The guilt of the sum is greater than that of all of its parts?

Once again this week the tragic case of Baby P(eter) is on the news screens of the UK and once again the Press screams about individual’s incompetence as the failing(s) but it may miss the collective target in terms of overall responsibility.

Imagine if you can a situation in the UK where a group of GPs work closely with a group of health visitors in a practice setting. Over the years they develop a rapport where each knows the strengths and weaknesses of each other and also they know their patients.

Their social intercourse on a daily basis means that little snippets of information are passed between them. For example there might be a family of concern about whom a conversation similar to this might take place en passant:

"Hello Northern Doc, you mentioned the other day that child X had condition Y."

"Yes I did. What of it?"

"Well did you know that their Mum was assaulted last week?"

"No, I did not. Who by? "

"Her new partner."

"Who’s that?"

"Dicky W*nker. "

"Really? Didn’t he do time a few years back for indecent exposure to minors in the local park?"

"I didn’t know that Northern Doc but I am now on the case. . . "

A simple sharing of information like that combined with follow up by those concerned might just lead to the exposure of a Schedule 1 sex offender who had been beneath the radar for years.

Now the Party does not do information sharing between professionals although it wants you to share all of your information between Party members via the Summary Care Record. Information is often the key to protecting children but information in isolation is often useless.

Protecting children, and the elderly, is like a jigsaw puzzle. If you hold a small piece of the jigsaw in isolation you do not see the whole picture. The ability to share the pieces may give you an increased chance of seeing the whole picture.

Which is why the Party took away our health visitors and reorganised the way in which we now work. What used to take one conversation like the one above now takes several phone calls and days of waiting just to identify the responsible individual. Having identified them you then have to find them to actually talk to them and share the information.

The current state of NHS health visiting means that trying to complete the jigsaw as a GP is hampered by the NHS adopting so called “silo working”.

The sum, here the protection of the individual, is greater than all of its parts, for all of the parts are usually there. They, as usual, are not shared. So the sum fails but the individuals are blamed. They are blamed for the failings of those who instituted the sum.

The sum was devised by our politicians and all their little local commissars. It was they who ultimately employed all those who failed and it is they who also dictated their terms of engagement.

Praise be to the Party for they are once again all wise (after the event). The problem with the Party is that when the system fails all fail for they cannot without the system.

The depressing thing is that it is said it will happen again. Unfortunately it will and all of the NHS reforms of the last 13 years have made it easier than ever to happen for they have destroyed the information sharing that is vital if these tragedies are to stand a chance of being avoided.

Rats leaving the sinking ship?

Well the change in the UK Government and its great White Paper of NHS liberation has locally led to the very loud sound of the scurrying of claws being heard on the wooden deck of the super liner that is NHS management.

In our local shires loads of rats are apparently leaving, nay, high jumping and triple jumping away from their ships and looking for pastures new. They continue to deposit their droppings for as they scurry away their underlings are being promoted above and beyond their limited incompetence. Lots of their junior offspring are struggling to function for NHS management is a rigid Soviet style dictatorship and no-one dare make a decision without the say so of the local Great Leader(s).

New junior rats, in the same way as in war field promotions are rapid, are crawling up the stairways of the sinking ships of local PCTs. While grandiose titles are being bestowed upon them and may sound good they are merely the equivalent of being promoted to being the executive officer on the RMS Titanic.

The captain of the Titanic at least had the grace to go down with the ship he had mismanaged. The rats however are climbing the greasy pole in the hope that if they sh*te hard enough on their colleagues they may just reach the heady heights of the as yet undefined new super carrier of NHS management called the NHS Commissioning Board.

The rats that are jumping the sinking PCT/SHA ship may yet live another day and unfortunately populate the new SS NHS Commissioning Board when it is finally launched. This means that however good GP consortia may become those who have mismanaged the local Soviets for years may scupper any improvements that might come out of GP consortia when they are finally allowed to do something.

We thought, after talking to some colleagues from other Northern shires, that this process was just peculiar to the local and neighbouring Soviets but it would appear that the rats are now more like lemmings if this article is to be believed.

Praise be to the Party who will ensure that the new NHS Commissioning Board will be full of great captains like Admiral Nelson. Or will it be more like the Caine mutiny?

Defence reviews, the NHS and who is the real enemy?

This week in the UK there has been published a defence review which is a euphemism for defence cuts against a background of a bankrupt economy which must see things go.

