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EDITOR'S CHOICE: Fiona Godlee The world is watching the English experiment BMJ 2008; 337: a953 [Full text]

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As Doctors, What Are We Expected To Do?

Kadiyali M Srivatsa   (29 July 2008)

The ethics of PCT decision-making on funding of cancer treatments

Timothy S Maughan, Joanne Rule   (30 July 2008)

Cancer Waiting Times

Edward J Fitzsimons   (31 July 2008)

The World has turned its back on the "English experiment"

Taiyyab Mehmood   (2 August 2008)

Treating the clock, NOT the patient compromises patient safety

Syed Ishaq Husain, Dr Dipesh H Vasant, FY2 General Medicine, University Hospital of North Staffordshire   (8 August 2008)

As Doctors, What Are We Expected To Do? 29 July 2008
Kadiyali M Srivatsa, GP Woking Send response to journal: Re: As Doctors, What Are We Expected To Do?	If doctors are to take the lead in health care, things could be better,” but you need to understand what are the doctors expecting in return. If the World is watching us, we are not setting a good example because we are more worried about targets than our patients. We must first understand what our job is and take a closer look what our ethics dictate: “Alleviating pain and suffering”. Target-driven practice, cost saving exercise and nurse led practice is certainly making my life as a doctor very uncomfortable. It is unethical to ask patients to book an appointment in the morning resulting in stress and discomfort. I am amazed such atrocities have been allowed to escalate by the so-called noble profession. Our Lord Darzy must know healthcare cannot be like selling apples in a supermarket and cannot be commercialised. He must also be aware that a crowd is the main place for spreading various infections including the ones we have not successfully eradicated from our hospitals. He is passionately pushing forward with his project of building polyclinics, despite pleas to abandon this reform from doctors and patients. I am sure people in the future will have fond memories of his innovation and may even call it “The Bug Chambers of 21st Century”. As a young doctor (25 years ago), I remember discussing with friends about what speciality we should take up. I choose paediatrics because as a doctor you need to be a good at observation, psychology and passionate about children. My good friend took up medicine because he was good in pathology and remembering names (iatrogenic, idiopathic and allergies) and the one lacking common sense, but a good craftsman said he would like to be a surgeon, because he could open someone’s abdomen and see if there exists a problem rather than waste time investigating and offering medical explanation. After all these years, I started looking back to see if I have done anything worthwhile in my life, like saving someone’s life and could whole heartedly say I have cured someone’s illness. Unfortunately, I have not. Medicine does not offer any cure, so why do we need doctors anyway? Computers can may do our better job. I think I am good at supporting a family in grief, and feel sad that it is becoming difficult for me to provide this service due to the barrier created by the NHS reforms. You mention that GPs are allowed to exclude clinically inappropriate patients from target calculations. This is not a simple issue, because we often hear stories that patients who are not listed in our target group have been neglected. There may be one or two such patients but these get buried in the pile of statistics. I think we have forgotten that one day we may be the ones who may be buried in such statistics. I agree with Dr Fiona Godlee’s comment “the continued and costly pattern of redisorganisation caused by too many changes not well thought out.” Doctors, like me, who are innovative and passionately believe in contributing to our society, are shunned (as a pimple on their bum). We don’t disappear, but keep writing to them and trying to get some helps and support. There comes a time when doctors like us will develop fatigue, and the administrators and management consultants selling my service are draining our resources, yet we are helplessly watching these heartless money- hungry, bonus-driven, often failed administrators from the private sector managing health care. After twenty five years of contribution, I now feel ashamed to tell anyone that I am a doctor. For this I must thank the health care reformers and the managers who are making a living selling my passionate dedication and care. They have successfully doomed our profession and are now sending us to the gallows “Polyclinic” where infections spreading by contact (superbugs) will threaten our patients and our very existence. I hope doctors like us will soon wake-up and start working towards preserving our contribution to our next generation. Competing interests: None declared
The ethics of PCT decision-making on funding of cancer treatments 30 July 2008
