Monday, 30 April 2012

Yessum mistress beat us some more.

A while back we did a piece on how members of the Royal College of General Practitioners (RCGP) exploit GP registrars in a similar way to which certain ecclesiastical organizations treated those juniors in their care for their spiritual betterment. If you have not been on the receiving end of senior members of the RCGP exploitation of GP trainees (now called GP registrars) you will not understand where this piece is coming from. We would suggest you read our previous piece before reading further.

A former main stay of our early blog reading has pointed out in one of their much missed posts (hint) what another newer blogger has written which has sparked a huge number of comments including those from the new Uncle Tom of the RCGP sorry we meant nice Auntie Clare about the proposed extension of GP “training”.

The doctors in training we have had here at ND Central, our GP registrars, our F2 doctors and our medical students have all been groomed as per the current generation of ivory towered educationalists and all have said the same thing at some point during their time with us.

"We learn most from seeing and treating patients on our own".

This is akin to flying. You need a certain amount of training to be able to fly but you learn most from your personal experience. Now we would not suggest a mere 7 hours in a Spit as being adequate to enable a new GP to take to the flying of their patients in practice but for years the current system has worked.

Our doctors in training also comment about how retarded the eportfolio and the buzzword “reflection” is and resent having to complete it to keep their RCGP overseers happy. The same overseers never had to do this complete waste of time so does that mean their trainers are in fact crap doctors ill prepared to be full time GPs in the 21st century as they never did any electronic “reflection”?

Most of our doctors in training are bright and will very quickly analyse a situation and realize if there is a problem and because they are conscientious strive to correct any error and learn and remember how better to perform next time. The human brain is a complex computer and this type of education is adaptive unlike an epratfolio where hours of retarded reflection will be of little use if you suddenly can’t get your gear down or an engine fails. Another year of debriefs and eportfolio box ticking will be of no extra benefit compared to a year of flying solo.

The poorly performing doctor will not be weeded out by the epratfolio for we have dealt with these and they are bright enough to realize how to have a shining eportfolio while being completely useless. This is akin to a pilot with a logbook showing many hours in the air who can barely fly.

The more hours in the air you have the better a pilot you should become (assuming that basic training has been correct). There are minimum numbers of hours needed to fly different types of aircraft and we are sure that Auntie Claire would be happy to board an aircraft the pilot of which had done more hours reflecting on their simulation flying than flying the real thing especially if Auntie Claire’s ticket was that much cheaper as a result of similar reforms of the aviation industry.

No doubt Auntie Claire feels that the extra year of hours on the epratfolio will mean a nGP registrar will be able to think more for themselves having been groomed and exploited for another year of debriefs and already the medical press are suggesting that this year will be spent in areas that most GP trainers would not touch with a barge pole.

Those of us who have been collectively abused over many years by former senior abusers, sorry members, nay fellows of the RCGP have not reflected on this abuse as being good we have analyzed it and learnt that it was bad and as such have changed our practice to ensure that we protect our doctors in training from this kind of exploitation and abuse.

Our personal experience is that GP trainees/registrars were used, sorry trained, to allow the trainer more work avoidance or opportunities to do other (more lucrative or interesting) things than treat their own patients. Give GP registrars an extra year of flight simulation and “reflection” thereof and that will not make them better GPs in the same way that less hours flying make for better and safer pilots.

But just like in Uncle Tom slaves are there to be exploited by their masters and mistresses. And like those who have been abused abusees accept this as the norm and perpetuate further abuse to maintain the status quo unless they rebel or resist.

Tell us Auntie Claire who should we believe and why is it a good idea for an extra year? Obviously you support the idea of clinical commissioning as does a once a weak man who thought 5 years would be better. In order for experienced GPs to be able to do clinical commissioning or RCGP work they will need someone to cover their surgeries.

Is your extra year merely a way of ensuring a cheap supply of experienced labour to enable their overseers more time away from practice without having to pay for expensive fully trained GP locums?

Or will they be claiming locum expenses and using GP registrars instead? Don’t laugh we know this has happened and happens.

Will free thinking GPs involved in training lie down and let someone tickle their belly and say yessum this sure feels good or will they stand up for their GP registrars? Will GP trainers opt to wear blue to protect GPs in training from exploitation or don the grey, whistle Dixie and tell their GPs in training to go pick some more cotton, dawg?

Praise be to the Party for continuing to provide high quality medical services by driving down costs and exploitation of those in training. Is there any Abraham Lincoln anywhere amongst the current crop of overseers in the medical educational establishment at present?

We’d better get back to picking some more cotton in case we get Scot juniored by another group of overseers.

