Wednesday, 30 June 2010

Grannies and druggies.

If you look at the title you might think what the hell are we at ND Central thinking of?

Well at first sight the link is not evident but if you bear with us it may become apparent.

The link is drugs. Now because your first thought will be grannies and druggies no way man. But stick with us for it is very yes, way man.

Let us go back a few decades when a group of drugs called benzodiazepines (or benzos in current street speak) were marketed.

These were prescribed as sleeping tablets or “anxiolytics” to relieve anxiety but rapidly became recognized as being “addictive”.

Some of the team recall how they as junior doctors were told to prescribe Temazepam as a sleeping drug and Paracetamol as a painkiller for all inpatients to avoid being called up at 02.00 because a patient could not sleep or had a headache.

The bible of UK prescribing, the British National Formulary (BNF), back a quarter of a century ago said these were addictive and advised short term prescribing only.

Sleep deprivation is a powerful tool and after a couple of nights without sleep and being told prescribe or else you won’t sleep most junior grunts succumb to the sleep deprivation avoidance method of prescribing the above drugs to every patient they admitted.

Remember our seniors, tucked up in bed, told us only prescribe for the condition required not in advance for that is bad medicine. Right.

Not a problem until the patient was discharged and the doctor doing the discharge wrote automatically, without checking preadmission drugs, why the drug had been prescribed in the first place and was it still required post discharge?

Again sleep deprivation led these doctors to ignore these basic checks. If a patient on no previous pre admission drugs had come in and been prescribed these drugs on discharge it was house officer induced not necessarily therapeutically indicated.

As a result some people may have become addicted to benzos as a result of a short stay in hospitals. A larger number we suspect as a result of GP ignorance and incompetence over several decades. These patients are often now pensioners who have been on these drugs for years and are resistant to any change especially stopping them.

Even if you as a GP do try and stop these drugs it is very time consuming and you will encounter a lot of opposition from these older druggies. Often the approach is to let nature and time eventually eliminate the problem passively although this is not good prescribing.

A case a few years ago highlighted this and how quickly a drug, which should at the time it was initially prescribed only have been used short term, became used long term.

So let any GP without any patients on benzos be the first to cast a stone at our assertions above.

Things have got worse due to the explosion in opiate misuse.

There is a cascade of what drug addicts will use to avoid heroin withdrawal.

The gold standard for a heroin misuser is heroin which is an opiate. If you can’t get this then other less strong opiates will do for example Dihydrocodeine (DF 118) as a stop gap which can sometimes be bought off old grannies to top up their pensions as they pay not for their prescriptions especially if they have alleged chronic back pain. They can just re order if they do have back pain they are less suspect.

If that does not work then benzos can help addicts sleep when they are withdrawing but hey they need huge doses. So an elderly aunt on long term benzos loses the odd prescription and almost every request for a lost prescription is for a drug of abuse.

One of the strengths of general practice is that staff come to know family relationships. So if a granny Wilma starts losing benzo prescriptions this could be forgetfulness but if grandson Wayne is a known user then this can be nipped in the bud.

The lost prescription ploy usually goes along the lines of (but there are many sub variations):

I put the Crown Jewels and the whole of the Bank of England’s gold reserves into a locked box in an armed convoy on my way to my holiday at Aberystwyth and despite no interruptions when I arrived the Crown Jewels and the whole of the Bank of England’s gold reserves were there but my month’s prescription of benzos were not.

Can I have another a prescription?

All that security and teleportation too? Have we missed something here? Why do we never get requests to replace the paracetamol tablets that were prescribed at the same time and were in the same locked box as the benzos?

Benzos are also currency in that they can be converted into cash but selling them onto other addicts which can then be used to buy harder drugs. So an addict who gets a months worth of benzos, from a dodgy GP say 120 tablets worth £2 a shot on the street, could get a little Brucie benzo bonus of £240 a prescription and then if they “lose” it and blag another prescription, another £240 + benefit.

