a link to the excellent historical site Geoffrey Rivett annotates;
http://www.nhshistory.com/
Tuesday, 26 February 2013
Police force and shotgun licenses
In light of Dunblane et al etc etc and recent changes to authentication for a license and a 'reverse' burden of duty upon Gp's, my collegaue 'jwc' has crafted the following letter;
'"Dear Mr Plod
Please find enclosed the original letter from yourselves informing us of the recent shotgun application for the named individual : “Grant or renewal of a firearm and/or shotgun certificate”. It is being returned to you along with this standard covering letter.
Irrespective of any agreement between the police and the BMA regarding the content of these letters, we are in no way bound by any such agreement. There is an implication that we will consider the content of the letter and inform you if we have any concerns. This cannot be done without a proper review of the medical notes. This is not an NHS service and there is no obligation for the practice to comply with this request.
If you feel you require a report on the medical condition of the patient in question, then you are welcome to request one. We would require a signed consent from the patient, and also an indication of the scope and information you would like to have in any such report. As this is not an NHS service, the writing of such a report will attract a fee. This can be discussed further with the practice manager.
For the avoidance of doubt, this is a standard letter which has been attached and returned to you immediately on receipt of your standard shotgun letter; the original letter has not been seen or considered by any of the clinicians in the practice.
Thank you
The surgery"
'"Dear Mr Plod
Please find enclosed the original letter from yourselves informing us of the recent shotgun application for the named individual : “Grant or renewal of a firearm and/or shotgun certificate”. It is being returned to you along with this standard covering letter.
Irrespective of any agreement between the police and the BMA regarding the content of these letters, we are in no way bound by any such agreement. There is an implication that we will consider the content of the letter and inform you if we have any concerns. This cannot be done without a proper review of the medical notes. This is not an NHS service and there is no obligation for the practice to comply with this request.
If you feel you require a report on the medical condition of the patient in question, then you are welcome to request one. We would require a signed consent from the patient, and also an indication of the scope and information you would like to have in any such report. As this is not an NHS service, the writing of such a report will attract a fee. This can be discussed further with the practice manager.
For the avoidance of doubt, this is a standard letter which has been attached and returned to you immediately on receipt of your standard shotgun letter; the original letter has not been seen or considered by any of the clinicians in the practice.
Thank you
The surgery"
Sunday, 24 February 2013
GMC & IPSOS-MORI survey
DrSoupDragon has learnt of an intriguing survey directed at those age 55 and older holding GMC registration;
'..Dear Dr X,
Can you help?
We are pleased to invite you to take part in a web based survey that Ipsos MORI, the independent research agency, is undertaking on behalf of the GMC. As part of the GMC’s ongoing financial planning activities, they wish to explore doctors’ views of remaining on the register in order to more accurately forecast the number of doctors who are likely to leave the register over the next few months.'
'..Dear Dr X,
Can you help?
We are pleased to invite you to take part in a web based survey that Ipsos MORI, the independent research agency, is undertaking on behalf of the GMC. As part of the GMC’s ongoing financial planning activities, they wish to explore doctors’ views of remaining on the register in order to more accurately forecast the number of doctors who are likely to leave the register over the next few months.'
rather fascinating and plainly an interesting fishing expedition given the current medical climate in the UK wrt the toxic mixture of Pension Changes/Revalidation/CQC/ etc ad nauseum.
The GMC planning its finances !
Informal soundings suggest most asked are not replying in any constructive/instructive sense merely letting the survey stew, and not displaying their hand.
We may be seeing a receding tide prior to a Tsunami.............
Watch this space...................
Friday, 22 February 2013
Integrative Governance
Work in Progress;
as John Reid was heard to say ' oh F*&* not health', Dr SoupDragon has plumped for IG and the mediation/resolution of internal/external COI within commissioning providers.
