Whatever you think about the efficiency and value for money provided by the NHS, there has, recently, been an increasing realisation, among the general public, that it is not the “great British treasure” it was once purported to be. In the last few years it has lurched alarmingly from scandal to scandal – dirty hospitals, lack of nursing care, spiked reports, variable death rates, and expensive compromise agreements to silence whistleblowers.

But I would predict that what we have seen, thus far, is only the tip of an enormous iceberg because the bureaucracy has become so self-serving and the structure of the organisation is so incestuous that we can be pretty certain that uncomfortable truths have been buried wherever possible.

Unaccountable Local Health Boards have conspired with professional bodies and incompetent regulators to ensure that the many serious abuses that have been perpetrated will not easily reach the public domain.

So let me tell you a story.

Dr Smith is an eminent GP working in South Wales. He is heavily involved in his Local Health Trust and sits on many important committees.

Dr Brown, one of the other doctors in his practice, has become aware of the predilection of Dr Smith to prescribe Fentanyl patches to almost any patient complaining of pain. Fentanyl is a synthetic opiate, about 100 times more powerful than morphine, and is really intended for terminal patients and those in chronic pain – people who have already built up a tolerance to other opiates.

Unsurprisingly, the indiscriminate prescription of this drug has caused an unusually high death rate amongst Dr Smith’s patients and Dr Brown raises her concerns with him. At this point, Smith tells Brown to mind her own business and continues as before.

Dr Brown then alerts her Local Health Board to the issue and an investigation is conducted in secret. As a result of this enquiry, Dr Smith is cautioned by the Health Board, asked to undertake retraining and prohibited from prescribing opiates….for a year. Of course, colleague relationships have, by now, become strained, to say the least, and Dr Smith, who is head of the practice, launches a campaign to compel Brown to leave it.

At the end of the opiate prescription ban, Dr Smith commences, once again, to routinely prescribe Fentanyl patches to his patients and many more die as a result. Moreover, Dr Brown has, by this time, noticed that there are statistical spikes in the death rate of Smith’s patients prior to him going on holiday (he gets paid “ash money” for each death).

Dr Brown once again reports the matter to the Health Board which responds that her concerns have already been investigated and dealt with. (Please note that it is not in the interests of those on the Health Board to investigate and discover that Dr Brown’s allegations are true – that would be a catastrophic outcome for them).

Brown then repeats her allegation to the BMA who initiate an inquiry but then conclude that they cannot investigate the details of the case or come to a judgement as the matter had already been dealt with by the Local Health Board, which has legal responsibility.

When Dr Brown finally reports what has happened to the police, they interview Smith. He tells them that the allegation is entirely malicious and has, previously, been fully investigated by the Health Board. This is confirmed by the Health Board to the police, who are satisfied and take no further action.

By this stage, Dr Brown’s position in the surgery has become entirely untenable and she is forced to leave. Dr Smith continues to practice as before.

So, what do you think?

Well, I’m guessing that, if you’ve got this far, the main question you would like answered is whether or not the above is a true story or a work of fiction.

And the point of this blog post is to demonstrate that, unless I decide to tell you, you will never know……..

Mina Field August 25, 2013 at 14:09

Ok, I’ll bite. I tend towards the belief that the accusation is indeed
malicious; that the accuser is one of those young and aggravatingly pc types,
who have swallowed the textbook that says that all ailments can be cured by
thinking nice thoughts, relaxation, and eating well. They go into fits of the
vapours at the mention of, say, valium, and somehow think that nobody got
treated correctly until they personally qualified, about two years ago.
Furthermore, whilst making much of the (true) fact that these patches should
be prescribed only to those already opiate tolerant, the author neglects to
state whether these patients meet that criteria. One can only assume that they
do.

Miss Mildred
August 25, 2013 at 09:47

Just had a quick resume on Shipman and his home visits. I find it
extraordinary that those who worked close to him took ages to twig that he was
up to something. As soon as I got the sense of what he had done, I could never
have dreamt of the extent of his murdering practices. They went back in time
to when he was a young doctor too. I do feel that Shipman’s activities made
for a profound mistrust in the NHS. Followed by the MRSA scandal and other
nasty infections. Staff seem to permanently be pulling on blue gloves. There
are hand cleansing dispensers everywhere. The mountain of discards after every
procedure are astounding….In service training has always gone on anyway. There
are always bad practices with some staff, no matter how well trained. Some I
met over the years were born lazy and feckless, as in every other walk of
life….but more deadly. I just told them I was aware of their doings and would
take it further if they persisted. If everyone did this, the scenario, as
presented, would be less possible.

Ian B August 24, 2013 at 12:58

If this were a real case, the implications regarding the “Ash Cash” is so
serious that this is not a matter for the NHS or BMA, but the police. Which is
where the suspicious doctor should take it, rather than a blog. It’s not a
matter of NHS politics, but criminality.

That’s my view anyway.

Engineer August 24, 2013 at 13:24

Well, the police were involved, but were fobbed off by being told that
the suspicions were malicious, and had already been investigated by the
Health Board.

Criminality? Well, most certainly a gross failure of professional
responsibility. Result of investigations? Carry on regardless.

For those of us who use medical services, very worrying. How can we be
sure that proper standards are being upheld?

Jonathan Mason
August 24, 2013 at 13:37

There are some dangers with Fentanyl patches, for example you have to
make sure to take off the previous patch before applying a new one to be
sure to get the right dosage, the drug may interact with and potentiate
alcohol and other drugs, may cause dizziness so the person should not drive,
may cause constipation that could cause a fatal bowel rupture, and since
opiates depress breathing one would not expect them to be prescribed to
patients with respiratory diseases, and so on, but since the doctor was on
holiday, he could not have personally been administering the Fentanyl
patches, a task that would be done either by a visiting nurse or by the
patient him/herself, or by a carer if the person is incapacitated, so
probably impossible to find grounds for murder charges unless there was
something specific in the cause or manner of death that I have not thought
of.

[I suppose in the case of overdosage, there might be some necessary
precautions, for example the pharmacy only issues 5 patches at a time, and
only on receipt of the empty packets from the previous 5, but I doubt
whether this happens in the community. Hospitals and nursing homes handle
these substances much more carefully.]

On the other hand, if the deaths could be shown to be linked to incorrect
prescribing, interactions with other prescribed medications, etc. then
surely this would be a matter of medical malpractice and negligence, not
murder, and to be handled by the medical authorities and civil courts.

James L August 24, 2013 at 09:02

It is well known that doctors with a certain type of personality can
develop a “God complex”. Having the power of life and death over patients
becomes an exhilarating high and, of course, being God, they can never be
wrong. This was the back story to Shipman.

In the above example it doesn’t really matter whether Dr Smith is
deliberately and wilfully killing his patients or not, the result is that they
are dying from the drugs he is prescribing and, for whatever reason, he is
unwilling to change his behaviour. Whether this is due to malice, misanthropy
or a massive ego is irrelevant, the point is that the culture of the NHS and
the reflex defensive stance of the medical establishment mean that such a
doctor can continue to practice and continue to kill.

Regarding the truth of the account, the sharp eyed crossword solver might
conclude that the writer has left a clue in her choice of pseudonym.

Bob August 24, 2013 at 03:20

It’s a bit sad to read this on a blog that I respect. My experience as an
ex employee and more recently a customer of the NHS is that the vast majority
of staff DO care. Of course there are a lot of pen pushers, but a lot of them
exist as a consequence of having to administer constant changes, and
initiatives introduced by successive governments. If they didn’t exist it
would result in clinicians having yet more paperwork to do and meetings to
attend.
The real problems in the NHS (not the sometimes hysterical and
exaggerated ones we see in the MSP), are down to govt interference and simple
under-funding.

Ho Hum August 24, 2013 at 11:38

Good observational skills. Spot on diagnosis.

Kryten might have asked “Are you a doctor?”
. (Series 2 Ep1 if you’re a Red Dwarf fan)

Engineer August 24, 2013 at 13:17

I’d take issue with the idea that the NHS is underfunded. The Health
budget is £120bn, that’s £2000 a year for every man, woman and child in the
UK, near enough. The real question is not whether the funding is sufficient,
but whether it is being used effectively. I would suggest that there is
considerable scope for more effective use of that funding.

Governments should interfere. When scandals such as MRSA, the retention
of bodyparts after autopsy and the recent spate of examples of poor care are
uncovered, it seems that the instinct of all health institutions is to close
ranks and resist any action that might improve standards. In such cases, the
only advocate those of us forced to pay for and use inadequate services have
(and a rather poor one at that) is government. In such cases, it is
government’s duty to act on behalf of the country, and kick the guilty
parties very hard. They don’t do enough of it.

Ho Hum August 24, 2013 at 14:00

With due respect, Mr Engineer, I think that the type of government
interference that Bob might be referring to is that which causes the
structural mayhem. None of the organisational restuctures that have been
made over the last 20 years or so has been left alone long enough to allow
anyone to make them work. And the politicians and policy makers certainly
don’t have to

NHS restructures really aren’t sweetie shop stuff, or just moving a few
chairs about. The cost is astronomical, and not just in monetary terms.
When you get politicians throwing it all up in the air, now as frequently
as every two years, it’s almost miraculous that there are still sufficient
people who care enough to put in the effort to keep the wheels on the
wagon.

