The manager will see you now?

Here in the UK you can tell we are in the run up to a general election as all three parties have suddenly become interested in the National Health Service. This is not because they want to improve patient care, for this they endlessly hamper by reforms. It is because they want to score points off each other in order to either, preserve their current position of power and privilege or, because they wish to acquire power and privilege.

Those of us grunts on the front line know whoever wins will not help us but will either, continue with their mismanagement of the health service or, will seek to change course and introduce more mismanagement via new “reforms” for the “better” using similar ideas to their predecessors but with different names and emphasis.

Medicine has changed by the introduction of new drugs and treatments but as GPs our job as doctors is still the same. We talk to patients, examine them, try to come up with an idea of want is wrong with them and either, treat them ourselves or, send them on to an appropriate service or consultant for their condition.

This process is largely unchanged and most patients will recognize this process. What has changed is the bureaucracy of NHS data collection and box ticking that doctors, nurses and any other health care professionals involved in treating patients have to record and submit from their consultations.

The data a healthcare professional needs to do their job is normally in the patient’s medical notes. However, managers are not bright enough to read or write and understand medicine so they employ healthcare professionals to extract the data and submit it to them in simple forms they can just about understand.

As the information these managers needs changes with each new "reform" for the "better", each healthcare professional is obliged to frequently learn new "skills", not to treat patients, but to submit information to managers so they can justify their largely futile existence in terms of healthcare to patients delivery.

We here at ND Central know that our patients want to see doctors and nurses, by enlarge, when they are ill and usually that is NOW, this minute. We suspect that if you surveyed people this is what they would want, and expect, the NHS to provide.

We were listening to a 12 o’clock news bulletin as we set off to do home visits one day this week having been in surgery working since 07.30hours and heard the following statistics on it which we repeat from memory.

Increase in NHS managers last year 12%.

Increase in NHS managers in last decade 80%.

Increase in consultants in last year 7%.

Increase in GPs in last year 5%.

Increase in nurses in last year 2%.

Compare that with our practice in the last 10 years:

Increase in managers = 0%.
Increase in nurses = 0%
Increase in GP = 1 GP but due to increasing list size we are still under doctored despite living in the hugely affluent parts of Northenshire.

We are still delivering healthcare with almost the same resources as 10 years ago. Despite huge sums of money having been chucked at the health service in the last 12 years by the Party we ask, where has it all gone and what has it actually delivered to the customers of the NHS, our patients?

Praise be to the Party who as ever are all wise. We are sure there is a survey saying that of a 1000 patients who were asked, “if ill would you rather see a doctor or a manager?”, 80% said they would rather see a manager.

How else can one justify these figures?

(Could not find link to news bulletin but a couple of links re similar figures are here and here).

Ooops? Has he done it again?

We are not that bright here up North especially as we are sitting drinking on a park bench in the sunshine but we read a little piece in this weeks BMJ 20/03/10 pg 616 entitled “European court rules minimum cigarette prices illegal.” (Sorry link only provides 150 words of full article).

It starts with the sentence:

“It is illegal for European governments to impose minimum retail prices on cigarettes as a deterrent against smoking.”

Another sentence then says:

“However, the Luxembourg based judges confirmed it is quite legitimate to impose heavy taxes on tobacco products to discourage consumption.”

We are sure that both Sir Liam, the out going now time expired Chief Medical Officer, and the Scottish legislature are thinking of a minimum price per unit of alcohol?

Does this mean they cannot as this is "uncompetitive"?

Of course the summary of the ruling means that increased taxation is still an option but then that might increase inflation and inflame the already miserable people. It is, however, still a legal option.

Praise be to the Party the creators of the free market especially in healthcare and to Sir Liam for his Party approved protectionism.

Confused anyone? Must have another bottle of cider while it is still cheap . . .

In loco parentis?

While cruising in our NHS provided Ferrari along Northernshire’s leafy lanes and high moorland along twisting roads we were flipping the channels between the happening yoof boogie box beat channels as we hit the heady speeds of 60 mpg in second and the more serious dolcet tones of the UK Radio 4 six o’clock news.

An item caught out attention late into this news program regarding an inquest verdict were a boy who died from an asthma attack might have survived if teachers had acted earlier.