Wednesday, 25 April 2012

Murkeet musings # 2.

Following on from our first musing a recent conversation with a fellow grunt in the field opened our eyes to some other “free” market activities that most patients may not be aware of. Our fellow grunt works in a dispensing practice in deepest rural Northernshire which is one of the anomalies of the NHS for while most drugs are dispensed by chemists in certain areas of the UK, for example in rural locations where there might not be enough patients to support a profitable pharmacy, local GPs are allowed to dispense drugs under slightly less onerous regulation than would a chemist.

Our fellow grunt was bemoaning the fact that in the recent past their normal wholesalers have suddenly been unable to obtain drugs from certain drug manufacturers in the free market. In our colleague’s view the manufacturers have started to act as cartels. A few years ago our colleague said that there were only 2 local wholesalers from which they bought their drugs.

Only certain “newly” created “wholesalers” can supply these particular drugs from these particular drug manufacturers and these “new” wholesalers only supplied drugs from one particular drug manufacturer. So their dispensing practice serving an isolated rural community now has to order only from what is termed in the NHS a “preferred bidder” in contrast to the previous NHS “choice” option of 2 wholesalers who could possibly compete on price for a particular drug.

In order to maintain their patients’ supply of drugs our colleague’s dispensing practice has HAD to sign up to a certain (preferred bidder aka any willing provider) wholesaler or face the alternative of not being able to supply their patients in spite of the “free” market.

Several months later although our colleague had paid the “market” price for their drugs they suddenly noted several hundreds of pounds being added to their drugs bills per month.

Further enquiries led to the fact that the pharmaceutical industry, champions in the eyes of politicians of the free murkeet, had not only restricted supply for previously freely obtainable drugs from 2 local wholesalers down to one preferred bidder aka any willing provider only but had also added a “premium” for doing so.

If you did not order enough drugs from this “preferred bidder aka any willing provider” of goods for the NHS “internal market” the provider can charge you extra per month in our colleague’s case several hundred pounds a month per month for a “target” shortfall of a much much smaller amount for not ordering enough drugs per month.

So the “choice” provided by the current NHS murkeet and the free market means you now have only one choice of supplier (instead of 2) and if you don’t reach a “target” (set by the supplier using the “choice” agenda) your costs rise. No restriction of the free murkeet here comrades or supply cartels.

As our colleague said to us you cannot predict illness and hence the need for drugs but the pharmaceutical industry feels it can and shafts you accordingly each and every month as you now in the NHS murkeet have a “choice” of only one supplier not “any willing provider” for dispensing practices.

Can we now see the new NHS Tripartite murkeet doing the same if it has not already done so?

Think ISTCs and Darzhole centres.

ISTC charge fixed block contract costs and if they don’t do all they are contracted to do they trouser the costs but do not give a refund for things not provided but charged for. Anything else, including their failures, the NHS picks up the pieces for.

Darzhole centres agreed to treat a certain number of patients and when this number had been treated they shut up shop and the local NHS picked up the pieces for extra work at no extra cost while the Darzhole centres ceased working but were still getting paid.

Examples of NHS “world-class commissioned” fixed price contracts charging above market prices to provide less than the then current NHS “providers” (hospitals and GPs) and then when you don’t use them enough (because the contract says you can’t) they cost more to terminate than run and more to pick up the pieces of what they haven’t done.

In our colleague’s case they have not bought enough drugs but they have treated their patients and been penalized for doing so by the current and soon to be NHS murkeet. In the case of ISTCs and Darzhole centres the NHS has bought both too much from each and received too little and the private sector has won hands down.

Will the nice new (MRC)GP commissioners do any better then the previous “world-class” commissioners? We wonder who the bookies would put money on to make a profit based on previous form? Nice but (commercially) dim GPs or market savvy private sector friends of the Tripartite NHS coalition?

How many GPs or anyone else reading this will know how the free market works outside of NHS "internal market" healthcare or be able to work out how Marshall NC/DC new murkeet will work? Who do you think will win?

You the patient or nice Mr Andrew’s NHS murkeet friends?

Praise be to the Party and its Tripartite healthcare policy for providing the same as before by charging more to ultimately deliever less in the process for ones tax pounds. Darzhole centres and ISTCs were but the beginning of the shafting of the NHS towards the weapons of AWPs’ mass destruction.

And they worked so well didn't they?

Wednesday, 18 April 2012

Doctor’s dilemas another one.

Question: Where's me phone?

Answer: Where you left it - at the doctors.

