Wednesday, 30 December 2009

NHS “Consultation” and Parking.

When most people use a market they pay for a service.

For example, if you go to a shopping mall you pay for what you buy and you park for free even if you don’t buy anything.

Compare that with the current NHS “market” where the service is provided for free, namely your treatment, but “co-payment” link is not allowed so hospitals can continue to charge you for parking, television and phones for patients but comrade patient your treatment, whatever that is, free.

All the above are examples of the current NHS internal “market” which costs each of us a fortune in taxes but delivers no real healthcare benefit which is what the NHS is supposed to be there for – real healthcare, for all.

If you have paid taxes you have already paid for your treatment, already paid for the hospitals and already paid for the car park to be built that you are now being charged to park in.

If you go to a shopping mall the private sector have paid to build it, have paid to provide parking, provide parking usually for free and make a profit.

The NHS “market” struggles to break even.

So imagine our joy when we heard that our beloved health secretary, Andy Burnham, say there will now be an eight week “consultation” regarding NHS parking charges as they had “caused great resentment” to “ensure that plans were affordable at a time of pressure on NHS finances”.

No way man, surely not? Andy Burnham, the only politician in touch with the people after all these years.

What joy! Another NHS consultation which means they have already made up their minds and want a public “consultation” to rubber stamp their plans.

Parking charges are the only part of the NHS “market” that works i.e. makes a profit from a small initial outlay to provide a “service”. In this case the “service”, namely screwing the public and its own staff to pay for the privilege of using something the vast majority of them have already paid for, is now to be “consulted” about. Great.

Praise be to the Party for shopping malls. Parking is free, we usually get what we want on the first visit, and, apart from Christmas, there isn’t usually much of a wait.

Why hasn’t the NHS “market” done the same? Still after more than 12 years of both Parties charging for parking and talking markets at least someone has the decency to “consult”.

Don’t hold your breath too long. We are in a recession after all and 8 weeks on the National Debt will have grown some more. Anyone guessed the outcome?

Monday, 28 December 2009

Burke and Hare do Choose and Book 002.

Welcome back dear reader to our humble but warm fireside on these cold, icy Northernshire nights which are good for neither man nor beast especially real world GPs. Are you sitting comfortably? Another glass of mulled wine perhaps before we continue on our perusal of the Choose and Book Christmas special?

We are now onto Chapter 4: “Acting on behalf of Referring Clinicians” from the wonderful winter's evening read found here:

“Clinicians (e.g. GPs) should be aware of their responsibilities when referring patients, especially when delegating these responsibilities to non-clinicians (e.g. PCT-based referral management centres) to act ontheir behalf.”

Lots of words later implying that this is a tightly regulated process such as “strongly enforced by the Registration Authority (RA)” –whatever that is and

“parts of the referral process may sometimes be delegated (with caution) to named and adequately trained administrative staff.”

Well this is called General Practice and responsibility and delegating to our staff is nothing new to real world GPs but to the authors of this report it is a road to Damascus moment. The art of being a good officer is, after all, delegation.
More sinister is the next paragraph:

“When deciding that an onward referral is indicated, a clinician accepts the clinicalresponsibility for that referral, and for the actions of any staff acting on their behalf.”

Seems OK thus far as that has always been the case even with paper referrals but read the next paragraph:

“Although not always ideal, parts of the referral process may sometimes be delegated (with caution) to named and adequately trained administrative staff working within the same referring organisation, usually where direct contractual and supervisory arrangements are in place. If referrers delegate the short-listing of services in this way then, in keeping with General Medical Council recommendations on delegating responsibilities, they are responsible for ensuring that staff to whom they delegate are adequately trained and have sufficient clinical knowledge of the patient and their condition to make the referral and/or short list appropriate services”.

Digest and pour yourself, if you are a GP or any genuinely responsible person with concerns for your healthcare, another glass of mulled wine (preferably a pint) and pull your chair closer to the fire as things are going to get colder.

Now we wonder how many GPs got up one morning and thought let us invent a referral management centre? According to this chapter we are now responsible for the actions of those Poliburo commissars who MANDATED the referral management centre onto GPs probably without any consultation – they just appeared. However the PCTs are NOT responsible (for their actions) according to this less than learned tome it appears that GPs are for the whole referral process.

A possibly interesting legal point here?

If a PCT, which establishes and runs a referral management centre, diverts a referral letter from a GP, for example a letter specifically addressed by the GP to a chosen and named orthopaedic surgeon (more on this later), to see a physiotherapist then the GP is legally responsible for the PCT’s actions?

We know this is correct as we all know NHS mangers are responsible for nothing so Choose and Book enables those in the bottom third of our education system to kill and injury patients without ever going to medical school and walk away Scot (or is it Gordon free?) and blame it on the doctors? Nice one comrades.

Choose and Book empowering incompetence through unaccountability and inability. Why have a Lockheed SR-71 designed on a slide rule by people with ability 40+ years ago when you can have Choose and Book designed by committees manned by those with inability and no experience of real world General Practice?

One did the job and holds numerous records. The other is British.

This is bad enough, dear reader, but pour yourself another pint this time of Southern Comfort with an old Peculiar chaser, it is after all winter and read on into Chapter 4.

“Referrers (e.g. GPs) may wish to consider using a Clinical Assessment Service (CAS), if one exists, if referral pathways are complex and if this will provide additional clinical benefit for patients. CAS functionality is supported by Choose and Book, but should not be used as a disguise for purely administrative referral management centres.”

May wish to consider? Once again we had zero NHS “choice” and they provide no additional clinical (medical) benefit.

For those readers not familiar with a CAS concept (or is it spelt Kaz?) it is whereby a local Poliburo (PCT) decides it will try to save money and intercepts GP referral letters to real medical consultants using the “Choose” and Book computer system = more Soviet style control.

The Politburo then allows a delta grade (sometimes) a “medical” pratitioner decide whether your patient, who you referred to see a consultant, needs to see that consultant or, if the delta grade thinks otherwise, you can see someone cheaper.

If the deltas are lucky you get better and they save money. If they are not it is back to the GP to be re referred back to the original consultant and hope that the delta grade reads the sentence “has already seen or had treatment X and it did not work” before you are finally get to see the original consultant.

This KAS concept exists for one reason only to save PCTs money. It was never ever designed to improve patient care and it fails miserably at this.

It is not a “Clinical” service as clerks and alternative practitioners are not medical, it is not “Assessment” as they can’t even read to whom the letters are addressed and serious cases slip through with alarming regularity and it is not a “Service” it is a disservice to any patient unfortunate enough to have their referral diverted to care on the cheap.

It is in fact CRRAP (Clinical Referral Redirection Approval Process) not CAS and designed and run by morons.

Once again Referrers may wish to “consider” using a CAS even though in practice we have no choice despite the “not mandatory” clause we discussed earlier but we have only the NHS “choice” as GPs and patients.

Let us paraphrase the last paragraph of Chapter 4:

“PCTs should take responsibility for these CAS services (no chance NHS management has no responsibility only incompetence), ensuring that they are set up with the support of (NO they were forced on us) local referrers and that administration staff do not assume clinical responsibilities (which they do call centre staff tell our patients they need to see a physio not a surgeon even when patients argue against them).”

Well a couple of pints of winter warmth added to by the smug satisfaction of knowing that all that should have happened with the implementation of Choose and Book in Northernshire has not from this wonderful piece of seasonal joy has left us a little tired.

The snow is falling, the mercury, sorry mercury substitute, in the thermometer is falling and so we must put our slippers, night gowns and night caps on and retire upstairs using the light of our candles to the 4 poster in our large manor house before braving the winter cold in the morning for the Saturday sea of wellness and DNAs (did not attends due to hangovers). It is Christmas after all.

Priase be to the Party and all its stooges. Will there soon be a bumper sticker saying we love Choose and Book?

Doubt it.

Friday, 25 December 2009

A Happy Christmas to all our readers and thank you.

At this time on Christmas Day we suspect that most people are with their families and certainly the worse for an excess of calorie and ethanol intake. Certainly the many contributors of the team have dispersed far and wide for a few days.

We would like to remind our readers of the following “facts” and hope that they heed our advice in the same way that we respect those seniors who advise us (for the better of course).

Remember, dear readers, do not allow anyone under 50 to touch alcohol for this is harmful, stick to no more than 6000 calories on Christmas Day for any more will be harmful, do not wash the turkey for this is most harmful than washing your hands and, finally for younger readers, in this their possibly first white Christmas, do not eat either yellow or brown snow for these are neither frozen lemonade or frozen chocolate and may be harmful.