Certain things here at ND Central struck us at how defence and the NHS ride a similar route to obtain the same result. While defence is about protecting us from without should we not be looking at the enemy within namely Government and Party ideologically driven incompetence?

One of the biggest things in the defence review is that the UK will spend £ 6 billion on 2 new aircraft carriers. Most excellent news apart from the fact that they will have no jet aircraft on them for many a few years to come.

This would never happen in the NHS. No-one would be daft enough to spend £ 12 billion on a failed computer system meant to do 90% of all NHS referrals by December 2006 that only now just manages 50% of referrals. Would they?

No-one would top slice budgets to fund privately run ISTCs (Independent Sector Treatment Centres) which run at below capacity but, at which whatever level they run, still cost the tax payer 100% of cost regardless of numbers of patients treated (or aircraft taking off from them?). Would they?

New defence threats have been identified like that of an influenza pandemic. Did we not have one of those PanicDemics last year whereby the collective incompetence of Government invented a nonexistent threat that almost took down general practice due to goading of the Public to panic in mass numbers? Nobody would be that daft, would they?

Cyber terrorism is identified as a “new” threat to the UK. This is made so much easier by incompetent but expensive IT provision at the behest of the State. NHS IT is a victim of its own incompetence as the drive towards centralisation of medical records leaves it open to being crippled by a few well placed pounds of explosive or a local IT idiot who knows nothing. No-one would design a central medical records’ system that vulnerable to being crippled on a regular basis by its own, would they?

All of these of examples of how poor the NHS/Defence departments are. All of the above of examples whereby there is an enemy which impacts on those on the front line.

Who is that enemy? Well in general practice it is the Department of Health and the local Soviets aka PCTs who for years have been mismanaging locally central policy and whenever they cock up it is our problem to sort out even though it is their responsibility.

And the MOD? Well far be it for us to comment given that locally jobs will go.

Praise be to the Party for all of their reviews. They serve us all so well.

We in general practice, and our colleagues in secondary care, will carry on picking up the pieces. The Party may not be happy for some “aircraft” may be forced to land on "aircraft carriers" that they should not be allowed to.

And that is less expensive and better than ditching in the drink . . . but GP commissioning should stop all of that by delivering empty carriers like the defence department?

The absurdity of the NHS internal “market”.

A while ago one of the team flew a sortie to another part of the UK for a meet with fellow comrades from grunt school some of whom had come from other countries. As with all reunions it is a time for catch up, compare and contrast individuals’ experiences and consume a few naturally fermented organic chemical containing beverages.

Specialities tend to congregate and after a while the conversation turned to GP commissioning and what was happening locally. What was interesting was the compare and contrast element against a worldwide background.

One of the squad told us that in their patch a Darzi practice, paid for from the public purse to benefit the private sector had been so “successful” that it had been told to stop “treating” patients. Others said that those Darzhole practices on their patch(es) were being terminated due to the fact that they cost more than local GPs but then the lawyers became involved . . .

Despite the fact the collective IQ at this point was in the thousands, the individual blood alcohol levels were well above local legal driving limits, everyone had a Homer Simpson “D” word moment as these issues were discussed. A heated conversation followed and there was a diverse nature of opinions about this situation, always the case when more than 2 doctors meet and talk especially when they were from different specialities and parts of the world.

One group said this made no economic sense for although a Darzhole centre was successful it was public money paid to the private sector and the private sector should be exploited to the full.

Another group said can you imagine if this was McDonalds who had opened a new restaurant that had exceed targets would they shut it down? Hell no they would chuck more money at it and milk their success.

A third group (way?) said this is the current NHS “market” whereby contracts operate within the framework of the alleged free market but the NHS commissars who administer them are former Soviet Bloc Party driven target obsessed commissars who cannot see that what they have done is a) successful b) an efficient use of public funds and c) that by their actions and inabilities they are actually denying patients healthcare which is what they are charged with to provide and were actually meant to provide as comrade commissar NHS “commissioners”.

There was a lot of input from those overseas saying that they wished they were in that position for they could use the increased success to improve capacity and therefore income while increasing the provision of service to patients albeit at a price. There were also a lot of opinions at this stage of the evening that were unprintable.

This led onto a discussion about GP led commissioning as proposed by the current Party(s). Fine in principle, the alleged free market one, but if applied against the background of a (failed) Soviet styled centrally fixed price market and heaps and heaps of paper shifting between bureaucrats as opposed to hands on patient care will generate what exactly?

The same but different?