Last week in the UK we were in the midst of the Easter school holidays and for some unknown reason GPs’ with families want to spend some time with them. For some unknown reasons our patients wish to spend time with their families at the same time. As a result doctors with families are few on the ground while patients with alleged illnesses are crawling out of the ground in locust like hordes of unceasing wellness.

In amongst the ever increasing “it is an emergency I need to be seen today” 15 extras one of our acutely “ill” patients left their mobile phone. In the first 12 hours or less that it was with us this heavily damaged phone which had clearly seen better days recorded no less than a hundred missed calls mostly over night.

Doning our NHS flu PPE (Personal Protection Equipment) kit we have removed the item to a secure environmentally protected unit provided as part of the NHS flu Pandemic contingency plans for the treatment of key personnel (PCT Chief Execs) and contained the hazzard therein. We knew it would be safe there for there was an extra curtain provided as part of the extra PPE provided by those in charge in extremis.

Drawing lots one of us entered the secure unit to answer the phone in order to determine who its alleged owner is/was/might be at great personal risk given the state of the phone.

After answering several clearly concerned friends' or relatives' calls the conversations we had with them were along the lines of:

"Where’s me mate?"
"Are you Dave?"
"I need Dave I’ve got to get some gear, sorry mate he owes me someit,"
"I’m doing a job for him when’s me kit coming I did it . . ."

Surprisingly “Dave” with all of their very concerned friends and relatives asking repeatedly after him didn’t have any who were keen to give their friend’s name to us even when we explained why we wanted it.

Using all of our years in the medical profession we were by a simple process of elimination able to track down after three weeks of NCSI (Northernshire Crimo Scrotscene Investigation) able to trace who we thought the owner might be just before the battery ran out. We would have loved to have returned some of the calls we received but for some reason there was no credit on the phone.

Herein lies the dilemma for us here at ND Central:

1) Do we dispose of the offending item currently isolated from the world as a health hazard into a secure sharps box to safeguard humanity?

2) Do we hand the item over to the Police as lost properity in the hope that the local guardians of law and order will do their utmost to track down the phone’s rightful owner?

3) Do we contact the local Federales and say we have reason to believe that the phone is a major crime scene and so risk a breach of patient confidentiality as a result of being good citizens?

4) Do we waste valuable practice time and effort trying to trace the owner who could barely stand or walk when seen and who thought that in his one “had to be seen today” appointment they would get 3 other chemically challenged individuals seen for urgent prscriptions for stuff that had been spirited away by the marauding hordes of the invisible benzo and Z-drug fairies who because it is Spring and the mating season have been very busy lately?

You the jury have the case. What should the doctor concerned do?

Praise be to the Party for allowing general practices across the land to be lost property offices at no expense to their patients and the numerous gifts (usually mobile phones and car keys) that they leave on our desks on a regular basis. How much time should we spend informing our patients of their lost property?

Or should we as GPs be good citizens? Discuss.

Monday, 16 April 2012

Murkeet musings # 1.

Now that the Health and Social Care Bill has received Royal assent we here at ND Central have been having a series of discussions about the NHS murkeet and how it might change for the better or not. The architect of the bill is a Mr. Andrew Lansley who is a right wing conservative politician who has never worked in healthcare.

One of the Conservative Party’s principles is that of the free market whereby initiative and free enterprise should be encouraged but as we hope to show the healthcare market is anything but a free market.

To most customers the idea of choice when they shop would seem self-evident. Take a humble tin of baked beans. Different manufacturers make and market them. Different shops sell different varieties and charge slightly different prices. This would appear to be a free market offering the customer widespread choice both of product and of price. Now given that there are different manufacturers of drugs you would think that the same would apply?

Let us take the baked beans of the antibiotic world Amoxycillin and see how the free market works in healthcare. Lots of companies make it and it is a cheap drug to buy in the bit of the free market that exists in its passage towards the customer or as we prefer to call them the patient.

The wholesale cost of this drug is about a pound (or less) for a typical prescription of 250mg three times a day for a week. Now if you buy from a manufacturer of your choice this drug that is where the Conservative’s free market ends and you now enter the NHS murkeet.

To the untrained eye there are lots of retail outlets where you could “buy” your Amoxycillin. These are called pharmacies or chemists. You can take your prescription for Amoxycillin to any one of them. It is your “choice” as a consumer.

For 90% of people in England and for all those who live in Northern Ireland, Scotland and Wales the NHS murkeet fixes the price at a very desirable £ 0.00 to the customer which means there is little, or no, need for any competition here. Therefore the NHS internal murkeet works doesn’t it?

