Some thoughts on the year 2011 from up North.

Traditionally at the year’s end people reflect backward on what has been and think about what they hope will be. Most humans are optimistic but as one ages in general practice one becomes more pessimistic with each change of Government or “new idea” that comes out of the Department of Health or local PCT.

As GPs we should treat patients. We are trained and able to do so and by and large we do. We are not so dumb that we believe that all those in jails or politicians are saints but overall most people in medicine care and try to do their best to the best of their abilities, their training and knowledge which we know varies from individual to individual and from place to place.

In 2010 the great Marshals NC/DC launched a war of liberation of the NHS something we haven’t quite got yet. It was sold as a “bottom up” liberation as opposed to a “top down” reorganization which has become even before the relevant legislation is passed a bureaucratic quagmire going nowhere fast.

Every GP is in this quagmire to some extent treading water and wasting time and money away from patient care to deliver Marshals NC/DC dream of liberation which increasingly looks like the Red Army’s advance into Eastern Europe at the end of World War 2 looked to those dreaming of democracy in countries occupied by the Nazis.

The “bottom up” reorganization with the clinician in the consulting room being in charge is prevented from doing anything useful by the (non) top down reorganization dictating the rules of engagement (ROE) while the real ROE are still being thought up on the hoof and modified on a daily basis. And that is before its codification into legislation and thereby enforceable diktat.

As a result the real net reform of NHS to date is business as usual at the frontline. A centrally, politically controlled Sovietized medicine of tick boxes that deliver piss poor patient care by ensuring that your GP gets paid to tick patient useless boxes at the expense of treating patients.

Preventative medicine is easier to control and reward. Life saving medicine is acute real time and unrewarded.

As a GP if you resuscitate a 3 month old child successfully from a cardio-respiratory arrest in your surgery or a patient of 45 who walks in feeling unwell who has a VF arrest using a defibrillator you purchased yourself because you thought it was a good idea to have one this is all available to the government for no charge. No box ticked but a clear benefit for the patient.

Do a cholesterol on a stable diabetic/angina patient or a patient with mental illness every year which is normal and requires no treatment and you are rewarded for doing so. One intervention makes a clear difference the other intervention’s benefit is of debatable benefit but rewarded.

Patients want care especially when ill and this is what most of us are trained to do. Increasing they are getting care not for acute illness which is unpredictable and therefore not Party controllable but for Party determined “illness” in the form of boxes to be ticked.

The need for boxes to be ticked to generate income, for we all need money to live, has led to more and more of our surgery time being filled by reviews of well patients and of us seeing less and less illness. Party determined “illness” is taking priority over real acute illness.

This is not medicine it is a retarded bureaucracy of medicine determined by politicians’ needs and not by patients’ real illnesses. It is said if you want to learn surgery go to war. If you want to learn bureaucracy go into general practice.

Praise be to the Party for pursuing policies of reform which are nothing more than command and control of patient care by politicians at the expense of real hands care of patients and their actual illnesses. Commissioning is not about getting good care it is about controlling costs and will be centrally controlled.

A Happy 2012 to you all and to use an expression from one of the teams’ previous lives - stay frosty. We suspect this year in United Kingdom general practice will be a bleak one with every more expected for ever less and even more interference from on high that will not benefit patients - only politicians and their friends.

Helf and safety and a few erratic Christmas musings.

For those of us here at ND Central old enough to remember the use of candles with which we used to do our homework in the 1970s powercuts is nothing new. What is new is what we found atop a candle bought from a local shopping establishment which beggars believe (see above).

This is similar to our doctors in training who are now asking us 2 years after they qualified to certify the fact that they can put IV cannulas in something which we in General Practice do once in a blue moon. Apparantly in hospitals only registrar grades, which apparantly now includes GP Principals, can do this because under the new eportfolio fellow doctors in training in the same year as they were are certifying their peers in training making a mockery of the new online e-retardation portfolio as a means of proving competence.

If you have not seen a doctor in training do a IV cannulation how can you in all honesty say they are competant? By implication having done a year’s plus worth of house jobs, sorry comrades foundation year 1 (F1 jobs), they should be but I suspect Mrs Jones the vicar’s wife would be a bit miffed if we asked her to allow our F2 doctors to cannulate her when she merely comes in for a repeat hormone replacement prescription so we can sign them up.

Still their fellow juniors can and no doubt such probity issues will be swooped upon at their next appraisals (not). The GMC and Deaneries can’t have F2 doctors signed up for cannulation skills in hospitals when they will be doing it many times a day it would make a mockery of revalidation. We'll do it instead in GP placements.

So we will have to consider whether we can at ND Central light a candle for Yuletide in our own homes for we must surely have to conduct a risk assessment and ensure all the proper safety equipment is in place? Fire proof gloves, eye goggles, fire retardant clothing, a selection of fire extinguishers, a first aider, a fire safety officer, a fenced off exclusion zone, a fire access and assembly point all for one little decorative candle on top of a Christmas cake.

We are so thankful to all our patients who at one surgery have bought Yuletide joy to all of us by nicking from the surgery the empty cardboard boxes wrapped up to replicate presents under an illuminated (risk assessed) Xmas tree now mercifully free of its once proud baubles to bring some festive joy which no doubt have found a new alternative happy home for Xmas.

Given last year’s zero attendance at a Xmas Eve surgery we are sure that our ever appreciative patients’ health will be being looked by caring publicans as they engage in healthy self care by getting rat faced before smashing up our Police officers’ in the spirit of universal love and joy that is Christmas in some parts of Northernshire.

On Christmas Day we are sure they we partake of the 8000 calorie Xmas workout and that is just the chocolate in their kids’ Christmas’ stockings. Spare a thought for their little canine chums who no doubt will pig out on the copious quantites of uneaten and wasted food. Our veterinary colleagues tell us that pancreatitis due to over ingestion of fatty food by middle aged dogs goes up at Christmas big time.

We hope that all of you who have been kind enough to read our little thoughts from Northernshire this year have enjoyed some of them and we thank those of you kind enough to have spared the time to post a comment or two. We hope that you will all enjoy a happy safe and healthy festive Christmas and the same in the New Year.

Contrary to popular belief the NHS and GPs are still open and availible for business day and night something that many patients found surprising today when told of this by King Herod their GP as they bought their little cherubs in for a pre Xmas check to ensure they would not interupt their Mummie’s or Daddie’s own 8000 calorie Xmasfest by being ill. We are sure they are plenty of in laws that can do that without any angelic little helpers.

Enjoy and be careful out there!

Praise be to the Party for creating Christmas and all its trimmings. Can’t wait for the sales rush on the 26th and our on little post festive rush on the 28th. Watch those candles carefully and remember to follow all the instructions on them to the letter.

NHS Global™ goes globally nowhere.

Blogging is quite a good way of recording ones thoughts at a particular time and sometimes when you read something you wrote a while ago it shows that sometimes we have a healthy degree of cynacism here at ND Central.

We wrote a piece in April 2010 and poured a lot of scorn on the idea then and a piece in the Pulse magazine has revealed that the net income earned by NHS Global™ is a massive zero. In fact it will have made a net loss to date after all the expentiture to generate nothing.

We particularly like the bit in Pulse where a former big man in the NHS, none other than the former director general of commissioning at the Department of Health Mark Bittnell, was predicting last month that NHS Global would deliver £ 50 billion for the NHS. Good start then thus far and we all know how much income commissioning has generated cost the NHS. No wonder the world is queuing up to buy NHS ideas and innovation.

Praise be to the Party for yet another good idea to generate income that has cost us all.

What will they think of next?

Tonsillitis.

A teacher once said that you have no bigger group of idle malevoent gossipers with nothing better to do and no purpose in life whatsoever than parents at the school gate. The teacher said that they could create a serial sex offender axe murderer out of a new born if they wanted to by the sheer power of disinformation. In the recent past we may have seen this in action.

