Wednesday, 28 July 2010

Liberating the NHS: some thoughts on the Great Patriotic White Paper 003 of 007.

Recovered yet from the last chapter of the NHS “Liberation” War? It is hard work comrade and many will suffer as we fight to achieve the true liberation of the NHS Motherland on the orders of the new comrade Marshals NC/DC.

So mount up as we go onward to the second battle “Putting the patient and public first”.

Stirring words from our comrade Marshals and they should know given their collective humble upbringings about comrade Joe Public and their healthcare needs.

Don’t forget your bingo card so let us begin with the first section of this battle of liberation: “Shared decision-making: nothing about me without me”.

Notice the start of possible subtle recurring themes? “Nothing about me without me”. Seen this before?

“The Government’s ambition is to achieve healthcare outcomes that are among the best in the world. This can only be realised by involving patients fully in their own care, with decisions made in partnership with clinicians, rather than by clinicians alone.”

Sounds good a bit more flannel and then:

“But compared to other sectors, healthcare systems are in their infancy in putting the experience of the user first”.

They certainly are for when you are a politician or a manager who might speak to one or two patients a week, if they are lucky, in one of their “surgeries”, see how much time they spend listening to the experiences of the user.

If you guys came and spent a couple of weeks in an A&E department, a general Practice surgery and an acute hospital admissions unit you would realize why. For none of your advisors have ever been there. The troops on the ground know what the problems are there and their managers and politicians ignore them or deny them.

Still we know when grunts and patients on the ground complain that there is no ammunition,beds or nurses there will be more pearl handled sidearms for the managers as a result.

They will look into the problems, do nothing and pat themselves on the back for doing so well.

“The new NHS Commissioning Board will champion patient and carer involvement, and the Secretary of State will hold it to account for progress. In the meantime, the Department will work with patients, carers and professional groups, to bring forward proposals about transforming care through shared decision-making.”

Not the NHS Commissioning Board again? Its responsibilities mushroom every few paragraphs. How will it cope? Is the buzz word “champion” the same as the word “ignore”?

Shared decision-making” is that the same as more "consultation exercises"?

Onto “An NHS Information revolution”. More good Soviet top down words here “revolution”. Jo S would be so proud of his new boys.

Information is not knowledge or experience. You can read a book on how to drive a car, fly an airplane but still that is theory. Information in isolation is not experience or necessarily how to do something.

“The Government intends to bring about an NHS information revolution to correct the imbalance in who knows what. Or aim is to give people access to comprehensive, trustworthy and easy to understand information from a range of sources on conditions, treatments, lifestyle choices and how to look after their own and their family’s health.”

That paragraph is clearly written by someone who has never worked in frontline healthcare as you would be amazed by just how much information, and disinformation, is out there. Just try listening to patients. Information is not the problem, quality care is.

Read on:

“The information revolution is also about new ways of delivering care, such as enabling patients to communicate with their clinicians about their health status on-line. We will provide a range of on-line services which will mean services being provided much more efficiently at a time and a place that is convenient for patients and carers, and will also enable greater efficiency”.

Now we like technology, well some of us do here at ND Central, and have had a Eureka moment after reading that paragraph.

For example: why not let surgeries and patients book hospital appointments on line and call it Choose and Book?

Or why not let patients be able to ring a call center 24/7 to discuss their symptoms and let us call it NHS Direct?

All examples of centrally imposed NHS IT driven efficiency? Excellent bring it on (line) we love progress. All of the above ideas have been tried, failed increased GP workload and patients hate them. They want to see real doctors and nurses.

Spend more to achieve less? Been there done it and all we get is more “efficient” square wheels.

We bet no-one in frontline healthcare wrote that pile of smoking dung which smacks of something repeating itself comrade for the clear “benefit” of the comrade patient.

“Information generated by patients themselves will be critical to this process, and will include much wider use of effective tools like Patient-Reported Outcome Measures (PROMS), patient experience data and real-time feedback.”

Amazingly frontline healthcare professionals like doctors and nurses already do this on a daily basis with no fancy initials and without having to go to a PROM.

It is called talking to, listening to and learning from patients.

If several of them say to you “I have seen surgeon Y and they were crap”, and they have complications you can report this and nothing happens.

You then stop referring patient to that surgeon and thereby improve healthcare without involving useless management “tools” and abbreviations.

Read on and see that the rise of data collection management via already failed methods e.g. patient experience surveys and real-time feedback which results, as it does now, with patients being completely ignored.

Imagine a health service manager listening to Ferdinand Magellan saying “I have sailed round the world?” He would have been told his metrics did not meet the patient experience survey results and therefore the world was still flat.

Read paragraph 2.8 in its full but only if you are having difficulty sleeping and want a laugh. Look at the last sentence and what we said 2 paragraphs above.

The last sentence says “The Department will seek views on how best to ensure this approach is developed in a coherent way”.

Not that difficult but you might have to start by talking to people who probably already have the information you want for the first time.

Paragraph 2.9 starts with “Information will improve accountability”.

We think you can ignore the rest of that long paragraph as historically whistleblowers who point out something is wrong have been persecuted. We respectfully draw your attention to this site (slow to load).

We see only the creation of more useless and expensive management who will be unable to see a Gulf of Mexico sized oil spill on a sheet of A4 paper even when someone tells them “there is something seriously wrong here”.

More information about commissioning of healthcare will also improve public accountability”.

And who’s going to provide this?

