Abuse of NHS Doctor’s Appraisal System

Some in the NHS  wish to use GP appraisals as a reference system, to check for suitability for a particular job by asking to GPs to send in their appraisal output data or “copy of appraisal”.  There are also administrators who wish to use doctor’s appraisals as a management tool for audit and performance in line with other work sectors’ appraisal systems.  The reply must be no to any request send copy of appraisal or appraisal summary to employers.  Doctors are already concerned about reflection in their appraisals after the Dr Hadiza Bawa-Garba case.  This new use as a reference tool would make matters much worse.

It was discovered in March 2021 that the GMC seemed to support the employers’ new stance  with a statement on GMC web site Appraisal documentation is confidential. When requested, doctors should share summary appraisal outcomes with the organisations where they work (in addition to their designated body) but they should not be expected to share their full appraisal portfolios on a routine basis.”    It turns out (March 2021) that the GMC now recognises that this wording is an error and will be changed.  The thrust of this essay remains true. I have been assured of this after representation to the GMC by the RCGP Revalidation team on my behalf.  My view is that, if anything, doctors could provide the appraisal statement which is a few tick boxes that in effect states that we have had an appraisal.  The statement is very different from the appraisal summary which is the detailed nub of the appraisal and should never be shared, nor should any other part.

Appraisals, if used as references by NHS Trusts, other employers or GP practices, will compromise the appraisal process and could break revalidation.  A salaried GP would certainly not want to share their appraisal  with their workplace and practice manager. Appraisers will start designing the appraisal output to reflect a new status as a reference for third parties to view, and not as the appraisal output is currently assumed to be; a confidential, reflective document, while appraisees will not mention serious issues.   

Below is the letter that started my concern I received after some months working via an agency.  I had worked in that area since 1993, and appraised locally.  I was licensed and revalidated:   

Hertfordshire Community NHS Trust   1st  August 2018                                                  Dear Dr Bulger   Re: Appraisal Output request for Gerard Bulger  As you will be aware the Responsible Officer regulations came into force in 2012. As the Deputy Responsible Officer for the Designated Body Hertfordshire Community NHS Trust (HCT), I am accountable for seeking regular assurance that Doctors who work for HCT in any capacity are up to date and fit to practice across their whole scope of work.  As such and in accordance with the HCT process Non Designated Body Doctors’ Governance Process’ approved in January 2017 by the Workforce and OD Committee, I kindly ask that you provide your last appraisal output form no later than 8th August 2018.As you will be aware the Responsible Officer regulations came into force in 2012. As the Deputy Responsible Officer for the Designated Body Hertfordshire Community NHS Trust (HCT), I am accountable for seeking regular assurance that Doctors who work for HCT in any capacity are up to date and fit to practice across their whole scope of work.”  

In March 2021 I got another request, a CQC inspired compliance list from another employer which included a demand for “copy of my appraisal”, as if standard and matter of fact.  My reply to both reply was no.  The employers can check references, my place on performers’ list (so therefore appraised) and can check I am licensed and revalidated on line.  The Trust or any other employer have no right to demand to see my appraisal output (which, as it happens is suitably glowing, so I should show it off); the  principle is that that appraisals are also private reflections.

West Herts Trust  tried to apply to NHS England for the appraisal data is if I was moving responsible officer that is moving area, using the RO to RO form (MPIT). NHS England’s response was robust and the request refused.  The data cannot be used by anyone other than the doctor’s one and ONLY responsible officer.  NHS England’s Programme Manager replied to me in 2018:” We would not consider sharing your appraisal documentation with any employer and it should not be used in the manner in which your organisation is suggesting. I am happy to write to them on behalf of your RO to confirm your fitness to practice and that you are fully engaged with the appraisal programme.  That is all..”

These requests are a nasty extension of the use of the appraisal system output as a reference and a management tool.  This is not appraisal’s purpose, which is about probity, reflection, developing a personal development plan for licensing and revalidation.  No doctor should volunteer to send their appraisal output to anyone outside their own Responsible Officer’s team.