We would also advise that the new sport of bowl the Pope at Xmas over is not a good idea as the collateral damage of cardinals with broken legs merely increases Accident and Emergency waiting times and is harmful for those slipping in snow and breaking bones for non sporting reasons.

Thank you for reading and for those who have taken the trouble to comment thank you too. It is much appreciated that you take the trouble to do so and has led us to explore other avenues as a result.

Now onto the 57th unit of alcohol . . . .a slight excess over what was a once “safe” weekly limit.

Praise be to the Party for inventing Christmas unless you have to work.

At least this year it is as white for the first time in years as MPs’ expenses are in contrast to the overpaid idle GPs who do not get 3 weeks off for Xmas. . .

Tuesday, 15 December 2009

Burke and Hare do Choose and Book 001.

As the festive season approaches you may be struggling to find a present for someone. If you are looking for something that will cost you your marriage or lose you a life long friend and that special someone happens to be a user of the Choose and Book (C&B) system may we suggest you look no further than here.

This little festive gem will bring seasonal joy to any user, or non-user, of C&B as we hope we shall show with some extracts from its 24 pages of joyous reading. It was found using a link from the weekly BMA unsolicited email shot to its member using the intriguing title of “How to use Choose and Book correctly” or to give its official title “Responsibilities and operational requirements for the correct use of Choose and Book”.

Now it is cold and damp outside in Northernshire today so, dear reader, pull your chair closer to the fire, pour yourself a glass of mulled wine and something for your blood pressure and we shall examine some of the pearls of festive joy we have discovered.

Look first at who the “Target Audience” is, well it is the Christmas panto season, on the second page (PCT CEs, NHS Trusts CEs, SHAs CEs, Communications Leads, SHA Directors of Performance, SHA Chief Information Officers, SHA Choose and Book Leads) and then look at the extensive circulation list. Clearly this document is intended for those who use C&B are a daily basis.

Read the Foreward obviously written by retired doctors who have not worked with patients for years as the following sentence clearly illustrates:

As set out in the Operating Framework for 2009/10, the long term transformation of the NHS requires a move away from top-down methods to an enabling role for the centre, with more power and responsibility residing with patients and clinicians.”

The next and finally paragraph illustrates so well this monumental sea change in Party Central policy change comrades as more than mere words:

“This guidance has therefore been prepared to help organisations understand the importance of using Choose and Book correctly. Standards and requirements described here should be recognised and implemented in all organisations using Choose and Book and providing services to NHS patients so that all patients wherever they are in England experience the same high quality access to NHS care.”

Fired up with winter warmth from these inspiring seasonal words lets us continue onto the first Chapter “Clinicians using the system themselves”.

Whilst aiming to be flexible and support many different models of referral, Choose and Book was designed, and is still intended, to be used by clinical staff to initiate and accept a referral, with non-clinicians fulfilling some of the purely administrative functions associated with the process.

The ‘Gold Standard’ for the correct use of Choose and Book is, therefore, for a referrer to have a choice discussion with the patient and subsequently to initiate the referral, with the patient still in the consultation

The last paragraph reads:

“Within a provider organisation, the ‘Gold Standard’ is for a clinician to review their own referrals online, accepting, re-directing and rejecting referrals themselves using Choose and Book, and for provider administration staff to do any re-booking, letter-issuing or other administrative tasks, as required.”

We wonder how many real working GPs in the UK will recognize this as the antithesis of how C&B is being used? No Brownie points for any of us here at ND Central or we suspect in most UK practices. Another glass of mulled wine to ease the next chapter in?

Chapter 2 “Free Choice”.

Well that glass went down very quickly and rapidly into the fire but please do not do this, dear reader, as glass in the ashes is a Health and Safety issue for our maids.

Chapter 3 “Promoting (not mandating) the use of Choose and Book”.

1st paragraph reads:

PCTs should encourage referrers and provider organisations to use Choose and Book wherever possible, by actively demonstrating its benefits rather than by mandating its use.”

Clearly no local Politburo commissars know this as C&B has been MANDATORY for all referrals (apart from the several pages of exclusions of course) forever as local PCT commissars crawl up politicians’ gastrointestinal tract in search of the Order of Gordon 1st Class for being good little comrade Soviet top down enforcers.

Choose and Book is by far the safest and most reliable way to make patient referrals. In a choice environment, where patients have the option of going to a wide range of provider organisations, it is simply not practical to rely on the old, paper-referral method. PCTs should therefore work with local referrers to help them understand all the benefits of Choose and Book (for both themselves and their patients), helping them to overcome real or perceived barriers that are in the way of effective implementation and proactively encourage usage of the system.”

We like that paragraph lots of weaselly management speak like “it is simply not practical to rely on the old, paper-referral method.” Why it was less work, less paper, quicker, cheaper easier to use for all involved and meant the patient saw the right doctor?

helping them to overcome real or perceived barriers” The real barriers are the biggest obstacle for any real doctor or secretary using it as crap is crap and the stench of uselessness is real to all who struggle to use it. But then:

“Use of Choose and Book should not, however, be made mandatory.”

Praise be to the Party for this little gem which we shall return to. Please feel free to read it for yourselves and compare it to your own experience of C&B.

We would however recommend a good case of wine and a catering pack of your favoured antihypertensive agent be on hand as you do so.

Monday, 14 December 2009

Tales from the Outpatient Gulag – an update on current “world-class” cancer care in the UK.

Earlier this year we wrote about our experiences regarding cancer care in the UK NHS for an older relative.

The surgery was a success and so was the reconstruction needed for our relative and they were very pleased. They were particularly impressed by the consultant who did a whole day’s work and had almost got home when a complication set in and they returned for another working day, this time in the evening and early hours to ensure a successful outcome. The following day they spent another 6 hours in theatre in ensure a successful outcome not just one consultant but two both surgeons.

Unfortunately in the recent past our relative has developed pain in one of their limbs which might, or might not, be due to a possible recurrence.

For those of us with the benefit of a first world education the investigation of this pain would have been simple and would have required initially 2 different types of scan of 3 different areas of the body in order to determine any possible cause and determine treatment.

However UK healthcare is no longer world-class it is “world-class” a throw away expression beloved of NHS managers and politicians to try and convince the public that crap care is something else other than crap. In this instance a world-class healthcare system would have done 3 scans in a morning seen the consultant with the results and sorted out a treatment plan based on the results. Simple.

Now the NHS does not do simple but it does do bureaucratic, institutionalized incompetence par excellence so how many scans do you think our relative had and how long did it take to get them? Have a guess.

Well in the end it was a total of 6 scans instead of 3 in a morning spread over 6 weeks. Of the 6 only 3 were actually needed the other three were “mistakes”.

No doubt the local Thickerazzi will say well you got scans what more do you want?
The right ones, quickly, perhaps?

Of course not comrade, the “market” will not allow such over production. One tractor per week is your lot comrade. Take it or leave it.

This is the response of the ignorant who know nothing of medicine until it affects them. Those of us with the misfortune to having been using the relevant scans 25+ years ago expect people in the 21st century to be using them better than they were then but having scanners is not the same as having the ability to use them properly.

The results (eventually) suggested the clinical diagnosis (which is that of doctors based on history and examination alone) that there was a recurrence. The recommendation was for further chemotherapy something our relative dreaded. Two options were outlined one less aggressive the other more so. If you have ever had the misfortune to have had chemotherapy then less is better so this was opted for.

By now our relative had had enough of “world-class” care and transferred to a local teaching hospital, still relatively in the Dark Ages, and their scans were seen and a further scan PET (Positron Emission Tomography) scan suggested.

This type of scan has been available in some of the more forward thinking teaching hospitals in the UK but not in Northernshire until recently. In the same way that consultants with a first world training would ship patients 30 years ago down South of Northernshire to get CT and MRI scans today’s first world graduates struggle to do the same.

Our relative was greatly impressed with their PET scan for they were treated as a human being for the first time in weeks at a private installation but paid for by the NHS with the only wait being a weekend (by chance only). One scan was requested and only one scan done.

Now remember dear reader the diagnostic delays due to more scans than needed equalled weeks of delay and uncertainty (did we mention pain and fear as well?) and on the advice of the oncologists our elderly relative wanted to go to a social gathering which they felt was OK and so the chemotherapy was differed for a further week or so.

Unfortunately the sudden development of the inability to properly move a limb revised all these plans considerably. The tumour had invaded the nerves that supplied this limb and reduced its usefulness considerably. The oncologists were contacted, seen the next working day and IV chemo was now considered more appropriate.

Praise be to the Party for dumbing down medicine to the point that even local consultants cannot logically determine how to scan a cancer patient and for the systemic incompetence that means 3 scans in a morning equals 6 scans in as many weeks. Still our relative lives in a “world-class” PCT so should expect, and get, no more than this.

