Sunday, 30 November 2008

NHS Treatment of Patients: the Shotgun approach (Drs) vs the finely honed NHS Manager Sniper. Your life in their hands.

Patient: I am bleeding from my arse I think I have piles . . .

Doctor: You may have piles but after examining you I am concerned you may have cancer. I would like to arrange some more tests to make sure that you haven’t . . .

Manager: you do not have cancer as it costs too much to investigate so we will send you to a complimentary therapist who is an expert in colonic irrigation and can decide if you have a cancer as they have never seen it or operated on one but they are cheap.

NorthernDoc’s scientific team had the misfortune to go to a meeting with certain paid up members of the Party. These were all less qualified and experienced in the field under discussion than NorthernDoc but as a result have power.

One of them repeatedly claimed to be a “clinician” which is defined by the Shorter Oxford Dictionary as “a clinical investigator; now, a doctor having direct contact with and responsibility for patients”.

The alleged “clinician” was in fact a jumped up alternative or complimentary therapist with the title “consultant” which can be obtained faster in non medical professions than a doctor can qualify as it is a cheap meaningless title and used to be termed a “senior” complimentary therapist which is more accurate.

This was to “sell” the local Politburo idea that Drs are expensive and quality health care is cheap especially if the managers organise it. The upshot was that the local comrade commissar managers had seen a statistic and decided to bugger up loads of peoples’ lives based on the bottom line (cost).


When you start in medicine you feel that you know everything and believe that what you are told in medical school for example bleeding from the back passage is something serious. As you get more experience you realise that yes it might well be and you should investigate it thoroughly for you cannot tell that it isn’t something nasty until you have done so.

Medicine is not a snipers rifle it is more often than not a shotgun. As a good doctor you should refer to a specialist in order to exclude this small but life curtailing possibility. This may seem like shooting a shotgun and potentially hitting nothing but you have to fire the gun (refer) in order to chance hitting a target but know that more often than not that you will miss.

Doctors unfortunately (or fortunately?) miss more often than they hit but then that is because they try to be safe. If you do not look then you will not find.

Unfortunately NHS mangers eye sight and general health and ability would disqualify them from any active military or otherwise useful service to the country.

They assume that if out of a 100% of people referred to say a surgeon only 25% need an operation then 75% of the 100% do not need to see (an expensive) surgeon or even be referred in the first place. They need to see an alternative practitioner who based on their less extensive and much cheaper experience (which involves no assessment as to who might, or might not, need an operation as they cannot operate) can save money (but not lives).

NHS managers are therefore the elite snipers of the NHS.

For they “see” what the thick overpaid doctors “miss” namely the result of medical investigation not the clinical suspicion. They are so much better at treating patients as they failed to get anywhere near a medical school. They see that 75% of referrals need no (expensive) treatment and therefore are a waste of time and more importantly money.

Unfortunately like a sniper they miss what is going on outside the snipers sight (the 100% who might just possibly be ill) that some of the patients are actually ill and will be missed by complimentary therapists who have never dealt with ill patients who need surgery.

If you therefore work on the management assumption that 75% of GP referrals are crap then it makes sense to refer all GP (100%) referrals to see the “alternative therapists” as they are cheaper but unfortunately and unbeknown to managers are thicker than themselves and would miss the 25% that need surgery.

Why? Because the alternative therapists have only ever seen the 75% that DON’T need surgery but they have never seen the 25% of people THAT DO NEED SURGERY.

Therefore a thick manager can decide that a patient who has seen a doctor who has decided that there may be a chance (1 in 4) of something nasty that needs to be excluded then the manager who has not seen the person can exclude the 1in 4 possibility of something serious by using the Party Centrals means of control called Choose and Book.

Because all referrals are mandated to be sent via Choose and Book instead of the referral letters being screened by consultants they are now screened by complimentary therapists a few of whom are “consultants”. In other words when a GP in Northernshire asks for a more qualified and experienced opinion (which we used to get when real consultants read the letters) we now get a complimentary therapists’ opinion who has less experience than the referring GP.

Result? Patients who are ill and need surgery are subjected to unnecessary and painful complimentary therapy while getting worse until usually after weeks the therapist realizes there is something wrong and asks for a surgeon to see them which the GP already had done several weeks earlier, or the patient is so peed off that he comes back and asks for a referral to a real consultant (which we had asked for in the first place).

Ergo management thinks that the scum known as GPs refer 100% of patients in order to only get 25% operated on and so complimentary therapy (which is cheap and thick) is the way forward.

If you are in pain and there is a lasting solution that may be achieved by surgery I suspect that most people in pain would consider the option of surgery.

But this costs and requires an opinion of a surgeon who may be able to help you IF there is an option. Managers who are all wise as organs of the Party know better and so you are denied this option (unless you have private insurance as do those who work for Connecting for Health.)

