Saturday, 30 January 2010

NHS Choices value for, or burning our, money?

After another popular extra long Gordon shift (remember the silent f in shift after the word Gordon) we said goodbye and hoped that our staff, who daily thank Gordon for disrupting their family life on a regular basis by offering extended access, would have an enjoyable weekend. Judging by their general demeanour it is clear they are getting peed off by the increasing amount of sh*te coming down from on high.

A good officer should motivate their men but, when the officers are peed off by those at the top, it is hard and if your morale is the same as the troops and you are fighting a war with no weapons (access to first world medicine) and no logistical support you know you can only hold the line for so long before you crumble and start taking casualties. Most GPs already have in the form of a pay cut year on year, increased work for no extra pay and increased taxation.

Small hint politicians if something is free people will take it whenever it is, whatever it is and wherever it is whether they need it or not. Try offering heroin 10 grams a time for free at 02.00hrs on the top of Ben Nevis in a blizzard and you will find queues of people who will take it (and keep coming back for more).

When we finally got home, kicked the kids, beat the wife and drunk a bottle of Scotch after the usual 18 hole round of golf that is a typical day in General Practice in the UK, we put on our reading jacket and read the GP rags and found the following article. The site referred to is here.

We asked ourselves how can a Government spend, and justify, the cost of 28 8 doctor practices on a website which does sod all? How can the costs have doubled in a year to deliver nothing useful?

If you have not as yet discovered this little gem take a look at the featured today item and amaze yourself at how much you already know about feet. Clearly those who wrote this did not discover by the time they hit junior school that clean socks daily, washing your feet with soap and water and taking your shoes of before going to bed helped prevent you getting teased in the playground. However, the authors, now website designers in their 20s or 30s, feel that their newly acquired knowledge should be shared with all.

Click the NHS Direct Get Medical Advice now link and go to the symptom checker. Being slightly merry grunts on a Friday night we went to the picture and clicked on the male genital link and found that what we had been taught in grunt school was wrong. We only needed to know 4 symptoms for both male and female genital symptoms. These are: burns and scalds, female vaginal problems, missed period and rashes.

We thank the Party and its organs for correcting our ignorance regarding male genital problems. We now know what we should ask the next time a male presents with a lump in his testicle. We shall ask him about any burns and scalds, any female vaginal problems, has he missed a period and does he have any rashes? We can see the look on his face now.

He will probably answer no to all of the NHS Choices male genital symptoms and so we can send him away knowing there is nothing wrong with his genitals. When the solicitor’s letter comes complaining about the missed testicular cancer diagnosis we can rest assured that our defence will be rock solid as we will quote the NHS Choices website that does not list testicular lumps as a male genital symptom and so there can’t have been anything wrong can there?

£ 28 million pounds on a website up from £ 13 million pounds in a year to produce what can only be described as a load of bollocks. A good comprehensive medical textbook would give you more information at a fraction of the cost.

We here in Northernshire live in an area of unbounded affluence and over educated patients and the car park is full of Range Rovers, BMWs and Jags and all of us drive Ferraris as do our staff we are so well paid. Just down the road is a heavily under doctored area and for a quarter of the cost of this useless website this area could be brought up to the right number of doctors per head of population.

Which, dear reader, do you think does more for the health of a population? The right number of doctors trousering a salary and providing health care to real patients or a load of website designers trousering millions to produce a website that an intelligent 11 year old doing a biology project could probably do a better?

It is after all your money so go on have a read. You might realize that you know a lot more than your average NHS website designer knows about healthcare but you won’t be as well paid.

Praise be to the Party whose wise use of technology to improve healthcare must be lauded all over the first world as a beacon to lead lesser countries forward.

We think not either that or we had a bit too much to drink last night after work.

Wednesday, 27 January 2010

Burke and Hare do Choose and Book 004.

Welcome back dear reader. Recovered from the excitement of the last episode in this exciting winter tale of woe? There is not much further to go, just 2 chapters so charge your glass, it is now a little warmer here in Northernshire and the snow is gone but still draw up to the fire and we will begin.

Chapter 9: “Availability of Appointment Slots on Choose and Book”.

This chapter starts with 3 paragraphs of the finest Party speak out as to what those at the top think should be happening (and is?) in the real world:

“Where services are provided under a standard NHS contract, appointments for these services must be made available on Choose and Book. It is a contractual responsibility for provider organisations to ensure that they have sufficient appointment slots available to meet patient demand and PCTs should ensurethat these contractual obligations are met.