The GPs who are being GPs now, who will soon be working on commissioning, and also having to produce reports about their commissioning, or possibly a new type of manager to improve accountability?

In another little cuddly grey box there are a few more bits of common sense that have been frequently ignored. It says that “In future, there should be increasing amounts of robust information comparable between similar providers on:

Safety with no doubt added matron power for example about levels of healthcare-associated infections, adverse events and avoidable deaths, broken down by providers and clinical teams.

Effectiveness: for example, mortality rates? does this mean deaths possibly on a ward by ward basis to not doing . . . and patient-reported outcome measures. Is that another tacky stretch limo trip to a local PROM or are we just thick up North?

If you are concerned regarding the liberation of your own personal medical details, a keystone to the doctor patient relationship for centuries, then hold on to your hat for the Parties of the individual are about to possibly show their commitment to you.

Paragraph 2.11 starts benignly enough:

“We will enable patients to have control of their health records. This will start with access to the records held by their GP and over time this will extend to health records held by all providers. The patient will determine who can access their records and easily be able to see changes when they are made to their records. We will consult on arrangements, including appropriate confidentiality safeguards, later this year”.

Sound familiar? Looks like the online transfer of medical records will continue even though it is totally unnecessary for the treatment of patients and will cost a bomb.

2.12 “Our aim is that people should be able to share their records with third parties. . . .We will make it simple for a patient to download their record and pass it, in a standard format, to any organization of their choice.”

But then the next paragraph shows the underlying reason for NHS computerization of records the “Making aggregated, anonymised data available to the university and research sectors . . .” and how long before the private sector gets its hands on all this information and exploits it? Think it hasn’t already been doing this for a while? Click this link.

Ask your doctor if you have given your consent to take part? And Big Brother wants more.

There will of course be robust safeguards “. . . to protect personally identifiable information. We will consider introducing a voluntary accreditation system . . .”.

Patients and carers (and hackers?) will be able to access the information they want through a range of means . . .”

Now we would not suggest that Big Brother is going to become bigger just read further:

We will ensure the right data is collected by the Health and Social Care Information Centre to enable people to exercise choice.”

Old Party out New Party in, spot the difference? Déjà vu? NHS IT looks like it is going to get bigger like it or not. And it continues in a similar vein until the excitement of “Increased choice and control .”

Are we having another flash back here? The choice word again but here with the control word. New Party same as Old Party for they admit that “The previous Government made a start on patient choice . . .”.

It certainly did it, denied it par excellence. You could have any choice as long as it was that chosen for you by the local Party and its commissars.

Of course the implication is that the failure of choice is the GPs’ fault “just under half of patients recall their GP has offered them choice”. Could this be because there was no choice or is that people don’t remember much?

Can you describe what your other half is wearing today? Try it, it might be important if there were to be a disaster and you would want to try and identify someone over the phone. Were they wearing their pink or grey shirt with their jeans or where they wearing slacks? Try it.

There is another little cuddly grey box full of nice things a bit like a child looking in through a sweet shop window at lots of nice things but knowing also that nice things are expensive. “You can even register with any GP practice with an open list without being restricted by where they live.” Familiar?

Another long boring paragraph but alarm bells ring when the words “. . . maximising use of Choose and Book.” Why? This is centrally controlled denial of Choice by morons who claim you have a choice.

Talk about resuscitating dodos, we have said before no-one writing this White Paper has been in Front Line medicine for decades.

The previous Government recently started a programme of personal health budget pilots. International evidence, and evidence from social care, shows that these have much potential to help improve outcomes . . .”

In other words if you have to pay for something you might not use it so much but read on:

“ the Department will encourage further pilots to come forward and explore the potential for introducing the right to a personal health budget in discrete areas such as continuing care.”

We like the word “discrete” Does that mean a wad of twenty pound notes in a plain brown envelope passed under the desk to a patient with a certain illness? “Don’t tell anyone I am giving you this money or they will all want it.”

“We expect the choice of treatment and provider to become reality for patients in the vast majority of NHS-funded services by no later than 2013/4. The NHS Commissioning Board will have a key role . . .”

Haven’t we already had “choice springing out of our eyeballs? And the NHS Commissioning Board following the end of the SHA/PCTs how are the 5 lowly paid members of this board going to be oversee yet another task?

Onward comrades, and remember this is a hard war of liberation, to the next section. Stay awake for we would hate for our NHS to be overtaken by evil Soviet forces called Government so let us rally and read “Patient and public voice”.

Sounds so lovely but Uri do not listen to your sergeant when he says no-one listens to the patient or the public voice.

But onwards we must not tire for the good comrade Marshals ND/DC say:

“We will strengthen the Collective voice of patients, and we will bring forward provisions in the forth coming Health Bill to create Health Watch England, a new consumer champion within the Care Quality Commission.”

In the same way that criminal gangs introduce their own street speak so does any new Government possie introduce a whole load of ghetto speak like this possibly more quangos:

“Local Involvement Networks (LINks) will become the local Health Watch, creating a local infrastructure, and we will enhance the role of local authorities in promoting choice and complaints advocacy through the Health Watch arrangements they commission”.

Presumably under the Big Society all these new organizations will be staffed by local volunteers?

Brace yourselves comrades for what follows may be a work of fiction para 2.26:

“All sources of feedback, of which complaints are an important part, should be a central mechanism for providers to assess the quality of their services. We want to avoid the experience of Mid-Staffordhsire, where patients and staff concerns were contunally overlooked while systemic failure in quality of care went unchecked.”

