All 3 entries tagged Health

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April 15, 2010

Health plays key part of UK's first televised election debate: leaders clash on cancer waits

The future of the NHS and service provision formed a central part of this evenings national election debate from Manchester screened live on ITV with concurrent audio on BBC Radio 4. Health care as expected did play an important role this evening. Here are a few quotes from the chief protagonists, Brown and Cameron:

Gordon Brown on the leader of the opposition, and on health care in general.

He [Cameron] couldn't give the same personal guarantees that we're giving about specialist cancer care

Fair to our National Health Service

Protect our helath service

David Cameron: rhetoric, with some serious points.

Choose hope over fear

Stop labours 'job tax' which could destroy our economy

If you work had 'll be behind you

If you're old and you become ill we will always be there for you.

Gordon Brown attacked the leader of the opposition about their plans and possible changes to the two week wait.But what is this two week wait? If you work as a doctor in the NHS, you'll already know, but for those that may not be so well informed, what does the two week wait actually mean in practice?

Essentially the 2WW (as its popular abbreviation) is the target that a patient with suspected cancer should be seen within two weeks of the referral being received. A good system? It seems so. Actually the targets go further, with the first 'definitive treatment' being delivered within the first 62 days from referral. This essentially means if you need an operation to have your cancer out, it is the responsibility of the doctors to diagnose it and treat it definitively. This means the necessary scans, biopsies pre-op checks and the like to achieve things. Lots of NHS initiatives have been criticised. The four hour wait has long been criticised by doctors (including this one) in Accident and Emergency departments, however it does seem to have driven up standards and efficiency in our hospitals. In principle, the two week wait is a good thing. So why would it be cut by the conservatives?

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The answer is complex, and not explained in the media writ large. There has been much focus on labours mailshot to potential cancer sufferers, but what politician in their right mind would cut such progress? (Guardian coverage here). The answer lies in policy and procedure, and represents why health is such a sensitive topic. ON the basis of Browns comments above, who without health insurance would not vote Labour? Unless the plans are presented clearly and simply (tonight they were not) it is difficult for those even inside healthcare to make informed voting decisions on such issues.

The conservative leader did consistently focus on the fact that Labour has had 13 years to fix things: how is Labour currently planning to fix things? By saving money, lets look at if its going to hit the workers in the health service (me) or the patients (me). Are there tough choices that have really been outlined for the NHS to date in terms of cuts?


Efficiency Savings: What is the level of 'pain' the NHS can expect?

These points come from the Department of Healths own press release hereI cant help but provide my own bottom line opinion for what it means to staff and patients.

The Department of Health and the NHS will meet this target through a range of activities including:

  • "Up to £1.5bn will be saved by driving down the costs of procurement through securing best prices for goods and services"
    • The bottom line: no pain for the workers or the patients
  • "£100m will be saved by taking a new approach to the National Programme for IT that offers greater choice to local hospitals"
    • The bottom line: no pain for the workers or the patients (unless you're in IT!)
  • "£60m will be saved by reducing the amount of energy the NHS uses, to deliver a 10 per cent cut in carbon emissions"
    • No pain for the workers or the patients, lots of energy saving light bulbs on the shopping list
  • "Up to £70m will be saved from more efficient use of NHS estates"
    • No pain for the workers or the patients, don't expect to buy the local hydrotherapy pool at a cut price
  • "Up to £555m by reducing staff sickness absence in the NHS."
    • No pain for the workers or the patients, unless you're doing things you shouldn't be.

Andy Burnham the health secretary had the following to say on the 4.5billion saved in the budget.

The NHS budget is in a strong position after a decade of record  investment. I am pleased that today’s Budget locks in that growth, guaranteeing that frontline NHS funding will rise with inflation in 2011-12 and 2012-13.  As a result of this funding, the NHS is today more resilient, has more capacity and provides better care than ever before.

Healthcare, two week waits, cancer services, provision of care for the elderly, the payment of this care, and taxation of those receiving it will continue to play a key part in the election leading up to May 2010. As you can see how these policies, and changes to current policy are presented is likely to influence the publics next choice of government.

Missed it? You can catch up on ITV here on what went on. Id be interested to hear comments from anyone and everyone on the above musings...


February 03, 2010

Web Based Learning in Rheumatology, where are we now, and where do we need to be?

We all know about the potential of the web, but how should it be best put to use? Here are some of my musings frommy own thoughts on web based learning and rheumatology as it stands today.internal rotation of the shoulder

Background

When considering web based learning (WBL), extensive research has been conducted to compare e-learning against more traditional teaching methods. Up until recent years, the majority of educational research studies into WBL were non inferiority studies, or comparisons of additional e-learning resources ‘added into’ standard curricula (Cook, 2005, 2008). The largest meta-analysis of WBL learning in healthcare conducted to date has concluded that it is not if, but how we deliver web based learning that is the most critical question facing educators (Cook, 2008). It was confirmed by Wong (2003) that delivery of web based teaching is not simply a case of ‘putting your course on the web’. Robust evidence does not exist on exactly how the delivery of this material influences learning. Few studies attempt to directly compare two different approaches, with almost no data on an ‘interactive video’ based approach compared to a standard online presentation of material.

WBL in Rheumatology
Education in musculoskeletal medicine provides some evidence for some forms of WBL when added to traditional methods (Wilson, 2006); however I have identified no trials that compare different online strategies to teach a clinical skill. Various e-learning techniques have been tried, but they are often not web based. The Arthritis Research Campaign (ARC) have produced a more traditional CD ROM based e-learning package has been evaluated, and been shown to improve OSCE scores post intervention and improve self reported confidence (Vivekananda-Schmidt, 2005), however WBL has not been studied extensively studied by the ARC, or other research groups.

