Wednesday, 25 August 2010

Liberating the NHS: some thoughts on the Great Patriotic White Paper 006 of 007.

Well comrades, still awake? We are now onto the penultimate battle of the Great Patriotic White Paper of liberation of the NHS entitled : “Cutting bureaucracy and improving efficiency”.

Images of the team at ND Central walking around our local Soviet with chainsaws sprung to mind at our regular resistance meeting but then we must on and read.

A short spiel on economics follows but then: “Cutting bureaucracy and administrative costs.”

We are told that the new Party’s “ . . . first task is to increase the proportion of resource available for front-line services, by cutting the costs of health bureaucracy”.

Read on dear reader for “Over the past decade, layers of national and regional organizations have accumulated, resulting in excessive bureaucracy, inefficiency and duplication”. We won’t say we told you so but just read UK General Practice and medical bloggers to see how it is.

Onto the second paragraph 5.4 which says that “PCTs – with administrative costs of over a billion pounds a year – and practice based commissioners, will be replaced by GP consortia”.

An interesting statement that which shows those who wrote it have not got a clue. PCTs = crap and expensive yes but “practice based commissioners” have cost local practices a fortune to do nothing so how does that save the NHS? And who are the practice based commissioners?

None other than the self same GPs who will be in GP consortia. And who do we think they are going to employ to do the commissioning while they do their day job? So clearly lots and lots of central Government “savings” farmed out elsewhere. Or did we miss something?

“The Department will shortly publish a review of its arm’s length bodies. . . . we abolish organizations that do not need to exist.”

Anyone need any help? Just read a few medical blogs for starters. Have chainsaw will travel.

Lots more flannel follows but in para 5.6 a small glimmer of realization “But it has rapidly become clear to us that the NHS simply cannot afford to afford to support the costs of the existing bureaucracy; and the Government has a moral obligation to release as much money as possible into supporting front-line care.”

We cannot argue that last one with the good comrade Marshals but we have a sneaking suspicion as we probe further behind the White Paper that bureaucracy is going to increase via the NHS Commissioning Board and all 150 of its yet to be announced 150 “outcomes” which we suspect will enable GP consortia to swim the 100 meters in a “record” time while weighed down with a huge millstone of bureaucracy tied around their neck from central Government regardless of any moral obligation they may feel.

At present, there are over 260,000 data returns to the Department of Health . . . we will consult on the findings . . .”

Another done deal?

“The Government will cut the bureaucracy involved in medical research”.

What does that mean it will take less than a year to get approval for a medical research project? Can you imagine Alexander Fleming advancing medical science in today’s climate? A potential yes from the team at ND Central although it does involve a “review” = another committee.

Para 5.10 scuppers out limited joy re medical research with the following words:

“We are moving to a system of control based on quality and economic regulation, commissioning and payments by results, rather than national and regional management”.

The words "payment by results" have dashed all hope as another attempt to resuscitate the long decayed corpse of the NHS internal market appears to be on the cards here.

“ . . . we are committed to reducing the overall burdens of regulation across the health and social care sectors. . . . undertake a wide-ranging review . . . with a view to making significant reductions.”

Starting to recognize the pattern? Cut costs so have a review establish a committee but then:

“The reforms in this White Paper will themselves have one-off costs. We shall ensure these are affordable . . . while ensuring funding is focused on front-line patient care.”

Which bit of the chicken and the egg did we miss here. We will spend more on the frontline but in order to do so we have to spend more money on a review. Guess which, comrade patient, will come first to you and your family? The chicken, or, the egg?

Still do not be dispirited for read the next bit “Increasing NHS productivity and quality.” It starts with the following battle winning sentence:

The reforms in this White Paper will provide the NHS with greater incentives to increase efficiency and quality:

for such words have motivated NHS staff for generations to shout the following encouraging words urging their fellow comrade workers onto victory:

On no not another set of reforms”.

Another cuddly grey box from NHS La La land follows full of patient words and pseudo market language.

Para 5.13 states the “Taken together, these ten changes will bring about a revolution in NHS efficiency.”

And so after ascending onto Mount Sinai the latter day prophets Dave and Nick (Davnic?) did descend and bring down carved on 2 pieces of silicon chip the new 10 commandments of revolutionary NHS efficiency.

Para 5.14 starts with “Enhanced financial controls” which starts with “As well as providing incentives for greater efficiency, the new arrangements will provide for greater financial control:

And is followed but a second cuddly grey box. And look who pops up yet again? The NHS Commissioning Board with yet more responsibility. This is surely going to be a very small Board at this rate of knots?

