Back in 2003, I pointed readers in the direction of a Guardian interview, by Decca Aitkenhead, with a teenage mother called Hannah White. She gave birth to Ebony in the middle of her GCSEs, and still managed to get great results.

The comment thread on my post turned into something of a support forum for teenage mums, which offers fascinating reading in itself. Hannah came along and contributed from time to time, but towards the end of last year it kind of petered out.

But now, Hannah herself has posted on there again, letting us know that she’s now got her degree and has started working full time in neurosciences, as Ebony has just turned five.

I just think this goes to show how the stereotypes of teenage parents can so often be wide of the mark.

Congratulations, Hannah, and all the best for the future. 🙂

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The inefficient status quo - surely there's a better way?

There’s been a lot of heat about the NHS National Programme for IT recently, with both Labour and the Conservatives suggesting that it will be, at best, scaled back. Often referred to as “the £12bn NHS Computer”, the idea of having a national IT system for the NHS is often ridiculed as one of Whitehall’s biggest white elephants.

But, contrary to what almost everyone else thinks, I firmly believe that a national NHS computer system is a good idea. I think it has the potential to revolutionise healthcare, and vastly improve the health of the British population in a much more meaningful way than anything else the NHS has ever done.

As a doctor, I’ve worked with a variety of NHS IT systems, some of which are brilliant, and some of which are terrible. On the one hand, I’ve worked with an electronic patient record system in a hospital Trust that is an absolute disaster of a system. It does not fit in to the way anybody works, it is obstructive, and it actually provides less data in a less useful manner than the paper system it replaced. It is terrible, and should never have been introduced. Projects like this give NHS IT a bad name.

On the other hand, I’ve worked with SystmOne in Primary Care, which is a Department of Health endorsed Über success of a computer system. The data is stored in a secure cloud, the program auto-updates, and it is constantly being improved. It’s a massively powerful system. When recent research showed that a high proportion of patients with diabetes and a history of heart attacks would have undiagnosed heart failure, it was the work of moments for a practice near me to generate a list of such patients and invite them for screening. The upshot was that the detection rate for heart failure soared by a factor of ten, and those patients are on the right treatment for their condition.

Without the IT system, this could not have been efficiently acheieved. It would have involved looking through thousands of sets of paper notes, which is just not practically possible. The implications for the availability of this sort of intervention are manifest. And that’s on top of the often sold benefits of all doctors, wherever you go, having access to the same set of complete medical records.

The disease-coding in SystmOne is done in an intelligent and unobtrusive way. If I type someone’s blood pressure in as part of a consultation, this is coded instantly and automatically by the computer, which merely highlights the data to show that it has been entered into an encoded database. Similarly for when I enter a diagnosis – coding is quick, automatic, and accurate. If, for example, I note that someone has diabetes, this is automatically captured and the patient is automatically sent letters for diabetic annual reviews. That is astoundingly clever, and stops individuals falling through nets.

Incidentally, the crap IT system does none of this. It is badly designed by people not familiar with the day-to-day workings of individuals in the hospital, and is actually obstructive when it comes to getting things done.

In most hospitals which remain paper-based, data intelligence just does not exist. The data on millions of pages of paper notes cannot be effectively mined. In order to receive payment for the services an NHS hospital provides, all the paper notes are shipped to a department named ‘coding’, where they are combed through by a team of non-medically trained secretaries, who decide from the often illegible medical notes how many patients with a given condition have been treated, and what interventions have taken place. It is slow, innaccurate, labour intensive, and doesn’t result in a patient identifiable database for mining. It is an extraordinary waste of time and money.

If a system like SystmOne could be extended to cover all NHS care, all over the country, the database it would produce would be immense, and the opportunities for mining of that data would be far more advanced than anything else undertaken by any country on earth. We would know at a glance if an outbreak of a disease was happening in a paticular area of the country. Research could be acted upon in a flash with intelligent, national, targeted screening programmes. And that is just the start.

A well implemented national NHS IT computer system would revolutionise care in the NHS – and frankly, for that, £12bn is an absolute steal.

This post is based on my contribution to Episode 17 of The Pod Delusion, originally broadcast on 15th January 2010. Other topics that week included “The Big Freeze”, Google, and ITV’s regional decline. How could you not want to listen to the whole thing at poddelusion.co.uk?

