from severely disturbed psychotic individuals who should be in hospital. Indeed it is suggested that 900 mental health homicides have taken place since 1993 although I have no definite reference for this figure.

I am a Trustee of a mental health charity, ASSIST Trauma Care. At present the organisation provides support and therapy to the families of homicide victims in England and Wales working for the Ministry of Justice. Over a three year period there have been about thirty mental health homicides referred in, many of these are psychotic sons murdering their mother (presumably because the rest of the family have long since washed their hands of the disturbed boy). They are deeply tragic cases for all concerned.

Mental health care is frequently described as the Cinderella of the NHS and the service provided by ASSIST is also significantly under-funded. In these days of austerity it is important that is not squeezed to destruction.

No evidence of radical NHS re-think by politicians

By Tom Goodfellow - 26th September 2013 9:28 am

Political conference season plods on its weary way with occasional bursts of entertainment such as UKIP’s “slutgate” story, while the Lib Dem conference passed largely unnoticed (can you remember anything that was said?)

On Tuesday morning I was entertained by listening to Ms Harridan Harman on Radio4 opining on HS2 - the proposed high speed train link. “We need to do a cost benefit analysis. That is we need to find out the anticipated cost then work out what the likely benefits are (sic)”. Well thank you for making that so clear! There is nothing like being patronised by a politician first thing in the morning to set you up for the day. Why does she always sound as if she is talking to a class of naughty five year olds?

One of my second cousins is currently the General Secretary of the Labour Party (well somebody has to do the job), and his charming wife is head of communications at the MPS, so I had better be careful what I say. But I listened to Ed Miliboy give his set-piece conference speech and frankly a more vacuous, cliché-ridden load of old tosh would be hard to imagine.

In my view it was pure populist drivel peppered with various sweeteners in an attempt to attempt to bribe the electorate. In the interests of political balance I should state that I am expecting much the same from David Cameron next week. Politics is now to do with presentation not substance, and Labour’s “One Nation” slogan seems a little hollow with the vote on Scottish Independence less than a year away.

Miliboy’s “show stopper” was his announcement that he will freeze energy prices for 20 months immediately after he is elected. I am not expert enough to know whether this is a good or bad idea. On balance the pundits seem to think it will be bad because of the law of unintended consequences. But what it worryingly shows is a desire to return to top-down, command and control, political micromanagement. This, in my opinion, is what has contributed to the current wretched state of the NHS.

This of course brings me to Miliboy’s comments on the NHS. Apparently he is going to rescue it from the Tories (wild clapping, foot stamping and cheering from the audience).

There was lots of rhetoric about the dreadful mess the Tories have created (probably true), and he was also very critical of the “name, blame and shame” culture against doctors and nurses, ignoring the fact that this reached its pinnacle during the Blair years.

But Ed, what exactly are you going to do to “rescue” the service? Any politician can get a cheap cheer by saying the NHS is “safe in our hands” and no doubt Cameron will say something similar next week. But what are you actually planning - do you have any actual policies?

You could, of course, scrap the Health & Social Care Bill and introduce yet another fantastically expensive NHS reorganisation. But I doubt you will. You might get rid of competition in the health service, but Blair spent seventeen years building it up, standing on the shoulders of Margaret Thatcher. So I suspect you will find it hard to swim against that particular tide.

The problems facing the NHS are immense and highly complex. What is needed is radical systems re-thinking not party political sloganising. Sadly I see little evidence of this in any of the parties, and none of them are brave enough to think the unthinkable, let alone speak it.

Perhaps UKIP will hold the balance of power in the next parliament and join a coalition government. Then we might get beer swilling, fag smoking Nigel Farage as Health Secretary. Now that would be interesting!