Plainly links to Governance structures will lay heavy on his mind over the next few weeks!
http://www.wales.nhs.uk/sitesplus/documents/829/Integrated%20Governance%20II%20-%20Governance%20Between%20Organisations%20Bullivant%20et%20al.pdf
http://nhschoicestraining.spinningclock.com/Documents/Information_for_Boards_-_Principles_of_Governance_with_HCAI.pdf
http://www.peterborough.nhs.uk/documents/Publications/Integrated%20Governance%20Framework%20-%20Approved%202008.pdf?preventCache=30%2F01%2F2009+08%3A57
http://www.see.nhs.uk/documents/meetings/public_29_07_2010/integrated%20governance%20strategy.pdf
http://www.nhsconfed.org/Publications/Documents/guide_to_governance_for_health_and_wellbeing_boards210612.pdf
and the francis reports 1 + 2
http://www.midstaffsinquiry.com/pressrelease.html
as John Reid was heard to say ' oh F*&* not health', Dr SoupDragon has plumped for IG and the mediation/resolution of internal/external COI within commissioning providers.
Plainly links to Governance structures will lay heavy on his mind over the next few weeks!
http://www.wales.nhs.uk/sitesplus/documents/829/Integrated%20Governance%20II%20-%20Governance%20Between%20Organisations%20Bullivant%20et%20al.pdf
http://nhschoicestraining.spinningclock.com/Documents/Information_for_Boards_-_Principles_of_Governance_with_HCAI.pdf
http://www.peterborough.nhs.uk/documents/Publications/Integrated%20Governance%20Framework%20-%20Approved%202008.pdf?preventCache=30%2F01%2F2009+08%3A57
http://www.see.nhs.uk/documents/meetings/public_29_07_2010/integrated%20governance%20strategy.pdf
http://www.nhsconfed.org/Publications/Documents/guide_to_governance_for_health_and_wellbeing_boards210612.pdf
and the francis reports 1 + 2
http://www.midstaffsinquiry.com/pressrelease.html
Homeopathy
whats all this nonsense about water being made more 'potent' by dilution?
As they say 'en France' BoooooooooooooooF.
As they say 'en France' BoooooooooooooooF.
Thursday, 21 February 2013
Problems in secondary care and commissioners
Work in progress;
How to address probs generated in secondary care to commissioners under the guise of not fulfilling the criteria of contract and or Tarrif.
1 need to know tarrif cost and components of what cost should provide/deliver
2 need to know contract specification ie Service Level Agreement SLA.
3 people - who to address issue to -> CCG/FT etc etc
4 need to disseminate to whole of primary care so problems can be accurately defined and pushed back to originator.
How to address probs generated in secondary care to commissioners under the guise of not fulfilling the criteria of contract and or Tarrif.
1 need to know tarrif cost and components of what cost should provide/deliver
2 need to know contract specification ie Service Level Agreement SLA.
3 people - who to address issue to -> CCG/FT etc etc
4 need to disseminate to whole of primary care so problems can be accurately defined and pushed back to originator.
Link to Tarrif 2012-13
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_132654
go down to the xls spreadsheet link named 'Download 2012-13 Tarrif information spreadsheet'
et voila,
go down to the xls spreadsheet link named 'Download 2012-13 Tarrif information spreadsheet'
et voila,
Wednesday, 20 February 2013
Witch Doctor Blog and Accountability
a sage take on the Francis report and Accountability [or not] in the NaSH;
http://witchdoctor.wordpress.com/
http://witchdoctor.wordpress.com/
Noctors vs NotaVets
http://nhsblogdoc.blogspot.co.uk/
Physicians do not know much about surgery, haematologists do not know much about cardiology, psychiatrists do not know much about orthopaedics and GPs, well, they do not know much about anything. And yet, we all went to medical school and so, before we became specialists, we were doctors. We had learnt how to analyse problems and how to know our boundaries. Those five years were not wasted.
Another email arrives, this time from a Consultant Psychiatrist somewhere in the West Country. Her teenage daughter, who is herself about to go to medical school, fell off a horse last week and hurt her shoulder.
I had a look, and although I am but a humble psychiatrist, I knew it was a bust clavicle. Palpable lump, point tenderness, severe pain. Pretty obvious diagnosis. Sling and rest is all that is required but I am a psychiatrist. Better go to A/E and get it done properly. She should probably have an x-ray, just to confirm.
