Tuesday, 29 March 2011

It is all so simple.

One of the great things about being able to read is that you can. You can use the method most of us were brought up on namely text written on a paper format or as most of you reading this will probably be doing now reading off a computer screen of some description.

The content would be the same but the impact of the presentation may differ somewhat. If you are a reader of the GP magazine called GP you can see its latest electronic version here.

This however lacks the impact that the human mind can get by flicking through pages of paper quickly. Here is a series of headlines relating to GP commissioning/health care reforms that impacted on the human mind after reading the first 6 pages of the paper version of GP magazine from 25 March 2011:

GPs must join up to end care lottery.

PCT bid to cut costs endangers patients.

BMA to step up its Health Bill opposition.

QOF will not pay GPs for rationing NHS care.

Tory GP MP warns reforms will privatise commissioning.

Consortia must save £4bn by 2014.

DoH drugs plan could raise NHS costs.

Consortia told to ignore DoH advice.

GP consortia face fines of up to 10% turnover.

Health Bill limits consortia control over spending.

And we thought commissioning was oh so simple.

Praise be to the Party for its consistent approach to inconsistency and keeping us all guessing where it will land up as we gaily follow the yellow brick road which gets longer with each turn of the page – or should it be with each extra mouse click?

Sunday, 27 March 2011

Blue on blue on blue.

In the military the expression blue on blue refers to the fact that friendly units are firing on friendly units. This is not good as the idea of war is that blue should fire on orange i.e. friendly forces should destroy enemy forces as per the former Cold War.

Most politicians can comprehend this concept but when it comes to shooting fish in a barrel or taking pot shots at anything that cannot fight back the NHS is a classic blue on blue situation.

Politicians of all Parties claim to be “friendly” towards the NHS but most are covertly hostile and all of them like to take pot shots at it for it is an easy political target to hit.

So Za Nu Labour and the ConDems all have the same ill fated plans being reinvented and thrust down the throats of all in healthcare and thereby they inflict them on patients who may, or may not, have voted for their (covert) plans.

The NHS is experiencing the biggest onslaught of friendly fire in its history from not the usual 2 fronts (Conservative and Labour) but 3 the latest blue being the Lib Dems. Imagine a previously solid British square at Waterloo being assaulted by an Apache gunship, a cruise missile and an Abram’s tank all within 2 years. Anyone fancy a punt on who is going to win?

Blue on blue on blue. A great way to win a war - keep shooting your own and the enemy will win without a fight.

Question is who is the enemy? It can’t be the NHS for all three Parties are standing firmly behind their “own” personal friend the NHS with their jackboots in its back about to push it off a cliff.

For simple grunts on the ground this is the question. Most of the NHS works and that which does not can often be fixed cheaply locally.

If a car's spark plug does not work do you fix it by taking it to a crusher? Anyone in Westminster heard the expression “if it ain’t bust don’t fix it”?

Praise be to the Party for giving us more war with each reform but not defining the enemy. We on the frontline are fighting the enemy of illness on one front while fighting a constant rear guard action against political interference.

A war on two fronts is not usually a good idea but most medics have done this since the inception of the NHS. Anyone wonder why the NHS isn’t working? Most healthcare workers faces are well and truly bruised by the politicians smacking us in the faces time and time again.

For what?

Monday, 21 March 2011

The ever rising costs of PFI?

For most of our patients and indeed ourselves being all multi millionaire GPs the biggest investment we make is buying a house. Most people in order to do this, unless you have oodles of cash stuffed away in your mattress, use a loan to finance this purchase usually called a mortgage.

To keep the maths simple let us say you borrow £ 100,000 over 25 years at a fixed annual rate of 5% interest. How much would you end up paying in total?

We think the answer is about £ 175,000. So that is the total cost of loan and interest to buy something worth £ 100,000.

During the second world war Britain borrowed money from the USA and Canada and finally paid this off in 2006. According to this article the USA loaned the UK £ 2.2bn and the UK paid back a total of £ 3.8bn over 61 years at 2% interest per year. Granted these were desperate times but the figure repaid is about three quarters of that borrowed similar to the house mortgage.

So how much does it take to repay the loan taken out to build a new hospital? A trip to another part of Northernshire gave us an idea. A news item on a local TV station lead us to this programme and if you have 5 or so minutes then watch from 36.37 onwards. We have touched on this topic not too long ago as well.