Patients must expect to be able to book an appointment at their chosen provider organisation using Choose and Book. Lack of available appointment slots prevents patients, referrers and The Appointments Line (TAL) from booking appointments. This creates additional work for provider and referrer organisations, and a very poor patient experience. It also undermines one of the key objectives of Choose and Book, which is to provide patients with greater certainty about their appointment, at a very uncertain time in their lives.

Shortages in available appointment slots usually occur because provider organizations are unable to meet demand and/or have actively reduced their appointment slot polling, perhaps in an attempt to meet 18 Weeks Referral To Treatment targets, but have done so without increasing capacity.”

Any real world GPs reading this sentence:

“It is a contractual responsibility for provider organisations to ensure that they have sufficient appointment slots available to meet patient demand”.

must be tearing their hair out as when, if ever, has the NHS been in the Utopia described here?

When, if ever, have PCTs met their contractual obligations?

Anyone sued a PCT and won for breach of contract? We think not as they get away with doing nothing all the time.

“Lack of available appointment slots prevents patients . . . creates . . . a very poor patient experience”.

Nothing new there, comrades, C&B is just the start of any patient’s “very poor experience” of the NHS. The last paragraph must be one of the greatest examples of someone telling Grandmother how to suck eggs.

How many people in your average Poltiburo reading that will think:

“Oh no we shouldn’t have done that, we should have employed more doctors and nurses to increase (clinic) capacity, built more operating theatres and increased their funding and staffing to increase capacity.”

Rather than employed a clerk to “actively reduce their appointment slot polling”.

One method is cheap, involves little work, thought or expense and does nothing for patients. The other does not.

Which, dear reader, do you think happens in the real world outside of Choose and Book La La land? Is there now a department in the Department of Health called the Neverland Choose and Book Ranch?

The last paragraph clearly was written there:

“PCTs must take ownership of local appointment slot and capacity management issues in their area and proactively monitor and manage their local provider organisations in line with their existing contracts.”

Does that mean an end to patients being sent back to their GPs to book another C&B appointment slot when there are no slots for a particular clinic after a “request” is put in by a surgery for an appointment? Mental image of revolving door comes to mind going round and round and going nowhere other than in circles of denial of patient care while NHS managers twiddle their thumbs.

We are sure that PCTs and their commissars having read chapter 9 will be increasing capacity in the NHS in the biggest “surge” of clinic expansion in the history of the NHS. (Not).

On to chapter 10: “Directory of Services (DoS)”.

To quote from the second paragraph:

“The DoS is often described as the ’heart‘ of the Choose and Book application, because it holds information that describes the services that organisations offer and enables referring clinicians to search for appropriate services for their patients.”

Well if this is the “heart” of Choose and Book then it has been in asystole ever since its inception.

It must have been designed by a dyslexic illiterate simpleton on speed whose first language is reverse Polish logic who has never worked in General Practice or done anything remotely medical like work as a secretary, receptionist or GP in the real world, oro as an appointment clerk, medical secretary or consultant in a real world hospital in the NHS.

There used to be a computer operating system called DOS (Disk Operating System), that at one time, before Windows, operated computers and was useful.

The NHS does not do useful but it does do crap hence the initials DoS.

Notice the subtle play on words to remind you of something that was once useful and associate that within your mind in the hope you think it is something good and useful rather than what it actually is namely crass DROS (Dickweed Redirection of Service).

For those of us of a sad ilk the term DoS also stands for Denial of Service (attack) for attacks on computer installations but in this case the DoS has come from within the system itself and a DoS is all that DoS delivers.

It has put more doctors, secretaries and receptionists off using C&B than any other part of its, sorry for the grunt word, p*** poor design.

We will quote an example of a colleague’s experience who thought C&B was good until this happened to them. They had wanted to refer a patient with suspected gallstones to see a surgeon in case the patient would benefit from having their gallbladder removed.

So our colleague thought, as a doctor, and went into DoS (DROS), thinking that this will be under gallstones which is normally the preserve of the general surgeon ergo to refer look for a C&B appointment as follows:

General Surgery > Gallstones.


Boy, were they wrong. The local idiots do not do gallstones in general surgery as you are taught in medical school although for some reason you can find them under Gastroenterology but they do not remove gallbladders which is what was wanted.

Still it is gallstones so a receptionist might book it unaware that gastroenterologists do not remove gallbladders, they are not surgeons, but it says gallstones so that is alright and they will book a patient an appointment so will meet targets. The patient will come back to GP land and say “they won’t remove my gallbladder can I see a surgeon ..” .

