Wednesday, August 29, 2007

To find a GP

… on the NHS Choices website, you may have to be lucky.

The NHS Choices website is where Joe and Jane Public are meant to find the information to make informed decisions about where they want to be treated – you know, find and register with a GP 40 miles away rather than the one round the corner. Duh!

Apparently, 50% of information on GP opening hours is inaccurate. So you are a member of the 16% of the public dissatisfied with GP opening hours, you have chosen your GP because s/he still runs some “out-of-hours” services and having looked up your GP’s opening hours on NHS Choices, you will find … a locked door. Because the GP practice has opted-out of “out-of-hours” services. Or maybe the 16% are dissatisfied because they looked up the opening hours on NHS Choices onlt to find them incorrect.

A third of GP names are incorrect. Dr Rant is confused with Dr Purple who is confused with Dr Brown.

Another NHS IT fuck-up. Of course, they are not blaming themselves, but the Primary Care Trusts and want the PCTs to provide updated information. Why didn’t they do a random sample of the data? And do the PCTs not have accurate data.

Fuck-up all round methinks.

Report here.

Tuesday, August 28, 2007

Medical Update

Kezia's counts still good so she continues with 6-MP and oral MTX and also starts the dreaded 5 days of Dexamethasone.. Also had her monthly vincristine injection today. We have now finished the first of six maintenance cycles.

Lauren and Rob's Fergus has had his portacath removed. Congratulations! Funny how procedures stateside and in the UK differ - Kezia had her Hickman Line removed a month or so back and they didn't install a portacath to replace it - they only install a portacath in the occasional case when a child cannot cope with injections. Kezia only gets an injection once a month and copes with it well.

Blog Rating

My blog-rating has improved! You better keep your children out of here!

NHS Acronyms

A commenter on this post about the length of health authority names on Simplicity’s blog states that the LAU or Low Activity Unit in his area are … the acronym and title given to the Mortuary!

I admit to having been confused myself by all the acronyms, terminology etc both on the medical side of Kezia’s sickness and treatment on the one hand and by the National Health Service’s bureaucreacy on the other. Of the former I now have a grasp – symptoms, organ functions, drugs and their modes of action etc - but the latter seem unfathomable. PCTs, ATs, SHAs ...

If I cannot figure them out, how will your average punter? Especially when they are “consulted” on NHS “reform”! And for our foreign readers it must be even more so …

So here is a quick layperson’s guide to the main administrative units of the NHS bureauracy …

Acute Trusts: these are the ones who run the hospitals. Kezia was diagnosed in an acute trust hospital and is now being treated in another acute trust’s hospital, as the latter is a regional centre for more specialised care. But as they belong to different trusts and as the former, where she was diagnosed and we now reside, does not have a centre of regional specialised care for children with serious illness, it pays the latter trust, which does, for Kezia’s treatment.

A bean-counter’s paradise!

The NHS website also ingenuously claims that the receptionists, porters, cleaners, domestic and security staff are “employed” by these trusts. I know for a fact that at the Royal Manchester Children's Hospital the security staff are not employed by the trust – they are employed by a private contractor.

Primary Care Trusts: a PCT is your General Practitioners. Well, not really … not any more. It is also, I suppose, your walk-in Sunday 24-hour ASDA hypermarket clinic where you will see an MTAS unemployed junior doctor trying to make ends meet and who knows fuck-all about you because he cannot access your medical records on the NHS IT Spine.

The PCT must monitor all the other types of other trusts in your area – hospitals (see above), mental health (see below), patient transport including A & E (i.e. the Ambulance Trusts – see below, but does this mean the Acute Trust “contracts” with the Primary Care Trust which “contracts” with the Ambulance Trust? I’m confused!). It must “make sure” (what the hell does that mean?) that your dentists and opticians are in place.

So PCTs get 80% of the NHS budget.

Ambulance Trusts: self-evident. There are 13 of these organised on a regional basis. I don’t quite understand how these fit into the supposed policy of “internal competition”. An Acute or Primary Care Trust in the north-west of England is hardly going to contract the London Ambulance Service NHS Trust.

Foundation Trusts: these are hospitals "run by local managers, staff, members of the public, which are tailored to the needs of the local population". They have more financial and operational freedom than the other types of trusts and supposedly represent the government's policy of decentalisation. Introduced in 2004, there are now 67 of them. The public sector trade union UNISON does not agree arguing that they will in fact lead to greater inequalities in the NHS.

Care Trusts: these combine healthcare and local authority social care. They often provide mental healthcare and sometimes primary care.

Mental Health Trusts: self-evident.