Back in September, the Family Planning Association was publicly worrying about the fact we were in a recession. With something rivalling the foresight of Derren Brown, they came to the conclusion that a recession would mean NHS budget cuts, and they were frightened for the future of their service. They thought that a lack of willingness to talk about sexual health issues would lead to their services being the first to be cut. Or, as they more memorably put it, their services will be the first to be cut because

no-one will complain to the local paper about a longer wait to get their genital warts seen to.

Frankly, I don’t think they need to worry so much. Whilst, perversely, sexual health services aren’t sexy, there are much less celebrated parts of the NHS. Like those that deal with children with serious mental health problems.

Back in 2006, I wrote a polemic on here about the underfunding of Child and Adolescent Mental Health Services (CAMHS), and I guess it’s become something of a recurring theme on here. Back in 2006, services were underfunded to such an extent that 25% of the country didn’t have CAMHS crisis teams.  If, like Newt in Hollyoaks, a schizophrenic teenager wants to kill themselves, there was no-one to call to get immediate specialist help. For adults, there are dedicated teams.

We’re now in 2010, at the dawn of a brave new decade, and over the intervening years not much has really changed. Just last year, The Guardian reported how many young people were waiting almost three and a half months for specialist assessment of their mental health problems – with 75% of them having no support whatsoever in the meantime.

Compare that level of service to the sexual health drop-in clinics or the guaranteed two-week cancer wait, and you begin to see the level of neglect of CAMHS in the UK.

Child and adolescent mental health problems are the very definition of unsexy. All of us regularly see tin-rattlers and chuggers asking us to support a whole range of childhood cancer charities, or raising money for hospitals like Great Ormond Street or the soon-to-be-opened Great North Children’s Hospital – All worthy causes in their own right.

But collecting-tins for children with mental health problems are very seldom seen, not because the diseases are less common, but just because of the level of public misunderstanding of the field, and a general perception that mental health problems are unpalatable.

1 in 3 of us will have cancer at some point in our lives. Similarly, 1 in 3 of us will have a mental health problem at some point in our lives. And, thanks to the chronicity of mental health problems, 1 in every 6 people are suffering with a mental health problem right now. And 1 in 10 children have a diagnosed mental health problem.

Which of those statistics have you seen on a TV ad or bus-stop poster recently? I’m guessing only the first.

Thanks to tabloid newspaper obsession and the underactive imaginations of TV and film scriptwriters, popular conception links mental illness and criminality. Criminals and the mentally ill are one and the same to many people. Of course links exist – I’d be a fool to deny that mental health problems are rife in our prisons for example (there’s a post for another day) – but when such vast numbers of people are affected, it is hardly the case than one equals the other.

Problems of perception likely affect CAMHS even more than adult services, as I’m sure many Daily Mail readers fail to believe that mental health problems can affect children: They’re probably seen as a Guardianista cover-up for naughty kids who should be caned rather than mollycoddled. Against that background, I’d wager that many people would rather write to their local newspaper about their genital warts than about their personality disordered child.

Luckily, there are some people out there who care enough to try to change the status quo. There’s a great charity called Young Minds who recently launched a manifesto on child and adolescent mental health issues, in an attempt to influence the political classes in a General Election year with a view to tackling these issues for the long-term. To his credit, Nick Clegg of the Lib Dems seems to be broadly in support of what they’re trying to do.

But the fact remains that CAMHS are chronically underfunded, and definitely underappreciated. As things stand, CAMHS win no political votes, and so when looking for things to cut, they will likely be first in the firing line.

In this context, I hardly think the Family Planning Association needs to worry. As long as preventing teenage pregnancy remains a vote-winner, their services will be well-funded.

Perhaps one day, CAMHS will be able to enjoy that level of confidence and certainty too. For the sake of our children, I hope so.

This post is based on my contribution to Episode Two of The Pod Delusion, originally broadcast on 25th September 2009. Other topics that week included the BNP on Question Time, an undercover homeopathy sting, and the future of intellectual property rights. How could you not want to listen to the whole thing at poddelusion.co.uk?

You know those bags of Rowntree’s Randoms, constantly advertised on TV? Seemingly reasonable people suddenly start spouting inappropriate words for their situation because they’ve indulged in a jelly sweet which has an unusual shape?

