Jambalaya

That Blair did not sack Ms Hewitt in his panic reshuffle on Friday simply confirms that what he really intends is the sack of the NHS.

Shortly after his election in 1997, he exhorted his drooling NHS acolytes that they had no more than 10 years to ‘save the NHS’. He embarked on an ambitious programme of reform (or modernization as he would prefer it known). Few would argue with the need for reform and not many with its direction. The problem has been with the manner of its execution.

The irony is that those of us NHS professionals who have dedicated our working lives to the NHS would have gladly ‘saved’ it for him, given half a chance. For some reason Blair resents professionals and professionalism, and has done a good job of carrying the media with him. He sees doctors and nurses not as much as caring as heavily unionized and self-interested. The reception afforded Ms Hewitt at a nursing conference last week will have simply reinforced that view.

The reality is that most of us are exceptionally hard-working and dedicated to doing the best we can for our patients, and for the NHS generally. The new consultant contract was predicated on the belief that we are all lazy sods and that management needed new levers to bring us into line. In truth, the necessary levers were always there but few had the leadership qualities to use them effectively.

Just last week a good friend of ours had an elective surgical procedure at our hospital. All went well and after her discharge she called me to say just how amazingly well it had all worked. She also noted just how hard the nursing staff were working and the long hours the consultants were putting in. (Thanks to the European Working Time Directive, this degree of commitment is now rarely apparent in the junior medical staff.)

As the media has been quick to spot, the new consultant contract proved more expensive than anticipated and it is now being ‘blamed’ in part for the NHS overspend, when all that has happened is that a bit of transparency and accountability has been brought to play which highlights how hard the majority of consultants have actually been working. More than they reckoned— and now we have the extraordinary spectacle of a consultant workforce that is now financially substantially better off but more demoralized than ever. Thank goodness Andrew Foster has decided to move on.

So what happens next? Well, having heavily overspent on salaries and disastrous PFI contracts, the NHS will have to claw back as much as it can by wielding an indiscriminate axe here and there. It is going to be very painful and the worse is yet to come. Nor would Gordon Brown have it any other way: the Treasury has long been convinced that the NHS is a lost cause financially and he really must be smarting at how his generosity has been rewarded.

And that’s before we even consider Connecting for Health…

Blair is a conviction politician. No harm in that except that he also believes (more strongly than anything else) that the end justifies the means. I’m not certain it ever does but, to be sure, the two don’t mix well.

A rather depressing article in E-Health Insider reports on what sounds a bit like a panic measure:

NHS Connecting for Health is urgently looking for experienced NHS clinicians, interested in ensuring that NHS IT systems are fit for purpose, to be flown out and work on assignment with clinical software developers in India or the United States.

It has been my impression for some years that the politicians driving this (not very original) vision have been blindly seduced by BigCo IT into believing that simply rolling legacy systems from across the Pond and imposing them on an unwitting NHS would be a piece of cake. Not so. As any observant student of large IT projects will tell you, a system stands or falls on its usability far more than its underlying sophistication, and you cannot assume that usability in one context translates simply into usability in another. Put more simply, the North American healthcare system and the NHS differ in so many social, cultural, and professional respects that a system designed for one will almost certainly fail in the other without significant redesign. It is no surprise then that the successful contractors are discovering that their prized systems are needing to be rebuilt virtually from scratch.

The real sadness is that if those driving this scheme had thought differently, they could have harnessed the knowledge, expertise and enthusiasm behind the large numbers of successful small scale systems that were already in productive use throughout our NHS. As it is, a large cohort of “early adopters” now feels alienated and frustrated.

The more egotistical brand this as the The world’s biggest IT project. It may well be the largest, centrally-driven, top-down IT project on the Planet—but that is hardly a category with a conspicuous history of success. I suspect that the real contender for the “largest IT project” accolade must be the Internet, which is unquestionably hugely successful. Think for a moment about how the Internet came about: its project director, project manager, project plan, champions, whoever. Then read Tony Hoare’s 1980 Turing Lecture: The Emperor’s Old Clothes (especially his take on the classic Hans Andersen tale at the end, and the following quote).