The words bull and excrement come to mind and if you want to see how this works in practice check out the Ward 87 blog. There is a lot there regarding events in Staffordshire and it will take a lot of time to read but it is very enlightening.

Still it might all get mentioned on the “Local Health Watch” TV program investigating crimes against local health care.

Skip the cuddly grey box it is merely brown and smelly and another layer of bureaucracy to replace the SH/PCTs that will disappear.

And at long last we reach the end with a nice little “onion” picture of the new cuddly NC/DC version of healthcare for the future.

Praise be to the Party for once again putting the patient first behind the Party and all its new quangos. Are we just dumb oop North or have we just had a mega déjà vu moment from Za Nu labour in terms of health policy?

Tuesday, 27 July 2010

A drive home and some thoughts.

This evening one of the team had the “pleasure” to do one of our, and our staff’s, beloved extra Brown ones.

These are those extra surgeries that a former unelected leader of this country thought that his people needed because they couldn’t get to see their family doctors as they were too busy working.

These have not been popular with most GPs as for starters it meant extra hours for no extra pay and we have some of the longest working weeks to start with. It has not been popular with GPs’ staff particularly those with families as it disrupts their days and weekends. They certainly haven’t been used by many commuters up North for most of those who attend are pensioners followed by children.

So once again as we drove home from one of these extra commuter friendly surgeries, where we had seen the usual pensioners hot off the 19.00 train from Kings Cross, and the work weary toddlers back from Amsterdam on the 18.50hrs flight to our local airport, we thought.

Our main thought, as we drove our state funded Farrari at 200 mph, sorry officer it was only 60mph, along the high deserted moorland lanes of Northernshire, was what is the former “Great Leader” doing now?

Actually our main thought was that was of avoiding the pigeons. For pigeons in these parts are grey and so is the tarmac.

Once most of the workers are tucked up at home watching the evening soaps after their working day which runs from 09.00-17.00hrs the local pigeons descend for an evening feast of discarded McDonald’s meals chucked from cars during the day.

Pigeons avoid the roads during the working day but outside of it they lurk on the roads almost invisibly until disturbed by the odd passing GP after an extra Brown one.

The sight of a large pigeon struggling to clear the top of the car is not pleasant and this often happens more than once on early morning or evening drives home. Some of the local McDonald's fed pigeons are overweight and could put a big dent in the bodywork so thay are best avoided if at all possible given their stealth camouflage.

We digress somewhat for we were wondering what the “Great Leader” was doing now? A normally good source of information is the political blog Guido Fawkes who seems to have had similar thoughts and you can see how much time the "Great Leader" is spending representing his constituents here.

Worse still tomorrow he will have to suffer a shortened summer break of only 38 days.

We felt good that in the same period we had had 5 days more holiday than the days he attended the House of Commons. It made us feel that we needed the extra Brown ones as we were inspired by his tireless, selfless devotion to his patients, sorry constituents, of Kirkcaldy and Cowdenbeath.

At least he alone made the idle overpaid GPs earn their money by doing some work, for a change.

Praise be to the Party for giving us men and women who know the people and seek ever to improve the NHS on their behalf. No doubt there will be more such wisdom and hard work for some to come in the near future.

Sunday, 25 July 2010

Statistics, QOF, fraud and detection in the NHS.

While busily waiting for the next patient to attend during our Party imposed one 10 minute appointment slot suits all, 2.5 hours of booked surgery as opposes to 1 hour of actual of consultation time, we used the down time to trawl the web and found this interesting piece on a BBC News website.

Now if you have a scientific background this makes perfect sense.

If you only have a Harvard or Yale MBA, which all our local PCT managers have, even the cleaners, then you can be sure they understand this excellent piece on how statistics can make you a killer when in fact you are not. For just listen to them act as judge and jury on any topic while they are busy working.

Two examples from general practice illustrate this.

The first involves their policing of the QOF points. QOF stands for neither a Quality nor an Outcomes Framework.

It merely means a box has been ticked on a computer program. You do not need to see any patient, or give any patient any treatment, just tick the box. And, as a result, you, as a GP can get paid. Simples.

So a practice that has average number of QOF points will not incur any investigation even though none of its patients are receiving any treatment but will still get paid.

Now the NHS has “robust” anti fraud policies so that no GP with no qualifications can ever get away with prescribing creosote for toothache – we jest not read down this link towards the bottom and another did the same too read the small print at the bottom. The NHS has some of the finest forensic brains in the fraud busting world which would make CSI seem like rank amateurs for the only bit of a CSI episode they could understand was the adverts.

They employ advanced fraud busting techniques like if you get the top end of QOF points you are bent.

Of course in the same way that the “boffs” in their class at school got 98-99% scores in exams it was because they were “bent” not clever, or when they are grown up good doctors, while the fact your average PCT fraud buster got 40% in their exams was ‘cause the ref weren’t on their side.

If you are in the bottom of QOF scorers you are also bent. For surely you are not looking after patients? This might be the case but there might be another reason for this, for example the patients do not come to clinics.

And indeed this might be a combination of the above factors. A high scoring practice on paper but when you actually start looking at the patient care it is nonexistent?

However if you are in the top of the local QOF points or the bottom ones you are suspect and will receive the third degree.

This is the average PCT fraud busters approach which is similar to those in Whitehall who saw all of those Weapons of Mass Destruction from afar but in fact they saw nothing but they were still there, allegdedly.

