Friday, 16 April 2010

Something’s missing . . . up North.

Today is a lovely Spring day here in Northernshire. One of the Practice’s traditions is that whenever possible on a Friday we usually try and slip in a Resistance meeting with some of our doctors and students in training at a pub in the countryside. These are referred to as educational meetings.

It has been a while since we have been able to have one and for the first time this year we sat outside. In the lee of a northerly wind it was pleasantly warm in the sunshine. Several people made a point that something was missing and that the birds were singing louder than usual.

Was this is collective hallucination or were our feathered friend now using amplifiers to compete with the background noise? A chance glance upwards revealed why this might be so.

There were no vapour trails in the sky. None whatsoever. We blogged earlier this year about how many aircraft pass over our manor every few minutes and as they do so they emit a low level drone of jet engine noise in the background which we learnt to ignore years ago.

Today there was none and so our feathered friends sounded louder.

Praise be to the Party for inventing the volcano. A clear case of the law of unintended consequances.

But how long will this state of play last and what effect might it have on Partners who are on holiday abroad at present but need to be back at work next week? The twitchers among our number were not complaining today but come next week . . . who knows?

Tuesday, 13 April 2010

Fire up the Ferrari. It is Spring.

One of the team did the extra Gordon surgery this Saturday morning. Due to the huge demand from busy commuting pensioners and toddlers, and the fact that the sun was out, half of the patients did not turn up for the extra Gordon despite there being a huge demand for it (according to Gordon).

This was despite huge complaints during the week in the real world of General Practice, where politicians do not treat patients, that due to a shortage of GPs due to school holidays there were no appointments. There was coincidentally very little real illness but it all wanted to be seen NOW.

This is par for a Saturday Gordon surgery in Northernshire and probably reflects the over abundance of GPs in these leafy Northern shires where we reside and practice medicine.

When we left the surgery there was bright sunshine pouring down onto Northernshire. The red paint work on our state funded Ferrari, so lovingly polished by each GP’s own personal car valetor, was gleaming, for all Family Physicians in the UK earn £250,000+ (US $ 375,000 +) for playing golf each day and it beckoned “drive me now”.

So the Sat Doc fired up the engine and we went off for a spin in sunny, springtime Northernshire.

We left the quiet conurbation and sped into upper grassland. The roads were quiet and the bends were fun and for several miles there were daffodils in bloom along the roadside.

Certain new blooms had sprouted along the roadsides which we think belong to the genus, Electiononus Placcus Consvertas, as well as the, Non Turbinus Windus Giganitus, which added different colours to the normal yellow of the daffodils.

As we ascended from the grassy fields of the main roads towards some of the more twisting and demanding high moorland roads we noticed another new hazard. Lots of newspapers have commented on the large number of potholes caused by a “harsh” winter here in the UK.

In our highly affluent part of Northernshire the local Councils has not only done a good job of keeping the roads generally clear but are also filling in potholes on the main routes at a pretty good rate too.

However, on the country roads, the word pothole is a bit of a misnomer as some are more accurately described as car swallowers.

If ones Ferrari only has a few inches of ground clearance a 6-8 inch deep erosion of tarmac at junctions where large wheeled tractors and tanks churn up tarmac in areas as wide as your car led us to calculate whether if at 60 mph the fall of a car would lead to the base of the engine and most of the car’s skirt being ripped out by the harshly damaged tarmac.

We think our knowledge of Newton’s laws of motion combined with a drop in speed and some serious zigzagging saved us from an expensive engine and front end rebuild.

We also thought of our last week and comments from various colleagues about what we had actually done work wise as doctors.

The overwhelming thought was we had been spending hours each day seeing a never ending parade of NHS managers coming round and assessing “quality” through various initiatives among others called DES/LES/World Class Commissioning and Practice Based Commissioning.

All of us had spent sometimes more each day being involved in “quality” and “performance” inspections from delta grades at the local PCT than seeing patients.