So to build a hospital costing £ 65 million using the examples above you might think the total cost would be around £ 114 million if you say three quarters is the amount paid back on top of that borrowed.

According to the programme the ANNUAL repayment figure is £ 16 million pounds a year (about 14.5 fully staffed 7 doctor practices) so perhaps the total capital will be paid back in just over 4 years then a few more repayments and the interest would be covered too?

Well no according to the programme the total cost will be £ 570 million when the bill is finally paid in 2045 - 45 years, £ 570 million in total for £ 65 million of hospital.

This is the cost of the first PFI hospital - there are over a hundred NHS hospitals financed in this way - introduced not in war time but in relatively affluent times which is going to make a small number of people very happy and rich and make a lot more much poorer.

It seems that PFI doesn’t just take the people’s money it also takes something far more basic in terms of an excretory function. For once the two major Parties are to blame for one created the concept and the other exploited it so we all have been shafted equally by both.

Praise be to the Party for its fiscal prudence not just then but for many more years to come. The zeros coming out of local healthcare budgets will continue to rise for years to come. As someone said pay for almost 2 houses to buy one with a mortgage but with PFI pay for 8.77 hospitals and get just one.

Pure world-class prudence.

Sunday, 20 March 2011

Retreating armies and sleepwalking GPs.

One of the advantages in being involved in the training of the next generation of doctors is the opportunity it gives us here at ND Central to meet other similar minded doctors from other areas on a fairly regular basis. These are not just fellow GPs we also get to meet our consultant colleagues.

What we find is that both GPs and consultants are both the same in terms of what the intended reform of the NHS involves and surprisingly are just as confused. It is clear that some areas like ours with our Harvard and Yale MBA rich PCT are streaking ahead of the field in terms of GP led commissioning while other areas are going nowhere fast.

Historically retreating and defeated armies have usually employed a slash and burn strategy to leave as little as is possible to the incoming occupying army. In areas where co-operation between PCT and GPs such as ours is good then the damage will be minimal.

However from talking to our colleagues in other areas of Northernshire it is apparent that certain Soviets are being very obstructive and refusing to relinquish any power to their local GP consortia and are indeed dictating the terms on which any form of GP led commissioning can take place.

From a military point of view this is an excellent tactic. For although the PCTs have taken casualties in terms of staff lost, by refusing to release power and information to local GP consortia, and, we have heard of some that are trying to force local GP consortia to merge against the wishes of the consortia involved before they will engage, they are clearing playing a long game.

By doing nothing, and if local GP consortia don’t get Pathfinder status, they can’t be forced to do anything with local GPs they are engaged in a bunker mentality that ultimately will see the same idiots at the local Soviets remaining in power and continuing to run the local Soviets until they finally are torn down as the GPs finally storm the Reichstag.

But when the GPs finally get into these little Soviet empires what will they have? No knowledge of what is going on for they have been shut out. The GPs will have the power but no infrastructure. So what will happen then?

The self-serving PCT will be the only viable player in town and so this tactic preserves the status quo. What is worse is that some GPs we have spoken to realize this is happening and see that they are sleepwalking into this unless you get Pathfinder status. How one gets Pathfinder status is a mystery but there are rumors that PCT approval via way of the SHAs may be part of the process.

So in areas where the PCT has been run as a Soviet top down dictatorial authority it appears that it will be business as usual. Fortunately in our part of Northernshire this is not the case but we know that some of our colleagues are sleepwalking into this scenario and what is worse the Ceausescu’s currently in charge preside over some of the areas of worst health inequalities as a result of their benevolent years in power.

We hope that Mr Lansley is aware of this gaming activity especially if you listen to his last few seconds of this propaganda clip regarding GP Pathfinder consortia at a Downing Street reception. It can’t possibly be that the Emperor Ming does not know what is going on in some of the least healthy but far flung parts of his empire?

Praise be to the Party for once again ensuring that all pigs are still equal as always. We wish our less fortunate colleagues well in these uncertain times and thank them for sharing their positive experiences of NHS Reform.

Education is after all is the sharing and transmitting of information and if you are reading this then thank a teacher. Both health and education are to become increasingly rationed and costly to those that need and use them despite of reform of both for the better.