Your local chemist buys their drugs from a wholesaler and then in effect sells them on to the customer which is really the Government. Now all members of the current Tripartite coalition on NHS murkeets believe that the cost of drugs to the State should be fixed by something called the Drug Tariff. This is what the Party will pay, a fixed amount to any (willing provider) chemist for a given drug and you cannot negotiate a different price

The chemist gets a dispensing fee for each prescription as well as the Party’s Drug Tariff price via the fixed NHS murkeet. A good chemist will try to maximize their profit as a supermarket does by buying low and selling high.

In other words if for the sake of argument the Party via the Drug Tariff decide in a free (fixed) NHS market that a week’s supply of Amoxycillin is worth £ 2.00 to the Party then if a chemist can buy this drug for say £ 0.75 they can make a profit of £ 1.25 plus the dispensing fee for that prescription.

So up to this point everyone is happy. The Party uses the free market to fix prices and keeps costs down, the wholesaler is happy because they are making money and a good chemist will also use the NHS “free” market to maximize their income.

But what of the 10% of consumers in England who actually pay for their prescriptions? They are used to shopping around and finding bargains but when it comes to healthcare the Party does not do a free market approach it screws the prescription paying member of the public by a heavily fixed NHS murkeet.

The prescription charge paying customer has a free choice of any retail outlet called a chemist but when they are there they have a “choice” of the same murkeet “fixed” price. The fee paying NHS customer can shop around for different outlets and possible variation in quality of the Amoxycillin supplied (although chemically it should all be the same) but like the NHS tariff the “free” NHS market allows a fixed price only.

Furthermore in the NHS free market the price is fixed and in the case of prescriptions for Amoxycillin the customer is paying well over the odds for something that is worth only a few tens of pence.

And so comrade workers given that the HSCB is designed to open up the market and encourage competition given all of the above and the fact that price is not negotiable only “quality” is, how will the NHS customer (patient) benefit from all of these reforms?

In essence the reforms are no different from the way anyone who pays for prescriptions benefits now. A lot of people are paying too much for their medicines now well above what the free market charges and only a few paying customers will actually benefit from the NHS prescription charge murkeet.

Will the new “any willing providers” do as our retail chemists do and seek to maximize profit from the “fixed” NHS murkeet price or will they scorn profit and concentrate on increasing quality regardless of cost?

Next time you get a prescription ask your chemist whether they go for quality or profit? Their answer may tell you a lot about Mr. Lansley’s new “free” market, competition, quality and price. They are effectively the same.

Praise be to the Party and its commitment to opening up the free healthcare market using the time honoured laissez-faire approach to benefit us all in the same way that the Soviet Union did democracy.

Maybe some more murkeet musings to come?

Wednesday, 11 April 2012

'We are not reorganising the bureaucracy of the NHS, we are abolishing the bureaucracy of the NHS.'

Well comrade workers while you have been busily working away on the front line you will be pleased to know that the Party has been busily working away on your behalf to fulfill its promise quoted in our title. You can read the latest counter strike in the current NHS war on reducing bureaucracy here.

We will not do an in depth analysis of the 119 presumably new targets outcomes criteria in this (draft) document but if you are in need of inspiration for the war of NHS liberation you can see it in glorious monochrome and various shades of blue here.

Marvel at how little information will be required to enable your clinical commissioning group (CCG) to be authorized. We are sure your average GP will be able to put all this together on their laptop in a 10 minute coffee break and without the need for any additional bureaucracy. Remember comrades this is just a draft. By the time it is rewritten and revised we are sure that the final document will merely require a CCG to submit a piece of paper written in their best handwriting and signed in blood with the simple declaration of “Yes, we can.”

Comments in the piece in Pulse like “In everything we do we will be bending over backwards to have the maximum number of CCGs authorized with the minimum number of conditions” from Matron Dame Barbara will clearly appeal to a certain group and illustrate that the Party is keen to ensure their process is up and running ASAP at all costs. The three comments at the bottom of the piece provide a rather more forthright assessment.

Once again the Party keeping to its commitment of abolishing the bureaucracy of the NHS on our behalf. After all some bureaucrats are going have to prepare the single piece of piece of paper that will be needed, another one will have to read it, some will have to stamp it approved, approved with conditions or fail and then communicate all of this.

Of course like all good Soviet structures there is no right of appeal but you will be able to query assessments made by the NHSCB. You will be reassured by the words at the end of section 7.16 Ongoing assurance that the drive to reduce bureaucracy is going full steam ahead for it says “Details of the accountability framework will be published later in the year”.

Did you notice a subtle change of initials in the above paragraph? No National Commissioning Board (NCB) now have you noticed it is now the NHS commissioning board (NHSCB)? We love simplification here at ND Central.