A wasted gastroenterology appointment followed by the finally correct general surgery appointment assuming that the gastroenterologist refers the patient to the surgeon but more likely they will write back and suggest that the GP does this and so the process repeats itself and in doing so delays patient care and increases the local hospitals income. And increase “productivity” graphs?

Instead after half an hour of ringing round, that is the equivalent of seeing 4 patients under the old average minutes per patient, but with NHS efficiency savings this is now 3 patients, with some idiots in the BMA wanting 20 minutes a patient appointments, presumably so more doctors can book C&B appointments themselves while ignoring illness, they finally found how to refer a patient with gallstones.

They found it under General Surgery > Lumps and Bumps > Gallstones along with haemorrhoids and virtually every other surgical problems that can be removed unless it is more than 1.5cm large in which case the NHS is incapable of removing a single 3cm large gallstone.

So much for all of our medical training as to what we should have been removing as junior doctors on “lumps and bumps” operating lists.

Instead of us doing simple operations like removing lipomas and sebaceous cysts, we should after all the super improved reforms of MTAs and Modernising Medical Careers (MMC), have been taking out gallbladders instead as they are the new “lumps and bumps” leaving consultants to do the sebaceous cysts and gallstones greater than 1.5cm or those “lumps and bumps” located in the neck. C&B’s DoS tell us so.

We won’t recount another colleague’s experience of trying to find Nerve Conduction Studies. If you have a day (or a month) to spare and wish to experiment with mind altering substances there is a small chance that you might just find it.

These examples took hours of our secretaries time to find, in a world class PCT with “world-class” IT provision, and DoS defies all logic human, Vulcan, Klingon or otherwise.

It is impossible to use even if you have ten minute appointments and do nothing else other than make a C&B appointment. You can’t do both namely see a patient and use C&B which is why so few, if any doctors who work in real time General Practice, use it.

Needless to say neither doctor citied above now uses C&B and both have “lost” their Smartcards. Check eBay for a laugh and remember how many “secure” Smart cards have gone missing.

Onto the second sentence in the paragraph more Party speak:

“For provider organisations, the DoS provides a ‘window’ through which they can display and ‘advertise’ their services.”

Ah ha the now dead NHS internal market being given new life by these fine market sounding words. Anyone thinking that the DoS “advertises” services must have been a keen reader of Pravda as the information is nigh on useless.

The final paragraph says it all:

“By following this guidance, referrers should know which patients are most appropriate for a service, provider organisations should receive appropriate referrals and patients should be given appropriate and helpful instructions prior to attending their appointment.”

We would wish to paraphrase this and say:

“That after doing GP training and knowing what is, or is not available locally and, if need be nationally, a GP will be able to refer a patient to the most appropriate service without the aid of an expensive useless pile of crap called Choose and Book. This is, after all, what good GPs should be doing, and were trained to do, anyway.”

They did this before Choose and Book and for a lot less money and more efficiently too. Patients actually had choice as well.

Praise be to the Party who, as ever, have shown us GPs how wrong we are, and in doing so have given us the wonder of Choose and Book. Shame the authors never did any GP or medical training or things could only have got better . . .

Jo Stalin would have been so proud and envious of his protégés (stooges).

Monday, 18 January 2010

Snow, snowploughs, improving services and why Practice Based Commissioning will never work.

One of our number spoke to a journalist friend who knows our frustration with some of the items in the title. They suggested that we look at a link on a local BBC News website. Unfortunately the link will have expired by the time this is published but some of the more technical of our crew may try and get the video up as a link a bit later but we make no promises.

It was the story of a farmer with a tractor. A tractor that can be fitted with a snowplough who offered to clear roads in a village called Kilburn in North Yorkshire for free, gratis, nothing (you will notice our use of literature from the Carry On films no less).

He approached the council who sent him a contract with 16 terms and conditions. It said he had to have £5 million of insurance, a particular type of fluorescent jacket, a certain type of flashing light and could only use agricultural diesel if the plough was fitted at the front of the tractor.

The more “enlightened” press so beloved of medical bloggers here in the UK have run a similar story here.

The story reminded us of why Practice Based Commissioning will never work. If a GP comes up with a good and simple idea like using a snowplough to clear roads of snow the local Poliburos (council) will swamp it with bureaucracy rather than have it succeed.

The news item ended with a picture of the tractor and snowplough going nowhere and being wrapped in computer generated red tape sitting idle in snow.

We think the news story is a modern parable about PBC. Here endeth the lesson.

Praise be to the Party for why, when you can make things better for people via something simple, do you make things more bureaucratic?

Saturday, 16 January 2010

The rain came and so did the flood . . .