At first I hoped that such a technically unsound project would collapse but I soon realized it was doomed to success. Almost anything in software can be implemented, sold, and even used given enough determination. There is nothing a mere scientist can say that will stand against the flood of a hundred million dollars. But there is one quality that cannot be purchased in this way—-and that is reliability. The price of reliability is the pursuit of the utmost simplicity. It is a price which the very rich find most hard to pay.

Then go place your bets.

The Health Minister, John Hutton, today described a BMA report on the Government’s A&E targets as “deliberately misleading”. He must be rattled: the report is on the whole very supportive of the improvements that have been made in A&E departments—it simply highlights that going the ‘third mile’ is in some ways counterproductive, and may actually be harmful to (some) patients. It is certainly leading to a great deal of ‘headless chicken’ behaviour on the ground, and brings out the worst in managers, who are under extreme pressure to deliver the full target (98% of patients seen and dispatched within 4 hours of arrival in A&E). This cannot be in patients’ best interests, Mr Hutton.

Tony Blair however was more conciliatory, agreeing that the four hour target may be too rigid. He said: “Most people would say the accident and emergency departments today are a lot better than they were…We feel, and maybe we are wrong, that one way we’ve managed to do that is by setting a clear target…But maybe we need to look at how we have sufficient flexibility in the targets.”

Dream on.

The undoubted intellectual high point of the conference was reached this afternoon when Julian Le Grand gave a shameless plug for his recent book. Professor Le Grand is the Richard Titmuss Professor of Social Policy at the London School of Economics and has recently started a 6 month secondment as health policy advisor to the Prime Minister. Simon Stevens, his predecessor at Downing Street was to have presented in the morning, but stood down in the light of his recent defection to the private sector.

Julian Le Grand has a major interest is in the motivation of professionals, which he believes is the key to policy design in the public sector. His recent book asks how professionals in public services can be motivated to deliver quality:

Can we rely on the public service ethos to deliver high quality public services? Are professionals such as doctors and teachers really public-spirited altruists - knights - or self-interested egoists - knaves? And how should the recipients of those services, patients, parents and pupils, be treated? As passive recipients - pawns - or as active consumers - queens?

[He] argues that the original welfare state was designed on the assumptions that those who worked within it were basically altruists or knights and that the beneficiaries were passive recipients or pawns. In consequence services were often of low quality, delivered in a patronising fashion and inequitable in outcome. However, services designed on an opposite set of assumptions - that public service professionals are knaves and that users should be queens - also face problems: exploitation by unscrupulous professionals, and over-use by demanding consumers, especially middle class ones.

He suggests avoiding situations where ‘knightish’ and ‘knavish’ incentives work in opposite directions (e.g. private practice), and try to get them pulling in the same direction—as with GP fundholding.

After lunch Pam Garside chaired a session in which Sir Graeme Catto, President of the General Medical Council (GMC) reminded us what the GMC is all about —To protect the health and safety of the community by ensuring proper standards in medicine,— and how revalidation will work. Later this year, registered doctors will be asked if they wish to be granted a ‘licence to practise’ (without which, one assumes, practising will be illegal). From next year, maintenance of this licence will depend on successful revalidation. Although in discussion it emerged that the actual mechanics of revalidation is anything but clear, for most of us working in managed environments this will depend on providing evidence of satiscatory appraisal, even though appraisal is meant not to be a means of performance assessment.

Alistair Scotland then presented a ‘whistle stock take’ (sic) of the National Clinical Assessment Authority (NCAA)’s recent activities. Referals od doctors with problems continues to rise [I wrote down 1.2%, but missed the denominator]. Referalls of GPs and psychiatrists are particularly on the increase, the latter perhaps reflecting the problems of a shortage specialty operating in an a poorly-managed environment beset by the disruption of multiple mergers, rather than any particular characteristic of psychiatrists. Overall, Alistair was upbeat about the impact of the NCAA, feeling that it is having a useful effect on the number of suspensions, but noting that nearly a quarter of these are ‘resolving’ by the individual concerned resigning his or her post. The age of referrals to the NCAA co-incides with what is assumed to be the peak of one’s productive life: there is no excess of newly-qualified consultants, partly allaying fears that shortened training would reduce competence.