Strategic Health Authorities: these serve as the interface between the Department of Health and NHS trusts. Their role is essentially the development of regional health policy and planning. Thus the North West SHA was responsible for the Healthy Futures and Making It Better reforms in NE Greater Manchester and the north west respectively.

Special Health Authorities: these are health services that are national in scope such as NHS Blood and Transplant and the infamous National Institute for Health and Clinical Excellence (which, among other, decides which drugs can or cannot be used in the NHS).

Now, the actual name of your local trusts may confuse you even more. The Essex Rivers Healthcare Trust gives you no indication of what type of trust it is. The Manchester Mental Health and Social Trust could be a Care Trust or a Mental Health Trust. The Bexley Care Trust is not a Care Trust, it is a Primary Care Trust.


Monday, August 27, 2007

Paediatric Oncology

The BBC last week regurgitated old reports derived from the Eurocare programme showing much of European cancer diagnosis and care was superior to the U.K.’s. Oh for fuck’s sake you have reported on this before, especially as Eurocare’s most recent reports were published in November 2006.

(The BBC’s Health reporting goes from good to bad, bad to good – I think they need a new Health section editor – Dr Crippen/Dr Rant, who is s/he and cannot we do something about this person?).

But it did draw my attention to two deserving pieces in the latest issue of Lancet Oncology about paediatric oncology (here and here, but you will have to complete the free registration).

In the first, entitled Political momentum and paediatric oncology, the author (seemingly American) states “the increasing politicisation of paediatric oncology should bring further benefits” … couldn’t agree more, “hear, hear”!

The piece pointed to the rally that Lauren and Fergus attended at the US Congress in June supporting the proposed
Conquer Childhood Cancer Act to provide USD 150 million of new funding for paediatric oncology research over five years. And the Lancet reports this has gone into a quagmire of congressional committee stages.

The second Lancet piece, UK childhood cancer survival falling behind the rest of EU?, looked at a 2001 Eurocare study of paediatric oncology care from 1978-1992, comparing paediatric care in different countries across Europe, rather than the newer 2003 Eurocare study of the period 1990-94.
In both studies the U.K. remains down the lists. The 2003 report does not change the U.K.’s ranking much from the 2001 report,

Paediatric screening and therefore rapid diagnosis does seem to be a big problem – in Germany every child has a primary-care paediatrician who undertakes regular health checks.

In the UK a young child is not scheduled for a regular GP check. Maybe, if you are lucky, a “health visitor” will come and check up. We have one – and she’s great. She is the first to admit “I am not a nurse and I am not a GP” and she is certainly not a paediatric screener – she is there to help us out with social difficulties (like access to the GP, or arranging an interpreter for a GP consultation although most GPs, certainly in our geographical region, are aware of this service) or arranging someone to help us out with transport, school, shopping or immigration … so, as we cope, she just pops round for a cup of tea! To be quite honest her job title should not include the word “health”.

She is not a Health Screener and our GP, in his contract, has not been given, the job of screening every perinatal in the country .

So it is up to the GP to identify an abnormal condition when the parents take their child in with a “common” complaint,

So my GP should be screening my child … but, hey, the government didn’t put it in his/her contract …

Two statements stand out from these two Lancet pieces:

Paediatric oncology has long been the poor relation of adult oncology: treatment developments are slow and children are often given older medicine or regimens, or drug doses adjusted from adult schema without an appropriate evidence-base.

Sub-optimum survival is just one of example of the worse state of children’s health care in the UK compared with many countries. The perinatal mortality rate puts the UK in the 15th position in Europe and there is clear evidence that children with diabetes are not receiving optimum care. Although there is a National Service Framework for children, which sets standards, there are no targets. Children continue to be a low priority for the NHS”.

Hemorrhoids and Hernias

Reading the BBC and Eurocare reports earlier in the week informed me that Colorectal (colon = large intestine, rectum = just before your anus) Cancer is one of the commoner cancers so I looked it up on Wikipedia … and I have two of the classic symptoms methinks. Blood when you defecate and reduced size of stools. Also I have pain in my lower right abdomen, around where your appendix and caecum are, near the end of the colon. I have been ignoring these for months.

Oh fuck! Confused thoughts. I have to provide for Kezia, Jaime and Nanda. If it is cancer, I have to go back to the U.K. If I have cancer and leave here, I will lose my job. If I have cancer and go back to the U.K., how can I work and support them.

So I went to my workplace doc on Thursday morning who massaged my abdomen … and said

nah … you’d feel pain here.

b) I’ll send you to Cuban surgeon N. at the hospital for a rectal examination and if he finds nothing in your rectum, then we’ll think about a colonoscopy (sticking a tube all the way round the convoluted turns of your colon) when we have the results.

