Tuesday, 23 February 2010

More joined up thinking?

This morning we trawled the medical press and found this article in the UK GP magazine Pulse. Not been able to find anything definite to back it up on the DoH website unless it is hidden in Sir Liam's fortnightly bulletin for journalists. A real rivoting read fully of pretty graphs all in colour too.

Later in the day when we were working we found that the Jobbing Doctor (respect) posted this piece.

What are we simple GPs missing?

A National Health Service?

The message?

Which is . . .

Praise be to the Party for its consistency in a “crisis” of its own making which means we here in the UK in general practice are clearly like mushrooms kept in the dark.

And when the "big one" hits, what then? Doesn't bear thinking about but we will have to cope regardless of such co-ordinated central "planning".

Saturday, 20 February 2010

A new change in NHS Porcine strategy?

On our regular trawl of medical rags one of the team noticed a little piece entitled “GPs to check for swine flu”. It would appear that the National Swine Flu Pandemic line is being shut down and Sir Liam Donaldson will be writing to us.

Now most GPs in the UK will, we are sure, be up in arms knowing that this vital resource is to disappear as they will have seen loads of correctly diagnosed cases of swine flu appear in their surgeries saying they are no better after Tamiflu and are coughing up loads of green phlegm, finding it painful to pass urine and have sinus headaches.

They will, however, take great comfort in knowing that it could be reinstated in a week should the need for this vital service come again.

The setting up of a call centre is a great Za Nu Labour tradition and the success of NHS (re)Direct shows what a cost effective waste of trained nurses they can be. Those of us at ND Central who are of a slightly cynical disposition wonder how long it will be before a “Turn In a Taliban” hotline will be set up to help our boys and girls in Afghanistan? Surely it is better to use a mobile to turn in an insurgent rather than detonate an IED?

Call centres, so much better than real soldiers or nurses on the ground.

We digress slightly. It would appear that the director of porcine matters has sent a letter to practices saying that they should now deal with swine flu enquiries. When we left it had not arrived on our desks so what follows is based on the article alone. Could it be this one?

The article in the GP magazine, sorry we can’t link to it, says that GPs should use the algorithm used (so successfully?) by the Swine flu line to determine who gets Tamiflu.

Now we at ND Central thought, being professional and medically trained, how can we use a highly sophisticated tool without some form of training? Surely each doctor, nurse, receptionist and (window) cleaner who is there to diagnose swine flu, which the National Pandemic Flu Panic line has done so successfully and efficiently, will need at least the 3 hours training given to each call centre operative before we can even stand a chance of being able to play scrabble and diagnose swine flu.

It would be clearly irresponsible for any healthcare professional, even one who remembers algorithms from the 1970s for programming computers with Fortran and Cobol languages, to even dare to use an advanced algorithm to determine who should, or should not, be issued with a Tamiflu voucher (if we could find one) without the 3 hours training.

One of the team has managed to save their patients from the widespread slaughter by the evil swine flu but in doing so has only issued 2 prescriptions for Tamiflu. One we have blogged about before and the other was a case of identical twins one swine flu line positive and was to avoid a potential complaint for not issuing it and was totally unnecessary. Only one of these prescriptions was actually dispensed.

Still it is good to know that the director of all things porcine has deemed fit to write to his humble serfs called GPs and tell them that they are now the National Panic Flu line.

Of course we could always as doctors continue to do our jobs and try and avoid missing “swine flu line” appendicitis and “swine flu line” meningitis all diagnosed using an algorithm and scrabble and successfully dispatched with Tamiflu.

Praise be to the Party and its director of all matters porcine. We are sure many will pray to him when desperate and their faith and trust will be appropriately rewarded. We grunts on the ground will stick with our training and not bother with the algorithm or Tamiflu.

Interesting how many letters we have had from the local Darzi centres that contain the nurse generated diagnosis of “Influenza” and the patients are treated with Tamiflu and Erythromycin. Clearly our training is so out of date with “modern” medicine here up North.

Or is it?

Tuesday, 16 February 2010

Exclusive (not)! The Party is now giving the Comrade Patient extra Choice. Read all about!

Being up early to do an early Brown shift (remember the f ?) one of the team cast an early morning view over the UK medical blogs and found a couple of pieces that have appeared in the last few hours. They concern an article in the uk medical magazine called Pulse and the bloggers are the Jobbing Doctor and the Cockroach Catcher who put there own take on the original article which is here.

