A speech for all reasons.

Now being an overpaid underworked GP in Northernshire means that at the end of the working day one hands over the keys of ones Farrari to ones manservant and goes to dress for dinner.

As one does so one may watch the news on that most modern of appliances called the television usually a 7 inch monochrome device for only people who need home visits have 90 inch colour ones, 5 cars in their driveways and cannot come to surgery as Wayne is doing a “deal” and on the sick with a bad back.

We really must get more au fait with the use of elephant doses of Diazepam in the management of back pain and remember the really dark opaque glasses to shield our eyes from plasma TV glare and industrial ear muffs to protect us from the surround sound system on such home visits for acute emergencies such as itchy scrot that is doing his head in but he has gone out - sorry doctor.

Meanwhile back on track and at the usual GPs baronial mansion house, whilst being served our G&T and while the memsahib was away at her toilet preparing for dinner, we watched an item on the British Broadcasting Corporation’s evening news.

We heard this and thought this was a slight case of déjà vu and spot the difference between the Parties for all three seem to be rolling out similar speeches about any (still) vaguely useful and cheap public service they are meddling with the one difference being that one and a half of them are in power.

The link to what we listened to is here and we reproduce the text with a few thoughts which if you cut and paste summarize the current attitude politique to healthcare/education/anything that might help you advance yourself or make you better.

So here goes:

The White Paper therefore proposes unconstrained recruitment of the roughly 65,000 high-achieving students, scoring the equivalent of AAB grades or above at A-level.

We will bail out the organization using private sector funding paid for over many years and increase service provision as a result of a public sector/private sector engagement.

Quotas for those students will be abolished and funding will go to whichever university offers them a place they accept. In addition, we will create a flexible margin of about 20,000 places to reward universities and colleges that combine good quality with value for money and with average tuition charges, after waivers, at or below £7,500 per year. That adds up to around 85,000 student places—roughly one in four places for new entrants contestable between institutions in 2012-13. We aim to expand this further year after year.

We will introduce competition via a market of sorts with additional capacity provided by any willing provider but wouldn't dream of centrally fixing prices.

We will also extend the scope for employers and charities to offer sponsorship of extra places, provided that they do not create a cost liability for the Government, and provided, of course, that there is fair access for all applicants, regardless of ability to pay, and no sacrifice of academic standards.

We ain’t going to pay for nuffink the Big Society will and everyone will have“equal” access if they can pay for me bitches.

The reforms put students in the driving seat, but if they are to use that power to best effect, more than a liberalising of the quotas regime will be needed.

No decision about me without me and in order to put you in charge there will have to be some reform and you will have to pay more to get less.

Prospective students also need to know far more about the academic experience on offer. We will therefore transform the information available to them about individual courses at individual institutions. Each institution will make available key items of information, such as contact hours and job prospects. Information will also be available to outside bodies, such as Which?, so that they can produce their own comparisons. That will lead universities to match their excellence in research with a high-quality academic experience.

More league tables and expensive websites anyone?

We listened to this little less than 2 minute speech on the video link and thought of a word relating to something bovine for has not much similar been said about the NHS by all Parties? Give the people and the professionals the illusion of control but only if they can afford it?

For reasons of brevity we have confined our comments to the BBC piece. You can, if you are a cowpat afficionado, read the whole speech here. We think all 3 Parties are doing an excellent job recycling these cowpats for different public services.

Praise be to the Party for allowing all of the many, who paid for the education that benefited the few now in charge, to have the privilege of paying for what they gave the few for free.

Welcome to NHS Reform and the Market movie coming to a child, a mature student or university near you soon in its follow on Education – the sequal to NHS reform.

More "reform" anyone? We’ll ask Kato to get you some more . . .

E-portfolios.

It would appear that some other counter revolutionaries at a despotic meeting of seriously ill informed and well time expired minds are suggesting that the flagship of the Scottish Silicon Glen IT revolution called NHS Education for Scotland, the all powerful e-portfolio is a waste of time. No.

Nothing new to those grunts on the ground for all our junior doctors have said the same for years but if those most out of touch at LMC level have heard of it then Apollo 13 must be hot news there as well as the recent launch of Sputnik.

Now we here at ND Central use many computers for a variety of things usefully like timing our microwaves, setting our DVD recorders, operating our washing machines, digital photography, car engine management systems, flying planes all simple uses of high technology which actually do something useful that NHS IT does not.

They work (more of the time than NHS IT) for we rarely if ever ring the “help” desk to get a job number for something that never gets better like NHS IT.