This brings us onto the second argument doing the rounds of the thick regarding PCTs and their Harvard MBAs saying that referrals are too high.

Is that the same as saying illness is too high? “Comrade Zhivago you have referred too many cases of TB from your labour camp. Please stop this as we have overspent our TB treatment budget and you are referring above the 5 year plan targets”.

Is a high referring practice a “poor” practice because it refers everything correctly or, is it a “poor” practice because the GPs are crap and can’t manage simple things that better practices could?

Equally is a low referring practice a crap practice because it does not identify and therefore ignores disease and fails to treat it, or, is it a good practice because it treats disease that does not need to be referred to hospital?

Both these instances affect GPs and if you read the link you might start to realize that some things can appear to be real not because they are but they can also occur by chance.

If you think the odds are small then try this one for size. We wrote this piece on Friday night at the Café Michelle after reading it in the afternoon. We were going to proof read it and publish it today expecting no-one else would have spotted the original piece in the link above.

What are the odds of 2 medical bloggers, one a consultant, respect Dr G, the other a GP reading the same article and being prompted to post their thoughts on the same day? Statistical chance or conspiracy? You decide and you can read Dr Grumble’s thoughts on the same item here.

Praise be to the Party whose knowledge of statistics is second only to their knowledge of healthcare and how to run it. We are in such good hands.

PS Seems another medical blogger has read our inspiration for this piece the Witch Doctor. Did all of us have a slow Friday afternoon and “randomly” click on the BBC News website? Cue X-Files music . . .

Thursday, 22 July 2010

A NHS Website for all seasons?

There have been a few articles recently including in the main stream press about the cost of Government websites for example here and here.

Given that some of our medical students top up there meagre “income” by designing websites, we have been offered ones for between £50-100 and examples of their work for various organizations including businesses show that a simple easy to use website does not cost too much to have designed for you.

You can even find these “metrics” on you guessed it a Government website.

An article in the GP Magazine this week shows just how good the bright boys and girls are at the Department of Health are. Unfortunately we cannot link to this article but it concerns the fact that during the World Cup the Department of Health spent £ 15,300 on a Facebook “health game” called the “NHS World Cup Football Fan Fitness Challenge.” It also featured on the NHS Choices website and an iPhone application .

You can have a look yourself here. It is called a "tool".

A staggering 12,000 people accessed it which meant it cost £ 1.28 per user the article says. We tried working through it but it is like most things British and sporting you don’t get much further than the first round and then nothing happens.

We have featured this site before and we went back to our post and amazingly all the links still work so if you have any male genital problems check it out for loads of "helpful" medical advice.

The article goes on to say that the Department of Health’s website costs £ 2.9 million a year to support its soporific green tones. Have a look at the inspired design and click any link to see them in their full glory. While you are there, at present, you could even read about Liberating the NHS. Party on dudes!

If we add the two figures you get roughly £ 32 million for 2 websites or £ 16 million per site a year. We asked our colleagues if any of them had a turnover of about a £ 1 million and did some multiplication and think that you could get about 160 whole time equivalent GPs, 160 nurses and healthcare assistants as well as secretaries and reception staff who between them could provide full time GP surgeries and the services offered there to a population of 320,000.

Now if you are ill which would you want to use or see? A doctor, a nurse or a “tool” on a NHS website? Which is most likely to be able to help you?

Praise be to the Party who gave us the phrase a bad workman blames his tools. Based on our experience of NHS IT and websites there are sure to be many good tools in the DoH’s IT department.

Monday, 19 July 2010

Liberating the NHS: some thoughts on the Great Patriotic White Paper 002 of 007.

Well comrade healthcare workers on the frontline, the executive summary must have stirred you up in to a fever pitch of liberating zeal. You will no doubt by now be burning your local PCT and looking forward to section 1 “Liberating the NHS”.

We would urge you to have a stiff few vodkas for although the first battle in the liberation of the NHS is a mere 28 paragraphs it is word heavy and a long battle.

Gosh it starts so well as do all patriotic wars of Liberation with the following words of inspiration to those on the frontline (don’t forget your bingo cards as you read):

It is our privilege to be custodians of the NHS, its values and principles. We believe that the NHS is an integral part of a Big Society, reflecting the social solidarity (no reference there to Polish liberation comrade?) of shared access to collective healthcare, and a shared responsibility to use resources effectively to deliver better health.”

Phew the bingo card is red hot after that one short paragraph and it gets better!

“We are committed to an NHS that is available to all, free at the point of use and based on need, not the ability to pay.”

We think this means don’t cancel your BUPA subscription yet.

The usual empty words of increasing health spending, fairness, doing what is right etc follow. The new quango, the “NHS Commissioning Board" will have “an explicit duty to address inequalities in outcomes”. Whoopy we can’t wait to see how little this will mean but how big the salaries of those working for it will be.

Furthermore “we will uphold the NHS Constitution” and, “By 2012 will publish the first statement of how well organisations are living by its letter and spirit.”

Anyone know what is in the NHS Constitution? We know of it but it is an irrelevance to our jobs in the same way as the Geneva Convention is to those in Quantanamo Bay.

Current statutory arrangements allow the Secretary of State a large amount of discretion to micromanage the NHS.” Clearly “large” and “huge” are not the same words when applied to buggering up the NHS.

“We will legislate to establish more autonomous NHS institutions . . .” more quangos anyone?

Read on to the section “The NHS today”.