West Herts implied in the letter that in effect a doctors could have more than one GMC responsible officer, so each Trust could view appraisals outputs. 

BMA: Responsible Officers (ROs) are the individuals within designated bodies who have overall responsibility for helping you with revalidation. A designated body is the organisation (likely to be your main employer) that will support you with your appraisal and revalidation.  You only have one designated body and one Responsible Officer irrespective of how many organisations you are contracted with or employed by. Only UK organisations can be designated bodies, because the legal rules that determine this – the Responsible Officer regulations – only cover the UK.

GMC: Taking Revalidation Forward  the GMC has the following statement in Sir Kieth Pearsons recommendations (Appendix B)
9 Responsible officers should make sure that the revalidation process for individual doctors is not used to achieve local objectives that are not part of the requirements specified by the GMC. 

LMC: “believes this is a gross misuse of the appraisal process and that there are no such requirements for outputs to go to new employers”

GPC: An employee should not be requesting this information and you do not need (nor should you) share it. All they need to know is that you are on the performers list (which you can only do it you are keeping up with appraisals and revalidation. 

During my time as an appraiser I assured my doctors that the appraisal process was confidential, and that the only person who may see it would be their one and only responsible officer and their appraiser.  A doctor has one, and only one GMC Responsible Officer, no matter how many employers he or she has.

We have understood that appraisal remains a formative and reflective process. The output has no pass or fail unless there are clinical risks found or the doctor is not engaging.  The purpose of appraisal is to demonstrate continued probity, learning and reflection to keep a license.  The doctor’s one R.O. can approve for revalidation after five years.

A Trust can check that a GP had had a recent appraisal, that he is licensed, revalidated and on the GP performer’s list.  It does not the appraisal output to confirm a doctor’s fitness to practice.  Should a Trust need to know that a doctor is suitable for a particular job this is achieved by references and interview.  The appraisal data would be a poor way to do this.  To provide appraisal data to third parties is an extension of the appraisal and revalidation system beyond its scope and purpose.

GPs must refuse to send appraisal output demanded by employers. They have no right nor reason to see it. 

Gerry  Bulger

https//bulger.co.uk/message.htm

 

Covid: Bureaucracy blocked Clinicians working

Time to rage against most of the NHS? 10/01/2021

At the height of the second wave I was waiting for the call up to help in the overwhelmed hospitals or for the vaccination campaigns.    Not a word, not a single email.

Meanwhile my inbox was full of requests from Australian agencies offering up to $2,700 a day for Covid related work, in a country where, so far, Covid is pretty much under control.  I also remain on the Australian register, but I cannot get there unless I self-isolate at my expense in special hotels, and I would need a new visa.

Here in UK I did the in-house training for NHS Nightingale and its on-line modules, got the lanyard, ID card, staff number and T-shirt, but thankfully never needed.  I also other modules and the NHS “credentiality” checks for 111 primary care work. All that extra training is imposed on doctors as if they are not already in practice. It was designed for those coming out of retirement, and the rigid rules set place could not be changed for those already working and appraised.   A list of some of the stuff is here:  https://www.bbc.co.uk/news/uk-55516277

Most of so-called mandatory training modules such as anti-radicalisation are not even mandatory at all. Apart from some internal health and safety rules, there is no legislative or GMC requirement for the training modules. The “mandatory” aspect is an NHS urban myth that keeps many in employment.  Doctors must be professional and keep up to date.  We undergo annual appraisal and then revalidation to prove it. That alone is our training duty.  The NHS as invented the rest.  It may seem sensible that module to recognise allergic reactions.  But if any doctor does not know how to recognise or deal with that then we need to look seriously at the 10 years+ of medical training.  I very much doubt the Health Secretary’s vow to reduce this will have a lasting effect, as the culture to require this nonsense it too imbedded. https://www.bmj.com/content/372/bmj.n13

Did anybody in NHS other than Casualty and ITU staff in the NHS know there was a war on?   Could they not slash these requirements and call up trained doctors to help?