Timothy S Maughan, Consultant Clinical Oncologist, Professor of Cancer Studies Velindre Hospital CF14 2TL, Joanne Rule Send response to journal: Re: The ethics of PCT decision-making on funding of cancer treatments	We recently co-chaired the Cancer Agenda 2008 meeting with leading cancer clinicians, each of whom is expert in their specialist field. One theme that emerged was the high level of concern about the ethics of PCT decision-making on the funding of cancer treatments. Increasingly, clinicians express feelings of tension between their obligations to individual patients and those to society1, 2. Clinicians are trained to provide the best care to their patients, but recognize that this conflicts with the ability of the NHS as a whole to provide optimal care to all patients with all conditions in a just and equitable way in an economically limited system. In the UK societal responsibility for these decisions is expressed through the work of NICE, the SMC and similar bodies. Clinicians recognize the value and necessity of that work in providing a rigorous framework for these evaluations. The judgments of NICE, however, allow for the use of non-approved treatments in “exceptional cases”. The principle of natural justice supports equity of treatment for all people using cancer services. This is being undermined by different interpretations of exceptionality and the decision to argue for this can put the responsibility - but neither the decision making nor the funding - back in the clinician’s court. We believe that there should be equal access to cancer therapies, regardless of where you live. As this is not the case, we urge that national guidance should be provided to define “exceptional cases” so that there is at least a level of consistency in approach between different geographical areas. We believe that the professional bodies, and this journal itself, should challenge PCTs to show that they have adopted a coherent, cogent and above all a transparent approach to making decisions about the funding of therapies. Such equity is not even theoretically possible without full access to information. Without transparency of information, patients are unable to consider fully their individual options. The vast majority of people want all possible information about their illness and want to know whether treatments are available or not. They want the right information, at the right time, with the support they need to use it3, 4, 5, 6, 7. We believe that informed consent demands openness and honesty in the disclosure of information, as does the respect and trust considered essential for patient-professional relationships8, 9, 10. These issues have been teased out in a paper produced by Cancerbackup’s Clinical Advisory Board and available from that charity. Our concern is about the lack of congruence between the ethics of openness and the lack of transparency and consistency of PCT decision-making on the funding of cancer treatments. We would be interested in hearing other views on the issues raised. Yours faithfully, Joanne Rule Patient Advocacy Adviser Prof Tim Maughan Consultant Clinical Oncologist/ Professor of Cancer Studies/ Director, Coordinating Centre, Clinical Research Collaboration Cymru/ Director, Wales Cancer Trials Unit Cancer Agenda is supported by an unconditional education grant from Pfizer Oncology. References 1 Tauber AI. A philosophical approach to rationing. Medical Journal of Australia 2003;178(9):454-6 2 Beach MC, Meredith LS, Halpern J, Ford D. Physician conceptions of responsibility to individual patients and distributive justice in health care. Annals of Family Medicine 2005;3(1):53-9 3 Cox A, Jenkins V, Catt S, Langridge C, Fallowfield L. Information needs and experiences: an audit of UK cancer patients. European Journal of Oncology Nursing 2006;10:263-72 4 Lawrence Z. Building on the best; choice, responsiveness and equity in the NHS. Health Expectations 2004;7(2):176-9 5 Jenkins V, Fallowfield L, Saul J. Information needs of patients with cancer; results from a large study in UK cancer centres. British Journal of Cancer 2001;84(1):48-51 6 Meredith C, Symonds P, et al. Information needs of cancer patients in West Scotland; cross-sectional survey of patients’ views. BMJ 1996;313:724-6 7 Cancer - a public priority? Attitudes towards cancer treatment in Britain. 2006. IpsosMORI Research study for Cancerbackup available via Cancerbackup web site. 8 Beauchamp TL, Childress JF. Principles of Biomedical Ethics (5th edition). Oxford University Press; 2001 9 Moral and ethical principles in end of life care. Open University http://openlearn.open.ac.uk/course/view.php?id=2494 10 Doyal L. Good clinical practice and informed consent are inseparable. Heart 2002;87:103-6 Competing interests: To the best of our knowledge Pfizer Pharmaceuticals, who provided an unconditional educational grant to support the Cancer Agenda meeting, will not benefit financially in any way from the publication of our letter summarising the concerns which arose at the "Cancer Agenda for 2008" meeting.
Cancer Waiting Times 31 July 2008