And they did.

Wednesday, 9 December 2009

Close Encounters of the Northernshire kind.

Most people in the UK like watching nature programs on the television and the BBC have produced many excellent nature programs over the years. Like many people who watch such programs you think if one goes into the hills with a camera you will get such a shots. This is what you think when you are young.

As you get older you realize that nature filming and photography is a combination of luck, a degree of experience sometimes combined with training and a hell of a lot of patient waiting. It is a little like general practice in some respects. If one of these is missing so is the diagnosis or, in photography or film, so is the shot.

We have noticed many things by chance rather than by Attenborough positive film crews over the years like birds of prey downing doves or a bird of prey being harassed by magpies. Lizards on Northernshire’s moorlands which we would have associated with Italy. Owls 2 foot tall sitting in a suburban garden which if you get to within 3 feet would open an eye in daylight to warn you off – they are big when perched up on a wall believe us.

One of the advantages of living in the high moors and forests of Northernshire is that in the winter darkness comes early and so the ocularly challenged human being struggles. If you combine this with a new puppy, beyond the poopie stage, you occasionally have your sleep disturbed in the early hours for a call of nature.

So you get up and allow puppy out into the enclosed area of your average Northernshire GPs’ 20,000 acre estate and wait. Puppies are curious and this one found a breach in the razor wire perimeter fence and went wondering out onto our high moorland estate. A wait and see approach yielded little in the force 10 gale at minus 3 and there was a severe chill in the Trossachs that meant a return to the house.

A few minutes later we espied the pup waiting at the back gate and went out to let it in. In doing so we triggered the security light closest to the house and as we walked on towards the gate we triggered a second light.

At that instant the security light flipped on and we saw a large owl descending rapidly towards the back of our puppy. It was a huge owl which we had seen occasionally flying horizontally when security lights were tripped by it flying low and completely silently too.

In the same moment the light came on the owl must have seen us and there was a completely silent back flapping of wings to stop its rapid descent towards the back of the puppy followed by a rapid diversion to a convenient mounting point before another diversion out of the security lighting.

Puppy did not see, or hear a thing but puppy is about the size of a small lamb.

We have been in this life for a number of years and this was the first such heart stopping moment we have encountered. Puppy is now under armed escort for nocturnal poopies. What a sight though! What a heart wrenching moment but there, but by the grace of God, do we all of us go even puppies.

Praise be to the Party and all those who live in London and think that it is the real world. We used to but have since seen things that otherwise only David Attenborough and TV reporters would see.

So it is off to the dodgy dossier section of the local B&Q to buy some owl seeking Patriot (disabling) missiles and radar ex armed forces just in case . . .

Tuesday, 8 December 2009

Licence to kill? We busy doing nothing . . . .

For most of the British public the decision of the General Medical Council to introduce a licence to kill, sorry practice, will be of as much interest as a parson’s burp on the island of Tokelau.

In summary the GMC (all praise to them for whatever it is they do with our 410 sovs (or £ 410) registration fee a year has decided that you can now as a doctor be:

1) unregistered but useless = cheapest
2) registered and unlicensed = expensive (£145) and useless
3) registered and licensed = more expensive but able to work as a real doctor so possibly on balance a tad useful for those that earn their living this way.

An aside dear reader regarding option number 2, if you are desperately lonely or bored have a look here at question number 4:

“Holding registration without a licence allows doctors to show to employers, overseas regulators and others that they remain in good standing with the GMC.”

We like that phrase “good standing with the GMC” it reminds us of showing “respect” in The Godfather movies. An intersting turn of phrase for having paid their (reduced bung) registration fee. But enough and onward that was the boring but an educational bit for our readers over with now onto the real point of this post.

The date for being licensed was 16 November and if you ever visit the GMC website and some of us do mainly to check if dodgy doctors who are working are actually registered you will have read, assuming you are able, a note saying that after the licensing date this information will appear on the GMC website for free, gratis, nothing.

With us so far?

So if you want to find out if a doctor is registered, licensed and therefore legally able to practice do you know how you may be able to find this out?

If you cannot work this out we suggest you leave now and enrol in your local junior school for the start of a lifetime’s education that you have missed. Or work for the local Politburo they need class acts like you and it is a job for life.

A good 6 weeks before the LEGAL need for a licence an elite branch of the local Thickerazzi sent a letter out locally to each GP asking them if they:

1) had applied for a licence


2) would the doctors send them a copy of the letter saying they could have a licence.

As with all the important and highly useful Politburo requests there was the usual “urgent” deadline. Vitally important as any employee of a local Politburo has to finish work by 13.00hrs every Friday. What they do the rest of the working week is a complete mystery.

In other words are you still legally able to practise medicine now (yes we don't need a licence) and more importantly WILL you be able in a few weeks time when licensing comes in?

This was so that the local Politburo could ensure that all the performing seals on the local Politburo’s (GP) “Performers’ List” were able to practice medicine with a licence that you hadn't got, didn't need and was not legally needed at the time of asking .

Well done comrade managers we are sure you will have had a triple vodka and caviar for this completely wasteful use of public money and a waste of GP time to achieve what?

A list of doctors who may have a licence to practice medicine a few weeks before they are legally required to do so?

And if one of them had been struck off would they still be on the Performers list when licensing comes in?

Several of us here at ND Central found that due to our age we could not remember if we had applied for a licence, or if the dog had eaten the letter for the licence, or if it was in the back pocket of our jeans that went into the washing machine. Still if you are senile you can still be on a Performers' list as long as you send your letter in.

Given what we said would it have not been cheaper for one NHS comrade manager to spend an hour on the GMC website when licensing was ACTUALLY introduced and LEGALLY required to ensure that the performer’s (seals) list was UP TO DATE?

Of course not comrades, as any Soviet system has full employment of comrade workers busy dong nothing. They are not that bright. What are these people doing with our money and more importantly what do they actually achieve?

Nothing perchance? You decide this was not made up.

Praise be to the Party who protect the Public from “dodgy doctors” by squandering the Public’s money on useless exercises in incompetent bureaucracy.

What will they be asking for next?

Doctors’ death certificates from all those currently employed by the local Politburo to enable them to plan workforce requirements for the next century? Jest ye not, it might be next, dear reader given the current state of NHS Management . . .

Thursday, 3 December 2009

Swine Flu Exclusive: seen in an Associate Teaching Hospital in Northernshire.

While sitting in an associate teaching hospital, don’t know what one is we only knew of real teaching hospitals, we saw the following piece of information a wall:

“Comrade Patients, due to current infection control guidelines all magazines and toys have had to be removed from waiting room areas due to the current threat of swine flu”.

Now we know why we failed microbiology all those years ago (not)!

We thought that influenza was an airborne acquired infection that you breathed in, in order to get it. Remember coughs and sneezes spread diseases?

If we only had known that its principal vector of the transmission of (swine) flu was toys and magazines we would have passed our exams magna cum matronis!

No wonder Sir Liam and Dame Christine earn their bucks for cream cake eating and “re educating” our lack of knowledge regarding infectious diseases.

Still we did put that sexually transmitted diseases were acquired from toilet seats and that you could become pregnant by kissing and holding hands the second time round in our microbiology exam so we were once correctly politically re educated (not).

Toys and magazines spread diseases but coughs and sneezes and door handles do not.

Praise be to the Party and all its infection control guidelines.

We counted 20 door handles that we touched on our way to this outpatients in this hospital and all the doors glistened with signs saying “sanitized for your protection from swine flu” and every door had an antiviral and antibacterial rub which said use this before you touch the door handle (not).

Ask yourself which is the greater risk for acquiring a disease? Picking up a magazine or a toy in an out patient department or touching all the door handles in a hospital on your way into a hospital out patients? Which has the most hands touching it?

No wonder, given such notices and nationwide preparation, we are truly the best prepared joke in the world for swine flu. You could not make it up, could you?

Monday, 30 November 2009

More Education, Education, Education? Medicine and Education a few parallels.

While driving home earlier this month a few us “customers” of state funded education heard that the Party feel that parents who “cheat” should be penalised for advancing their children. When we say cheat we mean trying to get their children into the best schools. Not too long ago the Party felt that co-payment should be verboten and so we here at ND Central started to note a few parallels between education and healthcare.

No surprise here given that one of us at ND Central was a victim of the “Old” Labour Party educational policy which dictated that all comrade serfs’ children, regardless of their ability, should be downgraded to a Party sponsored education, called comprehensive schools.

At the same time that the Old Labour Party elite, sorry they were called MPs then, who were the “true socialists” in those dim and distant days, felt it was totally acceptable for their children to be sent to Public schools (no doubt on MPs’ expenses). At that same time they, as parents, sorry political commissars, insisted that other parents’, their serfs’, children should be given the same “choice” that they had and given a true Soviet equalitarian comprehensive based education as opposed to a State funded (via MPs expenses) private or Public school education.