Super buzz words follow here: “At its best, the NHS is world-class. The people who work in the NHS are among the most talented in the world, and some of the most dedicated public servants in the country.”

Yes it is, and they are, and if you have had the privilege of working in genuine first world medical centres the benefits of their abilities are self evident.

Unfortunately most of the current swamp of NHS managerial incompetents do not ask how high can we jump but, how low as an intellectual slug can I crawl, to meet my targets and get paid and have done so for the last 13 years and called everything “world-class”.

It maybe “world-class”, but, and this is an almighty but, it is not first world class. If you think the NHS is world-class you are probably an NHS manager who thinks that wiping your bum once a week and having a dip in a sheep dip every other Christmas is “world-class” hygiene and that you can defeat MRSA by a wash your hands campaign.

“Other countries seek to learn from our comprehensive system of general practice, and its role as the medical home for patients, providing continuity of care and coordination.”

Since when? Most countries seek to avoid the costs and since when has “continuity of care and coordination” (hint Darzi centres, walk in centers, NHS Direct) been the home of any Government policy? Care on the cheap is the bottom line and in an economic down turn . . .

The NHS has an increasingly strong focus on evidence-based medicine supported by internationally respected clinical researches with funding from the National Institue for Health Research, and the National Institute for Health and Clinical Excellence (NICE).” Really?

Anyone playing a game of intelligent medicine Top Trumps knows that whoever quotes NICE has already lost the argument. Try it an international conference and reduce your audience to uncontrolled laughter. “Evidence-based medicine” is not cutting edge science it is a fudge often used by Government to justify crap care.

Other countries in the world admire NHS delivery of immunisation programmes.” Look at the map to see how good we are or again here.

And “Our patient participation levels in cancer research are the highest in the world?

An achievement? Or perhaps because the cancer care provided means that the survival rates and treatment provided are amongst the worst in the civilised world?

Ever been a patient who has been mismanaged and then had people falling over themselves to offer you a chance to take part in a trial? Dead if you do most certainly dead if you don’t. No Win Britain, like the World Cup, we take part but unfortunately the patients lose as the Managers try repeated new training techniques for the players sorry, patients.

There is nothing better than “take a chance” card in the NHS cancer care monopoly game. If you live in Mayfair you are more likely to win than down the Old Kent Road even in a National Health Service.

Now we are getting serious. “Compared to other countries, however, the NHS has achieved relatively poor outcomes in some (most?) areas.”

The Party leads on to some well hackneyed healthcare beasts to frighten Johnny Public like MRSA, and DVTs and even asthma but fails to comment on the causes of these diseases.

The “NHS also scores relatively poorly on being responsive to the patients it serves”. Never? Does that mean it fails to listen to its non paying customers?

The NHS is admired for the equity in access to healthcare it achieves; but not for the consistency of excellence to which we aspire. Our intention is to secure excellence as well as equity.”

One is cheap the other usually costs. Someone once said of healthcare you can have universal coverage, excellent care and cheap costs but you can only realistically have 2 out of 3 not all 3.Which do you think will win?

But onto “Our vision for the NHS”.

All in a little grey box. Lots of lovely words all about NHS la la land which few, if any, who work on the front line will recognise but all would like to provide. Anyone who thinks that is how the NHS works in the real world should seek immediate help from a mental healthcare worker as it should be laminated it and using it as a tool to screen for severe mental illness. Paragraph 1.10 if you are desperate.

Anyone who thinks this “vision” is real and works in the NHS at any level is mad or is a politician.

Back to black and white as it then says “This is our vision.” A dream or delusion? Read and decide for yourselves especially if you live and work in the NHS.

Our strategy to implement this vision draws inspiration from the coalition principles of freedom, fairness and responsibility.”

More piggies anyone? Freedom, fairness and responsibility?

We’d keep paying the BUPA subscriptions for when you are ill Freedom, Fairness and Responsibility will all be top trumped every time by NHS “efficiency gains”.

Now at last we get on to some bona fide military tactics. Stand easy soldier but listen up for:

The headquarters of the NHS will not be the in the Department of Health or in the new NHS Commissioning Board but instead, power will be given to the front-line clinicians and patients.

The headquarters will be in the consulting room and the clinic.”

Excellent! Our consulting rooms will now be like little Abrams tanks where we as the GP, the tank commander, can direct our crew to fire our patients at any target we like with no rules of engagement?

The Battle of the Economic Bulge won in the consulting rooms of NHS General Practitioners?

“The current architecture of the health system has developed piecemeal, involves duplication, and is unwieldy.”

Why is this so despite every Government since its inception “reforming it for the better”? Surely it should be running smoother than any Formula One car ever has?

“Liberating the NHS, and putting power in the hands of patients and clinicians, means we will be able to effect a radical simplification, and remove layers of management.”

Can we think of any recent liberations where troop numbers are reduced after the war is won? Equals more management but this time not central Government ones so that is OK.

Next we are onto “Improving public health and reforming social care”.

“Liberating the NHS will fundamentally change the role of the Department. Its NHS role will be much reduced and more strategic. It will focus on improving public health, tackling health inequalities and reforming adult social care”.

Nothing new there it will continue “strategically” reforming the NHS for the better, comrade healthcare workers in the same way it has for the last few decades.

“The forthcoming Health Bill will support the creation of a new Public Health Service . . .” Not another quango?

“PCT responsibilities for local health improvement will transfer to local authorities”.

