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?

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.

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. . .

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.

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.

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 . . .

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

and

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 . . .

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?