So far so good. I take daughter to the minor accident unit. Seen by an Nurse Practitioner, who carefully examines her, and diagnoses '?acromio-clavicular joint strain'
Oh well.
Off to x-ray. Nice radiographer chats to soon to be medical student daughter and points out the fracture to her.
“Cor!” says daughter.
Back to see NP. He looks at x-ray, gives daughter a sling and gives good advice about rest, mobility etc. I smell a small rat.
“How long do you think the fracture will take to heal?” I ask.
“Oh, it's not broken,” he said. “It's just a strain”.
Could I have I look at the film?” I say.
He in turn now smells a rat. “Do you know about X-Rays?” he asks. I say I am a psychiatrist, but I learnt a little about them at medical school. We look at the film. I point out the fracture.
“Oh, that's just a line on the film” he says, ignoring breaks in the line of the cortex, the increased density in the overlapping ends etc. etc.
“OK”, I say, “well, we'll wait for the report from the radiologist” and we leave. Daughter is impressed. "I never knew you could be tactful, Mum."
Now, this is all rather trivial really, but it illustrates a more important point. A poor examination gave a false diagnosis, which was then adhered to despite evidence to the contrary. We can all be guilty of this. But doctors are trained carefully, and have the knowledge to move on from this position of error. I have lost count of the number of times my teachers said 'Never make the facts fit a theory. Your theory must fit the facts.'
This NP, who was in charge of the unit, had obviously never gone through this process. It's not his fault. He is being used in a role for which he is simply not qualified.
In this case, no harm done. But what happens when he sends a child home with a sore throat, pyrexia and dribbling because he does not know of the significance of dribbling in a child who cannot can swallow?
I would not want this NP treating my daughter. Frankly, I would not want him treating my dog, which brings me on to the interesting case of Dr Susie Macleod who is an experienced veterinary surgeon in Hertfordshire. She employs a number of highly experienced veterinary nurses. In 2004 she set up a separate clinic seven miles away, entitled the Health4Pets clinic. This establishment was staffed wholly by veterinary nurses, with no resident veterinary surgeon on the premises, although there was regular communication by telephone with the main practice and webcam pictures could be transmitted between the premises. The clinic's main function was to furnish facilities for the vaccination of small animals by veterinary nurses at considerably lower cost than the charges made by practices where veterinary surgeons carried out vaccinations.
And why not indeed? Sending “nurse specialists” out into the community to manage asthmatics and elderly patient with heart failure and COPD is known to provide huge financial savings and free up doctors and hospitals for more important work. Why not apply the same cost savings to veterinary medicine?
The Royal College of Veterinary Surgeons were not persuaded. On the contrary. They considered that Susie Macleod’s behaviour constituted disgraceful conduct.
Section 19 of the Veterinary Surgeons Act 1966 makes it a criminal offence for anyone to undertake veterinary work unless they are fully qualified veterinary surgeons. Veterinary nurses are allowed to carry out certain limited procedures provided the animals concerned
are under the care of the veterinary surgeon and the treatment in each case is carried out by the nurses under the direction of the veterinary surgeon.
Susie accepted the following facts:
* a. she was not present at the clinic when the vaccinations were carried out;
* b. she had never examined the animals;
* c. she had never read the animals’ medical records;
* d. she had never discussed the animals with their owners or agreed to take on their care;
* e. she did not know of the animals’ presence at the clinic or their condition;
* f. she had no discussion with the nurse administering the vaccine about the animal or its proposed treatment;
* g. she had no knowledge of the animals at allSo what defence did Susie mount to these agreed facts?
Read the next bit carefully. You many have heard it before. Susie placed some emphasis, however, in her submissions to the Board,
on her provision of “protocols” to the nurses which they were strictly enjoined to follow. In each case the nurse had a sheet on which she was required to fill in details about the individual animal, ticking boxes as she went, with instructions to refer the case to a veterinary surgeon on making certain findings about its health or condition.