Recently lots and lots of parents have been presenting their precious little Tarquins and Chantelles in their droves not with the usual “really” sore throat or being “really” poorly as they trash the toys in a wrestling match to subdue and destroy the defenceless toy but with what they think their child has namely tonsillitis.

Really Mrs Slob your years of non attendance at any educational establishment let alone a medical school do you proud as does your 20 stone 5 foot 2 physique reeking of cigerette smoke although we know you only ever smoke outside to protect Tarquin’s and Chantelle’s delicate collective 80 pack year lungs from anyone coughing close to them in case they catch summit really serious.

Now being doctors we do not usually accept patient diagnosis as gospel for if we did we would have seen over a thousand cases of Lassa fever this month alone we instead do the grunt school honoured thing of taking a history.

The history shows that when Tarquin and Chantelle are asked to point to their “really” sore throat due to tonsillitis they point to their lower neck to a structure called the trachea (windpipe) many inches below the tonsils and their pointing finger even extends further down to the bottom of their breastbone.

The history also revels the prescence of a clear discharge from a snotty nose, a painful dry cough and if one listens to Tarquin/Chantelle telling Tarquin/Chantelle to f***ing give me that f**king toy a very hoarse voice. Observation shows a non coughing child and examination reveals a normal set of tonsils and a completely normal sounding chest.

Sorry to disappoint you Mrs Slob you cannot have some antibiotics to send Tarquin or Chantelle back to school with their “tonsillitis” so you can watch Jeremy Kyle and go Christmas shopping with your healthy friend Rothman. You will have to look after them yourself.

And thank you for noticing that we too have “tonsillitis” in the form of a dry painful cough, hoarse voice, cold and temperature of 40 degrees centigrade which is why you found it difficult to hear us above you shouting at Tarquin and Chantelle to f**king shut up as you were at the doctors while on your mobile ordering your five a day pepperoni pizza and chips for tea.

Praise be to the Party for ensuring that every Yuletide they try it on and on and on. Could this be an NHS Abba special? Sound quality is as good as listening to the mobile phone conversation described above!

More QraP - care pathways.

All three political parties in the UK regard the National Health Service (NHS) not as a service to patients but as a political toy that they can use as the Roman emperors used bread and circuses to placate the populus whom all politicians despise as did their Roman predecessors.

Your average Secretary of State for Health uses the NHS more like they do a toilet. They sit on it, crap on it and then move on to something else leaving all those who work in the NHS covered in smelly brown stuff that we then have to spend years sorting out while they disappear after a huge unproductive dump.

One of the things that strikes us repeatedly at ND Central is when children in often very deprived parts of the world are interviewed and asked what they would want to be it is usually a doctor, a nurse or a teacher all of whom should be professionals and by and large are trusted by most people apart from politicians who fear them. This is the perception in the third world where access to such professionals is less than it is in the UK and where professionals still have a degree of respect even if you cannot access them as freely as you can here both in terms of cost and distance.

Historically this fear of the professions has been so in any political persuasion from the far left (Pol Pot, Mao et al) to the far right (Hitler) and our current politicians are no different.

One of the most sinister manifestations of the theory of creep proposed by the medical blogger the Witch Doctor is we believe is that of the care pathway. What a care pathway is a mystery to those of us who actually treat patients but here are a few possible definitions here, or here or try here. We lost the will to live when we read the word tool for while we will happily here at ND Central to use a hammer as a real world tool anything branded a care pathway is merely a tool.

The care pathway is the creep of socialized medicine using the principal that all doctors are crap and the only people who can really treat patients are those who could only get into a medical school as a corpse to be dissected namely politicians and NHS administrators. This is why if you read the QraP indicators, Quality and Productivity comrades, you will see indicators Qrap 8 and Qrap 11 aka “Delivery of improvement along the care pathways.”

Over the last few months, and perhaps it is because it is autumn when nature starts to deposit and then digest all the detritus we have had increasing piles of detritus called care pathways for our consideration. Most are full of what might be best described as bovine excrement with frequent references to NICE manure and alternative manure treatments but packed full of the absence of any scientifically proven treatments.

What NHS care pathway would empower the professional to do to help the patient in the following instances?

NHS Care Pathway Apollo 13: Land on Moon and return to earth.
NHS Care pathway British Airways Flight 38: land on runway with all engines working normally
NHS Care pathway US Airway Flight 1549: take off do not hit any birds do not pass go and land as normal.

The answer is none of them for life is never as straight forward as a written diktat and sometimes deviation from the protocol is for the better as in all three of the above examples.

Fortunately in some areas of life a few professionals are allowed to make their own judgement but not in the new increasingly Sovietized NHS. Deviate from the Care Pathway comrade and even though you may save a spacecraft or land an airplane and all of its passengers safely you will fall foul of the Stasi and although you may save a life you may as a result not get paid for missing a quick Qrap.

Indeed every care pathway has been about restricting and denying care rather than allowing or improving access to care or the quality of care provided.

This is very worrying. For it is another nail in professional freedom for the Party are telling us what not to do now in order not to treat patients via Qrap. For there is now a target to reduce care see our last post and now insidiously via the Qrap above to reduce care further. So can you see where Qrap is going – reduce asthma care and then if asthma related admissions go up - introduce a new “care pathway” to reduce asthma admissions. Is this now the emergence of a Tripartite intergrated care pathway?

Deny NHS care via QOF micromanagement and allow the emergence of a better any willing provider?

What is worse is the fact that these so called pathways are determined by those doctors who believe that treating patients is best done in a meeting rather than in the consulting room. By avoiding patients this makes them better able to determine care for they will see not first hand the results of their mistakes, their little Qraps on their colleagues, for they are so busy castigating those who actually treat the patients to maintain the quality of care that they do not provide at all. Some may even be well hard once a week men.

Now for simple grunts in the field care of real pathways that patients can actually use involves such things as the application of a bit of Agent Orange to suppress weeds, a bit of gravel and tarmac here and there to ensure a smooth passage to the surgery or to repair a garden path in your average GPs baronial mansion’s garden not about the restriction of care via the local Soviet and its retards. Looking after paths is one thing looking after patients is a much bigger ball game.

When quack medicine, unproven treatments, and where and to whom you can refer for excellent treatment are denied by care pathways enforced upon GPs by the Thickerazzi of the average NHS committee does it not feel that the Eastern Bloc is back and back for good?

Praise be to the Party for progressive freedom in the form of ever restricted choice and centralized control.

We like bottom up reorganization of the health service it works so well as Orwell predicted many years ago. There may even be some new non top down, non targets called outcomes coming our way today – all 60 of them - whoppee!

Did Christmas come early to Northernshire?

Today (30 November 2011) those of us that are average Northernshire Ferrari owning GPs noticed something different as we began our long descent into the great metropolis. It was like a scene from one of those post apocalyptic holocaust films where someone wakes up and finds a car to drive only to find no people or other vehicles on the streets completely unaware of what was going on.

There was literally no traffic on the roads and it was similar to, but better than, going into work early on a Christmas Day morning. Many of our staff said the same that the drive was a pleasure and why was it not like this every day and our doctors in training commuting from other nearby conurbations arrived light years earlier than usual.

Now this is Shiteton an incredibly affluent area of Northernshire so we do wonder how others got on on the day of action over Party proposed reforms to pensions? The late news was ambivalent as to whether the day had been a success for the unions or a damp squib. In general practice at ND Central it was full on - no lunch or drink for the on call doctor until they got home well after 19.30hrs but some colleagues at the local tractor plant reported boredom as normally busy units were quiet.

Tomorrow will no doubt be back to commuting hell as usual and although our sympathies are with the strikers whose pensions are being well and truly shafted as they are an easy target for cash strapped governments (think Maxwell) whether it will make any difference will be a judgement to be made later as is often the case.

The news was full of gloom when we got home and partook of a refreshing glass of a fizzy fruit juice consumed faster than normal due to thirst and the news that we now have just ten days to save the Euro. Anyone remember 24 hours to save the NHS?

