Tuesday, 22 November 2011

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 . . .

1 comment:

English Pensioner said...

My GP has just retired, on his sixtieth birthday. I had a chat with him during my last visit as he'd been my doctor for over thirty years. I asked him why so soon, as previous doctors had stayed on considerably longer, he didn't exactly say, so I told him why I had been glad to retire from electrical engineering - new rules and regulations at regular intervals; spending more time ticking H&S boxes 90% of which had no relevance to the task in hand, leaving no time to consider the real problems; writing safety cases, consulting with people who had no knowledge of the subject (and whom probably couldn't even wire a 13A plug) all of whom felt it their duty to question the expertise of a Chartered Engineer of some 35 years experience.
He just said "Yes, it's something like that in medicine these days".

I haven't yet met his female replacement, whom will only be working three days per week which I assume will be considered an improvement as he did five days.