I was shocked and aghast attending “Pinnacle” and Covid Vaccine roll out on-line NHS Team Meeting seminar at the start of the vaccination programme.  Even the GPs leading it have got wrapped up in the bureaucracy of it and believed in it.  They should be in a rage.  Instead, their energy seemed to be directed to worrying about £10.00 fee for nursing home jabs.  Vaccinations centres as in GP hubs are being loaded with computers, printers and scanners and specialised software.  We all have computers in our pockets which can scan bar codes of all sorts, surely there is app for that would make that pile of kit redundant.   Less is more.

During that Team meeting it was clear that the hoops expected by the software and NHS minions were no longer necessary.  Previous anaphylaxis is not a contraindication, and no need to watch the patients for 15 minutes.

Sir John Bell has it bang on. “NHS could vaccinate UK against Covid in five days, says Oxford professor: Bureaucrats are blocking a rollout that could prevent many more deaths, according to Sir John Bell  https://www.theguardian.com/world/2021/jan/09/nhs-vaccinate-uk-covid-five-days-oxford-professor

Those working in Casualty and in ITU manage despite of the system. They pull in levers in Government and nothing happens, as the NHS system blocks and delays.  Time to rage against most of the NHS, not clap it. 

I carried on working elsewhere in the NHS part-time.

Dr Gerard Bulger BSc MBBS DCH FRCGP FRACGP CCFP

https://bulger.co.uk/message.htm

Junk is stuff in the wrong place

I was back down working in the Falklands in 2020. Behind the house was a yard with local TV tower with assorted radio junk scattered about. I was sure cared for and some is in locked containers, perhaps to be shipped back one day. It belongs to KTV Falklands Digital Channel https://en.wikipedia.org/wiki/KTV_Ltd. Later of course once out of Covid isolation, I met its owner Mario, VP8EME. In such Isolation, with no RS store or Amazon to deliver the next day, he needs to keep stuff.

To any amateur radio operator this would have seemed mouth watering stuff. Rows of parabolic dishes, some with various transponders still attached. Then power supplies, heat sinks, cables.

I suspect the reason for apparent discarding is that there now decent internet here via satellite, 4g mobile phones, a few free TV stations and more if you pay a fee to KTV. So individual dishes are no longer needed. There are issues with the local telecoms monopoly…even bringing down your out Satellite Phone with data is illegal, let alone setting up your own satellite data dish. All about those problems and more is on https://openfalklands.com

Upgrades to the telephone system filled the yard with even more stuff. BAS seems to have left a container here once used for HF coms.

Enough here to build a few antenna towers. Then there coils of fat low loss coax piled up. I assume too expensive to ship any of it back to the UK so it sits here waiting to be used, but I imagine the next project here would bring in new materials. This stuff is the wrong place. I assumed parts would be used and appreciated by many back home.

In memoriam: Looking at some of the old kit I appreciated the work and engineering involved in creating it within the last 30 years. Unless you build a cathedral everything we do is ephemeral. Much of this was so beautifully made with professional screening of parts, solid aluminium casing. A lot of thought and brain power, time and care went into each part, now not used. A graveyard of effort. Some of the boards have rows for Z80 chips which were used until quite recently, even a 555s.

Then I realised that even for hams and electronic enthusiasts little of all this is of use to us nowadays. It’s frankly simpler to write line of code into a computer than it is to make stuff. So we use the internal complexity of millions of transistors in a PC chip to achieve something that could be achieved in “simpler” manner by old school working.

Waveform Old school with op amps and 555 chips

But the old school in inflexible. Once made with wires and components it does its one thing. A Raspberry pi is cheap and light. Make an error reformat and start again. Reliable too. I had one doing its thing as router/VPN for over year without a reboot.