Yesterday, about lunchtime, it started raining here in downtown Northernshire. Slowly, as the temperature rose, the snow and ice started to disappear.

Last Friday’s “something for the weekend” emergency surgery had 3 punters. This Friday’s “something for the weekend” emergency surgery was full to the gunnels. Not one of them was an acute, life threatening, medical emergency. The first 5 each spent 15 minutes talking about nothing medical. As a doctor we were wasted as there was no illness.

For days our surgeries have not been full but the supermarkets have. Emergency surgeries of 24 patients have had maximums of 7 punters. What does that say about real illness, the effect of weather has upon it and how the population view General Practice as visits have been minimal which they should be anyway in any first world country?

Accident and Emergency attendances have been almost 5 times higher but this might be due to genuine illness like broken bones that needs acute medical care.

The cold snap has posed many questions in our minds about the use of General Practice by the population and its provision by Government, and illness and how, and when, it presents. We do not have the answers but we will try to find them.

The drive home was a mix of low cloud and fog on roads awash with water and the Practice Ferrari was taken on the back roads for a change albeit it at no more than 40mph at best.

The weekend forecast is for more rain and above freezing temperatures. This morning most of the snow and ice had gone so hopefully come Monday things will be back to normal. Full surgeries, possibly fuller than normal surgeries, as people now feel the need to venture out for “necessities” and “emergencies” other than food and petrol namely healthcare.

All of our staff we have spoken to this week have said the same thing that they wish the snow will go. Many have struggled in, some literally on hands and knees, using buses and trains instead of cars to get into work and many have fallen or skidded their cars but still they have come. They have arrived late but have arrived and then worked as normal.

Thank you to all our staff and we suspect in many other Northernshire practices the same will apply.

We would also like to thank the local ambulance service who have done an incredible job given the circumstances and for the first time in ages cancelled the normal outpatient taxi service that is 90% of their workload. Before the NHS emergency work accounted for 90% of the workload but it only took 2 years for people to realize that taxis are provided for free by the State for healthcare.

General Practice is not liked by the Party but, bar one day only, we have provided a full service.

Praise be to the Party for all of their support during these difficult times. It has been much appreciated as always.

The Met Office have forecast a milder and wetter winter as well what joy . . .

Wednesday, 13 January 2010

The Yellow card scheme and the new “Yellow card” scheme.

In a recent surgery one of us here at ND Central saw a patient who had had a severe allergic reaction to the swine flu immunization.

For those who are not familiar with the Yellow Card scheme, this is a voluntary scheme whereby doctors, and now patients, can report suspected adverse reactions to drugs via a Yellow Card in order to identify any problems with drugs.

Most drugs, before they go into practice, undergo years of trials but it is only when drugs are released into the general population that the real “clinical” trial begins. The Yellow Card scheme allows information to be collected about drugs when real doctors start prescribing drugs outside of the relatively controlled drug trial environment.

Since medical school we have had the Yellow card scheme instilled into us as a good way of identifying problems with drugs once they hit the market. An example we recall is that one of us saw a few days after the release of the non steroidal anti inflammatory drug (NSAID) Meloxicam a patient who we admitted with a gastrointestinal bleed.

At the time Meloxicam was being marketed as safer from the gastrointestinal bleed point of view than older NSAIDs but after a year, and we suspect other such Yellow card reports, the prescribing advice changed.

The Yellow card scheme has been around for a while and we thought let us print off a form and send our suspected reaction to the swine flu immunization in. So we Googled Yellow card scheme and got the following site.

Note that the opening sentence: “This site can be used to report suspected side effects to medication.”

Then look at the box below. Are the drugs listed in fact not “medications” or is something else going on with the swine flu immunizations and anti swine flu drugs? Click the link.

This got us wondering as to why the distinction between anti swine flu medication and other drugs. Perhaps we should be sending in Yellow cards for those people who have had antivirals prescribed by the National Swine Flu Pandemic flu hot line who did not have swine flu as examples of erroneous prescribing?

Some how we doubt the Party will be engaging in any objective assessment of their policies particularly in the run up to an election but then could this distinction regarding Yellow Cards for these drugs be part of this run up?

As the Witch Doctor, a medical blogger with a distinctive slant on the human medical world, would say perhaps this is an intertwinglement?

Praise be to the Party for are all drugs’ side effects equal or, are some now more equal than others? Perhaps our Chief Medical Officer could explain the distinction to us simple grunts on the ground?

Friday, 8 January 2010

Snow in Northernshire some practice points.