Once again Praise be to the Party for they are all wise. And NorthenDocs are thick.

Thursday, 27 November 2008

Eh up luv is tha doing a Gordon surgery or somemit else?

One of the team read with interest the Jobbing Doctor’s blog of their posse’s description of the extra hours for no pay that Gord the Holy, beyond all others than Mugabe, feels must be inflicted on GPs as penance for their sin of doing the contract.

Knowing that the next day NDs’ artistic member was due to do a “Gordon surgery” in a PCT building with no heating after a long and sub zero drive to work in the frozen North starting at 07.30hrs with 3 unfilled appointments at 10 minutes each then do a day on call until 18.30hrs with no heating this team member did say that they would be doing “an extra Brown shift that f**king day for no extra f**king cash but paying a f**king fortune for extra childcare”.

While we at ND do not condone the use of expletives we do note that the phrase “extra Brown shift” could, with the removal of a letter or the use of a silent f, become a phrase that could summarize a lot of current health policy being dumped on general practice.

Praise be to the Party and the ever changing English language.

Sunday, 23 November 2008

Practice Based Commissioning (PBC) and Practice Based Commissioning (PBC)

Many of NDs’ team have wasted hours over PBC and were heartened to read that the Kings Fund have decided that PBC is not working. We had realized that after a month of meetings but then we are only Drs not the Party who are all knowing and wise in healthcare matters. We therefore present this explanation as to why PBC has failed:

One of our glorious leaders great ideas was to reintroduce the flawed idea of fund holding introduced by the Conservatives a few years ago. This was basically the idea that you give each practice a budget to spend on their patients and hopefully reduce costs. Fund holding didn’t work because it costs loads to administer and hospitals fixed prices. Unlike supermarkets that can reduce costs simply because if you don’t shop there they don’t earn money the NHS is free at the point of purchase.

In other words if the punter don’t pay they don’t care what sh*te they buy = NHS as it is free. Go to a free drinks promotion or where someone pays for the bar and you will see what I mean - needless consumption of things you might not otherwise consume. Look at a suddenly empty shelf in a supermarket and ask why it has suddenly emptied since last time – hint look at the price reduction or 2 for 1 promotion compared with last time. So competition can never work in the NHS as there is no market as punters turn up knowing they can waste professionals time for free but politicians think otherwise as they are intellectuals.
However because of New Labour who, as true socialists believes that the consumer, not the Party, is king we now have PBC as the New Labour answer to health care inequalities but suffers from one fundamental flaw. What is it?

We know it is not fund holding because the Party tell us that it is not and do not give practices money to spend but they have to earn it by saving the Party money. However there is PBC and PBC. What is the difference?

PBC 1 (the 1 will help us at ND who are thick to work out which PBC is PBC) is where the local Politburo wants GPs to do extra work in order to save money by asking them to do the local hospital’s work. So if a GP does a hip replacement at his surgery the PCT will pay him under £20 (under the local Politburo PBC plans) and save the £5305 it would pay the hospital.

This is where the local Politburo “commissions” = PBCs the GP to do the work to save them money. We all know this will work because GPs are spending too much time on the golf course and not enough time banging in hips or doing triple bypasses all of which they learnt to do in their 3 years of what is now called “specialist training”.

The second version of PBC, PBC 2, is the idea where groups of GPs come together and try to improve the services that the Politburo and its’ wise managers have designed for their patients. Now this in theory might be a good idea as GPs will know which patients are waiting longer for what procedure as their patients moan on to them (not managers). They also know the good and bad hospital doctors and what needs to be done to improve the current systems. In this case the GPs would “commission” = PBC the service on behalf of the patients and hopefully influence its design.

However this idea has many failures the main one being that it would cost the local Politburos’ to run it as anyone knows that quality costs which is at odds with the core current NHS philosophy that the NHS is “care on the cheap”. It is therefore doomed to failure as the Party will not give money to people who might do things better than the comrade commissar managers who have so successfully run the health service for so long.

PBC 1 = secondary care decommissioning or dump it on the GPs to save costs which is after all the whole point of PBC.

PBC 2 could mean GPs in touch with what their patients’ need being able to purchase and even improve things for their patients. This however is not allowed as the Party and its managers know best and have done so for years. So PBC 1 is the only version of PBC that is allowed and so if you look at the force diagram above you can see that PBC is going nowhere fast as doctors and managers are looking at the same problem from different directions.

Confused? So are GPs in Northernshire who have spent hours sitting on their arses listening to fat managers giving presentations from NHS plc Party Central corporate laptops on PBC 1 while asking GPs how they should be saving the NHS money (or doing PBC 2) but not wanting to pay anything to “facilitate the process”.

Here are two examples from one part of the world of Northernshire of PBC 1 at work:

PBC 1 wants to reduce GPs orthopaedic referrals by 25%.