How busy the little comrade managers have been. We like their comments scattered around the original article like “maximise the capacity of our commissioning” = we have not cocked up guv and “robust conversations with GPs” = someone thick bullying GPs to get them out of something brown and sticky they got themselves into because they are thick and, finally the coup de grace, “It is incumbent on them as part of their registration with the GMC to use resources efficiently”.

Must have missed that bit we always thought it was to do the best for our patients which usually means ignoring managers as they only think how to do things cheaply for their patients (or do they have clients?). And guess who isn’t responsible “we have had very input in”. The only following orders clause. Read the paragraph yourself as it is fine Party speak.

It put in mind a plan that was proposed by a group of one the local Thickerrazis in our part of the world whereby GPs were going to get referral “targets” from the local idiot managers some of whom may just be able to give each of the fingers on their hands an individual number but they can’t do the same for their toes as they were always in the lowest of the sets for mathematics at school.

The plan went something along these lines. If you refer to target you get paid. If you go over the target you don’t get paid. If you do better than target you get paid more.

Now we know the Party are good at predicting illness and how it occurs in a population as the brightest idiots, those at the Department of Health, were spot on with their predictions for the Swine Flu Pandemic in the best prepared (laughed at?) country in the world for flu.

So the local idiots will be so much better at disease predictions as they are dealing with a smaller population whom they know so well from their daily dealings with their spreadsheets. Can you imagine this conversation as a result:

GP:Comrade Commissar Chief Executive I think you may have an ulcer due to the stress of you daily marshalling your troops in the Great Patriotic war against the imperialist GP scum and I would like to refer you for an endoscopy . . .”

Comrade Commissar:Make it so and fast as you would for any comrade patient, comrade doctor, as I am late for meeting on boosting hamster production to reduce health inequalites and improve equitable access!”

GP: “. . but Comrade Commissar if I refer you then I will not meet my target your under commissars have set me on your instruction and I would lose my 5 roubles a year bonus so I have to reject your illness request.”?

Neither can we but it seems that there are those who can and are actively trying to do so down in some of the southern shires of Northernshire.

Praise be to the Party for “socialized medicine” in the UK. Is “socialized” being corrupted now into “Soviet” style choice? Or are our early morning thought processes a little addled?

Things will only get better, won’t they?

Monday, 15 February 2010

Tales from the Out Patient Gulag: General Gordon versus Gordon Pasha.

We are sure many people in the UK will have seen Charlton Heston portray General Gordon as a heroic character in the 1966 film Khartoum.

In the same way that the once great British Empire has crumbled, as do all things great, including the NHS, we in the UK are seeing a once popular Government slowly sinking into the quagmire of oblivion. Any drowning soul clings desperately on to survival and grabbing at anything to try and maintain its expenses is vital to those in the political classes.

So as General Gordon walked down to face the enemy so the mighty Gordon Pasha might have to face the electorate in a similar “heroic” gesture in the fairly near future albeit after a Piers Morgan media special.

He, and his government, as have all governments before them, have decided that all of the evil scum on a benefit should have to go for an “interview” to weed out the greedy expense claiming MPs that are bankrupting the economy by getting paid large amounts of "benefit" to do nothing to see if any of them are capable of some form of real "work".

Nothing new there as history tends to repeat itself as the Conservatives in the 1990s decided that all people on the “sick” or unemployed should go for a “medical” to see if there were ill or otherwise fit for work when there were no real jobs available.

And guess what? Most of them were actually sick and millions was spent to confirm the fact that the vast majority of UK doctors know who is, or is not, fit for work. More spent to save money than money actually saved.

If you think you will never ever claim Incapacity Benefit think again, and think hard. If you are off sick with anything for more than 26 weeks and employed you too could become a member of the evil scrounging benefit scum that Gordon Pasha so despises and is after.

So our relative, who has a recurrence of a cancer, and who cannot work due to paralysis of a limb vital to their work is summoned to a Job Centre just 2 days before they are due to start chemotherapy.

Doctors and nurses will know that you do not do chemotherapy for a laugh or it would be a controlled drug and dealers would be selling it on the streets. For some reason they are not but the Benefit’s Agency, under Gordon Pasha, knows best and they are there to stop the scrounging scum.

An interesting experience for someone who has worked non stop (cancer treatment aside) since they were 18. Did we mention they have also paid, and are still paying, taxes?

So as a dutiful relative we took our relation to the Job Centre for a “Return to Work” interview 2 days before starting chemotherapy. This cost us, and relative, money and time and inconvenienced our relative who knew what was coming. They had had chemotherapy before and were dreading it - but still they went.