Which brings us to the Z-drugs (Zopiclone being the principle one). Once again alleged non addictive drugs are now currency and are frequently lost more often than the Crown Jewels despite their users air tight security systems detailed above.

This may sound a bit funny but in general practice these prescriptions and their loss creates a large amount of hassle. For we are basically dealing with liars and drug addicts at both ends of the age spectrum who feel that society owes them something for nothing.

While the younger addicts are using benzos and Z-drugs for different reasons the behaviour we see from both groups to get these drugs is the same. Both groups lie, cheat and deceive and, although the older ones do not usually resort to physical threats and violence that the younger misusers do, they are both as bad as each other.

A medical commentator a while back said something along the lines of what would happen if they bought a plasma TV and Blue ray recorder in the morning and went home with their “gear” and then “lost” their purchases?

If they went back in the afternoon to the shop and said they had put it in their car and they had disappeared by the time they got home could they, at no expense to themselves, get a replacement for their loss?

What do you think? Can you see the link between druggies and grannies now?

Praise be to the Party for the NHS and “free” drugs for those who abuse them. Unless you work and have to pay for your goods you do not realize how much free prescriptions for some cost those who work in general practice.

The costs to the rest of society are merely criminal.

Tuesday, 29 June 2010

I cannot ever get to see my GP, it always takes weeks to get an appointment. Some thoughts. The basics 001.

At ND Central this title has over the last few weeks has been a common opening gambit to a consultation from patients for both doctors and nurses. The implication being that as a result the patient has suffered and it is OUR fault.

The fact that it is often followed by a two minute monologue on the state of the NHS and, what if I was ill?, immediately tells a health care professional there is very little actually wrong with the patient.

You learn to develop a thick skin in general practice in the UK. You also know that if a patient is blue, unconscious, pulseless and not breathing rather than moaning on about appointments they might be actually ill as opposed to being pathetically well and whinging.

Let us have a think about not being able to get an appointment (the instant I want one). Lets start with some basic questions like why can you not get an appointment (the instant you want one)?

If it doesn’t cost anything and has some worth to a consumer, the patient, guess what?

Everyone wants it.

Our medical students from many nations overseas all say the same thing. "The NHS is brilliant, we can see a doctor and it costs us nothing unlike at home where it will cost . . . ".

Their idealism changes rapidly after they start seeing patients themselves and by the end of their time with us they keep asking why people are coming to see us with things they wouldn't bother a doctor with. Remember this is the hugely affluent and over educated Northernshire where we practise.

So if there is no economic check on the provision of healthcare to the consumer (patient), combined with potentially limitless demand for healthcare, which is pitched against a finite provision of healthcare then something has to give. Have you worked out what that might be yet?

Perhaps a shortage of appointments because there is no disincentive to use the service?

Would a charge for appointments make it easier to get an appointment?

Perhaps a sliding scale say £ 10 for a routine appointment, £ 25 for an “urgent” one? What about home visits at £100 a time?

We bet the “I can’t afford a taxi” argument would disappear overnight as a self preservation (health) argument and it is free argument would rapidly give way to a “how do I save money?” (economic) one and guess which usually wins?

Lots of time is spent talking about “markets” in the NHS but most peoples experience of real markets means that if you want something you have to pay for it. If you want it NOW you pay more or you wait your turn.

People are used to using markets and those who want things a bit quicker usually take advantage of private medicine.

Unfortunately this “market” option is unlikely to happen until patients have to pay so possibly the easiest way of “creating” more appointments, by managing demand, is not likely to be a political option so you will have to wait and continue to moan.

Let us now think about the diseases we see in general practice and whether most of them actually merit an appointment.

All of us here at ND Central have been through different General Practice Vocational Training Schemes. All of us know, and have been taught, that most illnesses we see in General Practice are self limiting.

In other words most illness gets better on its own. This is nothing new but is highly unpopular with Joe Public who since the advent of penicillin think there is a “pill for every ill”.

This means that if you have a cold, a sore throat, a case of diarrhoea and vomiting the vast majority of these will get better on their own. More often than not we talk to patients, examine them, tell them what they have got and give them nothing.

