Monday, August 23, 2010

Side Effects - both Pharmaceutical and Economic!

It is generally well understood that all medicines have side effects. Most side effects are unwanted but occasionally some are beneficial enough to encourage alternative use to be made of the drug, indeed to open up new marketing opportunities for the drug company that brought the drug to market and holds the patent.

While working at GSK  I was made aware that this was the background to an anti smoking drug which had been developed initially as an anti depressant. Users of GSK's anti-depression medication Wellbutrin (bupropion hydrochloride) often reported a lessening in the desire for cigarettes. Having been alerted to this consumer feedback GSK undertook further testing and the drug was found to be effective in treating smoking addiction, and helping smokers quit. GlaxoSmithKline "repackaged" Wellbutrin and marketed it as the smoking-cessation drug Zyban.

Pfizer had a similar unexpected huge hit when Phase 1 trials for a drug (Sildenafil ) developed to treat high blood presure and angina was found to have had little effect on angina, but could induce significant penile erection. Pfizer decided to market the drug for erectile dysfunction under the name Viagra

A similar attempt to treat high blood pressure - Minoxidil - has also found to have (short term) beneficial side effects as well as toxic ones. Minoxidil was first prescribed and used as an oral tablet to treat high blood pressure (it still is especially with persistent hypertension that cannot be controlled satisfactorily on other combined therapies). It was during its initial use that hair growth was noticed as a side-effect.

Not missing an opportunity, UpJohn explored developing it as a solution to hair loss and marketed a 2 percent topical solution in the mid 1980s called Rogaine. Since then, UpJohn has developed a 5 percent solution (extra strength Rogaine) and Rogaine for Women.

Topical forms of Minoxidil have moved from being a prescription only product to being available for over the counter sales. Since the 1990s, numerous generic forms of minoxidil have became available to treat hair loss.The oral form is still used to treat high blood pressure and ONLY high blood pressure in the US.  In the UK, Minoxidil for hair growth is not available other than over the counter or on line and then only with with a private prescription. The oral form, now out of patent, is still prescribed for persistent hyper tension but is produced by only one manufacturer (Pfizer).

I was prescribed minoxidil - in the past - and for many years indeed noticed the effect on hair growth. When I stopped taking Minoxidil the male pattern baldness that had been on hold reappeared.

I suffered for a  number of years ( about 4) with post operative infection, during which time the minoxidil was stopped and my blood pressure controlled with a combination of other drugs. The post operative infection  required  a 2 stage hip replacement leaving me with a few inches of femur and loss of about a cereal bowl's worth of thigh muscle. In time the renal clinic I attended began to notice that the blood pressure was again slowly getting out of control. Initial additions to the drug regimen and increases in strength failed to control it to the extent required and it was suggested that the systemic infection had exercised a vaso dilating effect which had the interesting and "beneficial" side effect of lowering my blood pressure). Successful cessation of the underlying (post operative) infection meant that a similar vaso dilating effect might be required through medication - like minoxidil - to regain control.

So 1 month ago I was restarted on minoxidil oral 5mg daily. My blood pressure returned to the levels that the renal clinic are content with and I tried to obtain a repeat prescription through the local pharmacy.

In the past the local pharmacy had experienced difficulties obtaining supplies and I needed to switch to a more central pharmacy that - most of the time - manged to secure an adequate supply.

I did not want to have to transfer "loyalty" again so hoped that the previous problems had been sorted out in the meantime ....... They may well have been ..... but to my surprise not only can the local pharmacy not get any until late September but the main central community pharmacy cannot either - saying that there is a manufacturing problem!

I emailed the consultant who prescribed the medication and sent a copy to the Pharmacist employed by the PCT to manage and plan community pharmacy services for the city in case this was symptomatic of a more general problem. In his response he pointed to a general problem with a number of branded medicines caused partly by the effective devaluation of Sterling and the European Community free market which removes any barriers to free trade within the community. It is therefore not in the interests of manufacturers to do anything other than maximise profits and satisfying those who pay most. One "side effect" of this is that they have imposed quota's on those customers ( such as the NHS) who are not prepared to pay most.