Such disadvantage is continued in this country in the course of “socialised medicine” and “socialised education” so that any black, inner city child with the intellectual ability to be a doctor will be denied a chance of a decent education, not because of race sex gender etc for these forms of discrimination are now outlawed, but because they live in the wrong street and because their parents cannot afford it.

This is fundamentally wrong.

Ability should be fostered, rewarded, encouraged and not penalised. A poor child who becomes a doctor will more than pay for their education via taxes (we estimate about 70% of their income per year will go to the State if that child becomes a GP) and the admission of people from various backgrounds will help enrich medicine by providing a rich vein of social experience as well as intellectual excellence and ability.

It was the same 30 years ago that one of us experienced “socialized education” but manage to rise above it even though it meant leaving the shores of Northernshire to experience true world-class education. Things are worse now due to the numerous reforms denying advancement via education to those gifted and the need for a large financial input in order to afford education. And that is if you have to live in the right area with access to good schools to start with.

Remember that everyone in the UK pays for state sponsored education and medicine via their taxes but not everyone gets a decent education (or healthcare) despite paying for it.

Given the “market” economy so beloved by the current Party Commissars in healthcare surely the fact that schools that are popular should mean that the money follows the patient, sorry pupil?

Oops we think there may be a cock up there. We think there may even be a slight “market” cock up here? The ZaNu Labour “market” theory would dictates that the consumer, the taxpayer, would have choice. We pay our taxes (our money as customers of the State) we want to go to school X or hospital Y.

Doesn’t work fellow comrade workers as the Party, all powerful, dictates your “choice” of healthcare (via “Choose” and Book run by the local commissars at the PCT), and your education (via local commissars at local Councils), in the same way it denies your children Blair care and Blair education using the well known Socialist Principle of all Gordons and Tonys are equal but some are more equal than others.

So No Joe the Plumber care here in the UK. No Joe the Plumber education here either. But Joe the Plumber (UK) works in a real market and charges what the hell he likes and gets his healthcare for free and knows his rights. You dear patient, or parent, operate in a true Soviet, or “socialized” market called the health service or school system. You can have any “choice” of school or healthcare as long as the Party approves.

Dissent, try to use your nouse, money or private healthcare and the Party disapproves and you will be penalized. Try to get your child into a good school and the Party will get you. Try to get your patient to see the right consultant and the Party will get you.

Old and Za Nu Labour are the same Party separated by a few decades but some of the names and most of the ideas are the same bar some mild tinkering with words and ideas and suits replacing donkey jackets.

Anyone see a headmaster refusing a Prime Minister’s child education based on his address? Doubt it but it is not the same for you or I comrade? We don’t get Darzi care when we are ill we get whatever cheap crap the people in the lower streams of a Northern comprehensive think is right for you based on their huge inability.

For some of the people running local healthcare now weren’t bright enough to hack it in the private sector or get into a University or medical school. They went into NHS management after failing several times in other jobs first.

Clearly in this respect Old and New Labour have succeeded. Don’t foster and encourage ability penalize it. You get what the Party provides and it is presided over by the least able of all, the NHS manager. The ones we know of were in the bottom third of a mixed ability comprehensive school in a large Northern industrial town.

Try to do better and you are penalised either financially by having to pay for better healthcare and education, or by the State denying you better care or education, that you have paid for by taxes and taking you to Court if you try to better your child.

So much for the every child matters agenda and the Children’s Act putting the child’s interests at the centre of any decision making process. So much for the mantra of “education, education, education” so often quoted from a former Party leader.

Education is the current way to advance oneself in our society and it should be provided on the basis of merit. If a child from an inner city school has the potential to be the next Einstein is recognized he or she should be sent to the best schools locally based on ability not location. If that child’s parents recognise this fact they should be encouraged in the same way that if they wanted to see a better surgeon at another hospital for a particular condition rather than a less good one locally they should be given real choice to do so.

Praise be to the Party who provide “choice” as a word but not as an option. Thirty years ago choice was limited in education locally but in healthcare it wasn’t. Now both are limited more than every before and more “choice” is in fact less.

No wonder the Americans are worried. More management means less progress and choice. Pay more get less. More Choice anyone?

Regardless of the politics who loses? The patient and their kids.

Thursday, 26 November 2009

Some thoughts while driving in Northernshire in Autumn . . .

Now that we are back on Zulu time or GMT the nights draw in quicker here in the more Northern parts of Northenshire and the change in light makes the drive into work literally appear in a different light. May sound like a bit of bull but any photographers will know what we mean.

One thing that has struck us is how many pubs (Public Houses or bars) have shut in the last 2 years along our drives to our various surgeries and visits. In the last 2 years we have counted 10.

Now this being one of the more intellectual and affluent areas of Northernshire the average working man after a hard days graft at the coal face that is the office will usually be off for a quick gallon at the local gentlemen’s club called the Working Men’s club in the Northern shires.

But the lights are no longer on and the windows are boarded up. We know not why as liver disease is on the increase and, coupled with the increasing number of signs on buildings reading “Licence to let”, or “Building for sale”, or “Can you run this pub”?, we wonder why these are appearing rapidly on once prosperous and booming businesses?

The dark nights have also unleashed a new hidden menace onto Northernshire’s already hazardous roads.

In addition to the odd deer, pheasant, uncontrolled horse, farm tractor, combine harvester, wet leaves, black ice and floods, we have here in Northernshire noted an increasingly common new hazard preventing our normal Mach 5 journey home in our state funded Ferrari (if you, or anyone, believes our current Party as to how much the evil under worked over paid GPs earn).

This may reflect the increasing aging of our population but it is an insidious problem, possibly a mission creep, which will result in more harm as it is an unregulated problem at present.

What is it?

None other that the nocturnal pensioner on an electrically powered mobility scooter.

Surely not? Yes not.

These demented “infirmed” users of these devices with cataracts are using them on Northernshire roads with passing places on hills and in the dark as well. Some will use lights or wear fluorescent jackets but others will not as using lights will diminish their battery power which is severely challenged by them going up the local 1 in 5 hills on their way back from the local tavern (still open) in a valley bottom.

Coupled with diminished hearing and eye sight these scooters have caused both Northern Docs, and local bus drivers, some scary moments on single track roads with passing places as they pull out without warning onto the unlit roads to avoid a steeper climb up a hill on the footpath parallel to the road which runs up a different contour from the road causing traffic to screech to a halt and crawl behind an almost invisible pensioner on an electric scooter up a 1 in 5 hill until the next passing place a mere 500 yards away at 4mph.

No insurance, no minimum standard, no licence but still a hazard particularly in the dark.

Now one is bad enough but there are now packs of them. Could this be the Marlon Brando Wild Ones generation of bikers making a final come back? A new Hell’s Angels chapter in the making the Mobility Scooter Granddaddy Hells Angels Drinkers Chapter?

We jest not this is all true not in a Northernshire Granny ghetto conurbations but in country lanes and villages. It may be related to the closure of a local pub that was on the flat but now the nearest pub is in a valley bottom we know not but there is a new hazard on the dark roads that hunts in packs.

Although not fans of over regulation there must come a point when there will need to be regulated. 8 deaths and a thousand injuries are quoted by the BBC in 2004 and it would appear that some (patchy) bits of law might apply already.

Praise be to the Party whose zeal to legislate and regulate is sometimes conspicuous by its absence especially for the protection of the individual as opposed to the corporate entity that is Government especially on dark nights in Northernshire’s dimly lit roads.

We would hate to dent the Ferrari on a mobility scooter oops we meant to say cause injury to an unlit pensioner. Could this also be an income generation measure to reduce the National Debt? Mobility Scooter Road Tax? Compulsory insurance? M(S)OT certificates?

Monday, 23 November 2009

Useless jobs in the NHS

If you have not read the most excellent Ferret Fancier’s blog and their post of how many useless managers (we would have liked to use a five letter grunt word that starts with s that had hi in it and ending with e but we thought better) are employed in the NHS in this country wasting tax payers’ money to achieve more management as opposed to the aspiration of Joe Public for decent, or even better, healthcare then we would urge you do so.

See also our photograph of this list on a wall and then think of the great new term that we love at ND Central from across the Pond called “socialised medicine” and you can see why the Americans are worried.

One of us here at ND Central went to sleep, sorry, to a local Party meeting to tell us something important (we think).

As far as we were concerned it was another example of NHS management (in)action namely creating people to do a job which does nothing useful but they (the NHS managers) will happily pay for it as if their box is ticked they get promoted. You get the idea more boxes ticked = more money wasted on more management expenditure = ultimately less patient care and therefore promotion.