Making savings during the transition” follows on with “We will implement the reforms in this White Paper as rapidly as possible”. Always a worry as how rapidly is rapid to the political classes? “But the NHS cannot wait for them all to be in place to begin to deliver improvements in quality and productivity”.

Patients are rightly demanding the former and the national economic position requires the later”. Patient usually want to see good medical care and care bugger all about the costs as they don’t pay up front and Governments have used this fact for years to bugger up the Health Service with numerous failed reforms.

And finally on to the last 2 mammoth paragraphs of section 5. The first of these starts with a QIPP = “The existing Quality, Innovation, Productivity and Prevention initiative will continue with even greater urgency, but with a stronger focus on general practice leadership.”

Lots of buzz word bingo words follow including reference to such QIPP successes as the “productive ward programme” = how to clean out broom cupboards, “increased self care” = stop eating/smoking/drinking you fat b*stards and the use of new technologies for people with long-term conditions = more nurses in call centres. All "proven" successes from a bygone Party.

A little nod to the Greens with some “improving energy” and “working with the Carbon Trust” should see all our patients healed remotely by an energy efficiency remote access call centre which is cost neutral.

The final paragraph is good for a few laughs as it would appear that “SHAs and PCTs have a current role in supporting QIPP”. This is sounding somewhat Soviet but read on:

In discharging this, and to pave the way for the new arrangements, they should seek to develop leadership of QIPP to emerging GP consortia and local authorities as rapidly as possible, wherever they are willing and able to take this on.”

So things that are to disappear are to take on leadership and then more worryingly:

“The Department of will require SHAs and PCTs to have an increased focus on maintaining financial control during the transition period, and they will be supported in this task by Monitor, The Department will not hesitate to increase financial control arrangements during the transition, wherever it is necessary to maintain financial balance; in such instances, central control will be a necessary precursor to subsequent devolution to GP consortia.”

Someone once said “No one would remember the Good Samaritan if he’d only had good intentions. He had money as well”. So if we tell the public that GPs are in charge but in reality we maintain the ancien regime and when Johnny GP starts to try spending money we stop him via central control who will be at fault?

Does this sound familiar?

Praise be to the Party for is that last paragraph another way of saying the Party is dead long live the Party? And blame the GPs when it goes wrong for they have the “control” but we have the money?

Monday, 23 August 2010

Homo iphonius?

A chance observation this weekend made us ponder as scientists the fact that we may be watching the emergence of a new variant of Homo sapiens. The observation was this.

We went to our local pathology museum, otherwise known as the supermarket, and witnessed a women pull into the space in her car next to us with a phone attached to her ear. She then proceeded to get a trolley and walking in front of us down every isle in the mammoth Fortnum’s and Mason superstore in Northernshire that all Northern Docs do shop at and never once did she remove the phone from her ear. Or stop talking.

Only when she arrived at the bespoke check out did she say “Wait a minute I will ring you back” and put the phone away. She unloaded her trolley and paid for her goods and then restarted the phone conversation again as she unloaded her shopping into the back of a Chelsea tractor so beloved of urban Northernites particularly of the female persuasion for their 4X4 abilities are so useful for getting out of puddles at the local supermarket’s flat and level tarmac car park.

Upon mounting her trusty steed the phone remained attached to her ear throughout as she drove away towards the motorway.

A discussion at the Café Michelle revealed that others had noticed a possible emergence of a new sub species of Homo sapiens.

It started with Homo whitevan homunculus which is the sub spieces where all men driving white vans have a limb increasingly adapted to holding a little electronic device permanently to their ear. This limb used to be a functional one but has become increasingly vestigial as it evolves to its new purpose of permanent aural placement of electronic devices at the expense of any useful work being done by the affected limb.

In surgeries we have noticed that now instead of people sitting waiting and ignoring each other by not talking to each other they now sit and stare at little electronic boxes instead.

When they are called in they frequently walk into the consulting room staring into these devices which is always a bit of fun if you open a door thinking someone has not heard you call them in and place a fist in their way.

The look of surprise is priceless as they walk through the magically opened door and almost hit you and your extended fist. A measure of how ill they are or what is most important in their life?

This new species also has a herd activity in that not only do the children walk into surgery and sit down looking at their phones but their parents do as well. Perhaps the experience of an older generation means they realize that going to the doctor involves an old art of communication that predates texting and email and you then get the following conversation:

“Chantelle switch that chuffing phone off and talk to the doctor.”

“Mam I can’t I am on facebook you tell him . . .”

Walking into our surgery buildings and in public places is becoming more hazardous and even driving is dangerous as the other day a woman on her phone walked out onto a pelican crossing when the lights were green texting completely oblivious to the road and the approaching vehicles. Only the screeching of brakes and the sound of several horns alerted her to life outside of her phone.