Margaret
Jervis August 24, 2013 at 14:01

Well the MRSA scandal was solved by re-introducing basic hygiene
controls. But I assume you are talking about the ‘ blame , shame, claim’
type inquiries. Seem to remember ‘ body parts’ – about the dead and the
simple failure of recording autopsy residues that have long been an
important resource of medical research-and not the poor sods that have to
use the NHS – did result in inquiries and big pay outs for relatives, with
fresh funerals for the parts and even slides, I understand, in some
instances. I simply don’t think this is the problem or the solution for
our collective and individual woes. Certainly the massive cost of these
enterprises greatly diminishes the public purse – which should concern us
all.

Jonathan
Mason August 24, 2013 at 14:32

Well the MRSA scandal was solved by re-introducing basic hygiene
controls.

I have no idea how much this would have cost, but presumably there
would have had to be new training and certification for every single NHS
staff, on every shift in every location in the country, plus the
training would have had to be added to new employee orientation NHS
wide. Then you would have to set up monitoring and reporting and
analysis at every NHS location nationwide.

It sounds so simple to implement basic hygiene controls like
handwashing, but maybe you have to install more handwashing stations
close to the patients, discuss what type of disinfectant soap or alcohol
is to be used, how long the hands have to be washed, how the hands are
to be dried, how the taps are to be turned on and off to avoid
recontamination, how to deal with issues of staff allergies to the
approved soap, ensure the paper towel dispensers are always fully
stocked and yet avoid wastage, blah, blah, blah.

And even simple and basic procedures that should already have been in
place, like ensuring that dirty linens do not touch the floor when beds
are being made, and that staff who have been handling dirty linens are
not handling clean linens with the same gloves are terribly time
consuming in terms of training and monitoring, not to mention expensive
in terms of gloves. Of course with protective gloves you also have to
have the hypo allergenic gloves available too, and the gloves need to be
available in a variety of sizes to fit male and female hands.

As you may figure out, I used to be a health services manager, and
maybe what I am saying is too obvious to mention, and I am just doing
the poor me routine, but it can be incredibly hard to implement these
procedures effectively when you have a staff of hundreds of thousands,
not all of whom are highly educated or motivated, and where the service
is only as good as the weakest link.

Margaret Jervis
August 23, 2013 at 22:54

Interestng diversion – – but a goldfish, Title of a fabulous novel by De
Clezio and also a beautiful song by little known Lithuanian but bagged as
Polish composer Moniusko. Contemporary of Chopin . Amazing but almost unknown
here. Funny that.

Elena ‘andcart
August 23, 2013 at 22:39

Not really, Ho Hum. Try again later.

Ho Hum August 23, 2013 at 22:41

Nice one. LOL

Elena
‘andcart August 23, 2013 at 22:49

Such is life. As long as you have one. Personally, I expect to live a
bit longer here.

Now what was I saying about Richard the Third?

charlotte August 23, 2013 at 22:30

I must be so lucky to have the GP practice that treats me in here UK. My
now retired GP decided to refer me when I reported to him with dry eye
syndrome. I thought it a waste of my time and public funds but I did go to see
the specialist who after examining my eyes told me I had a quite serious
condition that could compromise my sight with blindness. Thankfully it is
monitored regularly and has been thus far treated with laser. When I
experienced some fairly agonising pain my new GP diagnosed gall stones
immediately, and I was offered elective surgery within 6 weeks of my first GP
visit. I was very well taken care of at my local hospital and recovered well
enough to return to my manual job 7 days after the cholecystectomy. I did
however refuse the painkillers prescribed after the surgery which were called
tramadol and managed with ibuprofen and paracetamol.
Maybe Dr Smith just
got fed up with the constant stream of patients complaining of back pain which
seems to be the national illness in Wales.

Ho Hum August 23, 2013 at 21:40

@ Margaret Jervis – loads of comments

When it comes to discussion here on UK health and social care issues, you
could spend all day trying to inculcate some sense of reality and proportion
but you might as well spend your time trying to persuade the average DM reader
that the BBC is not the spawn of the Devil and that the ECHR is not part of
the EU a d is something that the UK was instrumental in creating, should be
proud of having done so, and is the last legal resort we have against our own
government when it turns its malevolence on us if we come in some shade that
it doesn’t like. You are not really going to get anywhere

The sad thing is that it then makes one question whether or not the
commentators who spout eloquently on other issues, eg the Savile stuff, really
have a clue about that either. I really hope they do, but sometimes I
wonder

Margaret Jervis
August 23, 2013 at 21:52

Thank you Ho Hum – there is a real dearth of imagination, not to mention
compassion, out there – and in here sometimes. But C’est la vie. La Vie est
….what was that word?.

Elena
‘andcart August 23, 2013 at 22:04

La vie est morte, I think you may be looking for. So long as it isn’t
you. See how you crack it.

Ho Hum
August 23, 2013 at 22:13

L’ancienne vie est morte, peut-être?

Elena
‘andcart August 23, 2013 at
22:17

Yer, something like that. But The French are better at that as
well.

Margaret
Jervis August 23, 2013 at 22:16

The dead are silent Elena. They do not exist.

Elena
‘andcart August 23, 2013 at
22:19

O really? Well Richard the Third has just had something to say
about that.

Ho Hum
August 23, 2013 at 22:32

Missed that. Was it suitably cutting?

Margaret
Jervis August 23, 2013 at 22:28

La vie est un poisson d’or. That was what I was searching for!

Ho Hum
August 23, 2013 at 22:40

Good think I looked up Google Translate. My French has its off
days, and I thought you were being Pythonesque

http://www.quotesandpoem.com/quotes/listquotes/author/monty-python

Mina Field
August 24, 2013 at 08:09

@Ho Hum
Yes, we know you wonder. You keep saying so. Even here, where
the topic is unrelated. To me, you appear overly concerned with the
matter.

Margaret Jervis
August 23, 2013 at 21:12

The lawyers are there by invitation MTG.. You are encouraged to claim by
the NHS itself which somehow hopes to get payback. I have no truck with many
of the PI lawyers with their ‘bleeding hearts’. Many are ‘Christians’ of the
‘health and wealth’ variety. But they are the camp followers of Mother Courage
and her Children. Yes Brecht has his faults, but on this he was spot on. That
was a 20th c take on the thirty years war – sometime back but worth looking
into.

MTG August 23, 2013 at 20:47

There can be little doubt the UK’s main public services are corrupt and
self-serving but where the exact truth lies in this particular instance,
cannot be established from the ‘facts’ presented. Should we accept without
question that the indiscriminate prescription of this drug has caused an
unusually high death rate amongst Dr Smith’s patients? Ahead of any
vilification for under or over-prescribing fentanil, it is important to know
whether Dr Smith was responsible for a skewed ratio of elderly patients who
were in chronic pain.

If you are looking for rogues and parasites embedded within our public
services, the biggest of these are the lawyers, Anna.

Ho Hum August 23, 2013 at 21:29

I’m not a doctor, but on the basis of your opening phrase, I’d suggest
you see a psychiatrist

Otherwise, the lawyers may be a pain, but they are there primary as a
result of the legislature’s failure to create any legal structures that
actually make sense, or are operationally competent

MTG August 24, 2013 at 08:16

*yawns*

Ho Hum
August 25, 2013 at 00:34

Sleep apnoea, maybe?

FWIW, that was a joke

Margaret Jervis
August 23, 2013 at 20:41

I think we can agree here that ‘health’ and fear of mortality are very
important issues to us all . This used be punctuated with fear of
accountability, sometimes unjustly. But no matter. Conscience still is
inviolable – even if nobody else cares

I think it is agreed that there are serious problems with the NHS as run –
but the extent and nature of this is in dispute..

Certainly it would seem likely that if everything is run by push button
machines with the lowest grade staff delivering care , some disjunctions may
occur.

AS for diagnosis – problem is that angry people are sometimes angry for a
good reason and sometimes not – their problem lies elsewhere. It takes a keen
realisation of what’s being said and the reasons for it to discern. Current
guidance probably does more to hinder than help on this matter.

Are there lots of homicidal maniacs around in the NHS – no. There are lots
of people with their minds distracted – Twitter, FB, all sorts of claims that
appear (to the person) ‘off the wall’

There is a massive disconnect in our society and that is the problem.

I realise there are many benefits to the French system of healthcare but
you don’t have a bill for 5,500 euros to pay as I do. Yes I can claim 80 per
cent back. I don’t have french health insurance. I pay my tax in the UK. I
think the
French have their own rumblings about healthcare costs.

Inadequate care diagnosis and treatment. yes. Apparently improved now. I
had a friend who died having been diagnosed with malaria after a short visit
to Niger. She never left the local hospital despite having the deadly strain.
She was getting fine and due to be discharged when she died. Could she have
been saved elsewhere? I don’t know. We weren’t told before her death it was
this deadly strain. Made me think about malaria as a killer given the
predominance of AIDS as a killer at that time. This was way back in 2003.
Thinks have changed thanked to Bill Gates. But I’m still angry about the DDT
restrictions.

There is so much that needs to be done, but homicidal maniacs are not the
issue.

Elena ‘andcart
August 23, 2013 at 21:07

I don’t think that anyone believes that The NHS is peopled by homicidal
maniacs. Just by people who don’t give a fuck, because why should they? They
get paid anyway. They have no need to keep people of my age alive, or even
to care. There is no incentive. Nothing to care about. Just some boring old
biddy who should probably be dead anyway if she or he didn’t need
help.
And don’t tell me that they somehow learned to care while they were
taking their Degrees in People Management. That’s the thing you see. People
Management. They know everything about managing people, and sweet fuck all
about people.