We thought how much paper was being produced to show to former flu line operatives with important sounding job titles who could just manage to read how to do their job off a piece of paper held in their hand throughout the visit to demonstrate “good practice” dictated by those that are at best in the bottom third of the United Kingdom’s education system but who are now in charge of your health service in the UK.

This made us angry as by striving to meet dumbed down targets and over bureaucratic nonsense we are in fact harming patients mainly by not seeing them.

Still the sound of our Best of Bucks Fizz CD in the boogie box and some serious cornering meant for a short while we had some serious well earned R&R and our minds were distracted from work. We were happy, it was spring, nature was coming alive and we were enjoying the changing brightly lit and now snow free scenery. We all need our escape moments and this felt good. Roll on another barbeque summer?

Praise be to the Party for inventing Monday’s for its comrade workers to enjoy. We can’t wait.

More quality visits and inspections anyone? Any chance of seeing and treating a real ill patient not a target?

We doubt it but we live in hope.

Thursday, 8 April 2010

We are off . . .

Well the worst kept secret in British politics was leaked over the Bank Holiday and confirmed earlier this week namely the date of the next General Election.

Now elections in the UK for those of us at the coalface of healthcare bring many reactions.

13 years ago a lot of doctors were sick of the Conservatives and thought that a change with a promise of decent funding for the NHS would be beneficial. Several medical bloggers, more longstanding than we, have stated this on their blogs over the years but all have realized this optimistic hope turned out to be a very false dawn.

Although percentage GDP spending on health has increased the average grunt on the ground as a GP is still is using a flintlock musket as opposed to a M16 to deliver health care today. Some of us a few decades ago saw better healthcare offered to patients then than we can now get locally and that was from watching Quincy ME.

The media are having a field day as they have a month to analyse every politician to pad out news and are already predicting a hung parliament (one where no one Party has a majority) and its dire consequences for us all and so are bigging up minor parties to pad out media minutes and column inches.

Those of us in healthcare who have been around for a while are just waiting. While we can exercise our democratic right to vote, it will not alter what whichever party gets it will do to the NHS.

History is said to be written by the victors and so is healthcare policy.

The picture above (click it to enlarge it) illustrates our thoughts on politics and the NHS. A once green and promising leaf of an idea called the NHS has been successively nibbled by the slugs, snails and caterpillars of successive political reforms over the years to produce a moth eaten leaf in tatters.

Each Party continues to eat away at the leaf, a different bit at a time, rather than to build on its strong bits to produce a useful, functioning NHS and discard the tattered bits which it leaves to fester sometimes indefinitely.

We are on a bit of a cynical roll here due to a huge influx of grunt humour the last few days so stick with us.

Healthcare in the UK appears to be a protected commodity (at present) for all of the Parties for they are all promising to protect the NHS with no cuts in funding. No cuts in funding is not the same as keeping pace with inflation.

The UK economy at present is not like a lifeboat sitting high in the water keeping all government departments dry and above the waterline.

It is a life boat full of holes though which debt is incoming with all of the parties desperately trying to bail debt out of the lifeboat to keep it above the waterline and avoid UK plc going under.

Within the lifeboat, on different seats, are the various departments including the NHS which is sitting close to a smaller hole than most other departments leaking debt at a slower rate so the bo’suns are all telling us.

No politician is plugging the holes and the lifeboat is still sinking.

One Party is saying that it will continue to pour in debt and the lifeboat will sink but if all hands in the boat are kept well fed then eventually they will pump the lifeboat dry despite the continuing influx of debt bringing it down.

Another Party is saying jettison the debt heavy bo’sun and this will stop us sinking and get a new lighter bo’sun who will make us all bail harder in the hope the boat rises a little quicker by reducing the influx of debt.

The Third way are the liberal democrats.

This is our reflection on current UK politics. As far as healthcare is concerned no way will be easy.