Some of this stuff here could be used for interfacing, a PC’s output need to attach to something in the end.

VP8DPD G3WIP

Hyperoptic Fibre Broadband Routing IPv4 & IPv6: home servers

At last, in our central London family apartments we have 1GB connections with Hyperoptic. Reliable and fast. We get the speeds advertised, and one our flats it is even a little faster. Ping is time 1ms. With such fast speeds, upload as fast as download, it is tempting to run servers at home and run a private cloud. The snag is the devices at home are not reachable using IVp4 from the internet; the home routers are behind CGNAT, just as phone companies do in order to share the rationed IPv4 addresses and protect their network. You can pay Hyperoptic extra each month for a fixed IPv4 address that is then reachable from the outside using IPv4. You do not need to. Better to use IPv6 anyway.

Your home or office devices can be reached by IPv6 addresses from the internet which when calling from on an IPv6 enabled network. IPv6 is fixed and you are given a whole reachable subnet. Then you set the home router’s IPv6 filter, that is open pinholes to any local device IPV6 address and ports you want. You can now have multiple reachable devices on the same port, say 443 as there is no address sharing (NAT).

Connection is fine from IPv6 enabled networks away from home. It does always work from some workplaces or from phones outside because many ISPs still use IPv4 only routing. To solve this I use another server (my VPS) that has IPv4 and IPv6 connections. I use the VPS as a middle man to “cat” the connection from IPv4 to an IPv6 address. I can access home systems anywhere and can give my home machines domain names IPv4 and IPv6 with DNS entry. On this middle machine, a Linux site (a VPS) I use SOCAT command with the IP and ports I want like this:

socat TCP4-LISTEN:9831,fork,su=nobody TCP6:[2a01:4b02:a40a:4b10:af9b:c59c:b1b8:2e7x]:2529.

So connecting to VPSserver:9831 using IPv4, connects to my a home device on IPv6:2529. Can also run a VPN though it (SoftetherVPN). It’s magical (don’t forget to open the port on the middle server). It is very fast, I do not notice any degradation.

By the way, I found that if you have two places with Hyperoptic fibre connections you can access the other by using the internal Hyperoptic IPv4 addresses that are given to the routers (in 10.0.0.0 range). These internal Hyperoptic IPv4 addresses seem fixed. Mine has not changed over multiple reboots. I am pretty certain all this will pertain to any fibre provider.

https://bulger.co.uk/message.htm

Windows 10 Security Update KB 4545706 allowed NHS.NET to block access home devices.

Technical Issue for UK doctors working at home

Windows 10 Security Update KB 4545706 on home machines blocked access to directories on my home LAN. This was an NHS.NET imposition

Windows 10 Security Update KB 4545706 blocked connections to any device on my home LAN which had any guest access, with message “your organisation blocks unauthorised guest access. These policies help protect your PC from unsafe or malicious devices on you network”. Rubbish I thought, there is no organisation, I am me at home.

There was no solution on the internet. All was working fine before update, and the buttons in Network and Sharing had not been defaulted back. I log into my NAS drive with name and password, so it seems windows was detecting ANY guest access on the Networked drive (NAS) and blocked the device entirely in explorer but not to its SSH or its web interface.

I removed the update, and all working again but I was puzzled by the phrase “my organisation”, so went digging

I discovered on my Windows 10 machine under “access to work or school” NHS.NET was logged in. As I access the nhs.net email service via a browser, it should never have done this; that is been set up as a workplace. I do not log into work systems or go onto any NHS LAN, so this “facility” was not needed.

It is possible the last Windows Security update has enabled the organisation, NHS.NET to impose its standards (no guest access on any device the LAN) onto my domestic machine. None of this documented. It explains the popup box reference to “your organisation” I have removed this “account” under access to work and school (some windows “feature” , default imposition I suspect), and I will see if the update on return blocks access to my WD My Cloud NAS. I can of course still use browser to access nhs.net mail.