Snow is white rain or frozen water that falls from the skies under certain atmospheric conditions. In terms of its impact on United Kingdom there seem, based on our cumulative experience here at ND Central, to be certain patterns that occur each time we get a bit of the white stuff.

The first is when more than a centimetre or in old money about half an inch falls in an hour or so all businesses shut up shop and decide they have to drive home. In doing so all roads become congested and traffic grinds to a halt.

Full surgeries result in no more than 3 patients turning up in 3 hours and local politburos whose function is vital to the smooth running of the NHS shut up shop too and vanish.

We here in GP land wait until the last patient is due to have left and then spend 4 hours in traffic doing the normal half hour commute.

The next 2 days virtually no-one ventures out, local PCTs declare public holidays for all their staff for increased efficiency while GPs open and most staff manage to get in after the first day of disruption. Initially few patients turn up and home visits decline to almost zero as people realize that they can’t get out so their GPs can’t in either as opposed to the normal GP visit request of we can get out but can’t be bothered.

Surgeries experience new hazards.

When one walks into reception it looks like it has been a convention for incontinent geriatrics as in front of each desk is a large, and increasingly larger each hour “wet patch”. The entrances to the building look like a rugby team after 8 pints of lager has decided to let rip in the same spot and there is an even bigger wet patch that squelches under foot and water is visible either side of your boot. And that is with the extra carpet on top of the wet patch to absorb the water deposited by all the patients’ footwear.

Footwear also changes with most now wearing Wellingtons. For those of us that have to do visits a good pair of Italian made mountaineering hiking boots capable of taking crampons combined with Yeti gaiters are essential for visits off the main roads where the hazards of compacted snow and ice and a foot of uncleared snow present the combined hazzards of slippage and very wet trouser legs (well you did ask!). One does not wish to land up in A&E as a GP wearing a pair of normal leathered soled shoes in these winter conditions as we can hear the laughter now.

The interior of the car after a few days develops a new damp odour due to the deposition of snow from boots and the daily commute starts with 10-15 minutes of clearing any new snow off the vehicle and de-icing the windows on the outside and increasing removal of water vapour from the inside before one can safely drive off.

Although the practice has grit bins these empty rapidly and soon grit becomes unobtainable.

As the roads become clearer surgeries start to become full again and visits increase although the hazards do not disappear once one leaves the safety of the main gritted routes. Taxi trips increase as people cannot get their own vehicles out and although a lot of people do walk some fear the risk of falling on iced pavements outweighs the cost of the taxi fare.

Examinations take longer as patients arrive looking like suburban Yetis in increasing numbers of layers and bizarre South American woollen headgear to protect them from the bitter cold of the walk from the house to the car and then the second exposure to the Arctic conditions from the car to the surgery.

In rooms with poor heating electric fires appear in order to prevent the occupants’ hands turning blue during the course of a surgery and the sight of patients in Yeti wear recoiling from the first touch of real cold from a doctor’s, or nurse’ hand which has been in the cold for more than a couple of minutes.

One of us went to a local hospital yesterday and made a very pointed observation that while the local supermarkets. which don’t charge for parking. had managed to grit and clear large areas of their car parking space the hospital had only cleared a small part at the front main entrance and, despite charging for parking, had done nothing to clear the roads or parking areas.

We did note that they were starting to put some grit down using a makeshift hopper on the back of a van but we suspect this will have little effect on the 2-3 inches of compacted snow and ice that had developed after several days of no treatment. The local shopping malls’ car parks were snow free oasis and well gritted by contrast and still they offered free parking and make a profit.

People have been so much nicer too. One of us was helped by a complete stranger to dig a car out after we had to abandon it on the first day of the snow. We were digging away merrily on our own when suddenly a second shovel starting working. Neighbours have been helping people with their cars too. A patient told us that most of the residents of their close on a housing estate, 9 in all, came out to help an ambulance that could not get up onto a main road for 20 minutes.

So here are a few thoughts and observations from the winter wonderland that is Northernshire at present. Hope our readers wherever they are in the world are enjoying their version of our winter wonderland. And some forecasters are predicting up to 2 weeks more of this.

We will cope we have done so before it just makes life a little harder that is all.

Praise be to the Party and all its wise managers who will be coordinating the war on winter with the same efforts used to fight the deadly swine that is the ‘flu. We are in all in such good hands.

Right checklist: boots, gaiters, crampons, ice axe, shovel, window scraper, rope rucksac with emergency kit, snow chains, lashing and lashings of Kendal’s mint cake, flask of warm cocoa and most importantly, for emergency use only, the hip flask and its off back to work we go . .

Something for the weekend sir or madam?

Tuesday, 5 January 2010

There is always a first time . . .