She went on to argue that…
a veterinary nurse could carry out booster injections, so long as it was under veterinary direction, which she interpreted as extending to the system whereby she gave standard directions to the nurses by means of the “protocols”.
And what did their Lordships think of that?
"Their Lordships also consider, however, that the treatment carried out by the veterinary nurses in vaccinating the animals cannot be said to have been done under the appellant’s direction. The appellant argued that her “protocols”, consisting of instructions to the nurses and forms which they had to complete, constituted sufficient direction to them. Their Lordships cannot agree. They do not wish to attempt to define in detail the circumstances in which treatment is carried on under the direction of a veterinary surgeon, for those circumstances may vary widely. The concept does, however, connote an element of immediacy and potential control of the treatment which was wholly lacking in the carrying out of vaccinations at the Health4Pets clinic.
…..At its hearing the Disciplinary Committee was advised by its legal assessor that disgraceful conduct in a professional respect is conduct which falls far short of that which is expected of the profession. Their Lordships consider that that was an appropriate definition and that the Committee was correctly advised...
…their Lordships have no hesitation in upholding the decision of the Disciplinary Committee that the appellant was guilty of disgraceful conduct in a professional respect. The detailed findings made by it and the expression of opinion contained in its judgment that the appellant’s actions were capable of jeopardising animal welfare give sustainable grounds for reaching its ultimate decision, and their Lordships are of opinion that that decision fell within the ambit of sustainable conclusions."
The Veterinary Profession is not dumbing down. It is not going to allow protocol driven tick-sheet veterinary medicine to be practiced by unqualified “veterinary care professionals.”
Susie Macleod was reprimanded for disgraceful professional behaviour. We can be sure that she will not in the future be letting her nurse specialists loose on animals.
The question for doctors, patients and the NHS is obvious and I will not labour it. But the next time the cardiac nurse quacktitioner pops in to treat grandma’s heart failure, or the next time you visit a quacktitioner run walk-in clinic, try to forget that it is illegal to treat a dog in this fashion.pen on nhs
Physicians do not know much about surgery, haematologists do not know much about cardiology, psychiatrists do not know much about orthopaedics and GPs, well, they do not know much about anything. And yet, we all went to medical school and so, before we became specialists, we were doctors. We had learnt how to analyse problems and how to know our boundaries. Those five years were not wasted.
Another email arrives, this time from a Consultant Psychiatrist somewhere in the West Country. Her teenage daughter, who is herself about to go to medical school, fell off a horse last week and hurt her shoulder.
I had a look, and although I am but a humble psychiatrist, I knew it was a bust clavicle. Palpable lump, point tenderness, severe pain. Pretty obvious diagnosis. Sling and rest is all that is required but I am a psychiatrist. Better go to A/E and get it done properly. She should probably have an x-ray, just to confirm.
So far so good. I take daughter to the minor accident unit. Seen by an Nurse Practitioner, who carefully examines her, and diagnoses '?acromio-clavicular joint strain'
Oh well.
Off to x-ray. Nice radiographer chats to soon to be medical student daughter and points out the fracture to her.
“Cor!” says daughter.
Back to see NP. He looks at x-ray, gives daughter a sling and gives good advice about rest, mobility etc. I smell a small rat.
“How long do you think the fracture will take to heal?” I ask.
“Oh, it's not broken,” he said. “It's just a strain”.
Could I have I look at the film?” I say.
He in turn now smells a rat. “Do you know about X-Rays?” he asks. I say I am a psychiatrist, but I learnt a little about them at medical school. We look at the film. I point out the fracture.
“Oh, that's just a line on the film” he says, ignoring breaks in the line of the cortex, the increased density in the overlapping ends etc. etc.
“OK”, I say, “well, we'll wait for the report from the radiologist” and we leave. Daughter is impressed. "I never knew you could be tactful, Mum."