A self sustaining spiral of ever increasing expense and incompetence the essence of NHS management.

Let us go back a while to a former time where there was a job called a navigator. This used to be a highly skilled and important job based on knowledge, science, mathematics and a degree of experience.

In the Royal Air Force you used to get half a wing or a brevet as a navigator the idea being you can tell a pilot, who flies a plane, how to get from A to B. Although navigation is not an exact science especially in war time when it is reckoned that only 1% of bombs hit their intended targets (WW2) having a good navigator meant that at least you could get home to fly (and die) another day.

So the local Thickerazi have rolled out a totally new and useless job called the “care navigator” which they say will help the demented patient “navigate” the “complexities” of the “patient centred” NHS to “facilitate” them accessing “world-class” care.

This will be delivered locally via 6 nurses on the frontline of health delivering one to one, “personalized” care by sitting beside a phone. Similar in a way to the couple of people employed locally to sit at a local Poliburo sponsored Swine flu help line (we jest not).

Can anyone see the problems here? “Care navigation” versus real healthcare and help? 6 nurses sitting by a phone as opposed to 6 nurses delivering one to one patient care, or boots on the ground to use the current expression.

Did the RAF use navigators based in a call centre in World War 2? No they were real human beings in real aircraft whose lives depended on many things especially the ability to find an airfield to land on always useful if you are in an aircraft just like getting the right healthcare. It might even save your life.

Remember dear reader that the answer to any problem from the Party is to create a call centre (and lots of managers to run them).

Successes include:

NHS (re)Direct
the National Swine Flu Pan(dem)ic line and of course

BT (India). Yes months on BT (India) are still delivering dial up service at home and after 5+ years a dial up service via N3 at work the later service at your expense.

So bums on seats in call centres top trumps boots on the ground every time for NHS managers with a “problem”

Given these “successes” and please bear in mind for whom the “care navigator” service is for the demented patients of the United Kingdom let us think how this might work.

A concerned relative consults a doctor, or a real nurse, who gives “the care navigator” contact details to the dement’s relative.

Dement’s relative then puts contact details, no doubt on the NHS corporately produced card, on the side of the kitchen along with messages to “shut the door”, “take your tablets” and “do not ring your doctor unless it is an emergency”, “do not reorder your prescription you already have enough drugs” and “poo in the toilet”.

So want does the average dement do?

Come on stupid they completely forget to take their tablets, leave doors open and ring the doctors every 5 minutes to re order their medication and request a visit as they feel “dizzy”. And did we mention the toilet?

However, they suddenly see the “CARE NAVIGATOR” card, and to a stirring rendition of the Dam Busters’ March from a long time ago in their minds they suddenly remember the War and the Blitz spirit.

Let us not pee and crap on our beds and wander naked in the streets at night there is a war on we must all pull together. We, the dements, of Britain, shall dig for victory and ring the Care Navigator.

That we teach the Hun and damned Bosch a lesson! (Quite right their pensioners get better healthcare than we do and they lost the War).

The relatives will of course be thinking, thank God we rang the care navigator, it was the only way we will get this bird down and into a nursing home. If only.

So lets run through this idea again.

A nurse sits at a phone, a highly skilled “care navigator” no doubt wearing a badge as per the Service, for demented patients who are meant to ring them to get help from the “care navigator”. How much of the conversation do you think the dement will remember?

Anybody brighter than your average NHS manager, or a work avoiding nurse doing “care navigation”, able to see a slight problem with this idea?

Like who tells the demented patient about this service? Perhaps a “care navigator facilitator" when it does not work? Another nurse off the front line? Cue another level of “service” provision?

We have already seen this with Community Matrons who have failed spectacularly at reducing hospital admissions that they now have created a Community Matron “support worker” formerly called a district nurse to help them look after their six patients.

More and more chiefs, less and less Indians but at more and more cost to deliver less.

Given the current state of public funds and the inevitable needs for cuts a few of us at ND Central can see one place where the axe should fall with no harm to patient care.

Useless job number 2: "the discharge co-ordinator".

When we were grunts if a patient was fit for discharge this was arranged by the ward staff. Usually staff nurses, sometimes with ward clerks involved, under the supervision of a ward sister who would between them arrange all the bits and pieces needed to allow a patient to go home.

This was in the days when wards had real nurses in adequate numbers and with enough beds to treat patients. MRSA was there then but easily manageable as there were enough isolation facilities, nurses and beds to contain it.
These days are long since gone as despite an increase in ill patients and a population increase of 10 million the number of hospital beds per head of population has decreased. No rocket science here comrades less fuel in a rocket leads via “efficiency savings” to get more bangs for your buck. Or was that deaths for your dollar?

So what used to be a simple procedure called a discharge is now made more complicated as someone now has a job to be a “discharge co-ordinator”.

Rocket scientist or an auxiliary nurse promoted? Have a guess.

Such is the success of these highly paid professionals that if you have ever been on an NHS ward as a patient (and two of us have been in the recent past) and been discharged at 08.00hrs by a consultant can you guess when you actually are allowed to leave a ward?

Try 15.00hrs.


Because the pharmacist who dispenses your discharge drugs was on a ward round.

A pharmacist on a ward round? Bit like a chocolate frying pan but they are important para medics and no doubt the "discharge co-ordinator" had vectored in this 7 hour wait into their incredibly complex NHS navigational equations to improve patient care on the frontline.

Sit on your (ar*e) when well doing nothing waiting for almost a whole working day for an incredibly important pharmacist to dispense drugs that they could do in 15 minutes or less. But the ward round was important so up yours you are only a patient. A 7 hour wait is perfectly acceptable and it is being “co-ordinated” as well.

Gone are the days when Sister would have noticed that a patient discharged by a consultant at 08.00hrs was still on a ward at 10.00hrs and dispatched an auxiliary nurse to get the TTOs (abbreviation for take home drugs) and got them within the hour.

Praise be to the Party for creating “care navigators” and “discharge co-ordinators”. What will be next illness “observers” or nurse “co-pilots”?

Whatever happened to trained nurses in adequate numbers to do the job? We know they are replaced by managers and call centres. Progress.

Wednesday, 18 November 2009

The NHS Brand or Ronald McBrown on corporate identity.

Fellow bloggers and readers while doing some research for a post one of us stumbled across the NHS Brand Guidelines website.

Being good scientists and scholars we did study this website and if you have no surgeries or anything else constructive to do for the next week then we respectfully suggest that you trawl this website to see where tax payers’ money is being spent (on healthcare).

Go to the Homepage. Look to see what is in the centre: a section for dentists. Are we thick up North but when did anyone in this affluent area get access to a NHS dentist especially as an emergency?

Look at the rotating images and see how clean everything in the NHS is. We all know that actors and film, or photographers’, studios rarely see the number of patients in a day that real healthcare professionals and institutions do. Notice the subtle ethnic “diversity” and images of children being cared for by the benign “NHS brand” team of website designers as opposed to real healthcare professionals. Don’t the patients look so well and the staff so relaxed and rested?

Check out the About the NHS brand to learn that “this website is a central resource for all those involved in developing NHS communications”. Hmmh clearly no-one there talks to patients or to us on the frontline.

It finishes with the sentence “whether you are a communications professional working within the NHS, or an external supplier providing design or print services, our guidelines will show you how to use the NHS brand properly and effectively”.

Nice to know that the frontline staff in the NHS are being provided with all this vital information to help them treat patients. Next time we access an NHS print service as part of our families healthcare we will be greatly reassured.

Back to the Home page. There are 21 options in the drop down menu in the blue Welcome box. Being thick enough to be GPs we went straight to the last one “unsure?”
Reading this we found the following sentence:

If you're not sure where to fing the information you're looking for, . . .”

Clearly Vicki Pollard is now working for the NHS as a website designer and doing nothfing, whatever. But getting paid for it no doubt handsomely.

There is even a telephone number possibly a “NHS Identity Helpline” call centre? For the paranoid perhaps?

Try checking out the section we think might apply to us we think it is General Practice.

There is even a a 4.2Mb pdf document with a warning large file size (think steaming pile of cow dung) underneath it. It is 103 pages long and we suspect that a quick skip read of the first few pages will make the idea of hammering nails into your feet a more rewarding experience than reading the rest of the document. Go on give it a try. If you are not a GP there are loads of other such documents to download too some even bigger than ours!

Try reading the first page and see what it says, remember we found this site by accident:

This need has come from:

GP surgeries and primary care trusts (PCTs) asking us how to use the NHS brand within their surgeries

Of course we have been we have been banging on their doors for years asking how to use the NHS brand and we suspect that every other GP and medical blogger in the UK has been doing the same too.