I’m beginning to wonder whether Gordon Brown has accidentally ingested a whole packet of the Prime Ministerial equivalent. How else can you explain the way he claims to be “pleased” and “proud” to apologise for the appalling treatment of Alan Turing, surely one of the greatest British heroes of the twentieth century? The words are simply inappropriate, as can be clearly seen by applying them to similar situations:

Mr Smith, I’m pleased to have the opportunity to apologise for your wife’s unfortunate death!

Mrs Jones, I’m proud to say that I can apologise for running over your cat!

Mr Thomas, I’m pleased and proud to apologise for your son’s death in Afghanistan!

Except, Gordon Brown wasn’t pleased and proud in the latter case. He was reportedly “devastated” about recent deaths in the country. Not angry, not apologetic, not regretful, not mourningful, not sorry, just “devastated”. Of course, not “devastated” enough to go to a military funeral, or even visit any injured soldier in hospital. Just “devastated” enough to repeatedly use the word and move on.

There are some who suspect there’s something altogether more worrying underlying Gordon Brown’s unusual responses. They claim, based on reports that he must avoid eating cheese and drinking chianti, that he is taking MAOIs, and old-fashioned kind of antidepressant.

The assertion that Gordon Brown uses MAOIs was recently made plain by Matthew Norman in the Independent, after months of hinting from Simon Heffer in the Telegraph and Matthew Parris in the Times.

The substantial problem with this theory is that virtually no-one takes MAOIs, as they’re extremely outdated and have some pretty nasty side-effects. On top of this, there are manifest reasons for avoiding cheese and chianti: A tendency for migraines, a plethora of food allergies, or a sensitivity to appearing too middle-class.

Yet whether or not he’s taking MAOIs, there are substantial rumours suggesting that Gordon Brown might be depressed. Whether or not this may impair his ability to fulfil the role of Prime Minister is debateable.

Iain Dale, for example, believes that it shouldn’t matter if Mr Brown is depressed – he deserves our compassion more than our criticism. He cites the example of Churchill, who was undoubtedly depressed but still a great Prime Minister.

I see entirely where Iain is coming from, and, for what it’s worth, I largely agree. I see no reason why depression should preclude decent Premiership.

But we live in a media-driven world that Churchill never experienced. Churchill was an alcoholic, and this may never have affected his leadership. That didn’t stop the Lib Dems overthrowing Charles Kennedy – their most charismatic leader to date – because he was a recovering alcoholic. The image wasn’t right. And if the image of a recovering alcoholic isn’t right for leader of a liberal party, how can a person with mental health problems ever be the right image for a Prime Minister?

To me, it actually doesn’t matter whether Gordon Brown is depressed or whether he fits the model image of a Prime Minister. What matters is that he’s terrible at his job. Performance must surely be judged above all else, especially for one of the country’s top jobs. And Mr Brown fails that test, and fails it miserably: From the economy, to student debt, to any one of manifest crises between which Mr Brown has lurched, it’s clear that he simply doesn’t have “The Right Stuff”.

But in today’s politics, who does? David Cameron? I suspect we might be on the verge of finding out.

Last Friday, The Pod Delusion launched. The pilot episode included a contribution from me on this subject, on which this post is based. Now go and listen to the rest!

Andy Burnham has written a piece for today’s Guardian announcing that

For Labour, it all comes down to defending the N in NHS … By contrast, the Tories are ambivalent about the role of the centre, preferring localism in health as in other areas.

It’s probably churlish of me to point out that Mr Burnham has previously espoused about the paramount important of locally, rather than natioanlly, influenced healthcare (“The hospital and Primary Care Trust must listen to patients and local people and involve them in shaping the future of the hospital” – hardly a nationalistic approach).

To point him in the direction of the Conservatives’ 45-page Green Paper on the NHS in response to his claim that “on health, Cameron doesn’t do detail” would probably be missing the point.

And let’s just ignore Mr Burnham’s complete lack of insight into the effect of his target-driven culture – Patients being moved like pawns around a hospital-sized game-board to avoid staying in one place for too long – regardless of their clinical need.

Let’s just park all of those thoughts in the vastly overpriced hospital multi-storey, and concentrate on his main point. The ‘N’.

I’m an ardant supporter of the broad principles of the NHS. I think healthcare free at the point of need is a wonderful thing. But I don’t subscribe to Andy Burnham’s ideology of a national health service with national targets to tackle national problems.