Question is as was the case then what are we actually saving, saving from whom or what and who does this salvation actually benefit? The Party or the people?

Still the sun will come up tomorrow and it will be business as usual as it was today at ND Central. Shame the drive to and from work won’t be as good as it was today.

Praise be to the Party for allowing us drivers the odd day to enjoy the roads they charge us so much to drive on at the expense of so many whom they allegedly serve.

I am a patient . . .

For more than 3 score and ten years we have lived in the United Kingdom and have seen many changes. We recall the early days of the NHS and of being able to go to a school based on ability not on the ability to pay. As a result of our education we were able enough although not rich enough to go onto a real University for our fees and grants were paid for by the state via our parents and others’ taxes.

Through our own efforts and the foresight of our forebears we have advanced ourselves free from the shackles of institutionalized prejudice based on the bonds of class and wealth and by opportunities based on ability and education we have prospered both in terms of health and financially.

We have bought forth two generations of our children and grandchildren and hope that we may live to see a generation of great grandchildren all of whom have benefited from our hard work but principally from education and as a result they have all gone further than our own parents could ever have expected or dreamt of.

However such progress is seemingly being darkened by a dark cloud passing over all by politicians who have benefited as we have from state funded healthcare and education but who now regardless of race, creed, colour or political persuasion wish to deny our children’s children that which they themselves have had so freely and as a result so richly profited from.

Nowhere is this more so than in healthcare.

I am a patient and I have a dream that one day the NHS will return to being a service based on medical need alone not on politically driven priorities.

I am a patient and I have a dream that all those who are trained to work in healthcare learn to care and treat patients first above and beyond any slavish desire for useless tick box bureaucracy that serves not the patient.

I am a patient and I have a dream that my treatment will be dictated by a doctor that I know and trust not by a PCT diktat, a NICE guideline or centrally dictated target for I want a trained professional to treat me as an individual for my medical condition for I remember the Cold War and have seen how deprived those who lived in the Eastern Bloc were as a result of centralized state control with no accountability.

I am a patient and I have a dream that when I see my doctor he or she will treat me for my illness alone and not waste hours of my time asking me to go for patient useless tests every year that treat me not.

I am a patient and I have a dream that when I develop a potentially life threatening and/or a life limiting conditions and I see my doctor I get prompt treatment for the illness that is not delayed by bureaucrats telling my doctors to treat a waiting list target before a true medical need.

I am a patient and I have a dream that those who abuse the health service and prevent those with genuine need from accessing it are penalized for doing so rather than repeatedly rewarded for their abuse at my and many other patients’ expense.

I am a patient and I have a dream that when I go into a hospital I am cared for by highly trained professionals whose sole purpose is my healthcare, my well being and my recovery who are not distracted from my care by the need to complete endless paperwork while neglecting patients like me.

I am a patient and I have a dream about the NHS free at the point of care, available to all based on need not ability to pay that is not destroyed by those who know nothing about me or about my illnesses or about healthcare.

I am a patient and I have a dream that when I have a life threatening illness I do not have to repeatedly use my private health insurance to maintain my quality of life for I have paid and still pay my taxes for together with the National Insurance that I have paid over my whole working life.

I am a patient and I have a dream that the doctor treating me will be able to do so to the best of their ability based on the latest scientific research and that they can give me the best care available regardless of any politically doctored or dictated evidence for I am a patient in need of care from and by a professional not by a protocol.

I am a patient and I have a dream that the NHS might one day return to being a being a high quality state funded service providing care for patients who have paid for it delivered by healthcare professionals not a money consuming bureaucracy that provides no hands on care for patients.

I am a patient and I have a dream that when I become too old and infirmed and my family can no longer manage to care for me that the promise of care from the cradle to the grave will be there and still honoured when I am most vulnerable and in need but may not be able to represent myself as I can now.

I am a patient and I have a dream that what I have enjoyed in my lifetime from the NHS will be passed onto and available to my children as a beacon of how a civilized society treats its people and meets their healthcare needs in an equal and fair way based on medical need alone.

I am a patient and I have a dream that I and my family will be able to live that dream paid for by all of our taxes but equally provided for those who are less fortunate than us who may be unable to pay but hopefully still be able to receive that which we do and that those less able to pay will not be denied the same healthcare should they need it.

Mr. Cameron, Mr. Clegg and Mr. Milliband do any of you still have or share the same dream as your parents and grandparents may have once had?

Praise be to the Party and its NHS reforms and reformers and to some of our more senior patients and our parents and grandparents for their indirect inputs into this piece over the years.

We cannot ever better the original speech but can draw inspiration from the sentiments expressed in it and try as did the original orator to right injustice and inequality wherever it is be found even it is to be found in healthcare.

C-sections and NICE twaddle.

Like all GPs in the UK the team at ND Central own Ferraris and commute along Northernshire’s high moorland roads and through its forests from their baronial mansion houses daily to serve their patients. During this arduous chore a few of us listen to the radio. Several of the team this morning heard an interview on the BBC’s radio Four news which can best be summed up as like watching a couple of pensioners trying to emulate a world championship heavy weight boxing contest.

The link to this is here and it illustrates what our fellow GP blogger said in their piece here.

We don’t know how long the link will last so here is the moron’s take on it. The interview is very long (10.21 minutes) by UK media standards and the twaddle is produced by a Dr Gillian Leng NICE’s deputy chief executive who has loads of obstetric experience if you read here and who says:

“We think that the rate of Caesarean section is likely to decline as a consequence.”

Really? A few choice grunt words came to mind as we heard this pontification for over the years of doing medicine we have heard repeatedly from our colleagues in midwifery over and over again that there has been an increased demand for Caesarian sections that are medically unnecessary.

This is akin to NICE recommended compulsory castration to prevent testicular cancer, the removal of all skin defects to prevent melanoma, and the removal of all subcutaneous fat to prevent obesity. All medically unnecessary, but available, treatments if you so wanted.

Unfortunately we suspect that NICE is doing what it is paid to do to review “alleged” evidence and pander to the politicians to justify their interference in matters medical.

Of course those NICE people do not understand the NHS “meerkat” of NICE cuddly toys held up by politicians to tempt patients, sorry punters their way. Who could resist a NICE cuddly “meerkat” when it is always free when know your NICE rights?

If you were too posh to push and you used to have to pay for it and your local supermarket now gives it away for free where do you think the stampede would be that would crush you?

If the NHS offered euthanasia (or any other medical treatment) for free that is not currently available we bet you that the euthanasia rate (or other treatment) would go up, not down, regardless of need.

Anyone fancy a bet on whether C-section rates will go up or down? After all a NICE lady doctor has told you what will happen and we bet you trust all that is NICE?

Don’t you?

Praise be to the Party and its all wise idiots at NICE who have already increased obstetric costs in a time of increased poverty of resources but for what medical gain? We look forward to next year's drop in the C-section rate and to our trouserring a few pounds from our friends at the local bookies.

The law of intended consequences - patient safety and more radical pharmacism.

There is something new in the Quality and Outcome (QOF) framework which is neither Quality or Outcome based medicine just a set of tick boxes to see if GPs are doing any work and to begrudgingly pay them for doing so. QOF is not a fixed set of “quality” goalposts related to any first world quality medicine.

QOF is merely a football kicked by the Party to control cost and a profession. Whenever GPs achieve a “quality” target and have to get paid the Party shifts the “quality” goalposts to ensure less payment or worse even dumber medicine something our American cousins fear for they call it socialized medicine.

Part of the new QOF is something referred to as the QP indicators that stand for Quality and Productivity. We call them QraP points for short because we have problems pronouncing our r s.

Read the indicators and see how a GP once a professional qualified to work independently has to all of a sudden engage in “quality” loveins with the PCT (morons) and “external peer review” (Party stooges) to judge such things as prescribing and referrals. If this process continues unabated patients will not be able to get into the consulting rooms for the number of committees of unrelated “professionals” sitting in there to ensure “quality” Party medicine.