Beware, in the past after much prompting you may have logged into NHS.NET as an orgnaisation,( it is now under access to work or school). Remove it, it is not needed to access nhs.net. Using browser alone for NHS net is fine. Along the line, as a pop-up message on the right, windows 10 asked to log into your NHS account, at the time no warning what it meant. What that did is now very bad after the recent update. Go to “access work and school” and try and add a workplace, there are now dire warnings about how the workplace can take take control. I have never seen or used this area before, but I saw there I had been logged into NHS.NET as a workplace. The recent security update allowed NHS.net to take control. In search glass type in “access to work and school” and make sure your account at nhs.net is not logged in. It was on my machine. NHS net via browser still works.

https://bulger.co.uk/message.htm



Three Broadband 5G. Atrocious upload

Update on 5g Three Broadband (as was Relish broadband)

See 2015 blog on the 4g Three Boadband product

I get on the phone to dump Relish (Three Broadband), giving up the £30 a month contract after some years with them.  I was getting better connection and upload speeds on my phone.  My phone uses the same Three’s Network 4g or Vodafones’ 4g (it’s dual sim).  Setting my phone as a hotspot was better than using the Three home broadband hub. Time to give up on the 4g Relish (Three) home broadband hub.

Three Broadband then said 5g was now in my area, so I was sent the new Huawei 5g hub/router (over £350 to buy).  My testing went ahead using wired ethernet from hub to PC.

5g is only JUST available in my flat in only one spot, at an impossible to mount area within one bedroom.   Then it seemed that if I made any adjustments to the router firmware, such as change the LAN IP range, the router lost its ability to find the local 5G signal.  It would only find 5G tower after a hard reset.  That is all support would suggest.

Huawei H112-370.

The best 5g I got was with the hub router propped up on books in one precise spot was 100MB/s.   What was most disturbing was the fractional upload speed, best at 2.8Mbs.   Everywhere else in the flat is it the hub dropped down to 4g but at least that gave better upload speeds of 4-6Mb/s

Best with 5g:

Best 5g in area and 5g Area in our flat near window, pointing at local tower.

Three Broadband will not tell you what upload speeds to expect, talking rubbish that it depends on various factors, but those factors would also affect download speed, although I accept transmission power is lower from the hub. One the other hand power is needed for reception’s download handshaking so I would have thought factors affecting download would affect upload to the same extent. Perhaps 5g is more complex.

Three Broadband refuse to give any indication of an upload guide number, and simply state “it is not guaranteed”. That is all they will say.   Three Broadband’s refusal to give any technical details to users is something Ofcom should look into.  We should know what we are buying.  Upload speed and with latency are crucial factors for a useful broadband connection; download speed is just on factor and is a bigger number.  It is the only one they like to headline.  Funny that.

They probably refuse to quote any number because upload is deliberately throttled.   This was the case with their original Relish 4g hub (again this was never mentioned anywhere on their web site).  The best upload speed I got on 4g on Relish hub was 8MB/s despite downloads of up to 72Mb/s .   Most 4g SIMS in phones are pretty much synchronous, you get similar upload and download speeds unless the network is busy.   I gather some “5G” systems split upload and put upload back onto 4g.  Perhaps this is what Three does, but seems slower than when the hub is using 4g. All very odd.

The hub is not locked, so I was able to put my 4g Vodaphone SIM in the Huawei H112-370 hub this afternoon, a busy period in central London (things here speed up evenings and weekends).  This afternoon it gave 72Mb/s download and 20Mb/s upload.

Vodaphone 4g sim in the 5G hub. Note upload speed

Using 4g Vodaphone sim in the Huawei hub this busy afternoon in central London.

In the evenings on 4g phone sim I often get 98Mb/S with 70Mb/s upload, or uploads can even faster than download.

So I am sending back the Three Broadband 5g hub.   5G is hardly here at all, and upload speeds are atrocious.