Margaret
Jervis August 23, 2013 at 21:15

Agree.

Elena
‘andcart August 23, 2013 at 21:58

Thank you. This is disastrously sad. Society is measured by it’s
treatment of old people, and by the treatment of it’s sick and ill. And
by anything that escalates the death of any of them, even by default.
And I don’t care how much it costs to avoid this. But I can no longer
believe that this is what will be done in UK.

binao August 23, 2013 at 22:12

Sorry Elena & Margaret, but as a serial glass half empty person,
my recent experience at two local hospitals (w sussex s. coast) and my
troubled local GP surgery show a real change, and I earned my living for
a while doing turnarounds in business, so I am acutely alert to
presentational crap.
Maybe this is a bit of grass roots change, maybe
it’s just local, but I had to say to some people how impressed I was;
not a medical or technical judgement, I’m not competent, but how I was
treated and communicated to.
The fact that their attentions have, in
protecting my survival diminished my quality of life is perhaps a trade
off to be debated.
But I understand the basic problem of the public
sector and the primary motivation of preservation of the organisation-
look at the reformed local govt pension scheme 2014 for instance. If
only we had an answer- socialism doesn’t.

Elena
‘andcart August 23, 2013 at
22:25

Sorry, not sure what you are saying. My glass is always half full.
Until it is empty, of course.
I have long earned my living by
cutting grass. That puts you where you ought to be.

Mike August 23, 2013 at 19:57

Going back to the original post; yes I know from my own experience that
there has been inappropriate prescribing of opiates and similar drugs. However
Shipman was a ‘one off’, he was a psychopath who took delight in death. The
government and its creature the GMC (its run by a journalist with no medical
or health care experience or qualifications remember) have got themselves
wound around the axle trying to ‘prevent another Shipman’. Well if they had
done nothing, there would likely have not been another Shipman. That said,
re-appraisal etc which has been the eventual result was long overdue.

I do have some training in medical statistics. I do not believe that it
would be possible to see a statistically significant up turn in an individual
doctors death rates (unless he was dealing in Dr Mengele type numbers) before
he/she went on holiday. Statistics can do a lot, but they aren’t that good.
Did the complainant mean that there were a few extra deaths? Fine, say so, but
don’t invoke statistics.

The original post was probably, to my mind, a fictional representation of
what can happen.That said, were the two doctors the only ones in the practice?
a two doctor practice is very rare these days, what about the others?

Mike August 23, 2013 at 20:00

Further to my last, the BMA is a trade union. Why go them? They don’t
initiate inquiries.

Jonathan Mason
August 23, 2013 at 21:06

Shipman wrote “old age” as cause of death on the death certificate of one
of his victims. This alone should have been a signal that something was very
wrong as “old age” is not a proximate cause of death in medical terms. He
should at least have had the decency to write something like “cardiac
arrest” or “respiratory failure”.

http://en.wikipedia.org/wiki/Death_by_natural_causes

Margaret
Jervis August 23, 2013 at 21:18

Jonathan. Everybody dies. Maybe it’s just gravity in some instances. I
think sometimes ‘proximate cause ‘ is a bit of a DSMer.

Jonathan
Mason August 23, 2013 at 22:35

Of course they do, but their GP doctor has a list of their medical
diagnoses during the living phase of their life and can have a stab at
the most likely cause of death. “Old age” sounds like an offhand cruel
joke especially if it was applied to someone who died at home and was
not considered close to death prior to being found dead. Especially if
they were murdered by their doctor.

On the other hand I would agree that the death of Jerry Falwell was
an “Act of God”, but would one put that on the death certificate?

Margaret
Jervis August 23, 2013 at 22:45

Used to be said that ’cause of death’ could be in many instances
surgery – but rarely mentioned. this was because in the old days
people used to open up to see what was wrong and if could be fixed.
Sometimes could, sometimes not. But the surgery would hasten death
when not. The hazards of the ‘laparotomy’. But if this had been put in
the death certificate – and this was before rampant litigation – then
who would be blamed?
But if you didn’t explore by surgery and the
patient died – that too would be seen as negligent. There are clearly
fine judgments to be made in many cases re intervention. But how can
you be sure that the ’cause’ attributed from the list is the actual
cause and not a combination of side effect drugs etc in context? Would
you put he died from morphine?

Mike August 23, 2013 at 22:36

Cardiac arrest = heart stops. Respiratory failure = stops breathing.
Neither is a cause of death, they are mechanisms of dying. The coroner
will not accept them as causes of death.

Elena
‘andcart August 23, 2013 at 22:57

Somedebody obviously hasn’t been watching Holby General. Patients now
tell the doctors what to do. Cut out my Spleen? Do me a favour. Bugger
off.

Margaret
Jervis August 23, 2013 at 23:00

Maybe that’s part of the problem Elena – Cart and horse and all
that?

Elena
‘andcart August 24, 2013 at
00:28

@ Maragret Jarvis. You don’t actually believe that shit, do you? No
one I know does. It is just passing entertainment for all of us who
are bored out of out wits most of the time.

Look now, there is a serious problem within the British National
Health Service. It costs you nothing, and so you are worth nothing.
You pay nothing and so you must expect nothing.
Yes, I know that
your money is taken at source, presuming that you even have a job in
the first place, but by the time you get to my age you are only a
burden, and have the audacity to expect a Pension. Not to mention The
Winter Fuel Allowance. God give me strength. I will have the barstards
on that one.
There is no longer anything that I can do for England.
I am never going to be able to help my rotten country ever again. I am
only going to cost them money. What would you do with me?
But
France doesn’t feel like this. They still have some respect for old
people. And no one is ever rude to me here. France would only ever try
to help me if I needed it.
So chuck your own baby out with the bath
water.

Do you seriously think that I don’t know what you think you are
talking about? Of course I do. But the system is grossly flawed. It
gives unstintingly to those who give nothing, and then hurries the
deaths of people who are no longer useful.
In France my Health
Insurance keeps me alive, although I happen to believe that it is a
bit more than just that

And what was the Blog Post about anyway?

Jonathan
Mason August 24, 2013 at 04:23

OK, but if the coroner won’t accept these, then surely he/she won’t
accept “old age”.

Mike
August 24, 2013 at 08:08

I’m retired, but when I was young the coroner would accept old age.
However, what does it matter? Unless there is something suspicious,
the coroner won’t order a post mortem, so the doctor can write just
about anything. There was a medical myth that during the troubles in
Ireland an IRA member had his death certificate written as ‘Acute Lead
poisoning’. The doctor forgot that lead poisoning is an industrial
disease, and because of that the coroner ordered a post mortem, which
showed the lead to be in small discrete 7.62mm packets.

The Blocked Dwarf
August 23, 2013 at 19:23

Let it not be said that the German Health Care system is not without it’s
problems…to match those of the dear Old NHS….

The big headache for the German Medical Insurers at the moment is that they
have, to put it in lay terms; too much money!

Yep, just let one infuse for a moment will yous, TOO MUCH MONEY. They
provide a level of care and cover that even the super-duper new improved NHS
can only dream of providing and they don’t know whether to sink the monthly
premiums or scrap the nominal ‘surgery charge’ . Its a headache for sure….a
scandal almost…and someone will have to DO SOMETHING.

Ho Hum August 23, 2013 at 19:06

BTW, as someone pointed out on another thread that I was a bit out of date,
I am aware that the Liverpool Stairway to Heaven is being phased out.

I do also know about its possible replacement, the Lancaster Ray of
Death

http://www.dailymail.co.uk/sciencetech/article-2389473/Death-Test-Skin-test-predict-long-youll-live.html

Ho Hum August 23, 2013 at 19:03

There are always other ways of looking at issues, and I wonder if maybe
this article provides some indication that NHS hospital care really is killing
people in droves?

http://www.independent.co.uk/life-style/health-and-families/health-news/99-per-cent-are-happy-with-nhs-hospital-care-in-a-survey-where-only-10-per-cent-actually-responded-8737724.html

Now, as only 10% of the patients responded, one could possibly conclude
that the absence of comment from the rest was due to their stay having ended
with their being ushered on to a guided tour of the Liverpool Stairway to
Heaven. The doctors would be very content and unlikely to say much as they
supplemented their earnings by spadefuls of ‘ash cash’

To expand on that further, and deal with one obvious objection, the lack of
complaints from the resultant millions of bereaved relatives could then, of
course, just be a reflection that they were eternally grateful to the NHS for
having bumped off their too close and most expensive in the first place, and
sparing them the trouble of looking after old Grandma and Grandad as they
dribble over the chintz sofa as they watch ageing 60′s Porn Jockeys in endless
repeats of Flop of the Tops

As an aside on the Florida licensing, well, the US is fascinating as having
a reputation for individual freedom and a Constitution with principles to die
for, but, so help me, while I can understand some listing requirements, I
could hardly believe it when I saw that Florida actually keeps ‘State’ records
of the 100+ Facial Specialists in Nassau County – and presumably others too. I
couldn’t bring myself to look at what sort of complaints might have been made.
If you want the government to do all that for you, where do you want to stop?
You might as well list all the dog walkers too. Ultimately, you’ll need a
licence to prove you’re competent to walk across the road

Jonathan Mason
August 23, 2013 at 19:24

I could hardly believe it when I saw that Florida actually keeps
‘State’ records of the 100+ Facial Specialists in Nassau County – and
presumably others too.