Valium, laxative and no food overnight and I am ready to have my rectum examined. On the couch. N. says to get into a “cat position” i.e. on my knees and elbows with my arse in the air! How undignified when it is not sexual! But, at least, having been there, it is not novel!

A hemorrhoid.

He turns me over and says cough – at the moment my lungs are most empty he massages my abdomen. A small hernia!

To treat my Pile – 90 suppositories!

To treat my Hernia – not yet, it is too small.

I am grateful.

Friday, August 24, 2007

The Axe Has Fallen

Alan Johnson is determined to make sure that "more services are delivered closer to home".

Thus the Healthy Futures and Making It Better proposals for restructuring health services in the Manchester area have been approved by the Independent Reconfiguration Panel and the Health Secretary himself.

Thus the town of Rochdale will no longer have A & E and maternity services. You can no longer be born in Bury nor Salford.

Reports here and here.

Shame on you Mr Johnson.

Thursday, August 23, 2007

The Opposition's Plans

… don’t give me much faith … our Noble Opposition has launched its pre-election campaign claiming that the government is going to cut A&E and Maternity services at 29 hospitals – and it claims to have the list of hospitals where the current Labour government wants to make these cuts. See this BBC report.

The BBC also lists the 29 hospitals named by the Tories here. The government laughed at the inaccuracy of the list and a Tory Member of Parliament even had to apologise to NHS employee constituents at the concern his party’s claims had caused! And after a Conservative Central Office researcher apologised to Telford's Princess Royal Hospital about Tory claims that maternity services were to be cut there, the party immediately retracted the apology.

Curiously, our local general hospital, where it is proposed to cut A & E and Maternity Services, and currently under IRP review, is not on the Conservative list. Is that because we are not important to the Conservatives because our constituency is a solid Liberal/Labour vote?

What party will get it right?

Update: And now our local MP has woken up to the fact it was not on the Tory list.

Wednesday, August 22, 2007

Malaria Eradication

Malaria is a shitty, piss-poor, easily-prevented, easily-treated, easily-eradicable disease that kills millions throughout the world every year.



Let’s talk about me (as usual) and malaria first. I’ve had it too many times to count – and, hey I’m still here! The very first time was 6 months after getting back to England from a year in China and 3 months in India. I spent two weeks with flu-like symptoms in a student house during the Easter holidays and “the flu” wasn’t clearing up so I eventually ... phoned Mum and Dad and said “I’m coming home”. I got home, they took one look at me, called the GP and I was sent to hospital.

Isolation. I could be contagious. In those days (1980s) a very very simple malaria test could only be executed at the two tropical medicine hospitals in the UK so the turn-around took a few days. Whilst we waited for the results and as my paternal grandfather had died from lymphoma, they had a cancer “specialist” come and look at me. Results came back, a course of Chloroquine and off-you-go – not that they didn’t invite me back to their Friday lunchtime general-meeting of interesting cases at which I was asked all about how I had felt. … like a long case of flu …

Six months later it recurred. Remember your father, uncle, grandfather who served in S.E. Asia during the war who always had bouts of fever for years and years? Well, nowadays and in the 1980s, there is a way of getting rid of recurring malaria. Just the doctors at the local general hospital didn’t know. I went to the local GP – she was Indian – I said I’ve got malaria, I want a prescription for chloroquine. She was very sympathetic, and knew, but she said “No … if you wanted it for arthritis, fine, but for malaria I have to have a blood-test result”.

Another four days of waiting … but this time, in addition to the Chloroquine to get the malaria out of my blood, she gave me Primaquine to get it out of its safe-storage in my liver and thus prevent it from recurring.

Malaria is caused by a parasite of the genus Plasmodium. In humans there are four species that cause malaria – P. falciparum, P. malariae, P. ovale and P. vivax. P. vivax is the one that remains dormant in your liver, if not treated. P. falciparum does not but is the most dangerous and can directly kill, if not treated. All these species are transmitted into human blood through the bite of vampiric Anopheles mosquitoes.

The malaria parasites have, over the recent past (let us say 150 years) developed resistance to the drugs used to destroy them (cunning buggers). Once upon a time P. falciparum could be treated with Chloroquine – now it is all but useless.

In our tiny African country, malaria has been a major killer ever since it was colonised (it was uninhabited at colonisation). The principle parasite is P. falciparum, although very small percentages of the other species do occur. As our country consists of two small islands at some distance from the continent, we are an ideal testing-bed for eradicating the disease – this has been achieved on other islands, for example, in the Pacific, the most notable and most relevant to this post being Taiwan which was certified as malaria-free in 1965. This is equally borne out by two outbreaks of the sleeping-sickness vector, the tse-tse fly, in the last century on the smaller of our two islands and which was eradicated twice.