Which ones given no PCTs or SHAs will our local councils take over? Or another layer of, sounds boring, quangos? Could a theme be emerging? Abolish one, make two . . .

“The Department will establish a commission on the funding of long-term care andsupport, to report within a year.”

Oh no not another one?

“The Government will bring together the conclusions of the Law Commission and the Commission on funding of long-term care, along with our vision, into a White Paper in 2011, with a view to introducing legislation in the second session of this Parliament toestablish a sustainable legal and financial framework for adult social care.”

Another one?

Another section starts with the title “The financial position”.

A simple summary of this is there is no money good luck.

And so at long last we arrive at the end of the first great battle of liberating our NHS the conclusion: “Implementing our NHS vision.”

Read our selection from this:

“This White Paper is our strategy for the NHS during this Parliamentary term, so that it is liberated to deliver the best quality care over the longer-term. In the next five years, the coalition Government will not produce another long-term plan for the NHS.”

Just going to have major re tinkering with this one every few months?

And finally dear comrade reader anyone who is a professional knows that the buck ultimately stops with you, in contrast to current NHS managements where failure means promotion so look at what the new Anglo-Soviet war on liberation ends with (altered annotation = ours):

“Once they are in place, it will not just be the responsibility of government, but of every commissioner, every healthcare provider and every GP practice to ensure thattaxpayers' money is used to achieve the best possible outcomes for patients.”

Praise be to the Party for so clearly setting out who will be at fault if the Great Patriotic War of Liberation fails. The infantry on the ground of course how could it be the Marshals in charge’s fault?

NHS Reform: if it ain’t broke, keep fixing it until it is.

Can't wait for the next installment can you?

Wednesday, 14 July 2010

Liberating the NHS: some thoughts on the new Great Patriotic White Paper 001 of 007.

Comrade patients, the cry to battle against the oppressive Fascist scum who have been running the NHS has come from our glorious Socialist leaders of the coalition of Allies. It is time to liberate the NHS and to battle for the freedom of the supreme Soviet of patients.


Think we might have gone off on one there after all it was just another White Paper which you can read in all its revolutionary glory here. It has six sections and an executive summary so we thought we would “analyse” each bit and for those avid players of buzzword bingo we will put in red any buzzwords on our bingo cards. If you want to play along you can get a bingo card from here.

So eyes down for “Our strategy for he NHS an executive summary” so grab you PPSh-41 and join us in the liberation of the Motherland.

The document starts with a 3 paragraph mission statement. Always good to start a war of liberation with a strategy. It is the usual we think the NHS is a good idea and should be free, we will pump loads of money into to achieve “results that are amongst the best in the world”. Not world-class or is this now passé?

Next is “Putting patients and public first” which starts with this phrase in italics “no decision about me without me”. If this is to be a core principle what happens to the unconscious patient? Or don’t they count in the new NHS?

It goes on to say patients will have “increased control over their own care records”. Interesting to see what that might mean. An opt out clause, or perhaps having to opt in, or better the abolition of the electronic Summary Care Record?

Then the “choice” word appears no less than 5 times in 2 sentences. Particularly interesting is the “extend choice in maternity through new maternity networks”. Is this the arrival of the cyber midwife or an end to the normal way of producing babies?

Some ideas just get recycled so patients will be able “to rate hospitals and clinical departments”.

Fighting a war of liberation requires the establishment of new elite units and as this is a Great Patriotic War of Liberation, the Party “will strengthen the collective voice of patients and public through a powerful new consumer champion, HealthWatch England, located in the Care Quality Commission”.

Well that should mean a toothless tiger although when we first read it we did wonder if this would be a new BBC program hosted by Nick Ross and highlighting unsolved crimes within healthcare?

Onto “Improving healthcare outcomes” and the word world-class makes its first appearance. There appears to be a contradiction in what follows in that it starts by saying the “NHS will be held to account against clinically credible and evidence-based outcome measures” which we would hope most doctors try to do but then the antithesis of such a noble and professional ideal appears in that “Quality standards, developed by NICE, will inform the commissioning of all NHS care and payment systems”.

No let up there in State funded interference in medical care under the new Party.

Any hope that the internal market will disappear is dashed by the phrase “Money will follow the patient” and “Providers will be paid according to their performance.”

Still awake comrade for “Autonomy, accountability and democratic legitimacy" follows with stirring management buzz words like “will empower professionals and providers” a couple of good words for your bingo card in that one.

To free up more doctor and nurse time to treat patients it is planned to “devolve power and responsibility for commissioning to the healthcare professionals closet to the patients.” What joy to come!

After years of being involved in commissioning we are now about to be involved in yet more commissioning. Remember all those meeting sitting around going nowhere? Well there is more to come and until we know more we are in limbo going nowhere fast so no changes as yet there comrade commissioners.

And it gets better, another quango to brighten the dark hours as we head towards our liberation. A “NHS Commissioning Board” will be established no doubt to employ all the senior managers to be made redundant? It does however say “we will limit the power of Ministers over day-to-day NHS decisions”.

Dream on guys no Party in the history of the NHS has kept its grubby little hands off the NHS.

And then “All NHS trusts will become or be part of a foundation trust”. Will this be by driving up, or down, standards or just changing the names on the signs and letterheads? Top market tip buy shares in printers and sign painters for they will lead the economic recovery via the NHS liberation budget.