Will the White Paper improve things or will it drown us as GPs in a sea of mountainous bureaucracy while denying us seeing any patients? The overwhelming opinion based on this discussion is that it will.

It is like trying to break the 100m spirit world record while wearing leg irons. However much you talk it up you will never succeed under the current rules of engagement.

But then it will all be the GPs’ fault won’t it?

The market. Certain elements are successful for example private medicine and McDonalds and then there is the NHS “internal” market.

Our patients tell us which they would like and also which one they actually get, and will get, as they tell us we currently have billions to spend (not).

Praise be to the Party for all new NHS reforms. We are lucky to have once again met up with our colleagues from grunt school. The debate will continue. And what of patient care?

Whatever. Politicians come, bugger up the NHS, and go. Doctors and nurses pick up the pieces time and time again. It will be no different this time.

Sex and the elderly.

In the United Kingdom sex does not happen. It is officially not talked about but amazingly we have some statistics to be proud of despite its non existence for example the high rates of teenage pregnancies and increasing rates of STD in the elderly.

Increasingly the idea that elderly people, like those over about 23 years of age, are actually having, and worse still enjoying it, is causing some disquiet in certain journalistic circles.

This might be due to the fact that if you have sex, an allegedly pleasurable activity, it might incur some risks as well as be morally abhorrent to the ruling classes unless it is for procreation purposes rather than recreational purposes (dirty buggers says the average Daily Mail reader).

It would appear that there is an increasingly high rate of STDs in our “senior citizens” of the bonkaholic generation. Remember that these bonkaholics grew up in the generation that created sex in the swinging sixties and it would seem they are still swinging.

The contraceptive pill is now passé for they are postmenopausal and so the threat of pregnancy has passed them by but has been replaced by other problems like certain dry or limp areas.

HRT is now the WD40 for the females who pioneered the liberation of women and the permissive society by using the Pill (dirty buggers) and the new male Wild Ones are using the Harley Davidson of the shaft world called Viagra (dirty buggers) and its successors to spread STDs to new levels in their age group.

From talking to GP colleagues whose practices dispense these drugs they are now the suppliers of lots of discrete under the counter brown paper packages of Viagra to the elderly who insist that these packages are supplied to them “with discretion” as they don’t want their wives to know of their purchases.

Furthermore the number of requests for “blue pills” for those over fifty who are “disappointing their wives” (aren’t males just so selfless?) or “who have met a new lady friend” increases year on year. A number of elderly “gentlemen” also request these pills in catering packs especially those who spend many months a year abroad in countries such as Thailand the so called “Sex Pats” (and they claim their winter fuel allowances!).

Curious how the sexual liberators of the sixties are now being liberated from the problems of elderly sex that would have denied their grandparents what they can now enjoy so much and freely? Isn’t pharmacology great?

Praise be to the Party for liberating the NHS and for “liberating” some of our elderly patients. Curious how HRT is free to all pensioners but other drugs are not. Did we miss sex equality? A lot of our patients do (dirty buggers).

Work, ethics and patients. To treat or not?

One of the team has recently had one of the most uncomfortable consultations we think one can have as a doctor. This is the consultation where, after treating a patient, you have to then treat the cause of your first patient’s illness namely another patient. We had a long chat about this situation.

This is especially hard in certain situations. The most obvious is in combat where if you play by the “rules” you have to treat enemy combatants as well as your own.

Who do you treat first? The “right” answer is the most serious injured but the emotional answer is very different. In current conflicts it might be do you treat the Taliban or your own troops first? Medical ethics would determine that you treat impartially but human emotions may cloud that professional impartiality.

What about the situation when you treat a patient who has been hit by a Heavy Goods Vehicle (HGV or truck). You spend an hour treating them in an Accident and Emergency Department (ER) and despite your best efforts the patient dies?

The next patient in the A&E department you are asked to see is the driver of the HGV that killed the patient because they are “upset” but they are unhurt, not dead, and still alive. Sometimes they are racked with guilt sometimes merely inconvenienced.

You may then have had to deliver the deathogram to the family of the patient involved when they turn up in A&E an hour or so later having been told, euphemistically by the Police or a work colleague that a relative is seriously “ill” and they should go to hospital ASAP. Not just doctors involved here but nurses, police officers, fireman and ambulance crews too have these scenarios to deal with from time to time.

What about the situation where you see an abused child and treat them only to see their abuser as the next patient claiming an “alleged” assault by the mother of the child and wanting treatment?

These are some of the consults the team at ND have collectively done over the years and raise loads of questions about ethics, morality, impartiality and more importantly what one does as a doctor in these situations and how one copes.