Job Centres have changed a little since some of us were medical students and used to be able to sign on as scrounging benefit scum and we got grants as well.

Now under Za Nu Labour, the Party of the people and working class, where students are encouraged to have loans and acquire debts before being allowed to pay taxes and so contribute to the stable economy and pay for it ad nauseum – we think we may be off on one so back to the plot.

We reported at the desk and noted a “customer care officer” dressed in a uniform like a policeman with an ear piece in their ear standing by an Ann Robinson like lectern and were guided to the part of the Job Centre where we were to meet an operative called “Diane” who had spoken to our relative half an hour earlier to confirm that they would be attending.

“Diane” had heard (a week earlier after a whole load of forms had been filled in) that they were due to start chemotherapy. Indeed our relative was on the way out of the house and said the same to “Diane” when she phoned to check that our relative was well enough to attend. Nice caring people those who work in jobcentreplus as they are now called. We are still trying to work out what the plus is over the old jobcentres.

We were ushered to the opposite end of a room and told that “Diane” would be informed we were there as “Diane” was busy.

After watching 3 loads of Waynes, Darrens and Shazas come and go for their “hour” long “interviews” (it said so in the letter), the Job Centre floor walker who every 5 minutes had walked by from one end of the room to the other said:

You are wearing a shirt and tie and a suit and have been waiting a long time who were you due to see?”

Bright boys and girls those fraud busting benefit workers they even have a memory and can observe things in half an hour so none of the 3 lots of Waynes, Darrens and Shazas we had seen come and go while we were waiting were going to leave this morning without a job after their “hour” long interviews.

This “operative” went to see what had happened and we were rapidly shunted to see “Diane” faster than you could get Gordon Pasha to be run over by a cortège in Wooton Bassett (if he survived the crowd standing along the road).

Now one of our observations compared, with the 1970s and 1980s, was how well presented the Job Centre staff were. None that we had seen thus far were over weight they were smartly dressed and generally respectful until we met “Diane”.

“Diane” had been busy at her desk, no doubt eating the cream cakes that contributed to her 30 stone 5 foot nothing physique. We had seen no-one walk to or from her desk in the half hour we had been waiting and sitting looking directly at her location although we did not know this.

Despite having been allegedly told that we were at the opposite end of the open plan office Diane had made no effort to move from her desk. She had not even picked up the phone although she had an hour earlier (by this time) to confirm that our relative was coming.

Lots and lots of empty apologies for eating another half hour’s worth of cream cakes and happily doing nothing. (No doubt someone realized a target was being missed as well?).

Then the “interview” begun in an open plan office (no confidentiality here comrade your bail conditions and our medical problems are all in the public domain).

We had up to now spent half an hour listen to Wayne explain about how his bail conditions meant he could never work (Wayne was a drug addict and a patient) while at the same time Tony was asking how long he had to wait for his interview for benefit that was delaying him from going for a real chance of a job by going to a real job interview.

“Diane”, whom we sure was highly qualified in something useful other than lard, had great trouble understanding medicine and how chemotherapy kicked the sh*te (sorry for the grunt speak) out of you but she did try. She thought she had seen one other “client” who had had this treatment but couldn't remember much it was so many cream cakes ago.

She did, after a bit of prompting agree to suspend the monthly interviews for Incapacity Benefit for 6 months (lots and lots of subtle hints re compromised immune system, being knackered etc slowly penetrated the lard) and told us if someone summoned us to a medical that we should “tell them” (like we had told “Diane” before this one?) and “something” should be done.

She gave us some leaflets which had the infamous “Choice” logo word on it combined with the NHS logo and these explained something to us that as GPs no-one has told us about.

It is called the “Condition Management Programme”. For a while now we all have received letters saying that patient X had completed theirs and with no medical information on them they were sent to as GPs. Until now we just ignored them.

Now we know what these we will continue to ignore them as they are medically irrelevant and no help to our patients. So our time spent was not completely wasted?

Praise be to the Party and Gordon Pasha for halting the evil Incapacity Benefit scrounging scum.

He like General Gordon will see the net result of their endeavours hopefully on the steps of some once proud building. While history may suggest that one Gordon may be seen as a hero the other will be seen as someone who did not save a soul by all his endeavours but has placed a burden on all of us for decades to come.

But at least he allows “Diane” to get paid to eat her cream cakes and save us from the evil scrounging benefit scum that are cancer patients undergoing chemotherapy with loss of limb function due to the diagnostic delays endemic in "world class" NHS care as well.

Well done to all the Gordons and “Diane”s you are doing a fine job.