The previous government held talks before the election this year to try to attend to this unintended consequence of "world class commissioning" in primary care and the current coalition are also planning to respond. The problem is indeed more widespread than minoxidil and it appears that the current work around is to contact manufacturer's direct and I guess plea for special treatment. The notes of the discussions in Spring 2010 about
Branded Medicine Shortages can be read by clicking on the link to the left.

So we really are "all in this together" - and unless the NHS is ready to compete with other customers of big pharma, some patients may well be denied medication they require as an unintended consequence (side effect even!) of current economic woes and pursuit of "world class commissioning". In my case I have obtained a further month's supply becasue the hospital consultant has agreed to issue a prescription that the hospital pharmacy will fulfill. I'm not sure this represents a lomger term remedy but am grateful for small mercies.

In these days of separate budgets (even though all funded by public taxation) I am grateful that the accountants and managers remain ignorant as I 'm sure they would not allow this "cost shifting" to take place.  I hope no-one on minoxidil is denied further supplies and suffers a stroke or other avoidable incident.

I wonder what jobbing doctors (and Jobbing Doctor in particular) make of this. I'm sure it would be enough to make Dr Grumble and others pause for reflection.

Tuesday, April 20, 2010

Clear Skies

Having just returned from 10 days touring Southern Ireland, in glorious sunshine for most of the time, we were struck with how clear the views were back in the UK. Was this a by product of the volcanic ash - we wondered? Perhaps the plume of volcanic ash high up (and out of sight in the atmosphere) was blocking out other - more usual - pollutants?

Then we realised that perhaps it was the total and prolonged absence of air flight that might be responsible. After all the largely invisible pollution that we are told is caused by air travel is supposed to contribute to a "greenhouse" effect and accelerate global warming. But it is very difficult to see the proof of this with ones own eyes.

The ferry from Dublin arrived in Holyhead around mid day and after a short stop at relatives on Anglesey our 3 hour return trip to Sheffield took us within sight of both Snowdonia and the Derbyshire Peak District. Rarely - if ever before - have we seen distant ridges, summits and exposed rocks so clearly defined.

Snowden and its neigbouring peaks were clearly visible as were the patches of snow on high ground in shady nooks and crannies. The sky appeared cleaner, and bluer that we can remember and this contributed to the clarity of distant vistas along with the blue sea with white waves rolling in to sandy beaches around Llandudno. Great Orme Head was clearly visible in its entirety - no need to extrapolate from partially visible views between cloud. The climb out of Glossop and views toward Kinder Scout were as full of detail as we have ever seen. Gullies as well as ridges stood out far more clearly than we could recall seeing before. Then we could feast our eyes on the deep blue of both Ladybower and Derwent Water reservoirs as we neared the end of our trip along Snake Pass. We could clearly could make out millstone grit of Stannedge Edge towering above both reservoirs, against a beautiful blue sky dotted with white clouds. Then it was up toward Strines moor and sneak rear mirror views back toward Whin Top before Sheffield unravelled as we approached it along the Rivelin Valley. High up to the right, towards Lodge Moor, I could see standing stones in the mid distance that I never knew existed.

I know it is selfish but if the Icelandic Volcano is the cause of this "revelation" of nature's glories  in the North of England then I hope it continues a little longer so I can capture some of our local views on camera.

The overall effect has been similar to the transformation of vision an optician achieves when fitting the correct strength lens during an eye test ( or possibly after a cataract has been removed). We can remember only a few occassions, in the last 25 years or so, when travelling from Higgor Tor, and stopping to overlook Sheffield above Ringinglow, that we could not only see the shape of  distant landmarks like Loughborough and Ferrybridge Cooling TTowers but further out to Drax and also to an unknown power station beyond even that. I am sure we would be able to see a similar distance as clearly this afternoon had we taken that route back home.

There probably have been days when we have witnessed a similar clarity - so our experience today is certainly not proof of the otherwise hidden effects of air travel but it does seem highly suggestive.
I wonder if anyone else has had similar experience and reflections in the last couple of days?

