Monday, 30 January 2012

Big Brother’s members continues to get bigger.

We here at ND Central apologize for using smutty innuendo in our title but a piece from the GP magazine caught out eye and a lot of it we found quite offensive for it is showing how clearly the bottom up liberation of the NHS is more of a monster top down command and control exercise. We took offense to the classification of cataract surgery and knee replacement surgery as low clinical value treatment that must only be restricted on the basis of strict evidence based criteria.

Well if these are procedures of low clinical value then we are sure that some alkaline substance sprayed into the eyes of the dumbkopf that thought this was a low clinical value treatment followed by a knee capping might make them realize the high clinical value that both of these procedures have to patients. Not being able to see or to walk comfortably are not fun and correction of these has a very high clinical value to the NHS customer aka our patients.

However it is not the patient who is in charge of the NHS it is the Party. Remember "no decision about me without me"? These are seemingly become more and more meaningless words with each day of top down reform bottom up liberation that passes.

You haven’t yet seen another layer of top down control via bureaucracy coming to control bottom up GP commissioning decisions via the Quality, Innovation, Productivity and Prevention Right Care Team? Not heard of this quango? Give it a Google (ooh no misses!) and you might land up here.

You might want to checkout a Right Care “bespoke” Health Investment Pack (HIP weren’t they formerly another bureaucractic nightmare called Home Information Packs once?) for your area. Go on give it a go for your PCT and look at all the pretty, pretty colours on all of the graphs.

You might want to look at About QIPP Right care and its 3 bullet points

Improved clinical involvement in commissioning.

Is that the same as we are telling you what to do?

Stronger patient involvement through shared decision making.

Is that the same as we are telling you what your only choice (if any) is?

Supporting commissioners with knowledge, information and coaching to consider the legitimacy of variation and thus whether the level of variation.

Is that the same as we are telling what to do in order to make sure you meet our targets outcomes?

And this is all to be “evidence” based? You can even have a HIP Guide for GPs if you choose to register something we think we shall decline.

Seems the more the war of liberation goes on the more the top down reform of healthcare goes on so that GP Commissioning Groups are going to be told what they can and cannot do by all those HIP Right On Care guys and gals at the new and rapidly evolving mushroom cloud that is the NCB.

You know all this makes perfect sense and you can find what all this is really about in the sentence:

"QIPP is working at a national, regional and local level to support clinical teams and NHS organizations to improve the quality of care they deliver while making efficiency savings that can be reinvested in the service and deliver year on year quality improvements."

That is a polite way of saying we will command and control you to reduce services and save money.

Praise be to the Party for its transparency of opacity when it comes to giving the troops on the ground what they need. More diktats and stats Herr Doktors?

At this rate we will soon be ready for another quick QraP.

Thursday, 26 January 2012

QOF and squeegee gangs.

We wonder how many patients may have had at this time of year letters along the following lines (we have put our real thoughts in brackets):

The doctor/nurse/adminstrator in charge of your (insert name of a Party determined illness) has noticed that you have not had the following:

blood test/blood pressure/asthma test/cholesterol test/(your head shoved down a toilet test for no reason other than QOF says we should do so test).

As part of the practice’s commitment to your health and well being (that’s a pack of lies we want to get paid if we tell the truth) we invite you to make an appointment for this with a doctor/nurse/healthcare assistant.

It is vital that you have this test to ensure your continued good health (if you don’t all your sexual organs will shrival and drop off or some other implied threat inserted here)

Please ring on the above number to arrange for this test.



Now we bet no GP will have ever have sent such a letter or asked staff to ring certain patients and “invite” them to come in for some “tests”.

The annual GP QOFing season is on so if you are a patient look out for numerous invites to perform tests to ensure that your Party approved illness is well “managed” by the medical process of ticking a box determined by some dullard in Whitehall the sole purpose of which is to try and reduce payment to your evil overpaid GP. Any real illness can be treated usually without all these mostly unnecessary extra tests done for no medical benefit other than doctors’ pay reduction.

A simple example would be if you have a mental illness do you need your cholesterol checked every year if you are well? Would your identical twin without any mental or other illness get the same intensive “treatment” as you? No discrimination here comrades as all patients are equal in the NHS and we are all in it together . . .

We think that as a patient with a long term condition being QOFed is a bit like being squeegeed at the traffic lights. Your windscreen is clean as you are well and so you get from your doctor a totally unnecessary load of soap and old flannel packaged to make it look like it is something useful to you when you don’t actually need it to make someone a fast buck.