The relationship between teachers, doctors and illness has changed a lot in our professional life times in the UK. We will not comment regarding the progressive dumbing down of education whereby only 5% of people were once thought to be “intelligent” enough to go the university whereas now 50% are able to achieve this educational opportunity in the same way that in the last 12 years average height for males in the UK has gone from 5’10 to 7 foot. The same we are sure has happened for IQ in that now 50% of the population now has an IQ of 130+ by Party diktat.

Clearly the Party has redefined the normal distribution or engaged in some serious massage of educational standards to achieve this “rise”.

One of the team had a child who developed diabetes and required insulin while at junior school. As parents we were educated regarding this and told what to tell the school. We went and told the school and said there was a chance that the child might develop a low blood sugar and may require sugar if this happened. In those days this was in the form of glucose powder or tablets or if you were really posh Lucazade and a bottle was left with the school.

On occasions this was needed and the teachers duly gave glucose when required.

Fast forwards a few decades to the “far more educated” population because 50% of them now go to a University and look at the child with asthma where no-one called an ambulance.

UK GPs will often get appointments for “emergency” prescriptions for asthma inhalers for children who take the same inhaler to school that they use at home. A parent is allowed to kill maim and abuse their child (until caught) but a teacher in loco parentis cannot administer a drug to a child unless the drug is prescribed by a doctor, is in a box labeled by a pharmacist which can only be used for that child in these educated shires up North.

Where will this madness end? Imagine our child having a hypoglycaemic attack today, with the treatment being available to save its life being denied by a “professional” because they do not know the policies or procedures and the bottle with the life saving glucose was not labeled by a pharmacist “Give 100mls if required”. Should we abandon the teaching of first aid to the general public for fear of everyone being sued for intervening to try to save lives?

Praise be to the Party for all of its wise legislature and protection of the public by its proscription of everything that every professional can and can’t do. Prevent the use of common sense and you may cost lives but all boxes are ticked, and all policies and procedures will be followed so no problems.

The only thing preventing life saving in the community is the fear of fear itself not the ability to do something as this sad case illustrates. More proscription anybody? Coming to your profession sometime soon so watch out.

QOFing and tiffin.

Anyone fancy a spot of QOFing?

For those of us here at ND Central who have an artistic streak the great British institution of high culture known as the “Carry On” films are a must. They are on a par with Shakespeare and Wordsworth for their literary content and messages they convey about British society from the 1960s to date. Well one of the two last statements might be true?

One of the better of these intellectual treats, which vies with the film Carry on Screaming, as the best Carry on is the film “Carry on up the Khyber”.

This is a parody at various levels of the British involvement in India as well as the British class system and a complete pee take of Empire reflecting Britain’s decline as a world power and more recently as a “world-class” player in healthcare.

One of many scenes from the film that sticks in our younger then, and culturally uneducated minds, is the one when the incumbent governor, Sir Sidney Ruff Diamond, played by Sidney James, stops work for “tiffin”.

This is a clearly metaphor for the great British tea break. In order to “right a wrong” caused by his own wife’s infidelity Sir Sidney indulges in multiple liaisons with the wives of his adversary the Khasi which are euphemistically called tiffin.

Nothing hardcore, or even softcore, this was British 1960s innuendo at its peak.

In our younger years tiffin was a great source of hilarity as it meant doing nothing useful which we suspect many of those from the Indian subcontinent who will recall the largesse of Empire will no doubt relate to.

In the UK most GMS practices are engaging in a newer version of tiffin called “QOFing”.

QOF stands for the “Quality and Outcomes Framework” and at this time of year a lot of QOFing is going on to make up the maximum number of QOF points. This is the system of ticking government boxes whereby GPs can try to increase their income by ticking a series of boxes using the saying “points mean prizes”. The more points you have the more money your Practice gets. This is income that potentially GPs have some control over in contrast to the Global sum element of GP pay which is calculated using the transparently opaque formula known as the Carr-Hill formula.

Try Googling this one and see how easy it is for GPs to check how much they should be paid. Can you find the formula? We’ve been looking for years.

If something new is wanted by Gordon Pasha and his mandarins at the Department of Health that they do not want to pay for it is always “in the global sum”. Can you find it?

Government however can also change the rules and so each year there are less points with which to win prizes (= pay) and these points become harder to earn as the government can changes the rules merely “by consulting”.

British doctors are an intelligent group of fools led by idiots.