5g here is giving 100Mb/s download with upload throttled to 2.8Mb/s, that upload speed is a fraction of what normal 4g offers.   There is no question that the better option is still 4g and is cheaper.  I plugged in a 4g USB modem into my Draytek router with a Smarty sim, which gives unlimited data, decent upload speeds at £20 a month no contract. Done deal while waiting for the block to get fibre installed.  Hyperoptic fibre cable is synchronous and we get at our other flat 700Mb/s up and down with low pings.  5G can wait because there are some nasty marketing practices bordering in fakery here. Deception of customers by deliberate omission, made worse an outright REFUSAL by support team to state the facts.

Gerry Bulger

https://bulger.co.uk/message.htm

Working from Work: Access your home PC as a Web page from anywhere.

Screen shot of my PC logged into my apartment’s PC as a web page. I can do this from work

Thininfinty Web login

Working from areas with tight security and behind firewalls which you cannot control can be very problematic.  Some places the blocks are simply too clumsy, making internet connection almost useless. Even medical sites such as dermnet.nz can get blocked (skin tones=too much skin). Or using medical terms such as “Oral” too much. So safely log into your home computer.

The simplest and secure solution, that does not imply any hack, download or compromises the security of the work site, is to connect to your outside home computer using a web page, port 80 or better port 443 (https, encrypted).  Those ports are never blocked.  This method does not require ANY software installation at the work end.   You are simply viewing a web page on any browser. You are not downloading or introducing anything of risk to the work system.  No malware can pass.  

The setup is to uses Thinfinity.   This offer a fast VNC like connection to your home computer using a web page alone.  Once installed on the home computer, at work just type in the URL or IP address of your home machine on the work PC’s web browser, eg   https://10.20.30.40/ or something like https://myhome.mydomain.com   

On your home router you will have to port forward port 80 or 443 to your home computer that is running the Thinifinfity workstation server, and that machine needs to be left on!  Give it a strong long password.

The non-commercial single use workstation license is free.

That’s it.

You can then look at all emails, all files, one drive, dropbox, edit stuff and post to NHS email address, and even use WhatsApp messaging that is connected to the phone left in the car.

I set it is as a subdomain of my own domain, so it can share the site’s lets encrypt SSL certificate.  You can use http, port 80, but it is not encrypted. Thinfinity have their own certificate system for https, but that requires connecting to their servers, which could get blocked, and the certificate did not work when I tried.  Domains can be created for any home router using dyndns or similar products, but I feared such domains may be blocked, so I used my own.  You could use the home IP address if it is fixed.

To untrained it could imply a security worry. From work, via this system, you can see on your home computer thus any site or file, such as time-wasting Facebook. But we are responsible professionals and just need access to all our clinical stuff.   

There is no record on the work computer or knowledge what sites your home computer has been looking at.   The work computer just sees the connection to a single domain or the IP address of the home machine as a single encrypted web page. All its doing is sending a screen image.

When logged to your home PC via Thinfinity in there is a hidden menu at the top middle: clicking on it you can scale the screen to fit the browser window. You may also need to hit refresh there if not seeing a window.

Gerry Bulger

Contact https://bulger.co.uk/message.htm

Older links on similar subjects

http://bulger.co.uk/satellitecost2.htm

http://bulger.co.uk/softethervpn.htm

Doctors Cause Crime

Prison Healthcare

There has an exponential in the use of gabapentin and pregabalin medication amongst prisoners over the last decade. These drugs are now almost exclusively used by those with other dependencies in prisons. During this time of increasing use of these gabapentinoids and other prescribed medications, we saw seeing an increase of violence in prisons. This violence may not be due to illicit Spice use and the past reductions in the number of security staff.

I am the suspicious that us doctors may not be doing any good. Doctors do not have any medication to treat crime, but our best of intentions may now be causing criminal side effects.