Now, this is all rather trivial really, but it illustrates a more important point. A poor examination gave a false diagnosis, which was then adhered to despite evidence to the contrary. We can all be guilty of this. But doctors are trained carefully, and have the knowledge to move on from this position of error. I have lost count of the number of times my teachers said 'Never make the facts fit a theory. Your theory must fit the facts.'
This NP, who was in charge of the unit, had obviously never gone through this process. It's not his fault. He is being used in a role for which he is simply not qualified.
In this case, no harm done. But what happens when he sends a child home with a sore throat, pyrexia and dribbling because he does not know of the significance of dribbling in a child who cannot can swallow?
I would not want this NP treating my daughter. Frankly, I would not want him treating my dog, which brings me on to the interesting case of Dr Susie Macleod who is an experienced veterinary surgeon in Hertfordshire. She employs a number of highly experienced veterinary nurses. In 2004 she set up a separate clinic seven miles away, entitled the Health4Pets clinic. This establishment was staffed wholly by veterinary nurses, with no resident veterinary surgeon on the premises, although there was regular communication by telephone with the main practice and webcam pictures could be transmitted between the premises. The clinic's main function was to furnish facilities for the vaccination of small animals by veterinary nurses at considerably lower cost than the charges made by practices where veterinary surgeons carried out vaccinations.
And why not indeed? Sending “nurse specialists” out into the community to manage asthmatics and elderly patient with heart failure and COPD is known to provide huge financial savings and free up doctors and hospitals for more important work. Why not apply the same cost savings to veterinary medicine?
The Royal College of Veterinary Surgeons were not persuaded. On the contrary. They considered that Susie Macleod’s behaviour constituted disgraceful conduct.
Section 19 of the Veterinary Surgeons Act 1966 makes it a criminal offence for anyone to undertake veterinary work unless they are fully qualified veterinary surgeons. Veterinary nurses are allowed to carry out certain limited procedures provided the animals concerned
are under the care of the veterinary surgeon and the treatment in each case is carried out by the nurses under the direction of the veterinary surgeon.
Susie accepted the following facts:
* a. she was not present at the clinic when the vaccinations were carried out;
* b. she had never examined the animals;
* c. she had never read the animals’ medical records;
* d. she had never discussed the animals with their owners or agreed to take on their care;
* e. she did not know of the animals’ presence at the clinic or their condition;
* f. she had no discussion with the nurse administering the vaccine about the animal or its proposed treatment;
* g. she had no knowledge of the animals at allSo what defence did Susie mount to these agreed facts?
Read the next bit carefully. You many have heard it before. Susie placed some emphasis, however, in her submissions to the Board,
on her provision of “protocols” to the nurses which they were strictly enjoined to follow. In each case the nurse had a sheet on which she was required to fill in details about the individual animal, ticking boxes as she went, with instructions to refer the case to a veterinary surgeon on making certain findings about its health or condition.
She went on to argue that…
a veterinary nurse could carry out booster injections, so long as it was under veterinary direction, which she interpreted as extending to the system whereby she gave standard directions to the nurses by means of the “protocols”.
And what did their Lordships think of that?
"Their Lordships also consider, however, that the treatment carried out by the veterinary nurses in vaccinating the animals cannot be said to have been done under the appellant’s direction. The appellant argued that her “protocols”, consisting of instructions to the nurses and forms which they had to complete, constituted sufficient direction to them. Their Lordships cannot agree. They do not wish to attempt to define in detail the circumstances in which treatment is carried on under the direction of a veterinary surgeon, for those circumstances may vary widely. The concept does, however, connote an element of immediacy and potential control of the treatment which was wholly lacking in the carrying out of vaccinations at the Health4Pets clinic.
…..At its hearing the Disciplinary Committee was advised by its legal assessor that disgraceful conduct in a professional respect is conduct which falls far short of that which is expected of the profession. Their Lordships consider that that was an appropriate definition and that the Committee was correctly advised...
…their Lordships have no hesitation in upholding the decision of the Disciplinary Committee that the appellant was guilty of disgraceful conduct in a professional respect. The detailed findings made by it and the expression of opinion contained in its judgment that the appellant’s actions were capable of jeopardising animal welfare give sustainable grounds for reaching its ultimate decision, and their Lordships are of opinion that that decision fell within the ambit of sustainable conclusions."