Basically any profession that allows one person to lay hands on another
person has to be licensed so as to make sure that the person practicing the
profession is aware of necessary laws, hygiene requirements, and so on, and
to protect the public from sexual predators, child molesters, and so on. I
don’t know much about facials, but any occupation that involves treating
another person with chemicals is potentially risky, for example hair
stylists and beauticians use hair removers, hair straighteners, dyes,
bleaches, and so on, some of which can cause allergic reactions or burns.
And I am not even going to mention Brazilian hot wax treatments and the body
parts to which they are applied. Hair stylists and beauticians also have to
be trained to recognize signs of infestations such as lice, other
communicable diseases, skin diseases, and so on.

The person needs to be trained to know what precautions to take, what to
look for, and what advice to give the person affected if something goes
wrong.

I am not so sure about dog walkers, but in Florida even grass cutters and
mowers or landscapers (known in UK as gardeners) need a license as they may
be required to use poisonous weedkillers, and need to be able to recognize
certain malignant infections of trees and plants such as citrus greening or
invasive weeds, not to mention being able to identify the four kinds of
poisonous snake found in Florida and know how to approach or avoid any
protected species such as alligators.

Perhaps if Britain had had professional licensing for disk jockeys, it
might have all turned out so differently.

Ho Hum August 23, 2013 at 19:43

It sounds like a socialist’s idea of paradise, the achievement of
government control without then taking on the responsibility of actually
having to do anything practical. A sort of ‘You do as I say’. Or, if over
there, business interests are, as they do often seem to be portrayed as
being, inextricably interlinked with the governmental process, is that not
just plain good old fascism? Well, I never. Who could have thought it. The
USA, a fascist socialist state.

Jonathan
Mason August 23, 2013 at 19:51

Fascist, socialist state? Yes, that is pretty much what it is. With
so much regulation, the field is always slanted in favor of big business
franchises with in-house lawyers and small print authors, rather than
the little guy. You will probably make more money if your hair salon or
lawn mowing business is affiliated with a big franchise, but a lot of
the money that you make will be headed to corporate HQ and you will
never really be your own boss. Socialist fascism, yes, that is exactly
what it is.

Mizz Mildred
August 23, 2013 at 18:00

My friend and I used to say, after some doctors crass errors of judgement,
as we observed it to be, that resulted in the loss of a baby. ‘If only they,
the public knew’. Now, when we are older and in need of various treatments to
stay well or even alive. It can be very scary to reflect on what we might have
witnessed, mainly in hospital practice, in relation to ourselves and the
standard of care given to us. My husband had to campaign hard for the right to
walk under supervision. He was placed on a ward with mostly senile patients
and had NOT AMBULANT written on a white board on the wall above his head. He
waylaid the hierarchy on a ward round and insisted on being assessed to walk
with a frame. Of course he could walk! However, as regular users of NHS, I
feel strongly that so much NHS bashing is out of order, unless it leads to
some constructive outcome of immediate benefit to the patients.

binao August 23, 2013 at 17:34

Once we’ve been exposed to modern health care in other countries, it’s
difficult to view the nhs as adequate or well run. I do not suggest that we
should ignore the real commitments and dedication put in at all levels by
some; but we should be horrified at the tolerance, even protection of those
who do not measure up. We’re not looking for special rare qualities, we’re
looking for the care, human respect, and professional competence that are
basic requirements of the job; of most skilled and professional jobs.
I was
hardly an unbiased observer during the last years of my late wife, but during
regular and frequent outpatient visits and distressing stays in local
hospitals, I formed very negative views. The hostility and disengagement of
some staff for no obvious reason, the poor hygiene in wards, the lack of
weekend support in hospital, all had the smell of an organisation one step
away from collapse and with no obvious sign of anybody managing i.e. setting
standards and direction.
But that was 2-3 years ago.
My own experiences
with GPs, and with Consultants and surgery staff in one of the same hospitals
recently were as chalk to cheese. The same hospital department that ‘treated’
me 5 years ago was now staffed by people behaving as if I was a human being
instead of an inconvenient interruption. My GP (not really mine, but dealing
with me this week), telephoned me at home to give the results of some tests
carried out an hour or two before and to advise me of planned actions with
explanations.
So someone’s getting some improvements moving.
With about
one and a half million staff (I think) it isn’t going to be quick.

Margaret Jervis
August 23, 2013 at 17:34

Yes. Remember the kerfuffle about heart op baby deaths in Leeds? that was
based on mortality data. But I would imagine it’s very difficult to take
different variables into account. If a GP has an elderly/terminal weighted
caseload – he’s going to get more deaths than the one the Mums like for their
kids. That of course was the case with Shipman but that was supposed to be the
dark ages of data collection. But once you see things like ‘local politics
etc’ you never know which way the balance goes – does he make enemies (inside
and outside the surgery) has the the smear machine gone onto overdrive, is
there someone vindictive/jealous/vengeful out to get him and this grows and
grows? Or is he unduly ‘protected’? But the base data of mortality figures
would be indicative – tend to think the adage once you start to deceive what a
tangled web you weave would become apparent if there was intentional
pre-meditated harm. Psycho/sociopaths are compulsive (and often convincing) –
but tends to show in other areas of work and life. Like you I tend to think
it’s a hypothetical example but the pseudonymous author has not been revealed
as Anna as far as I can see,

The Roofer
August 23, 2013 at 17:17

I thought that the GP appraisals and revalidation were supposed to me the
place to review GP’s prescribing behaviour. I am not saying that it is the
best place to catch Anna’s hypothetical example of a doctor potentially
killing patients but this would be the fall back surely?

Margaret Jervis
August 23, 2013 at 16:14

It’s an easily made but unfortunate typo I agree and you’re right – I
didn’t check the pedigree of the link. Yes I remember ?Dale county ‘ritual
abuse’ cases in the 80s, and the notorious Janet Reno of the ?Wacko massacre,
but I know that the separated parents contact system in Florida has inspired
family law reformers here for over a decade – without it budging the decrepit
system in place one inch. The mind boggles at the openness of access to
witness statements – even redacted. But presumably this would be only after
the close of an investigation or trial? there would surely have to be some
decision-making as to relevance though. Do I need to know that my hairdresser
was found smoking in the locker room for instance? (of course this may well be
a sackable offence – but you get my drift). Of course trades like hairdressing
aren’t registered professions here – even therapists aren’t and there’s a
continual row about how and who should be in charge of this. But then it’s
almost impossible to succeed in a complaint against a registered psychiatrist
or chartered psychologist – particularly if third party. So don’t hold your
breath. But if we ever get out of the mess we’re in here – the Florida model
will be worth considering.

Jonathan Mason
August 23, 2013 at 17:08

No, you don’t need any particular reason to check up a hairdresser’s
information. You really don’t get the idea of open government, do you? I
hope I have got the link right, but if you go to this page and choose any
Florida county at random, you get a list of the licensed hairdressers (known
as cosmetologists). Fill in any blanks on the form as “cosmetologist.”

https://www.myfloridalicense.com/wl11.asp?mode=2&search=City&SID=&brd=&typ=

Jonathan
Mason August 23, 2013 at 17:09

This link may work better. Just check the box for county.

https://www.myfloridalicense.com/wl11.asp?mode=0&SID=

Jonathan
Mason August 23, 2013 at 17:23

If you go to this page you can look up any medical doctor in Florida.
Just enter “medical doctor” and select any county at random, then click
SEARCH. When it gives you a list of doctors, you can click on their
license number to see whether they have any disciplinary actions,
suspensions, etc. It will also show whether they are licensed to
prescribe narcotics. If the doctor is dead, this will also be
stated.

http://ww2.doh.state.fl.us/IRM00PRAES/PRASLIST.ASP

Margaret
Jervis August 23, 2013 at 17:47

Thanks but I couldn’t find any complaints!

the GMC list will include any restrictions and in fact even interim
panel findings are published with details of complaints.

Here’s a random example I picked up. http://www.mpts-uk.org/static/documents/content/08_July_2013.pdf

the full hearings are in public.

Is the Florida system any more open?

Jonathan
Mason August 23, 2013 at 19:06

@Margaret

Yes, interesting point. If you look up the doctors named here, they
seem to be in the clear on their licenses in spite of having been on
trial on a federal indictment (but found not guilty) however there is
a further doctor (Don Hall) mentioned who may have a separate trial
regarding the death of a patient in a Jacksonville motel. If you look
up Donald W. Hall’s medical license, it states it expired in 2000,
which cannot possibly be right as I worked with the old fool years
after that date. I also happen to know that he had previous medical
misconduct problems.

The article says:
Donald Hall might go on trial later. He
faces the same charges as the five acquitted but also faces an
additional charge for the April 2010 death of Robert Lee Johnson, who
overdosed on oxycodone in a Jacksonville motel. Investigators said
Johnson obtained the drug at Duval Wellness.

But Hall, who is suffering from Alzheimer’s, might never see a
courtroom. His competency to stand trial is now being assessed, said
U.S. Attorney spokeswoman Amy Filjones.