We do not use an e-portfolio to determine whether an individual can qualify as a doctor for those dangerous enough to be bad doctors get round this flawed system easily. Only a seriously brain damaged retarded educationalist dean dude high on some unnatural herbal substance would use this Braindead E-Retarded Portfolio (BERP) software to determine how good a doctor actually is.

Think about any other things that have crawled out of (NHS) Scotland and screwed up the NHS. Think Brown and Blair, think NHS “reform” and think computing (Choose and Book, Summary Care Record et al and their creators) and can you start a common theme re new ideas and their origin and how useful they are especially when it relates to high quality education and computing for the NHS?

Which is curious for once Scotland produced most of the world’s ships that usually carried people on real journies all be it at a high price in terms of some of our forebears’ health but then there was no NHS Education for Scotland so that must be why.

Those educated in Scotland for some reason see things that most people do not see. Weapons of mass destruction and an end to boom and bust are but 2 examples and as such they are deemed fit enough to screw up the United Kingdom’s medical education via Scottish IT. Even the opening screen cannot fit automatically onto your computer’s screen. This tells you how “good” those programming it are or how desperate they are to hide? Look which bit is cut off here.

The great thing about the e-portfolio is that none of the, excuse the very rude grunt word, sh*ts that devised this pile of retardation ever seemed to have used computers when they trained as doctors. Certainly no-one thought about security for doctors in training could at one time do their own assessments all they needed was an email address and anyone can find an NHS email address.

Our medical students, our F2 trainees and our GP registrars are increasingly troubled by the need to be groomed to complete their BERPs which is worrying as BERPing is seemingly occurring at an ever earlier age in medical training.

This is driven by a bunch of pillocks at deanery level and reinforced by their rubber hose beating stasi boys and girls who insist that doing a BERP is a good, not retarded thing because “it is er a good thing” but they are “only following orders” and having so much fun by setting increasingly tighter deadlines for completion of the BERP especially towards the end of GP training.

Our intelligent junior doctors and medical students see this for what it is a completely useless unproductive waste of their time. They want to learn from patients in the time honoured way of treating patients (remember patients dean dudes?) with good clinical supervision not BERPing in isolation with a computer hairy palms and poor eyesight being the sole result of this process.

Of course this might be the end result for those inflicting BERPing on their poor doctors in training. Give them hairy palms, short sight and a computer and a good BERP and that will make them all most excellent consultants or GPs?

Dream on dudes.

We are not computer phobic by any means here at ND Central. Indeed we are the complete opposite but when it comes to delivering care in the field a protocol on a computer or a good BERP are about as useful as a pacifist who does not know how to resolve a deadman’s click in a fire fight or someone unable to intubate and cannulate at a paediatric cardiac arrest when it comes to hands on clinical care.

Did doctors who did not BERP compromise patient care by being on wards looking after patients for hours longer than our current doctors in training spend tapping on keyboards? Instead of BERPing to prove how good doctors were did they instead spent time on the wards, talking and learning from their patients and seniors. This information was retained in their heads for years to come for future reference rather than sitting and entering meaningless, useless data on a hard drive to gather electronic dust and tick boxes?

Most excellent if the quality of patient care is now determined by a good BERP rather than the treatment a patient receives from a doctor. MMC will have succeeded despite its critics. And patients?

Is a doctor without a BERP better or worse than a newly trained well BERPed up doctor? As a patient should doctors be BERPing or treating?

We at ND Central think all junior doctors deserve a good burp after a good night out in the mess as part of R&R after some serious clinical work. We think that getting junior doctors to engage in seriously unproductive BERPing is a waste of their time (and ours) and totally unproductive unless electronic boxing ticking is the new way of medical/nuring/social service/anything training for the better? Believe us BERPing involves lots and lots of box ticking but sod all patient care.

Praise be to the Party and we await the day when the BERP will treat you now. Until then we hope to train a trained doctor who will do so without impolitely and wastefully BERPing.

After all those writing this piece did not BERP once during their training and succeeded despite this handicap of not being modern doctors trained by ticking boxes rather than treating patients which is the antithesis of BERPing.

History is said to repeat itself but we doubt any of our intelligent academic colleagues would make the same mistake twice with unworkable software . . .

All change?

When the great war of NHS liberation was declared we were told that this would not be a top down reorganization. A certain Mr Cameron even said 'We are not reorganising the bureaucracy of the NHS, we are abolishing the bureaucracy of the NHS.'