Tuesday, December 22, 2009

Generosity is natural for kind-hearted people - health - 21 December 2009 - New Scientist

A couple of years ago I read that people who demonstrated altruistic behaviour had an area of the brain that was physically different from those who were more selfish. It struck a chord and in a way I wanted to believe that this was true. It would go some way to explain the difficulties I have experienced in the past debating social policy with those motivated by dread, envy, fear, greed and hatred, rather than altruism, benevolence and charity.

The ethos of "public services" in the UK has for the last 20 years been under pressure and lost ground to unregulated greed as these 2 distinct world views have "arm wrestled" for public support.

In the light of the financial crash and wasteful public investment in Bliar and Brown's "Third Way" strategy of foisting a choice agenda on all - whether they want it or not -, perhaps the "Prosocials" will be able to better understand the inability of the "Individualists" to even see how their own self interest is best served by reducing inequality if they read this article in New Scientist where these 2 terms are defined alongside recent neurophysiology and neuropsychology findings:

Generosity is natural for kind-hearted people - 21 December 2009 - New Scientist

If the amygdala - where the difference in brain activity is apparent - can be affected by nurture as well as genetics ( as future research will attempt to discover) then "we" face a moral dilemma in terms of whether or not we would want to encourage prosocial behaviour. Think about it for a minute. It would be difficult to frame a question about this that was completely open. I suspect that I would fall into the prosocial group and therefore think it would be "right" to try to adopt policies that encouraged altruism. However the theories of selfish genes and an evolutionary mind (one that is predisposed to survival in hunter gatherer societies) does make me aware that a conscious choice to "buck the trend" might not necessarily be a sensible way forward. Individualists will argue that it is selfish, competitive behaviour that has improved the lot of many generations. Prosocials will no doubt point to past and present exploitation by the lucky strong over the less fortunate but often more numerous weak.

If future research ever allows us to measure the distribution of "prosocials" and "individualists" by geography, occupations, income etc it would certainly "concentrate minds" as this inevitable debate rolls on in the decades ahead.

The Importance of Economic Equality

It has taken a good 6 months for the important book "The Spirit Level : How More Equal Societies Almost Always Do Better" to be published in the USA, which on most indicators comes out as the least equal society ( - even more so than the UK!)

The proof is based on 2 sets of indicators one of which is a series of comparisons among the individual States of the USA.

It will be interesting to observe how the the "American Dream" performs when confronted with evidence of The Importance of Economic Equality.

This link will take you to an article published on-line by Time (and CNN) where the 2 authors address a number of questions. This has allowed them to update their evidence with the fact that " more-equal societies are more innovative in terms of patents granted per capita This is probably because they develop more human capital. Kids do better in school, and social mobility is higher"

Friday, November 27, 2009

Counter Intuitive Reading

In the last 12 months, after several years of enforced inactivity due to post operative infection and 4 hip operations in 2008, I am amazed at how much more I seem to have read. As I spend less time sitting and more time doing why is it that I have read far more this last year?

I think it has to do with having the ability to get up and select books from the shelves as well as having the ability to travel more and as a result wait around in departure lounges. Perhaps it is also the realisation that after reading something - that is thought provoking - I am able, if I were so inclined, to do something about it, even it is is only replacing the book on the shelf, sharing it with a neighbour or friend or helping to set up a local group to take forward a book's aims.

Anyway I thought it might be useful to record the books that I have read in the last 12 months - so here goes:

( 1) Uncle Tungsen - Oliver Sacks - an account of his early fascination with chemistry.

( 2) Bad Science - Ben Goldacre - how the worried well are exploited by the inadequacy of their own numeracy

( 3) The Culture of Contentment - J.K. Galbraith - Prescient analysis of financial crises

( 4) Hegemony or Survival - Noam Chomsky - America's quest for global dominance

( 5) The Gods That Failed - Elliot & Atkinson - How blind faith in markets cost us the future

( 6) Perestroika - Mikhail Gorbachov - New (then!) thinking for our country and the world