Knowing Hall, although I have not seen him for more than 2 years, I
am a teeny bit skeptical about the Alzheimer’s diagnosis. More like
Pinochet’s syndrome, I would think. When he was working at the pain
clinic, he told me he had never made so much money in his life and was
laughing his head off about it.

http://jacksonville.com/news/crime/2013-04-11/story/jacksonville-pill-mill-doctors-investor-found-not-guilty-all-charges

Margaret Jervis
August 23, 2013 at 13:42

Jonathan – you would be crazy to take up any kind of public services job it
every internal enquiry were made public. It’s equivalent to having everybody’s
medical records available to each and all online. We need to have trust in the
integrity of our public services and the procedures designed to monitor them
and most importantly in good judgment and common sense. There are many cases
where these processes malfunction. Upholding the status quo – yes but often
because they can’t see the wood for the trees. They are unable to make
reasoned judgments, while in other matters are so risk averse they can’t see
how ludicrous and counter-productive their judgments are. I don’t know how
such a thing can be righted – it’s like Byzantium all over again. But all it
should take is for the people in charge to see sense.

Jonathan Mason
August 23, 2013 at 13:55

Jonathan – you would be crazy to take up any kind of public services
job it every internal enquiry were made public.

That is pretty much how it is under Florida’s open government “Sunshine
Law.” Individual medical records can be redacted to remove demographic
information if quoted in publicly available documents.

We need to have trust in the integrity of our public services and the
procedures designed to monitor them and most importantly in good judgment
and common sense.

As in Operation Yewtree?

Jonathan
Mason August 23, 2013 at 14:01

Here is the FAQ on Florida’s “Sunshine Law” as you will see, copies of
all public records can be requested. The Florida Supreme Court has
determined that public records are all materials made or received by an
agency in connection with official business which are used to perpetuate,
communicate or formalize knowledge. They are not limited to traditional
written documents. Tapes, photographs, films and sound recordings are also
considered public records subject to inspection unless a statutory
exemption exists.

http://myfloridalegal.com/pages.nsf/Main/321B47083D80C4CD8525791B006A54E3

Margaret
Jervis August 23, 2013 at 14:13

My point is we need to trust in our institutions and there’s much good
that can be salvaged. personally I think the police are pretty much beyond
the pale. But I guess we would all be hollaring if the whole thing was
dismantled. If you want to see an example of a police force which looks
like it might be doing it’s job go to the City of London police – see the
clarity. The inclusion of all crime stats broken down into offences. From
this I suggest that it might be a force – tiny – that is reasonably
functional that I could trust. Of course serious fraud issues are often
taken over elsewhere.

GMC hearing are publicly available on line and may be open to the
public. As are the Teaching cases and other regulated professions – don’t
know about the General Social Care Council – that’s a very weird body as
with much in social services.

Not sure about what the Florida system is – would have to check it out
and will.

But audit trails should be available to people accused at least in the
UK, and are not.

Margaret
Jervis August 23, 2013 at 14:32

Thanks – I see that it’s not all sweetness and light in Florida http://blog.safeshepherd.com/139/sunshine-law-spreads-evil-darkness/
Public
interest ‘exemptions’ appear to be selective.

Still not sure about the terms of reference here – in social services
case conferences for instance once it became the right of the client to
attend , the decisions were made at informal pre-meeting meetings –
‘clients’ (the accused) can’t be trusted not be disruptive and sway ‘due
process’ you see,

But I’m sure we could learn alot from the Florida system.

Jonathan
Mason August 23, 2013 at 15:39

@Margaret. The blog you link to mentions “pubic records” so I
wonder how credible it is, as the state of Florida does not normally
keep records of Brazilian waxes, though lice infections are probably
somewhere there in the health statistics.

Nope, Florida is far from perfect, and there are lots of things I
truly hate about the place, but then you hear a lot about things that
go wrong there precisely because there IS public access to government
records, courts, etc, for example the Terry Schiavo case was a social
services related issue from Florida that you may have heard about and
also the Elian Gonzales case, if you are old enough. [I actually dated
a social worker from the hospice where Ms. Schiavo reposed.] The
Trayvon Martin case certainly got more detailed coverage in the UK
press than many prominent UK court cases.

Regarding the no mug shots published for cops, I kind of understand
this, because there are a lot of exceptions, for example home
addresses of registered nurses and doctors are held back from public
view, because prisoners could get their relatives to look up the home
addresses of prison nurses an harrass them at home, or their families.
You have got to be careful about exposing anyone who deals with
criminals in their work. However, you can look up the information on
other licensed professionals like hairdressers, architects, or
building contractors.

However the personnel records of said prison employees would be
open to the public all the same.

I don’t think that in Florida the Yewtree Report would have been
able to hold back all the underlying data from public examination. The
names and addresses of the plaintiffs could have been withheld for
confidentiality, but the details of all the plaintiff affidavits would
have been published.

Engineer August 23, 2013 at 13:14

I think we could all agree that the majority of GPs are decent people who
try to discharge their professional responsibilities to their patients
properly. However, human nature being what it is, there will be some who fall
short of this ideal for various reasons. I think what this article highlights
is that there is insufficient rigour in the arrangements for professional
oversight.

How should a doctor’s professional integrity be assessed? How often? How
intrusively? Would too much scrutiny force doctors to act only in ways they
know are ‘safe’, possibly to the detriment of some patients’ treatment?

Given that it’s our health and well-being in their hands, and that we pay
their wages (and other fees) through NHS contracts, I think the public does
have a right to express opinions on this. We are not intruding on a
professional person’s right to conduct their business as they see fit, since
their business has such a direct influence on us.

Yes, there should be greater scope for individual doctors actions to be
checked, repeatedly if need be, by some agreed competent and independent
assessment body. What we have at the moment clearly isn’t sufficient if the
premise of the post is true.

Jonathan Mason
August 23, 2013 at 13:28

How should a doctor’s professional integrity be assessed? How often?
How intrusively? Would too much scrutiny force doctors to act only in ways
they know are ‘safe’, possibly to the detriment of some patients’
treatment?

As I suggested above, there should be written standards for practice and
then if there are complaints against a doctor, his performance can be
compared against the written record to see if he has complied with all
components of the standards. It is basically a quality assurance issue,
isn’t it?

I think part of the problem is the overall lack of openness in government
and quasi government processes in the UK. Let’s assume that the case given
by Anna is a true story, then did the press (and by extension the public)
have information and access to copies of auditing tools used in the initial
investigation into the GP so that they could see how it was done and why the
findings were negative, and I can almost guarantee you that all the
information would be kept under wraps in the UK, or that even if the
information was available to the press, they didn’t give it to the
public.

Elena ‘andcart
August 23, 2013 at 13:49

I don’t know. No one is perfect. I only know that I am offered health
checks here almost every other day. All of which are free, and most of which
I don’t want to know about.
Ask Anna Raccoon. Pure chance and a bloody
good Doctor.
Don’t you see that Health Insurance alone encourages The
Republic of France to keep you alive. You die, they don’t get paid anymore.
This is what funds their excellent Heath Service. It isn’t in their
interests to allow you to die of neglect. Pragmatic, maybe. But who
cares?

And I do have to say that no one is ever denied Health Care simply
because they can’t afford it. It just doesn’t happen.

carol42 August 23, 2013 at 18:12

Just to show it is not all bad I was also a pure chance and a great Dr.
case. I was anaemic, got blood test which showed iron deficiency and most
would have prescribed iron and sent me on my way. My Dr. wasn’t happy and
insisted in further tests and found the cancer early enough to treat. A
lot depends on your Dr. and on your own ability to argue your case,
shouldn’t have to but it does. Just to say I lived in Germany for a few
years and liked their system better than the NHS and France sounds
similar, if more people here experienced these systems I think we would
soon see some changes.

Jonathan Mason
August 23, 2013 at 13:52

Would too much scrutiny force doctors to act only in ways they know
are ‘safe’, possibly to the detriment of some patients’ treatment?

Possibly, but on balance it is more likely to ensure compliance with
accepted minimum standards of care than to prevent delivery of optimal care.

I have seen a variety of health systems from the US, where everything is
done by the book to avoid liability, to the Dominican Republic where almost
zero written medical records are kept. For example at an Emergency clinic a
few weeks ago, I had an IV in my arm and was receiving IV drugs without the
clinic even having any written record of my name or having seen a copy of
any ID. Or for example, in the DR they will probably ask you if you have any
drug allergies, assuming they remember, before they give you something, but
in the US not having a WRITTEN RECORD of drug allergies would probably lay
the physician open to charges of criminal medical negligence in the event of
a negative clinical outcome.

However, the treatment I had in the DR (for gastroenteritis) cost me
about $100 and had I had the same treatment in the US in an Emergency Room,
it might have cost $2000, so there is definitely a huge cost factor involved
in meticulous record keeping and defensive medicine.

My impression is that medical practice in the UK is somewhat in between
the US and the DR. Physicians in the UK are more likely to be influenced by
NHS standards and guidelines than by threats of being sued for medical
malpractice, but the UK does a lot of research into defining clinically
proven best practices and its doctors are less likely to be influenced by
drug company reps.

Margaret Jervis
August 23, 2013 at 13:01

@Elena ‘ancart Elena I fully sympathise with you. But the hegemony of
personal suffering misses the point. Well yes my life was at risk actually
from the the thugs, thieves and god-know-who else I was exposed to in the
freezing cold all night in a leading European city.

In France you’ll get an xray – but you will have to cough up 20 percent of
all treatment charges after the event.. Which may be quite substantial.

Would yo prefer such a system operated here? There is plenty of very good
life saving treatment in the NHS that is free to users each and every day.
Please don’t throw out the baby with the bath water.