By this we mean that doctors are usually intelligent individuals who are trained to work individually, but not as team players, and so collectively are fools, as they cannot agree on whom to vote for, and so they appoint idiots as leaders of their profession.

So we return to QOFing and tiffin. Both are totally unproductive activities as per the Carry On films. The tiffin there achieved nothing useful but may have been fun for those involved and so does QOFing.

QOF is neither Quality, all the targets are dumbed down, or Outcomes, in terms of healthcare delivered to patients, as these are minimal but are all about box ticking for managers to justify their existence.

It means patients are “invited” to surgery for their healthcare for a whole series of mostly unnecessary things being done which clearly improves “Quality” and “Outcomes” for their GPs and their incomes and ticks managers’ boxes.

Take the simple example of angina.

This is cardiac chest pain which usually comes when exercising and used to be a clinical diagnosis. Clinical diagnosis means based on a doctor taking a history from a patient and examining them. In the vast majority of cases a simple trial of anti angina medication will establish the diagnosis at minimal cost.

The Party, however, knows better than the doctors so all “suspected” cases of angina must now have an exercise ECG. These used to be reserved for the cases where you weren’t sure but now all UK patients with angina should have one.

Result the cardiologists see no end of crap which a half brain dead decerebrate monkey of a medical student could work out was angina based purely on clinical grounds but no, as part of “Quality” and “Outcomes” tick box medicine, you cannot have angina, comrade patient, until you have had an exercise ECG.

So an expensive and unnecessary test done for most people but a Party box ticked showing “Quality” medical care and an “Outcome”.

Once you have had your exercise ECG you will probably get treated in the same way as before but it will just take longer.

Of course if your angina is serious and you need an “urgent” angiogram to tell the doctor whether you need a heart bypass operation this is not a QOF scoring item and you will probably wait a year or so to get one or die waiting. Still exercise ECGs are cheaper than angiograms so they are a “Quality” and “Outcome” issue.

First world medical care, for example a real “urgent” angiogram, if you need it, is not a “Quality” issue, nor is your death if you fail to get one an “Outcome” issue as long as you have angina and an exercise ECG that is all that is needed under QOF.

If your child has hayfever, and you get a repeat prescription for antihistamines for a 2 week period each year in June you will be invited for “a medication review” which achieves what? Nothing other than an inconvenience and a tick in a manager’s box to ensure your GP gets paid.

QOFing has generated a new form of “quality control” via the QOF visit each year for UK General Practices. Great you might think all those evil, overpaid, idle, golf playing GP scum banged to rights but just wait a moment.

One of the few of the team who actually read the nGMS contract and a few of the two thirds of GPs voted for it realized two fundamental flaws.

The less simple one was that this was a computer code generated contract. In other words if the code was on your hard disk when the Government software checked it at the end of the year you met the QOF and got paid.

Given a fairly logical, albeit impaired medically speaking structure, it would be relatively easy to write a program to create fictional consultations, recorded on a hard disk, plundered by Government software that would generate an income. If the codes are there the work is “done”.

QOF visits are done, each year usually by failing GPs who have no real work to do but like the money, and managers who have no ability or medical knowledge and they ask questions usually with the purpose of trying to intimidate practice staff and appear important. They have no ability and serve no useful function and certainly are incapable of detecting fraud as no-one asks the patients a fundamental question.

Have you actually had this treatment?

They prepare reports which say you have or haven’t ticked all the boxes. Lots of boxes ticked as a result of QOFing and tiffin.

Medical care is complex. Take a simple example you need you appendix removed because you have appendicitis. If it is not you die a very horrible and painful death.

Now under QOF appendicitis is not included but it might kill you. Appendicitis is therefore neither a “Quality” or “Outcome” issue for the Party but for the individual patient it could be a matter of life or death.

The second flaw is as follows: compare two different “Quality and Outcome” scenarios. One the high QOF scoring practice that uses administrative staff to read letters, extract data and code it. The doctors are absent or incompetent and they use the PCT funded out of hour’s service for any home visits which they do not do or they suggest that patients go to A&E.

You ring at 10.00hrs and are told the doctors are not available and to ring back after 18.30hrs the so called “core hours” which the practice does not provide.

The other scenario is the low scoring QOF Practice that actually see patients before they code data which is included in their QOF score and which NHS managers feel is failing. Here the GPs are available and on call and visit patients. They see their patients admit them and their appendix is removed with no complications due to early diagnosis.