Deciding which way to vote is for an individual and it is their choice. Whichever way you choose to vote, like sailors in a leaking lifeboat, we will be bailing like hell in healthcare just to keep politicians afloat for some years to come let alone make any headway.

And while we bale the NHS lettuce leaf will get nibbled some more as well.

Praise be to the current Party for giving its patients their first real “choice” in years.

And what a choice it is especially in healthcare. More lettuce anyone?

Saturday, 3 April 2010

Welcome to NHS Global™.

While busily doing nothing in a full surgery we were reading the medical rags. It being the day before a bank holiday in the UK, half of the morning’s patients put illness on hold and did not show up. This was probably because they had to rush down to the local supermarkets to panic buy booze for the next 4 days so they would not have to leave the comfort of their homes as it was a public holiday.

Come next Tuesday, when work looms large and the booze has run out, they will all be demanding emergency appointments for their on hold illnesses.

As a result of our net trawling we found this interesting article. A web search led us to this site and we duly read it with interest.

We thought what great ideas could NHS Global™ sell to the world? Perhaps a few great ideas like these:

NHS (re) Direct?

We suspect that countries in the third world will be crying out for a service run by nurses sitting in a call centre rather than treating real patients.

World Class Commissioning?

Read what the House of Common’s Health Select Committee thinks about this potential export winner here. This is a summary the full report is more damning.

The Darzi centres?

Unneeded expensive idea that costs up to 5 times more than normal general practice and see far less patients.

Choose and Book?

We suspect the world will be screaming out for things that do not work like this given the huge export sales to date of this product compared with Windows XP.

British medical graduates?

Possibly, one of the few NHS true export triumphs following the successes of the MMC and MTAs schemes. Spend a fortune training new doctors, don’t give them jobs here and let them go overseas to work. We supply doctors to another country with zero training costs to that country. Simple brilliant idea but a waste of public money.

We are sure our readers and fellow bloggers could think of more. But enough cynicism, shall we look in more detail at NHS Global™?

Look at its mission statement in the second paragraph according to Andy Burnham the Health Secretary:

“The NHS could generate additional funding from other countries and organisations using its knowledge and products . . .”

No budget deficient hidden agenda here then?

“There is increasing demand from Governments and organisations abroad to share knowledge, provide services, or even replicate parts of the NHS.”

There certainly is Andy. Every day we here at ND Central have to turn away foreign governments asking us how to do things the NHS way for:

“the NHS is home to world-class innovations that could benefit from a share in this market.”

We are sure other NHS GPs have the same problems as do we with door knockers as a result.

“The Department of Health has begun preliminary work with NHS organisations to bring products to market and will launch a call across the system for further ideas to be submitted for consideration by NHS Global.”

No half baked ideas here then as to which “products” will be sold by NHS Global™. Clearly a well planned and prepared launch for this new corporate entity.

Look again at the expertise they have gathered to launch this product in the beginning of this article.

Messers Brown and Burnham and the good Lord Darzi. Three men who between them who know sweet FA about healthcare but all 3 have considerable expertise to export about how to wreck NHS healthcare via “reform”. Now that information might be worth something to someone perhaps President Obama?

“Yeoh my main man Gordon, could you tell me how not to deliver socialized medicine?”

“Aye laddie, I can do so but, Barack, it’ll cost ye to use NHS Global™ . . . "

Look at what some of them go onto say starting with Andy Burnham:

“After a decade of record investment, the launch of NHS Global demonstrates that the NHS now has the confidence and capacity to play a greater role on the world stage. However, there is still much more that we can do and demand for NHS products and knowledge far outstrips supply”.

Quite right Mr Burnham loads of money misspent and despite this, demand for NHS “products” outstrips supply for patients here in the UK so what exactly are we going to export from our bountious surplus of healthcare “products” in the UK?

Some more wisdom from Mr Burnham:

“A key part of responding to the economic challenge that the NHS faces will be realising the full potential of innovation, not only making effective use of our knowledge and skills at home, but also making money abroad that can be reinvested back into the NHS. So we will invite NHS staff to come forward with their suggestions for the NHS innovations which we could take to the world and in the coming months we will commence a consultation on these proposals.”