Which bit did we miss about the non top down reorganization of the health service combined with the abolishing the bureraucracy of the NHS?

True a few managers have been made redundant locally but not nearly enough and those most incompetant survive to continue to wreak havoc and do remember this is one of the few local Soviets where all local NHS Commissars have either a Harvard or Yale MBA in contrast to those who failed in the too thick to fail comprehensive school system who as a result are found in most PCTs.

A small piece in the GP journal Pulse shows us how far the lack of top down reorganization is progressing. It says that cluster PCTs which do certain bits of NHS bureaucracy for the remains of the real PCTs who are still supervised by the Strategic Health Aurthority are now to be "outposts" of the new super uber quango the NHS Commissioning Board.

So the old system of

SHA > PCT > GPs

is now

NHS Commissioning Board in parallel with the SHAs > cluster PCTs now NHS Commissioning Board outposts > PCTs > GP commissioning consortia > GPs.

So much simpler now don’t you think?

(If you want a laugh read the article in the link and you might even find a new word or more for the buzz word bingo card. Anyone know what commentarit means? Or is it misspelling of commissariat?)

Admittedly some bits will disappear at some point but we suspect in order for the Party not to maintain its top down control that most of the “change” or “reform” will consist of merely rebranding the same groups of incompetant bureaucrats but essentially keeping the same structures with different names.

Commissioning and the concept of an internal market is merely a bureaucracy based on a failed Soviet style state price fixed model of a market. All GP led commissioning is at present is rearranging the deck chairs on the Titanic while all the time the space being left to rearrange the deckchairs gets smaller and smaller as more top down reform via the new state organ the NHS Commissioning Board and its new “outposts” is implemented.

If the price is centrally fixed and all commissioning activity is to be controlled by the NHS Commissioning Board and its new "outposts" what role do GPs have in the commissioning process as the Party tightens its grip?

We almost forgot what our role is that of the fall guys. For who do you blame when GP “led” non top down reorganzation all goes horribly wrong?

The GPs of course but now with added consultant and nurse members.

Praise be to the Party for continuing to support the lack of a top down reorganization and for continuing to abolish NHS bureaucracy. Aren’t they doing well?

The Spruce Goose theory of healthcare.

There have been many theories about flying and most of those that get off the ground do actually work. Some do not and they cost lives. The same applies to healthcare and theories that relate to it.

Politicians love to grandstand and while they cannot control such popular favourites as Manchester United they can tinker with the NHS and, with no experience of it except perhaps as patients, bugger it up some more every five or so years via the process called reform. You would think that with all the political reform the NHS would be something akin to a SR-71 or Concorde both planes developed in the 1960s but not bettered even today. They even flew and cost less than the huge failure that is the non-functioning NHS IT system.

For most people the NHS is a workhorse like the Boeing 747. Not exactly what all those who expect 5 star hotel service would want but it gets most people to their destination for example to Florida and back for less than we pay a GP a week.

The advantage of political power is that with it comes wealth albeit in the form of the taxpayers’ hard earned pounds. In the same way that Howard Hughes had wealth and therefore power he could build a monsterous aircraft called the Spruce Goose which flew only once. Politicians feel they can do the same without the benefit of a pilot’s licence or a mandate for their new reforms.

For the last 20 years politicians of all Parties have been building the Spruce Goose of NHS healthcare aka commissioning and the internal market. It is a monsterous beasty (beaurocracy) that will not fly (or deliver healthcare any better or cheaper) but because all of the political pilots think it is a good idea it must be capable of flying for it is a basic concept of aviation that that the more lift (spin) you have the higher you will fly?

Politicians deal with grand ideas while the aviation industry usually tries to get an aircraft from A to B in one piece at an affordable cost and with a close on a 100% success rate. Doctors usually try to do something similar with patients. We in medicine accept that we do not have a 100% cure rate. In politics anything less than a 100% record is clearly the result of “inefficiencies” that only politicians see hence the need for “reform”.

The NHS has traditionally used the 747 approach cheap reasonably comfortable but consistant unlike the Freddie Laker approach to healthcare that politicians of all persuasions seem to favour at present.

The analogy of aviation may be wasted on some but why after 20 years of costly failure are the 3 main main political parties in alphabetical order the Con Dems and Za Nu Labour trying to shaft the British public into a Spruce Goose as opposed to maintaining a tried and tested 747?

