Tom Goodfellow

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

Reflect on today’s events as well as WWI

By Tom Goodfellow - 5th August 2014 9:36 am

On my desk before me is a photograph entitled ‘4th Seaforth Highlanders returning to the front’. It shows a group of civilians and soldiers in Highland army dress standing before an iron railway bridge in the station in the Scottish town of Dingwall, Ross & Cromarty (as it was in those days).

Among them is my grandfather, Private Daniel Alexander MacKenzie number 393, with my grandmother Ada beside him and two of my aunts as small children. My mother had not yet been conceived. The date is November 5th 1914. I know this because I have located some of his military records which show he was on the expeditionary force at that time, returning home on December 8th 2015.

I understand that the regiment returned to the front a second time in 2016 but I do not have the details. Fortunately he survived (obviously otherwise I would not be here) but he never spoke about this to me as a child so I have no stories to relate.

As the world remembers the one hundredth anniversary of the start of the First World War and the sixteen million dead this picture holds a deep poignancy for me. Interestingly the iron bridge is still there but the station is now a Christian bookshop.

During the Second World War my father (not a doctor) was a lieutenant in the Royal Army Medical Core of the 157 Field Ambulance which was part of the 52nd Lowland Division.

I have the history of the Division and it makes fascinating reading. My father always joked that they were trained for some years in the mountains of Scotland, and were then landed in the flat lands of Holland!

However, he told me nothing else, either as a child or as an adult. In addition to the job of rescuing the wounded I think they also has to retrieve the dead. It was clearly very horrific and I suspect he suffered to some extent from what we would now call Post Traumatic Stress Syndrome. It is said that 2.5% of the world population perished as a result of that conflict.

But as the world remembers the events of one hundred years ago it seems that so little has changed. The last century held two brutal world wars but also other wars almost too numerous to mention. This century, in its first fourteen years, seems little different. We have had Iraq, Afghanistan, and many other horrific conflicts which are on-going.

All caring doctors will be appalled at the deeply distressing images emerging from Gaza as ill-equipped hospitals try to cope with the tide of casualties, many of them women and children. But we are also aware that the issues on both sides are complex and historical with individuals arguing passionately on each side of the case, which is true of many of the other conflicts. The devastation of Syria has dropped off the news headlines, but the death and destruction continues unabated.

We meditated on this in church today. The Christian faith is not sloppy and sentimental about these things. “Peace on earth and good will among men” is NOT the message given by the angels announcing the birth of Christ to the shepherds – that is a completely blatant misreading of the scripture and suited only for silly Christmas cards.

On the contrary Christ himself stated, “You will hear of wars and rumours of wars.” “Nation will rise against nation, and kingdom against kingdom.” “There will be famines and earthquakes in various places. All these are the beginning of birth pains”. Matthew 24.

Ebola is rampant in parts of Africa, and drug-resistant TB and malaria are becoming an increasing problem both in countries where they are endemic, but also here in the UK among the immigrant communities.

The previous Archbishop of Canterbury, Rowan Williams, has announced that there is a developing famine in South Sudan which will likely affect four million people. This is because they have not been able to farm their lands due to the on-going conflict.

There has been an earthquake in China this week!

The world has never been more uncertain and modern communication brings this right into our living rooms.

There is much to reflect on as we remember the anniversary of the commencement of WW1.

Assisted dying debate has been irrational

By Tom Goodfellow - 21st July 2014 10:21 am

Forty years ago, when I was a very junior houseman, a young man was admitted for surgery to remove a large malignant bowel tumour.

Post operatively he did very badly with an ileus which persisted for several weeks, dehiscence of the wound and a leaking bowel fistula. Finally, in desperation at the lack of improvement, the consultant performed a laparotomy (no CT scans in those days) and discovered that he had galloping cancer; his whole abdomen was infiltrated with tumour and faeculent fluid.

On return to the ward the consultant simply muttered, “Don’t let him wake up”. I then witnessed the surgical registrar and the senior ward sister administer a whopping dose of opiate. The young man never woke up and quietly died within twenty-four hours. That is how things were done in those days.

This was medical euthanasia, although I would maintain that it was in fact good compassionate medicine and within the law. It was accepted in those days that the administration of large doses of opiates to relieve terminal suffering was acceptable, even though it hastened the patient’s death.

I regularly witnessed similar practice when, a year or so later, I worked at one of the well-known cancer hospitals.

But things seem more complicated these days so let me relate a different case.

Several years ago the elderly father of a friend developed severe progressive dementia. He was cared for initially by his wife with family support. However increasing age and infirmity of both necessitated his admission to a care home.

After some months in the home he became unwell and, as seems to be routine practice these days, an ambulance was summoned and the old man admitted to hospital.

After a few days of IV rehydration and antibiotics he had recovered sufficiently to be discharged back to the home. However the severity of his dementia meant that he had no quality of life whatsoever and he required total care.

Over the next eighteen months this scenario was repeated five times. On the last occasion my friend was informed of the admission and managed to get there in time to discuss with the admitting team the appropriateness or otherwise of continuing active treatment. It was agreed that the old boy should simply be kept comfortable and he quietly passed away after a couple of days. The ‘old man’s friend’ had done the job.

In my view my friend was right to intervene; the treatment administered during the previous admissions was completely inappropriate given the clinical context. But it is difficult to blame the hospital doctors – in a busy emergency department such judgements are not always practical or possible. The real mistake was the 999 call summoning the ambulance.

Had the GP, in conjunction with the family and the home, made a proper care plan then the old man could have had a quieter and more dignified end in his own bed.