A good use of medical time?

Or pandering to the pathetic who just came for a “check” or for the name of a disease to tell their employer that they need sometime off? We think if you are completely well and want a check go to a bank they will probably charge you for something. Doctors are trained to treat illness, not wellness.

A lot of the diseases we see have been around for centuries and people have survived them even before the NHS was invented. This is nothing new and those of us in the UK who know who our parents are and who their parents were as well had such knowledge passed down to us.

Where grandparents paid for healthcare there was a pool of knowledge built up whereby simple diseases like chickenpox were recognized and diagnosed by the family rather than involving an expensive trip to see the GP.

The changes in the family structure in the UK means that such self obvious diagnosis now means a trip to see the GP.

Let us summarize our humble argument thus far.

At this point we have a “market” led healthcare system.

This market, where demand is not regulated by cost to the consumer, and, its demand is potentially infinite, is delivered by finite resources.

The vast majority of users of this “market” have diseases that are self limiting and will get better without treatment.

And people feel aggrieved they cannot get an appointment?

Praise be to the Party that created illness the vast majority of which gets better on its own. And then created the NHS to deal with this “problem”.

Wednesday, 23 June 2010

A Wednesday afternoon in General Practice and a football match.

In General Practice you see and hear a lot about people. Today was an interesting one.

A lot of our staff, who are mothers, were moaning that they had to be at work but their children’s schools were shutting for the England world cup game or their kids were being allowed to watch the England match rather than being educated.

The local and National radio stations were all reporting how benevolent employers were letting staff home early (to watch The Match) or letting their staff stop working (to watch The Match).

Those of our predominantly female staff who walk into a large market town for their lunch reported feeling intimidated by the large numbers of red shirted lads drinking ale at lunchtime and shouting.

For those of us in healthcare there appeared to be a National Holiday when all of us were at work.

Most surgeries were full but unusually there were odd gaps and fewer emergencies than usual.

While trying to do work on line a lot of staff reported that they could not access the internet for things like travel immunisation data until the match had finished. Our normal connection speed slow, in stone age rural Northenshire at the best of times, was really slow or non existant.

Could it be that the useless UK internet network was severely compromised due to everyone who was at work with broadband streaming the world cup to their desktop? A theory we shall see.

The drive home in the rural shires of Northenshire was also different. Normally there will in summer be a few people sitting outside on pub benches drinking.

This evening on one side of a road it looked like we were seeing Wellington’s red coats at Waterloo all armed with a glass of lined up against the dark blue and yellows of the local constabulary on the other side of the road. The red coats were spilling out of pubs in large numbers and sitting and standing on outdoor tables. The blues and yellows were fewer in number and standing beside parked up Police vans.

Not seen that before but fortunately no bricks or petrol bombs but nonetheless the Ferrari was pushed once the lights went from red to drive through these 2 lines of reds and blues.

So when we got home we found the result. A one nil victory for England.

Nice to know that an eleven man team, many of whom will each earn in a week what it costs our practice to run for a week, will feel they have earned their pay for collectively putting one ball in a net. For some reason our staff don’t feel the same.

Someone once said football is more than life and death. So is healthcare but one is usually cheap and readily availabe in the UK in contrast to that available in South Africa.

Praise be to the Party for providing football on TV for a fraction of the cost of a Darzi centre consultation and in doing so helping so many but to what exactly? Worse still there is more to come.

Are we just being miserable? Or, is the importance of kicking a ball about, rather than providing basic healthcare the world over, more than a game?

Monday, 21 June 2010

General Practice and the economy.

Well this weekend the mood has been sombre at the Café Michelle. Those working on the frontline know that this week there will be announcements from those on high which may affect we grunts on the ground and also our patients.

In general practice we see many patients who are depressed. Often the reason for their depression is debt and the inability to service it. Now we can treat the depression but we cannot pay off their debt.

Instead we advise them. We do not advise them to borrow more, for that way they will fall ultimately into the hands of loan sharks.