Now one such piece of QraP devised over a campfire by the Al-Qaeda school of radical pharmacists is that GPs prescribe too many drugs that enable their comrade patients to breath.

Such a fact presented to your average NHS manager will ring alarm bells for they will think high expenditure equals crap care as a number on their pretty, pretty spreadsheet is flashing red for a target is being missed albeit at the expense of well treated patients.

Unable to calculate, or explain the difference between what doctors do they will employ a "consultant" (pharmacist) to help them usually a radical who will allay their fears and reinforce their limited belief that all that is wrong with the health service is the GPs.

When you go through grunt school you engage in many alien processes that NHS managers and their Al-Qaeda radical pharmacist colleagues have never done. The first is that you learn a bit of science and then you progress to treat patients.

Such things take more than 3 years to do. In general practice a few years ago it would have taken a minimum of 9 years more like 10 to become a GP now in contrast to NHS managers and their Al-Qaeda friends who can achieve in 3 years or less what a doctor can in 10.

Take for example heart failure and the use of diuretics (water tablets) to treat it. If someone comes in with mild heart failure you might say start with a once a day dose of a diuretic (water) tablet of say 20mg of furosemide (frusemide). If that that does not work you would gradually increase it until symptom control and hopefully a well and functioning patient was achieved. You may even add in other drugs and titrate them according to the effect on the patient.

This is called medicine and the average pharmacist and NHS commissar manager have never had to determine (diagnose) an illness, or think about its possible causes or then go on to treat it and be responsible for their actions. Neither of them has ever had to titrate treatment against its response both on the disease and on the patient. As a result the pharmacist and NHS commissar think QraP is all wise.

The above is the care of the individual by a doctor not a pharmacist or a NHS manager nor the protocol or spreadsheet. None of them aims or shoots the rifle they just ration the ammunition (think of the scene in Zulu Dawn where ammunition is rationed in the face of overwhelming need).

Heart failure can present dramatically and suddenly with a patient waking up in the middle of the night unable to breath and pouring fluid out of their mouths as they drown in their own fluid. At such times those who dictate QraP rationing of care would be asleep and as much use as a chocolate jock strap in a hot oven to prevent facial burns. At which point a highly trained grunt would give many times more than any QraP dictated dose to save lives again something alien to a pharmacist or NHS commissar.

So let us look at a QraP idea thought of those by those in the bottom third of the UK comprehensive system and their buddies in the Al-Qaeda school of radical pharmacists.

Let us look at a group of stable asthmatics and reduce their treatment to save money for GPs never see patients and therefore cost the local PCT money via its drug budget but do remember that GPs, as doctors, are well used to increasing drug doses (mild heart failure versus life threatening heart failure) but equally they also REDUCE drug doses. For example patients with low sodium or potassium due to drug treatment. It is called optimizing treatment for an individual patient not treating a pretty, pretty flashing spreadsheet number.

Al-Qaeda pharmacists or NHS managers do neither of these things instead using socialized medicine, “contract” driven for enhanced “performance” they do “quality” via blanket reductions in asthma drug treatments using pharmacists. Pharmacists who take the trouble never to consult patients unless it is to do a totally unnecessary drug review (DRUM (dispensing review of use of medicines) or medicines use review et al) for which they get paid more than a GP consultation to do so but pharmacist good, GP bad.

Like the Darzi centres pharmacists workloads on such reviews are limited via contracts while NHS GPs are expected to see everything and anything for a fixed cost regardless of numbers so no piecework for GPs. Such pharmacist reviews usually have no change needed to treatment as their conclusion or try this drug instead we did and it did nothing so usually contribute nothing to patient care other than more pieces of paper and a longer stay at the chemist to increase someone’s income.

The reduction of doses of asthma treatment increases as per the local Soviets’ commissars’ and radical pharmacists’ plan which instantly reduce costs and so ticks all the QraP boxes which results in much vodka drinking and fellow Soviet body hugs as those in the bottom third of the United Kingdom education system fail to notice the law of intended consequences for they have done the same with step down dosage of ulcer healing drugs and delayed antibiotic prescriptions.

GPs for some unexplainable reason notice increased attendances of previously stable asthmatic patients with shortness of breath. These then require treatment with steroids (cannot prescribe those for they are too expensive and “evidence” shows enteric coated steroids is too expensive as well) and often hospital admissions when patients cannot breath.

So when we are told that £ 10,000 has been saved in a quarter on asthma inhalers as a result of Al-Qaeda socialized medicine and we are doing well and yet the extra 10 admissions for an acute exacerbation of asthma at around £ 3,000 a shot means we now have to reduce our unplanned admission rates. Are we the only ones to see through the fog of QraP and the law of fully predictable consequences?

QraP is any ongoing process so we have to meet in the near future to discuss ongoing “progress”. No doubt the increased admissions due to poor asthma control will be a non issue? If untreated asthmatics die then that is the ultimate “quality” in the “productive” new world of the market driven NHS?

For dead patients are cost neutral.

Praise be to the Party for allowing the thick to increase costs and NHS workload for a negative financial gain. Those who deliver such outstanding service for the NHS could only be better deployed in Afghanistan in the neutralization of IEDs - they are wasted in healthcare.

More QraP to come comrade patients . . .

You cannot be serious?

Our friends at Pulse have provided a little gem as to how little use some bits of NHS management are. You can read what we believe is the original document here.

Now for those of us who work in real medicine this will not be an issue. If you are off for less than seven days any patient who wants a sick note for such a period will not get one. They will be told about self certification whatever their little Führur of a manager (NHS or otherwise) says.

If you take strike action that is your NHS Choice and you should accept the consequences. We would not expect our taxes as GPs and the tax paid by our staff to subsidize your withdrawal of labour. If your employer wants to argue the toss let them do so at an employment tribunal but please do not waste your GPs’ time at their behest.

We really do wonder what some NHS managers do with their time but if anyone is looking for some quick NHS efficiency savings we have a pretty good idea where to find some.

But lo as GP entrepreneurs we see a little glint of goodness in amongst these dark tidings of NHS management woe for cash strapped practices.

Read note 2 on page 1 of the original document. We will be happy to provide such certificates to any reasonable employer at say £ 100 a shot?

Game on anyone? Let the specialist commissioning of such a service commence should be ready to roll by Christmas 2027.

Praise be to the Party for ensuring that all comrade workers can have their cake and eat it possibly at everyone elses’ expense? They cannot be serious, can they?

A trip to the attic and some thoughts on NHS computing.

There are certain things that as an oppressed minority in general practice you can only do when the memsahib is away and one of the team did just this at the weekend.

They went up to the attic (disgusting) to retrieve a computer from almost 20 years ago. The dust on all the components coated their fingers and as they pulled the pieces from the attic they saw many things that were once the workhorse of their general practice and which still held useful information which was the purpose of this quest to answer a patient’s query.

The computer was reassembled without a single USB or PCT IT technician (delta grade triple star the NHS’s IT elite able to connect a monitor to a computer in less than 3 days and disable a practice as a result) but with lots of screwing (disgusting) of old fashion cable connections. When fired up the screen only displayed the message on the massive Cathode Ray Tube (CRT) screen of no video input with associated muscle ache from carrying it downstairs.

Disaster no flat screen light weight flat screen here but another trip to the attic found an even smaller CRT screen (bigger than the local Soviet allows their doctors to watch today) and on connecting and with a bit of experimenting and remembering the correct firing sequence for the cylinders of this particular piece of electronics the screen lit up.

The screen boasted of its massive 16 000 kb of RAM, its 90 MHz processor combined with a stonking 500Mb hard drive. Cutting edge in its time this brute of a machine ran a business for more than 5 years. The data required was extracted over a couple of hours and transferred to a more modern machine but what struck us was how easy it was to access this aged computer.