On Friday 18 July, their Lordships debated Lord Falconer’s assisted dying bill. I don’t want to rehearse all the various arguments other than to say that, in my opinion, to ignore the strong views of many disabled individuals and groups would seem to me to be foolishness in the extreme. I also think that the well-known adage ‘hard cases make bad law‘ is totally apposite in this case.

But the clincher, in my view, is the ’six months’ prognosis. Any sensible doctor knows that that is daft!

But it seems to me that society is confused and divided on this, and I accept that these issues are very complex. We spend ever increasing resources on investigating and treating a patient whose life is clearly coming to an end while vociferous groups are campaigning for assisted suicide and euthanasia.

These days it seems impossible for many to die without having multiple investigations, and I witness this on a daily basis as frail elderly folk or the terminally ill are wheeled in for yet another scan which will make no meaningful difference to the outcome.

This week, during a busy ultrasound list, I was asked by a junior if I would urgently scan a patient with acute kidney injury. I normally agree to such request on the grounds that it may significantly alter acute management. However the patient they wheeled in was a demented 92-year old! My report simply said, “92-year-old kidneys”!

These days it seems that every confused elderly patient brought in by ambulance will have a cranial CT scan on the rational that “we might miss something” or “please exclude a ….”, and every patient with mild SOB will have a CTPA to exclude a PE. There seems to be little joined up diagnostic thinking.

Please don’t get me wrong. Of course I fully support appropriate investigation of patients, irrespective of age and infirmity, but the emphasis is on the word “appropriate”!

There does need to be a discussion in our society around the end-of-life issues, but I am not convinced that the debate so far is rational. It seems to me that the case supporting Lord Falconer’s bill rested heavily on emotion and “hard cases” rather than rationality.

We are told that 69% of the population support assisted dying but then 60% would like to see the re-introduction of capital punishment! Should we go with the crowd or what? Those who oppose the re-introduction of the death penalty do so because they believe it is wholly wrong in principle, and those opposed to assisted suicide do so on the same basis.

Of course the assisted suicide bill is completely different from the case I described initially, but I for one would be deeply unhappy if our society chose to choose the slippery slope of assisted dying. Instead let us find a middle way of protecting the vulnerable while not striving officiously to preserve poor quality life at all costs.

“Thou shalt not kill; but needst not strive officiously to keep alive.”

Beware of the old man in a hurry

By Tom Goodfellow - 30th May 2014 11:35 am

The day finally arrived! On May 10th I officially became a SENIOR CITIZEN (or aged parent as the kids call me). We celebrated with a very nice family dinner which I somehow ended up paying for. Plus ça change! However the State pension has started arriving in my bank account so in a strange sort of way I feel richer despite having to pay 40% tax on it.

My birthday fell on a day when I was not at work so I was spared the indignity of balloons festooned over my office door, a Zimmer frame bedecked with tinsel and a bag of Werthers Originals on the desk. Mind you I do not qualify as a genuine Original having no grandchildren with whom to share my sticky toffees.

So there it is – the trust has already received my official resignation letter and on November 30th I sail off into the sunset to get a life for the rest of my life. And none of this zero hours contract nonsense so that I can come back and do “sessions”, i.e. rescue them out of the chasm left by my departure. Over forty year in the NHS is enough for anyone, and in any case I cannot be bothered with this revalidation nonsense.

So six months to go, feet up, gradual wind down as I hand over all my responsibilities while it slowly dawns on them who/what they are losing!

Er…not quite! By some dark twist of fate I suddenly find that all has changed. I am no longer simply the funny old geezer in the departure lounge waiting to check out but in fact I am, once again, in charge! For perfectly legitimate reasons our radiology clinical director had to stand down with zero notice, and I was not exactly run over by my colleagues vying with each other to take his place.

How did they get you to agree to do it you might ask? Well they took me into a basement room, strapped me to a chair and dripped ice cold water onto my bald patch. They then slowly recited the latest Planning Board minutes while waving a copy of Standing Financial Instructions in front of me. I pleaded with them to stop, but it was when they produced a proctoscope and a large syringe that I finally cracked. “I surrender” I screamed, “I will do it”! (Perhaps I have exaggerated a few details but old men are allowed to tell tall tales).

Now my once quiet agenda is becoming steadily filled. Far from dreaming of leisurely cruises and sun-drenched beaches in far flung places I have to attend meetings to discuss important things. I have to think strategy and policy, plans and procedures. When the on call rota has been cocked up I have to sort it and persuade reluctant colleagues to cover the gaps. I have to explain to them up there why the radiology department is failing to keep up with the ever rising demand on our services with no increase in resources. I have to compose conciliatory responses to angry litigious relatives as to why an early lung cancer in a 78 year old life-long smoker was missed on the initial chest x-ray. And much much more!

But there are advantages to this. Firstly I have nothing to lose – a very strong position to be in. I am also very interim while I wait for my colleagues to get their act together and chose a successor. I retire on November 30th come what may and will leave the consequences of my sojourn to others. Then I obviously know the job inside out (having done it before) so, by and large, I know how to get things done, and what to do when you can’t. I can call in many favours because I still have many friends and allies out there. Also it no longer matters too much what I say or do – it is too late to make enemies or play managerial politics.

But lastly I enjoy a challenge, and there can be few things more challenging than a medical managerial role in the current NHS. But, to misquote Enoch Powell, “All medical managerial careers end in failure”. This is because trying to change things in the NHS is like wading through cold porridge. But ultimately all your colleagues get sick and tired of you and it is best to go quietly. (I have known some over the years who have gone on far too long and have reaped the dismal consequences).

But I only have six month left - I am ‘an old man in a hurry’, so beware!

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.