We instead suggest a trip to the Citizens Advice Bureau (CAB) to get some help with their debts and angry creditors. Those who do, and many try several times as there are always long queues at local CABs.

Often they find their trip leads to a huge weight being lifted off their shoulders and a gradual recovery both from their financial burden and their depression. It does however take time and selfdiscipline.

Unfortunately as a nation our “betters” seem to have ignored basic principles something for which we will all pay, possibly for decades. However at the time it may have been the right decision.

There is no secret about the fact that affluent people tend to have better health than those with less. We suspect that over the next few years more will have less and that our workload for those suffering diseases whose aetiology is financial will increase. That is the nature of healthcare in an economic downturn and a recession.

Let us hope that those in the Westminster branch of CAB give our leaders good advice. We shall see later today how their patient, the British economy, will fare and as a result how we as doctors and our patients will fare too.

Praise be to the Party for Prudence for whom all of us in healthcare, both as workers and patients, are about to pay for big time.

We suspect here at ND Central that things are only going to get tougher. We shall see later what tomorrow will bring . . .

Thursday, 17 June 2010

We thinks they protest too much?

Watched an item on Channel 4 news towards the end of the program last night about MPs protesting about the clamp down on their expenses and the introduction of an electronic expenses claim system. The British serious news is not normally known for their sense of humour but when we watched it again and again this was actually quite funny. The link is here and the item starts at 19.00 minutes into the clip. Link should be there for a week or so.

How sad. The MPs complaining have imposed completely useless software on anyone who works in General Practices without any consent or consultation. Just listen to what they are saying.

What are they protesting about?

NHS technology is said to be good for it was they who told us so. So any Parliamentary technology should be good too. They have only themselves to blame for it after all.


Less efficient?

Delays treatment for patients (sorry wonga for MPs)?

Denies choice?

Increases everyone who uses it workload to do the same job?

Compromises their confidentiality?

Pays useless individuals to do nothing to service it?

What more could any MP want from Government software?

Welcome moaning Labour MPs to what you have done to those working in the health service for the last 13 years with your Soviet style implementation of useless IT. A few of you are clearly feeling angry about this but that pales into insignificance compared with the daily anger of those thousands forced to use useless NHS IT by yourselves.

Praise be to the Party for the “progress” that is finally catching up with those who thought of it and who have inflicted it on those who work in the health service.

Now you know how the workers feel. Feels good doesn’t it comrades?

Paper bad, electronic good. Is there at last some equality finally among the pigs?

Enjoy. Things can only get better with every upgrade that will be coming your way . . .

Monday, 14 June 2010

Bad weather, building work and reassessing patients.

It is said that the British apparently talk about nothing else other than the weather. Today in Northernshire the weather has been typical British summer weather. Wet, cold, dull, misty and overcast. Perfect champagne and strawberries weather or if old, miserable and lonely a perfect day for a trip to the doctor.

This barbeque weather has coincided with some recent building work which has led us to make some interesting observations regarding our patients’ true health.

Many years ago a friend from school worked for a small unit of the Government which assessed patients who were claiming industrial illness compensation. As a receptionist they sat in an office which overlooked the local car park.

They would watch the claimants walk unaided up a steep hill from the car park into the office where they arrived by lift. The walk from the car was frequently unaided but the walk from the lift on the flat into the waiting area was different.

Relatives were often there to give assistance, help was always asked for and oxygen frequently deployed in order to ensure that the claimant got their claim.

Unfortunately the doctor’s office also overlooked the car park and they could see the same sights and the claim was not based on acting but on the appearance of an x-ray.

This was a few years ago and recently some building work disabled a lift and rather than using a tannoy we had to call patients ourselves due to a major change in the layout of the building that caused a lot of confusion to patients some of whom had been coming to the same unchanged building for 50 years.

What struck us was how breathless people were after walking up one flight of stairs as there was no upstairs waiting room.