Edward J Fitzsimons, Senior Lecturer in Haematology; Lead Consultant West of Scotland Blood Cancer MCN 2002-08 West of Scotland Cancer Centre,G12 0YN Send response to journal: Re: Cancer Waiting Times	'The World is watching the English NHS experiment'(1) raises concern at politically driven initiatives and the targets that may follow. The Cancer Waiting Times Initiative is a prime example of the Editor's justified concern. Cancer Waiting Times define the UK target whereby the maximum wait from urgent referral to the treatment of all cancers will be 2 months(2). The Lead Consultants from the Managed Clinical Networks (MCNs) for all adult cancers in the West of Scotland have together raised their concerns at the clinical cost of the Waiting Times Initiative(3). There is such considerable overlap between the symptoms of benign and malignant disease that many cancer patients do not receive urgent GP referral. Those Trusts then that fast track urgent referrals in an effort to comply with the target do so at the expense of those patients who do not receive urgent referral. The greatest concern however is at the damage the Initiative has done to clinical audit. Effective clinical audit is the single most important means by which we assess the quality of cancer care. Regional review in the West of Scotland has shown that the pressure on audit staff to submit quarterly Waiting Times has adversely affected clinical audit of treatment and outcome. Pressures have increased with demand for weekly progress reports on Waiting Times. Some MCNs are unable to carry out any form of patient followup. Now then is the time to refocus attention on clinical audit rather than Waiting Times. Clinical audit underpins the activity of each Cancer MCN and is the key to quality assurance, service improvement and better cancer care. This must now be the focus of cancer data collection and thereafter Waiting Times the product of clinical audit; not vice versa as currently exists. REFERENCES 1 Goodlee F. The World is Watching the English NHS experiment. BMJ 2008;337:a953. 2 The NHS Cancer Plan. The Department of Health 2001. www.doh.gov.uk/cancer/cancerplan.htm. 3 Fitzsimons EJ, Jones R, Whitford P et al. Cancer Waiting Times: the Clinical Perspective. Scottish Medical Journal 2008; 53, 2-4. Competing interests: None declared
The World has turned its back on the "English experiment" 2 August 2008
Taiyyab Mehmood, Medical Doctor Trainee Surrey, UK/Riga, Latvia (EU) Send response to journal: Re: The World has turned its back on the "English experiment"	Firstly I was not aware the NHS is or, really should say was an "English Experiment. I would say the NHS in Wales,, Scotland and Northern Ireland would be perturbed of a suggestion that the NHS was conjured by the English, and not the British. For I beg to ask what is the medical establishment and so the situation in Wales, Scotland and Northern Ireland? Therefore for sake of clarity and accuracy, one shall refer the "English experiment", being a total misnomer, as the British NHS. This is the first point I wished to bring to the attention to all. I do concur with the author, on the sad fact that the clear continuous every growing ineptness of the health politics that shrouds and handcuffs the NHS and its employees to its whims for voters and so called "political correctness" is totally unravelling the hard work by those who formed the NHS and the enduring loyal staff who are taking for granted to be "slaved" to kept the NHS going since the political internationalists in the early 80s onwards. Then doctors,nurses, midwives and allied health professionals were happy and proud to work for such a service. Then indeed then the world was indeed watching the NHS with envy, and it would not pass me that the Americans across the pond, thought to template the system but make it one above for their capitalist medical system, to the NHS system, that I suppose the former communist states at the time, were envious of the NHS, as former communist professors of mine told me as so in Latvia. Yet very regrettably for us, the British, however far from the truth is so today, where many of them became new EU member states in 2004, and 100s of their doctors flocked to UK with "dreams" to work in a 1st world modern system, only to be disappointed with the system compared to their homelands, many moving on to Norway, Germany, and to USA. This is a fact that perpetuated evidence contrary to what the author feels the world is watching NHS as if on the tethers of great concern. This is foolhardy thinking to say the least. Many Eastern and Baltic Europeans have told me that they see the NHS worse than even their homeland medical system of today. What one has to be aware is the complacency with the NHS is rife, and each and every person can do something - however small, even to make their concerns aware, with no fear or fret of consequence to be open, to reassert the value of the NHS for it to be again the envy of the world, for them to watch it with respect. I am happy the author made reference to Don Berwick and his very valid 