Elena ‘andcart
August 23, 2013 at 13:18

Don’t be silly. I pay for Health Insurance, and willingly. And do you
seriously believe that I would deliberately risk my life for what it might
cost?
Oh, excuse me, I am dying of Tuberculosis but I can’t afford to
protect myself or the rest of the population.
And besides, all treatment
for possibly terminal diseases is Free in France, especially if they are
contagious.
I am utterly stunned by your spurious arguments. I might stop
laughing sometime tomorrow.

The Blocked
Dwarf August 23, 2013 at 18:39

I suffer from FABS (that’s F*cking Angry Bowel Syndrome- what IBS wants
to be when it grows up). Shortly after it was diagnosed by my Brit GP (aka
“the Purple People Eater”) I went to live in Germany. I say it was
‘diagnosed’ by my Brit GP but as I would have had to have waited 2 years
for a simple Ultrasound scan (the sort of thing every GP in Northern
mainland Europe has in his surgery) & an appointment with a
consultant, any diagnosis was tentative.

My German GP performed the scans, Electrocardiganswhatis,
tv-down-throat-thingy all himself in his surgery and then gave me the
number of the Uber Chief Gastrologist at one of the most famous university
clinics for me to phone for an appointment.

I rang the Uber Chief Gastrologist and spoke to his secretary. She
apologised that because the doc had been ill himself, his appointments
were booked solid etc and I would have to wait TWO WHOLE WEEKS to see
him!

Let me repeat that; the secretary of one of the finest gastrologists in
Germany and probably Europe, apologised for a 14 day waiting time -when in
England an appointment with the lowest ranking general consultant (fresh
from Backwardstan School Of Medicine) would have meant a 24 month
wait!

And no there was no fees, no hidden charges and no payment in advance-
my compulsory but private medical insurance covered everything.

Sorta settled any question about which Health Care system is better in
my mind. Until I went to live abroad I too thought the NHS was the finest
health care system in world, the *snork* “envy of all” and that all the
poor old Johnny Foreigners had to pay to see a doctor even if they were at
death’s door.

Elena
‘andcart August 23, 2013 at 19:28

Don’t tell me about it. I have seen what comes from that sort of
neglect. And it ain’t funny. And I have seen what they do in France. Oh
My God, one week for an appointment, and you don’t finish up with an
ulcerated bowel that can’t be saved.
Nothing to do with me, but I
wouldn’t wish the ultimate surgery on my worst enemy, which as it
happens she was. But that is by the by. The awful old cow was grossly
neglected. And I expect that you know what happened after that.
It is
all so terrible you see. And it would never have happened in France.

Ho Hum August 23, 2013 at 11:59

Oh, and as a last contribution for today, linking compromise agreements to
whistleblowers, as if they were something used solely to silence such people,
is bollocks. They have been standard practice in public and private sectors
for years, and no lawyer worth their salt would let you mutually end anyones’s
employment without one

Margaret Jervis
August 23, 2013 at 12:46

And anyway – nobody is ordering these people to accept their mega payoffs
in the compromise agreements. And criminal matters are always excluded.

These people are shameless IMO.

Jonathan Mason
August 23, 2013 at 11:51

If there is a risk management problem with the prescription of Fentanyl or
other narcotics in GP surgeries, there should be guidelines, policies and
procedures governing the prescription of the drug to outpatients under the
NHS. For example prescription of Fentanyl should be linked to certain
qualified diagnosis codes, and possibly must be initiated by a specialist
consultant.

Here are the standards for prescribing narcotics for Florida:

Standards for the Use of Controlled Substances for Pain According to the
Boards

Evaluation of the patient
Complete history and physical
examination
Documented nature and intensity of pain
Underlying diseases
and conditions
Effect of pain on physical and psychological
functioning
History of substance abuse
Indication for use of controlled
substances
Treatment plan
Objectives used to determine treatment
success
Further diagnostic evaluations or treatments planned
Therapy
adjusted to individual patient needs
Informed consent and agreement to
treatment
Risks and benefits discussed with patient
When possible,
patient should receive medications from one physician and one
pharmacy
Written agreement if patient is determined to be at high
risk:
Urine/serum drug level tests
Number and frequency of
refills
Reasons drug therapy may be discontinued (violation of
agreement)
Periodic Review
At reasonable intervals
Reevaluate need
for opioids if goals are not met
Monitor
compliance
Consultation
Refer as necessary
Extra care with patients
having history of misuse or living arrangements conducive to
misuse/diversion
Addiction medicine consult for patients with a history of
abuse or comorbid psychiatric disorder
Medical records
History and
physical examination
Diagnostic, therapeutic, and laboratory
results
Evaluations and consultations
Treatment objectives
Discussion
of risks and benefits
Treatments
Medications (including date, type,
dosage, and quantity prescribed)
Instructions and agreements
Periodic
reviews
Compliance with controlled substance laws and regulations.

Florida, in practice, is considered to be very lax, though recently it has
clamped down on “pain management clinics” that dispense drugs in large
quantities to medical tourists from out of state and make a LOT of money for
their operators. The problem is that they do meet all the standards shown
above, as it is not difficult to comply with paperwork standards once one
analyses what is required and the whole process can be done on a kind of
factory production line once forms are designed that will meet the standards
if filled out in full.

Internet pharmacies with mail order delivery are a whole other issue.

Elena ‘andcart
August 23, 2013 at 11:17

It is in fact the reaction of The GMC and The Police that is the most
worrying. If this story is in fact true. But even if it isn’t, it could well
be true somewhere else near you.

Margaret Jervis
August 23, 2013 at 11:50

Ok Elena – where’s the evidence?

Elena
‘andcart August 23, 2013 at 12:04

I personally don’t have any evidence that this story is true. But then
I didn’t say that I did. However, I wouldn’t be seen dead within a hundred
miles of any UK Doctor or Hospital. And that is due to personal and life
threatening experience.

Margaret
Jervis August 23, 2013 at 12:33

Elena I can see how this may make you justifiably wary. I had a very
bad experience with a bank – and no recompense because I felt too ground
down to climb up the arcane complaints procedure . Private sector bank
and international. Wouldn’t go near it with a barge pole again. But I
went back to the bank next door which is also private and international.
There’s lots I don’t like but I trust it more or less with my money. I’d
been with that bank for thirty years before I was lured by the other’s
‘attractive’ current account interest rate. Even now I’m waiting for the
mega-crash I feel it is due.
Point being that I still have the need
for banks and still place my trust in them as most people do. and
probably staff from the one move to the other. The bad bank had very
helpful branch staff – with no power of course. Their phone banking was
a nightmare of unbelievable intractablity, idiocy and outright cruelty.
As I discovered when I was stranded abroad without being able to
withdraw a penny of my own money. And did they care when I had to be
rescued by a relative and had bronchitis for a month? Not a jot.
Interesting time on streets up all night though – and some strange and
wonderful memories of sights I would not normally be privy too. And
those are the ones that linger. And I still trust my bank.

Elena
‘andcart August 23, 2013 at
12:50

Hardly the same as nearly dying of Tuberculosis, is it. Simply
because it was all in my mind. And despite the fact that my mother
died of it at the same age that I was when I had it. Also with young
children. And myself had juvenile TB.
There is no way in which
France would deny me an Xray if I asked for one, even if they did
think I was crackers.
And besides, you can hear a damaged lung
through a bloody stethoscope. But Oh, No. Middle class white English
women don’t get TB. So go away you silly woman.
And that is only
half of it.

Elena
‘andcart August 23, 2013 at
12:52

PS. I can’t believe you said that.

Fred Thrung
August 23, 2013 at 13:14

Yeah. All too believable. My local hospital tried to kill me three
times when I had to have a thyroid operation.

Elena
‘andcart August 23, 2013 at
13:25

They nearly had my womb, mate. That was serious. Fortunately I had
become a trifle attached to it, so I asked a few pertinent questions.
My womb is still with me to this day, albeit surplus to requirements
now.
You really don’t want to know any more about it.

Ted Treen
August 23, 2013 at 14:23

The real Hippocratic oath:-

Thou shalt not kill!
(but need not strive,
officiously to
keep alive)

Arthur Hugh Clough – 1819-1861

alan scott
August 23, 2013 at 18:27

You are lucky, Elena, still being in France (I think). We spent most
of 26 happy years until 2012 there in full confidence with their medical
services.

Elena
‘andcart August 23, 2013 at
19:07

There is nothing to fault about The French System, Alan Scot. And
the older you get then the more important it becomes. I am very far
from ill at the moment, but I do know that I will not be ignored if I
ever am. And I won’t have to wait for half a year either, even for
something as stupid as an ingrowing toenail, heaven forbid. There
would be someone on my doorstep before I could even think about
it.
I just don’t understand this horror of paying some not so huge
amount. I pay it on my Basic British State Pension, and I do not
begrudge one penny of it.
And not so lucky either. Just a choice.
And I am sorry for whatever drove you back to UK. When you get old and
possibly ill then how you will be treated does matter. And I would not
trust that bunch for half a farthing.

charlotte
August 23, 2013 at 22:14

‘I wouldn’t be seen dead within a hundred miles of any UK Doctor or
Hospital’
If you live in the UK and are sick and need treatment what
choice?