Granted we see a biased population who are allegedly ill and therefore might be presumed to be less than 100% fit but when as a doctor you are struck by the fact that most 50-80 year olds could walk up a flight of stairs without being breathless while those in the 20 –50 year old were struggling, without any other existing disease it was a revelation.

What was more striking was the fact that those who had other disease affecting their breathing, for example heart failure or chronic lung disease, where sometimes less short of breath at the top of the stairs than some of the overweight 20 year olds who sounded like they had run a marathon. Their kids however being thin had no such problem and were frequently on the landing before their parents were even half way up.

Perhaps there is an argument for building all new surgeries 50 yards from the car park on a slope with the doctors’ offices looking out onto the slope from the car park? That way we could assess our patients’ cardiovascular fitness, their fitness to fly and whether they qualified for a Blue Badge just by observation?

Doctor’s time saved, more honest answers by observation and a gradually fitter patient population. Just a thought, inspired by the inconvenience of some building work.

Praise be to the Party for inventing builders and allowing us to observe our patients outside of the chair where we see most of them.

Tuesday, 8 June 2010

Parallel universes, wormholes and Airedale.

For those of us of an artistic temperament science is a bit of a mystery. However we can just about watch an episode of Star Trek and grasp some of the concepts there. We can watch the likes of Stargate and marvel at the imagination and science behind these ideas and think what if?

But then some of us in our dealings with the NHS noticed that the ideas in these programs do actually exist in the real world. There are parallel universes and black holes and even wormholes.

The parallel universes we encounter daily are the NHS aka the real world where most patients and those who practise medicine on the frontline live and work and thereby experience UK medical care.

Running parallel to this with no idea of this world is the MHS (Management Health Service) which is a rapidly expanding world of low density matter which will ultimately imploding if current universe theories are to be believed as although it is of low density matter the quantity of this matter is expanding at an alarming rate.

All matter exerts the force of gravity and so this large collection of low density matter will ultimately implode and forms a large dense cluster of matter called a black hole.

The third parallel universe is the Department of Health and Government aka the Party. Although this is smaller in size than the NHS, and the increasingly larger MHS, it is a far more sinister universe as there is a huge amount of incredibly dense matter there that has a disproportionate amount of influence on UK healthcare far beyond its ability.

Now because these are parallel universes there is very little communication between them. Such that exists are the wormholes that seem to operate in what is called a top down approach. So the DOH/Party has a wormhole into the much larger MHS universe which in turn has wormholes into the real world where patients and health care professionals work within the NHS.

Any wormholes that operate in the opposite direction have an incredibly short existence as the people who know what is going on are only rarely granted a wormhole (audience) with these parallel universes. As a result they are ignored as being 3 separate parallel universes they continue in the same space/time continuum but are essentially completely independent of each other.

So if something new, or wrong, happens in the NHS it can rarely be communicated to the DoH/MHS universes due to the infrequent wormholes that occur between these universes. If it is communicated then it will be regarded as spurious background radiation noise as those listening to it will not be capable of understanding anything other than DoH/MHS speak with is at best a primitive incomprehensible language.

A report from a hospital in Northernshire called Airedale actually makes reference to this “parallel universe” theory. It is regarding 3 deaths attributing to a nurse there and we watched the story this evening on Channel 4 news and thought after several minutes this sounds all too familiar. The interview afterwards was more enlightening but we can't link directly to it you will have to watch the program yourselves while the link lasts.

So parallel universes within the NHS are now official. The full report is here but here are is a link to the local press's coverage of the story.

The bottom line is when managers set the addenda patient care suffers. Blow the whistle and you suffer. Staffordshire hospital déjà vu? And so it will continue.

Praise be to the Party for without science fiction how could we ever explain how the NHS is so dysfunctional? Once again corporate responsibility leads to individual unaccountability and no doubt those responsible will move onwards and upwards.

Monday, 7 June 2010

What does “world-class” anything mean in the NHS?

If you live and work in the NHS you will be aware that language changes as it does in the real world. There is nothing new with new terms coming in like CT or CAT scan (computerised tomography/computerised axial tomomgraphy) or MRI (magnetic resonance imaging) scans.