Following on from yesterday’s weather related post, one of the team, for the first time in their professional lifetime, failed to get their Ferrari out of their manor house’s drive and into work due to snow. There is a huge sense of failing in not being able to get in but the conditions were not the best for rear wheel drive vehicles and most people on the manorial estate that all GPs reside in were in the same boat. More people on foot than usual and all saying the same thing we set off for work and then stopped and hadn’t moved since.

At 06.00hrs was there only yesterday's thin covering of snow by 08.00hrs there was 4 inches. A snowplough got out at lunchtime but the track it cleared and the grit it spread is now covered over by fresh snow. We are stuck and it is still snowing.

The telephone lines have been most entertaining as they are several feet lower than normal and every now and again one of them will start bouncing up and down for no apparent reason before a white, snake like, curved line of snow plummets downwards. The line has broken one thinks as one watches the snow fall down creating a curved indentation in the untouched newly fallen snow?

It looks like it has as one looks at where the line was but then if one looks a foot or two higher one sees the telephone cable is still intact. The schools are closed, the buses cancelled, blood collections normally collected by taxi are being yomped to local hospitals. Those of the ND Central team who could get into work went in 4X4s, on foot or as best they could. Some of us, for the first time ever, could not.

Praise be to the Party for it is always prepared for everything. We are surprised that no-one senior has been wheeled out to tell us how we are the best prepared country in the world for flu, sorry we meant, snow.

Must have been the “wrong” kind of snow? And the ice man cometh tonight . . .

Monday, 4 January 2010

Winter in Northernshire and a new decade.

Today saw a change in the working practices of one of the team here at ND Central as for the first time in decades they did not do the “something for after the weekend” Monday morning surgery. This was due to changes in personnel circumstances and illness within the Practice that meant certain days in the week were less well covered. So like many GP Practices we had to think and adapt the way in which we operate to cover need.

This meant for one of us, instead of being stuck in traffic after more snow on the ground, competing for road space with mothers whose faces were intently shouting at the back seat: “Tarquin will you stop hitting Chantelle with tha Nintendo I am trying to concentrate” seconds before they plough into a line of stationary traffic which “stopped too quick and me eyes was on the road honest officer” we were stuck at home.

An unusual experience not going into work on a Monday (apart from Bank Holidays) for the first time in one’s long working life. Still we did not sit idle as we had plenty of paperwork to do.

At about 10.00hrs we took the dogs for their walk in daylight, not darkness, bright winter sunshine with a brilliant blue sky and no clouds to be seen. There was no traffic noise and the huge blue dome above the thin sprinkling of white newly fallen slow crunching under our boots made Monday feel so much better than normal even though it was minus 4.5 degrees C.

What struck us as we walked was the silence broken only by the noise of jets visible via their vapour trials above us and the crunching of the snow under our boots. At this time of year you realize how many aircraft are above us in the UK but most of the time, because of cloud and wind, you do not see and may only just hear them. Today we counted 8 aircraft in the sky at high altitude at once. Some were flying North to South (or vice versa) or West to East (or vice versa).

All incredibly ordered and the only thing disturbing the silence of a Christmas card perfect winter scene. We thought if there were say for the sake of argument 450 passengers on each plane then above us could be a total of 3600 people en route to various destinations. And this was being repeated every 10 minutes or so as the first planes left our view and were replaced by others following the same directions albeit on slightly different flight paths.

This meant in the course of our hour long walk and according to our mental mathematics that 21600 people had past over our heads in an hour. More than twice the size of our Practice and anyone of which could have been the victim of a terrorist attack.

Scary thinking on a free Monday morning but like all good grunts on the ground we just get on with life aware that life is not a risk free phenomena.

Tomorrow we will not be so lucky. We will be in the morning rush hour with the Shazas driving Tarquins to school. There will be ice on the road and idiots who know that the stopping distance at 80mph on a dry road is 8 feet on ice it is the same. (Stopping distances on snow and ice can be 10 time the normal “8 feet” dear reader).

So while we considered the empty and silent Northenshire winter countryside we felt small but at peace. Does anyone wonder why GPs increasingly opt for early retirement?

After this unique Monday, many more of which may/may not be coming our way, we can see why.

Praise be to the Party whose dedication to finally providing GPs with an occupational health “service” is matched only by its desire to make medicine more and more unsafe while making flying “safer”.

Body scanners at airports, but not for local hospitals (unless by charitable donation), restricting pilots’ hours while increasing GPs and junior doctors, will they be doing the same for the NHS as they do for aviation?