( 7) Rumpole and the Penge Bungalow Murders - John Mortimor

( 8) The Anti Social Behaviour of Horace Rumpole - John Mortimor

( 9) Rumpole and the Reign of Terror - John Mortimor

(10)Rumpole at Christmas - John Mortimor

(11)Parkinsons' Law on the Pursuit of Progress - C Northcote Parkinson

(12) Cabinet of Mathematical Curiosities - Prof Ian Stewart

(13) Reckoning with Risk - Gerd Gigerenzer - Learning to live with uncertainty

(14) Trust - Anthony Seldon - How we lost it and how to get it back

(15) The Spirit Level - Wilkinson & Pickett - Why more equal societies almost always do better

(16) Putting Patients Last - Davies & Gubb - How the NHS keeps the 10 commandments of business failure

(17) The Shakespearian Stage 1574-1642 - Andrew Gurr

(18) Shakespeare's Advice to the Players - Peter Hall

(19) 1599 - James Shapiro - A year in the life of William Shakespeare

(20) The US Constitution - Hennessey & McConnell - A graphic adaptation

(21) A Fair Field and No Favour - Gideon Haigh - The Ashes 2005: the series of a lifetime

(22) Shaltiel - Moshe Shaltiel Gracian - One Family's Journey Through History

(23) The Bielski Brothers - Peter Duffy - 3 men who defied the nazi's built a village in the forest and saved 1200 Jews

Some books I have yet to start:

( 1) The Human Brain - Rita Carter - Illustrated guide to its structure, function and disorders
( 2) Fools Gold - Gillian Tett - How unrestrained greed corrupted a dream, shattered global markets and unleashed a catastrophe
( 3) The Economics of Innocent Fraud - J.K. Galbraith - Truth for our time

And now some of the books I started but have not finished ... yet ... still...

( 1) The Great War for Civilisation - Robert Fisk I got to page 432 of 1300
( 2) Imperial America - Gore Vidal
( 3) The Secret Life of Words - Henry Hitchings - How English became English

Wednesday, November 11, 2009

Sharing the Lessons of NHS Funded Research

I attended a conference at the Royal College of Physicians yesterday which reviewed progress with NHS funded research through the National Institute of Health Research (NIHR) and in particular its Health Technology Assessment (HTA) arm.

I am one of 3 lay members of the HTA's Pharmaceutical Panel - it is 1 of 6 such panels that filter out initial proposals for funding before they are considered by a Prioritisation Group and if approved by a Commissioning Board.

The process has been described as similar to the Grand National with a number of fences to be cleared before funding will be allocated. Using this analogy my role is therefore one of the twigs that make up the first hurdle. Also on the same panel are some very eminent practitioners with specialist clinical and pharmaceutical knowledge. One of these is Ben Goldacre - of Bad Science fame and another is Carl Henghan of the Centre for Evidence-Based Medicine, Dept of Primary Health Care, University of Oxford. Both are frequent commentators on Radio and TV on aspects of evidence based medicine.

The conference was chaired by Richard Smith, former editor of the BMJ and some 25 years or so ago an earlier TV medical pundit who sought to explain science to a lay audience.

He had just returned from a 5 day conference in Germany exploring how best to promote health literacy. Ben Goldacre was there as was Gerd Gigerenzer, whose book "Reckoning with Risk" I have almost finished. The book describes how it is almost impossible to achieve informed consent without understanding clearly the natural frequencies of possible outcomes.

Giggerenzer describes the fallacy of relying solely on percentages to express risk and describes workshops where clinicians have demonstrated themselves to be as innumerate as the general population and felt uncomfortable being asked to work out real risk. He describes how, once problems are restated in terms of natural frequencies- i.e. out of every 10,000 people (with a particular set of characteristics) how many would for example test positive when screened but not have a problem, or test negative but have the problem (false positives and false negatives) ,- the clinicians feel more comfortable and better able to share the risk with their patients. He also uncovers the hidden costs of false positive and false negative results - for example false positive HIV tests that have resulted in suicides. He makes the telling point that sometimes more people can die WITH a condition than OF it. For example prostate cancer in men. This is something that the "worried well" need to be more aware of if they are not going to harm themselves at great cost while benefiting only the growing band of today's equivalent of "snake oil" salesmen.