There was no password to gain access to the windows program for this computer ran using the DOS program (not the useless D(r)OS of Choose and Book) and you had the C: \ prompt which you followed with the hallowed secure password “win”. Access was almost instant.

No Smartcard, only one password for the most secure of files and the whole box that contained the PC weighed less than one of our current laptops. And what is more the whole boot process took less than 2 minutes which was like warp speed compared with today. All you needed to run a GP practice was still there and functioning.

Would we here at ND Central be able to access our current PCs in 5 years time? What about 20 years? Clinical systems demand regular password changes every 2 months. NHS Smart (Dumb arse) cards we believe automatically exclude users after 2 years until their local Soviet redefines them as suitable users of the clinical data that they create and record to enable them to treat patients.

The centralization of medical data although by some may have been seen as a relief to GP Practices but increasingly we see it as part of the control of the medical profession. In order to do your job as a doctor you need access to medical records. No access to medical records = can’t do job.

The NHS Smartcard is there not to keep people out of the medical records you create but to control which doctors are allowed in and hence able to work. We no longer have control over our access to the records that we create in the same way we had with paper or practice hosted computer systems even though the paper records were technically the property of the Secretary of State.

The data we required was easily extracted and most of the time spent doing this was with getting the hardware up and running from the attic. The same would be so of paper records.

Could you as a GP answer a complaint from 20+ years ago when the records may be on a computer? Can you remember your passwords or even your PINs from 20 years ago? Could you if you had ever assembled/built a computer yourself remember how to do so and get it to work?

Where do you your computer’s hard drives go to when replaced (Africa perhaps?) and given that now the Party has so generously relieved GPs of their financial responsibility for computers who defends GPs in the event of complaints? No records we believe means no defence. Are the centrally held server records so beloved of the Party still going to be there in 5, 10 or 20 years? Our old hard drives from various clinical systems still are.

Do you know where your hard drives from 20 years ago are? Can you access them? Can you remember the passwords?

Of course the benevolence of the Party is such that this will all have been thought of but issues of different coding of information from system to system means that data accurately recorded once may be inaccurately transferred over several years of changes of clinical systems which may well haunt us as GPs for years to come.

Paper records although bulky are easy to read (subject to doctor’s writing), are very personal and they need no electricity, no password, no dumb arse card and it is most satisfying to be able to answer a patient’s query about something that happened to them 50 years ago without going into the attic (disgusting) for the information was available from that time and was accessible to anyone able to read which would rule out most who work for local NHS IT.

Can today’s doctors say the same about what happened to someone in 50 years time? Paper has stood the test of time will NHS IT do the same?

Praise be to the Party for ensuring that a trip to the attic (disgusting) means we have experienced more advanced and secure IT on a desk 20 years ago than we do at work today for there was no internet or Party attempted centralization of records via a central summary care record which holds information as securely as a sieve holds water.

Furthermore these were “our” records and we as professionals knew where to find them and controlled access to them. This is no longer the responsibility of doctor but we are sure that other professions like lawyers and accountants will not have Smartcards or a national network of lawyer or accountant records to share with the world wide web as doctors are forced to do.

You have been warned.

Anyone done the maffs?

We have been informed that a Caesarian section will now be a right rather than a medical necessity. A few thoughts occurred to the team. Let us suppose that you work at a hospital that does 12 deliveries a day and that all the women opt for a Caesarian section rather than a natural childbirth.

Let us assume that each Caesarian takes half an hour of operating time then any hospital operating new NHS C-choice™ would have to find a mere 6 hours minimum of theatre time a day above what is provided now. Operating time is not the only thing that would have to be found there would need to be found additional anaesthetic and associated personnel time, surgeon and assistant time, midwife time, paediatrician time as well as porters et al and of course those most essential for true patient care the NHS commissars to prepare the bills that allow the NHS to work independently of all of the aforementioned non essential personnel.

The hospital would also have to find 12 beds a day as well as recovery staff time and ward nursing staff time and that is assuming that these are all done as general anaesthetics rather than epidurals which take longer to work and all were done as day cases.

Indeed our recollection of elective Caesarian sections done under regional anaesthesia which you can bet will be the norm for those too posh to push so they could see their darling little Tarquin or Chantelle-Detritus-Leah (it's exotic!) born and post the event on YouTube was that 2 maybe 3 could be done in a half day session.

So 6 hours of operating time is being optimistic it is more likely to be 2 or possibly 3 theatres operating for a full day plus the increased number of staff. In order to work this would need to be available for 365 days a year as well as facilities for any emergency C-sections.

Obviously as this would be C-choice there would be peaks and troughs for Tarquin’s and Chantelle-Detritus-Leah’s planned arrival into the world. For example I couldn’t deliver at Christmas as I would miss my turkey and heaven forbid any obstetrician says to a woman the only slot we have for an elective C-section is on the night of an X-factor final, FA cup final, or a Big Brother eviction. How would Wayne Trotter the father cope? You can bet that he and Sharon will know their rights then.

The article quotes a figure saying that a one percentage point reduction in C-section rate saves £ 5.6 million. Does that mean that if 100% of births were done by C-section up from the current 25% the NHS would have to find £ 420 million a year for a procedure that some would argue is not being done for a medical reason?

And in order to double check the maffs if one takes the figure of 708, 708 births in 2008 take 75% of these and multiple by the quoted £ 800 extra per birth you get a figure of £ 425 million. Not a small chunk out of £20 billion NHS efficiency savings over five years in the midst of a recession.

Then there is the morbidity and mortality to add in. Yes deaths from anaesthetic complications have decreased in pregnant women over the years but if more women have abdominopelvic surgery then DVTs will increase. We believe that 60 in 100,000 women who are pregnant will have DVTs which is an old figure presumably based on a 25% C-section rate. If that rate increases will DVTs and PEs and their 1% mortality go up as well as general morbidity for example wound infections to match the increase in numbers done? More operations means more chance of misadventure so what would happen to NHS indemnity bills and defense society charges?

Now we are simple GPs here at ND Central and while doing home visits one of the team heard an interesting point being made on a popular TV show as they listened to the normal chest of the infirmed but “too idle to come to surgery”, the ancestor of the "too posh to push" generation. This urgently infirmed geriatric had wanted to be sure they were well enough to go to their granddaughter’s Halloween Party and outdoor barbeque – presumably as the evil looking witch with nicotine stained nails, eau d’cigarette body odour and scary brown hag dentures –  followed by trick or treating with Jemima-Louise.

The point was made on the programme that NICE stood for National Institute of Clinical “Excellence” (not) – got us listening – and that Marshall DC’s poll rating with female voters is low. Could this be the answer to another medical blogger’s posed question?

We await the final publication of any NICE guidance and their reasons for suggesting their policy. We hope that following on from this that all cosmetic procedures will now be available on the NHS for surely if everyone is now too posh to push then no-one is too poor to be ugly?

Praise be to the Party and its NICE organs who evaluate “evidence” rather than science and come to some fairly doubtful “best” political practice ideas.

Dark nights and darker thoughts.

For those of us who live North of the Thames the inevitable move towards autumn and winter leads to a rapid shortening of the daylight hours. Now darkness is good for members of the Resistance based at the infamous Café Michelle for it allows more covert activity and as the temperatures drop the thought of a night with good company and a few fermented fruit beverages is very appealing.

At one recent such meeting we were discussing the state of the current health and social care bill and what had been said at various meetings and events that members of the team go to. We are a very broad church here up North in terms of our interests and associations and as a result encounter a wide range of opinions and thoughts on matters political and practical. After a few fruit juices the thought processes sometimes deviate from true logic and what follows is one such deviation.

For those of you not lucky enough to live in the Shiteton PCT’s area of enlightenment you will not see the results of early GP led commissioning. Here GP commissioners have many fruitful meetings and are reshaping local healthcare by the minute as all our Harvard and Yale educated MBA PCT commissioners always start the meetings with the words:

“How can we help you master/mistress? We are here to serve your every whim for the betterment of your patients all praise to Andrew the great prophet and liberator of the NHS.”