Sunday, 3 January 2010

Burke and Hare do Choose and Book 003.

Winter is getting worse here in Northernshire but the Party wants to warm up those on the frontline have published a little seasonal encouragement to all those using Choose and Book which we are considering here at ND Central. So join us by our warm hearth and partake of some Christmas spirit dear reader. Port or Madeira? Small glasses this time as there is a little less to consider.

We are onto to Chapter 5: “Technical Support”:

“IT problems are often cited as a reason for not using Choose and Book; problems such as speed of access, Smartcard activation or integration problems with existing clinical or patient administration systems cause great frustration amongst clinicians and their administrative staff. Many of these issues can be easily identified and resolved using existing IT guidance and resources.”

No argument with this. NHS IT is slower than dial up for clinical systems and when people try to use Choose and Book it gets crapper still. If anyone in the Government thinks that 3 minutes to down load 4 sheets of A4 is a fast system let them ring us on Whitehall 1212 and we will come and personally change the valves in their computer.

Most of the issues “can be easily identified and resolved”. However, this is dependant on people knowing what they are doing and in computing, if you are good, you earn big bucks in the private sector. The NHS gets the dross so no IT problems ever with C&B as only the users ever see the problems, never the technicians or the authors of this sterling work.

Onto Chapter 6: “Referrals to Named Clinicians”.

Charge your glass dear reader as this chapter opens with a red rag to a bull:

“If a provider organisation accepts paper referrals to named clinicians then they should do the same via Choose and Book.”

Many, many light years away in a Choose and Book free galaxy we used to send paper letters one sheet only to named consultant via post. This worked well but then the local Thickerazzi decreed that under “Choose (not) and Book (not)” the only choice a patient could have was that of hospital.

Attempts by our dedicated secretaries to allow patients to see able consultants chosen by our patients were repeatedly blocked by the local Thickerazzi as they were providing Party “Choice” via Choose and Book which was that of hospital only.

“The ability to support referrals to named clinicians has always been a part of Choose and Book functionality.”

Bullsh*t (sorry, the grunt word slipped out). Only hospitals are bookable according to the local IT commissars who have always denied this facility to our staff and rejected any paper referrals sent to bypass it.

We would suggest another charge to one’s glass as look what comes next:

“Named Clinician functionality must, however, be used responsibly and should not be invoked routinely by referrers. This is because it may make it harder for provider organisations to manage appointment capacity and can, therefore, potentially increase the number of appointment slot issues and ultimately inconvenience both referrers and their patients.”

Now everyone knows that good GPs will always refer people with bladder problems to a heart specialists so this advice for idle, overpaid GPs to use “named clinician functionality” “responsibly” must have been an eye opener to any real time GP in the UK.

Thank you Burke and Hare we shall reconsider our referral policies and stop sending patients to named clinicians who are the best doctor for that particular patient’s needs and more importantly “make it harder for provider organisations to manage appointment capacity”.

Will you be supporting us along with the Department of Health at any GMC hearings?

Read the rest of the paragraph “it may make it harder to manage appointment capacity blarred de blarred de blar”.

In other words popular and good consultants must not be used in order to meet waiting list targets so you must now refer patients to the crap consultants so local Politburos can massage their waiting list targets. Hence you can only have a “choice” dear reader of hospital under the local Party’s “Choice”.

Another port or madeira? Chapter 7 is next “Clinicians reviewing referrals Online”.


Provider organisations should ensure that all clinicians (e.g. consultants or Allied Health Professionals) providing services on Choose and Book are issued with Smart Cards and that they manage their referrals online within the Choose and Book application – rather than administrative staff doing so on their behalf.”

More words of wisdom from La La land? Consultants are busy and many we know often only see the referral letter when they see the patient.

As a consultant colleague said:

“We have 20 consultants in our speciality and when a letter was addressed to us on paper, we read it and if it was to the wrong consultant we sent it to the right one and they then sent an appointment out to a patient based on the letter.

Now GP receptionists make the appointments and see our specialty and book the first consultant they see or who has the shortest wait not the right one. This means when we see the patients they are usually in the wrong clinic and we have to arrange another appointment to see the right consultant after already having seen them. It is a pig’s ear and that is being polite”.

Another shot as these are short chapters? Chapter 8 “Training”.

“PCTs and provider organisations should ensure that all relevant staff (for whom they are responsible) receive regular and appropriate training on Choose and Book, especially when new functionality becomes available.”

Nice to know that since the inception of Choose and Book we have only ever had one one hour session (which was actually 2.5 hours with the trainer boasting that if they were in a purpose built C&B training centre that could make it last 4 hours as each person would have had their own computer not 10 huddled round each computer) and most people found watching the ceiling more exciting.