And what does the NHS do best with innovation Mr Burnham? That’s right it ignores it so your fine words mean nothing and the consultation on these proposals means it is already a done deal and we all know who will have been done? UK patients and their healthcare.

Next we have something from the head manager of the NHS, Sir David Nicholson Chief Executive of the NHS whose words we publish in full and suggest you use a NHS Manangement to English translater to determine what this paragraph means:

“The NHS provides high quality health services to patients everyday. International demand for knowledge, skills and services developed in the NHS is growing. What we need is a more systematic approach to supporting NHS organisations in making the most of these opportunities and bringing benefits back to the NHS and the taxpayer. NHS Global provides us with the opportunity to take a significant step forward in making this happen”.

Obviously Sir David has the same problem with door knockers that we have here at ND Central being constantly interuptted by overseas governments saying how do you do it? Starting to see a theme, real or imagined, regarding income generation?

And finally a man, who given his extensive lack of knowledge of primary care medicine and aviation was brought in to wreck UK General Practice and is tipped to be building the successor to Concorde in his spare time but still has managed to acquired a new job title so lets big it up for Professor Lord Ara Darzi who is now the:

UK Global Health and Life Sciences Ambassador.

Does that mean NHS Gobal™ is a country?

“From my own experience I know that the NHS is home to some of the most exciting healthcare innovations in the world. There are new ideas and techniques being developed every day to provide our patients with an ever higher quality of care. There is significant international demand for NHS products and knowledge and it is important that NHS organisations are supported in making the most of this opportunity.”

We do wonder what experience you will be drawing on Professor Lord Darzi and are they knocking on your door as well? How do you manage to do any surgery? The financial success of the centres named after you and their under utilization by patients perhaps?

“Proper management of our knowledge and skills will create additional income to invest back into frontline services. At the same time, greater participation in the Global Health agenda will provide greater security to the UK and the rest of the world in confronting international health security challenges, such as pandemic flu. NHS Global will be key to unlocking this potential and, in doing so, will bring tangible benefits to the NHS, the UK and the world”.

“Proper management” now we know we are onto a winner as the NHS is a world leader in management growth to deliver nothing better in healthcare other than increased bearocracy. Notice several subtle references to bringing in income? We aren’t going to be selling the family silver via NHS Global?

Our learned Lord goes on:

“The NHS leads the world in technologies and innovations to combat healthcare associated infections (HCAIs). There is significant demand from other health systems across the world to learn from the NHS.”

He is right we probarly lead the world in the number of HCAIs in contrast to countries like Holland so selling this knowledge on how to acquire these infections will be a gold mine for Gordon. It is one of the NHS’s proudest achievements brought about by numerous healthcare “reforms” over the last 12 years.

Now we get onto the funny bits:

“In addition, the NHS Institute for Innovation and Improvement’s ‘Productive Series’ and NHS Direct Software are examples of projects that could generate international business.”

Well we had only heard of one out of the three but do wonder if the “Productive Series” is related to the Productive ward initiative of broom cupboard cleaning?

We must not be too dismissive of the good Lord Darzi as look what he says next:

“NHS Direct software enables non-clinical staff to direct calls for clinical advice where appropriate, depending on callers’ responses to a series of linked questions about their symptoms. This reduces staffing costs while maintaining standards of safety and quality”.

Clearly a man who lives in the real world and recognizes something brown and “world-class” that should be exported (to another planet?).

Well at this point we lost the will to live and we will skip the next few paragraphs and go to the end:

“The Department of Health will consult on an operating model for NHS Global in the coming months and subject to the outcome of this consultation, expects to launch NHS Global in the summer.”

We can’t wait.

Praise be to the Party for its launch of the new Bristish Leyland of healthcare, NHS Global™.