One of the conference highlight’s was Hilary Thomas’s presentation on leadership. Hilary has pursued a strong career through academic clinical oncology and leading a cancer network, and is now medical director of the Royal Surrey County Hospital. This was a well-crafted presentation which though covering familiar ground, was sufficiently challenging (The NHS must change faster if it is to survive) to keep our attention at the end of a long morning.

Whilst medicine was once considered simple, ineffective and generally safe, rapid technological progress, expectations & demand, and government intervention has changed all that. The US healthcare system is now largely driven by the pharmaceutical industry, and globalization will extend this to us all. [It already has.] Tomorrow will need to be proactive rather than reactive, characterized by partnerships not paternalism, and with healthcare based around the patient, and not the institution or [professional] tribe. Honesty and integrity will be vital.

Challenges for tomorrow are education, short-termism in the NHS, its treatment of senior managers [hear hear], and combatting the growth of regulation and reorganization.

Just one minor regret: Hilary’s love of gastronomy merely served to highlight the awfulness that was to be lunch.

There then followed a panel discussion, chaired by Charles Swainson, though by now the programme was running late and time was short, limiting the session to 5 minutes per panelist and a few questions from the floor.

Peter Lees thinks that we are missing a trick with patient liaison. Until recently it never occurred to him (or I suspect most of us) to actually ask his patients what they thought about him and his service. Rather bravely he has directly recently done just that with a few patients, and found the experience very rewarding. As a result he feels that if we could only ‘let our patients in’ in this way, they could be strong advocates for us.

Steve Evans took the managerial line humourously with a Goff cartoon of a manager telling his staff “I’ll be in charge of delegating all the blame”. He commented on growing perceptions of increasing managerialism in the health service and problems with the quality of middle management. He also felt that consideration of doctors as managers was misplaced—doctors are managers.

Sîan Griffiths lauded the Wanless reports and exhorted us to take up the public health agenda in our day to day work. The burden of preventable disease is growing such that healthcare will break unless we take this seriously. We all have responsibilities for this within our Trusts, with employees, with patients and as corporate citizens.

Ken Aswani reminded us that the PECs are the professional executive committees of primary care trusts (PCTs) which have responsibility for improving health, delivery of primary care as well as commissioning all healths services for its patients. The PECs thus give professional locally a prominent role and opportunity to shape tomorrow.

The full title of Denis Smith’s presentation was The road to nowhere? Pillars and other metaphors for changes in healthcare, but as usual his metaphors were exceedingly obscure. Denis’s BAMM presentations have become legendary for their side-splitting humour, often funny to the point of obscuring his underlying message. This time, though still very funny in places, he had a more approachable message— namely that (if I may paraphrase) every system has embedded within it the seeds of its own failure, and that in trying to compensate for this we simply add to the complexity and, ultimately, to the certainty that at some point failure will occur. When it does, unravelling the ‘root cause’ can be a nightmare. Systems work because of the people in the system, but failure often reflects system complexity rather than human error.

[This theme will be familiar to computer programmers, and is well illustrated by the repeated security failures in Microsoft’s Windows operating system. CAR (Tony) Hoare wrote about the phenomenon over 20 years ago in his Turing Award lecture The Emperor’s old clothes. The parable that ends his lecture is well worth reading, as is the full text]

Denis is a natural, gifted and entertaining presenter. His visuals are the complete antithesis of the powerpoint misery which was the butt of yesterday’s rant (probably in part because Denis uses Keynote rather than powerpoint).