Elena
‘andcart August 23, 2013 at
22:35

But I don’t live in The UK. That was the choice.
When I first
came to France I had very little money to sustain me. I just got off
my backside and got my hands dirty. It isn’t difficult.

charlotte
August 24, 2013 at 18:50

No it isn’t difficult Elena to get a job, but the UK isn’t set up
like many European countries as are far as medical insurance is
concerned and so the average UK citizen will pay more per capita for
health insurance here than people who are in countries where it is
common to have private health care, that’s what I’ve been told anyway
by a friend who works in private health care insurance. Certainly I
got off my backside when I was 13 and have worked full time ever
since. I’m 62 with no plan to retire and I’m happy to work full time,
which as I run my own business is nearly always in excess of 45 hours
a week, but I can’t afford private health insurance. However, private
health care has its problems as well, nothing ideal.

Ho Hum
August 24, 2013 at 20:23

@ charlotte August 24, 2013 at 18:50

OK, I’ll bite

If a lower percentage of the UK populace fund their care via
private insurance, for any given volume of treatments to, say, one
patient in each of two different countries, even if delivered and
charged for at the same price to the insurers, the overhead costs of
the insurers will be proportionately higher in the UK as they will not
have the equivalent economies of scale and volume of clients over
which to spread their administration costs. Hence, the total premiums
charged to any individual in the UK would have to be higher.

Although why anyone would want the UK to expand the use of an
administrative system which, if adopted universally, would actually
increase the total amount they paid in administration costs for no
overall extra benefit for everyone is beyond me. Most people who
really understand the implications and consequences, and still
advocate doing so, are after your money, not your wellbeing

This makes for some salutory reading.

http://content.healthaffairs.org/content/23/3/10.full

This includes a statement that 24% of US healthcare spending is on
administration of the whole edifice. There’s a WHO paper to be found
somewhere which was a study on PHI administrative costs, and these are
on average 3 times the admin costs of healthcare funded through social
security schemes.

As there is a limit of 1 URL per post, some more to follow

Ho Hum
August 24, 2013 at 20:25

@ charlotte August 24, 2013 at 18:50

Even the Americans seem to recognise that our admin is more
efficient – this was one of many, but it’s easiest reading

http://conversableeconomist.blogspot.co.uk/2012/05/why-does-us-spend-more-on-health-care.html

Ho Hum
August 24, 2013 at 20:26

@ charlotte August 24, 2013 at 18:50

And this doesn’t make us seem all that bad in overall comparison
with other nations

http://www.commonwealthfund.org/~/media/Files/Publications/Chartbook/2010/PDF_2010_IHP_Survey_Chartpack_FULL_12022010.pdf

Ho Hum
August 24, 2013 at 20:28

@ charlotte August 24, 2013 at 18:50

And just have a look at how cheaply we actually get things

The info in the Scribd panel is interesting

charlotte
August 24, 2013 at 23:46

@ Ho Hum
I’m perfectly happy to date with the treatment I’ve had
from NHS. I wondered if the links you sent were comparing with figures
with NHS or with private practice in UK?
I would like to see some
services improved such as physiotherapy for stroke patients and after
surgery, the people I see from week to week after knee replacement
surgery for instance seem to recover quicker with private physio than
those on the NHS because they are seen personally and more frequently.
I suppose the service is over subscribed but I do think that the
individuals who give the treatment try so hard to help everyone. my
experience with NHS has been a positive one and everyone involved with
my care plan were brilliant.

Ho Hum
August 25, 2013 at 00:32

charlotte August 24, 2013 at 23:46

Glad to hear that it’s been OK for you.

You’re right about the Cinderella Therapy Services. They’ve never
done as well in funding terms as anyone who has needed and used them
might expect. Most healthcare has an elastic demand, and they are
oversubscribed more than most, and so end up being delivered more
thinly than they should be. We spent a not inconsiderable sum of money
ourselves on one of our children, as did many of our age cohort who
faced similar problems, but not all of them were as fortunate. They
don’t really catch the public’s eye, until you need them, so they
don’t register too much on the politicians’ radar.

BTW, the links provided were really there to provide some expansion
on your comment re differing national health insurance costs, drawing
out some comparative cost, access, and perceived quality issues re the
pros and cons of international PHI vs SSS funded services, albeit in
fairly general terms.

And nothing is perfect. As you rightly say, private care here isn’t
without its problems either.

Ed P August 23, 2013 at 11:00

Whether or not the scenario is real, the attitude and response of the BMA
and police is all too believable. I’ve had personal experience of the
Kafkaesque obfuscation one receives after filing a medical complaint – closed
ranks, being fobbed off with spurious details, never any admission of guilt or
malpractice, etc.

Margaret Jervis
August 23, 2013 at 11:16

Yes Ed – this is true of most public service complaints procedures that
I’ve come across. But allegations of criminal abuse against professionals
tend to attract the same kind of zealous overreaction that the poor punters
seeking redress for the same against themselves are subject to. It’s
possible that there’s some kind of massive cover-up but unlikely – and in
fact ‘Dr Death xyz’ may already have been shunted up the food chain for a
ritual dismemberment – we don’t know.

Ho Hum August 23, 2013 at 12:00

It’s nice to see common sense in action

Margaret Jervis
August 23, 2013 at 10:51

@dimwit – Sorry but the 1980s Community Care Act as with the Children Act
was virtually Labour driven. Local authorities were at that time Labour
dominated and the social services directors and their acolytes in the volorgs
wielded a powerful stick in these matters. As a social services journalist at
the time we used to joke about the director’s and la politico meetings as
being ‘the Government in exile’. The NHS reform was quite a different kettle
of fish and deeply resented – but the NHS was not run by local authorities.
Fact is Thatcher wasn’t really bothered about these services where she had
very little direct sway. It was selling off council houses, private enterprise
in business and wrangles over Europe that excited her zeal . The NHS and
education were marginal interests and she made a poor job of both instigating
much needed reforms. But it was the Labour hegemony of social services that
became the seedbed of many of the flawed practices welfare and criminal
justice systems that are wreaking havoc with our trust in the judgment of
public authorities and institutions today.

belinus August
23, 2013 at 10:59

Do you really believe we have a three party state in the United
Kingdom?
All government people are Crown appointed, they do not reign
they rule on behalf of the Crown (Executive Powers).
The Queen Reigns but
does not Rule, she delegates power to her appointees, ergo every prime
minister that has been since the Civil war.
This protects the queen and
crown from political scandal. Of course the simple terminology to describe
this position is proxies, fronts, they do not serve the people that elect
them they serve the Crown.

Ho Hum August 23, 2013 at 11:55

Thanks for that. It has saved me a lot of time.

The sheer ineptitude and cluelessness of the Labour administrations was
obviousness almost from the start. I’ll never forget my sheer disbelief in
reading their first ‘circulars’, which could be condensed to ‘we don’t
really know what needs done, but if any of you guys has a bright idea, feel
free to give it a go’. They got a fright when the the consequences started
to come out.
The only SoS who really seemed to understood the implications of making
change on a grand scale, and how to manage that, was, so help me, old
Kenneth Clark.

And it was Labour who were in power when the bulk of the management
information changes were introduced, doing probably not much different from
what the Tories would have done. Efficiency was increased enormously when
people could actually see what was really going on, and just how bonkers the
differences in clinical practice and resultant costs could be for the same
thing, as done individualistically in different places. But so help me,
politicians just don’t seem to believe that management can be done with
about 95% knowledge, without scrubbing around for the minutiae that makes up
the other 5%

As for slagging off the accountants, most people completely forget (or as
is probably more likely, are just cluelessly ignorant) that cost is merely
the measurement of what goes on in the real world, when translated into its
lowest common denominator that we all use as a means of exchange of value.

The whole purpose of having financial information in the public sector is
to help those who are doing whatever is incurring the cost to see the impact
of their actions in measurable form. That’s even better when allied with the
activity data that goes with it. The aim being that they can do their jobs
better for you, as the person who pays the insurance premium, and as a
patient if you are ever as unlucky as to have to make use of the policy
cover, both in the quality of their output. It also provides some
accountability for the use they make of your money and be accountable for
doing it well, as managed by your representatives who run it on your behalf,
politicians, managers , staff, whatever. No more Sir Lancelot Spratts, thank
you

And any accountant who thinks he is the one who actually runs the show,
or even thinks he should, is an idiot

alan scott
August 23, 2013 at 18:24

Accountants are clerks, book-keepers, not managers. Never the twain
should be confounded. Just look at their respective
responsibilities.
All this started in the late 50s when just everybody
had to become a “professional”: grilled meat and french fried potatoes
chef, anyone?

Ted Treen August 23, 2013 at 14:16

“‘…are wreaking havoc with our trust in the judgment of public
authorities and institutions today…”

As a 63 year old of reasonable intelligence, I must add that never in my
life have I been so disenchanted with, mistrustful of, and cynical about
professional bodies which in my youth, certainly exhibited the appearance of
dedication, care and even altruism.

It is the opening up of this void which is almost as unforgivable as the
individual cases. Will this trust ever be re-established?

alan scott
August 23, 2013 at 18:25

See my above about “professionals”. Everyman and his dog (poor beast!)
a “professional”.

DimWit
August 24, 2013 at 20:03

Ur right there Scotty.

Todaze professional, eXtwerps.

2-Day Course, 4-Ring binder, 3-Ring Circus !

” And the next act, Ladiez n’ Genamen, Boyz n’ Girlz, , is….”

belinus August 23,
2013 at 10:49

Does the doctor also have shares in the company that produces the
patch?
Face the music…they are killing you with medication, this is just
the tip of the iceberg.