Now in the UK there is a phrase “it is good to talk” which derives from a series of adverts for a UK telecoms company in the 1990s but it would appear that some of the human species is losing the use of limb for anything else other than using a small electronic device and also slowly losing the ability to talk to people as a result.

Is this relationship between the limb and the phone a parasitic one or a symbiotic one? Only time will tell.

Mean time the Northern Doc law of mobiles still applies which states that the mobile always rings within 2 minutes of the patient sitting down and the caller always asks:

“What has the doctor said?”

“I will ring you back I am just with them now”.

Praise be to the Party for telling us it is good to talk. Talking to doctors is free but talking on a phone costs. No wonder the phone always comes first.

Friday, 20 August 2010

Rights and choices.

If you are a GP in the UK you will after a few years begin to recognize that patients will insist on their “rights”. If you are a GP, and especially one with an interest in matters legal, you rapidly recognize that these “rights” are not legal rights they are in fact patient demands.

Although we live in the most affluent and educated parts of Northernshire these “rights” are still demanded often on a daily basis.

One of the most common rights is the “right to have a baby”. This is often from a 20 year old drug addict covered in tattoos with a catalogue of STDs and numerous social and criminal problems. Because of her age and circumstances she is “entitled” under the local Soviet’s protocols for reproduction aka socialized medicine, to have full investigation and 2 cycles of IVF in order to fulfil her wish for a child.

Now “rights” should be universal but consider a middle class professional couple who met late in life and decided they wanted a family when they felt financially secure. Because they are “too old” they do not have the same universal “rights” as the first patient.

There is a difference between patient perceived “rights”, and what is medically appropriate for individual patients and what the Party feels its people are entitled to.

The People feel everything is their right, however medically inappropriate or unnecessary, the doctor often feels that certain requests are medically justified but ultimately the State is the final arbiter.

The patient is the “consumer” in that they ultimately pay the bill but, although Government likes the idea of “free markets”, it nonetheless exerts market control in healthcare via the Party and its local organs.

Can the current Government allow a “free market” in healthcare to succeed in a recession?

We think that the devolution of commissioning is perhaps the biggest restriction of “customer” choice in the history of the NHS. Yet it could be one of the biggest potential liberators of the “customer”.

And who will ultimately restrict the “choice”? Not the Government, now, but the evil GPs.

For it will be GP consortia, rather than the State, that will commission local services.

But will the State allow a free market for local GP consortia?

We doubt it for we suspect that as we write this there will be Whitehall mandarins writing pages and pages of rules as to what can, or cannot, be provided by the NHS internal “market”.

So despite pledges of increasing individual freedoms the new Party will be busy restricting the freedoms of individuals in healthcare via its new organs of control the GP consortia.

Praise be to the Party for allowing the “customer” “free market” choice. The question is how much choice will cost, how much can be afforded and how much will be allowed?

We like “free markets” here at ND Central. Things can only get a) better or b) worse.

Thursday, 19 August 2010


We are sure that up and down Northernshire GPs will be getting ready for work and wondering what items of creativity their patients will bring them today. One of the greatest items of creativity our patients bring us is encapsulated in the expression GANFYD which at first sight looks like a hamlet somewhere in the Celtic province of Wales but it in fact stands for Get A Note From Your Doctor.

Up North there is a sister hamlet called GALFYD which is Get A Letter From Your Doctor which is the local variant of this expression.

The Doctor’s letter is to most patients the equivalent of Dr Who’s sonic screwdriver and will open any door and bring untold riches to them if they can just blag one from the doctor. The usual ones are “The social have said I can’t have my benefit so I am appealing and they told me I need a letter”.

“I don’t like my current council house and I applying for a 17 bedroom mansion and they told me that if I get a letter from my doctor about my verruca then I will get one/move up the list.”

Do you notice a common theme? Patient wants something and feels they are more entitled to it than their fellow humans. They have not come of their own volition someone has TOLD them to get a letter.

Now most patients believe that their doctors are a) nice people who will do anything they ask and b) believe anything that they are told.

Some maybe but others know that for both of the above requests these letters will achieve nothing. They will however waste doctors’ and secretaries’ time. How do we know this? Because the local councils and benefit agency have written to us and said so. Both organizations say if they require medical information they usually write to doctors directly.

Patients do not take kindly to being told no and usually a prolonged period of procrastination follows the word no. Other examples of letters that we decline are the drug addict who wants a letter to excuse them from a court attendance or doing something like community service. The usual rule here is if you are fit enough to go to the doctor’s surgery you are fit enough to go to court.