The first speaker at the conference was the Chief Medical Officer Sir Liam Donaldson. I first met him when he was The Regional Medical officer of the Northern Region and I was working at the Nuffield Institute Leeds University just after leaving the NHS after 20 years in a variety of management roles. I was a mentor to a trainee who was attached to Liam's department. I had "worked" with his predecessor as Chief Medical Officer Sir Kenneth Calman in the past. We had both spoken to clinicians in Scotland on clinical engagement with management . I had just completed a report for the then NHS Management Board based on some quick and dirty research and was able to share the outcome with those present. Ken who was at the time CMO Scotland while still practicing as a Cardiothoracic surgeon shortly after went on to be the CMO for England and Wales, succeeding Sir Donald Acheson (who was CMO at the time that I was seconded to the Department of Health). SIr Liam gets a bad press from clinical bloggers who see him as a tame patsy for the current government and their peddling of ersatz markets and false "choice". They are also upset with him over hte dumbing down of medical education and the rise of "noctors" (not doctors) , "Quacktitioners" (nurse practitioners) and similar attempts to dilute the skill levels of those providing clinical care more cheaply to the masses while ensuring that the political class and their hangers on continue to have access to the best that is available free of charge because of who they are and what they know about manipulating the system to their advantage. His recent inability to answer a straight question about the relationship between government and scientific advisers in light of the sacking by the Home Secretary of Professor Nutt underlined the difficulty he faces speaking with any credibility on such issues. His predecessor Ken Calman had no such difficulty - perhaps because he was what GPs and others would have regarded as a "real doctor" and not one of the band of "failed doctors" that they feel find their way into "Public Health". Ken Calman retained that sense of Independence of thought, speech and deed - or at least was able to get away with that impression. Sir Liam struggles in comparison.

However yesterday Liam was on firmer ground. He was returning to an area that he had made significant contributions to before he got embroiled first in General Management (as Chief Executive of the Northern Region) and later in national politics (that's the small "p" not the large "P" as in Party Politics) once elevated to the NHS Management Board as CMO.

He dug out notes he had written 10 to 15 years before and which were still relevant today. These included concerns he had about how best to disseminate the results of properly conducted research. He mentioned the concept coined by Rogers of the Diffusion of Innovations and remembered scribbling down the acronym NIIMBY (or as he pronounced it Nye Imby) - meaning Not Invented in My Back Yard. Others used have used the phrase "Not Invented Here" to describe this reluctance to give credence to evidence from elsewhere.

Sir Liam felt this barrier to dissemination might be based on feelings of humiliation and inadequacy. My own notes of his talk show 2 triangles at this point. The first with the apex at the top and a number of bands is Maslow's Hierarchy of Needs with "self actualisation" at the top. My second triangle was the inverse of this. The same bands but with self actualisation at the bottom and the "base" of the triangle at the top. Local managers and clinicians have increasingly been denied the space to experiment and pilot while at the same time the Dept of Health has moved away from disseminating good practice developed locally and concentrated instead on micro management. The long term consequences of this are spelt out in sections of Anthony Seldon's latest book "Trust: How we lost it and how to get it back"

The last 25 years in public service have seen this inversion of the hierarchy of needs magnified large with top down targets being driven on by bullying tactics based on the use of Dread, Envy, Fear, Greed and Hate. These motivational triggers have replaced the Altruism, Benevolence and Charity that were much more evident 25 years ago. Forget about "self actualisation" - survival is all that matters now - but don't breath a word of that to the press - remember what happens to whistle blowers! Perhaps these are areas ripe for the Chief Medical Officer to demonstrate his leadership qualities and rise to the challenge.

Nevertheless Sir Liam identified 6 ongoing concerns that needed to be addressed if the lessons of NHS Research were to be better diffused in the future.

The last 4 of these I managed to note down as:

3. Models of care are difficult to spread
4. NHS Leaders and managers are not evidence literate
5. Too much recent system change without piloting or evaluation
6 Clinical Behaviour Change is the hardest to achieve and is why technical changes appeal more because they offer more hope of success.

Sir Liam stressed his 4th point and I was reminded of evidence of this from my own past:

1) The time I was told by a Chief Executive that it would be a waste of everyone's time if I was to proceed to the panel interview after the preliminary series of exercises as I had demonstrated that I was "too data driven" for him and his team to feel comfortable with as his future deputy.