The Spuce Goose only just flew once. Most of the electorate have surpassed that limited expensive triumph via the 747 of healthcare. The same basic model has been updated by Boeing over the years in the same way that medicine updates itself but from the passengers the outside looks essentially the same and it still flies. There are a few changes that some might note like new engines or TV screens in the back of seats rather than cinema style screens but what the patient sees is the NHS 747. They are not looking for Spruce Gooses when they look for healthcare.

How come the politicians of 3 supposedly independent parties are trying to lift the long dead Goose out of the water as opposed to getting a reasonably priced 747 bird to continue to fly? One is expensive and wasteful folly the other just keeps on going with minimal cheap maintence. How come all three political parties are trying to be Howard Hughes in a time of recession?

Praise be the the Party for realizing what we do not that one Spruce Goose with one flight of fancy will care for so many more patients than 40+ years of 747s which fly daily.

The NHS works – without politicians – keep them out of the cockpit and keep the 747s flying. They get you there without the commissioning and internal market crap. The new revised revised revised revised Spruce Goose of healthcare which has just recovered from a near fatal stall is still trying to lift off, for how much longer will it continue to do so before it is confined to history?

Many a true word spoken in jest . . .

Last week while one of the team was acting as officier of the day and patrolling the practice perimeters all right then signing a few prescriptions they overheard a conversation between some of the reception staff. One of them had managed to get some tickets to see the now middle aged boy band Take That in concert and was clearly loving the attention of and jealousy of her co-workers who would have given their right arms for such tickets.

Now, given the ages of the staff, who would have been pre teens and teenagers when the Osmonds were the hot ticket in town, age had not mellowed their adulation of their rock gods or their individual lusts after their favourate band members. They were no longer pre teens and were mostly mothers with teenage kids and the team member, one the minority sex at ND Central, knew that when these staff members went out socially there was usually a large amount of fermented fruit juices consumed.

The team member made an off the cuff remark that the local Police must be dreading the coming of a Take That concert to their patch for dealing with a football riot would be easier than policing a load of hormonally challenged, booze sozzled middle aged ladies lusting over a boy band only a few years younger than themselves. This did not go down too well with the boy band droolers who quickly oppressed the minority and told them to get back to work. Some of us know our place at ND Central and did just that.

We did not think much of it until someone told us about a news item on this morning’s news bulletin. Can you guess what it might have been about?

Have a look here if you can’t.

Praise be to the Party for hell hath no fury worse than . . .

a drunken group of Northernshire women lusting after that which they can never have. Don’t try stopping them . . . ever!
You have been warned!

Independent media and “independent” reviews.

After the reveille bugle had sound this morning, one of the team’s early birds tuned into the ITV 05.30hrs morning news bulletin where the headline was that of the publication of an “independent” review (? by government stooges) to be published later today.

The BBC news at 06.00 we are fairly sure, but are prepared to be corrected if wrong, mentioned also a review but not an independent one. Surely a small reporting error we thought after some discussion. However the BBC one o’clock news also reported “an independent review”.

We would say we were waiting with baited breath to see how many seconds or minutes of a degree the “independent” navigators of the current SS NHS Titanic of reform for the better recommend that its course be changed.

Praise be to the Party for more unnecessary reform but at least this time it will have been “independently” scurtinized at least by the media.

Privatization by stealth?

We wonder if anyone else in GP land has noticed subtle changes to their practice based staff and not realized that what seem to be small and incredibliy awkward changes were in fact part of a possibly more sinister plan?

Many many moons ago we used to have district nurses and health visitors attached to ND Central and they had their own part of the ND bunker as offices. This arrangement worked very well for it meant that we had regular communication and if things were not done it was easy to chase up who was responsible.

Now the Party does not like professions to fratanize for if this occurs then counter revolutionary ideas might be born and a cohesive resistance to its benolvance might develop so a few years ago it removed our attached district nurses and health visitors away to new Party controlled central barracks.

Communication went from being face to face on a daily basis to such advanced methods as message books which were read “whenever” someone happened to be passing or leaving phone messages on an answer machine or via a Party controlled call centre with the inevitable dilutation and censorship of information.

Needless to say the local Soviet will have held a public holiday and drank lots of vodka to celebrate its success in improving local services. Those on the gound saw once good services destroyed and a two way exchange of information destroyed too. The health visitors were particularly missed as it gave local paedophiles a free reign but this was Party approved for we were repeatly told that this new model for health visiting was the highly successful Doncaster/Haringay model. So no chance of a baby Peter or a Victoria C here in Northernshire.