The next bit we are sure will wake you up as it is called “Cutting bureaucracy and improving efficiency”. Subtle change in wording as “savings” are now replaced by “efficiency gains” which need to be achieved on an “unprecedented” scale to release £ 20 billion” by 2014.

Reduce “NHS management costs by more than 45% over the next four years, freeing up further resources for front-line care.” Is that the front-line called the Treasury by any chance?

We will radically delayer and simplify the number of NHS bodies . . .We will abolish quangos that do not need to exist . . .” and replace them with new ones (see above)?

And finally we reach the “Conclusion: making it happen”. “We will give the NHS a coherent, stable, enduring framework for quality and service improvement,” by once again reorganizing it.

Praise be the Party for liberating the NHS.

Will this be the kind of liberation enjoyed by Eastern Europe at the end of the Second World War? We shall see in the next 6 sections of this White Paper after all this was just the opening skirmish in the liberation of the NHS.

Sunday, 11 July 2010

Fundholding about to be reborn?

There would appear to be a change a coming in the NHS as we know it.

And the Daily Mail says this.

Oh no not another pay rise for doing nothing. How do GPs cope with being the most highly paid in the world? Possibly because our workload is amongst the highest in the world and about to increase as we take on another job in addition to our already many day jobs?

Now anything that keeps changing its name is usually worthy of a degree of scepticism.

Think “Health Authority” or “Primary Care Group” or “Primary Care Trust” or now “NHS Shiteton”. Same group of incompetent idiots doing the same job but hiding their incompetence behind ever changing names.

So the former idea of “fundholding” aka “practice based commissioning” aka “world class commissioning” will become whatever the new word is, or will be, possibly “federating”?

Let us consider a few basic facts:

1) The country is in deep economic brown stuff.
2) Although the NHS budget is protected, this does not mean it is going to increase which with inflation will mean effective cuts in all but name.
3) Commissioning in its various guises does not work, thus far, and we have had 20 years of it.

We hope these simple truths are self evident to our readers.

Ergo central Government will appear to decrease costs and appear to generate “efficiency savings”.

However central imposition of failed ideas will lead to local increases in costs to GPs/GP consortiums/GP Federations etc.

As GPs will then have to become managers this will lead to a possible reduction in GP availability. Alternatively they may employ private contractors to do this for them and there are locally people positioning themselves to do this and in doing so make a profit at the expense of the healthcare budget. Alternatively they will employ the redundant local NHS managers, at their expense, to run the local NHS budget.

Excellent - not.

We await the exact details but it will inevitably mean yet another reorganization as to how GPs and their staff work and more bureaucracy.

So given the current “market” theory why not suggest a change that makes GPs “responsible” for a budget and gives patients a “choice” but also makes the patient, “accountable” for their choices to someone they may just respect?

At present “the consumer” in the NHS, the patient, has no responsibility and can take themselves anyone within the NHS at no cost to themselves. If you are a nutter with no friends you have unlimited access to the current NHS “Choices”.

Why not introduce (new) GP commissioning (nGPC), notice the subtle rebranding of old ideas and words, whereby if a patient accesses a health service the local GP is billed from the patients own “share” in their practice’s budget?

If the GP feels that the patient’s choice is inappropriate, for their alleged healthcare need, then the GP can block the charge to their budget, and on behalf of the State, reclaim the cost of the service used from the patient?

That way the State would not be the judge on who spends the NHS’s money but the local GP would be and, because they know their patients, they know whether their patients accessing of healthcare was medically appropriate, or not, they could be judge and jury?

This might make patients think.

For example if you go away on holiday and forget your medication whose fault is that? At present it is the NHS budget’s fault and your drugs are replaced for free. Not a medical reason so bang £65.00 for an A&E attendance + cost of drugs to patient. Bet they won’t do that again.

If we as GPs tell asthmatics they can get inhalers on repeat prescriptions from us but instead they go up for a routine prescription for an inhaler from A&E at £ 65.00 a shot and a GP says no, you pay for that as it is available free from us, guess what might happen?

Maybe this form of commissioning might be more cost effective as people would be financially accountable for their own actions if they are not medically appropriate, but would be free to use the health service at no cost if they are genuinely ill?

We, as GPs, already do this when we read discharge letters from hospitals, outpatient clinics and accident and emergency departments so to tick a box saying “Practice pays bill” or “Invoice patient” (with extreme prejudice?) would be very little extra work for most GPs but such fun!

Instead of sharing our concerns and frustrations with our colleagues as we read our correspondence, "Oh no, Patient X has had their fifteenth inhaler from A&E this week" we could be sending them a bill and suggesting they actually get their asthma treated by us.

This was just a thought as we discussed fundholding as it was, the dismal failure of current commissioning and the (black) thoughts of things to come this week over a few medicinal beers at the Café Michelle.

Still, at the end of the evening, the thought of some ND Central’s prime NHS misusers’ faces on being told they would have to pay for the NHS and its services was well . . . priceless.

If only . . .

Praise be to the Party who appear to be starting a summer of many nights of the long knives.

And many nights of GPs reading long documents, meetings, reorganizations . . . all for the benefit of our patients?

Or for that of the Exchequer?

Monday, 5 July 2010

I cannot ever get to see my GP, it always takes weeks to get an appointment. Some thoughts: The Party(s) 002.

We continue on from our rant regarding what our patients are repeatedly telling us about their alleged inability to get appointments when it suits them.