10 suggestions, that I hope any humble and progressive hospital administrator in the NHS will take heed to help "coma" NHS from collapse and fall to prey to the capitalist unethical vultures i.e PFI's, to milk the taxpayers money into their pockets - a fact, none may dispute. For if not then each and every staff, must raise such valid suggestions, and any more that they see fit, without sounding as a moaner or not with the rest "of the chums". I concur with the reference made to Nigel Rawlinson's comment on how these tortuous targets are a total back pain for the A&E staff, were at the UK hospital I am at in Surrey with a new pilot Rapid response team has made a clear "loophole" where patients in A&E, are just quickly seen to by a doctor (that a specialist nurse, could really do), and then catapulted into the MAU - medical assessment unit- whose already stressful situation with its barges to the full, now are leaking with so much work, that a morning ward round takes from 7.30am to 11.30am for the consultant (who had to work till 10pm that day and then go back to his living dotting family and hit the sack, only to repeat this "nightmare" again. Such dedication from a consultant I take my hat off to him. For not a care from the heads of NHS - Whitehall and the government from such dedicated consultants. All this while the A&E staff are impatiently twiddling their thumbs on their seats wanting to do their job and not lose their skills - that I must point out is no fault of theirs naturally, but of course whoever conjured up such a plan. So the crux of this new system to appease the government are the already hard-working overstressed medical staff - naturally their morale will go down and their "love" of what NHS stands for, doing all as a job, as a prisoner just doing his "job" passing each day in cell (the prisoner at least has no targets to achieve!). This all in all culminates with the continuous media downtrodden on the system so making the society, including the staff, who sacrificed their lives, to do the job with little output. This brooms away the world to watch us not any longer, and if do, to be surprised what has happened to the once great NHS for a blink before moving their eyes to Scandinavia or USA. What the NHS needs, is what happened in the IT and commercial multinational firms in the 90s I experienced and took part - is to get independent consultants with the empowerment to first collate the ideas from all staff and make a business model of the NHS - truly find the weakness at all levels and at all angles and then with no hindrance from the hospital administrators, clinical directors, governments or Whitehall (especially them), to make NHS streamlined, efficient, organised with in place a proper management team, ridding and moving of any staff they see fit is hindering the NHS machine as a "profit" organisation. Yes, the socialist NHS system needs some capitalist input as those people minds are free of cobwebs passed down in the NHS, and can breath new fresh life with open and clear mind, with the notion that socialist medicine is yet to be practised - evaluated reorganisation. These business consultants can be paid, only if no loss in that hospital from their changes is made on a low commission basis - thus in their sincere interest to make it work or else any loss and their have to pay for the difference to the year previously - and many do work on that. Better this way than to advance pay them which grows over the time line,as was the case of the NHS IT project system. The same to the hospital administrators and bosses to be paid a bonus equal to the salary of an average NHS staff, if and if they do their job with minimum wage as their salary. So no PFI's are needed (most having non-director interested from politicians anyhow or their cronies) who are amassing profit from taxpayers money. Or the NHS having clever accountants amassing so much money to show it has a surplus or near £2billions, the NHS hospitals are in debt, as the one I am at in green Surrey. The human factor is the biggest part of the equation. For MRCP PACES exam in the communication skills, the empathy and showing concern is a huge part, yet in reality the bare minimum is done esp by the junior doctors - no fault of their own, due to the ever growing debts and uncertain career prospects and the awful work schedule, and incorrect pay salary etc -so lose the plot why they did medicine in the first place, than just being told they are good in science so go down the "trapdoor" of the medical world. Again a business perspective is needed where what matters in terms of quality is needed of service to the patient (really this is an anarchic word that "patient" should be replaced to "medical client" -and that will make NHS and its staff see the service requirer in a whole different light). One UK consultant told me astutely - in UK the patient asks the doctor what the doctor can do for them to get better, and on the Continent the "medical client" asks that they themselves may do to get better. Thus