Coming to a car park near you soon the Brown Maxi, the Burnham Princess and the Darzi Allegro all three models representative of the best in current British health care in the same way that the cars bearing these names once represented the “best” of British automotive engineering in the 1970s and made us the laughing stock of the automotive world.

What are they on?

Friday, 2 April 2010

Dr Crippen has gone, please come back?

For those of us who are junior in the blogging field we have noticed the retirement of the Dr Crippen aka NHS Blog Doctor website in its entirety. When we looked for it today as a reference source it was not there.

Please Dr C put it back?

The likes of you inspired us Northern thugs to put fingers to keyboard and to comment, as you had, on how bad the NHS was despite the government spin. Together with Dr Rant’s, Dr Grumble’s and Jobbing Doctor’s blog you were our stable reading material which opened our eyes and inspired us.

By all means cease to post new blog posts, but, please do not deny history the benefit of your wise musings.

We understand retirement but remember your postings were an accurate, contemporaneous record of UK general practice healthcare that will be missed, if it is not current, but lost forever if you remove it from the blogosphere?

Please re up if only as an archive of UK healthcare in the early 21st century?

Praise be to the Party who invented Dr Crippen’s blog and opened our eyes to the fact that the NHS is poor to the point of laughter but for the fact that to get there it has cost millions of wasted tax payers money to do so.

Respect Dr C.

Thursday, 1 April 2010

Common drugs, rare problems and protocol free solutions.

One of the current joys of general practice, for those of us here at ND Central who have a scientific medical background, is that you are (still) allowed to practice medicine scientifically rather than by protocol.

We apologize for banging on re protocols but every staff member here is sick of NHS and local Politburo protocols increasing their workload but delivering bugger all real healthcare.

This privilege is being increasingly eroded by the actions of the Thickerazzi who feel that all humans are created equally thick, as they are all failed Einsteins, and can only do things by reading from a script usually prepared for them by those just fractionally brighter than they are.

In this way they hope to control, in a Russian Soviet style which they have not yet noticeed failed 20 years+ ago, what everyone does in medicine and bring it down to the lowest common denominator of intellect, that of your average PCT Chief Executive.

They hope that the Thick will truly inherit the Earth for they perceive that they will run it for the betterment of us all (into the ground).

A delusion is sometimes defined as a belief in the absence of reality.

Under the current policy of care in the community for the mentally ill, all those who suffer from permanent delusions of grandeur and misplaced ability are now employed by PCTs and the Department of Health and remarkably get paid, sometimes huge salaries, while they have their “treatment”.

If you think that anyone here at ND Central can rustle up a mitre joint or service a jet engine after reading a set of laminated protocols over lunch then think again.

We know we cannot.

We know that real professionals need training, knowledge, ability and skill. Some of these attributes you may acquire by birth and genetics but most of which you will acquire by education, practice and experience.

We, as doctors, would not like to even attempt the tasks above as we prefer to practice safe medicine not cheap laminated protocol moron medicine. We know our limitations and this is important which is why we are not joiners or jet engine technicians.

For there are old pilots, and there are bold pilots but there are no old, bold pilots in aviation and good pilots like the fact that the number of their takeoffs hopefully equals their number of landings. The reason there are no bold, old pilots in aviation is that these pilots eventually crash and burn.

Rather like politicians reforming the NHS. Nothing useful achieved, like a landing, just a huge pile of burning wreckage which they always walk away from Scot free unlike anyone flying a plane or managing a patient where you are accountable either via a death or the loss of your career.

We are doctors whose skills take many years to learn and are not acquired by the reading of a laminated protocol. They are based on a core of knowledge acquired at medical school, refined when you start learning medicine for real as a junior doctor who is guided by those more senior and experienced and (hopefully) refined from every patient you see and learn from.

Not an A4 laminated sheet of paper.

We respect other peoples’ acquisition of skills and those of us who were crap at metalwork at school, but who excelled at technical drawing, realize that there are horses for courses.