2) My attempt to set up an "Informed Management Unit" at the Nuffield Institute instead of the Information Management Unit that the NHS then seemed to want. It was difficult to "market" this concept when complexity of IT systems was in reality the greatest excuse for decision avoidance by managers and politicians at all levels and judging by the mess and waste of the latest National I.T. strategy it still is!

3) My failed attempt in 1973 when as a junior administrator at Pontefract General Infirmary I wanted to analyse hospital deaths and plot against staff rota's to see if there were any anomalies. (I had been sensitised to this by the response of staff who paid cremation certificate fees to junior doctors - known as "Ash Cash" - when I had asked if anyone took advantage of this.) One of the junior doctors at the hospital at the time was Harold Shipman. I was told that this was not something that hospital administrators should concern themselves about and to get back to balancing the petty cash!

4) My analysis of hospital death rates that was the front page story in the Times by Jeremy Laurance in April 1993. Responses from a Regional Medical Officer and a Hospital Chief Executive at the time indicated that they were both unaware of their relatively poor performance and what was more disturbing did not care anyway.

There are many more examples but these were what came to mind at the time.

20 odd years ago I was asked to take the lead nationally on a aspects of Organisational Development when seconded to the Dept of Health. The work was scuppered by the hasty reaction of the Thatcher Government to being embarrassed by clinicians over care being denied to children in A& E. This broke the unwritten compact between politicians and doctors and as a result, the gloves came off and successive governments have pushed through the choice and market agenda ever since. At the time I was asked to look at 2 aspects, (1) To what extent there was agreement on Key Values that underpinned the NHS and (2) What could be done to improve relationships between doctors and managers. I will return to this work in the future in another posting and when I do will edit this post to include a link to the findings and lessons.

Having conducted a survey of a couple of dozen hospitals where it was thought there were good relationships between managers and clinicians I had identified 30 actions that could contribute. What emerged as the top priority was "Agreement on what constitutes Quality".

If I was to repeat the work today I would want to include Gerd Giggerenzer's work and add in "Agreement on how to Reckon With Risk using Natural Frequencies", albeit with a flash card explaining terms with some examples.

Reflecting on Darell Huff's book How to Lie with Statistics, Giggerenzer has a chapter (12) devoted to "How innumeracy can be exploited". It mirrors much of what Ben Goldacre draws attention to in his articles, blog and book about Bad Science.

Perhaps a joint understanding of how innumeracy can be exploited would be a good shared starting point for overcoming barriers locally between researchers, clinicians and managers. Arising out of a series of workshops to achieve this, that would be delivered locally, researchers, clinicians, managers and - lets be really visionary - patient & carer representatives might be able to agree on some top priority evidence based plans for the future attention.

Perhaps this too is an area where Sir Liam could show his leadership qualities in the future and build on his past achievements in public health and evidence based medicine. A start could be made by the HTA insisting on the use of natural frequencies when is own panels consider prevalence rates and probabilities, they could also insist on research findings being expressed in a similar fashion. Monograms for public consumption could be published as a separate series. As was pointed out most members of the public reach for Google and do a search on any diagnosis. They are faced with a plethora of unsubstantiated advice. Perhaps the Dept of Health needs to divert some of its advertising, marketing and consultancy budget to paying Google ( and similar advertising funded search engines) for priority placement of Ads that highlight these public monograms. Again this is something that Sir Liam could take action on.

These are just a few thoughts - from a lay representative (who was able to attend the HTA conference) - on how to better disseminate research findings, engage local managers in the process and provide the worried well with some tools to overcome the exploitation of their own innumeracy.

Tuesday, March 18, 2008

The overzealous auditor - Part 2

While the Thatcher government were battling with the miners of Yorkshire, Nottingham and Kent, another industrial dispute rumbled on for over a year. It was a strike of ancillary workers at Barking Hospital in Essex and was in support of the cleaning staff who had their hours severely reduced as a result of the general introduction of contract cleaning into the NHS. The sad thing about this was that Barking Hospital had a long and successful history of employing contract cleaners before it became required to test the market.