That is not good for it deprives both talent and need of improvement.

Saturday, 19 March 2011

Compare the market . . . ?

Some of the team have been freezing their rocks off in a good cause in a dull, cold, mist and cloud covered part of the world devoid of the internet but via other electronic media we have been able to warm up our little frozen bits upon the warmth of wisdom dispensed by none other than the Secretary of State for Health Andrew Lansley MP. We heard him while mobile with nothing else to do other than concentrate on the narrow tracks we were driving along through the dense mist with precipitous drops to one side and hard rocks to the other.

Come to think of it that isn’t too dissimilar to our day jobs in helping patients “navigate” their hazardous NHS “journey” - oops slipped into buzzword bingo land lets get back to the blog world.

He was interviewed on the Radio 2 Jeremy Vine program and you can listen to it here. It is fairly obvious that the knowledge of the health secretary appears to be an integer located in the range –1 to 1 as he has not a clue about general practice in particular and the NHS in general. Come to think about the same applies to his interviewer.

We cannot recount the whole of the interview but some bits did almost distract us from driving the “Ferrari” we were in. Bits of it to our crude grunt minds explained the huge “differences” between the “old” NHS and the “old” Party’s reform s and the “new” NHS and the "new" Party’s reforms and we recalled another failed "market" system from a while ago as a result.

So are we sitting comfortably? The Lansley bit starts at 18.24 so if you move your sliders to about there we will begin.

We start with Dorothy’s knee. You can see poor Dorothy sitting at home, all alone in the world, in her high backed chair, with her 1950’s NHS specs and her ill fitting false teeth from the last time she had NHS dentistry, white haired and with swollen ankles unloved by anyone other than a Radio 2 presenter and her “new” good friend Andrew. Andrew is clearly Dorothy’s advocate for almost immediately he says the most important thing for Dorothy is that she

“. . . gets really good care . . .”.

The implication is that presently Dorothy’s knee is ignored. Dorothy’s new friend, in addition to the scarecrow, the cowardly lion and the tin man, Andrew goes onto to say he wants to

“. . . hold everyone to account for the outcomes we deliver . . .”

note the royal we that will never apply to him?

Andrew continues to say that if Dorothy has a knee operation then the operation done box is ticked but no-one checks on poor old Dorothy (aah how sad dear readers Dorothy is all alone in the world again apart from her new knee that no-one cares about). So all of the patients seen post joint replacement in outpatient clinics are not being checked but Dorothy’s other new friend Jeremy says he thought that was the point of all those new targets you hated so much.

The blind leading the blind? So Andrew has

“ . . . set out for the first time a really systematic view of what those outcomes should be . . .”.

Isn’t Andrew so kind to poor Dorothy and her new knee? A return to the cradle to the grave healthcare by abolishing targets and replacing them with “outcomes”. No new bureauocrats here checking up on Dorothy (and her knee).

Dorothy’s other new friend Jeremy then goes on to say that if a private company run by the Wicked Witch from overseas (boo) sets up a “knee place” this will drive the Good Witch of the local hospital out of business. Andrew is quick to reply and says that the

NHS sets a price”.

Starting to sound familiar? All good Conservative free market stuff here but it won’t be a tariff will it?

Words like GPs and patients commissioning the care and the money follows the patient follow. Jeremy then starts to talk (dirty) free market saying if the successful overseas Wicked Witch provider does so well that the local hospital shuts down then she doubles her prices what happens then?

What follows then is a core Conservative value of the laissez faire philosophy summed up in the phrase from Dorothy’s new friend Andrew:

it is not a free market

which he says not once but twice. At this point our traveling companions were in hysterics and what followed at about 24.00 minutes forced the driver to slam on the brakes.

“ . . . and there is a regulated market with regulated prices but it is a social market not a free market . . .”

In 6 minutes of driving over hazardous terrain we had heard the architect of the liberation of the NHS describe what exactly?

What we have heard for the last 13 years but being played by a slightly different instrument? We thought the Cold War had been won but when you hear the words “ . . . and there is a regulated market with regulated prices but it is a social market not a free market . . .” you realize what a huge chasm of grey British political party’s healthcare policy is and it is all the same horrible shade.

You could if you wish listen to the bitter end at 39.07 but we think we heard the best bit. If you fancy a laugh have a listen but be quick as we do not know how long the link will be on the website and please do not listen and drive – a safety warning from the team at ND Central.