Even the more educated members of our society will (allegedly) ask for doctor’s letters. For example a common ruse by local solicitors is to send a patient to get something that solicitors would normally be charged for or a patient would have to pay for as part of a compensation claim.

Examples are “My solicitor says you are to refer me for physiotherapy and here is a letter saying I should have it” or “My solicitor says could you give me a copy of my notes for date Y” or “My solicitor wants a letter to confirm disease X, Y or Z. Can you write me one now?

Such requests are usually turfed back to our esteemed legal colleague with the request that if “the solicitor wants it they ought to write to us and specify exactly what they want”. Usually no such letter appears so whether the solicitor actually wanted anything or the patient was lying we do not know but no time or expense is wasted on our part.

2 recent such requests for letters prompted this piece. The first was a request from a patient to tell their employer that they were fit for work after they had returned from a holiday abroad. The second was from a patient who wanted a letter to show their employer that they might need to go for a pee during the working day.

Think these are bad then have a look here at some of these examples from the originator of the GANFYD expression and some more information about doctors’ letters is here.

Praise be to the Party for instilling the idea of the GANFYD or GALFYD into patients. What will they bring us today?

Monday, 16 August 2010

Liberating the NHS: some thoughts on the Great Patriotic White Paper 005 of 007.

Well fellow comrade GPs we are now engaged in a war of liberation for “our” NHS. The nights are starting to draw in, and temperatures are starting to drop up North, but still our all wise and knowing Marshals NC/DC shall ensure our victory in the Great Patriotic War of Liberation of the NHS via that most powerful of weapons the White Paper.

Let us mount up and rally onto chapter 4 “Autonomy, accountability and democratic legitimacy”. More stirring words of freedom for all NHS comrade workers from our leaders. Read on.

The Government’s reforms will liberate professionals and providers from top-down control”.

Fantastic we can stop reading and go home and do our job for the first time in 13 years.

Sadly no for we are due “Greater autonomy . . . matched by increased accountability . . .”. More regulation anyone?

Onto “GP commissioning consortia” which we think are the ConDems new version of multifunds which arose during fundholding - the prequel to Commissioning the Movie III outlined in the next few paragraphs.

Lots and lots of buzzword bingo words follow like “patient pathways”, “clinically-led”, “. . . crucial role that GPs already play in committing NHS resources through their daily decisions. . .”.

Is that the same as GPs treating patients?

Our model is neither a recreation of GP fundholding nor a complete rejection of practice-based commissioning.”

Is that the same as the previous Party’s commissioning is not fundholding idea for “Fundholding led to a two-tier NHS; . . .” but the ConDems version will not cause this as all GP Consortia will be created equally good comrades?

Another cuddly little grey box follows full of La La land happy thoughts and oh look the NHS Commissioning Board has yet another job to do.

A number of PCTs have made important progress in developing commissioning experience . . .”.

Quite right comrade Marshals. NHS management has increased at a far greater rate than frontline healthcare provision and we suspect will continue to do so at an exponential rate from what we have read thus far.

Primary care trusts will have an important task in the next two years in supporting practices to prepare for these new arrangements.” We would like to think up North that this important task would be to disappear completely but we fear this means that the idiots running the current local healthcare system will lose their jobs at the local Soviet and some will be reemployed via GP consortia.

Comrade workers paragraph 4.9 must reassure all those fighting the liberation war for the NHS as it says “The final shape of these proposals will depend upon our consultation findings . . .”.

We all know that consultation means the decisions have already been made.

Now comrades we must not be dehumanised or brutalised by the fight to liberate the NHS for just working for it does the same so let us move onto “An autonomous NHS Commissioning Board”.

You can skip the next few paragraphs as it sounds like the reinvention of the Department of Health by another name despite another cuddly grey box and the rather worrying words “It will not manage providers or be the NHS headquarters”.

It will just “ . . .hold GP consortia to account for their performance and quality”.

Worryingly is the start of “Establishing the Board and managing the transition” section which starts with the words “The Board will be established in shadow form as a special health authority from April 2011 . . . it will be converted . . . into a statutory body . . .and will go live in April 2012.”

So until this body goes live and NICE has its 150 outcomes what happens to local GP consortia? Well thought through this liberation war looks like the motor has stalled until at least 2012.

The NHS Commissioning Board it would appear will not just be the Department of Health 2 but a SHA (special health authority aka strategic health authority) as well para 4.13.

Look comrades there may be light on the horizon for the next section is entitled “A new relationship between the NHS and the Government”. Could this be one where healthcare professionals are allowed to work free of political interference in order to provide the best for their patients?

Another cuddly grey box follows which outlines the Secretary of State’s relationship with the new Department of Health, sorry NHS Commissioning Board, but we can’t see the words healthcare workers anywhere within this box.