More cream cakes anyone?

Thursday, 11 February 2010

A couple of old chestnuts 002 - out of hours care.

We wonder here at ND Central where we have all been since the introduction of the new General Medical Services (nGMS) contract in 2004 as the well known intellectual news channel here in the UK, GMTV (known affectionately here as Gormless Morons’ TV), last week was trying to bluntly dissect why the out of hours service for General Practice is so bad.

It would appear that the reason that the out of hours’ service is so bad is “because of the doctors”.

A health minister who was wheeled in said more or less the same claiming that before the nGMS contract things were so much worse. In those bad old days you got to see a GP and it cost so much less. No-one stated the barn door obvious, least of all the little housewife friendly pixie of a Gormless Moron TV presenter, who did not know how to get out of hours care for his family. Instead he blamed the doctors.

Given that as a minimum he will be earning at least twice, possibly three times as much, as most average GPs earn for a fraction of the work and bugger all responsibility just for smiling sweetly it just shows how well “ability” is currently well rewarded by the Party.

Perhaps, as concerned General Practitioners, we should refer him to social services as a case of potential neglect of his children as he clearly, and publicly, does not know how to get medical help for his children out of hours? What would he do ring NHS (re)Direct to be told to see a GP or go to A&E?

Well Mr GMTV presenter why don’t you try to present the truth? Here are a few facts about out of hours care. We have written it very simply so that you, if you can read, or one of your researchers, can hopefully understand it as you struggled to hear what the doctor you interviewed was saying:

1) GPs are no longer responsible for out of hours care unless they decided to continue to do so after the introduction of the nGMS contract in 2004. Most did not.

2) The people who are responsible are the local Primary Care Trusts (PCTs) that used to be called Health Authorities.

3) If there is a problem with the out of hours services then GMTV should speak to someone from the PCTs. However, these are NHS managers and are in the same bottom third of Northernshire comprehensive schools that went and did media studies when we were younger. They will not be up before 09.00hrs unless, like you, they earn a huge wad for doing so.

4) The cost of providing out of hours care for your children was valued as £ 6,000 per GP per year to provide roughly the same number of hours cover per year. We doubt that would cover your cleaner’s, or even your childrens’ nursery bills per year let alone provide a qualified doctor for them, if you were bright enough to know how to ring your surgery in the early hours of the morning.

5) In order to opt out GPs took a pay cut of £6,000 a year for the privilege of letting PCTs provide the out of hours service on YOUR behalf as public servants.

So Mr GMTV presenter, or rather your researchers, get your facts correct. It is the likes of you and your fellow presenters that have contributed to the up surge in measles in this country for you can do so much more damage in 2 minutes of ill informed ignorant “journalism” that will damage patients’ health and takes years for us to repair.

Praise be to the Party for pointing out how bad out of hours care is and blaming it on the doctors. Remind us who devised, and agreed the system with the doctors as part of a “contract” that was voted for in a democratic election and accepted by the Party.

The Doctors have done their bit. Why oh why, has the Party and its organs failed so miserably with out of hours cover? Did they underestimate how much it cost to run and found the private sector to be so much cheaper and more efficient?

We suspect there may be an undercurrent here possibly giving out of hours back to GPs? It would only take a Party “consultation” and then they could alter the contract . . .

We might even be £6,000 richer with even more hours added to the working day for us and our staff.

Wednesday, 10 February 2010

A missive from a professorial colleague re junior doctors’ training and conditions.

The Good Old Days?

Every now and again we get correspondence from our betters here at ND Central and one of us received this link from a certain Professor whom we have featured before.

We thank our academically more qualified colleague for this link as they too are trying to maintain medical standards against the onslaught of dumbing down of education, in particular medical, here in the UK. The link is here.

Please be aware that there are at least 4 grunt words in this animated video and a few stereotypes that we would question but overall the points are well made. It runs for about 6 minutes.

We think it must represent a lot of junior doctors’ concerns and experiences.

Praise be to the Party and all its organs for the "success" of MMC and MTAs. Why make something better when you can make it so much worse?

And get paid and knighted in the process . . .

Sunday, 7 February 2010

A couple of old chestnuts 001 - trauma survival in the UK.

The BBC and ITV news networks here in the UK have very little real news to report and so have raked over a few old medical coals in the hope of shedding some light in the otherwise foggy and cloudy UK at present where large numbers of drivers seem to think that headlights are passé in such conditions.

We here at ND Central think that there is nothing new in this story as a few decades ago those of us that were junior surgeons, both general and orthopaedics, and those of us who were anaesthetists all encountered the same problems. When there was major trauma there was no-one senior around.