Soap and old flannel will we are sure appeal to anyone who went to a public school especially if administered in the showers by a matron in a uniform but to anyone else it will be a load of froth on your windscreen - completely pointless and very annoying.

Praise be to the Party for ensuring that year on year GPs and their staff are spending more time squeeging windscreens than doing real medicine. Don’t worry if you can’t see your GP with real illness. If their QOF points are squeegee clean then they are Party approved excellent GPs for ticking all the Party boxes while ignoring your real healthcare needs. QOF you know it makes sense medicine.


Monday, 23 January 2012

The new word on the block.

There appears to be a new word on the block in GP land and it is called integration. Now those of us in GP land who have a scientific background know this as a very powerful tool used in mathematics that can produce useful results.

The new tool sorry word on the block seems to have come from the Future forum which is neither the future nor a forum as it is a government appointed quango to lubricate the Health and Social Care Bill up the arses of the unsuspecting British public via a sham consultation and its leader gives us a math’s lesson here. If you want a read you can learn about Mrs Crabtree here someone that no GP will ever have seen or encountered in their professional lives.

Now integration is a word we have seen here before in healthcare in the guise of several previous buzzwords take for example integrated nursing teams.

At the time this buzzword was doing the rounds we had then, pre TCS (Transforming Community Services), our own attached district nursing team based in the surgery with whom we worked with for the benefit of our patients but for some reason they were not integrated. The nurses were employed by the local Soviet but resided in our premises and we played on the same side as they did namely that of the patient and this arrangement seemed fairly well integrated to we who are simple grunts in the field.

However integrated nursing teams were not what it sounded like on the tin. It was in fact the local Soviet asking us as GPs to take on the budget, albeit less than the then current cost, for the nurses and manage it for them hence the term integrated nursing teams. So professionals working together are not integrated you only become integrated when you manage the budget not the patients.

Now in Shiteton in the run up to NHS privatization we have TCS district nurses the location of whom is a top secret for they are now deployed in secret central barracks to ensure greater integration with their medical colleagues and to ensure complete work avoidance and unaccountability. Is the new integration in fact differentiation?

So what of now and the new integration? What is it? Some examples taken from the GP rags say that this involves the overhaul of the GP contract to promote “integration” of practices. What exactly does this mean? New super large health centres 1960’s style or a rebranding of Darzi centres anyone? May be the forced mergers of local practices for efficiency gains?

Clinical commissioning groups must show ability to integrate during authorization process. Haven’t a clue what any of that means but might it be the top down bit of the bottom up liberation of the NHS via the National Commissioning Board (NCB)?

Integration may mean to explore ways to pool health and social care budgets. Is that the same as to save money but not improve care a bit like integrated nursing teams?

When you have been in medicine for a while you hear the same ideas repackaged with new buzz words. It is said that every generation of surgeons who goes to war makes the same mistake and tries to close contaminated wounds rather than leave them open to heal. Just as new surgeons make the same mistakes and do not learn from their predecessors so does every new Party not learn from the mistakes of the previous ones.

Praise be the Party for reintroducing calculus into the medical syllabus. We suspect that those talking of integration missed out at school on how useful real integration can be and are merely using the word as something to paper over a large series of budgetary cracks.

Anybody notice the similarity between the new NCB and the former NCB (National Coal Board) in terms of integrated efficiency on a mammoth scale?

Tuesday, 17 January 2012

Less is the new more. Practical QraPing vs patient care.

In contrast to politicians who litter their speeches with their constant encounters with the vox populi your average Ferrari owning GP living in their baronial mansion house who daily is on the golf course would never see a patient in their life, if you believed the politicians. Hence their constant need to bugger up things that work via reform (the politicians that is).

We bet if one such GP said that patients would prefer to see their GPs in a surgery rather than have their GPs sitting in meetings looking at pretty, pretty graphs the politician would tell them where to get off and set a once a week GP on a future forum to put such a devient GP in their place.

A recent meeting and a series of conversations with GPs from other practices shows how central Party control is taking more GPs further away from patient care in order to direct them towards tri Party care aka commissioning. We return once again to the QraP (QP indicators = Quality and Productivity) indicators of the useless QOF (Quality and Outcomes Framework) of the nGMS (new Genral Medical Services) contract.

QraP is nothing more than Party approved love ins and huge group hugs to ensure that all GPs are equally dumb, Party dumb, deny patients care dumb to save managers money by not treating patients dumb. We have posted before on this but the slow onset of terminal buttock ischaemia from sitting on our arses in (medically) useless meetings is starting to affect our sanitity.