Look at the bewildering array of options on the GP site which we have looked at and after an hour of research at the Café Michelle have barely scratched the surface of this hidden gem of NHS excellence in wasting tax payers’ money.

On the web page there are 3 GP categories. Unfortunately we fall into the D or Delta fraternity here at ND Central as we do not use the NHS brand on any of our Practice correspondence so no doubt there will be a visit soon from the NHS Brand Stasi for a spot of political reeducation or is that rebranding?

If you are still breathing after being underwhelmed by this marvellous website of Party speak (deep breaths, dear reader, think calming thoughts of steaming dung heap to counter any negative thoughts or emotions) then navigate to the Useful Links and click on the bottom link Tone of voice: Words and written communication.

Start reading this section and image the text being read by Telly Savalas as Ernst Stavros Blofeld in the James Bond film On Her Majesty’s Secret Service in a darkened room.

Read the section Respect, understanding and accessibility and see how communication should be. Anyone ever hear a PCT manager speak “free of jargon, free of acronyms and free of overly technical language”?

Clearly even the PCTs are not on message so we GPs have no hope but carry on listening to Mr Savalas’s dulcet tones in your imagination as you progress to bits that might just be relevant to GPs’ daily lives the “One-to-one communication with patients and the public”.

Every time you communicate with a patient or a member of the public, you are acting as an ambassador for the NHS. You are projecting the NHS identity. Remember, first impressions count, and what you say and how you say it will impact on that person’s confidence (positively or negatively) in our ability to do a good job.”

Now why were none of us told this in medical school? All those lectures, booklets and sessions on communication skills and we were not told that we were not doctors but were in fact ambassadors for the NHS constantly apologising for its inefficiences and difficiences. We did not realize we were projecting the NHS identity we thought we were being doctors.

How could we have got it all so wrong?

Praise be to the Party for enlightening our darkness as to what we are actually doing with patients – projecting the NHS identity. So much better than treating them and making them better. And this will not have cost the taxpayer a penny.

This is the polite version the grunt speak version is as follows: what a load of paired dangling male sexual organs contained in a sack. Money to burn anyone?

Thursday, 12 November 2009


The last few days have been crap days for a number of reasons for us here at ND Central but what caught our collective attention was the recent out pouring of apparent public grief in the UK.

Commentators at the annual Remembrance Day Ceremony at the Cenotaph said there were more crowds than usual. This week we watched scenes that evoked memories of the funeral of Diana, Princess of Wales when hearses with coffins inside this time with the bodies of fallen serviceman, were covered with flowers as they passed through a normally quiet English village of Wootton Bassett.

This got us thinking about grief and peoples’ reaction to death. One of our forebears lost 5 of their siblings and a father in one year. A few short years later more of their family were lost in the First World War albeit just within the last one hundred years. Infant mortality was high then and deaths in the First World War were in the tens of thousands in a day alone.

One death is a tragedy, a million is a statistic said the “great” Soviet leader Joseph Stalin well known for his humanitarian views and influence on current Party thinking especially freedom of expression.

But perhaps there may just be a point?

When infant mortality is high then losing a child is as upsetting to parents in these times as it is today. Emotions do not change but circumstances do.

If those around you lose their children to disease and in large numbers perhaps there is a degree of desensitization that sets in as a means of evolutionary self preservation?

Similarly if you lose a loved one in war, especially if you believe it to be unnecessary, this is not good but if tens of thousands do the same does it alter one’s perception of loss?

One person’s death or a few people’s deaths versus tens of thousands? Which is the greater grief?

Which is the greater absolute “loss” versus the greater Media interest?

For any human being the death of a loved one is distressing. It takes time to come to terms with and usually involves the support of one’s friends, or family although increasingly there always seems to be the all wise watcher of the UK Soap opera called Eastenders whose perception is that you always “you need to go and see your doctor.”

It devolves any responsibility for our own disquiet with death or disease and it is free in the UK. Grief then becomes an “illness” not an uncomfortable unpleasant emotional state.

So often within 24 hours of a death we will see relatives who have been sent always by someone else as an “emergency” and usually expecting the magic grief prevention pill which they have been told we have by whoever refers them to see us.

They usually get nothing other than a bit of time spent explaining that grief is a normal but unpleasant experience and what they are experiencing is normal.

Yes, you will be crying. Yes, you cannot sleep and yes, you will be thinking of him or her all the time but this is normal. Yes you may feel disbelieve, anger, guilt or any other emotion but this is normal. You will get better but it will take time.

Time is a great healer but unfortunately works slowly. Time spent explaining usually works better than the quick fix usually expected pill based alternative.

Disasters create Media induced grief. Would the tens of thousands slaughtered on the first day of the Somme have been reported in the same way that a servicemen’s death is reported today? Would Wootton Bassett have stood still for a 20,000 long cortege in the same way that the Public honoured those fallen in the last few days?

Same loss of an individual to the individuals concerned, same emotions but different circumstances and more importantly numbers.

Grief is an immensely personal thing. It is also a highly collectively hijackable thing via the Media but still, at whatever level one thinks of it, it boils down to the relationship between the individual, those around them and the deceased. It also now boils down to how we as Society, via the Media, view death.

The support provided in the UK usually also boils down to that between the individual and those they deal with. Often that is the principly the local undertaker followed by a local GP or in the military medical officer or members of whichever faith the family subscribe to. Before free healthcare the family would shoulder a lot of this as would local ministers of religion. It is a deeply personal relationship and always takes time to resolve.

While we here at ND Central do not have any qualms about public outpourings of grief we know that behind all the pomp and ceremony there will be a few individuals working locally to help bereaved individuals in all manner of different capacities.

We are relatively lucky in this day and age that the widespread losses that even 2 or 3 generations ago wiped out huge parts of families have been reduced to the point that death is a relatively rare occurrence in most peoples' lives although one that we will all with certainty experience on a very personal basis.

Thinking back just a hundred years ago to our forebears’ experience of losing several children to disease then losing several young adults a few years later to war must have been awful.

The human emotions were the same then as they are now, the circumstances were different. Grief is grief is grief but society changes and not always for the better.

Our thoughts go out to anyone who has experienced the loss of a loved one however it was caused. It is never easy whatever the circumstances.

Who knows whether one of us here at ND Central will have to break the news of a death to someone today, go out and confirm a death, or see a relative who has been bereaved. For some of us more than others it is a regular occurrence and has to be handled with sensitivity and tact.

Death always has the upper hand and always plays the game by his rules. We just follow.

It does not get any easier the more you do you just get more used to it. It is however part of the job and we will get on with it as always, however hard.

The same can be said for the military and the relatives of those killed in action for we feel war will always be with us.

Praise be to the Party for all their support for our servicemen and servicewomen.

Fortunately the Services have their own methods of support evolved over years to help those with loss. They may not be perfect but they have stood the test of time certainly longer than the NHS.

We await the centrally Party approved NICE guidelines on how to deal with grief (military personnel) but a lot of us have already learnt the hard way. We are but grunts on the ground and cope accordingly - without guidelines, on a one to one, very personal level with no cameras in sight.

Thursday, 5 November 2009

More NHS Choice, Swine Flu and Immunization.

One of the advantages of being involved in medical education is that every now and again you go to meetings and talk to different doctors at different stages of training outside of your own Practice. A few days ago one of us did just that and came back with a rather worrying story.

It would appear that one of the many local hospitals is “encouraging” their staff to have the swine flu immunization.

Obviously an excellent idea of the benevolent Party looking after its own as it says, in one of its briefings for managers, that if you are sick with the dreaded Swine flu then you cannot be allowed to work and look after patients.

How caring is the Party? It is so concerned for the well being of the comrade workers on the frontline that, in order to enable them to continue to care for their fellow comrade patients, it is offering them a free flu jab ahead of all others.

The carrot.

What is more worrying is that staff are being told that, if they do not have the Swine flu jab, and then they dare to be ill with Swine flu, they will face "disciplinary action" for not having had the “voluntary” swine flu shot. If they have the shot and get Swine flu they will not. Same illness, two different outcomes?

The doctor in training from whom we got this little gem in passing also said that managers were prowling the wards at night in the small hours to immunize their staff after these threats. Good stasi tactics there comrade managers.

The stick.

Now we may be old fashioned here at ND Central but we still, as far as we know, have the concept of informed choice in healthcare.

Unless the Law has changed as a result of us here in the UK “democratically” accepting the Lisbon Treaty after the "promised" referendum, a patient has the right, if they are compos mentis, to decline treatment even if it may harm them (assuming no other conflicting law for example the Suicide Act).