How is WBL Delivered
Web based learning (WBL) is commonly delivered in the form of a Virtual Learning Environment (VLE). A VLE can be thought of as a navigational menu driven system by which a student directs his or her educational pathway through a series of resources or activities. Any accessory materials such as pre/ post teaching evaluation can be delivered, with the results often being automatically collated by the VLE. This structure allows the delivery of educational material to trainees, in a reproducible, secure way. Each VLE can be accessed by students and teachers, with different priorities and user privileges available to users depending on a pre determined level of access.

Online material can be presented I a number of formats inside a VLE, namely via traditional text and pictures with associated connections between topics (hyperlinks), or via more detailed methods incorporating video and audio based aids to assist in their development. There is evidence to support that the more sophisticated the technology or advanced the delivery method, there is an increased associated cost. Furthermore this has been shown as one factor to dissuade medical schools in the United States to sharing online e-learning material, or producing open access medical resources (Huang, 2007).

In summary there is a large amount that is still to be studied relating to web based learning in  Rheumatology. Where do we go from here?

Selected References and Further Reading, if you're interested...

Badcock LJ, Raj N, Gadsby K, Deighton CM. Meeting the needs of increasing numbers of medical students--a best practise approach. Rheumatology  2006;45(7):799-803.

Cook DA, Levinson AJ, Garside MD et al. Internet-Based Learning in the Health Professions, A Meta-analysis. JAMA. 2008;300(10):1181-1196.

Cook DA. The research we still are not doing: an agenda for the study of computer-based learning. Acad Med 2005;80:541-8.

Cook DA. Where are we with Web-based learning in medical education? Med Teach. 2006;28(7):594-8.

Downing SM. Reliability: on the reproducibility of assessment data. Med Educ. 2004;38(9):1006-12.   

Huang G, Reynolds R, Candler C. Virtual Patient Simulation at U.S. and Canadian Medical Schools. Acad Med. 2007;82:446-451

Kay LJ, Deighton CM, Walker DJ, Hay EM. Undergraduate rheumatology teaching in the UK: a survey of current practice and changes since 1990. Arthritis Research Campaign Undergraduate Working Party of the ARC Education Sub-committee. Rheumatology. 2000;39(7):800-3

Norman G Eva KW. Quantitative Research methods in medical education. AMSE. Edinburgh 2008.

Vivekananda-Schmidt P, Lewis M, Hassell AB.Cluster randomized controlled trial of the impact of a computer-assisted learning package on the learning of musculoskeletal examination skills by undergraduate medical students. Arthritis Rheum. 2005 15;53(5):764-71.

Wilson AS, Goodall JE, Ambrosini G, Carruthers DM, Chan H, Ong SG, Gordon C, Young SP. Development of an interactive learning tool for teaching rheumatology- a simulated clinical case studies program. Rheumatology (Oxford). 2006 Sep;45(9):1158-61.

Wong G, Greenhalgh T, Russell J, Boynton P, Toon P. Putting your course on the Web: lessons from a case study and systematic literature review. Med Educ. 2003;37(11):1020-3.


August 11, 2009

Politics and the NHS, Productivity, Targets and Numbers

The NHS is coming under increasing scrutiny, and the issues around its funding once again making front page news. There are some recurring statistics: productivity in the NHS has fallen by 4% despite a large cash injection from 1997 onwards.

But what does this mean? There is an increasing drive for doctors in training to have formal management qualifications. With this in mind, what does a 4% increase in productivity actually mean? Does every doctor do 4% less work? Are patients likely to get only 96% of the treatment that’s should be given to them? More importantly if a trainee inside the organisation, with an interest in management has little idea of how the numbers are derived, and what they mean to the average medical clinic, A&E department or on call surgical list, then there is a problem.

The most telling argument was a rule mentioned in passing to me by a colleague. It doubles follows a principle which despite my ‘intelligent’ Google searching, I cannot find…It goes like this: once you turn a marker of performance into a target, that marker of performance ceases to accurately reflect performance.

When applying this to the NHS you get a simple, understandable concept. Consider the Emergency department 4 hour wait. It is likely that departments that were seeing, treating, discharging or transferring patients within 4 hours of their arrival in that department were good A&E departments, better than the ‘norm’. Where is the evidence for this? Common sense and expert opinion!

Once the 4 hours becomes a target, then hospitals managers will be ‘forced’ to hit those targets. If that means renaming a bay in A&E as an inpatient observation ward then so be it. If it means treatments being delayed, then so be it. Its increasingly common for junior doctors to be faced with management policies at their inductions, and the potential repercussions of not fulfilling specific targets set. Its more likely that they will be turning away from the NEJM to the other publications (for example form the Medical Defence Organisations like the Medical Protection Society) that produce survival advice for newly qualified doctors in changing times.

The difficulty is introducing the kind of lean management principles reported in the late 1990s by the American Academics that sought to find out why Japanese Car manufacturers like Toyota could produce and import cars to the US for less money than their American counterparts.

It is the challenge of meaningfully measuring and quantifying management performance in the NHS that is the challenge. Getting from line staff (like myself) to understand the concepts of productivity is critical, as is giving departments this sort of information.

If the focus shifts to lean and efficient management processes, then the numbers behind the targets will follow. The measurement of markers of productivity needs to be more transparent to staff, patients, and contributors to the NHS budget (British taxpayers) to allow them as voters to make informed decisions surrounding healthcare policy.


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