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.