We are so lucky but not many leagues away we are aware of the complete opposite where local Soviets are dictating the rules of who can commission what and on what terms and as a result nothing is happening. Equally we know of other Soviets and GP commissioning groups that are in between these extremes.

Historically Government does not like resistance and certainly the old Party did not like GPs for they did what the Party asked but the Party did not like having to pay for that. It is uncertain at present what the current Party’s true thoughts are regarding GPs but it is clearly engaged in a campaign of lies, sorry spin, about how much “support” there is for their reforms in all sectors of the medical profession.

Commissioning has failed expensively over the last 20 years but is being reborn and re-branded but this time with GPs nominally in charge of much larger scale commissioning by GPs than ever before. Previous attempts at commissioning failed in times of plenty while this time we are in a time of recession.

We are told that this will be no top down reorganization but it is clear that local initiative is set to be stifled by the new financial politburo call Monitor and clinically via the new uber super quango the NHS Commissioning Board and its regional under boards.

So if GPs get to play commissioning how many of their ideas will be allowed by the bureaucrats who failed to make commissioning work in its previous guises? The Party can fight any Clinical Commissioning Group (CCG) on two separate fronts to prevent successful GP commissioning. One front is via Monitor using financial constraints and if that does not work they can fail an idea on clinical, quality or outcome grounds with support from other limp organs like NICE via the NHS Commissioning Board.

Add in a recession and reduced funds by virtue of inflation combined with a hugely flawed process and GPs are now fighting on three fronts with no ammunition or weapons centrally provided and still having to do their day job as well.

It is possible that despite “best” intent we GPs may all be looking into the large toothed jaws of possible global failure except that this time the Secretary of State may be able to wipe their hands of their enforced failure for they can blame the GPs instead. Failing that a change of Party might do the same job and blame the GPs as well. Is the strangling of local initiative by centralized Party control part of the Liberation process? And from whom is the NHS to be liberated from?

So in the dark corners of a Northernshire cellar in front of a blazing fire we got to “the what if” stage and dark thoughts loomed large. If GP commissioning fails perhaps the benevolent Party would have to step in and take over via the (its) Commissioning Board and Monitor and maybe a few other central organs of control? The Press would have a field day and say GPs “couldn’t” and therefore “shouldn’t” run the health service.

Completely understandable if you have to fight a boxing match with both hands tied behind your back, wearing a blindfold to outfox your opponent who can see where things are going, with lead boots from local NHS management to facilitate your forward progression and the complete absence of any seconds.

The next step might be to rein in GPs autonomy and perhaps enforce a salaried service in order to control any clinical dissidents and at the same time reduce costs and recoup all the excesses of the failed CCGs. A new leader might be required to sort things out and take charge perhaps a more powerful than now Secretary of State?

The new leader might then be free to bring in the private providers to run things better and then employ them via corporate entities? We won’t mention the words dentist in our discussions on these dark matters for it has happened there already.

Could it be that the Tripartite healthcare policy has one aim and that is to reduce GP control over and involvement in healthcare? For if GPs cannot successfully commission can you successfully refer or treat patients as independent “self employed contractors”? The system would clearly then need “reform”. The thought processes got darker and darker as the evening wore on until someone said some time honoured magic words to rid us of our demons.

“Time please ladies and gentlemen of the Resistance haven’t you got nice surgeries to go to tomorrow morning?” Yes we have but dark thoughts will be with us as we see our first commuting toddlers and pensioners at seven thirty hours tomorrow as true beneficiaries of previous “market” reforms.

Then the alarm went off and it was time to get up and go once again. At least this weekend we get an extra hour and the next early morning might not be as dark, for a while longer.

Praise be the Party for always needing to reform things even if they work. Let us hope our dark thoughts were merely a bad dream.

Why?

Why is it that patients who buy home monitoring blood pressure measuring machines, who record it 5 or more times a day on a spreadsheet that they give to you, who also attend nurse clinics where their blood pressure is taken sometimes the day before you see them always ask if you would “just” take their blood pressure?

Surely this is pandering to the pathetic worried well? Just in case one of the following:

their one Campbell de Morgan spot
their verruca
their paracetamol relieved headache of seconds duration
their self inflicted Gaviscon eased indigestion
their coital avoiding headache
their red face
their feeling dizzy
their not feeling right or myself
their I went to the gym and the instructor felt that a blood pressure of 110/80 at age 97 was a bit high/low

is a sign of high blood pressure?

Patients always know when their blood pressure is high for they can feel it is so when it never is. Could this be a huge revenue earner for the health service?

If you buy a television, even a computer capable of watching TV be it broadcast or via the internet, a DVD/video recorder or mobile phone that can receive TV in the UK you are asked to provide your name rank and serial number and address to the retailer which is then sent off to the TV licensing authorities who check if you have a TV licence.

Perhaps we should have a scheme whereby if you buy a blood pressure machine your details including NHS number are sent off to the new commissioning board who would automatically disqualify you from ever having your blood pressure taken again for you have opted for private healthcare? Given the state of NHS IT when you next see your GP a huge flashing screen would say to any nurse/doctor/healthcare assistant ineligible for NHS BP care and smack a £20 charge if patient asks for their BP to be “just” checked.

Sound familiar? The pandering to the pathetic well is a growth industry and should be ripe for Government picking? Instant deficit reducer. Instant pandering to the pathetic well reducer of unnecessary surgery attendances for many of these patients always opt to be seen within 48 hours or as an “emergency”.

Praise be to the Party for encouraging people to pay for their cake and eat it and then to come back for seconds they don’t need or pay for.

PS we at ND Central do not have a problem with BP monitoring and some of us have in the past regularly done 5 minutely BP readings for when you are bleeding to death from a knife wound it is then useful. When you are a bleeding heart forget it.

The 0845 number debacle.

One of the great successes of Za Nu Labour’s running of the National Health Service was its use of a system of government that used to be common in Eastern Europe. It was called communism whereby everything was dictated from the central offices of the all wise Party under the guidance of the supreme leaders the Laurel and Hardy of modern healthcare Mr Blair and Mr Brown all for the benefit of the people.

The former ex great leader was famously handbagged by a patient who asked him about his health reforms and to explain why she could not get an appointment under all of his improved access targets. Under Comrade Blair’s preferred model such dissent would have resulted in a quick trip up to a gulag for a period of re-education but under what remains of democracy and public scrutiny in this country his lack of knowledge of matters healthcare was on view for and enjoyed by all.

Following along from his enlightened leadership one of the reforms that the new General Medical Services (nGMS) contract ushered in was the need for a single phone call to enable instant access to your GP or more importantly the out of hours service.

Now in theory this would seem at first to be a good idea. You dial one number and can access your, or a, GP 24 hours a day. True market reform for the good comrade patients’ benefit no evil private sector backhanders here. The non paying customer, we call them patients, gets instant self centred medical gratification a bit like certain politicians and their DVDs but then these cost the taxpayer via the MPs expenses.

Prior to this at ND Central we had a single telephone number which when the working day used to finish at 18.00hrs would switch on to an answer machine which gave the contact details for the out of hours or deputizing service that we as GPs paid for to cover our patients after hours to allow us some sleep.

Now the blessed Tony, a true socialist conservative Anglican Catholic, who believed in comprehensive education for all, bar his own children, in the NHS for all, except when he was ill, and who can now do no wrong, he only has to confess not to be responsible, thought let us supply the out of hours care using the private sector for private medicine good, socialised medicine bad and costs rose astronomically for a worse service.

Back to the phone call side of things this two phone call issue was clearly a huge problem to the likes of Tony and Gordon for they were all wise and so the nGMS contract gave prizes for a single call. Being true socialists and wishing to share this great idea of a single call for all ills an 0845 HEALTH (we purposely omit the W at the start of ealth) was suggested and PCTs, government sponsored enforcers “encouraged” GPs to sign up for deals with 0845 numbers. If you don’t you won’t get paid for you will fail to provide a Sovietly acceptable one phone call to tick the “quality” box.