The successful tenderers had previously employed staff on hospital rates of pay and with pension rights similar to those of NHS staff. This had been written into the contract by the health authority. The health authority limited its role to clearly specifying what was required and closely monitoring the contractors own supervisory arrangements. With the clamour to test NHS support services against the market (or "contract out") to reduce costs the successful tenderers at Barking however found they could no longer compete without severely restricting the hours their staff worked.

One saving that was being made by competitors new to the market place was to pay staff on a part time basis only thereby allowing the employer to avoid having to pay National Insurance for their employees. Furthermore the new entrants to the contract cleaning market place did not offer pensions comparable to those in the NHS. The previous contractors did in the end hang on to the Barking Hospital cleaning contract but only by severely restricting the terms and conditions of employment of previous loyal staff. Sadly it appears that when prioritising which staff would have to suffer the most dramatic reductions the opportunity was taken to settle some old scores and not everyone was treated fairly.

For other a year therefore there was a picket line outside of Barking hospital. All deliveries were challenged and in the early days ambulances refused to carry patients across the picket line. I saw a patient with one leg hopping from an ambulance to cross the picket line under his own steam and others on crutches making their way as best they could to out patients. This did not last for long however and in the end ambulances were allowed to cross. The strikers drew the line however at the health authority's own laundry van. Initially the drivers ignored the pickets and continued to collect dirty linen and deliver fresh. But they were under pressure to show their solidarity by refusing to do this any longer. I accepted their predicament and arranged for a rota of senior health service managers to drive the laundry van and do the unloading and loading on a daily basis.

This continued without too much problem for most of the year that the dispute lasted. There was a hiccup however when the laundry staff were asked to stop handling theatre greens from Barking (these are the gowns worn by theatre staff). Although we used disposables as much as we could the Theatre gowns were not then capable of being substituted. I intervened to talk to the laundry staff and shared with them what I understood the true position to be (including the fact that this action alone would stop operations at the hospital). I asked them to reconsider while I waited outside. When I returned to the meeting I was pleased to hear that they had voted to return. When I asked one of the laundry staff (with who I had worked during an induction day I had arranged for myself) how close the vote was she said "it was not close at all - we all voted to return and when Pat ( the shop steward) asked for a show of hands a number of us raised both hands!"

It was against this background that the overzealous auditor decided to launch an investigation. It had been reported to him that a laundry van matching the description of those used by Redbridge HealthAuthority had been seen regularly outside a private nursing home with which Redbridge had no contractual arrangement.

He had calculated the additional mileage that this regular trip would entail and the mileage of the planned route of the hospital van and the additional mileage was broadly equivalent to what would have been travelled to provide an illegal service to a private nursing home. He satisfied himself that his informant was correct about the regular deliveries and collections. He came to me asking that on the basis of this evidence I immediately sack the driver and launch an internal investigation into the laundry staff to see who else was involved in this fraud.

In the circumstances of the industrial action at Barking and the recent reversal of their decision to stop providing theatre gowns to Barking hospital I was concerned what effect these suspicions would have on our ability to continue to treat patients at the other hospitals in the district let alone at Barking.

I suggested to the auditor that as I was due to drive the laundry van that evening to Barking I would check the log myself and the accuracy of the odometer to be satisfied that the discrepancy was real.

Its just as well that I did! No sooner had I sat behind the wheel to note the odometer reading to record the starting mileage than I realised that the odometer recorded distance in kilometers! The form used to log distances was headed up "miles travelled".

Nonetheless I assumed that the overzealous auditor had corrected for this so recorded the start and finish readings, converted them to miles and could confirm that the odometer readings were relatively accurate.

The next day I asked to speak to the auditor and realised he had not corrected for the difference between miles and kilometers. We then quickly calculated that the apparent additional mileage each week was entirely explained by this failure to convert back to miles. This still left the sightings however.

It turned out that the neighbouring health authority (Waltham Forest) had jointly purchased a fleet of laundry vehicles for both authorities the colour scheme of which were the same and the registration numbers were in sequence. What's more the neighbouring health authority did have a contract to provide laundry services for the private nursing home outside of which the auditor had spotted our apparent fraudulent driver!