Now in the “market” economy, that is the current NHS favoured by all Parties, including the previous one, very few people, and we suspect this includes politicians realise that the vast majority of GPs are what are termed “self employed contractors”. This means that they do not get paid salaries as most employed people do.

Most GPs are no different from any other self employed people for example plumbers, corner shop owners or builders. Now businesses earn money as a result of satisfying the local market and making a profit.

Several of us at ND Central before we became Partners did some locum GP work. What struck us all was the sheer number of different appointment systems in operation at different surgeries that we worked at. These included 5, 7.5, 10 minute appointments or even 20 minute appointments and different ways of delivering them. For example turn up on the day, book in advance, we will only book so many in advance and the rest are drop ins and so on.

You could literally go from one part of a city and see one system of working and a mile up the road there was a completely different one.

So how could this be given that there is an alleged National Health Service in the UK?

Well we are simple here at ND Central and we suspect it was the fact that GPs adapted their provision of appointments to their local population and tried to arrange their workload to meet their local demand and also preserve their health, sanity and resources. We think this may be called being in business and hopefully "the contracted performer's service provision satisfying the local market”. (We love brown smelly NHS speak!).

One of the biggest restrictions to the availability of healthcare in the UK is whichever Party is in control. For it decides it knows better than those grunts on the ground. After all they saw all of those WMDs the world is still looking for and we missed too. But we are just thick GPs not politicians.

For the last 13 years we have had the Za Nu Labour Party who adopted a Soviet top down management style of the NHS and failed to realize that, with the exception of China and North Korea, this had failed the world over.

So how has centralizes Soviet style control reduced the supply of appointments given that NHS expenditure has increased?

Well let us look at the alleged Quality and Outcomes Framework known as QOF which was part of the nGMS (new General Medical Services Contract) contract introduced in 2004. At the start of the nGMS contract the average appointment time for GPs was reckoned to be 7.5 minutes.

The Party, aka Mr Blair and Mr Brown, none of whom had any experience in healthcare, knew better and introduced a huge financial incentive for nGMS GPs to provide 10 minute appointments.

Many practices resisted this initially but, as Tony and Gordon thought that GPs who honour contracts should be paid (less), Tony and Gordon cut GP pay. However, as income started to drop many nGMS GPs started to introduce 10 minute appointments. Not because they were needed but because income was dropping. Money is the fuel of any business.

As a result local experience and knowledge, which had evolved different ways of working to satisfy local need, was replaced by Gord and Tony’s centrally controlled vision of healthcare where all people needed one size of boot.

Size 13 steel capped jackboot. Take it or leave it comrade one size fits all.

So what happened?

We give you a link to a now retired blogger’s thoughts on this and they did this at about the same time as we did and we suspect other GPs did too.

We would have liked linked to another GP blogger’s thoughts, more eloquent and experienced than we but Jobbing Doctor seems to be having a rest. We hope that Jobbing Doctor will return soon as the UK GP blogosphere is impoverished by the absence of someone who can post so well and frequently on a variety of matters GP.

A simple calculation of how many appointments at 5, 7.5 minutes and 10 minutes can fit into an hour (12, 8, 6) reveals the potentials drop per hour in the availability of GP appointments by adopting a centralised approach to GP appointments if you deliver healthcare via five minute appointments and then have to go to ten.

The Party has also introduced many other Soviet means of increasing local GP “efficiency” by denying patients appointments to see GPs.

Think about the 48 hour access target. The 48 hour access target meant that regardless of what your problem was you had a Party given right to see a GP in 48 hours.

Under the old system we used to hold “emergency” surgeries and all patients were given a card telling them that “emergency” appointments were for one problem only. The appointments were all 5 minutes only. Not for follow up appointments, or for repeat prescriptions, or for repeat sick notes or for getting results all of which are PREDICTABLE events unlike genuine illness which is not.

So five minute appointments were replaced by 10 minute ones. A potential 50% reduction in availability of appointments unless you double your working hours. As a result of ten minute appointments it has meant that some of us now spend more time waiting for patients than we do actually seeing them and more importantly we are seeing 6 an hour instead of 12.

So our “emergency” appointments were replaced by 48 hour access appointments which were rapidly used by those incapable of planning their lives and who had nothing better to do then play lotto appointments each day, twice a day, hoping to hit the last digit at the right moment on their phone to get an “emergency” appointment which met the 48 hour target for what was rarely illness.

Of course if an all wise Party cuts the number of appointments, surely it will increase the number of GPs during its tenue? Look what it says here:

“The strong growth rate in the number of practitioners noted last year has continued and the count of GP Providers has also risen, albeit at a slightly lesser rate of 4.6% since last year after a relatively static few years; the 10 year average annual % change is however only 0.3%, up from 27,681 in 1999 to 28,607 as at September 2009.”

By our maths that is a 3.3% increase over 10 years. Compare that with the 100% increase in managers over the same period and 12% increase alone last year.

We calculated that we dropped the number of patients seen in a week per partner by 22% on average and were spending 33% longer per patient over all following the switch to 10 minute appointments.

Another example of financial prudence from the old Party? No wonder Gordon was keen to introduce extended hours for GPs. For even with these we still provide almost 14% fewer appointments than we did before with no increase in GP manpower.

So if you cannot get an appointment think about what we have said and do not blame the receptionists. Remember GPs merely followed orders and gave you the patient what the Party thought you needed.

Praise be to the Party who by increasing appointment lengths to benefit you the patient have in fact made it harder to see GPs. Still there are some who think 20 minutes would be better . . .