Back in 1982 a WHO-sponsored initiative attempted to eradicate the malaria vector, Anopheles mosquitoes, using the notorious insecticide DDT. Although the incidence of malaria decreased, it also resulted in the death of much poultry and livestock. The campaign was “imposed”, was not integrated, was resented, was not sustained and malaria made a comeback with a vengeance.

In 2002-2003 another attempt began receiving a range of inputs from a range of donors. US and Portuguese research, education and promotion of impregnated mosquito nets by the Seventh Day Adventist development agency ADRA etc etc.

But the biggest input has been from the Taiwanese. They have some experience in its eradication.

The Taiwanese part of the programme has two main components:

  • prevention through the spraying of house interiors.
  • treatment with the latest anti-malarial medications.

The insecticide used is Alphacypermethrin. This does not require a general fumigation, as DDT, but is sprayed on the interior walls of houses. The mode of action is surprisingly simple - the mosquito bites an infected sleeping person, has a good meal and then goes off to have a fatal siesta on the nearest impregnated wall.

Supposedly, the effect of one application will last 400 days – but I am sure this will vary with the absorption capacity of the surface being sprayed. Untreated wood, varnished or painted wood or cement block, matt or gloss.

The Taiwanese claim that Alphacypermethrin is ecologically safe. However, there is no biodiversity impact evaluation as part of the study. I have certainly noticed a decline in butterflies in recent years – this could just as well be due to other factors (e.g. climate change) but monitoring could be worthwhile both for human health and biodiversity.

The second component of the Taiwanese programme is treatment. The traditional treatment, chloroquine, has been largely ineffective for several years as Plasmodium falciparum has become resistant to it. Various other drugs have been used here – Quinine, Fansidar, Mefloquine, Halfan etc – but there were no guidelines and each doctor would prescribe what s/he felt fit.

Now we are using in the first line a combination treatment of Amodiaquine and Artesunate. Clearly, the former is part of the quinine family (of which I haven’t studied the modes of action as I have with the chemotherapy drugs Kezia is taking). The latter has a fascinating history!

The mainland Chinese started studying the anti-malarial effects of the traditional anti-malarial medicine derived from the plant Artemisa anna back in the 1960s. For various reasons, including the upheavals of the Cultural Revolution, the positive results were not published internationally. When they were, in the 1990s, they were pretty much “poohed-poohed” by the developed world except … the pharmaceuticals who pricked up their ears and went for it big time! The plant’s active ingredient was Artemisin and soon the synthetic Artesunate was developed.

Artesunate is fast-acting but has a very short half-life (i.e. very quickly disappears from the blood). Amodiaquine has longer half-life. The tablets are marketed in packs of a pair a day. If there is still some residual malaria, then a second line of attack is used – the trade name Coartem, a combination of Artesunate and Lumefantrine (in turn developed from halofantrine, the basis of Halfan, which at the time of its recent development was revolutionary in its approach to killing malaria parasites).

Prophylaxis, if you are pregnant or a tourist, is more controversial and I won’t deal with here.

Anyway, the initial Taiwanese trial on our smaller island saw the hospital’s 21 beds in two months go from 100% occupation to 0% occupation. Two years later the hospital internment rates from malaria had maintained, indicating the mosquito had not developed resistance to the insecticide and the malaria parasite had not developed resistance to the treatment medications.

The programme has now been introduced to the larger island.

Tuesday, August 21, 2007

Medical Update

Kezia's counts today were good enough to resume chemotherapy - so back on 6-mercapturine and oral methotrexate.

Friday, August 17, 2007


Today is the end of the family’s holiday in Blackpool.

For our international readers, let me explain a bit about Blackpool (to which I have never been) …

was established as a tourist resort in the late 19th century. The textile mills of Lancashire would shut down for two weeks every summer for holidays and the mill-workers would travel some 40 miles to the seaside towns of the north-west coast of England, the biggest and most famous of which was Blackpool.

Three piers were built, the Blackpool Tower (a miniature Eiffel Tower) rose above the town and numerous amusement, catering (Fish and Chips) and boarding establishments were established.

In this era of cheap flights to warmer climes, the British seaside resort survives to varying success. I remember well having a seaside daytrip to Skegness on the Lincolnshire coast with the church youth group, at the age of 14, and, for the first (but not last time) getting roaringly drunk and singing the Sex Pistol’s “Anarchy in the UK” through the streets to the beach. Our Vicar, as well as the 20-year old of the youth group leader were very liberal (another post!).