Now if any lawyers are reading perhaps we could suggest that rather than sniffing round A&E departments there may be rich pickings to be had here.

Employment Law, European Law, Human Rights Laws surely are being breached here as well as basic medical and nursing ethics and codes of conduct?

What if a patient who is coerced to have a shot gets Guillain-Barre syndrome? A lawyer’s Christmas present in one convenient bundle perchance?

And at what cost then to a local hospital or more importantly to the NHS for the incompentent local managers’ zeal in the face of basic medical ethics and human rights?

Come the New Year we may start to know the success or failure of the Swine Flu pan(dem)ic vaccination program in terms of Guillain-Barre syndrome. We are normally great advocates of vaccination when the science is there but given the fact that a few days ago the local Politburo came to immunize priority staff and less than a third of the doctors took it up does that tell you something?

Praise be the Party for we know it to be all wise.

We hope it rewards these managers with the prize that they will surely richly deserve a one way ticket to their spiritual homeland:

North Korea.

Saturday, 31 October 2009

Halloween some Odds and Sods

A few little bits have caught our collective eyes as we here at ND Central go through the 100+ letters we each get a week.

We are always keen to “embrace” new treatment options and the suggestion by one of our local eye consultants for us to arrange “dermatological relief” for a patient was interesting.

It reminded one of us a line from a UK gangster film, we think it was The Squeeze 1977, where a cop was asked if they wanted “special relief”?

Another new therapy we observed for treatment of a fracture from an orthopaedic clinic was to try “vibration massage therapy”.

Long gone are the simple days of plaster of Paris, metalwork and the odd antibiotic as core orthopaedic treatments.

As none of us knew what these actually meant we felt we have either been out of hospital medicine too long, watch the wrong kind of films or have an odd sense of humour?

We could also just be plain pig ignorant. Still it gave us a few giggles.

The Walk In Centres continue to provide us with lots of evidence of rain forest deforestation but not much evidence of useful work.

One punter, sorry patient, there is of course no real market in the NHS, had been 5 times in 4 weeks and the history and treatment was the same on all 10 sheets of A4 paper produced.

The same history, examination and conclusion = “viral infection”, all 4 lines of it, in the 2 sheets of A4 per attendance repeated 5 times was as relevant to us as GPs as a used piece of toilet paper in a sewer.

Unfortunately one question had been consistently missed and had it been asked, 2 weeks ago, would have given the diagnosis in 2 minutes not the 5 times 20 minute consultations.

We asked the relevant question and the patient got better with the right treatment.

Someone has said that 85% of diagnoses in General Practice you can get on the history alone.

All of our consultants at medical school said that a good history was vital and only after a few decades of multiple history taking and seeing lots of patients and doing sometimes many unnecessary tests do you realise that this is true as a result of experience not a short course.

Until you observe those in training (medical students, F2 trainees, registrars and even nurse practitioners the new Vim of medical healthcare on the cheap) and how they fail to listen though inexperience, not inability, you do not realise that taking a good history from a patient is an art that takes a long time to do well.

That is if you can remember your own short comings, which we feel is vital in teaching, for if you forget how bad you were once, you become intolerant of ignorance which we should be correcting via education not humiliation.

These skills cannot be learnt in a few short weeks or, even less now, as “education” has improved so much under ZaNu Labour’s rule, that in 3 hours of Party sponsored “how to (mis)diagnose swine flu” courses anyone can play doctor and get away with murder.

We are situated close to several largish conurbations and we have noticed a number of different formats of walk in consultation printouts (mostly rain forest and knowledge unfriendly) but one we had not seen until now had the following code sitting in amongst the crap printed on them:

Mobility: WALKING

We shall be looking out for any variations on this one given that these are “Walk In” centres.

Would one get treated if you “hopped in”, “roller bladed in” or were “carried in”? Would that alter the mobility code?

Surely given their name, all mobility codes should be “Walking”?

Heaven forbid someone from a local military base might abseil in from a helicopter but we are sure there must be a code for that, comrades? Or would they be denied treatment as they did not walk in?

Finally we asked each other how many cases of genuine swine flu we have seen?

Answer none. Lots of Tamiflu positive patients but no genuine confirmed cases. There are rumours that the Health Protection Agency have been swabbing patients and finding large number of people have had swine flu but with little or no symptoms. These are just rumours which will no doubt be suppressed as if this got out there would be nothing left to panic the population with and the benevolent vaccination program might not be of any use.

Still our patients know better than as all of them are convinced they have “flu” but they have managed to drive in, park their cars after taking their kids to school, on their way into work and then walk in to see us to tell us they have “flu”.

These acts themselves tell us they do not have real “flu” most of them just have minor upper respiratory infections as do the rest of their families, schools and work places which is usual at this time of the year. We are still waiting for our first proven real bacon butty case of flu.

It is of course Halloween so no doubt the Department of Health will be allowed out to play out unchecked for one night of the year in contrast to the rest of the year when it inflicts all manner of horrors on patients via their “initiatives”. This morning’s patients at one of their bright ideas, the Gordon surgery for busy commuting pensioners, at one of our less affluent branch surgeries more than surpassed the local supermarket’s Halloween horrors and that was in daylight.

Praise be to the Party and all its new health reforms.

We wonder which one of them was responsible for the new “reliefs” and “therapies”? Sir Liam or possibly Dame Christine or maybe it was a joint effort?

No doubt NICE approved all of them as part of evidence based politico-economic medicine if only we could recover their rainforest depleting missives from our shredder to read the relevant ones . . .

Has science finally disappeared from good medical practice or are we just taking the proverbial?

You decide dear reader we just live this daily. Beware the ghouls and beasties tonight for if they do not get you the DoH will!

Sunday, 25 October 2009

Beware Greeks bearing gifts.

Being in the “market”, a real market not the management structure called the “NHS market”, for a new partner a few of us saw our eyes drawn to an article in the GP rag called Pulse magazine.

Now anyone here in the UK looking to recruit a new partner as an established GP practice would look upon £225,000 (over 3 years) as a god send to boost income as virtually all GP Practices have, and will see, a drop in income as a reward for fulfilling their side of the new GP contract which has displeased our political masters so much.

The exception being the “private” contractors, some of whom will also be local GPs, supplying the Darzhole centres who we reckon will, for providing less than half the services that we do at ND Central, will be raking in as much in PROFIT as our whole Practice TURNOVER. These will be generously funded to ensure their success as they are political structures provided by “private” providers rather than things that are actually needed.

In English this means a million quid for an 8 doctor practice which includes the doctors pay versus 2 million quid for a 3 doctor practice but here the profit is the same as our turnover. Private is clearly best, comrades, it costs so much less than Publicly funded general practice.

This is why we say onto thee, dear reader, beware of Greeks bearing gifts.

The Trojan Horse is the fact that any Practice(s) greedy enough to take the comrade Commissar’s schilling will in effect be losing any independence they have as they will be expected to sign up for a PMS (Personal Medical Services) contract.

Historically PMS contracts for GPs in the UK have been financially better paid (although that is changing) but the downside is that you lose your medical independence as the Party seeks to control how you “practise” medicine via the PMS contract it negotiates with you.

Although there is an alleged” National Health Service” in the UK it is in fact a multi national health service with each local Politburo or Soviet (PCT) dictating the local supreme idiot commissar’s (Chief Executive) policy for local healthcare loosely based on the supreme Soviet’s (Department of Health) view of the current Party’s (Government) healthcare policy.

If, and this is a huge if, the local commissar has a brain this might result in some degree of local improvement.

However, the NHS’s “socialized medicine” means that this is nothing more than an attempt to cut costs via imposing a PMS contract = more local idiot Party commissar’s control.

For any US, and indeed UK readers’, you have to realize that all NHS commissars have at least 3 degrees from either Harvard or Yale or, in some cases from the lesser universities of Oxford or Cambridge as historically the brightest of the United Kingdom’s graduates go into NHS management in contrast to those who struggle to make it into medical school (not!).

This is why NHS managers struggle to improve healthcare in the UK as they are always hampered in their efforts by the less intelligent medical profession. This then angers the Party, who being true Socialists, hate the bourgeoisie called medicine as the Party represent the “workers” of the private sector and will happily trouser anything forthcoming from them.

So while we would like to replace a partner there are no local Party bungs unless we sell our souls to the dark side of “socialized medicine” = total Party control. Although we would like to be as intelligent as the local commissars we know we would struggle to keep up so we shall decline their gift of a horse even if it means a few more years of siege.

But still like the Trojans, after almost as many years of siege by Za Nu Labour, sorry the Greeks, there will be those in the Resistance who may take Gordon’s commissar’s schilling and sell out.