The scientific approach is that you devise a theory, or “hypothesis”, devise an “experiment” to prove or disapprove it and revise the theory on the basis of the experiment a “conclusion”.

If the theory is correct then subsequent repeats of the experiment should lead to fairly consistent results.

A recent consultation led us to think about how the protocol driven inferiorocracy, that is the current NHS, would have coped with a set of atypical symptoms.

We would love to have had access to the ultimate inferiorocracy, the NHS (re)Direct computer system but we do not have. We cannot, therefore, test this one on the ultimate of ZaNu Labour’s dumbed down protocols and see how it would have coped.

We could, however, guess the outcome.

The symptom with which we were presented with was:

I clean my nose with a toilet brush each morning but in the afternoon I use a toothbrush. The rest of the time I am fine”.

Now as some of the most inferiorly educated members of UK society called doctors, whom we hope, and pray, are not as yet, soley QOF orientated, protocol box ticking morons this symptom got us thinking.

We thought, as any intelligent member of society would have, we have not got a clue what this means.

So we went back to basic training. We did as we were taught at medical school.

We took a full history, examined the patient and arranged a basic set of blood investigations.

However, we were still puzzled by this set of symptoms. We had in decades of collective practice never seen, or heard of, this set of symptoms either, as an individual or, collectively as a team.

Our taking of a history, combined with a review of medication, suggested a remotely possible, but a highly unlikely, cause for our patient’s symptoms.

There was a very small chance that this might be the cause and so, before the blood tests were done, we suggested a possible “hypothesis”.

We asked the patient to perform an “experiment” and stop taking a medication they were on even though they were taking a homeopathic dose of this commonly used drug.

When the patient returned all the tests were normal. More importantly so was the patient.

Our educated guess, combined with our scientific approach, had produced in less than a week of waiting for test results a result, a “conclusion”.

No further unnecessary tests or referrals were required although we were thinking should we refer the patient to a neurologist (as a possible brain tumor) or a psychiatrist in case their symptom was a sign of severe mental illness.

We do wonder how many other such “experiments” are performed each week in UK general practice? And more importantly how many of these are successful, cheap, protocol free, test free “experiments” result in a successful outcome (“conclusion”)?

And how do they compare with protocols followed by other “scientists” employed by the likes of NHS (re) Direct?

The same morning we did this “experiment” we did a whole surgery and did not follow a single NHS protocol.

If you are a properly qualified doctor you have to formulate a “hypothesis” each time you see a patient. Sometimes this is called a differential diagnosis, or in other words, your symptoms might be this or this or this.

This process of science in the NHS in general practice involves as little risk to the patient as possible but gives the maximum return to you as a doctor in terms of minimal diagnostic expenditure (to the State) to get a diagnosis as quickly, and as cheaply, as possible.

As a doctor you have to think about how to prove or disprove your theory and devise an experiment.

This is a summary of what your average UK GP does most of the time they see you.

It is not First World medicine, where the patient above would have had a brain scan and referral to see a psychiatrist and a neurologist ASAP for the remote chance that there would be something seriously wrong.

Common things are usually common in medicine, rare things are usually rare but not always so, but need to be looked for and considered with every patient for the price of (medical) freedom (to practice) is still eternal vigilance.

Experience does not give you all the answers as we learn all the time as GPs. And that is the point.

We should learn every time we see a patient and so slowly refine our practice (of the art) of medicine hopefully for the better.

Protocols stay the same, they do not learn from experience, as they are incapable of independent thought or learning.

Protocol driven medicine are the summaries of the thick as they try to break down a complex subject into something that they were incapable of understanding or doing but which they seek to control.

Praise be to the Party as they surely via reforms would have solved this problem so much more quickly, efficiently and cheaper than we could have ever have done?

Protocols. The future of medicine?

We hope not as they will miss, or dismiss, much more than they ever usefully achieve as those who use them will never think outside of the laminate.

At the moment we as doctors are still free to think. Let us hope that this freedom is preserved.