despite all the suggestions above, the society today is different to when the NHS is formed and expected above and beyond from the doctor than God may do. Education all around is needed. A big task I do hope one of the big 5 consultancy firms may assist the NHS at all levels from the cleaners, upto the nurses, doctors and to the top, the hospital mangers, administrators and the inept "know-it-all" politicians..Then and only then may the World restart to look at the NHS GREAT British Health System. :) Lastly I say let the doctors run the NHS free and independently from the inept government as the Judges are judicially free from the government is the very first and big step needed. It goes without saying really that no Doctor can then become a politician as "Lord" Darzi is. We do not need him or who his cronies to be under the thumb of the politicians and their election agendas and spin doctors. We want him in a free NHS, as the Law judges are totally free to do willy nilly as are the prosecutor lawyers to squander the funds of legal processes to many folds higher than 20 years ago. Then and only then will the world return its face to our Great nation and then truly, God willing, be the envy of the world, as the Scandinavian and USA systems are today. Lets take that flame of icon of health system back as it was in the 70s and before when then truly the world was watching the "Great British Experiment" and proud it was to be a doctor in the NHS system. Peace to you all! :) Competing interests: None declared
Treating the clock, NOT the patient compromises patient safety 8 August 2008
Syed Ishaq Husain, FY2 General Medicine University Hospital of North Staffordshire, ST4 7LN, Dr Dipesh H Vasant, FY2 General Medicine, University Hospital of North Staffordshire Send response to journal: Re: Treating the clock, NOT the patient compromises patient safety	We want to echo the concerns expressed by Dr Fiona Godlee and Nigel Rawlinson about target driven care and its' effects on clinical care1,2 and describe our own experience. In our own trust, a University teaching hospital, there have been huge changes in the emergency care model over the past 12 months, attempting to address the demands of the 4 hour target, while maintaining patient safety. The latest initiative has seen merger of the Emergency Department and Acute (medical) admission unit into a single Emergency Care Centre. Previously all medical admissions at the trust would be reviewed by the medical team on call (at least the medical registrar) after the emergency medicine doctor, prior to transfer. A formal medical consultant post take ward round would take place daily. Under the new system medical admissions can be transferred without having being seen by the medical team on call and there is no formal post take medical consultant ward round in the Emergency Care Centre. These changes have undoubtedly decreased the number of four hour wait breaches. We were interested in what this meant for patients and their quality of care? A number of safeguards have been put in place under the new regime to try and ensure patient safety at our centre. Despite this there have been concerns from medical staff that these standards were not being met. Many of these were well documented as clinical incidents. In an internal audit, we used these mandatory safeguards as auditable standards and looked at all patients admitted in a one week period onto two general medical wards. Alarmingly the performance fell a long way short of the mandatory standards, with less than half of the patients having had blood tests reviewed prior to ward transfer, only two thirds of x-rays being reviewed prior to transfer and only just over half of patients had the necessary documentation declaring them medically stable for transfer. This represents significant clinical risk. Recommendations made from the audit to ensure safe practice are currently under consideration by the clinical director of Emergency medicine. Many of these suggestions are technically feasible but have financial implications, such as increased use of bedside blood testing technology, more frequent transport of blood samples to the laboratory and increasing on call/ ward cover to reflect the shift of work load from the admission portal to the wards. Simple measures such as educating staff about the necessary documentation prior to transfer and a mandatory transfer proforma with tick boxes have also been suggested. Nigel Rawlinson eloquently describes his beliefs about the effects of target focussed practice on holistic care and stress levels of staff.2 If the waiting time targets are halved as predicted by Dr Rawlinson2 then what further changes to the evolving emergency care models used in the NHS will it inspire? How can we protect patient safety in this climate when it appears to already being put at risk? References; 1. Godlee. F, The world is watching the English Experiment, BMJ 2008;337: a953 2. Rawlinson. N, Harms of target driven health care, BMJ 2008; 337:A885 Competing interests: None declared