The last blogpost has started up a bit of a discussion about the pros and cons of the NHS database, so I thought that it wold be an idea to make my thoughts on such a system clear.

While it might make the retrieval of notes simpler and more convenient, the security risks are frankly too great. The cost will spiral and *********

We can first look at the cost, going on previous history the UK government seems to have an almost pathological aversion to being able to bring IT project in on either budget, or time. The cost has already spiralled beyond the initial estimates.

Discussion point - find governmental IT projects that have come in on time and budget.

The people who would be using the system don't particularly want it. The BMA think that it should be an opt-in system with each patient choosing to be put on the database rather than automatically being assumed to give consent. This is a fine compromise as long as the people opting in are fully informed as to the risks of being on the database. There is a way to 'opt out' of the database, but there are rumours that people who are refusing to go on the spine are having their names recorded by the government.

Discussion point - given the technical knowledge needed to understand databases and security as well as the way the NHS runs, will anyone be fully 'informed' beyond us computer geeks. Also, is the recording of opt out names just paranoid rambling.

The proposed benefit is that medical notes will no longer get lost, or that if you are unable to communicate there will be easy retrieval of your notes enabling allergies to be avoided, pre-existing medical conditions to be taken into account and next of kin to be contacted. There is an easy way in which a more secure system can be created, and that is one that points to where a person's paper medical notes are physically stored. That way the database is just a pointer to a more secure system.

As for treatment for people who present while unconscious - most causes of unconsciousness are well know and are tested for and treated, if a person has a rare condition then they will often carry such information on them. They are the protectors of their data, not a third party.

Discussion point - if someone is without a form of ID, how will this database help them? Will this tie in with a national ID database scheme.

Just looking at the security issues is enough to make someone paranoid. In more than one hospital I've seen passwords and user names stuck to mobile computers - a cleaner could 'borrow' a computer easily and in the privacy of a cupboard log onto the system and gain access to your details. Even if the log-in is tied to staff ID cards the system will not be secure, cards will be lost, or lent and borrowed. I can't imagine any ward sister sending home a nurse who is unable to do their job because of a lack of an ID card - they'd lend them their own.

Extend this to clerical staff.

Discussion point - this doesn't even include pure malicious attacks, agency nurses entering and leaving hospitals, patients stealing a glance at unattended computer screens or social manipulation attacks.

It would be trivial for me to socially hack the system and leave no trace of wrongdoing. I could sell your data on to nefarious parties for a tidy little profit.

But this is nothing more than we can do at the moment anyway - notes are lost, or looked over by people who have no right to do so. The problem is in the scale of the breach. I might have a friend in the notes section of the local hospital who can look up details for me - but that information is limited to people who have gone to that hospital. With the NHS database that 'local' become the whole of the UK.

Discussion point - part of risk analysis is how disastrous the consequences of a breach of security could be, having access to the entirety of the UK population's medical notes is pretty disastrous if you ask me.

Then there is 'function creep', we've seen this already in the use of anti-terrorism legislation enabling local councils to 'snoop' on people. What is to say that some government later on down the line decides to start selling the data to insurance companies, or to other government agencies like the census department. Even if you trust this government, do you trust every government that comes after them?

Discussion point - would legislation allay this fear, or just require a change in legislation later on down the line?

So, the NHS database would, in my view and the views of people much smarter than me, be expensive, unfit for it's purpose, horribly insecure to both technological and social attack and prone to function creep. In return there would be little benefit for most people.

Sure, have it as an opt-in system for those people who are willing to put their faith in a government system and local hospital and their ability to keep such data secure. But make it a fully informed choice, one where people are aware that it is being run by the same people that 'mislay' their normal paper notes on a regular basis.

I have a source who has let me know how insecure the proposed system is - I fully intend to opt out, and I work for the NHS.

More data lost from the NHS.

"Discs containing personal information on almost 18,000 NHS staff have gone missing from a north London hospital.
Whittington Hospital NHS Trust admitted the discs were lost when they were put in the post by mistake in late July."

I've worked at the Whittington A&E department in my nursing days and it's worrying to think that there is enough data now floating out there, lost, to comprehensively steal people's identity.

These details could be used to impersonate a nurse. A nurse that might have access to vulnerable patients.

Of course, when the NHS has all your details on a centralised system there will be 'policies and procedures' in place to prevent this sort of data loss happening. Just as the policies in place managed to prevent this data loss.

Oh wait, they didn't.

On a technical side, it would be much more secure to encrypt the data and send it via the internet than to burn it to media and send it by post or courier.

Related somewhat to yesterdays post.

