Martin McShane: My nose is out of joint

Martin McShane As is my wont, I was skimming the BMA news and hovered over the “See one, do one” column about working and surviving as a junior doctor. It was a well written and entertaining piece about getting behind the real reason for a patient’s presentation. A youngish, male patient presented with nasal symptoms but, in reality, wanted cosmetic surgery for a previously broken nose: a nice anecdote illustrating the importance of understanding the motivation behind the presenting history.

And then it all went horribly wrong. The article continues:

“I could operate to straighten the nose and that will improve how your nose looks, but quite possible it will make no difference to your breathing.”
“OK, doctor we try that,” he said, with his face once more animated.

“OK,” I said.

And we allowed ourselves small smiles.

I wasn’t smiling.

This week I sat in on a meeting about improving the management of patients presenting with stroke.

I have a personal interest in the stroke pathway. My mother died after multiple strokes had finally left her incapacitated. When she had her first stroke, I was immensely proud of the treatment and management which she received from the NHS. I was amazed by her recovery, despite all my experience. The care which she received allowed her to retain her independence, subsequently, for several years. My daughter, her grand-daughter, has memories of her grandmother which, without the NHS, she would never have. When my mother’s end came, she received exemplary care from both health and social services and died with dignity and respect.

I digress; let us get back to the meeting. A substantial number of senior clinicians and managers were present, with only two of us from the commissioning wing of the NHS. A leading consultant indicated that the acute trust could solve most of its problems by generating an additional £930k from best practice tariff. As far as I can determine, best practice tariff is predicated on what best practice should be. Is it actually paid for best practice? Leaving that aside, with the NHS facing a cold climate, I was ruminating on what we will have to stop doing in order to fund best practice in stroke care. I also reflected, more importantly, on which people are best placed to support and implement the best use of resources, other than front line clinicians? Without doctors prescribing cost-effectively, ceasing to use interventions of limited (or no) effectiveness and adopting quality improvement to reduce exceptional and unwarranted variation in clinical management, I know our director of finance has no access to quantitative easing of any sort.
Saying no may not bring a small smile, but if doctors continue to consume resources on the ineffective, inappropriate or the unnecessary, then finding the money for best practice is going to be impossible.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.