The Party and the local Politburo have increased orthopaedic consultant numbers by 200% as well as purchasing extra, but underused (because it is crap), orthopaedic capacity from the white elephant called ISTC (Independent Sector Treatment Centres) but GP levels are unchanged over 10 years in the one of the most under doctored areas in the country.

So having spent a fortune to increase capacity joined up NHS thinking says lets not use it but increase work for those already under resourced.

Another example is that despite there being “choice” offered where there was none by the Party the local Politburo commissar managers think (oxymoron we thinks there) that too many patients are going to A&E and feel that if GPs have a word with their patients this would stop the flow of (expensive) patients to A&E.

We know that will work don’t we? “I think I am having a heart attack but my GP said I shouldn’t go to A&E as it is too expensive so I will die instead”.

Where do they get the managers to think up this crap from?

PBC another great Party failure going nowhere fast but it will soon be “worldclass commissioning”.

Whatever that is.
Praise be to the Party.

Wednesday, 19 November 2008

NHS Announces the Biggest email spam experiment in the history of the Internet - Behold the “Communicator”.

"Its email Jim but not as we know it"

One of NDs’ number has been off for a trip across the pond and indulged in some fine R&R events like putting a few rounds into pictures of NHS administrators and returned to find in their in tray an article on the latest NHS improvement to NHS GP access. The source is the Pulse magazine link is here:

Of course none of the idiots that run the NHS realize that the basic problem with access is that we don’t have enough Drs (because they cost) but ideas are cheap so they are full of them along with certain brown smelly stuff that does not help patients and is best sent down to the local sewerage works which does more for public health than any NHS manager can ever do.

The NHS communicator is another wonderful idea from the Connecting for Health team who clearly are building on the other “successes” of the NHS IT system. A lot of the ND team gave up using NHS email over 18 months ago when following an “upgrade” the whole local system crashed and needed to be reconfigured for those sad enough to use it. The team has managed without NHS email for this long because it has acted as a huge spam magnet.

Now this is not the spam of various individuals offering cut price Viagra or counterfeiters or fraudsters it was the spam of NHS management. No longer do we have to log on and wait for up to 5 minutes a day to access the system before having to then down load spam city Arizona of crap like “Matron X will not be into work as she is having her legs waxed but will be available tomorrow but in the mean time contact her 15 deputies” all of whom then send messages saying that they will not be available and so contact the following. All of these messages were carbon copied (cc) to the deputies and then sent to everyone on Northernshire Politburo’s address book -sometimes 5 times. One of NDs’ new team members was given a new NHS email account and had 2500 messages on it immediately and this was all just from NHS staff.

So the new communicator will allow greater access to GPs on a “voluntary” basis. Any one out there bright enough to see where this might be leading?

As it is “voluntary” it will be included in “access targets” and GPs trying to avoid crap will lose money.

Those who use it will be opening the biggest Pandora’s box of spam they have ever encountered as patients will be less selective in their abuse of email than managers.

Still there may be some restrictions on this as the local Politburo imposed a 1Mb file attachment size on their email system due to “abuse” of sending pictures so at least we might be spared 20 13Mb photographs from Tony on the dole in Thailand asking his Dr in the UK what this strange tropical rash might be after sleeping one night in a strange bed because he can’t be bothered to pay a local doctor to look at it but would also like an urgent appointment the minute his plane touches down in 4 weeks time. Taken on his Canon D1 camera and sent from his iPhone and while I am on line can I order a repeat prescription, get some free condoms sent over, sick note for the next 6 months etc etc.

Now fellow resistance fighters the Party have started the biggest government sponsored spamming exercise in history. And it is coming your way soon. Let those who have no drug reps, financial advisers or other shady dealers on their lists sleep soundly. Otherwise be prepared for the tsunami of spam slowly building in an ocean near your communicator inbox.

Praise be to the Party and their stupid ideas that will deny healthcare through misguided attempts at technology that they do not understand but do profit handsomely by. 60% increase in IT budget to improve connections by BT anyone? Could this be the reason?

Thursday, 6 November 2008

NHS Efficiency

ND’s team is getting increasingly bored in surgery which is in part why the team have taken to blogging after many hours of reading other more established bloggers. But hang on we hear you say, how come you have so much time to do these things after all the health service “reforms” and “efficiency savings” that have been achieved?

A recent statistic shows that each year the NHS becomes 2% less efficient. Someone put it that if the Party spends £1 this year on the NHS then next year that £1 is worth 98p in terms of what it buys from the NHS and so on year on year.

Why is this so?

Well let us look at some of the reforms that the new General Medical Services contract has inflicted on one of the two front lines of the NHS = General Practice. Let us look at GP appointments and access.

Our last glorious Party leader Tony, currently struggling through the economic crises on a true socialist income of £12,000,000 a year lecturing to Americans wanted people to have access to a GP in 48 hours as all good but, paying, Americans do have?