Elena ‘andcart
August 23, 2013 at 10:45

Let’s put it this way. I shan’t be moving to Wales anytime soon.

PS. We all know that Ash Cash is true.

Margaret Jervis
August 23, 2013 at 10:53

@elena’and cart.

You make my point perfectly Elena.

DimWit August 23, 2013 at 10:27

Mag’s Tory 1980s-ongoing (thru Rupe’s pawns NuLab/LiteTory) regime of
uncaring false economy fraud markets, selling off cheap the UK ‘Family
Silver’; included many valuable NHS properties.

While introducing, untrustworthy ‘Trusts’ with bean-counters and petty
managers ruling eminent medics and caring staff.

Leading to the Tories early-1990s (don’t)Care In The Community Act, and NHS
(untrustworthy)57 Trusts.

Nationwide hugely valuable NHS real estate was sold off to private
developers by closing long-established large institutions.

Internal markets were introduced into the NHS, with accountants typically
knowing the price of everything and the value of nothing. With new health
authorities managing/mismanaging their own budgets and bought-in products and
health staff, often non-British. In order to be deemed a ‘provider’ ,
self-managed/mismanaged health organisations became NHS (untrustworthy)Trusts.

This vile Tory policy (merely continued by non-Brit Rupe’s pawns
NuLab/LiteTory) of mistreating, not caring for, and killing the lower-income
physically and mentally disabled, was rightly criticized by both Liberals and
true Labour in the late-1980s. They demonstrated that the care in many such
sold-off institutions had been satisfactory or good.

As with the early-1960s Tory ‘axeman’ Beeching deviously changing the train
timetables so that mainline and branch line trains no longer coincided and
became under-used and lines were closed and sold off to private developers.
So, by typical smoke and mirrors manipulation the deliberate underfunding and
mismanagement of the NHS by the 1980s-90s Tories was used as an excuse to
close and sell off many former health institutions to private developers.

NHS ‘markets’ and so called ‘care in the community’ were falsely presented
as a more cost effective way of helping the low-income sick and disabled.
Though the number of patients mistreated at-home and in large hospitals and
residential establishments including young children and babies dying;
continued to rise.

Plus: The Greatest ‘Market’ Fraud Of Our Times?
http://www.inquisition21.com/index.php?module=pagemaster&PAGE_user_op=view_page&PAGE_id=291R

alan scott
August 23, 2013 at 18:19

Almost the best one-eyed summary I have ever seen. Get some tablets!

DimWit August 24, 2013 at 11:04

Scott of the anTARTic tabloids.

Please be specific about moi FACTual omissions or inacurracies; or
just, ‘Keep Taking The Tory Tabloids’.

Not forgetting Swingin ‘60s thieving Tories also trashed the public
service railways while very CONveniently ‘jobs for their boys’ building
motorways contracted to, er ‘Marples Ridgeway’. Of Tory Transport Minister
Ernie’s missus, Mrs Marples, no BIG Agatha Crusty mystery there.

“ His period as Minister of Transport was controversial. He both
oversaw the significant construction, he opened the first section of the
M1 motorway, and the closure of a considerable portion of the national
railway network with the Beeching cuts. His involvement in the road
construction business Marples Ridgway, of which he had been managing
director, was one of repeated concern regarding possible conflict of
interest. “

Quote Swingin ‘60s TruLab P.M. ‘Dahlin’ Harold Wilson at a BIG
(pre-non-Brit/bent-Rupe) rabid-Right/Wrong-uns Press/Meeja amnesty: “I’ll
make this very brief. U stop lying about us, and we’ll stop telling the
truth bout U!”

Quote, Dad’s Army Corporal Jones, “They do not like it UP ‘em!”

We await.

LoL.

Margaret Jervis
August 23, 2013 at 10:24

Agree this is a ‘put up or shut up’ type case. The implication that ‘Dr
Smith’ is killing his patients to reap the cremation signing payments is so
serious that it is not a suitable topic for pseudonymous innuendo. All it does
is raise the fear that if anyone is prescribed Fentanyl there are at risk of
being prematurely bumped off. We all know that morphine in sufficiently high
palliative doses may shorten life in terminal illness – and in fact the idea
of legal ‘euthanasia’ will effectively prevent compassionate care of this
kind. It is vital that we regain trust in doctors and others who play such a
vital role in our lives. There is incompetence and negligence aplenty in our
public services. Intention however is step further and somewhat rare in these
quarters. Internal politics, whether it be a doctors surgery, BBC or police
forces, especially when linked to local businesses and politics, can all too
easily be turned into a partisan witchhunt – especially when driven by the
media.

Duncan
Disorderly August 23, 2013 at 10:57

I can quite believe that a doctor would misprescribe a painkiller.

I can also quite believe that Fentanyl, if in high doses or defective or
misused, can kill or at least shorten life.

But the suggestion that there is a statistical spike (who conducted the
statistical analysis?) in deaths before the doctor goes on holiday because
he can claim ‘ash cash’ suggests Dr. Smith is really a Shipman. If this
claim is not true, it would force me to doubt everything I have read.

Margaret
Jervis August 23, 2013 at 11:07

Yes Shipman was a strange fish – but the judge led inquiry led by Dame
Janet Smith (who she?) inflated the claims beyond credulity. And so now we
are encouraged to think that a ‘Dr Death’ hides behind a comforting smile
in every community, small or large…perhaps hiding ‘in plain sight’. They
are the ‘Jekyll and Hydes’ of your local health centre. And I can hear the
voice of the sentencing judge even now…over and over again. And yes, there
were massive compo payouts in the extended Shipman affair.

Fred Thrung August 23, 2013 at 10:02

I have very recently been prescribed fentanyl because other treatments no
longer control my pain from an autoimmune condition. As I always do I looked
it up on the web before starting to use it but so far I haven’t seen reference
to high mortality rates in users. So when will Sue Tristey tell us?

Anna
Raccoon August 23, 2013 at 10:08

Probably best you don’t read this Fred..http://www.aboutlawsuits.com/fentanyl-patch-631/

Duncan
Disorderly August 23, 2013 at 10:27

“Moreover, Dr Brown has, by this time, noticed that there are
statistical spikes in the death rate of Smith’s patients prior to him
going on holiday (he gets paid “ash money” for each death).”

That bit made me sceptical. Is the author sure that there really are
statistical spikes in deaths before the doctor goes on holiday? Can Dr.
Smith, even if wanted to, really be so precise in his misprescribing that
he can bump off patients so as to get the ‘ash cash’ before he goes on
holiday? Sounds like bollocks to me.

Ho Hum
August 23, 2013 at 11:27

Ash cash to pay for his holidays? At about £75 a head, or a cadaver,
you’d have to bump off a reasonable part of the South Wales population
to make that much of a runner. Still, we could get lucky, I suppose, if
it caught on…..

Anyway, he’d maybe better up his work rate quick.

http://www.pulsetoday.co.uk/your-practice/practice-topics/practice-income/gps-set-to-lose-cremation-form-fees-from-next-year/20002183.article

Duncan Disorderly
August 23, 2013 at 10:00

You could easily change the names of the doctors involved and their
location so as to avoid a libel suit, as I suspect you already have.

Also, would fentanyl really kill so many patients?

belinus August 23,
2013 at 09:54

I believe it is time that the people of Great Britain realized that today
the NHS is a death machine so they can fit their foreign nationals into your
home, your pension, and your country.

Do you actually care or is the medication more important?

Addiction what a pisser

Margaret Jervis
August 23, 2013 at 12:10

Well Belinus fact is many foreign nationals do work that Brits won’t do
including yucky badly paid care jobs. It of course a bother that while Uk
citiziens are barred if there is as much of a past whisper of an unrelated
complaint against foreign nationals receive a rudimentary check if at all –
and I doubt there are many if any countries that operate the kind of ‘soft
information’ police disclosures that we do never mind that fact the such
allegations are vastly inflated in this country. It does mean that a few
criminals are foreign provenance slip through the net – and I would imagine
most are concerned with financial advantage. But good management and
supervision and noticing the everyday should protect against the vast
majority of ill-intentioned bad workers from all places on the globe.
Language skills are to be preferred. But the constant belief that the
entirety of public services is some kind of Jekyll and Hyde that can only be
exposed ‘historically’ leads to a massive increase in false positives (that
may not be identified as such) and consequently a failure to recognise
glaring false negatives. This is not rocket science, common sense and good
judgment and a sound knowledge base are what is needed. Your depiction of
the NHS as a death machine is not one that most people would recognise and
the right medication can be a Godsend. It is important to realise that in
the midst of all this schlock most people are hard working and of good will
– misguided as many welfare and criminal justice professionals are.

Frank Limadere
August 23, 2013 at 09:34

“…And the point of this blog post is to demonstrate that, unless I decide
to tell you, you will never know…”

And even if you do decide to tell us we’ll never know. Unless you’re so
sure of your facts that you can risk a libel suit by identifying the doctors
involved.

Anna
Raccoon August 23, 2013 at 10:09

That is precisely the point Frank.

Ted Treen August 23, 2013 at 13:47

I, for one, believe almost every word of it:- the exceptions being the
names “Brown” & “Smith”.

How in God’s name can we deal with such arse-covering entrenched
self-interested parties?

OK, hemp & lampposts spring to mind, but for once, I suspect Plod
wouldn’t stand idly by – well, not EVERY time…