Praise be to the Party for inventing the art of reinvention in order to better us all via more bureaucracy and regulation. Isn’t it about time they did the same to other markets like supermarkets or has that been done before somewhere in the East?

We smirk as we wonder what the last great Conservative “reformer” of the health service must think of her new boy and his words. Is it time for a trip for someone to see Matron for some speech therapy?

Saturday, 5 March 2011

Top tips from a money saving GP expert.

We thought we might have a laugh and introduce a series of ideas on how the NHS could save loads of money for very little effort and perhaps as a side effect, in contrast to central Party diktats, improve patient care. Here is our first (possibly of a few?) GP money saving expert top tips.

When we were junior grunts the diagnosis of angina was clinical. This meant talking to patients and examining them without ticking any boxes and coming up with a differential diagnosis or list of things that you thought as a professional, rather than a Party tick boxer, the patient might be suffering from.

In the case of angina, classically described as central crushing chest pain occurring on exertion radiating into the neck and down the left arm causing the sufferer to slow or cease exertion and the pain resolves with rest, all one needed to try was a trial of a few pence worth of a drug to see if this eased the symptoms. If it worked the diagnosis was likely and then other more expensive drugs could be added to control the symptoms.

With advances in pharmacology the control of symptoms by drugs was added to by the use of preventative drugs like aspirins and statins. All good old fashion general practice and clinical medicine – simple, cheap and safe.

For more difficult cases, or where the diagnosis was not clear cut, then referral to a general physician or a cardiologist might be required who then might order an exercise ECG or stress test or proceed to more invasive tests if bypass surgery was considered. However most cases could be managed cheaply in general practice.

Such medicine was not considered good enough by the Party who via the QOF (Quality and Outcomes Framework) introduced the “quality” angina framework which if you wish to you can read it here.

So now instead of simple cheap GP management between 40-90% of patients are now expected to be referred to a hospital. Not the minority who used to be referred there but the majority will have to be referred in order to maximize GP income and tick the QOF boxes to show how "good" a doctor you are.

So now for every patient with angina either £ 93 of exercise ECG or £ 215 to see a cardiologist (click 2 Outpatient attendances) will be incurred to ensure that the GP is Party compliant and gets paid. And that is in addition to what was done previously.

If you look here you can see some figures for how many people in the UK have angina. So if you round up the figure to 2 million the costs of treating angina have gone up from a few pounds in general practice per patient to a few hundred pounds per patient if you follow the Party approved protocol.

Our former leaders felt that this cheap and cheerful approach which helped patients was not worthy of those who had not had the misfortune of ever working in medicine and so these wise idiots overnight increased the need for unnecessary investigation of the majority of those with angina by introducing centralized QOF control of medical practice. Even the Party’s tame GP attack muppet does not approve.

This is akin to looking in a field and saying there is a four legged animal with a white fleece, a black face, that chews grass and emits baah sounds and this looks like a sheep. It is indeed likely to be a sheep and does not require further investigation unless you suspect that the 3 foot long creature might be a blue whale in disguise as a sheep in which case far more expensive tests than the mark one eyeball might be required for example DNA analysis to determine if your case of angina was in fact a case of blue whale in sheep’s clothing. Such DNA testing is now required for all sheep by the Party to exclude the odd blue whale out there.

Medical training in the NHS has generally tried to minimize over investigation in order to get a result but Za Nu Labour’s QOF has probably increased over investigation with no discernable benefit in terms of “outcome” but as long as targets and tick boxes are met we know that “quality” care has been given.

Clinical medicine is ever changing and what might be de rigueur today could be heresy tomorrow. Ticking QOF boxes restricts clinical freedom and imposition of centrally dictated “outcomes” and economic control will severely restrict medical advancement and compromise patient care. For if in order to get paid the doctor has to tick the box as opposed to give a patient a better treatment than QOF allows this will clearly compromise patient care as QOF takes time to change.

Praise be to the Party for dictating how we should waste money. This is the sort of thing that GP consortia should be tackling but they can only do this if they come up with some NICE ideas that are Monitored and approved by the Board and its ultimate controller.

So we must now be looking forward to a new GP led free from central control NHS and money saving ideas like this will be so simple to do, won’t they?