Skegness, Southend, Southport, Morecambe. Margate

But Blackpool seems to have survived the “globalisation” of tourism and is the King of them all.

In 1999 Len Curtis (a local Blackpool businessman) whose daughter, Donna, died from cancer aged 20, in her memory and commemoration, established Donnas’ Dream House where families with very ill children can stay for a holiday for free. The house is made for kids – full of toys, the walls painted with cartoon characters – and Lucia tells me that they have recently opened a teenage room.

The visitors also receive free entry to various Blackpool attractions … so it seems they have had a full week …

Monday midday they arrived.

Tuesday: SeaLife Centre ( - a marine aquarium - Kezia was scared of the sharks, but Jaime loved it) and a Dr Who Exhibition (I gather Kezia was also scared – Daleks and Cybermen – I used to hide behind the sofa!).

Wednesday: the Zoo – Kezia and Jaime loved it.

Thursday: Blackpool Tower’s Circus – they loved it.

Thank you Len, thank you to the volunteers who have taken Kezia, Jaime and Nanda out-and-about! (Please pass on).

I don’t know what to say except you all have taken them into a magical world for a week, where the worry of Kezia’s illness has diminished a little bit for a little while before we get back into the drudgery of chemotherapy, hospital visits, standing at the bus-stop in the pouring rain, worrying about the bank balance etc etc.

Thank you.

Thursday, August 16, 2007

The Great British Public

… and what they think of NHS “reforms” under the Labour government of our now departed Prime Minister Tony Blair.

Recently the British Medical Association (basically the Doctors’ Union, although it has not been very effective representing trainee doctors during the recent training debacle and who have formed their own organisation RemedyUK) conducted a survey of the public’s reaction to NHS reform.

To summarise, the results reveal that the public still want a basically free national and “socialised” health service paid for out of taxes and national insurance payments.

Let us go into some detail ...

Question 1 (the most crucial): “The NHS should continue to be funded from UK taxes and free at point of use?

Answer: 93% agree

Question 2:The NHS should continue to be funded from UK taxes but, as resources are limited, it should be mostly free at the point of use and a small charge should be made for some services?

Answer: 53% agree.

And BMA policy does not agree with this stating it should be 100 % free. And I know some NHS doctors believe some services should be paid for (albeit with caveats).

So I went to talk to my workplace Cuban doctor about this. Remember that Cuba has one of the best-trained medical services in the world and, quite obviously, well-equipped, in the world. He estimated that a typical general hospital would have 10-15 basic blood analysis machines giving the range of results necessary for a standard assay as Kezia receives. Here, with a national population of 150,000 we have four machines. The cost of the machines is c. USD 15000, £7500, the running costs are minimal. The machine will be replaced every 3-5 years. Lab tech labour costs have to be added as well. He reckoned that if 800 in- and out-patients per month required a standard blood test once a month and were charged for it at a rate of £10 or USD 20, the tests would soon pay for themselves.

So, at a price of £10 a test, the cost of Kezia’s weekly blood test would be £520 a year. We could afford that.

Interpreting services, transportation services etc we certainly could not afford. It is a £50 round-trip taxi fare to the hospital, 14 miles away. So this year, with just one visit per week, that is £2600. When I get back to see them, I arrive in Manchester at 05:00 on a Sunday morning and wait 2 hours in the freezing cold to travel “home” because we cannot afford the £25 taxi charge … and anyway I wouldn’t want to wake them up before 6 on a Sunday morning.

The unemployed, the low incomes etc would need state support for even nominal charges.

Fortunately, for the PCT, Nanda has done away with interpreting services as I don’t imagine they come cheaper than £50 per hour .

The cost of her entire treatment, no. I have vague ideas from conversations with our consultant and our social worker, this will cost £100,000 (USD 200,000) or more.

Interestingly, here in our African country, there are nominal, subsidised charges for basic tests, X-rays etc. The International Dispensary Association Foundation provides the country with many low-cost medicines and medical supplies.

I earn, with a severely depreciating exchange rate, £27,000 per year.

Onwards … I am not going to discuss each questionnaire question in the whole document … read it for yourselves

82% agree that local doctors should have a major say in how NHS money is spent locally.

75% believe that all areas of the country must provide the same set of nationally agreed NHS treatments …

I mention this one because of this BBC report of the ludicrous on Friday whereby neurological patients in north Wales can, currently zap along the motorway for an hour for treatment in Liverpool (England) but it is proposed that they should face a 400 mile trip on A roads to go to Cardiff/Swansea in south Wales … who is going to be happy? The taxi drivers!