A life saved but no “quality” points for doing so. You could apply this to a whole range of medical conditions not included in the QOF framework but attention is paid to only the highest QOF scoring practices or the lowest ones by those that supervise or “manage” quality in the NHS.

Which is the “better” practice?

These scenarios are not made up they are real. And managed by managers who ticked the boxes but missed the barn door obvious and got paid for doing so.

Good QOF point free medicine might save your life and is cost neutral to the Party. Good OOF scoring practice = good practice? Think about it. This scenario has happened more than once and no amount of QOFing or tiffin will stop it.

Patients only find out when they change practice or if they come to harm.
This is neither “Quality” healthcare or a successful “Outcome” but it is QOF.

Praise be to the Party for QOF which has improved “Quality” and “Outcomes” beyond any country in the world that purports to practise first world medicine.

Mobile phones and General Practice.

We think here at ND Central that most doctors are, by and large, good communicators - not all - but most are as they have to be and more importantly should be. Most of our day is spent talking to people in order to get the information we need to diagnose and manage (look after) our patients.

Some say that 85% diagnoses in General Practice can be made on the history alone. For example the diagnosis of sinusitis is nearly always based on the history (unless you have access to x-ray or a CT/MRI scanner or are prepared to drain them in surgery under cocaine anesthesia).

At UK medical schools the belief that “communication skills” can be taught now leads to large parts of the course concentrating on teaching “communication skills”.

When we were young grunts, we were given a thin A5 leaflet on communication skills about 3mm thick which we still have. The last time we went to a tutors’ meeting we came away with 4 hard back books we were expected to read about communication skills 100mm thick. How things have changed but talking to patients is still the same.

Our medical students regularly complain about having to do communication skills teaching with actors and role play and they all say the same thing:

“It is alright but it isn’t the same as talking to real patients who we would rather see and talk to.”

There is a lot of sense in what these doctors to be are saying to us. For starters patients do not follow a set script in order to illustrate a set point.

Anyone who has been a GP for a few years will realize that the way in which they consult changes as they become better able to filter out information. What may have taken you as a medical student 20 minutes to complete, may take you as a newly qualified GP, some 5-7 years later, 10 minutes to work out but after a couple of decades you can do the same thing in a couple of minutes.

You learn to work out from the history what the patient is actually saying and filter out the superfluous information that may be wrapping up the key information you need. Combined with more experience of disease and how it presents your pattern recognition processes improve.

Now communication takes many forms for example verbal and non-verbal. The best doctor patient communication most would say is a face-to-face consultation.

The world, however, moves on and increasingly the telephone is a used as a communication tool. It can sometimes save time.

For example screening requests for home visits when a GP’s physical presence is not required. This is the norm in the first world but not in the NHS which is at least 60 years behind the times and cheap in doing so.

It used to be said that the average GP consultation was 7.5 minutes but a telephone consultation took longer at 10 minutes but this saves minutes compared with the average 30 minutes for a home visit most of which is spent traveling not consulting.

Patients like telephones for it means they can talk to their GP without having to miss their day time television fix of Phil and Holly and cuddly Dr Chris who is after all a real GP as he is on the telly and each GP will get several messages a day asking them to phone someone about X or Y.

Technology has moved on and we now have the mobile phone for better or worse. One of ND’s laws is that the mobile phone usually goes off just after the patient has just sat down and usually when they are onto their third sentence.

There is usually an apology, followed by a fumbling in a bag or a pocket and the phone is often not answered, in which case 2 minutes later it rings again.

Alternatively the following conversation takes place:

Patient: Hello?

Patient: I am in the doctors right now. I will ring you back and tell you what they said when I have finished.

Bye.

Sorry doctor.

Any GPs out there not experienced this one?

Changes in our society also means the use of mobile phones has changed. The influx of economic immigrants (from Eastern Europe mostly), and the dispersal of asylum seekers from the ports, meant that at one point we used to have a regular stream of interpreters attending surgery with patients whose mother tongue was not English.

The Party does not like this. Skilled interpreters are expensive and the Party expected all such immigrants to learn English.

Not an unreasonable expectation you might say but just think how many years it took you to learn English yourself to the point where you could have an adult conversation?

Compare talking with a native English speaker at age 2, 5, 11 and 18.