Many of my prisoner patients have recognised themselves in the following scenario:

You have a criminal tendency, making you feel nervous, or you may have heroin habit, whereby you have to “find” £100+ a day for that. This make you very nervous, an anxiety state. You go to your kind GP who gives you diazepam at least, but clonazepam is your preferred benzo choice (10x more potent). You now feel relaxed and invulnerable. You feel better inside yourself, but you are now worse to others.  Relaxed you can thieve more. Then there is that paradoxical aggression these medications give, so that knife you have with you is now more likely to be used. Of course you prefer the similar effects given by the gabapentinoids, the new benzos, which you can seek for that old ankle fracture and back pain. Gabapentinoids can give a high on their own, make heroin highs better and cheaper, and any spare capsules can be sold on.

Your life is now a mess, and you feel grief, guilt and remorse. These are uncomfortable sensations, which should protect you from more damaging high-risk behaviour. These feelings are depressing and annoying. Your GP now adds in an SSRI for your “depression”, but you may seek Mirtazapine, as you cannot sleep (perhaps partly caused by the cocaine), and you may want a bit of weight on. The anti-depressant detaches you from your emotions (that’s partly how they work in depression), releasing you from guilt and remorse.  

You now have ideas that others do not like you, you have no insight as to why that is so. Your mood swings are violent, disinhibited, so now you now have added quetiapine or olanzapine to the cocktail. These major tranquilisers were designed to stop the overthinking in a psychosis and schizophrenia, but here the tranquilisers block thought, further imagination and hope and they also make you fatter.

With this concoction of these prescribed medications you now are free of anxiety, grief, guilt, remorse and hope. You are detached and have no feelings for others. You now have full blown Iatrogenic Antisocial Personality Disorder with multiple convictions.

Weight goes on and on, blood sugar rises. You are now diabetic.

Full latest prison blog is here

 

More of the pointless NHS Administration

Most of the boxes are NHS related 1993-2008

I have added back an archive of NHS Commissioning documents based in Hertfordshire, 1999-2008.

Perhaps someone will copy and paste some of the old documents for yet another new project, as all has been done before under different names.  Family health Authorities, Regional Health Authorities, Area Health Authorities. Primary Care Trusts. Practice Based Commissioning Groups, and now Clinical Commissioning Groups.  It’s pointless.

All NHS reforms do is play musical chairs.  No reform dares start on the basis that these functions are simply not needed. They are moved to different named bodies.

I have worked in Australia where these layers of NHS administration simply do not exist, despite the fact that Australia is considered to be over governed.

https://bulger.co.uk/dacorumhealth

Part of the Achive

 

Shared Care Records Flawed. Wasted my time too

Shared Clinical Records Fallacies and its waste of time

 

Some of the work being binned and shredded

I am clearing out paperwork at our old office.  This pile is some of the work I did for NPIT and then CfH, Connecting for Health, the UK health service plan for a single NHS record.  It cost billions. It failed.

Although I got reimbursed for some of my time on committees this was such a waste of time and I knew it.  I was not popular as never liked the concept of a single health records anyway, and detested the idea that Government should write software.  The Government’s agenda and civil service procurement contracts were so precise that it was as if they were writing code.

The main effect, indeed aim at the time, was to kill off multiple medical UK IT businesses.   Only four primary care system survived. NHS bureaucracy believed that it would be so much better if there was only one system, one supplier in the NHS.  The next best option, as far as they were concerned, was that systems should all look and behave in the same way.  The result is that the fast and innovative clinical systems we had have become stuck in aspic.  The drive to innovate, to compete was killed off by the pressure and time needed for government conformance.  Little attention paid to what doctors, nurses or for that matter what a patient might need.  The systems in use now are slower and much less ergonomic than the medical system in place in the late 1990s.  Most UK GPs had systems on their desks by then because they saved time and created legible scripts and records.   Now systems slow down consultations and act as a barrier between doctor and patient. The doctor has to glare at the screen point a mouse at a tiny icon.