Remember the famous “why can’t I see my GP with a booked appointment?” incident?

This hand bagging of a Prime Minister who is happy to inflict his policies on his people without knowing its impact on the front line is so typical of NHS reform and a direct result of a centrally imposed target driven culture driven by people who have never worked in healthcare. In order to get everyone seen within 48 hours some surgeries had to scrap booked appointments because of demand or lose money.

At ND Central we used to have a mix of pre booked appointments and a daily “emergency” surgery where patients were given a card and told that this was for acute illness not for things like sick notes, medication reviews, follow ups, getting results etc. We had a degree of control over what an “emergency” was.

ND Central after a couple of years also introduced ten minute appointments for purely financial reasons as despite Party Central hype income was falling. Under the rules patients could come in with any crap not with acute illness just ring up and get an appointment no questions asked. Therefore there was no control on demand. And the effect of this was?

A direct reduction in General Practice efficiency due to Party Central. Why?

The Party “working day” for a GP is 10.5 hours from 08.00hrs -18.30hrs = 52.5 hours for a five day week vs the European working time directive that the Party has signed up to of 48 hours per week.

Suppose that you could see 24 patients in 3 hours under the old system. This would give you a morning and evening surgery of 3 hours each with a gap in between of some 4.5 hours where you could fit in visits, paperwork, meetings, clinics, sign several 100 prescriptions, read hospital consultant letters, answer phone calls, supervise trainee doctors etc.

Apply ten minutes appointment to 24 patients and you get two 4 hour surgeries a day and a gap in the middle of 2.5 hours. So in order to meet the Party target you have increased the time to see the same number of patients and decreased the time available for other GP jobs unless of course you increase your working day by 2 hours (and your week to 62.5 hours) that you would not get paid for. (However Government is holy and does not believe in contracts and feels that increasing GPs' working hours without pay is an OK thing to do.)

Now doctors are human. They have families and outside interests and like a little R&R. They also get bored sitting down for 4 hours and this increases the risks of DVT by doing a trans Atlantic flight every day of the week. So after much discussion the ND team decided that 3 hours was the most it could stand and so we reduced the numbers seen to fit two 3 hour slots and not reduce the other minor things that GPs do in between surgeries that do not count towards Party tick boxes.

(Numbers used are for example not actual before the local Politburo Stasis’ start sniffing and to make the mathematics easier for any innumerate Stasi snoops reading).

Thus we are spending more time and meeting a target but doing less work as a result. If someone comes in for a simple sick note this might take 2-3 minutes leaving 7 minutes spare per appointment. If this is repeated several times a surgery then there is a hell of a lot of (unpredictable) spare time but not time that can be applied to complex tasks.

A good example of this was the first extended hours surgery the ND team did which was 4 hours long and of that 1 hour and 55 minutes was spent waiting for patients. Last extended hours surgery was 3 hrs 40 minutes of “booked” appointments with only 1 hr 46 minutes working. So a GP was waiting, not working, the best part of 2 hours on a political whim.

This is what happens when the Party Central imposes targets that have to be met so Doctors and their staff get paid. Local flexibility and doctors’ knowledge are over ridden by the superior knowledge of the Party. The end result?

A decrease in efficiency.

ND suspects that they must be using British Leyland as their model for running the health service efficiently. Maxi or Micra anyone?

So if you can’t get a GP appointment do not blame the receptionist blame the Party for they set the rules. GPs only play by them.

Praise be to the Party.

Monday, 3 November 2008

NHS Rangers leading the way - the War on MRSA #1.

NothernDoc starts with this earth sh*ttering idea from one of the most renown leading “teaching hospitals foundation trusts” in Northshire.

To stop MRSA it is simple . . . .

Get your staff, all 3000 of them, to sign for the fact that “they can wash their hands”.

Brilliant Simple Cheap Ineffective almost scientific who needs Einstein just a Modern Matron, a few managers and an infection control committee.

Imagine if as a consultant surgeon (old school of training) you have done 5 years of medical school, a year as a house officer, up to 4 years as a senior house officer, 4 years as a registrar, 4 years as a senior registrar possibly a post graduate degree as well as passing the Fellow College of Royal Surgeons (FRCS) exam and oh yes during this minimum of 18 years of training you might just have had to scrub up at least once to go into an operating theatre on the odd occasion.

What a brilliant idea! MRSA cured in a stroke.

Some more pieces of revolutionary health care coming soon in the NHS management drive for more paper not patient initiatives (paper is after all cheaper than patients):

I can wipe my own bottom
I can do my own bra strap/fly up
I can print X for my signature
I can flush a toilet

5 simple cheap ideas at 3000 pieces of paper per idea = MRSA defeated with 30 reams of paper in one Trust alone.

Rangers lead on to victory.