Eliot Lazar is the Chief Medical Officer of the New York Presbyterian Healthcare System (NYPHS) and as such was personally involved with his institution’s response to the 9/11 disaster. His absorbing, extensive and at times moving presentation led us graphically through some of the horrors of the day itself, and then some of the lessons learned and how approaches to emergency planning have evolved as a result. The NYPHS is a major provider in the city and surrounding areas, and covers two major university teaching hospitals and dozens of smaller institutions totalling some 12,000 beds: a similar scale to our old Regions, though by no means the monopoly provider. Indeed, the complexity of inter-agency interactions that come into play in a disaster such as 9/11 are truly staggering.

However carefully one plans, and in whatever detail, something will likely catch you out. Patient flows are entirely unpredictable: victims will gravitate towards hospitals wherever they find them, not ‘rescue centers’ or wherever else they have been directed. Communication is critical but communication systems may be victims of the original disaster. [I understand that in this country the police have the power to take over and if necessary shut down our mobile phone networks in such circumstances). Manpower is not an issue: there was no shortage of volunteer manpower after 9/11 and the problem was turning many away without appearing ungrateful: wanting to help in an emergency is a powerful basic urge.

Disasters on this scale do not affect a single hospital but whole health care systems. Co-ordination between hospitals themselves and with hosts of other agencies is vital, and the ability to move surplus resources from one are to another more needy is essential. This needs the ability to generate rapidly inventories of available resources and communicate the information widely. Web-based systems are excellent for this, though what happens when the network infrastructure is also damaged was not mentioned. Interestingly, in ‘desktop’ exercises since the event, nurse shortages have been highlighted as a major potential problem.

At one point, Eliot asked how many of us had had discussions with our families about what we would do if struck by disaster. None of us had. This is apparently big stuff over the pond, and what we should be doing is detailed here.

Eliot and his colleagues have clearly been profoundly affected by their experience and have worked tirelessly to develop and disseminate good practice guidelines one hopes will never be needed. My sense is that major incident planning is fairly well developed (if not rehearsed as realistically) in the UK. As Eliot pointed out, we were there first, with the Blitz, but there are still things to learn for tomorrow.

Rising star Mark Britnell, CE of the University Hospitals Birmingham NHS Trust is clearly a visionary and strategist, as well as ambitious. He runs a major teaching hospital Trust, with a massive PFI rebuild on his books, and a likelihood (for him, certainty) that UHB will become a Foundation Trust very soon. In brief, his tenet was that since 1948 the NHS has been driven by central command and control thinking, with local ‘management’ just responding to central demands and not able to think strategically at a local level. [I had a flash of déjà vu at this point— 10 years ago when we first became a self-governing Trust we had, for a very brief period, a real opportunity to think plan and do at a local level. The problem was that few people actually wanted to play that game, and we didn’t get far before the government changes and the forces of centralization returned.]

Birmingham has always been a tough nut to crack. Medical (private practice) and local government politics never really saw eye to eye. Mark’s approach is to look to the future (it’s often easier to share a distant vision) and then work backwards to remove the obstacles. Sound good, doesn’t it? As a Foundation Trust, the full weight of the Harvard Business Review will be at his finger tips, building value chains with all manner of potential partners, and buying out those that don’t play ball.

Clearly, Mark’s hospital is ready for tomorrow. Is yours?

David Colin-Thomé took the after lunch slot but was not as stimulating and provocative as he can be. Perhaps it was because he didn’t have much new to say, perhaps also his slides were especially soporific. He laid out the familiar central market stall of improving access (capacity), personalizing care (choice), public health, chronic disease management (based in the community), etc., but there was little insight into ‘how’, and whether the good ideas and pilot projects would scale sufficiently in the real world. For those based in secondary care (most of the delegates), the world of which he spoke seemed rather remote from how it feels on the ground.

There was some discussion about the ‘gatekeeping’ role of primary care and how this has never been a formal role, but one which simply arose from the fact that when something is wrong we usually see our generalist GP first, who more often than not can deal with our problem completely. The introduction of ‘payment by results’ will, he felt, actually increase this gatekeeping role, though he was not impressed with the possibility that his PCT’s commissioning agreements might actually prevent him from referring a patient to the specialist of his (or the patient’s) choice.