The residents of Byker have different healthcare needs to the residents of Mayfair, and the needs of the residents of Tunbridge Wells or Toxteth differ equally again. Whilst it’s true that residents in none of the above places would relish waiting more than four hours in A&E, such meaningless targets do little to disprove the inverse care law which appears to be Burnham’s prime argument for focusing on the ‘N’.

In fact, quite obviously, the most imporant bit is the ‘HS’. The country needs a Health Service that is adaptable to the needs of all. Different locales will, necessarily, have different priorities. Giving Respiratory Medicine the same priority in the North East (where lung disease is relatively common) and in Southern England (where it is rarer) would appear to me to be a failing of a nationalised system, not a benefit.

Targetting outcomes seems eminently more sensible – The respiratory services in the North-East and the South don’t need to be equitable, provided the outcome – measured in cure rate, death rate, or howsoever seems most sensible to the respiratory physicians who are far more intelligent than me – is equitable.

That’s the kind of Health Service I would like. One with an ability to respond to the local health needs of local people – not by “national standards, national pay and national accountability” – all three of which have everything to do with bureauocracy, and nothing to do with healthcare.

Patientline Bedside System

I note with interest that Patientline, provider of controversial bedside phone-cum-television-cum-internet consoles in NHS hospitals, went into administration on Friday.

My posts on Patientline – dating back as far as 2005 – received numerous comments complaining about the overpriced nature of the system, as well as the poor customer service users received, yet I’ve always been one of the first to defend the system against criticisim of high prices: That particular problem has come as a result of poor contractual negotiations on the part of NHS Trusts countrywide.

The contracts negotiated vary from the flexible terms in which the systems are cutsomised and integrated into the hospitals IT system, to crazily imposing terms whereby the units’ screens can’t even be switched off during daylight hours. The NHS Trusts who allowed the units to be installed must have been aware that this private company was primarily interested in profits, yet allowed the installation to go ahead regardless: In some cases, through apparently give-away contracts.

The company spent hundreds of millions of pounds providing expensive equipment to patient bedsides across the country – replacing simple TVs which used to exist on wards. They then attempted to charge up to £3.50 per day for individuals to watch their souped up TVs, and charged up to 49p per minute for people to phone the units.

This represented unacceptably poor value to hospital patients – after all, who wants to pay £24.50 per week for Freeview? – and has ultimately resulted in poor value for the NHS: Essentially, patients are getting much the same service provided by the TV in the corner of the room and the portable payphone for many times the cost.

It’s easy to see the apparent advantage to NHS Trusts – able to boast about an apparent improvement in service whilst neglecting to mention the increased cost to patients – yet it’s hard to see how, at those prices, investors didn’t see Patientline’s business plan as critically flawed before it even got off the ground.

Private companies are, by definition, interested primarily in profits – not in the best interests of patients. This is the fundamental problem with PFI projects in the NHS, and that the government fails to see that time and again shows either great naivety or great incompetence. I suspect I know which.

The ghost of Patientline is rising, pheonix-like, in the form of Hospedia, who are attempting to become the monopoly provider of such services – and oversee the spread of these terminals yet further. By investing a further £12m in improved services and cutting prices, Hospedia hopes to make a go of this business. I’m not convinced it’s possible… I guess only time will tell.

» Image Credit: Patientline publicity image

In Tony Blair’s day, New Labour were the masters of spin – at their most effective when they did it so convincingly that we didn’t even realise the facts were being spun, or else we were led to believe that we could see through the spinning, when in fact that presentation was the intention all along.

Now, it seems, that’s all gone. Yet, oddly, it hasn’t been replaced by the honesty and straightforwardness we were promised – an honesty many would say was incompatible with politics – but rather by terrible attempts at spinning.

Take the Henley by-election: Instead of pointing out that this is a Conservative seat and virtually ignoring electoral defeat, the omnipresent ‘Party Sources’ are mumbling about victory being secured if Labour keep their deposit. They’re saying that anything over 5% is some kind of win. Oh, brother.

And all the while, Harriet Harman is squeezing out plans to support ‘positive discrimination’ – another bizarre New Labour oxymoron. Discrimination is discrimination is discrimination – whether or not it’s positive or negative depends on your standpoint. Is selecting a member of an ethnic minority to balance out a sea of white faces still ‘positive discrimination’ if you’re a serial killer, or does this only apply when we’re handing out things perceived as rewards?