Onto “Local democratic legitimacy”. This predicts the demise of PCTs but more worryingly suggests the transfer of “ . . . PCT health improvement functions to local authorities . . .”.

So the ConDems now see your local council as the new PCTs? Better start looking at the school league tables to see what your healthcare is likely to be like “ . . . the power of the local authority to promote local well being . . .”.

Grammar school good, comprehensive bad? Another cuddly grey box follows outlining the role of your local council, we think, in providing your healthcare. Given that they are probably cash strapped and short staffed can we guess who might just be joining their payroll at no expense to central government?

GPs working with local councillors? Interesting.

We march on across the steppes to the section “Freeing existing NHS providers”.

Autonomy in commissioning will be matched by autonomy for providers”. This can’t be a hint that privatisation via commissioning is about to loom on the horizon of the war of liberation of the NHS? We are too cynical we must return to just cleaning our weapons and let the comrade commissars do the thinking, Sergei.

We are onto a new concept “Our ambition is to create the largest and most vibrant social enterprise sector in the world. The Government’s intention is to free foundation trusts from constraints . . .”.

What the hell is “social enterprise”? We first heard this phrase when we played a video on the most excellent Ferret Fancier’s blog site.

Read para 4.21 for we think mixed left and right wing messages here. Suggests the coalition ain’t got a clue about healthcare.

Economic regulation and quality inspection to enable provider freedom”.

Providers will no longer be part of a system of top-down management, subject to political interference”.

Does that mean we as GPs can do our own thing? Somehow we doubt it for whenever freedom is offered unconditionally it is always followed by loads of conditions. Enter stage right Monitor “. . .the current regulator of foundation trusts . . .” whose sterling work in Staffordshire will no doubt mean some honours going their way.

Combined with added power from the Care Quality Commission whose first leader also had some Staffordshire involvement we know we are talking toothless tiger regulation by whom and for whom?

Who are the providers?

Another cuddly grey box follows about the role of the Care quality Commission. In the same way that a soldier on the ground takes comfort from their weapon and body armour the average NHS patient will be well served by these 2 pieces of NHS Personal Protection Equipment (Care Quality Commission and Monitor)for both should be awarded the Congressional Medal of Honour for their sterling service to patients to date.

Onto “Monitor’s scope and powers”. Mixed messages here some suggesting a possible free market laissez faire approach other hinting at a “market” with regulated prices. A little diagram follows and guess who is at the bottom of the pile? None other than the patients and public.

Onwards to para 4.31 “Valuing staff”.

The biggest cost to any organization is only now recognized with 6 lines of corporate bullshit. Why not just say you are all going to be shafted and ignored rather than use non words like “ . . . staff engagement, partnership working . . . improve staff health and wellbeing.

And for those of us who do not know who Dr Steve Boorman here is a link. Looks a bit like Al Borland from the TV series Home Improvements. You know we are well cultured in our TV watching habits here at ND Central.

The last three bits of section 4 actually relate to things that matter to NHS staff.

The first is “Training and education”. Lots of fine words and again the NHS Commissioning Board has it hands in education. It would seem that there will be “education commissioning plans” which will be “led locally and nationally by the healthcare profession through Medical Education England”.

In case you hadn’t heard of this organization here is a link.

The second is “NHS pay”. Don’t hold your breath regarding any increases or an end to central regulation we are in a recession with crippling National Debt as well. A few woolly words re need to end national control and move to local terms and conditions so no great changes.

The third is “NHS pensions”. If a government doesn’t like something you can bet it will order a review. So the words “. . . ensuring that pension solutions are found that are fair to the workforce in the health service and fair to the tax payer” properly mean we are all going to work longer to get less if we live that long.

Such is the nature of wars of liberation and so ends battle 4.

Praise be to the Party and its war of liberation. Only 2 more sections to go and it will soon be Christmas. Who knows we might then get a banana, or an orange, this year, if we are good little comrade serfs?

We certainly won’t get anything else other than unpaid work from what we have read thus far and our patients? What will their reward be for funding all of this liberation?

Sunday, 15 August 2010

Some ghastly reading about the past and perhaps a ghastly glimpse into the future?

While thrashing our Ferraris into work one morning this week one of us was listening to the news and heard the newscaster say that the PFI (Private Finance Initiative) used by the previous Party to build new hospitals is going to land up costing 6 times more than if the same hospitals had been built directly by the State. Even the Daily Mail have noticed this one.

No surprise there as if you have the money to build a house you do not usually take out a very expensive loan for the same amount to build something and then pay interest on it for years to come.