The first morning ended with a briefer than intended panel discussion led by Denis Smith, with Carol Black (RCP), Anna Walker (HC), Nick Bishop (HC) and Doug Russell (Tower Hamlets PCT). The discussion struggled to get off the ground with the panelists philosophically prevaricating over definitions of ‘safe’ and ‘who for?’. The eventual conclusion was ‘not safe enough’.

The inevitable parallels with the aviation industry reappeared though one commenter usefully pointed out that (unlike aviation) healthcare is not a simple interaction between people and systems—there is this confounding thing called disease to consider as well. There was much bemoaning the pervasive culture of blame, and how the legal system and media push for a scapegoat at every opportunity. One questioner pointed out the errors are often multifactorial or multistep and the sometimes the least significant contributing step is the one singled out for blame. There was also concern that the culture is engendering fear and defensiveness at an early stage of training, and that organizations that have high error reporting rates are frequently assumed to be ‘bad’, when the opposite is more likely to be the case.

Anna Walker, the new chief executive of the Healthcare Commission (the new name for CHAI, previously CHI—Commission for Health Improvement) spoke for the first time at a BAMM conference. She is new to healthcare, having previously been a Director General at DEFRA and before that at the DTI), but already shows an impressive grasp of the major political, strategic and practical issues facing the Commission.

The Healthcare Commission has regulator responsibility for the whole healthcare spectrum: NHS, private healthcare and voluntary organizations, working within a framework of government standards. Like CHI, it will undertake annual provider reviews, themed reviews, and investigate problem or failing organizations. In addition, it will likely take on the second stage of the NHS complaints process. It aims to do this with substantially fewer people and resources than sister organizations such as OFSTED. It will therefore not be relying on armies of paid inspectors (though may continue to second people from within the NHS, as did CHI) and will rely on organizations submitting a detailed self-assessment which will be rigorously analyzed and screened for deviations. Detailed inspection visits will probably be confined to poor performers, and high flyers. Cross-boundary issues are likely to be an early priority.

Asked if the Commission would tackle the government if its surveys or inspections found problems arising from central policy, Anna Walker made it clear that the Commission will be feeding back regularly to the Department of Health and would be prepared to ‘say the unsayable’ if it came across such problems. The Commission will also take into account improvement (relative performance) as well as absolute performance in its assessments, and recognizes that locality commissioning poses particular problems for hospital Trusts that have to work with multiple Primary Care Trusts.

Carol Black spoke on challenges facing the medical profession, mainly from her perspective as President of the London Royal College of Physicians and with the insight of a past medical director and a member of the NHS Modernization Board. She walked us through the globalization arguments and stressed the evolving demographic, epidemiological and social trends—aging population, ethnic diversification, changing patterns of disease, and consumerism. Age-related chronic disease, preservation of health and prevention of disease are becoming the main drivers, for which the traditional primary/secondary/tertiary healthcare structures are no longer. appropriate. She predicted greater emphasis on managing chronic conditions in the community (hardly an new concept) but in a planned, structured and integrated way (a bit more novel). Although she didn’t mention it as such, ‘plurality of provision’ is part of the scheme.

The RCP has clear interests in both acute and chronic care. It has recently published a working paper on Acute Medicine which aims to ensure that hospitals receiving medical emergencies are appropriately organized and staffed with physicians who are not merely competent but highly skilled in managing acutely ill medical patients, and for whom the medical ‘take’ is not a simple diversion from their specialty work but a major part of their (professional) lives. As a rheumatologist, Carol Black is particularly sensitive to chronic disease management issues, and her college is a partner in the recent publication Clinicians, services and commissioning in chronic disease management in the NHS with the Royal College of General Practitioners and the NHS Alliance. This makes recommendations on joint working, clinical leadership & governance, and service redesign.