The more educated of us knew of things that improved survival after trauma for example skilled paramedic care, rapid transportation from trauma scene to a site where specialised care was available and the so called golden hour. Such things we learned from our seniors especially those who had worked in the military and in the States. We learned too from watching American TV programs as M*A*S*H and Quincy M.D. and comparing them with our NHS and American textbooks found in better University libraries.

Today senior medical staff watch ER to keep up to date with the first world and weep.

We remember going to meetings with the consultants from A&E, anaesthetics, orthopaedic and general surgery to discuss how bad trauma care was and asking to be sent on ATLS (Advanced Trauma Life Support) courses.

The consultants, who were never there in the middle of the night, listened to our arguments and concluded that rather than allow the frontline staff study leave to do these courses, they would themselves go on these courses and relay down their knowledge while still sleeping in their beds when something serious happened and delaying authorization for urgent CT scans for head injuries.

Now there are big differences between the USA and the UK which were not pointed out in the BBC News item. We recall going to a lecture on gunshot injuries by an American surgeon from Texas who started by asking how many gunshot injuries did we get a year at our hospital?

The A&E consultants said one, maybe two in a busy year, and these were usually accidental discharges of shotguns by farmers going over styles with unbroken shotguns and one too many stirrup cups on board.

The surgeon from Texas could not believe what he was hearing for he said they had at least 2-3 stabbings a night usually early in the evening and later there were 2-3 shootings a night.

So perhaps one reason we are not good at treating trauma is that we live in a relatively “safe” country? An argument perhaps, but medical training should encompass the “what if?” element, and allow a degree of preparation for it even if it happens rarely.

Compare the standards of training for trauma. A good friend who currently works in the USA met one of us after a year into an orthopaedic training program. At that time one of us had done a year of orthopaedic surgery in the UK a good few decades ago now and, as doctors do we compared notes.

The amount of serious injuries they had seen made us look like rank amateurs. This was mainly due to the effects of crack cocaine and alcohol combined with the ready availability of firearms and motor vehicles rather than the huge availability of demented old ladies breaking hips and wrists.

It is said that if you wish to learn surgery go to war and certainly some of the injuries they had seen in crack houses where the inhabitants let rip with pump action shotguns causing multiple compound femur fractures at a time compared with the odd 3 or 4 closed femoral fractures (in ones) we had seen in the UK usually from road traffic accidents.

We compared our training. Before our friend could start their first medical job in the States they had had to do both the ATLS course and an advanced resuscitation program as well. We had a resuscitation officer teach us ours a nurse and maybe after 2-3 years into our post graduate medical training we might be honoured with study leave to go on one of these courses.

So perhaps the Americans are better at trauma than us for several reasons like being at least 20 years ahead, having better “basic” training and, last but not least, having more guns and smack heads with ready access to cheaper alcohol and petrol.

Now we do not advocate the introduction of the last few items but better training and trying to keep up with “modern” medicine are not huge items of expenditure but they could reap rewards. Unfortunately, this specialist training is time consuming and so it means taking junior doctors away from their “service” role which might mean missing waiting time targets while a few more trauma deaths is not a target yet.

As a result the NHS is still stuck in the meeting we had with the consultants a few decades ago. If it does not impact on anyone senior in NHS consultant or manager land it is not there.

Patients will continue to die from minor stab injuries because poorly trained surgeons cannot resect a liver lobe that is bleeding. Patients will continue to take five hours with multiple limb fractures and internal organ damage to travel 400 yards to an operating theatre to stabilise their injuries because of hospital bureaucracy and then develop life threatening complications as a result of unfixed fractures.

Lots and lots of NHS targets but nothing much has changed.

In GP land we have to do a mandatory resuscitation course once a year. It is a joke.

One of or staff showed us the latest “new” weapon in resuscitation. It looked suspiciously like a laryngeal mask that one of our number had used regularly as an anaesthetist 20 years ago. The trainer showing off this “new” equipment was a paramedic whom we had been involved in training when we were anaesthetists several years after other parts of the UK had introduced paramedics but remember this is the North.

This is not progress or proper training it is box ticking to show that we are being “trained” (badly).

We are still waiting for the same basic training that American junior doctors get before they can even start working. And this is several decades later.

Praise be to the Party for ensuring that all of us doctors are up to date. Trauma care has not changed much from what it was 20 years ago. We were behind then and things have not changed much since. The knowledge is there the implementation and application of it is not.