We return to the QraP indicators and will concentrate on QraP indicator 6 which can be found with the rest here. Once again GPs who are trained to work as professionals on an autonomous basis are now being subjected to an increasing collective centralized censure to ensure that all referrals are now collective decisions, not individual decisions made by an autonomous trained professional, leading to socialized medicine which to our limited minds smacks of the former communist model so loved in the former Easten Bloc (deceased) and still practised in the North Korea with its obvious benefits to patients there.

A recent meeting in order to achieve the net outcome of this process, a series of pro formas filled in and sent back to the local Soviet for them to approve, tick the box and authorize payment for GPs not to treat patients was an eye opener as to how low Brown/Blair/Cameron/Clegg/Lansley Party control has become in denying our patients real medical care.

Remember all of the above are fully trained medical professionals, public school educated, extremely privilaged people who have never worked in the NHS and so can speak with the same authority as a brothel owner on the benefits of virginity in increasing sexually transmitted disease and the birth rate via the private sector.

The QraP 6 indicator is as follows:

The practice meets internally to review the data on secondary care outpatient referrals provided by the PCO (Primary Care Organization aka local Soviet).

(italics are our counter revolutionary ones must stop watching Dr Zhivago).

Well for starters the information provided by the local Soviet was worse than useless. Lots and lots of pretty, pretty graphs and numbers in all sorts of colours they had found while pretending to understand Excel. If they had had to try and draw and label any of these graphs by hand on graph paper by themselves for their teacher at school they would have put them in detention for not producing anything readable. Oodles and oodles of pretty, pretty piles of paper going to a landfill site at the detriment of real patient care and in doing so achieving nothing towards real patient care.

When we had deciphered, or thought we had we had to guess what all the initials meant, we then followed the PCO’s pro fromas as to what we had to do and fill in. People who had failed in everything they did at school continue to do so as more and more of the data turned out to be at complete variance with the practice’s more accurate computer data. We found referrals we had made which we hadn’t and referrals we had that hadn’t resulted in patient care until the second or third request that had generated hospital income at the expense of real patient care.

We reviewed our referrals and collectively (see we are actually “team” players) agreed all were appropriate. We have done this pointless exercise numerous times before for NHS managers who are all better doctors than we are for some of them can count but only up to the number of fingers on their hands that they are not sucking in their mouths or stuck up some other dark orifice doing nothing useful.

Each time we have found that we could not prevent referrals and each time the concensus is that with hindsight we should have referred to a more expensive service to better serve our patients’ healthcare needs which is at odds with this exercise which is to save the muppets in PCO land money.

At the end of this completely useless exercise several pieces of paper were filled in and a  grand total of 8 days of GP time had been wasted to achieve what?

16 pages of A4 paper pro fromas filled in to achieve 6 QOF points at £130.51 per point for an average practice. This income would not even cover the cost of a locum to replace the lost doctor boots on the ground treating real patient in real time. It certainly did not replace the 8 full days of appointments lost for patient care and this is set to get worse under the Tripartite health policies being persued at present.

Praise be to the Party for giving us QraP 6 to deny patients’ care by removing doctors from treating them. QraP 7 is even better socialized medicine. How many more surgeries will have to be disabled to ensure that QuaP 7 succeeds?

Has anyone noticed the subtle subtext that QraPing is grooming GPs to become fundholders sorry clinical commissioners via clinical commissioning groups?

It is not big it is not clever and doctors should be using their time to treat patients. Not prop up a hugely flawed and failed idea called commisioning. When will the politicians wake up and see that they all are providing everyone with is less and costing more to do so?

Saturday, 14 January 2012

And it came to pass . . . eventually.

Sometimes recent events can trigger long forgotten memories of previous lives. Recently at ND Central one such event occurred.

Many many years ago in place that practised first world medicine a junior grunt in the middle of the night pushed an ill patient for an urgent CT scan. There were porters at this great centre of learning and nurses were not meant to push patients but as the porters earnt more per hour for a night shift than junior doctors they were allowed an uninterruptable hour for their midnight lunch and this was sacrosanct. Bugger illness we need our snap and are part of t’union.

So a junior grunt (the cheapest employee on the pay roll earning less than a 40 hour a week police office at the time for working a 100+ hour week) and a junior nurse (leaving a busy ward on take understaffed) pushed the ill patient several hundred yards and several floors up and down in lifts to the CT scanner.

In those days CT scanners cost about £ 500,000 to buy and another half million a year to run. Scans took sometimes half an hour per patient in contrast to the minutes they take to do today.