This at first seemed to be local Soviet incompetance but scratch a little deeper and this was not immediately apparent but it was in fact part of a process called TCS (Transforming Community Services).

Did you, or more importantly, do you know what this is? Try googling it and see how easy it is to work out what it actually is. You could try the FAQs here for starters. We did not until a recent lecture presented by a midget ex nurse, one of the snide evil idle kind who have spent all of their (very) limited time with patients doing bugger all hands on nursing before moving into nurse management and then onto NHS management.

At each level such snide evil idle kinds do less and less work but generate more and more for those few nurses that do what they used to be trained for namely to look after and care for patients rather than print off loads and loads of care plans to show patients were looked after as they died of dehydration.

This midget both of body and mind told their audience about how successful the TCS programme had been. Unfortunately Party stooges do not take kindly when their audience of frontline healthcare workers start standing up and asking midget mind why things are so bad and worse than before despite the midget’s Party spin.

Midget mind had to get the Stasi in to quell the disgruntled audience. No doubt when they went back to report to their commissars about their propaganda trip they would have told them that the sun was shining, wheat production was at its highest ever level and all was good in the world of NHS management cream teas and cakes.

What we learnt from midget mind was that the withdrawal of district nurses from the frontline and health visitors was all part of the TCS programme – whatever that is try googling this. Now consider the wider picture.

With the advent of commissioning one of the first things local GPs here in Northernshire wanted was the return of district nurses and health visiters to practices. Midget mind had told us that the first TCS contracts were up for renewal and with this information local GPs were keen to restore the status quo for the better.

Unfortunately this is not an option for a far more insidious parallel plan has been running. The parts of the local Soviet PCTs that were once “responsible” for the district nurses and health visitors were farmed off into little separate “corporate” entities initially part of the PCTs and then completely “separate”.

These little entities are now “independent” of the local PCT Soviets, have there own crap computer system (System One) that cannot (or will not be allowed to talk to any others despite SHA sponsorship) and have all been Party sponsored.

This division of a once more joined up service between GPs, health visitors and district nurses has been politically destroyed with the active involvement of the relevant professions at a senior (more lardy) level.

Locally resistence has been huge but of course ignored for when the sh*te hits the fan it will be those that knew better that go down the pan even if they dared to complain and resisted the policy not those who implimented it.

No doubt the TCS programme creates little entities that come whichever version of alleged “GP led” commissioning crawls out of the political slime will be sellable commodities and GP commissioners will have to purchase their services from former PCT bodies.

As simple grunts on the ground the “improvements” produced by TCS namely no district nursing or health visitor communications, less accountable care, delays in communication all have had a positive impact on patient care which is that of the negative for all are worse off especially locally regarding child protection.

Praise be to the Party for ensuring that when it comes to the provision of healthcare this will always be compromised by political expediecny at the expense of excellent healthcare.

This has all been done by stealth and unless there is a massive mind shift in UK healthcare policy whereby

Conservative healthcare policy = Labour health care policy = Lib Dem healthcare policy

ceases then there will be more to come. All of it of course for the better, comrade.

As directed.

Writing a prescription is a relatively simple exercise provided one knows a bit about drugs, can read and write and most importantly can do it safely. There are lots of short essays on how to do so and if you haven’t already done so, and believe us many doctors have never done so, the British National Forumlary is a good place to start. A few years ago the Medical Protection Society published a booklet on prescribing.

These were full of common sense things like don’t use Latin initials for example t.d.s. instead write it in English as “three times a day”. A lot of doctors still use the Latin abbreviations which are useful as a form of medical shorthand but can cause confusion in certain situations.

Another top tip was to only use the abbreviation mg (milligrams) and not use the abbreviation μg for micrograms which the article showed various ways that handwriting could convert the symbol μ into the letter m. Not to dissimilar to look at but a thousand fold variation in a dose that with some drugs could be very lethal so this was a good one to avoid.

For many years these simple principles have kept us going but in the recent past two organizations, both non medical ones, have decided like all impudent and ignorant children that they know better and would learn us doctors to do proper like what they does.

The first shot across the bows of HMS Smooth Prescribing was from the Al Quaeda school of radical pharmacists. On one of their many visits to educate those more knowledgable than they, they had decreed a jihad after issuing a fatwa against the term “as directed” (a.d. to use its Latin short hand) appearing on prescriptions.