The Veterinary Profession is not dumbing down. It is not going to allow protocol driven tick-sheet veterinary medicine to be practiced by unqualified “veterinary care professionals.”
Susie Macleod was reprimanded for disgraceful professional behaviour. We can be sure that she will not in the future be letting her nurse specialists loose on animals.
The question for doctors, patients and the NHS is obvious and I will not labour it. But the next time the cardiac nurse quacktitioner pops in to treat grandma’s heart failure, or the next time you visit a quacktitioner run walk-in clinic, try to forget that it is illegal to treat a dog in this fashion.pen on nhs
Tuesday, 19 February 2013
Kant vs Mill's
Kant in the Blue corner;
http://en.wikipedia.org/wiki/Immanuel_Kant
Mill's in the Red corner;
http://en.wikipedia.org/wiki/John_Stuart_Mill
and as Harry Hill is want to say, FIGHT...................................
http://en.wikipedia.org/wiki/Immanuel_Kant
Mill's in the Red corner;
http://en.wikipedia.org/wiki/John_Stuart_Mill
and as Harry Hill is want to say, FIGHT...................................
Servant Leadership
endepted to Hemadri;
http://successinhealthcare.blogspot.co.uk/2013/02/servant-leaders.html
a rather interesting observation.
vertical vs horizontal organizational structures;
http://smallbusiness.chron.com/difference-between-horizontal-vertical-business-25653.html
http://successinhealthcare.blogspot.co.uk/2013/02/servant-leaders.html
a rather interesting observation.
vertical vs horizontal organizational structures;
http://smallbusiness.chron.com/difference-between-horizontal-vertical-business-25653.html
Blame and responsibility in the NaSH 2013.
interesting how language is being distorted to suit the ends needed;
If you are a leader you lead....if there is a disaster you take responsibility.
Otherwise it's authority without accountability.
&
The fact that they are using the word blame to avoid responsibility in this manner is pathognomonic of a bureaucracy where the bureaucrats are more important than the object of the enterprise to the powers that govern it.
this refers to the Francis report;
http://www.midstaffsinquiry.com/pressrelease.html
If you are a leader you lead....if there is a disaster you take responsibility.
Otherwise it's authority without accountability.
&
The fact that they are using the word blame to avoid responsibility in this manner is pathognomonic of a bureaucracy where the bureaucrats are more important than the object of the enterprise to the powers that govern it.
this refers to the Francis report;
http://www.midstaffsinquiry.com/pressrelease.html
NHS Boss for the chop?
it does look as if the past is coming back to visit itself;
http://www.telegraph.co.uk/news/9879216/NHS-boss-praised-scandal-hit-hospitals-during-the-height-of-care-debacle-letter-shows.html
http://www.telegraph.co.uk/news/9879216/NHS-boss-praised-scandal-hit-hospitals-during-the-height-of-care-debacle-letter-shows.html
A confused health minister ?
https://docs.google.com/file/d/1Wjx_6qH7V2xLtDvSc2sTDzndd6FLgYNJlPOaFyp8UcL4jMTHXcPUsK-TjLlA-1npm6RNiRuOhUGTG8vP/edit?usp=sharing
The highlights
GPs are accused of (1) not treating asthma in kids properly (2) sending half meningitis cases home (3) admitting too much "minor illness" that could be managed at home (4) using drugs for kids which have not been tested in paediatric population.
dr roscoe ->'If half the cases are sent home, that means that half of all cases of meningitis are spotted straight away.. Given that they are a minute percentage of our hot and unwell kids I think that statistic is in fact excellent. I got into this argument about cancer cases seeing their GP up to 3 times before being referred, letter eventually in the BMJ. '
sephiroth->'"(2) sending half meningitis cases home (3) admitting too much "minor illness" that could be managed at home"
Point 2 would say we are being too offensive, while point 3 would indicate we are being too defensive?? Make your mind up you wazzock??'