Same language but used differently as one develops. So a couple of Linguaphone CDs is all a GP needs to master the complexity of all the languages of all the patients they will see and that includes Braille and sign language. Learning a language is that simple, if you are simple enough to believe the Party.

Immigrant patients now will attend and in broken English say they will ring a friend or family member to act as interpreter. This has its advantages not least that the Party is not paying for a skilled interpreter but the big disadvantage as a doctor is that you cannot guess if what you have said is being relayed to the patient.

If you have a physical interpreter and spend sometime explaining something and then 3 words only are spoken you suspect that something is not being passed on.

Worse still is the situation where if the same amount of time is spent explaining to an interpreter a complex problem and the answer is no without the patient being spoken to, you really do start to worry.

Well imagine combining ND’s mobile phone law with an Eastern European patient’s consultation. For 10 minutes we tried to communicate in broken English going nowhere fast until the mobile phone rang. A conversation in an Eastern European language ensued and then the phone was past to one of us.

“Hello doctor I am a friend of the patient who will interpret for them. Please tell me what you have said . . . . “

Well after 10 minutes of non communication there then followed a 20 minute 3 way consultation via a mobile phone which ended with the interpreter saying this would not happen in our country we would have got this test already without waiting.

It was embarrassing for one of the team to have to agree that in any first world country they would have had this test but this was the NHS. The interpreter told our patient this and they shook their head and said:

“English NHS was crap compared with their country”.

Did we miss something here but might it not have been easier to ask the friend to interpret at the start of the consultation? Still different times, different peoples, different customs, but as doctors we still need to communicate to do our job well.

And are former second world countries now providing better care for their patients than the NHS? The unfortunate truth is that UK healthcare is now worse than the former Eastern Bloc and is a joke compared with the first world where we trained.

Our patient told us this and we could not defend our system against theirs. Communication via an interpreter sometime tells you things you wish not to hear but which you know to be true.

You cannot defend the indefensible.

Praise be to the Party who must surely have invented communication skills and the mobile phone and combining them with honesty have given us real doctors called spin doctors.

We do not have interpreters to understand what these gifted communicators actually say onto us, so we don’t need interpreters to understand patients.

Or do we?

GPs as an emergency service? No longer according to BT.

While trawling the net looking for something else we stumbled across this interesting link. A little more research and we found this. Click the link on the NHS Connecting for Health website and read the letter to PCT Chief Executives and a few others but not amazingly to GPs.

When we started in General Practice we signed up to a “priority” repair service from BT.

Over the years only the 999 (ambulance, fire and police) services in the UK are classed as true emergency cases by BT where loss of telecommunications has to be fixed immediately. GPs are merely “priority” which we think means you will get fixed a bit quicker than Joe Public would but from experience about the same.

Given the poor state of the out of hours service locally, which has led to many of us being rung outside of the core hours (08.00 – 18.30hrs) by the PCT provided out of hours service, to be asked by the private companies who are the current out of hours service providers:

“ We have no doctors can you just deal with this problem. . ?”

it is clear that those life threatening emergency calls in general practice will just not get answered if there is a problem with our remote Northernshire cross country phone lines.

Surely though with the “world class commissioned” out of hours service there will be a responsible manager available 24 hours a day 365 days a year to deal with such a crisis? Seems no-one thought about this in the commissioning process as the private sector costing 3 times more than the old one is much better able to cope. They just ring the patient's own GP at no cost to them or the PCT commissioners.

Praise be to the Party. If the out of hours service can’t help you and they have rung your own GP whose phone is not working who you’re going to call?

Bet it won’t Ghostbusters but the ambulance service (their phones should be working as they are an emergency service) or A&E departments will have to deal with your “really” sore throat you have had for the last half hour. You will have no other “Choice” will you?

Scams, wheezes and targets.

We love the phrase “socialized medicine” here at ND Central and the current Party’s thinking and management of healthcare takes many of us back to our childhood days and service days when there was a Cold War on.

We remember reading many articles in the more learned free world press about Five Year Plans, about how wheat production had exceeded all targets when people were starving and wheat was being imported on the quiet from the US and Canada and there were so many tractors being produced that no one could possible starve.

Like many other UK bloggers the comparison between the former Soviet Union and today’s NHS has been self evident. There are many issues we could compare and contrast but we will stick with targets.

Just think how many targets have been set by the current Party and how many have been failed to be met?

The first set of targets most GPs would have encountered was the so called Quality and Outcomes Framework known with "affection" as QOF.