Uniquely among the Royal Colleges, the RCP has lobbied hard over the impact of the European Working Time Directive (EWTD) and particularly the SIMAP (rest in hospital = work) and Jaeger (immediate compensatory rest periods) rulings will have on our ability to sustain a safe and effective service in all hospitals after August 2004. Shift pattern working is not universally popular, especially amongst middle grade juniors and there are concerns for continuity of care and handover. Smaller hospitals will find it particularly difficult, and consultants will be increasingly drawn to the front line: probably no bad thing for patients, if only there were enough consultants. Various hospitals have looked at different staffing patterns and cover at night with some success. A major concern is that the changes in patterns of work may reduce opportunities for learning, though some data suggests that in larger hospitals with sufficient staff, shift patterns and night schemes may actually increase the proportion of time worked in daytime shifts, when there tends to be more training opportunities.

The first day of the conference went smoothly, though as usual PowerPoint intruded heavily in most of the talks. We have all been guilty of it at some time: it is so easy just to write one’s talk directly into PP, format it with bullets, indents and more, and just simply read it off to the audience. It is easy too to forget that the kind of audience one is talking to can read and digest a whole slide before one has stuttered through the first bullet point: transition effects that delay each paragraph until the presenter has caught up simply frustrate. Content and delivery has to be seriously good to overcome the deadening effect of most presenters’ slides. Today we had a spectrum: some terrific, some stimulating and some, well, there you go.

Perhaps part of the problem was that Aidan Halligan (Deputy Chief Medical Officer) set such a high standard with the first presentation that following speakers were cast somewhat into the shade. Aidan is always an engaging, thought-provoking, original and entertaining presenter, and today was no exception. His slides illustrate rather than drive his talk.

Aidan’s brief was The Challenges Ahead. We all know that for him (and, as he would have it, for us as well) is implementation of the massive IT programme for the NHS. But he chose to preface this with a gentle reminder that the uniqueness of clinical encounter between doctor and patient has endured over a long period and that we should not forget the ‘unwritten’ contract patients’ and clinicians’ contracts. The IT programme will come to nothing if not fully embraced by clinical staff ‘with enthusiasm’. Aidan’s aim is to engender that enthusiasm:

• Communicate as if the whole programme depends on it. (It does: how often I should communicate is how often I should kiss my wife: before someone else does.)

• Identify an enable local leadership. (And train them, too)

• Match and exceed the expectations of patients and clinicians.

There is no doubting Aidan’s enthusiasm and commitment to this. If anyone can communicate it to the service, he will.

[More to follow]

Last night the conference kicked off with a dinner for delegates sandwiched between addresses from two prominent speakers. The Secretary of State John Reid was to have been one but unfortunately was unable to come at the last minute, but the helath minister John Hutton steeped into the breach. His well crafted speech was apparently his own doing, not the civil servant-authored version that John Reid would have given. He was suitably (and I think genuinely) effusive about the key role that medical managers need to (and are) playing in the NHS as it goes through change after change. There was nothing particularly new or controversial; BAMM, the Department of Health and, of course, the government all came out smelling of roses. The NHS did pretty well too, having been pulled from the jaws of disaster by knights in shining armour, and all that stuff. Well done all!

Sadly, the meal itself came a poor third in the evening’s agenda, and we were rescued eventually by our Chief Medical Officer, Sir Liam Donaldson (minus charger). Liam had wisely guessed that powerpoint would not go down well at this juncture and spoke unaided by this—and his reading glasses. He recalled Alan Langlands’ metaphor Can the elephant dance? and gave his own view of the challenges facing our favourite elephant (the NHS) as it is forced to change over and over, much of it being a rant about the dangers of devolution. He stressed 10 points:

The British Association of Medical Managers (BAMM) is holding its annual summer school and conference at Stratford-upon-Avon this week, with the theme Tomorrow and tomorrow and tomorrow…

As a distraction from the awfulness of the hotel I shall see if I can blog the highlights of the event. I have my trusty PowerBook, but alas no WiFi installed, which is pretty frustrating as the hotel has WiFi access. A conference exhibitor has set up an internet cafe, so if I can transfer this to one of their machines with my USB disk or figure something else, we will be in business…

Ben Toth has unearthed a few newsfeeds from NHS organizations. Not very many but, taken with his own newsfeed, the content is already enough to demonstrate the enormous potential of this medium for disseminating ideas and generating discussion within the NHS—and bringing in the public at large. As yet, of these only Ben’s site is an actual weblog with a comment facility. And, curiously, the news in the NHSIA’s feed bears no relationship to the news on its home page.