Fallacies of a single record

1 “It saves so much money and time, and improves patient safety if there was a single system and NHS record”    Not true.   A single record lead to sloppy thinking and lazy doctors.  The patient is a day older.  The past record is just as likely to bias you in the wrong direction by what was written the past.   There is likely to be something new.  Take a history and examine the patient. It works every time!  This is especially true in an emergency situation.  Junior doctors should be forbidden to look at old records for 48 hours.

In the UK GPs can have access to records (paper for the most part) going back to 1927 as the records follow you around.  When working in Australia there is no such thing, and lo! to my surprise I did not miss the records clinically.  As a matter of prurience I might have.  When I told and Australian patient of GP UK record access she said that would a be gross invasion of her privacy.  She had a point.

2 “But we must know if a patient is allergic” .    If only recording allergy was that simple.  Most people who report that they are penicillin allergic are not.  A patient may report that she felt upset on that green pill, so not unreasonably the GP puts on his record allergy to green pill, so now the system will almost block the GP annoying the patient when attempting to prescribe green and related hues in the future.  Alas a hospital will interpret that to mean the patient will collapse with anaphalaxis to green pills.  To avoid this the GP now needs to record green pill allergy in greater detail, more than the patient nor he needs in his practice.  Detailing what was reaction, what type, intolerance of allergy, rash, urticaria, wheezing and so on and on.  It may need a tree of many codes to describe the reaction and how serious. It is so tedious that it is left.  But this coding dilemma occurs with recording of almost any disease. Heath Data has fractual properties, like the length of the coast of Britain, seemingly approaching infinity once you draw round each pebble or then grain of sand.   The level of detail you need to record depends on your need in front of the patient, its use to you, the patient and locality.

3  That leads onto the provenance of data.  Where is comes from has a huge effect on its meaning.  A nurse may find a patient confused, so she might record dementia on her system (it might even be recorded as Alzheimer’s).  For her work that all she needs to do to remind her.  However this could be any different type or dementia, or even psychological, dementia-precox (psychosis). Who and when was the data entered changes its meaning, and then who can correct it should it turned out to be a toxic confusional state.  Correcting data entered by others is a minefield in shared records.   A GP may record heart failure, but a Cardiologist may need to know what type, or worse it has since resolved and is still there on the record.

4  “Clinical systems can improve safety by warning doctors of interactions of patients other disease and between drugs”.   Unfortunately the fear of being sued by suppliers for failure to provide warnings, means that the most idiotic warnings pop up.  Such as in treating blood pressure: “Adding X with Y will cause BP to fall”…. YES that is what I want!  No intelligence in offering up these warnings which are so frequent, so minor, or that the risks are already fully understood beforehand, that doctors simply flash past all warnings as they are wasting time, in doing so increasing the risk a genuine high risk warning will be missed.  This is true for current systems and would be worse if there was a central record as that has to be designed for the most junior nurse doctor or admin clerk.

 

Solution.  Competing Systems: Healthcare Secure Search Engine.

Keep encouraging different systems.  The can use common coding systems as they do now. They can work differently, have different interfaces functions and innovate.

When a patient is seen at a different place, such as at hospital, an authorised doctor should be able to do a search of all NHS records within date ranges or selected places, to create a new record.  Preferably a day later.  This NHS search engine would be secured with two factor authentication or more, with swipe card; the patient notified that such a search was made and by whom and when.

That way provenance of each item is clear.  There would be no need to create a single record.  There is the NHS spine record, but it is only a summary with few details, and keeping it in sync with GP records is not easy.

Connecting for Heath was doomed.  Its premise was wrong, but those concepts and wish for a single patient record still come up. It still a dream of civil servants everywhere.  It is not needed and it kills innovation in healthcare computing.   Without NHS meddling we would now have slicker, faster, even tablet based clinical systems by now. More patients could be seen in less time.

Gerard Bulger

PS if you invent such a search engine I will need 5% stake in it.

 

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