The next two sections and five questions broadly concern the role of the private sector. The answers are more ambivalent, but on the whole the majority of the population do not want more private involvement. My take on the BMA’s and the public’s position is that they want the privatisation of medical services to be halted right now, it has gone far enough, whilst Tony Blair and the bitch (whoops Patricia Hewitt) wanted it taken further. We have yet to see how Gordon Brown and Alan Johnson will come out on this one.

To conclude, the BMA survey asks the public whether the Blair Labour government has improved our “socialised” healthcare system. 42% disagree, 34% agree and 24% don’t know..My reactions to this survey ,,,

1) Why is MRSA increasing in hospitals … because cleaning staff are private contractors who employ lowly-paid Philippinos who are overworked by the cheapest private contractor who imports them?

2) Why do we have presumably low-paid agency African nurses doing duty on nights because we don’t train enough UK nurses and because we don’t pay them enough.

3) Why doesn’t the UK pay its NHS nurses more to retain more so that we don’t need agency nurses, and at the same time give more DFID (Department for International Development) aid to pay the African nurses more to stay in their countries and avoid the “brain-drain” out from the developing world to the developed world so widely criticised.

Tuesday, August 14, 2007

At the Seaside

Kezia, Jaime and Nanda started their holiday at the seaside yesterday. Apparently Kezia is already saying she does notwant to go home! I'll tell you more about it later in the week.

Friday, August 10, 2007

GP Bashing

After having read the Department of Health's 2007 GP patient survey (about which we posted here), in which 84% of patients were satisfied with GP opening hours, I was somewhat surprised to see the BBC post this report on Wednesday about GP out of hours services and follow it up with a Have Your Say readers' comments stream. It seems comments are limited to the 16% who are not satisfied.

And I am amazed at the implicit racism of many of the comments about, presumably foreign (or is it just their skin colour?), doctors' English skills in what is supposedly a moderated feature.

Dr Rant is understandably angry. And the reasons why are explained a little more calmly here.

Thursday, August 9, 2007

Chemotherapy Overdose II

It is reported in the 21 April edition of the Pharmceutical Journal that a misinterpretation of a myeloma chemotherapy protocol consisting of idarubicin and dexamethasone (Z-DEX treatment) has resulted in the deaths of two patients. The wording “40 mg/m2 in divided doses over four days” has led to 40 mg/m2 per day rather than 10 mg/m2 per day for four consecutive days.

A further letter in the 5 May edition calls our attention to the Systemic Anti-Cancer Therapy Study currently underway and run by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).

NCEPOD, a registered charity, aims to “review medical clinical practice and to make recommendations to improve the quality of the delivery of care. We do this by undertaking confidential surveys covering many different aspects of medical care and making recommendations for clinicians and management to implement.

The aim of the study is to examine the care of adults with tumours, acute leukaemias or aggressive lymphomas who receive chemotherapy, monoclonal antibodies or cytokines and who die within 30 days of receiving treatment.

The protocol is here.

Wednesday, August 8, 2007

Medical Update

Kezia's neutrophil counts yesterday were still too low to go back on oral methotrexate and mercapturine. So she is off chemo altogether right now. Next week they go on holiday so no appointment - next is the 21st.


Alex, when he’s feeling perverse, blogs commentries of Rugby League matches (going off subject). So this weekend taking half a leaf out of his book (or blog) I’ll talk a little bit about our local sporting scene.

But let us start with me and Sport … not a particularly favourable combination … played rugby (union) at secondary school with some enthusiasm – I was no. 2, the hooker, in the middle of the scrum. I was short and fat which made me ideal for the position. I played in the school team for five years. Never scored a try but was notable as a tackler - I would put myself standing still in the way of a fast-running tall back who was looking over my head.

But at the age of 11 they put us on a 3 mile cross-country run in freezing cold rain on muddy paths – not fun!

The weather got better and we played hockey and rugby. I quite liked hockey but was not much good at it. The head of the PE department played for the England men’s hockey team. In the summer rugby and hockey stopped to be replaced by athletics, cricket and tennis. Athletics – the running wasn´t fun, but I was ok at shot-putt. Cricket – I was scared shitless by this very hard ball being launched at me at x miles per hour! Those were the days when the cricket “caps” did not have face protection. Tennis …

My success with rugby did not last. When we got to the two-year Sixth form (16-18 years), I was suddenly thrown into a semi-adult world of “large men” and I was finally growing out of “short and fat” to ”short and thin”. Demoted to a substitute 2nd XIV hooker. I arrived at the University of Leeds and two weeks after arriving the captain of the newly-formed Rugby League team (Leeds Uni did not have a League team !!??) asked if I would play hooker – I looked up from my Hall of Residence dining table to see a 6 foot something hulk and said … oh fuck … uh, no.