I wonder what software these NHS organizations are using? I bet won’t very often be MovableType, Radio Userland, or other mature weblog software. The NHSIA still seems to be pushing the rather hopeless Digerati product, which as far as I am aware does not have an RSS (or similar) newsfeed facility.

What is needed is a ‘killer’ site to publish (and advertise) a newsfeed. I have been working on the Health Service Journal (who so far have not returned my emails) and NICE (which I think is yet to be convinced).

Our local hospital is updating its policy on the use of mobile phones on site. The existing policy is sensibly liberal and recognises that the evidence of harm resulting from electromagnetic interference (EMF) is remarkably thin, but that the consequences are potentially dangerous.

It seems that if you bring an active (i.e. switched-on) mobile phone within a couple of metres or so of an electronic medical ‘device’ (monitor, infusion pump, whatever), the device could malfunction. It probaly won’t malfunction, but it might: good territory for precautionary principle afficionados, perhaps. Nevertheless, our existing policy basically says, don’t use mobiles within a few feet of medical equipment attached to patients.

However, a few nut-heads seem to be fanatically opposed to mobile phones. Period. Official-looking (but actualy unofficial) notices have appeared all over the hospital stating that mobile phones must be switched off, and some individuals have been subjected to verbal abuse for using their mobiles in public areas of the hospital.

A revised policy then appeared in draft seeking to ban the use of mobiles completely in any of the hospital buildings, and recommending the installation of monitoring devices to detect their ‘illicit’ use. This produced a flood of objections, the more sensible of which drew attention the benefits of mobile phones for visitors as well as staff (especially since public phones are extremely scarce). Ironically, a couple of our cardiologists had only shortly before published a very balanced editorial in the British Medical Journal pointing out that mobiles are not as hazardous as believed and recommending that they should be allowed at least in non-clinical areas. Others have taken a contrary view: the South Tees NHS Trust has followed the precautionary principle and opted for an outright ban, whilst, policy-makers in Glasgow opted for creating several mobile friendly places where the nearest electromedical equipment was at least 5 m away.

A recent on-line review revisits the evidence, and again finds it largely unconvincing. The reviewer neatly turns the argument on its head and suggests that maybe the problem (if there is one) is not with mobile phones, but with malfunctioning medical equipment. Perhaps it is more to do with poor EMF shielding in just a few medical devices rather than a problem with all mobile phones.

Fortunately, the local policy-makers seem convinced, and the ban now proposed will not be total, but applied to a just few critical clinical areas. Not really much of a change after all, except that monitoring for illicit use is againthreatened: something else our cash-strapped hospital can ill afford.

The following extract from yesterday's Prime Minister's Question Time in Parliament may (or may not) shed some light on this important question:

An article in today's Observer claims that "Britain is shamed by NHS death rate". It reports on a comparative study of surgical death rates after major surgery undertaken, but not yet published, by teams from University College London and Columbia University in New York which purports that that fewer American patients than British died in hospital after major surgery. The Observer journalist Jo Revill is quick to present this as further 'evidence' that the NHS reforms are failing, and harnesses comments from David Bennett of St Georges Hospital, who has been banging on — quite rightly, actually — about Britain's comparative lack of critical care facilities.

A worrying aspect of this report is that the headline 'outcomes' of this study have been accepted uncritically by the journalist concerned, and published without revealing sufficient information to allow readers to draw their own conclusions. The study is apparently to be published in a 'peer-reviewed' journal later in the year, and selective and uncritical leaking such as this prior to full and proper publication is simply unethical. An important aspect of peer-reviewed publication is that (in theory) details of the study method and the raw data are published to allow readers to draw alternative conclusions, and to form an opinion on potential confounders such as observer or publication bias.