The laws of physics are said to be absolute. Certain principles in medicine are said to be the same but are more likely relative.

Could you go home at night having saved the victim of a stabbing who only later turns out to have been the abuser of the stabber? Could you save the life of someone who had shot one of your own and still treat them after you know the facts?

We have had the self same situations in civilian practice and it is not easy. Fortunately such situations are rare but they always provoke thought and discussion for they are not easy to deal with.

Praise be to the Party who via the GMC provide us all as doctors with their “ethical” guidance. We thank our colleagues, both medical, nursing and in the emergency services and the UK medical defence societies for their more practical support in such scenarios.

GP Trainers.

In the United Kingdom most people when they are “ill” are seen by a GP. In the US we believe this is known as family medicine. In the long distant past you could become a GP after you had done a year’s worth of hospital medicine and then go out “into Practice”.

The UK Doctor in the House series of films based on a series of books by Richard Gordon illustrates this state of affairs in earlier times but in order to watch these antique films (50+ years old) you will have to find them. Sometimes they are aired on UK TV.

Watch them as a doctor and you will see how little has change watch them as a non medic and they are quite funny at times.

In 1981 we believe that the UK introduced VTS (Vocational Training Schemes) for General Practice. A seemingly good idea to ensure that any future GP would be trained to a basic minimal standard. In 2007 they also introduced a compulsory exam the MRCGP.

We have commented before re useless unnecessary electronic crap for medical training but this week we have been listening to a group of highly intelligent, well motivated doctors in training wanting to be GPs and also those who have recently qualified as GPs who were all saying the same thing while chatting in the breaks at a meeting.

All are enthusiastic, far better qualified in terms of letters after their names than are we but perhaps less qualified in terms of hours in the air.

They are complaining, quite rightly, about an increasing amount of totally unnecessary information that needs, or needed, to be uploaded to their e-portfolio at incredibly short notice. This is at the behest of their trainers and other educational supervisers. Here is a link to what an e-portfolio is and we love the description or it as “glue” which these young doctors were complained that they were increasingly stuck in.

For those that are not familiar with e-portfolios this is basically a useless piece of NHS software insisted upon by a generation of GPs who never understood computers but who thought they were great. They thought that if you could book a hospital appointment for a patient online then you could justify a half hour appointment time and so avoid any real work by being a booking clerk. Unfortunately they are in charge and so busy jerking off to matters electronic that they miss the basics of education.

They missed the space age, log table, slide rule and electronic calculator and no doubt feel that the film the Wicker Man is progress as it shows community involvement in holistic care. This is the Royal College of General Practitioners whose journal is so full of real science that you would believe the world is flat after reading it.

Now to become a GP trainer, in order to train a GP registrar, a future GP, you have to undergo a series of courses and approval visits as well as have the MRCGP exam. Being a human being is not an essential requirement as the training ensures that trainers are Party approved quislings. No bad thing but what is the net result of these?

Well from our own experiences and our conversations with new qualified GPs and those still in training and despite all of the “supervision” from the RCGP, locally we have a series of GP trainers who:

Ensure that all home visits are done by their GP registrars.

Ensure that all the on call work is done by the registrar.

Ensure that when they go to meetings the registrar covers their workload.

Ensure that if there is a visit each for a registrar and their trainer the registrar gets both.

Ensure that a registrar will cover their surgeries and on call whenever they can’t be arsed.

Ensure that the registrar on call for an out of hours session has all workload vetted by a trainer and done by the registrar

Such abuses are overseen, and approved by the RCGP. This was the experiences of the GPs and registrars we spoke to this week and is no different from those that we have endured under the 20+ years of VTS.

And some of the current RCGP abusers want GP training to go to 5 years? An extra 2 years of uninterrupted time on the golf course for GP trainers? Excellent.

There are a lot of intelligent GP trainees who despite having passed their exams are being abused by those meant to be supervising them.

There are also a lot of good and excellent GP Trainers who protect their Registrars from such abuse. This post is not about them it is about their less than professional colleagues.

This is not on.

Praise be to the Party for ensuring that despite slavery being illegal in the UK it still is allowed under the auspices of the RCGP. And this has been so for the last 20+ years and from what our younger colleagues were telling us was not too dissimilar to that which we experienced during our “training”.

Who can tell the RCGP of the abuse? None other than the GP Registrar who in order to qualify has to be signed up by none other than their abuser.

Sound familiar?