The hospital had very good radiologists and the junior grunt sat and spoke with the on call radiologist as the scanner warmed up and during the scan. Obviously a lot of the conversation was about the images we were seeing as they were slowly produced on the screen and we cannot recall the outcome of the scan but we do recall the radiologist’s comments as the scan progressed.

They told us about the costs above and said that the scanner “tubes” had a life expectancy of about 3 years (this was early CT scan days) and that given the costs to get best value they should be used 24 hours a day. Now knowing that the junior grunt was the lowest paid member of staff per hour in the hospital at night and, in those days radiologists did very little out of hours work and so were not that highly paid among consultants, the grunt asked why did they not do this?

The radiologist replied that they thought most patients would be prepared to come in in the evening in order to get scans done quicker but went onto say that they had looked into this and the consultant radiologists were prepared to do this so that they could offer a better service and reduce their waiting times for the one CT scanner they had.

The only thing stopping it being a cost efficient service was the cost of the overtime for the radiographers. The figure quoted was that they wanted 2-3 times their normal hourly rate for out of hours (17.00 - 09.00) during the week and more at weekends especially for nights. The huge cost involved on this one item of expenditure meant it was not possible.

Both of the grunts in the scan room looked at each other at this point as they could see the logic of using expensive equipment efficiently for the benefit of patients being scarificed on the absurdity of an institutionized selfish stumbling block.

Now at that time most places in Northernshire had not any CT scanners and were only dreaming of such magic but if we fast forward through the mists of time and memory to a Northernshire that now has CT scanners and even MRI scanners we come to the present and the event that triggered our little musing.

One of the team answered a family member’s phone and it was a hospital radiology department asking to speak to the family member. They left a message and asked if the family member would be prepared to come in for their scan 10 minutes earlier than their appointment.

And the time of their new appointment? 07.30 Zulu.

It has only taken over a quarter of a century to get to this stage that we had discussed in the scan room all those years ago. Who knows in a another 25 years time GPs in Northernshire may be able to request a MRI scan of a back after the lumbar spine x-ray is confined to the dustbin of history for investigation of back pain.

Now we heard someone wise in the ways of radiology talk about that idea in the same scan room how many years ago now . . . ?

Praise be to the Party for ensuring that when it comes to progress the NHS is designed to inhibit it at every turn. Come up with a good idea in the NHS and it will out committee you at every turn.

And still does.

Sunday, 8 January 2012

Private good NHS crap - unless it is breast implants.

As there is no real news in the UK the media have been having a feeding frenzy over the decision of a former historical enemy of the UK now a “partner” in Europe called the French to remove a certain type of breast implant. Already at the end of the week one of the team who was on call listened to a receptionist say as they put a call on hold “I have been waited for this one all week my first boob job panicker what do I tell them?”

The breast implant scare is a classic example of private versus NHS care. When people want something they initially try the NHS for it is free. Often genuine medical treatments are free and usually no problems. If something goes wrong usually the NHS will pick up the pieces in terms of medical care although not necessarily compensation. If they can’t get something then Mr or Mrs Disgusted go private and moan to their GPs about the NHS and their taxes.

The figures we hear are that only 5% of the defective implants were done on the NHS and these patients will be offered the relevant corrective treatment for free at least as far as the patient is concerned. The remaining 95% of punters are expected to go back to their private consultants.

The great thing about NHS care is that the private sector always has a bail out option. We would ask our fellow bloggers how many of you have not admitted a case from a private hospital where an NHS consultant treating a private patient had to admit their patient for bail out care when the operation went wrong or there were life threatening consequences?

Examples being haemorrhage, septicaemia, cardiac arrest and heart failure which the private hospital with no intensive care could not treat and it interfered with the consultant’s extra currciular activities.

At present there is always an NHS bail out facility. What will really p*ss off the private sector “I’ll pay for the cheaper option to increase profit” is that quality costs and that in theory their mistake should cost them dear. On this occasion it might cost them or their patients unless the private sector, some bits of which seem to be no longer in business, do the honourable thing. Patients won’t like that.

Mr Lansley in his naivety expects that the private sector will do the honourable thing and perform the corrective surgery for free. Question is, in the free market is honour a cost worth paying? Or will the private clinics who can’t be arsed to do anything that will cost them do the dump and run on the NHS thing?

Praise be to the Party for always providing the private sector with a rip cord. When it comes to private boob boos will the Party allow all those in the private sector who have fail to act honourably the opportunity to pull the NHS rip cord? Or as someone who flew in world war two without a prachute said to us many years ago if you don’t pull the string it don’t mean a thing.

NHS parachute or private crash and burn? Which do you think most NHS patients and private clinics will choose? And who will pay and who has profited?