In a comparative study such as this there are many potentially-confounding variables which can influence the interpretation of the observations, for example the selection of the patients, their ages and underlying conditions, the indications for surgery, the seniority of the surgeon, the support services available, etc. Without such information, it is impossible to determine whether there is any grain of truth in this story, or whether it is just another example of the British media hell-bent on discrediting the Government.

As it happens, I suspect intuitively and from my own observations that the general conclusions of the study may well be correct — but if they are, understanding the underlying reasons in a way that enables a constructive approach to improving the situation is not helped by cheap sensationalism such as this.

The Commission for Health Improvement (CHI) has released this year's 'star ratings' for NHS hospital Trusts. The star ratings are part of New Labour's misplaced campaign to 'improve patient choice' through the imposition of somewhat meaningless targets. ("If targets work, so would have the USSR" attrib. John Kay, Economist Apr 26, 2001)

Our local Trust (the Oxford Radcliffe Hospitals) has managed to hold onto its single star (or, if you prefer your glass half full, it only narrowly missed gaining a second). And all despite a financial crisis and the precipitous departure of its chief executive and chairman.

The Health Services Journal (HSJ) has spotted that there is a strong North-South divide in the distribution of stars, with the North coming out 'better'. I have written about this before, in relation to CHI's clinical governance reports:

...CHI is somewhat deficient in its attempts to explain or even understand why there is such variability. Funding distribution comes to mind as one possible factor...

The reality is that the star rating system detracts from good clinical care, distorts priorities, and produces dysfunctional behaviour at all levels, as highlighted by a recent BBC Panorama programme.

What all this means for patient choice is perhaps for patients to decide. Choice based on star rating seems somewhat limited for those in the South East region, unless one is prepared to be treated far away from home. This, of course, is not a realistic prospect for many and certainly not for those needing emergency care.

Our local NHS Hospital Trust, the Oxford Radcliffe, has just appointed its fourth chief executive in nine years: Trevor Campbell Davis who is presently CE of the Whittington NHS Trust in London.

Mr Campbell Davis succeeds the very accomplished and popular David Highton, who had hoped to stay in the post longer than his two predecessors (one of which, Nigel Crisp, now heads up the entire NHS). As far as one can tell, leaving was not one of David's planned career moves, and the NHS has as a result kissed goodbye to talent it can ill afford to lose.

There has been a significant hiatus since the interviews 10 days ago and today's announcement. One can only hope that Mr Campbell Davis has used the time wisely to negotiate himself some rock solid insurance lest he encounter a similar fate. We wish him well

Judging by a Guardian article today, Blair and Milburn do seem to be moving towards opening up the NHS to competition from private providers. Let's be clear: anything that reduces Whitehall's control and interference in the management of things they don't understand is a Good Thing (assuming of course that those taking the reins DO understand: but that's another story).

As Iraq fades into ancient history our beloved media have had to cast around for something else to fill the column inches over the Bank Holiday weekend, and once again the spotlight has fallen on the good old NHS.

This time it is the plan to turn some of the better behaved hospital Trusts into Foundation Hospitals, in theory more autonomous and less under 'direct' Whitehall control. This is sparking a Labour backbench revolt, led by the antediluvian Frank Dobson who did so much to wreck the NHS and demoralize staff when he was at the helm. The irony is that the Tories, who invented 'self-governing' hospital Trusts in the first place, look set to vote against them this time round. That's just plain silly - but what we have come to expect from Irritable Dowel Syndrome and his cronies.

It may have taken a while, but Alan Milburn has at last recognised that "You can't run the National Health Service as if it's the Chinese Red Army, from an office in Whitehall." Devolving power and responsibility is a sound management principle for a vast, monolithic organization: Margaret Thatcher new that. The main problem with the current plan is that, to start with, only selected hospitals will earn Foundation status. This is the real divisive issue. Alan and Tony should take courage and go the whole hog: make us all Foundation Hospitals at a stroke. That should disarm the critics.