I attended to a young lady with a slightly unusual and complicated complaint. She sat in my ambulance wearing a top with a plunging neckline - not a problem, I always do my best to look people in the eye and not at the level of the breasts.

I was getting the medical history and asked her if she was fasting.

'No', she told me fishing around in her cleavage and pulling out a cross, 'didn't you see I was a Christian?'.

'Erm', I blushed, 'I try not to stare down there...'

As far as religious dates go, Ramadan isn't too bad of an idea as part of the fasting is to have sympathy for those less fortunate than yourself. Of course that all goes out the window when you start stuffing your face as soon as the sun goes down.

This year it has seemed to 'sneak up' on us ambulance people, there was no memo or announcement that we'd have a month of Muslims falling over and collapsing. You would think that, in my area of London where there are many Muslims, the ambulance service would think to let their workers know.

The first I knew about it was from a patient who kept changing her story. She'd collapsed at work with abdominal pain and one of her workmates said that she was fasting. I was a bit surprised as Ramadan is normally later in the year and I'd heard nothing about it being this early. I asked if she was fasting because of Ramadan and she told me no.

Then, as we were rolling into hospital I asked her why she was fasting and she told me that it was because it was Ramadan.

Oh well.

It wasn't the only time that day that a patient changed their story, sometimes in front of the nurse that I was handing them over to.

The problem with Ramadan is when, as a friend of mine puts it, adherents try to be 'more Muslim than you'.

The Koran says that you shouldn't fast if you are pregnant or have a medical condition that means fasting would be too hard or dangerous.

Unfortunately some folks want to prove what good Muslims they are and fast anyway.

Then you end up going to Muslims who've collapsed. I wold also suggest that we get more calls for 'chest pains' as well, when people with indigestion call us out. It doesn't help that for a lot of our Bangladeshi population indigestion and gastric reflux is a very common medical complaint.

On the other hand, you still find yourself going to Muslims who have hangovers...

I'd like to see if Ramadan really does increase call rates or if it's just the impression that us road staff get. Might be an idea to increase staffing in heavily Muslim areas for the month if it is true.

It would perhaps be churlish to point out that I go for twelve hours at work without food on a regular basis. I can tell you that it doesn't make me feel any more charitable.

I look at my patient and consider my choices, either I act outside the policies that the LAS have set me in the best interests of my patient, or I follow the rules and provide sub-standard care.

What do you do?

Our patient is a fiercely independent woman - well into her eighties every morning she walks to the shops, has a potter around to buy her papers, has a chat to the shopkeepers and then returns home.

She'd had a fall because the strong wind that day had blown a door into her, one of our first responders was already there and had patched her up. We took her to the ambulance and completed the assessment. She had a cut like half of a 50p piece on her shin. Sometimes you can get quite nasty skin tears, but in this case it was more of a gouge, and therefore easier to fix up.

There was one problem, our patient didn't want to go to hospital and after she told us why, I cold only agree with her.

No problem, it would be a simple job to steristrip the wound closed, something our ECPs are well equipped to do.

Except there wasn't one working on this shift.

Now, as long time readers will be aware, I used to be an A&E nurse. Wound closure of this sort is something that I would do regularly when working in the minor injuries department. I could easily do ten such closures a day, all without supervision. Our doctors would tell me to clean, close and dress the wound and the choice of how to do this was down to me.

But with this lady, if I were to follow our policy, she'd be left with a cut that would be left open with little more than a bandage over it. This would not only cause scarring, but would also have a higher chance of becoming infected.

It just so happens that I carry some steristrips in my personal bag.

So, of course, I used my nursing knowledge and closed the wound using my steristrips. It is a low risk, high outcome intervention that I am competent in. At the end of the day I can justify taking this course of action to anyone who questions me, and more importantly, to myself. I can guarantee that I've done more wound closures of this sort than any of our ECPs.

Us ambulance staff work under guidelines rather than the more restrictive protocols these days and this means that we can do pretty much anything, just so long as we can justify it. While I've been been told that I shouldn't use my nursing skills (like cannulation) I can't see anyone having a problem with my course of action.

I sure that my patient was happy.

I've written before about our 'psychic computer' and the new policy of Active Area Cover (AAC), we've been told that it is to improve the public perception of the service and to better let us hit those rather pointless government targets.

If you remember (or reread the article) it involves a computer that was no doubt bought at considerable expense which predicts where calls are going to come from next Something that I firmly believe in a urban setting like London to be utter hokum.

But it would appear that it's not always being relied on, and instead those high up in management are making things up as they go along.

Consider the following two bits of evidence that I have collected personally over the last two days.