Remember dear readers that PCTs are staffed by those who at best were in your remedial class in any Northernshire comprehensive school a few of whom could read and count. So GPs were “encouraged” using the “free” market model so loved by Tony and Gordon to sign up to Party deals for GPs were given the same true NHS Choice offered to patients via the market which is none.

Move forward and although the Party dictated and approved idea is good a few people noticed that some pigs are more equal than others (Hewitt - excuse us we just sneezed) when it comes to profiting from telecommunications and a few dissenters in need of political re-education noticed that if they ring on a mobile, which after all is only the preserve of the politician and drug dealers, not a pensioner on a limited income, they were disadvantaged. For the 0845 number is not a local charge number it has many different costs depending where you ring from to access it.

So the Party does a massive U-turn on its equitable access policy and tells GPs you can’t have a 0845 number. You can look here for who hasn’t by PCT and compare them with the sink estate PCTs, sorry comrades, spearhead PCTs and see which PCTs have the best in remedial NHS management. This does seem to be a recurring association dear reader that we have noticed by chance during our researches over the past few years.

Now this is the history what are the practicalities to current GPs given that the true socialists Brown and Blair have peed over the NHS and retired to pastures newer, richer and more idle lifestyles that befit all true socialist Party members?

Well the first is that local Soviets are asking us (= demanding) that we GPs get them out of the brown stuff they insisting on putting us in. We now have to change our numbers or else.

This is excellent for the remedials who agreed the contracts but could not read all those big words in them for all they saw were the flashy teeth of the nice salesperson who flattered them and told them what a good deal this until they signed. When the X was one the bottom of the contract in the managers' best crayon the salesperson said "Thank you for signing and so long sucker” and disappeared in a puff of fairy dust never to be seen again.

And those signing such “deals” are the “world-class” commissioners of old trumpeted as such by the Laurel and Hardy of UK plc healthcare now joined by their new bum chums the Charlie Chaplain of healthcare (Lansley) with the help of hop(e)along Clegg.

So the get out clauses for GPs for contracts enforced on us are now as follows:

1) you can revert to your original single line with an answer machine and lose money for not providing a single point of access. Not a problem to us comrade GP we merely follow orders.

2) you can keep your current 0845 number and we will shaft you for doing so. Not a problem to us comrade GP we merely follow orders.

3) you can ask your current 0845 provider to change to another number that will be dialled when the patient dials 0845. Your current 0845 number then provides a call switching “service” which would involve no cost to the PCT morons who thought of this but scratch deeper and you find that once the call is switched from the 0845 number to your out of hours provider you the GP then pays for the patients call. So a patient's call to a surgery costs the patient but the patient's diverted call to out of hours costs the GP. Another great buy one pay for two value for NHS money idea like PFI. Not a problem to us comrade GP we merely follow orders.

4) you could consider doing the same using another provider and get stung in the same way. Not a problem to us comrade GP we merely follow orders.

5) you can pay a fortune for reprogramming your current phone system to divert calls which once again you have to pay dearly. Not a problem to us comrade GP we merely follow orders.

Best still we hear that some local Soviets are insisting that practices write to all their patients to tell them of the Practice new number change policy which would mean a net loss to correct "their" folly.

It is said that in any society there are rights and responsibilities. Increasingly in the NHS the rights of the politicians are that they have no responsibility and the same is so in NHS management. Until these groups acquire some responsibilities GPs and all involved in healthcare will continue to spend time not treating patients but mopping up political and management collateral damage inflicted on them via continuous "reform" and incompetence.

In the same way that these “world-class” commissioning managers have screwed up the Darzhole centres they have also screwed up the 0845 numbers and once again someone other than them will be paying for it.

Now if you were a betting man who would you back to win in Mr Lansley’s, new NHS market? The NHS’s commissioning managers, the patient or the private sector? Go on have a flutter it has to be a dead cert . . .

Praise be to the Party for allowing the least able in our society to bugger up the NHS time and time again. Bloody comedians only they ain’t that funny when you're the ones sorting out their fine messes once again.

Flu clinics and zombie movies.

A few years ago the zombie movie was quite popular and it is a film genre that has been around for decades perhaps the best known of recent British movies is Shaun of the Dead (2004). In virtually all such films there is a scene where lines of the living dead zombies march forward apparently unstoppable towards the heroes or heroines.

There is also the nursery rhyme if you go down the woods today you’ll be sure of a big surprise. Well as a public service announcement we would advise you that if you go down to your surgery at this time of the year you may also be sure of a big surprise. Yes go to your doctor’s surgery at the wrong time and you will see the annual zombie gathering that is a flu clinic.

Watch in amazement as line after line of the living dead hobble in waves towards the surgery seemingly unstoppable. Some can just walk on their own, some use a variety of walking aids that double as lethal weapons to those who are as yet not of the undead be it the form of walking sticks, Zimmer frames, wheelchairs and electric buggies. Others are helped by their relatives or carers and they have been prised out of their pre tombs for the annual march to the surgery for the life preserving anti zombie serum the annual flu jab.

In order to counter the waves of the undead surgeries have developed efficient methods of processing them. The undead are discouraged from regarding these flu clinics as drop in and moan clinics but the undead do not hear well at the best of times. The undead are processed brutally by the heroes and heroines of the annual general practice zombie flick the reception staff who ask them for name rank and serial number, tell zombie 6491 to expose your left (or right arm if left missing having been hacked off by one of the other undeads’ walking aids) and lurch forward to serum room X. NEXT!

At serum room X a nurse, doctor or other trained health care worker will plunge the life giving anti zombie serum into the exposed arm and utter the protective words “NEXT zombie to room X” and dispatch their current zombie before they can open their mouths and utter the well known zombie mantra of “While I am here . . .” NO NEXT!

They will have already tried that at the chemists before they got here as they can’t get their prescription which they forgot to collect the day before from today's zombie, sorry flu, clinic and will run out of tablets before the next surgery which would mean they would join the true undead. “You must help me doctor/nurse/receptionist” they whine with outstretched hands, pleading eyes, gasping their last . . . Wield the chainsaw and blast them with NEXT!

And so in at the front, report to reception no talking or moaning, jab and then out through the back the zombies lurch side to side slowly ever forward until they get back to the zombie mobile parking area. To those of us who are still alive this is as terrifying a place to be as is watching the waves of zombies walking in and through the surgery and out again.

Line upon line of white haired, hunched, swollen ankled, slowly moving from side to side faster than they move forward just defying gravity, spectacle wearing, false teeth clad sufferers of chronic diseases and well rehearsed self pitying regurgitated stories of woe kept going, i.e. just alive but not enjoying it. For we are living longer but not enjoying it, and they are here believing that the anti zombie serum will dent the Reaper’s scythe which it may well but it still keeps hacking away at their general health year on year with an ever worsening decline.

For in the limited space of a surgery the lurching zombie mode of walking is dangerous to most other than lawyers, indeed most of them in a major shipping lane could hit and damage something major usually a floor or failing that a supertanker but worse still is the spectacle of zombie parking wars. Here usually in small cars sometimes with one but sometimes with up to 4 zombies a vehicle they play dodgems and compete to park using the ancient way that headless zombies park using the touch park technique.

Leave your own vehicle here at your peril, walk here at your peril. Our staff park several miles away surrounded by anti terrorism concrete blocks just to be extra sure for whilst parking is a tactile experience for most zombies driving is more of a Braille reading exercise of straddling the white line and feeling for the cat’s eyes to know where to go and avoid bumping the kerbs which they frequently drive over and complain of the worsening potholes. Surgery walls frequently take damage on anti zombie serum days as zombies seek to avoid other stationary zombie mobiles in the car park entrance by giving them at least 3 times the width of the surgery car park as clearance.