Tuesday, 1 March 2011

“The mushrooms will be sprouting” and still are based on a still firm nutritional grounding.

A couple of things at work made a few of us recall the scene from the film The Time Machine (1960) where the hero of H G Well’s book, which we fondly remember reading on a plane to sorties overseas, sees an older man saying to the hero “The mushrooms will be sprouting”.

In the context of the film the “mushrooms” were the atomic bombs that the older person in the film was trying to save Well’s time traveler hero from for he was from a few decades before when he would have had no knowledge of matters atomic.

Today we saw a “magic” mushroom of truly atomic proportions. Although the PCTs are hopefully in their death throes the PCT vermin (thanks Dr R) continue to produce so much horse manure that they are still producing monster “magic” mushrooms at an alarming rate.

In our in tray was a 40 page document which must have taken months to produce as some of it was in English and would have required a remedial English teacher employed as a PCT consultant to produce it in any readable form.

It was branded as being an e-learning module for anyone (retarded enough but) interested and was sitting in a pile of papers but on the front was a missive saying that ALL staff in the practice MUST sign to say that they had trodden in the nutrient rich source of this monster “magic” mushroom by reading it. This to a management and bureaucrat hating group of GPs was a red rag and demanded a speed read stat. What followed in this 40 page rainforest deforestation exercise was a classic example of PCT vermin producing monster quantities of management mushroom food.

The most interesting “high” of our consumption of this “magic” mushroom was the bit saying what the “risks” were of not ingesting this vermin excrement fuelled “magic” mushroom.

Now what do you think the risks were dear reader?A plague of locusts descending on all those not eating these “magic” mushrooms of superlative wisdom? All local infants being slaughtered in their beds as a result of no-one signing the PCT edict? All women under 25 with cholesterols of less than 2 developing boils and buboes if they did not take their Party prescribed statins and the most junior of clerks in the GPs surgery had not signed to say they had read the 40 pages of manure?

No the “risks” of not have eaten, sorry read the “magic” mushroom, were more dire than even these pestilences for the local Soviet would not have met Nanonano land target 97.a.307.11/4 (risk one), would not meet Prince Caspian’s Nania Loveland winter paradise target (risk 2) and Snow White might never wake up as another fairyland target would not be achieved (risk 3). All such “risks” were local Soviet management targets which meant nothing to us and all of which will have delivered no useful care whatsoever to any patient. However these were the perceived and dire “risks” apparent to the collective authorship of this “magic” mushroom.

All clearly patient centered metrics requiring the necessity that every member of our general practice staff, most of whom would not have to ever to deal with this problem, having to sign so that the worthless piece of PCT vermin producing the horse manure feeding this “magic” mushroom of rainforest deforestation that will benefit not one patient on our patch will enable someone who failed at everything at school to keep their job (for now).

Such institutionalized crap still continues to deny real healthcare to real patients while the self same crap continues to tick boxes and continues on licking something else and so more such “magic” mushrooms will continue to sprout as there is still an ample and rich food supply for them to continue to thrive.

The author, or rather the department for it would have taken more than one neurone to produce this “magic” mushroom (and a remedial English teacher to rite it 4 ‘em) should be amongst the first to be culled from the local Soviets on the grounds of crimes against healthcare. Any other GPs fancy a night of the long knives out to remove “magic” mushrooms like this from their lives by permanently cutting off their food supply?

And the subject of this learned 40 page “magic” mushroom?

Basic patient centered ambulatory, self propelled, self provided by one client group for the enhancement of another clients’ group usage, sustainable naturally produced, non industrialized responsibly sourced neonatal nutrition with added health benefits to all client groups involved via better nutrition and weight management gains positively controlled and influenced via a centrally provided world-class commissioned commissariat the vision of which is the result of client centralized management provision enabling superior purchaser produced information for providers and their contractors due to enhanced management capacity for all affected service users and client groups.

Praise be to the Party for it is as ever all wise and knowing. Why employ a midwife to help patients’ breastfeed when you can deforest a rainforest and insist that every practice member of staff signs to say they have read a rainforest of horse manure to produce a “magic” mushroom that delivers sweet FA patient care?

How did we manage without such skilled managers before? Just think about the “risks” they have saved us all from this time. Close call guys and thanks we will miss you.