Unfortunately political dogma is usually not very intelligent, has badly impaired tunnel vision and if you are the Party in charge always wins over reason and rational argument until you lose power.

Nothing new here for this triumph of dogma over reason and logic has been going on for centuries just think of Galileo and the Catholic Church as an example.

Another piece of news that is hardly surprising is the frontpage article on the front of the GP magazine Pulse which we can link to but you now have to register to read it in full.

Local commissioning has cost practices thousands being paid to local consortiums which have produced no savings, no redesigned services and are effectively lapdogs to the local Soviets (PCTs) who block everything as they strive to cling onto power as the axe hangs over their heads.

We suspect that this loss of funds from frontline general practice, with few exceptions, will be the case in most places that practices are paying out money but getting nothing back for themselves and more importantly diverting money from patient care for the purpose of political dogma.

And what of the future? Well, unless someone pulls an all mighty great surprise of a white rabbit of healthcare Utopia out of a hat, we suspect that in 5 to 10 years time similar articles will be being read on the news and being read by a new generation of GPs.

People forget that in order for “markets” to work people have to make profits and customers have to pay for services.

A state run scheme one would hope will break even but, to do the same job and make a profit, will always cost more unless, of course, the state run scheme is such an incredibly inefficient dinosaur of an organization, in which case efficiency savings, sorry comrade reader, efficiency gains, would yield massive profits to the private sector.

Unfortunately the involvement of the private sector inevitably increases cost. If it costs £ 100 to break even then it will cost £ 125 to run privately as Joe Privates needs something for his or her dangling their bits into NHS business.

So are PFI and commissioning, sorry, “world-class” commissioning, two examples of the old Party’s dogmatic successes and financial Prudence? Is the New Party any different?

Praise be to the Party for the reason and logic of dogma which will cost all of us so dear for years to come. And please remember the old Party did all of this dogma in times of plenty . . .

Plus ca change plus c'est la meme chose?

Tuesday, 10 August 2010

A small victory for common sense that reduces injuries?

This weekend one of us noticed in a Sunday newspaper a very small piece of good news.

We do apologize for using the photograph above that many involved in health care may find highly offensive. That is just the face not the potentially offensive weapon although the two are linked.

Have a read here from a source on the other side of the Pond and see how many inconsistencies there are between the two pieces as you read on but remember accuracy in journalism is not essential to get the job done especially as they may be different stories?

The small piece led us to do research and we found this.

Isn’t curious how it takes a long time for simple ideas to pay dividends. Remember crash helmets, seatbelts, airbags and smoking bans?

So why are we here at ND Central so enthused by shatterproof glasses?

Well this is not a new idea and if you have spent an evening as the only doctor in an A&E department and out of 30 cases over one five hour period 27 were glassings you would be relieved at any potential simple reduction in workload and human suffering.

Most towns in the UK will have their own WMDs (Watering holes of Mass Disfigurement) where most weekends as the love of one drunken man, or woman, for another increases with each alcoholic beverage they consume until its eventual outpouring into violence usually at closing time.

The favoured weapon of choice is the glass ,for it is freely available, and glass is said to be the sharpest cutting substance known. Apply liberally to the weak flesh of the human body and all sorts of injuries can result mostly to the face, hands and forearms. Although the article in the paper said eyes have been loss we collectively have be fortunate enough to have been spared that completely unnecessary injury.

If the experience in the Southern Northshire port city of Hull is repeated then the £ 7 million savings multiplied by 151 other PCTs could result in a national saving of over a billion pounds in medical and legal expenditure?

Like many simple things it will probably take time to get going so until then A&E departments across the country will continue to stitch up glass cut individuals most weekends. They have paid for their beer but the glassing and the medical care will be free of charge.

Once they are stitched up and sober they might realize that, if they can get a conviction against their assailant then, there is criminal injuries compensation to be had as well as free medical care. And the legal costs involved here pale the medical costs into insignificance.

Praise be to the Party for giving us weekends with which to enjoy ourselves. We are sure our colleagues in A&E and the Police and Ambulance services look forward to them in the same way we look forward to Monday mornings.

Thursday, 5 August 2010

More GP idleness?

Several news stations yesterday carried stories similar to this one about the idleness of GPs and how it affects their patients particularly pregnant ones.

Now being in the trade and listening to various news stations during the day they all said that the most important contribution that GPs could make is their knowledge of patients and their families. Not their prowess in obstetric medicine for nowhere was there any mention of GPs carrying obstetric forceps and performing emergency forceps deliveries or Caesarian sections on kitchen tables.