We here at ND would urge caution for having invited the Greeks in, you may find that far from bearing gifts, they will in fact raid your family silver for years to come which you will have to pay for year on year.

Praise be the Party for free healthcare and for encouraging GP Partnerships in these austere times. They are all wise and as good socialists they want even.

As someone is said to have said (sometimes Lenin and Stalin are quoted as originators of this phrase) and we have checked our sources:

“The [capitalists] will sell us the ropes with which to hang them”.

So will they now “pay us” for new GP Partners?

Saturday, 24 October 2009

Job Clubs in the ‘80s recession, now in the Noughties, welcome the Leg Club.

While trawling the web, in yet another busy surgery waiting for work, we decided to have a look at The Comic and found an interesting article here that caught our eye.

Those of us old enough to remember the 1980s were reminded of “Job Clubs” where unemployed people were meant to meet up, exchange ideas and get advice to try and help them to find work (when there was actually very little or no work to be found).

We remember them well. We walked past people with no jobs in groups, usually of men, smoking lurking around the Job Club doors spilling out on to the street and looking like a posse you would try to avoid at all costs often funded by local councils.

We thought given, our memories of the former Job Clubs of the Eighties, we would have a look at the Comic’s “Resource Centre” where there is a new form of club, the Leg Club.

In summary it is “social model to manage treatment such as ulcer care”.

Sounds a little vague. Leg Clubs: a social model to manage treatment such as ulcer care? Can a “social model” manage other “treatments” such as coronary artery bypass surgery in a CABS Club?

We read on.

It tells us that leg ulcers affect people mostly over 65. Well nothing there new to your average Northernshire GP, district or practice nurse. “Evidence” shows this is expensive with slow healing rates and a high incidence of recurrence”.


Does “evidence” reflect the team here at ND Central’s experience that it is usually little old ladies whose only source of social contact is their ulcer?

If they complied with treatment their ulcer would get better but instead they remove dressings, develop multiple allergies to all known dressings and let their favourite pussy rub up against their festering ulcers and then complain it never seems to get better. And they sit with their leg down to “improve” circulation and “facilitate” healing and still they never get better.

OK rant over that description was just our own Grandparents over whom we had a degree of control and who mimicked every other geriatric leg ulcer patient we see. Patients, however, are more manipulative. For example ringing nurses after they have just put a new dressing on to tell them it has “fallen off” with no patient helping hands whatsoever honest guv.

Yes, ulcers heal slowly, and they do recur but if your ulcer is your only source of social intercourse then there is no incentive to get better.

It is also usually a pre morbid condition caused mostly by poor circulation which gets worse as you get older but we digress. These were just some thoughts from those on the frontline based on years of experience.

We were only on paragraph 2 just wait for paragraph 3 and its little “QUIP” and being “referenced” whatever that means by the Department of Health. So it already is doomed to failure or care on the crap sorry cheap.

The Leg Club idea was apparently developed by a former nurse of the year who goes on to say that “Collabrative working (comrade) is the bedrock of each Leg Club”.

Fourth paragraph and a good Party phrase or two already mentioned for the comrades in NHS management to absorb in their working week off.

The next two paragraphs, with lots of Partyspeak (if you want more of this check out this inpiring link on Leg Clubs) describe how they work which to our slightly cynical eyes at ND Central sound very like the current dressing clinics and tissue viability clinics held at local surgeries and dermatology clinics.

Further on GP involvement is kept to a “minimum”.

Excellent idea! Keep the idle educated GPs away from patients.

Next paragraph starts to shed a little light on where this might be coming from as:

“Established and run by volunteers in partnership (excellent Party word!), they are self funding (cheap), with patients finding ways of raising the money for the rent and equipment (remember care free at the point of need?). The cost to the Commissioner (ah ha the important one in the equation the new force of Darkness in NHS management) is in the nursing time and dressings.

True Party Central Utopia no cost!

Hmmm. Could we perhaps re write that paragraph to describe the current system as such:

“Established and run by district nurse, practice nurse and GPs they are cost neutral to the patients as the care is delivered in their own homes. The cost to the Commissioner is the nursing time and dressings. There may also, unfortunately, be GP and dermatologist involvement but at no extra cost to the commissars.”

Have they forgotten the additional costs for genuinely housebound patients like “Vera”, the case study, who will no doubt be volunteering to self fund taxi services to mosey on down to her local Leg Club shin dig in the same way that Vera does not now come to surgery so no cost there comrade commissar in you needing to provide transport to the Leg Clubs via the ambulance (free taxi for OAPs) service.

Read on dear reader for things are getting worse.

It turns out that clubs are supported by the Lindsay Leg Club Foundation which presumably is the new version of the Rotary Club devoted to charitable good causes?

Now it really starts to get interesting.

Click on the Leg Club Foundation link > Useful documents link and download the Leg Club brochure.

Just look at how a “Leg Club” will transform your patients.

Take Mavis Thistlewaite, 30 stone, five foot nothing, 60 a day lifetime smoker and a bottle a day of Scotch for good measure in her farmhouse high on a moor some 10 miles = 25 minutes drive to any social centre, with ulcers for 10 years as she watches day time TV with her legs massaged regularly by her 5 cats surrounded by their droppings and see how she will be transformed into a Leg Club brochure babe of the month.

Patients (sorry well looking geriatric models not real patients) wading in the sea, worshipping the Leg Club, practising martial art manoeuvres, smiling holding hands and not an ulcer or bandage in sight. Please look and see how Leg Clubs have been so successful.

Instead of just looking at the pictures of ulcers “transformed” try reading and see what the bottom line is. If you are just a tad cynical and bored by now just read the “Setting Up a Leg Club” section on page 8. Is this a possible Third way model for funding ulcer care?

Oh Lordy we are reading this and seeing our patients transformed by this new Messiah. Like St. Paul we now see the light and will start following the guide word for word. Tell us how do we get the handbook? Will there perhaps be a small donation to the Leg Club’s Messiah’s charity? (We couldn’t find that bit).

Still Resistance work at the café Michelle is hard. So after another trip to the Quartermaster for some top up rations we sat down for some more self directed learning from their website.

We looked at the “Corporate Partners” a few names we recognised and we are sure none would have any vested interests in this particular field of medical and nursing care except the one which had “wound care” in its name. Still 1 out of 16 may just be allowable.

This can’t be a public private initiative via a charity? We can’t be that cynical given our recent religious conversion to the “Leg Club” creed? But it is “referenced” by the Department of Health which we know likes care on the cheap and lots of private sector involvement to save money ( = pay more for less) a good Prudent “socialized medicine” policy (we do like that phrase here at ND Central it sounds so much better than incompetence).

But then we noticed, after more rations, and this Resistance meeting was after an early and a late Gordon shi*t for some of us, the link “Information for Motorcyclists”.



Well you can imagine the imagery that came to our collective minds at this stage in the evening.

Poor old housebound Mavis Thistlewaite on the back of a Harley being whisked to get over to her Leg Club by the local Hell’s Angels Chapter perhaps? A Community Partnership?

Will there now be a Northernshire Chapter of the Angels called the Leg Club Ulcer Seniors, the LCrUS Seniors for short, using a “social model” to help their leg ulcers? Nora Batty on a motorbike anyone?

We fell apart laughing at this point it had been a long day.

(For our overseas readers Nora Batty is a comic character from a long running gentle humoured comedy called Last of the Summer Wine set in southern Northernshire who was the love interest of a rough geriatric scruff who yearned after her wrinkled stockings. The picture here is not too dissimilar from your average Northernshire leg ulcer patient although Nora was a lot more mobile even on motorbikes).

A few more mouse clicks and we found a picture. Could this possibly be of the new “Messiah” mounted astride a Hog?

Well you can imagine that any more serious critique had long since evaporated at that point.

We do not know if Leg Clubs work. The nearest one to us in Northernshire would be about an hours flying time to reach such is their obvious success up North and we here at ND Central certainly have no axe to grind with Ms Lindsay but we do thank her and the Comic for inspiring this irreverent piece.

After a long hard day at the coal face and a few top up rations you do need a bit of light relief. It will take a while to get the imagery out of heads.

We really must get back to 5 minute appointments it will stop us trawling the Net in our downtime but the Party has decreed 10 minutes good = pay but 5 minutes bad = no pay.

Bored minds do mischief make. And we ain’t teenagers on a street corner.

Praise be to the Party and NHS Innovation. Heath Robinson’s ideas seem workable in comparison with some of theirs.

Those of us old enough to remember grants and UB40 cards as medical students here in the UK will be off to the Leg Clubs in the same way that we went to Job Clubs in the eighties. They were such a good idea. Some Job Clubs may still be here today? None locally but GPs and district nurses are still here so are the leg ulcers.