I still watch Rugby Union with enthusiasm. (Sorry Alex, the Beeb doesn’t show us Rugby League on satellite!). Two years ago I spent a wonderful fortnight watching cricket after work with Bill, an American friend – I don’t find many Americans who understand it! After a meticulous explanation Nanda actually understands 50-over games and with semi-interest has watched some matches on television. She and I haven’t got the time or patience for a full-blown test match. Tennis, Formula 1 racing (sorry Craig), the horses etc leave me cold although I do enjoy both the winter and summer Olympics and seeing some of the sports not usually shown on television.

And this leads me on to our sporting scene

Football (soccer to our US readers) is, obviously if you know Africa, the most popular sport. We have a league, a “cup” championship, and matches throughout the year. So I won’t talk about it except to say we still cannot get past the first round of soccer’s African Nations’ Cup!

Running (all distances) has had a small following of athletes since independence and we were represented by runners in the last Olympic Games for the first time (in the penultimate Games they arrived only to find that they hadn’t registered in time!).

In the last few years several “new” sports have appeared.

Taekwondo – at which we are competing at the continental level.

Chess - at which we competed at the continental level for the first time this year.


Cycling – particularly, I think, mountain-biking and competing at a regional level.

Beach Volleyball.

I have reserved until last our oldest and newest sports.

Our oldest is card games – particularly “Bisca”, and to a lesser extent, “Sueca”. Apparently, both originated on the Iberian peninsula but please go wiki them if you really want to know the rules - I know nothing about card games (never got beyond Snap, Beggar Your Neighbour and Hunt the Cunt).

On Sunday afternoons massive Bisca teams will assemble, home or away, at an appointed palm wine bar announced on the radio, and play a set number of bisca rounds. Bisca is played in coordinated opposite-sitting pairs, as Bridge or Whist. So one pair is from the home team, one from the away team and many secret signal plans exist for the pairs to communicate to each other their hand or what card to play next. Full of lively intrigue! A referee from each team goes round the tables and collects the point-based scores as each game finishes.

A good and lively time is had by all!

Hey, perhaps we could start an International Bisca Committee with Spain, Portugal and their respective ex-colonies around the world!

Our newest formalised sport is … Table Football!!

Tuesday, August 7, 2007

Blog Rating

My blog rating is getting riskier! (Previous rating here).


Dr Crippen, the NHSBlogDoctor, is taking a break from blogging. However, for the duration of his recess, Dr Rant will be running his weekly review of the medical blogosphere, the BritMeds.

Patientline V

We have posted about the NHS patients' telecomms provider Patientline before most notably in April when they hiked up the prices of making outgoing calls from 10 p per minute to 26 p per minute.

In the face of competition from mobile phones (after a relaxation on their use in hospitals), Patientline has reversed its decision and lowered the price of outgoing calls back to 10 p per minute. Incoming calls will remain at 49 p per minute!

Just for comparison a local call in the UK with the operator British Telecom on a fixed line is 3 p per minute. (BT call calculator here).

Friday, August 3, 2007

Children Fighting Cancer - Episode 3

Craig has finally got round to reviewing Episode 3 of Children Fighting Cancer. Thanks Craig!

Chemotherapy Overdose

Oh dear ... something else to worry about.

Two men being treated for cancer and leukaemia at Birmingham's Heartlands Hospital died after receiving five times the correct dosage of a medication on 20 July. Apparently the drug (I wonder what) is to alleviate the side-effects of cancer treatment. A doctor and two nurses involved are apparently away from work but have not been suspended, An enquiry is taking place by both the hospital and the coroner. Press report here.

The risk is real. The UKALL 2003 protocol warns "All medical staff involved in the care of patients with leukaemia MUST be aware that the inadvertent administration of vincristine by the intrathecal route is invariably FATAL. Vincristine should NOT BE AVAILABLE when an intrathecal needle is in situ. This protocol has been written to provide separation of intrathecal methotrexate administration from intravenous vincristine administration in time. An additional precaution is that the two drugs should not be administered in the same place ...The single most crucial element in avoiding errors is the appropriate education and training of all personnel involved in the administration of chemotherapy".

Wednesday, August 1, 2007

MTAS Chaos

MTAS chaos is slowly unfolding today as thousands of doctors start (or don't start) their new jobs. The young doctors' campaign group Remedy UK has a good round-up of news from around the country here.