The highlights
GPs are accused of (1) not treating asthma in kids properly (2) sending half meningitis cases home (3) admitting too much "minor illness" that could be managed at home (4) using drugs for kids which have not been tested in paediatric population.
dr roscoe ->'If half the cases are sent home, that means that half of all cases of meningitis are spotted straight away.. Given that they are a minute percentage of our hot and unwell kids I think that statistic is in fact excellent. I got into this argument about cancer cases seeing their GP up to 3 times before being referred, letter eventually in the BMJ. '
sephiroth->'"(2) sending half meningitis cases home (3) admitting too much "minor illness" that could be managed at home"
Point 2 would say we are being too offensive, while point 3 would indicate we are being too defensive?? Make your mind up you wazzock??'
Friday, 15 February 2013
QP avoidable emergency/urgent admissions
A rather wonderful arbitar of such by the ubiquitous Dr Spitfire;
'I have long since ignored diktats from above about reducing emergency admissions, attendences etc.
The managers will disappear over the horizon if the shit hits the fan because you failed to admit when needed.
When our QOF Qp indicators asked us to review our emergency admission referrals and identify any "inappropriate admissions", without actually specifying any criteria by which they were deemed inapporpriate, I set the standard thus:
The hospital team, on assessning the patient weere able, without bloods, Xrays or further investigation or monitoring beyond that of a GP service, to discharge the patient the same day.
I found we had no emergency admissions to hospital that met the criteria of inappropriate using this standard.
If the hospital team needs same day Xrays/bloods to arrive at a decision, then by default, that admission is appropriate. I will take criticism from managers or hospital consultants when patients are sent home without any investigations whatsoever. '
Johnleigh rightly comments;
'"Plus, you do know that most of the blood tests ordered on emergency admission patients are not requested by a doctor, but by the nurse at the door of the admission?"
On whose authority does the nurse do the tests?
Ah, "the doctor's" you reply.
I rest my case.'
and spitfire again;
'(to hospital colleagues, whom I admire a lot by the way to cope with heaving demands on them too):
tell you what in that case, next time you do a ward round on admissions as the senior doctor, tell your juniors you dont want to hear any results until you have clinically assessed the patient with the same equipment as a GP. Then decide if you can discharge without knowing them.
If you can, great, its an inappropriate referral/assessment. If you want to know the results before sending home, then you are in the same boat as the GP was.
It would be a useful teaching tool for the juniors, many of whom bemoan/interrogate us for sending up patients to be assessed (I remember I was guily of this too at that stage of training), to see if they can appreciate what it is like for us at the maximum uncertainty end, trying to make a decision in 10mins, or in an inadequate room on a soft sofa on a home visit to an acute abdomen.'
'I have long since ignored diktats from above about reducing emergency admissions, attendences etc.
The managers will disappear over the horizon if the shit hits the fan because you failed to admit when needed.
When our QOF Qp indicators asked us to review our emergency admission referrals and identify any "inappropriate admissions", without actually specifying any criteria by which they were deemed inapporpriate, I set the standard thus:
The hospital team, on assessning the patient weere able, without bloods, Xrays or further investigation or monitoring beyond that of a GP service, to discharge the patient the same day.
I found we had no emergency admissions to hospital that met the criteria of inappropriate using this standard.
If the hospital team needs same day Xrays/bloods to arrive at a decision, then by default, that admission is appropriate. I will take criticism from managers or hospital consultants when patients are sent home without any investigations whatsoever. '
Johnleigh rightly comments;
'"Plus, you do know that most of the blood tests ordered on emergency admission patients are not requested by a doctor, but by the nurse at the door of the admission?"
On whose authority does the nurse do the tests?
Ah, "the doctor's" you reply.
I rest my case.'
and spitfire again;
'(to hospital colleagues, whom I admire a lot by the way to cope with heaving demands on them too):
tell you what in that case, next time you do a ward round on admissions as the senior doctor, tell your juniors you dont want to hear any results until you have clinically assessed the patient with the same equipment as a GP. Then decide if you can discharge without knowing them.