Training it would seem “makes for a much improved professional and patient experience.”

So does something that works.

Praise be to the Party and all its wise IT mandarins some of whom might be able to change a fuse on a plug once someone shows them what a plug is.

They will just fill in a form for consideration by the IT commissioning department, electronic sub commissariat, plug subdivision, fuse special team, 3 amp (replacement not procurement) department.

Simple like Choose and Book?

Saturday, 2 January 2010

Za Nu Labour’s NHS for the old this Xmas.

This week, having had to dig ourselves out of snow at ND Central to get into work while on call, an hour of hard graft with a shovel followed by another hour’s worth of driving on congested roads, we encountered one of the many benefits of NHS reforms for the worse.

We will call it the rotating door of being old.

During our professional lifetime the population has increased by 10 million from 50 to 60 million, got older and more debilitated. Despite this the Party has ensured a decrease in resources to cope by decreasing hospital beds by possibly a 100,000.

Hence, in a grid locked Northernshire town in winter, due to 2 inches of snow, the local hospital discharged a patient who could not walk, lived on their own and was incontinent all of a sudden. The patient was admitted to hospital by us the day before in the exact same state.

Today we had a call to visit the same patient who could not walk, was still incontinent and lived on their own and who had not moved since their early morning discharge from a local hospital funded by a “world-class” PCT.

Lots of lots of phone calls from local care agencies insisting on a home visit.

There was no need. Care in the community could not cope. This was a direct failing of centralized NHS control and pressure on less hospital beds with more elderly needing to use them.

The patient needed care. This was being compromised by prats.

Some were talking Mental Capacity issues who were afraid of doing anything quickly for fear of impinging their “client’s human rights” (like being able to go to the toilet or walk without a carer) versus a patient’s need for acute hospital care.

Other prats, called “modern” matrons, aka work avoiding administrators incapable of do any real nursing, were trying to clear (sorry “manage”) hospital beds and bouncing anything that flickered an eyelid back home as by doing so they had passed a mobility assessment.

More elderly = more illness = more dependency leads to less beds = more care in the community = less resources for an aging and more dependant population. A classic success story unless you work in the real world and see its inevitable failure.

Net result: an old, incontinent, immobile biddy sitting in chair and admitted to hospital, assessed and returned to the same chair as the same old incontinent biddy sitting in a chair came from. Clearly 12 years of bringing the UK health expenditure up to the rest of the European GDP expenditure has achieved what?

The same but worse. Care on the cheap and the crap.

This will get worse and winter has not yet officially begun according to the Met Office but the Thickerrazi are hard at work blaming everyone and ignoring the one person that should be sorted by all of their ever increasing numbers.

The patient.

We wish this were just an isolated incident but we will each here at ND Central see several this winter. All will request home visits for patients who need hospital care but have been denied it. We used to visit but this is increasingly a complete waste of time as all you do is see the patient in the same state you saw them in the day before, unable to cope and needing care in a hospital.

We just sent the patient straight back in via A&E and via 999 ambulance to avoid talking to the bed managers who had already refused social services request to readmit the patient. Not the best use of resources but at least 2 lots of doctors (A&E and medicine) will look at the patient and hopefully one of them will realise that the patient cannot manage at home. It is usually easier to get into hospital than to get out (unless there is pressure on beds when the reverse applies).

The managers will not see this pattern as they do not see patients. They will see increased turnaround of patients in terms of admissions = income but will chastise GPs for 1) increased use of ambulances and 2) increased use of A&E services.

Such is the “joined up thinking” of current NHS managers they fail to see that early inappropriate discharge of patients actually leads to more expenditure and harm to patients.

They, however, do not see real patients only spreadsheets. They have tunnel vision and see only that early discharge saves money via the NHS Tariff whereby if old bid is admitted with a condition with a “trim point” * of 10 days for say £ 3,000 then 24 hours in a hospital = 9 days profit and a double whammy as there is an A&E Brucie bonus and a new admission tariff as well.

*(Our understanding is that the trim point is management speak for number of days a patient can stay in hospital for a given condition).

They will be wetting themselves with excitement in the same way that our patient was wetting themselves in their chair. All that profit and all that patient experience of the new improved “world-class” NHS.

Praise be to the Party and welcome to the “world-class” Northernshire NHS. “World-class” it is not unless crap is now the “world-class” NHS.

Plus ca change plus c'est la meme chose? Plus ca NHS change plus c'est la meme malhereuse chose?

(With apologies for our poor use of French.)