QOF is neither Quality, as all the standards are sub optimal compared with most current medically accepted guidelines, or Outcomes but merely a system of coding devised in a huge fudge by the Department of Health and the British Medical Association who between them trashed out a deal called the new General Medical Services (nGMS) contract in 2004. It is dumbed down medicine to allow thick managers to measure “performance”.

We here at ND Central think this is rich as those now measuring “performance” were those in our schools who could only just count and write.

The DoH fully expected these targets to be too tough for some of the brightest individuals in UK society to meet and expected most GPs to only score 600-700 out of the original 1050 points available.

Unfortunately, in the (currently?) free world that is the NHS, targets may be met as initiative is (still?) allowed. Most GPs scored a 1000+ and Gordon Pasha at the Treasury was not happy and so hated GPs for achieving what he, as an intellectually and ocularly challenged Scot, if you believe Mr. Clarkson from Rotherham, felt was impossible.

The Party however does not like initiative and so shifted the goal posts and has done so year on year with the aim, comrade patient, of improving your health care experience. Sorry we meant to say pay GPs less and so salvage the economy wrecked by the idiot GPs not those nice bankers and politicians who pay their bonuses (and expenses) out of your taxes. Remember dear reader you will always be able to see a politician or your banker within in 48 hours we are sure it is a target?

And more importantly if GPs miss targets they don’t get paid but bankers, if they make a loss do , as do Government ministers when they miss their own targets. Clearly a level playing field here comrades.

This week we have had a few irate patients who are starting to get wise to the scams, wheezes and targets that are delaying their treatment. Do remember this is the most affluent part of Northernshire and some of our patients can read, write and a few even use their fingers to count up to ten so we will be leading the UK in this realization.

The first was a patient who had been referred to a consultant who had waited a long time and thought they must be getting to the top of the list but had to go away on business overseas for a few weeks. Their problem was not life threatening but was getting worse as time went on.

Now, being a good comrade patient, they thought that rather than the hospital send them an appointment that they would miss when they were abroad, they would ring the consultant’s secretary and ask if they could not send them an appointment then.

Well done comrade patient, such self sacrifice on your part will help all of us in the Great Patriotic War.

When the patient was finally sent for their appointment they realized they has been waiting 22 weeks, not 18 weeks and questioned this.

"Oh no, comrade, you have only waited 18 weeks for when you are away on business, or on holiday, time stands still and the 4 weeks you were working does not exist or count as part of your wait."

So much for being helpful. We now advise all our patients of this scam if they tell us they are going away. If you miss an appointment another will be sent. If you tell them you can’t go your wait is increased.

Remember, comrades, 4=0 not 4≠0 as you were taught at school. Time and mathematics redefined by the Party for your, and all good comrade patients’ benefit.

Another scam we encountered this week is the “we will make you an appointment and then cancel it” but with a new twist.

This is pretty common in the NHS whereby in order to meet the 18 week target you are sent an “appointment”. Target met.

Then you get a letter saying “due to unforeseen circumstances” or “due to medical staff leave” you appointment has been cancelled. Well you probably have believed these scams but when you get the same letter 3 times?

One of our patients had this experience and rang to rearrange an appointment that clashed with an important family event.

They rang to rearrange their appointment only to be told that the next appointment was 6 months later. The patient questioned this only to be told:

“Oh no you can’t have that appointment it is outside the 18 week target and is the only one we have. You WILL HAVE TO GO back to your GP and ask them to refer you again so we can meet the targets”.

If this has happened the hospital would have been paid twice via Payment by Results as when the patient did not show the practice would have been billed. And then billed again when they were actually seen.

We wonder who is the loser under all of these Soviet style targets and scamming?

Just as the Soviet Union could not feed its own population during the Cold War and could not meet its own targets but always did, we now have in the UK a Department of Health and Ministers chucking out targets and not meeting them but scamming, lying and cheating in order to falsify figures.

Unfortunately only one person loses under this mountain of bureaucratic incompetence and that is the patient. The alleged “consumer” in the “internal market” that is there to serve (shaft?) them of their hard earned tax paid to Government.

Is the current internal “market" and targets, formerly known as the NHS, now merely a structure of healthcare of the managers, by the managers and for the managers (that) shall not perish from this earth?

Praise be to the Party whose many reforms and targets have made things so much better for patients.