If you can, great, its an inappropriate referral/assessment. If you want to know the results before sending home, then you are in the same boat as the GP was.
It would be a useful teaching tool for the juniors, many of whom bemoan/interrogate us for sending up patients to be assessed (I remember I was guily of this too at that stage of training), to see if they can appreciate what it is like for us at the maximum uncertainty end, trying to make a decision in 10mins, or in an inadequate room on a soft sofa on a home visit to an acute abdomen.'
Thursday, 14 February 2013
Friday, 8 February 2013
Thursday, 7 February 2013
Wednesday, 6 February 2013
Duty of candour....
the wiki definition is;
http://en.wikipedia.org/wiki/Duty_of_candor
i would contend candour can only be displayed if someone is listening and willing to action.
in a week when a politician Chris Huhne has displayed a decade-long gestation period to manifest 'candour', to be implored by the political classes is a bit rich.
nonetheless i would hypothecate the Ombudsman allied to the local Coroners Office with a little dusting of imagination and trust would be the perfect listening 'Auricle'. If this was made manifest it could stop Bristol, Alder Hay and Stafford ever happening again. It however requires political motivation and integrity.
interesting developments in the 'BMJ rapid response unit' [26 Feb 2013];
http://www.bmj.com/content/346/bmj.f1152?tab=responses
http://en.wikipedia.org/wiki/Duty_of_candor
i would contend candour can only be displayed if someone is listening and willing to action.
in a week when a politician Chris Huhne has displayed a decade-long gestation period to manifest 'candour', to be implored by the political classes is a bit rich.
nonetheless i would hypothecate the Ombudsman allied to the local Coroners Office with a little dusting of imagination and trust would be the perfect listening 'Auricle'. If this was made manifest it could stop Bristol, Alder Hay and Stafford ever happening again. It however requires political motivation and integrity.
interesting developments in the 'BMJ rapid response unit' [26 Feb 2013];
http://www.bmj.com/content/346/bmj.f1152?tab=responses
HeartSink remedy?
congratulations to drchuck ->'So I see this heartsink in clinic-chronic pain, under performing, recurrent S/A, quite probably a nightmare to manage as regrettably a number of issues have been medicalised needlessly and the unions and lawyers have been involved.
To cap it all the heartsink couldn't pour piss out of a boot with instructions on the heel.
The heartsink was accompanied by quite possibly one of the most hostile, belligerent people I have met who was acting as the heartsinks "advocate".
One of the complaints the heartsink has is that "no-one at work will take time to listen to me when I feel bad and my pain is at its worst".
The advocate thought this was an outrage, how dare they be unsympathetic and uncaring etc etc yaddah yaddah yaddah.
With some rather brave negotiation on my part I managed to persuade heartsink to the view that this wasn't really the role of colleagues or managers.
Well, snorted the advocate, if itsn't theirs, who the bloody hells is it?
Gently, oh so gently, I articulated the perspective that the patient was so lucky to have such a considerate and capable friend and that I felt the "patient" could usefully avail themselves of this persons support frequently and lengthily.
Cue horrified look on advocates face and beaming look of delight on patient.'
To cap it all the heartsink couldn't pour piss out of a boot with instructions on the heel.
The heartsink was accompanied by quite possibly one of the most hostile, belligerent people I have met who was acting as the heartsinks "advocate".
One of the complaints the heartsink has is that "no-one at work will take time to listen to me when I feel bad and my pain is at its worst".
The advocate thought this was an outrage, how dare they be unsympathetic and uncaring etc etc yaddah yaddah yaddah.
With some rather brave negotiation on my part I managed to persuade heartsink to the view that this wasn't really the role of colleagues or managers.
Well, snorted the advocate, if itsn't theirs, who the bloody hells is it?
Gently, oh so gently, I articulated the perspective that the patient was so lucky to have such a considerate and capable friend and that I felt the "patient" could usefully avail themselves of this persons support frequently and lengthily.
Cue horrified look on advocates face and beaming look of delight on patient.'
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