How Your Postcode Determines What Treatments You Can Offer

Why good fortune determines what care you receive

We're fairly fortunate in the UK. GMC oversight, annual appraisals, medical registers and national guidance ensure a minimum standard of competence and care across the country. Compared with other nations, the disparity in the quality of care between two hospitals here is far smaller.

But it's not zero.

Up and down the country, some services simply aren't available to NHS patients, either because a consultant doesn't offer the treatment or because the trust doesn't have the means to deliver it.

In a post last month, we covered two bickering consultants who couldn't agree on the best treatment for a pilonidal sinus. Let's revisit it.

For a long time, many trusts have opted to treat a pilonidal sinus with simple excision surgery. But depending on the anatomy and number of tracts involved, the excised area can end up being huge. Combine that with a wound sitting in a hot, humid environment close to, let’s call it a "non-sterile source", and you get sky-high rates of complications and recurrent infection.

Fortunately, we now have fancy lasers that can clear out the tracts and induce closure (a procedure known as EPSiT). For patients unsuitable for EPSiT, a cleft lift procedure has excellent outcomes.

Can every consultant general surgeon perform these procedures? Of course not. So a patient may get better care simply depending on where they live.

Now, nothing stops a patient asking to be referred to a surgeon who performs a different procedure. But unless our patient happens to have an FRCS (Gen Surg) we didn't know about, how would they ever know to ask? How would they know which treatment offers the best outcomes?

And so the postcode lottery continues…

Curiosity Can Kill Careers, But Where’s The Line?

Back in 2023, at Nottingham University Hospitals, 91 members of staff looked at the victims’ records after their deaths. Eleven were sacked. The trust’s attempt at damage control was to remind everyone that most of the 91 probably had legitimate reasons for accessing the records.

‘Snooping’ staff have been warned by the NHS that they either face the sack or even prison for accessing patient records without a legitimate reason.

“Legitimate reason” is where the issue lies, and nobody is defining it for the situations doctors actually find themselves in.

We can intuitively reason, however, that there will be doctors who view records out of curiosity or for personal reasons. Some jump to defend themselves using the guise of an educational opportunity. And whilst some of them may genuinely be looking at records to reflect and educate themselves, this is one of those justifications that is notoriously easy to use but incredibly difficult to prove.

Checking how a patient you handed over is doing. Seeing which ward a colleague has been admitted to in the trust. Or even glancing at a relative’s result. All of these actions are potentially career-ending or can trigger a criminal offence.

It’s also worth reminding everyone that, with the advent of the Single Patient Record, the number of records any given doctor can technically access is about to go up massively. Perhaps this NHS campaign has been launched at a timely moment, recognising this.

Be careful how “curious” you are at work.

Doctor’s Intentions Matter Just As Much As The Outcome

What is it that separates “Service-Provision” from necessary experience?

Have a read of the following thought experiment from the Philosopher Julian Bagini:

Bagini’s thought experiment isn’t just another euthanasia one. It’s about the doctrine of double effect. The idea that intention, not outcome, is what makes an action lawful, and even moral.

Every time you ask for the morphine or midazolam to be increased to manage escalating pain or agitation, even though you may know it can hasten death, you are operating inside double effect. Practically, this is why there is such a significant obsession with documentation in medicine. Here, the recording that the increase in the dose was titrated against a specific symptom is crucial.

Most doctors will make a double-effect judgement call on a regular basis, even if they don’t name it as such.

Before we leave this thought experiment, it is worth clarifying that the doctrine of double effect is not simply a legal loophole whereby writing ‘for symptom control’ in the notes gets you off the hook entirely. Of course the clinical circumstances, proportionality, intent and prescribing all matter. No, a 200 mg dose of morphine for ‘symptom control’ would not cut it.

“72,050 NHS staff opted out of their NHS pension last year, with most doing so to save money. This figure is up 15% from the previous year.”

“No one’s on-call weekend beats mine. A family decided to complain that their relative, given days to live and placed on end-of-life care, failed to actually die over the weekend, and it ruined their plans.”

“Isn’t it amazing how we’ve reached a position where logistical considerations are the reason we can’t make application-related decisions that would be for the best in our profession? For example, pre-MSRA, a minimum portfolio cut-off to remove people from the process who have little on their CVs and are applying to a speciality as a backup would be a complete non-starter due to logistical issues.”

“Saw another absolutely egregious ‘co-authorship opportunity’ on a paper advertised on LinkedIn this morning. When will this nonsense be put to an end? Surely we either need regulation or portfolio reform.”

What’s on your mind? Email us!

Some things to review when you’re off the ward…

Here’s an interesting article from The Times saying that one in six patients are now using AI for health advice, which prompts a warning for misinformation. But the irony is that doctors are doing the exact same, with nearly 30% of UK GPs now using tools like ChatGPT during their consultations. Let’s take a breath before we jump to “patients are the problem”. It seems that when it comes to AI, no one has it figured out yet.

Estonia, Singapore and Denmark already have a Single Patient Record (SPR). Estonia's version has existed since 2008. Here is a breakdown from the King’s Fund on what Britain’s version of the SPR will look like.

Weekly Poll

This week it’s a double!

Last week’s poll:

As a consultant, which would you prefer?

…and whilst you’re here, can we please take a quick history from you?

Something you’d like to know in our next poll? Let us know!

Escalation Anxiety: Seriously, Just Ask

It’s a well-known maxim that the doctors who keep their consultants up at night are not the ones who ask loads of questions, but the ones who are too worried to ask at all.

So, either way, your consultant isn’t getting any sleep.

With doctors rotating into new departments last month, we want to revisit the mechanics behind asking for help. Doctors often hold two immediate cognitive fears when faced with a sick patient: the first is the clinical thought of the deteriorating patient and what needs to be done about them; the second is whether they’ve crossed some arbitrary threshold at which it becomes acceptable to ask for help.

This second point ties into the idea of ego. Medicine is a discipline filled with ego, especially when it comes to ideas surrounding intelligence.

“Is my registrar going to think my neurology knowledge is atrocious?”

“Is my consultant going to ask for proof of my medical degree?”

The thoughts rage back and forth while the patient deteriorates in front of you, and often, when that plea for help finally arrives, it is far too late.

So, the on-call tip is to speak to your seniors early. If you are due to rotate to ENT as a core surgical trainee, firstly, good luck. Secondly, speak to your registrars early. Ask them what they want to be contacted about and what they expect you to have done first.

Perhaps they expect you to have scoped a patient with a potentially unstable airway before contacting them…