Central Manchester and Manchester Hospitals which run Kezia's hospital, the Royal Manchester Children's Hospital were expecting 173 doctors to start work today. A spokeswoman for the trust said there may be fewer operations. Good thing Kezia had her weekly appointment yesterday!

We will watch the reports unfold ...

General Practitioner Workload Survey

The 2006/07 General Practitioner Workload Survey was issued by the Department of Health yesterday.

The last one was in 1992/93 – so why the fuck did they not do one before they renegotiated GP contracts in 2003?

I am pretty glad both for us patients and for the GPs that you are now pretty much working to the European Working Time Directive hours.

I am pretty happy that average consultation time has increased from 8.2 to 11.2 minutes.

I am worried that nurse consultations have increased, given Dr Crippen´s and Dr Rant´s gripes about nurse practitioners … but maybe it is not necessarily bad … I note that Dr Crippen and Dr Rant do not complain about their practice and District Nurses, and maybe some nurse-treated complaints and minor injuries are allowing the GPs to spend time with patients with more serious complaints.

Healthy Futures, Making it Better and the IRP - Update

If you recall from earlier posts (here, here, here, here and here), the North West Strategic Health Authority has been planning to “reform” (or “shake up”) the structure of paediatric, maternity and neonatal services across the whole area through the Making It Better proposal and to the healthcare of all in NE Greater Manchester through the Healthy Futures proposals.

(An aside – what the fuck is it with such “trendy” New Labour speak for consultations to be named as “Healthy Futures”? Why not just “A Review of Healthcare in NE Greater Manchester”?).

Our local council protested the recommendations of the proposals, as it will reduce some local services, particularly A&E. Some other councils in the area were also unhappy. As a result, the proposals were sent to the Independent Reconfiguration Panel (IRP), seemingly a non-governmental body of government-paid advisors, that reviews protested health decisions for the Department of Health. The request for IRP review was submitted in Patricia Hewitt´s time (thank you, Patsy, at least you didn´t make a dumb decision this time – but …) and as the submittal date to the DoH was just before her demise and Alan Johnson´s appointment to the Secretary of State for Health post …

The IRP submitted their report on 26 June and was meant to be published (i.e. put in the public domain) on 28 July.

However, the publication of the IRP´s report has been postponed “indefinitely” (quoting a local newspaper report) to give Alan Johnson more time to study its implications.

According to a DoH spokesperson “Given the level of complexity, size and scope contained in the Manchester reconfigurations, the Department of Health would like to understand what plans there are for implementation of any changes and more time to give the matter proper consideration”. (DoH press statement here).

Good on yuh Alan for not making rash decisions – and I am sure you have important things to think about today, 1 August, with the fallout from MTAS and tomorrow or the day after or the day after … with the NHS´s Programme for IT, etc etc.

You have publically committed yourself to send all disputed consultations to the IRP (did Patsy not?). Good on yuh!

However, I am curious as to why the Independent Reconfiguration Panel´s recommendations are not made public before the ministerial decision is made.

Linux in Brazil

Well, I went through DeLiLinux and Damn Small Linux … learning experiences. Then it was pointed out to me that I would need an operating system interface and applications in our home language, Portuguese.

I couldn´t find Portuguese language and keyboard support for for these flavours so googled on “Portuguese Linux” and came up with … a whole bunch of stuff!

I had forgotten that Brazil, and the Brazilian government have taken on board Linux and open source software in a BIG way! To the extent that the government signed an agreement with IBM in 2003 to develop Linux implementation in the public sector! A three year pilot project to implement Linux in one government ministry began in 2004 so, I guess, must be coming to an end now. I await news.

One of the, what could be termed “middle-range”, commercial Linux flavours, Conectiva was actually developed in Brazil. It is based on the “top-range” Debian (Linux is an ongoing family-tree of operating system flavours).

Another Debian derivative is Kurumin Linux, apparently being used in the above trial, which comes with a “lite” version for older machines. It is far easier to install programs and devices through a “control panel” designed for computer users with little IT knowledge and the user interface is much more friendly. With some caveats it can use “pure” Debian program packages (suffixed deb instead of the ubiquitous .rpm packages used by Red Hat, Fedora, SuSe etc, which, seemingly, have come under some criticism).

It also uses the graphical HPLIS system for Hewlett-Packard printer installation.

As you can gather I`ve installed it on our test machine. Unfortunately, it is not available in English.

Today my boss bought us a Portuguese keyboard and you know what? … a Brazilian Portuguese keyboard is different to a keyboard from Portugal!