This simple term had become verboten in radical pharmacist circles and as such was now the source of a witch hunt as all true religious and science based zealots do embark on after reading holy scrolls from a Midlands “University” famed for the production of many social service graduates and media studies types all highly useful in healthcare.

The zealots persevered but those of us with memory and experience played them at their own game. What about patients on insulin who may need to daily change their insulin based on current blood sugars?

No “as directed” is not acceptable the scripture says so. So we will need to write a prescription with a specific dose for each insulin injection 4 times a day for every diabetic on insulin every day when we do not know their blood sugar readings?

Yes the prophet Keele is most precise on the interpretation of the holy scriptures for “as directed” is now heresy and the prophet is all wise. OK lets play the prophet’s game and guess what?

Eventually when it became unworkable the radical pharmacists accepted that the term “as directed” might just be useful. For thing like insulin and warfarin and bum cream and a whole load of other things where regular doseage is not required, cannot be predetermined and is dependant on variable feedback from blood tests and worse still the needs of a patient according to their lifestyle.

Patients involved in selfcare prescribing using their own judgement who needs them went the zealots of radical pharmacy all that is required is that the label is written as per the prophet’s will. We do not involve patients in “academic” pharmacy.

Unfortunatley we do involve patients for it is their symptoms that often determine when a drug needs to be used and unlike “academic” pharmacists we do not have the luxury of being able to sit next to each and everyone of our patients so that if they develop an itch, or rash or a pain we can instantly write a prescription dictating when, where and how often to apply a medicine. This is why the term “as directed” is useful and if a patient is sensible, rational and understands what the drug is used for there is rarely a problem.

Scratch one revolution. The revolutionary zealots crawled back into their tents in a far desert and we thought sense had prevailed until this week when the fedayeen branch of radical pharmacy reared it increasing ugly and gorgan like head when a colleague in a neighbouring practice, while the on call doctor, was requested to visit 27 patients to do urgent medication reviews at a residential home.

Could this be that a chance inspection of 27 inmates in one the Grim Reaper’s departure lounges had noticed that 27 of their residents had stopped breathing 3 weeks ago and there was a needle and syringe and an empty ampoule of 100mg of Diamorphine by the side of each decaying corpse? Were the last doctors to have visited none other than Dr H Shipman and Dr Ubani?

Of course not it was far more serious than your average day in GP land. Apparantly the home concerned had had an inspection by the Blair Quality Commission C(B)QC and someone had been upset by the fact that a few patients dared to have the blasphemous words “as directed” on their medication.

Now pharmacists and C(B)QC employees live in a magical world of excellence where nothing wrong ever happens. This is why we need more and more inspections by the local villages idiots who have failed throughout their lives to do anything useful and no-one liked at school.

We have seen the local parmaceutal advisers at work locally now their fellow zealots are at work with the C(B)QC. Worse still the zealots had affixed parts of their holy scriptures to the offending prescriptions saying that there were no directions as to how often to administer the medicines or even to which part of the body.

The first few of the presriptions so purified and freed from mortal sin by the zealots’ inspection were for creams. One was for a patient with widespread eczema which varied on a day to day basis both in terms of location and intensity and was treated with a mixture of steroids and moisturizers. The patient had had eczema since childhood and although physically infirmed was mentally able to dictate how to use the creams for best effect.

A disease that is variable in time, location and severity requiring differing amounts of medication at different times and locations cannot be prescribed for on every single occurrence in today’s NHS but despite this self evident truth attached to the offending prescriptions was the holy scriptures dictating that as directed should be removed and precise locations and timings be written instead.

Several other creams had been similarly cleansed by the zealots and all were conditions that varied as above.

So what did our professional colleague do in the face of the terror of the new Spanish Inquistion? Well they considered their professional responsibilities remembering that they were responsible for any prescriptions they signed. Those who did the inspection had long since galloped off and their faces were hidden under pointed hats with only their eyes visible and so there was no idea what qualifications (if any) they had.

The prescriptions had all be written correctly from a medical point of view, the staff at the home knew what they were doing and so did the patients and so passive resistance was employed.

Praise be to the Party for ensuring that no-one is too thick to fail and if you do you can always inspect something and take full no responsibility for your inactions. If you prescribe and make an error it comes back to haunt you. The ability to prescribe is hard won and carries with it responsibility.

The ability to prescribe responsibily to meet the needs of patients not those of protocols must come first for it is they that we as doctors are there to serve and protect. Of course if you want doctors to spend all day writing prescriptions and not seeing you just dial CQC PHARMACY for instant help.

Muppets.