Sunday, February 07, 2010

A senior doctor swore at me for staying with a dying man... THAT'S how bad Britain's out-of-hours crisis has become

(In a classic British government bungle, very few British doctors are prepared to work after hours because the government makes it financial folly for them to do so)

By Dr Ellie Cannon

Since qualifying as a GP I have chosen to work in an out-of-hours co-operative. I am one of a huge number of home-grown GPs to do this for the clinical experience, the skills training and, yes, the financial rewards. Working out-of-hours was a crucial part of my GP training, and for me it remains a fundamental part of being a doctor.

It is time-consuming, tiring and inconvenient. But I never assumed the work of a GP was going to be nine-to-five and I don’t believe I stop being a doctor in the evening when I go home to my children.

I realise this isn’t a view shared by all in my profession. Since 2004, many doctors have opted out of doing work that, I still believe, is a vital part of general practice. They did so because the introduction of a new GP contract has meant surgeries receive just 6 per cent more for providing out-of-hours cover for a lot more work. After costs that means very little difference in salary.

With a swathe of doctors no longer willing to pick up the phone outside surgery times, the out-of-hours co-ops were born. These are GP-run, not-for-profit groups that cover a far larger area than any practice ever would – half of Kent, for example. Many doctors who work in this way are well qualified, sincere and skilled but there is no requirement to be a regularly practising GP.

Nothing could illustrate the risks of the system more clearly than the death of David Gray. The 70-year-old died at the hands of Daniel Ubani – I struggle to refer to him as ‘Dr’ – a locum who had just arrived in Britain. This case may be extreme but it has rightly put the out-of-hours system under scrutiny, something I personally welcome.

Working for an out-of-hours co-op put me in the most harrowing situation I have ever faced as a doctor. One develops a degree of emotional resilience, moulded by years of seeing physical pain and emotional suffering, but there are times when that resilience is tested to the extreme.

I do my out-of-hours work on a Saturday night, when my children are in bed and my husband can babysit. Early last year, I had to visit a 36-year-old man called James, who was dying from terminal cancer. My remit was simply to make him comfortable. At this point he was beyond communication, hours from death and struggling for comfort.

Normally such patients are cared for by district nurses and the wonderful service provided by Marie Curie sitters, who look after patients in their final hours. Unfortunately, in the area this man lived, there were none available and the district nurses had finished for the night. This was a cruel misfortune for a man already dealt such a terrible fate. It is not an understatement to say that the family were devastated, trying to keep their dying son at home in his final hours with no professional care. I remember his mother hugged me on arrival, so relieved was she that someone had appeared.

From the outset it was clear that James needed more medication to ease his agitation. I spoke to the local hospice and started to optimise his drugs with the telephone guidance of one of its doctors. While I waited for the medication to take effect, I discussed with James’s parents what would happen next. I would leave for my next house-visit and, if he was still in pain, they would call the co-op back.

Because guidelines dictate patients are not allowed to call doctors directly, another GP would come to help. I couldn’t guarantee how quickly that might be but I would ask the co-op to prioritise any calls from this house – in general even an urgent call can take two hours to mobilise. That could have been all James had left. Not convinced James had been made any more comfortable, I again tried to optimise his medication. A momentary air of calm prevailed. His family were desperate to have a professional with them, as he was clearly swinging in and out of discomfort.

At this point, I made the clinical and humane judgment that I could not leave James. I firmly believe that most doctors would have done the same. My shift at this point was over and I judged that it was appropriate to stay out of my own time to ensure James was given the death he wanted. It was midnight. I informed my co-op driver and the base team of my decision and continued to monitor James, giving him the necessary medication and comforting his parents.

Within ten minutes I was called by the clinical supervisor from the co-op, an older more senior doctor. I was greeted with a tirade of abuse. Why was I staying wasting co-op time when there were a huge number of visits outstanding? I should call the district nurses, not waste doctor’s time on palliative care. Was I expecting someone to come and replace me? You can’t spend three hours on one visit! When I tried to explain the situation, he swore at me before hanging up. To add insult to injury, James’s father overheard and apologised for the trouble his son’s death was causing.

You see, while my supervisor was supposedly ‘clinical’, his concerns were anything but. The new GP contract is a target-driven concern. Shifts are paid by the hour, calls must be answered within a certain time and, most troubling of all, a certain number of visits must be undertaken in a six-hour shift. These are not measured by the quality of care but by the volume of patients seen. It is an alarmingly similar approach to the targets introduced in accident and emergency wards, where it has become more important that a patient is seen within four hours than by whom or why.

We have moved so far into a target-based system that common sense has been left behind. The clinical supervisor I had to deal with had forgotten his compassion for the dying and his empathy for a distressed colleague. Compassion and sense had been replaced with performance and targets; I believe he had forgotten what it means to be a GP. The out-of-hours services have to prove on paper they are performing well, otherwise the Primary Care Trusts take away their contracts for the next year. This poisonous culture means that they need to fill all shifts with doctors to have any chance of meeting these targets.

Does this mean the recruitment of doctors may be compromised? Clearly it does, as shown in the case of Mr Gray.