If you want to read this “report”, although it seems to be little more than the opinions of a GP and a couple of researchers at the Kings Fund you can do so here (takes a few seconds to download). There does not appear to be any medical obstetric input (apart from in the copious references at the end) but then reports don’t need experts in the field to be involved in their preparation. Think General Practice reform report and surgeon.

Now GPs do not act in isolation so we thought about the changes in our obstetric care. In general practice a good practice based midwife is a godsend. Getting a bad one is a nightmare as they usually have ex directory mobile phones, every afternoon off, frequent large areas of no mobile phone coverage and refer everything to you or the hospital usually without seeing the patient. They are often grossly obese as well.

The amount of antenatal work you get is therefore midwife dependant. Now lots of GPs will have lost their health visitors, district nurses and possibly midwives as the current “thinking” = political interference is that such “specialists” should not be practice attached but in Party sponsored centralized barracks.

The “report” highlights communication as an issue and cites electronic communication as the solution. Communication in our neck of the woods has been destroyed with 2 out of the three groups above for the above reasons.

We still see our midwives and have that old fashioned but politically incorrect and therefore inefficient means of communications called a “chat.” This outdated mode of communication leads to an exchange of information about patients.

We used to have such “chats” with our district nurses and health visitors which meant we knew about our patients and vulnerable children but the move towards electronic communication with records held on different computer systems which cannot (as yet? if ever?) talk to each other means that there are no longer any such “chats”.

We should all know by now what happens when information is not shared (hint Baby P et al).

The idiots in charge know about these problems but they are happy because there are supremely thick and ignorance, especially in child protection, is usually bliss.

We digress. A few years ago it was decided that healthy mothers should be looked after by midwifes for this is what they are primarily trained to do. To look after the normal but be able to recognize the abnormal but not necessarily be able to deal with all of it. So at a stroke most GP work with healthy antenatal patients disappeared.

We do usually see most pregnant women to filter out the high risk obstetric and medical cases, give them their Folic acid and smoking and other healthy lifestyle advice but as most pregnant women in these exceptionally affluent areas of Northernshire are so well we don’t usually see much of them until their post natal checks.

Our currently practiced based midwifes do an excellent job together with the local obstetricians. Any that do get ill we usually see and sort and, if need be, refer on.

The new GP contract also took away a financial incentive to see and look after pregnant women and as the above two centrally imposed ideas happened close together then the result is that which the “report” highlights.

So if you have nothing else to do then please have a read of the report. It tells GPs nothing that we don’t already know and you could write a similar report for any specialty that has been withdrawn from general practice over the last few years and come to the exactly the same conclusions.

Makes for good headlines, will make bugger all difference to the grunts on the ground and it is not our fault.

Praise be to the Party for changing everything and then blaming everyone else for their actions. We like accountability especially the kind where you always get away with it when things go wrong.

If only midwives, district nurses, health visitors, social workers and doctors had the same “accountability” when a system that they did not design (and even opposed) fails.

Monday, 2 August 2010

Liberating the NHS: some thoughts on the Great Patriotic White Paper 004 of 007.

Uri, Sergei, wake up fellow comrade GPs. We have a war to fight. The war to liberate our NHS. We have to work as GPs during the day and now run the rest of the Health Service in our spare time. Wake up Comrades, liberation from the scourge of more work may be upon us . . .

Quiet comrade soldiers for Marshals NC/DC have said the following so listen up.

We are now into section 3 of the war of liberation called “Improving health outcomes”.

We are told that the “The primary purpose of the NHS is to improve the outcomes of health for all:

Funny that, we thought its primary purpose was to treat patients.

We will start by discarding what blocks progress in the NHS today:

Does this means an end to constant Government interference with the NHS?

Sadly no, it means:

the overwhelming importance attached to certain top-down targets”.

In future, performance will be driven by patient choice and commissioning; as a result there will be no excuse or hiding place for deteriorating standards and our proposals will drive improving standards.

At last patient “choice”?

I have a sore throat give me antibiotics. Excellent. Medical science out of the window patient choice and commissioning is now the new science of medicine.

We will replace the relationship between the politicians and professionals with relationships between professionals and patients”.

Nice thought but whenever politicians offer bread and circuses it is always by offering the NHS as their Games. Healthcare professionals are sacrificed as gladiators in the Politicians’ games.

Instead of national process targets, the NHS will, wherever possible, use clinically credible and evidenced-based measures that clinicians themselves use.”

Never? A Government relying on doctors and nurses to tell them what should be done next? They will be asking airline pilots how to fly aircraft next but for some reason you never hear of politicians telling airline pilots how to fly the planes they fly in. They do, however, always tell doctors and nurses how to treat their patients.

In future the Secretary of Sate will hold the NHS to account for improving outcomes.