Given that zombies are the second most dangerous group of drivers on the road the collection of large numbers of the living dead on a small area of road is lethal. Many of our medical students know them for they are usually the 40 mph in 30mph zone drivers and 40mph anywhere else for they are pushing the envelope of geriatric speed endurance.

The combination of a heater on full, steamed up car windows combined with cataract ridden eyes, out of date glasses wrapped up in fifteen layers of 1950s duffel coats and driving gloves with protective flat cap head wear, unstable bladders desperate to pee somewhere and reaction times 10 times slower than normal means that a right signal means I have priority and I am turning into a car park regardless of on coming traffic as another zombie pulls out unable to see the other vehicles 12 foot in front of them BANG! Left turners fare little better KPOW! CRUNCH!

After several hours of zombie carnage the surgery building and car park go quiet as the living dead have been dispatched with enough anti zombie serum to keep them going for another year. However the living dead leave behind them several things. The odd walking stick, limb prosthesis, glasses, scarves, gloves, hats, car keys, false teeth, mobile phones, handbags, wallets and hacked off body part have all been recovered but the worst bit and this is true of any battle is the smell. Unwashed clothing with the subtle industrial strength eau d’urine being the most easy way to describe the smell of the living dead after their annual visit and it lasts for hours sometimes days even after the use of Agent Orange strength air freshener.

This is not an end to general practice zombie wars for within 3 days of the first wave of zombies receiving their anti zombie serum they start to come back complaining that having had their anti zombie serum they have now become real zombies by virtue of having contracted the flu from their flu jab.

Is the annual zombie movie of the average GP flu clinic all worth it? To a general practice it might generate a few hundred pounds of extra income but that is not without costs in terms of staff time and discomfort. Our understanding is, and we are welcome to be corrected if we are wrong, that it does not reduce hospital admissions one bit. Yes it may protect you against flu but there are plenty of other viral infections in the winter months that will accelerate our proto zombie population into full zombiedom and hence hospital admission.

Praise be to the Party for providing the zombies with their life restoring serum every year. We hope it is worth for you all.

Until next year? Anybody watch the march of the Lords into their bespoke zombie debating chamber . . . ?

The internal market, NHS “competition” and a Yorkshire practice.

A few bloggers have posted on a practice in Yorkshire offering to do certain operations for their patients for a fee. It seems from this link that health minister Paul Burstow does not think this is on as he and his Party seek to make this more the norm than the exception. How could this come about given the NHS internal market and competition?

Well perhaps it is the result of the true free market as opposed to the NHS Soviet style market? We have commented before on how the only part of the Party’s fixed NHS tariff, the only bit of which you can compete on is quality, not cost, that can be negotiated is the price a PCT can pay a GP to do a job cheaper than a hospital can. This means if a GP refers a patient to see a dermatologist with a mole then the cost of seeing the dermatologist is the same anywhere in the fixed price but competitive internal market that is the NHS Tariff zone. So the Party fixes cost but you can haggle all you like on quality with a hospital only GPs can undercut the hospital tariff price system.

So in general practice you get used to get the situation where NHS managers deep in their bunkers notice that as people become more vain they want moles removing a few of which may be cancerous which are the only ones that NHS commissar managers think really need removing. So being some of the brightest remedial class graduates they think did not GPs used to do that once and more cheaply?

We will give GPs a few farthings to do something that the hospital would do for a couple of hundred sovs and that should save us pounds. So the local Soviet commissars do this and go into the playground to play commissioning games and using the NHS Soviet free market model they restrict the number of cases GPs can do to save even more farthings.

If any of them spoke to GPs instead of dictating to them they would realize that minor skin abnormalities are very common and NHS consumers aka patients pay bugger all for anything so they will use the system as much as they like. NHS consumers, sorry service users, are well used to the concept of the free market especially when it comes to health.

Furthermore if you agree for example that a practice can only do say 30 excisions a quarter and the practice can do that in 4 weeks then where do the others go? Local GPs say that they could do more for cheaper but targets are targets so there is no extra money for doing more work so referrals to hospital continue to go up.

Now if you have been in a remedial class for all of your life and are allowed to play at being God in a PCT then the idea that you can stop your betters having something really appeals to you and so NHS commissars fix the market a little more. Not only do they restrict the number of procedures GPs can do cheaper than the hospital they stop the patients going to a hospital as well. The supply of dermatological surgery in the NHS free market has now been capped by your local PCT but the demand has not and it is not being met.

So you tell all the boffs in your class at school that you used to throw paper balls and other things at to stop being doctors and operating and you also tell them to stop being doctors by referring patients because we are not going to pay you so there! We are so big and clever with it!

Result if doctors cannot treat patient themselves or refer them to hospital because the local Soviet says you can’t how do doctors get round the not being able to treat their patients?

Well this is where the NHS “free” market comes in for it will allow any willing provider to set up shop. GPs are mostly small businesses and if you spot a way to make more money and provide a service being denied by the NHS then this is where the free market can help. You are not allowed as a GP to charge your patient for any NHS care but if the NHS does not provide the care you could set up as a private company and offer a service to patients for a fee. So the “free” market using innovation comes up with a solution to the problem created by the Soviet style NHS internal and centrally regulated market.

Simples. And we are sure that there will be plenty more such innovation as the money becomes tighter like the noose of central regulation of healthcare reform and it is probably an entirely intended consequence that has sneaked out a little too early for political comfort. Not all such any willing providers will be GPs but anyone who can see a way to exploit shortcomings in current and forthcoming NHS provision.

We here at ND Central wonder what will be the next any willing GP or provider opportunity? The way the NHS “market” works means there will be some and if you have the money you can always get better and quicker treatment when the NHS fails to provide.

Praise be to the Party of continuing reform using the current tripartite vision for NHS provided healthcare of expensive market good, cheap socialized medicine bad.

Do not shoot the entrepreneurs for they are just playing by the rules of the game and some of them may well win and win well. Their wins will probably be at the loss of the as of now non-paying consumer our patients and their future healthcare and wealth and all the result of a highly flawed centrally imposed market that has failed for 20 years.

And it continues to do so. Reform of a bad idea does not make it a better idea and even the politicians don’t like the result of their endeavours.

The results are in and . . .

We posted about the GMC consulting on whether it should regulate doctors’ lives outside of medicine and the results are in and can be read here together with some GMC thoughts on the issue.

In summary in answer to the question do you think the GMC should regulate doctors’ live outside of medicine the results were:

No              1100          94%
Yes                54            5%
Not sure       13            1%
Total         1167

If you look at the percentages if you were a politician you would regard this as a landslide result of a mandate saying that the GMC SHOULD NOT regulate doctors’ lives outside medicine.

However dear reader read further down and see that the amount of column inches given to the comments of the Yes voters is proportionally greater than that given to the No voters as is that given to the Not sure voters.

Read further and see that:

“Given the very large response to this question, we have decided to ask a specific question about doctors lives outside medicine when formal consultation starts later this month.”

Interesting words those for they remind us of the “ratification” of the treaty of Lisbon whereby if the politicians did not like the result of a referendum they wanted they have another one or the old joke that if the British ever solve the Irish question the Irish will change the question.

We are sure an elite team of (Daily Mail?) journalists will be at work drafting the question so as to get the right answer. Here is our crude attempt:

Should the GMC have the power to regulate the personal lives of all doctors if they are paedophiles?

Should result in more Yes votes than the previous question comrades shouldn’t it?

As someone once said on 10 July 1790:

“The condition upon which God hath given liberty to man is eternal vigilance; which condition if he break, servitude is at once the consequence of his crime, and the punishment of his guilt.”

John Philpot Curran Irish judge to which we would add a term some of us heard from modern(ish) military circles in Iraq:

“Stay frosty gents”.

We await the publication of the specific question with interest and whether the formal consultation will be along the lines of the Future Forum consultation on the NHS reforms.

Praise be to the Party for giving us the illusion of democracy within an increasingly Party controlled “free” state.