More recently the term MI (Myocardial Infarction or heart attack in old money) has been replaced by NSTEMI (Non ST elevation MI) and STEMI (ST elevation MI) which refer to changes in the appearance of the ECG which determine what is the best treatment for anyone suffering a heart attack.

Certain terms create confusion for example what is the meaning of STI? For some it stands for Sexual Transmitted Infection. It appeared a few years ago in A&E computer generated letters and took a while to work out what it was which is a Soft Tissue Injury.

Another is the abbreviation PID which could mean to a gynaecologist Pelvic Inflammatory Disease (the clap) but to an orthopaedic surgeon could mean a Prolapsed Intervertebral Disc (slipped disc).

So what does the NHS managers buzz world “world-class” mean when put in front of anything?

It certainly does not refer to anything from the first world. When we speak to colleagues Stateside and tell them of local “world-class” commissioning initiatives they fall about laughing and ask how we avoid being sued and how come we are so many years behind them?

It certainly does not refer to the second world which we think may now mean North Korea and possibly China.

The migration of people from Eastern Europe to the UK mean some of our biggest critics are patients from the former Eastern Bloc who can go home on a weeks holiday, get a scan and an operation done to cure them quicker than they can see a totally useless complimentary therapist in this country at a fraction of the cost. They also are better as a result of a trip to the former Soviet Union but still are waiting for NHS “world-class” care when they return.

It can not refer to the third world as patients of ours who have been unfortunate enough to fall ill overseas have all commented on how much better things there are in terms of resources and treatment and remember they have paid their National Insurance and Taxes and are getting their first world treatment from their travel insurance not their own country.

One in particular had in 2.5 hours a MRI scan, a consult with an orthopaedic surgeon and was seen by a physio quicker than their child was seen with a broken wrist in their local “world-class” A&E department.

So which world is the “world-class” world of the NHS and its managers?

Praise be to the Party for giving us the term “world-class”.

Is it the same as kids in the seventies cutting out Rolls Royce insignia and sticking it on their Choppers to make them look better than they actually are?

In fact the Chopper riding kids are now the managers . . . but they haven’t grown up yet or realized how p*ss poor and backward they still are. (With apologies for the more than usual grunt words).

Tuesday, 1 June 2010

They’re out.

Woke up this am and it was announced on the news how much the top civil servants earn. We had a quick look at those in the Department of Health. The spreadsheet with all this riveting information can be found on the Cabinet Office website or if you are too excited to wait it is here.

Now to your average Daily Mail reader and believer you will think most of these are not badly paid in contrast to your average GP’s £ 250,000 a year. Compare these figures below with the number of underpaid NHS managers:

David Nicholson NHS Chief Executive
£ 255,000 - £ 259,000

Claire Chapman Director General of Workforce
£ 220,000 - £ 224,999

Sir Liam Donaldson Chief Medical Officer
£ 205,000 – £ 209,999

Christine Connelly Chief Information Officer
£ 200,000 - £ 204,999

Gabriel Scally Regional Director of Public Health
£ 200,000 - £ 204,999

David Behan Director General of Social Care, Local Government and Carepartnerships (what a title anyone know what it means?)
£ 180,000 - £ 184,999

Duncan Selbie Chief Executive
£ 180,00o - £ 184,999

David Salibury Director of Immunisation
£ 175,000 - £ 179,999

Lindsey Davies Interim Regional Director of Public Health (you can even work out how much an interim is worth)
£ 165,000 - £ 169,999

Martin Bellamy ICT Director
£ 160,000 - £ 164,999

Sir Hugh Taylor Permanent Secretary DH
£ 155,000 - £ 159,999

It seems you get more for buggering up the health service and not seeing or treating patients than you do for seeing and treating patients. And we bet they can all be seen by any patient in the UK within 48 hours and are doing extended hours and weekends as well for the same salary.

Praise be to the Party for its new “transparency”. How long will this last we wonder?