Saturday, March 19, 2011

NHS: The Way We Were! Free!


Yes, the Cockroach Catcher came to England for higher training in Child Psychiatry in the early 70s and I also saw the film: The Way We Were then.

But this is not about the film!

In 2008, The Cockroach Catcher was published. It was fictional, the names were; the rest were all based on my experience.

Here is a part of the first Chapter:

“It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.”
          Those were more or less the words said at the transfer meeting by the nurse from the private hospital where Candy had been for the past eighteen months. She had been compulsorily detained twice and she had been put on Olanzapine.  Olanzapine is one of a new group of drugs licensed for Schizophrenia and has been found to induce a voracious appetite especially the bingeing of carbohydrates. Some psychiatrists have started using it for this specific effect. In Candy’s case she managed to fight the biochemical effect of Olanzapine.
          Candy was just two days free of tube-feeding, which apparently was the only way to get her weight to a less frightening level.
          Ethics in medicine has of course changed because money is now involved and big money too. What was in dispute in this case was that the private health insurance that sustained Candy through the last eighteen months had dried out. The private hospital then tried to get the NHS to continue to pay for the service on the ground that Candy’s life would otherwise be in danger. The cost was around seven hundred pounds a night.  Some would argue: since we as a state hospital would not be getting the money, why should we take the risk?  After all, the consultant in charge would be in the dock if the patient did die.  Nowadays, patients and their families are trigger happy and complain even if the patient becomes better. God help us if they die.

          I argued the case in the opposite fashion. We shall help the authorities without precondition and who knows, I may be able to get them to give us something when the time is right.
          Cynics at the unit looked at me as if I had just dropped off another planet. Get something out of the Health Authority? When were you born?
          A quick calculation gave me a figure of over a quarter of a million pounds per year at the private hospital.  No wonder they were not happy to have her transferred out.  Before my taking up the post, there were at one time seven patients placed by the Health Authorities at the same private hospital. Not all of them for Anorexia Nervosa, but Anorexia Nervosa required the longest stay and drained the most money from any Health Authority. I have seen private clinics springing up for the sole purpose of admitting anorectic patients and nobody else. It is a multi-million pound business. Some of these clinics even managed to get into broadsheet Sunday supplements.  I think Anorexia Nervosa Clinics are fast acquiring the status of private Rehab Centres. Until the government legislates to prevent health insurers from not funding long term psychiatric cases, Health Authorities all over the country will continue to pick up the tabs for such costly treatments.
          The poor nurse did not realise what hit her. That was my first week. I am never threatened. I like the challenge of difficult cases and definitive statements like – the patient will die.  I like to prove it otherwise.
          The nurse concerned was not naïve either. Far from it. She based her judgement not on what she knew about me. It was only my first week after all.
          No, she based her judgement on her knowledge of the unit, as she used to work here. She was once its lead nurse. Alas, poor pay and bad conditions coupled with the deteriorating consultant leadership prompted her to jump ship. I could not blame her for that.
          The unit went through a difficult phase until the last consultant was finally suspended. Even before that, other consultants started refusing to refer patients here, and the two main Health Authorities that the clinic served had to fund ECRs (Extra Contractual Referrals in the then re-organised Health Service lingo) to mainly private hospitals.
          Then the unit had a locum and the operation was scaled down drastically. Bed availability dropped to less than half the normal capacity and the waiting list for admission grew. Unlike elective surgery, some patients in psychiatry cannot wait. Beds had to be found and often they were placed with adult psychiatric patients. It was not ideal even for the psychotics and certainly inappropriate for Anorexia Nervosa. Private Hospitals had to be used.
          My first task as the new consultant in charge was to ask the Charge Nurse what would limit our ability to admit to full capacity.
          “Your time,” was his reply.
          So we aimed to move to full capacity, not overnight but within the following three months. The shock on the faces of the managers as this was announced at a meeting gave me such an adrenaline rush. 
          Or, did they think, “What a fool!”
          Fool or no fool, one needs to enjoy one’s work, even in the NHS.
          This perhaps is one thing that the government has conveniently forgotten. Many of us do what we do because we enjoy it. Otherwise why should anyone want to teach in universities when they can earn ten or twenty times more in industry? We may also decide to dedicate more time to work for personal pride and satisfaction. During the few years I worked at the inpatient units I spent in excess of a hundred hours a week there, one man doing the job of at least two.  In addition to that, I was still looking after two outpatient clinics.
          With increased capacity, we were ready to take on transfers. At that time the Health Authorities still had decent managers not yet blinded by directives and performance targets. For a start these managers did not interfere with clinical matters. For our part we were free to exercise our clinical judgment.  Unfortunately many consultants abuse this privilege of clinical independence, often making excessive demands for treatments and investigations, and managers have learnt to ignore them.  Worse the government set up this organisation called NICE (National Institute for Health and Clinical Excellence) to try to deal with such behaviour. 
          “It is our view that clinically it was wrong for Candy to be transferred at this stage. It was wrong for the NHS to accept her back and in our view Candy is in serious risk of – quite frankly – dying.” 
          The nurse was probably unwise to make such a declaration, as my mind was already made up to take on Candy regardless.
          What if the private hospital did not exist?  It would have been down to us then. So to me that was no big deal. After all, most private hospitals are notorious for transferring their dying patients to NHS hospitals so as not to mess up their pristine mortality figures. What was so different here?
          “Shall we meet the family?” I said, trying to break the ice.
          There had of course been a pre-visit by our Charge Nurse and his team.
           “This one is difficult and I think you may have a problem with father.”
          Candy led the three-some. She gave me such a look as if to say, “Wait till I give you all the trouble.”  She looked out of the window for the rest of the time. Mother was warm but worn. Eighteen months had taken its toll and she was gracious enough to be pleased to meet me. Father on the other hand seemed to show some anxiety. In fact, he was a quite a powerful negotiator, and had managed to persuade the insurers to agree to extend the private medical care for another six weeks on a shared cost basis, either with the parents or with the Health Authority.  He was still quite keen on the private treatment, and was half hoping that I would refuse to take Candy on clinical grounds and then the Health Authority would pick up the bill from then on.
          To be fair, eighteen months was a long time even for Anorexia Nervosa.  Perhaps someone else should have a go.  NICE had not yet come up with a standard treatment and I certainly would challenge them to do so. Tube feed everybody?  That would be the day.
          Mother was more intuitive and I think she got the measure of me very quickly. “Darling, perhaps we should give Candy a new start. The new doctor might work in a different way.”
          “It is the nurses that did most of the work.” A final and desperate attempt by the nurse from the private hospital to set the record straight was missed by the nervous family. The rest of the world still looked up to the consultant, perhaps not for much longer but until Armageddon, I was going to enjoy it.
          “I will give it my best shot.”
          So on a rather unusually beautiful sunny Tuesday morning, we received a soon to be dead Anorexia Nervosa patient who had been abandoned by her insurer to the unsafe NHS. What a challenge! Some of those at the meeting must have considered that I was delusional.  I believed that money should not be part of the consideration for the best health care and I was determined to make sure that my delusions should remain true for me.  I had to maintain a good service in my little corner of the NHS.
          Perhaps I was able to capture mother’s heart and gain her confidence through mine. She decided that they should give us a try.

You can read the full chapter here>>>>>>>>.

I would like to convince readers that the NHS is worth saving so for a limited time I am offering an electronic version free to any medical blogger, nurses and doctors that worked in the NHS and other health care systems totally free. Please drop me a note to my email address <cockroachcatcher (at) gmail (dot) com >or through COMMENTS.

Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
                                                                      The Way We Were

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

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