In the first episode, we were told to go on Active Area Cover on a street 0.2 miles distant from our station. As the policy lets us roam around within a radius of 0.5 miles I informed Control that we would therefore return to station and wait for a call there, incidentally allowing me to have my first cup of tea of the day. Our dispatcher agreed.

Then I suspect that someone had a word with her because she called us up less than 20 seconds later to move our AAC point much further away.

Surely if this is a science then the first AAC point would have been the best and it would mean that we shouldn't be moved seemingly on a whim just to keep us from the station.

The second episode was just as foolish. We are not supposed to be put on AAC within half an hour of the end of our shift. So I was surprised to be told to go out with just 12 minutes left in the window of opportunity. Well, I'm not allowed to refuse, so I asked where the psychic computer was telling me to go - for hasn't it scientifically predicted where the next call will be?

"Oh, go anywhere", I was told.

So with 42 minutes to go to the end of a twelve hour shift we were being told to go and drive around for twelve whole minutes.

I'm in the process of reading a book at the moment concerning American ambulance workers, and one part seems particularly apt - in it a supervisor is asked about how to manage ambulance staff and he replies that, as we are trained to gather evidence about a person's illness or injury in three minutes, we question everything. You can't just tell us that 'this is the way we are going to do things' and expect us to roll over and do it without some form of explanation or evidence.

A good example of this is the CPR guidelines that keep changing based on evidence - we have no problem in adapting our practice to use the latest evidence, and no-one questions it.

So here is the challenge - I know management read this blog. I want management to provide me with scientific, peer-reviewed evidence that Active Area Cover works in a high population density area. I don't want the marketing guff that the software company sends you - I want proper evidence. After all, isn't evidence what all modern medicine should be about.

I'd also like an assurance that the system is being used properly, and not to 'punish' crews. Is there an audit in place for example to see which manager sends which crews out?

Until I get that reassurance I will continue to suggest that the best thing for ambulance efficiency would be to buy the management in Control a load of cat toys, and let them play with catnip woollen mice rather than get bored and annoy road crews (and the poor dispatchers who have to phone us up and give us the bad news that we aren't allowed to remain on station).

On a more amusing note, two things which have lived up my shifts of late.

The first was when I asked a woman how many children she had given birth to and she answered, 'six or seven, I can't remember'.

The other was the GP who told a mother that the best way to get earwax out of her five year-old child's ear was to use eardrops and then root around with a cotton bud. Needless to say we were sent to the child after her ear started bleeding. As I've always been told that you shouldn't stick anything in your ear smaller than your finger, I suspect that this GP may have bought his GP certificate from a market stall.

Either that or the mother was mistaken - it happens sometimes.

Ergh - what a day...

There is a reason why so many of us who work in emergency healthcare hate Mondays, it's because they are one of the busiest times for us. Us ambulance types are run ragged, the A&E department is packed solid with few people moving up to the wards and I would imagine that GPs get a lot of 'emergency' appointment requests.

The reasons for this are many, and I may miss one as I'm writing this while my brain is still recovering from this particular twelve hour shift.

It's mostly to do with the weekend. Hospitals tend not to discharge many patients on the weekend as a lot of the 'non-essential' roles tend to keep office hours and aren't available during the weekend. Assessments for going home aren't done and there is often only one doctor team on call for for each of the specialities. Therefore one team is unlikely to discharge another team's patient.

So, over the weekend the patient's stack up in the wards and the nurses there are so busy trying to discharge them they are too busy to accept new patients from A&E.

This means A&E trolley waits go up which spills over into us ambulance staff waiting for a trolley to put our patient on, which means that ambulances can do less jobs in a shift.

From our end of things, we have three main types of patients, those who couldn't see a GP over the weekend and are now so ill they have to go to hospital, the patients that are finally seen by the GP who then sends them into hospital and the people who don't want to go to work or school or who didn't want to waste their weekend, but now they are off work, don't mind wasting that time.

So, Mondays are terrible and the sheer number of people going to the hospital tends to leak over into Tuesday.

We did do something unusual yesterday - we went to a little old lady who'd fallen out of bed, as she wasn't seriously hurt and didn't want to go to hospital we put her in her wheelchair and told her to call us if anything changed.

Seven hours later, to the minute we were back at her place because she'd fallen out of her wheelchair. This time she agreed to go to hospital as she'd skinned her arm.

What was quite sweet was that she was worried that we'd moan at her for calling us back. As I tell many of our patients, 'I'd rather be picking you up off the floor of this nice warm, clean and dry house than wrestling with some drunk by the side of the road in the rain".

And I'm serious about that.