Some thoughts on the year 2011 from up North.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Helf and safety and a few erratic Christmas musings.

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

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

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

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

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

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

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

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

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

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

Enjoy and be careful out there!

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

NHS Global™ goes globally nowhere.

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

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

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

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

What will they think of next?

Tonsillitis.

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

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

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

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

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

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

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

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

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

More QraP - care pathways.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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