Maybe we are a bit thick here up North, but is the word “outcome” the new word for “target”?

The NHS, not politicians, will be responsible for determining how best to deliver this within a clear and coherent policy framework”.

But who, or what is the NHS?

Are GPs as “independent contractors” the NHS?

Or is the “Department of Health” the NHS?

Anyone know the telephone number for “the NHS”?

So we move onto “The NHS Outcomes Framework”.

The current performance regime will be replaced with separate frameworks for outcomes that set direction for the NHS.

At last targets are replaced and now we have a “current performance regime” replaced by “separate frameworks” for “outcomes” that set “directions” for the NHS.

Just look at how many words have replaced targets, the things “that blocks progress in the NHS today”.

A new NHS Outcomes Framework will provide direction for the NHS”.

A new set of targets, sorry comrades, outcomes. Outcomes are not targets in the same way that commissioning is not fundholding.

It will include a focused set of national outcomes determined by the Secretary of State against which the NHS Commissioning Board will be held to account . . .

Focussed, national outcomes all new words for new central Soviet style “targets”, sorry outcomes?

Onto “Developing and implementing quality standards”.

Listen to this one comrades:

Progress on outcomes will be supported by quality standards. These will be developed for the NHS Commissioning Board by NICE . . .”

So no moron medicine here directed by politicians just “real world” science modified by “evidence-based” medicine “politically influenced” by the “independent nice people” at NICE.

NICE expects to produce 150 “standards” = targets or outcomes, dumbed down medicine for the thick and they will develop “authoritative standards setting out each part of the patient pathway”.

“Pathway = journey”. More word tinkering “To support the development of quality standards . . . "?

Furthermore “NICE . . . will advise on research priorities”.

We look forward to NICE research on is the Earth flat for this is surely nothing more than political control of the NHS by failed academics wanting a gong?

More frightening is the “We will expand the role of NICE . . .The Health Bill will put NICE on a firmer statutory footing . . .

Za Nu Labour reborn with legal clout? Sound familiar?

Central control on professional thought and independence leading to its being outlawed?

Think outside the new Party (grey) box comrade GP and the jackboot will get you but it will be a NICE and a legal jackboot too.

There then follows another cuddly grey box all about how the new Party thinks one should prevent DVTs and PEs.

Bet they have never spoken to any Coroners that realize that death happens regardless of guidelines followed or not.

However, if a Party puts “guidelines” or “outcomes” or “targets” in place, the Party can prevent all known deaths from DVTs and PEs. Coroners can now safely retire as from now on there will be no DVT or PE deaths because everything will be NICE.

We like the “Patients/carers are offered verbal and written information on VTE prevention as part of the admission process.”

Bet that will frighten off evil Johnny DVT and save countless lives at the cost of a few hundred hectares of Amazonian rain forest and the employment of not one extra nurse on any understaffed ward who might be able to mobilize a patient.

Clearly Marshals ND/DC like NICE as they think that “NICE quality standards will be reflected in commissioning contracts and financial incentives.

Once again no political interference here, comrade, just NICE, simple medicine.

Onto “Research”.

Research has usually been independent of Government so unless you are going to fund it, keep out. DNA and splitting the atom were not discovered by Government or anything NICE.

We now come to “Incentives for quality improvement”. Start rubbing your hands with glee for this surely must be where we, the evil under worked, overpaid GPs find out how much huge wonga wads are coming our way for our additional commissioning work.

The absence of an effective payment system in many parts of the NHS severely restricts the ability of commissioners and providers to improve outcomes, increase efficiency and increase patient choice”.

Does this mean an end to the flawed Soviet style market system where all prices are fixed nationally? Read on:

In future, the structure of payment systems will be the responsibility of the NHS Commissioning Board and the economic regulator will be responsible for pricing.

How are they going to cope, those busy little boys and girls at the NHS Commissioning Board, with it being so much bigger with each paragraph we have read thus far?

A new Department of Health 2 - The Sequel being born? And where did the economic regulator come from?

It is clear that the failed internal market is not dead it is a case of long live the “market” as “money follows the patient and reflects quality”.

Notice the subtle changes in wording so that what was once the NHS tariff is now “a set of currencies”. Does that mean health tourism is to be developed as a new income stream?

But Uri, Sergei come here quickly for para 3.22 tells us how we can make loads of money:

. . . we will introduce a new dentistry contract . . .

We must go away to dental school for if it is as successful as the last one there will be an even greater need for private dentists!

Praise be to the Party for giving us more of the same with different words. This war of liberation seems uncannily similar to what happened at the end of the Second World War in Eastern Europe.

Will our liberation now, be the same as theirs, was then?