The same propsals also, apparently, ‘ban ageism’ – the government pretended to do back in October 2006, as covered on this very site. I note that Ms Harman is bounding about stating that doctors should only refuse treatment to elderly patients on clinical grounds – not on the basis of age. Three points: Firstly, doctors are already required to do their best for patients, regardless of age. Secondly, is age not part of the clinical picture any more? Thirdly, does this mean that twelve year olds should be openly prescribed the contraceptive pill? We wouldn’t want to be discriminating purely on the basis of age.

Ageism goes two ways. Why is it that this government consistently pretends that ageism only represents discrimination against the old, just as they pretend that racial discrimination only represents discrimination against ethnic minorities?

And let’s not forget that much of the economic policy underlying the NHS is based on QALYs – Quality Adjusted Life Years. That is to say that if an operation costs £30,000 but will lengthen someone’s life by 30 years then the cost per year gained is £1,000. Such measures in and of themselves discriminate against older people – an 80 year-old’s life far less likely to be extended by 30 years than a 20 year-old’s.  The same treatment is less likely to be cost effective in the 80 year-old purely because of their age. Is this to be overlooked in future? How is NHS rationing to take place now?

I sincerely hope that this is a crappy proposal put forward to distract us all from Labour’s impending Henley hammering. It’s not the best of ideas, because it shows Labour in a bad light, but perhaps not quite such a bad light as being deeply unpopular.

On the other hand, if this is a serious attempt at law-making, then we’re all clearly doomed.

» Image Credit: Original image created by Graham Richardson, modified under licence

After five years, four homes, eleven housemates, seventy assessments, nine weeks in Canada, litres of sweat, countless tears, innumerable smiles, and a large dose of hard work, I was utterly overwhelmed today by receipt of the news that I’ve somehow successfully qualified as a doctor.

I guess the real work starts in August, when I take up my Foundation Doctor post.

Gordon Brown has a fascinating plan for the NHS: Increase patient choice, whilst simultaneously driving the cost of healthcare down to deliver better ‘value for money’. The plan is fascinating primarily because its two aims are utterly contradictory.

As any good economist – Gordon Brown included – will tell you, the greatest economies are those of scale. If the more specialist services from seven Anytown General Hospitals can be lumped together at the Bigcity Regional Specialist Unit, and the five GP practices in each Anytown are combined with the remaining General Hospital Services in a Polyclinic, then costs can be massively reduced. Less real estate, fewer administrative staff, and fewer healthcare staff are needed to serve the same number of patients. Economically speaking, it’s a nobrainer.

Yet while the out-of-town model is great for businesses and retailers, it’s crap for healthcare – and also flies in the face of current policy. Which is where Mrs Goggins comes in.

Gordon currently wants to offer old Mrs Goggins a choice of places to have her cataracts seen to – most likely, she’ll choose Anytown General, as it’s closest to her house and more convenient all round. She’s unlikely to be attracted by the lure of Bigcity Regional Specialist Unit, 50 miles away, and she’d rather wait an extra couple of months to have her eyes operated on closer to home. And that’s pretty much all well and good.

In a few years’ time, however, Mrs Goggins won’t have that choice. She won’t be able to go and see her local GP any more, she’ll have to travel all the way to the Health Village on the old Anytown General site, where she’ll be assessed by an economically friendly Nurse Practitioner, who will then refer her over to Virgin Healthcare’s Bigcity Regional Specialist Unit, where she can go and be assessed by another Specialist Nurse Practitioner who can consider whether or not she need make the 50 mile round trip again another day to actually see the consultant, and then a third trip to have the operation done…

When she gets to the Virgin Healthcare Bigcity Regional Specialist Unit, she’ll find she’s on a very noisy, open eight-bedded bay… but this is Virgin, so fear not, she can pay £15 per night to upgrade herself to her own private side-room with her very own TV. She won’t be able to afford to heat her house for the next few weeks, but it’ll be worth it to make her comfortable in hospital.

Her follow-up is, of course, based at the Hospital – disparate community follow-up services are desperately financially wasteful – so she can treat herself to a few more 100-mile round trips before even contemplating having the second eye done.

Of course, Mrs Goggins will still have some choice – she needn’t go to Bigcity if she doesn’t want to – she can go to any of the Specialist Units in the country, she’s not restricted to the nearest.

Or else, she could decide that the whole thing is far too hard, and she’ll just put up with her cataracts – And, after all, that’s the best choice for us, economically speaking.

» Image Credit: Original photograph by Christopher Walker, modified under licence.