I am in no doubt that there should be a return to a more old-fashioned approach because the fragmentation of the current system leaves little chance for continuity of care. GPs should treat patients they know, or at least ones they are aware of. Doctors and patients deserve that. I remained at James’s house, where I continued to monitor him and give him medication. I cried looking at the photos on the lounge wall of a schoolboy with a cheeky smile, who was now dying at just 36. Even thinking about it a year later I can’t stop a lump forming in my throat. I left the house when I felt that he was settled, about five hours after I arrived. He died at 4.30am in bed peacefully, with his family by his side.

Do I regret being involved? Absolutely not. Was I shocked, even as a jaded foot soldier of the NHS, by the reaction I received from my colleague? Absolutely. What could have been more important than making a dying man more comfortable in his final hours?

Meeting the time targets for my shift? Ticking the right boxes to show the co-op was performing well? There were no tick boxes for being a good GP, for compassion, or for helping someone to have a ‘good’ death.

For James, given the circumstances, I did the best I could have done. But his own GP, who would have known his family and had at least spoken to him about his death, would have been better than one who knew him for no more than five hours. The boy in the photographs, the boy with the cheeky smile and his whole life before him, deserved better than that.


A sad example of British government regulations leading to poorer health

DOCTORS have uncovered the first evidence that fathers of test-tube babies may be passing on their infertility to their sons. A new study has found that boys conceived through IVF treatment involving a single sperm being directly injected into a female egg often inherit shorter fingers, a trait known to be associated with infertility. The results raise the prospect of a new and growing generation who may be less likely to have children of their own.

There are now an estimated 1m children across Europe born through IVF treatment. Almost one in 50 British babies is conceived artificially and nearly half the couples having treatment go through a procedure known as ICSI (intracytoplasmic sperm injection). The technique bypasses the normal competition where only the healthiest sperm cell is able to reach the female egg and fertilise it.

Alastair Sutcliffe, a paediatrician at the Institute of Child Health in London, led the Anglo-German study which compared 211 six-year-olds conceived through ICSI with 195 naturally conceived children of the same age. The ICSI group were similar heights to the naturally conceived group, but the boys had significantly shorter fingers. It is known that men with low sperm counts often have ring fingers the same length as their index finger, whereas fertile men are more likely to have a ring finger which is relatively longer than their index finger. The effect is reversed in women, where the most fertile are likely to have index fingers significantly longer than their ring fingers.

Sutcliffe’s findings appeared recently in the journal Reproductive Biomedicine Online. “This is the first study of this kind on these children,” Sutcliffe said. “We don’t yet know the implication of the findings because the children are very young, but we need to inform people [about the possible risks of the ICSI procedure].”

Scientists have long suspected that the test-tube baby boom would bring its own problems. Infertility treatment began as a commercial operation only in the 1990s. The first ICSI baby was born in 1992 and there are now about 3,700 such births a year in Britain.

Finger length is known to be set within the first 14 weeks of pregnancy and is linked to testosterone exposure which is, in turn, governed by a specific group of genes. “This [research] is telling us that we should only use ICSI when it is absolutely necessary,” said John Manning, an evolutionary biologist at Southampton University who has examined the link between finger length and fertility and who is one of the authors of the latest study. “We know the extraordinary depression and pain that childlessness can cause and we have a responsibility to ensure that the focus on the wellbeing of the children born as a result of these techniques is as high as it can be.”

Josephine Quintavalle, from the pressure group Comment on Reproductive Ethics, pointed out that ICSI is becoming the preferred option in infertility treatment because of a shortage of healthy sperm. This occurred after the introduction of legislation requiring donors to agree to be identified to their offspring in adulthood. “Using ICSI is obviously counter-intuitive to good health and this research would demonstrate that may be true,” she said.

Allan Pacey, a senior expert in male infertility at Sheffield University and a spokesman for the British Fertility Society, said ICSI should be used “only when absolutely necessary”.

A spokesman for the Human Fertilisation and Embryology Authority, which regulates private IVF clinics, said doctors are expected to warn couples of the risks of treatment before they are enrolled as patients.


The Public Option Threat Still Buried in the Senate Bill

Most Americans now believe that major health care legislation will not pass this year. But as Heritage Vice President Stuart Butler explains in The New England Journal Medicine one seemingly minor proposal in the Senate health care bill could end up having huge repercussions for our entire health care system:

The Senate legislation contains strong directives to the OPM, requiring it to negotiate medical-loss ratios (the percentage of premiums that insurers actually spend on medical care for enrollees), minimum benefits, profit margins, premiums, and “such other terms and conditions of coverage as are in the interests of enrollees in such plans.” Crucially, the legislation also specifies that the OPM-administered plans would automatically be deemed to meet all the requirements for plans to be offered through the health exchanges created by the legislation.1 This means that OPM-administered plans could in practice operate free of many of the financial regulations that exchanges might impose on other plans, allowing the plans to operate under their own OPM-designed regulations.

How might the health care system evolve if this OPM feature were implemented as part of a modest reform package? Congress rarely gives an agency powers that it does not intend to be used. It also seems reasonable to assume that the people appointed to administer the new bureau within the OPM will be more likely to embrace the adversarial and regulatory philosophy of the leading congressional reformers and the CMS than the traditional “hands-off” culture of the OPM. Managed by such a transformed agency, the private plans that were part of an OPM alternative would probably come, over time, to look more and more like third-party administrators of a federally designed competitor plan, operating under rules significantly different from those governing competing private plans. The result in a few years could be functionally indistinguishable from a public option.

Butler identifies another proposal seen in the House bill that also could spell the death of private health care. Read his whole article here.


1 comment:

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