Praise be to the Party for ensuring that more GP time will be spent at the coal face of real NHS working to come while allowing us to ignore patients as it strives to abolish the bureaucracy of the NHS.

More reductions to come comrades, toodle pip!

Tuesday, 10 April 2012

The end of the QOFing year and why we are ashamed to be GPs.

QOFing is the process by which GPs in the United Kingdom who have signed the nGMS contract have a chance to increase their income above and beyond their fixed income determined by an unknown formula called the Carr Hill formula.

So as the QOF year end approaches we suspect that every nGMS GP and their practice staff will be trying to increase their income against a year on year decline due to “fixed” and decreasing Government payments via QOF and Carr Hill. This is in contrast to lawyers who have had their costs for obtaining medical information fixed by law (page 6) since 1998 but they are allowed to charge what they like as they work in a free market.

So at this weekend’s meeting at the infamous CafĂ© Michelle income and the subject of QOFing were discussed in depth as we know we are all about to take a huge hit in income not because we have worked less we know the reverse is the case. Most of our work is about treating real patients with real illnesses while QOFing is about treating Party defined illness and what the Party thinks is “good” medical practice. We have said before that QOF stands for neither Quality nor Outcomes just a mechanism to reduce GP pay.

As we discussed the lows and lows of Party dictated medical practice things like QOF, appraisal and revalidation and the prospect of the coming of CQC one of the team began to point out how low QOF “quality” indicators had become. They drew our attention to the Mental Health Indicators of this year’s QOF and to our own particular circumstances in our part of Northernshire.

Unusually for Northernshire we have an elite PCT staffed by those with Harvard and Yale MBAs and years of high flying corporate experience who out of the goodness of their hearts feel that this should all be brought to bear to improve our little part of Northernshire’s health service to standards enjoyed in the first world.

Furthermore in our patch we have a disproportionate number of our practice in the under fifties age group with almost universal employment in this group.

Now true mental illness occurs in all strata of society so given the above you would think that QOFing would be easy. Have a look at the nGMS Mental Health Indicators for 2011-12 and make your own mind up as to how much of the data being asked for has any relevance to a) any patient with a mental health illness and the treatment of their illness and b) anyone actually treating a patient’s mental illness other than an administrator. Then have a think about how does one go about collecting this patient and doctor useless information?

Most people in the UK with mental illness try to hide it because of the stigma the great British public attaches to it. If you have a broken arm people will happily sign your plaster of Paris pot but if you have a mental illness they will call you “mental” or “nutter” because they do not understand. There is even a TV advert trying to change this type of attitude.

Furthermore there is a recession and therefore pressure on jobs, even in areas with 100% employment, and so employees do not want time off work unless absolutely necessary.

Look at what QOF wants for mental health this year: BMI, alcohol, blood glucose, blood pressure, cholesterol tests and in women a record of a cervical smear (even if they have declined this test previously) all on an almost annual basis.

So you try different strategies letters inviting people in or phone calls and what we have found is that those who have mental illness are physically well and do not want to know. Strange that if you were fit and well in your twenties would you want to know or waste your time having a series of useless tests? After all most people know their height and if you have a set of bathroom scales why go all the way to the doctors to be weighed? How will that make your mental health better?

They are bright enough to realize that all of this information is totally unproductive to them and their healthcare compared with the real care their psychiatrists provide them with. The psychiatrists enable them to work and to raise families. The GP QOF indicators provide nothing other than data for NHS administrators.

Every psychiatrist’s letter we have read includes none of the above QOF indicators (apart from the odd mention of alcohol) so clearly this information is of no real use to those treating our patient’s real illness, their mental illness, as opposed to the Party’s defined “disease”.

After numerous rejections of our offers for QOF dictated “treatment” or “healthcare” together with a fair few abusive phone calls with those with more extreme mental illness who have told us in no uncertain terms where to stick the indicators we have decided to forego QOF retard mental healthcare and stick with what we were trained to do namely treat patients for their real medical conditions.

Not their QOF indicators.

Thus QOF has come to do what it has always wanted to do reduce GP incomes. If you read QOF indicators and their justification you would think there was some medical need for us to do all of QOF but remember that those who provide this “justification” would have in previous generations have told you that smoking and chewing gum improved concentration in airline pilots and so was a good thing.

No doubt the same people will be saying that QOFing, CQC and appraisal all have similar benefits for patients. A delusion is a belief in the absence of reality. A lot of people in medicine are clearly deluded should they be on a QOF mental health register? And what would they do when we invite them to attend for totally unnecessary and completely useless tests?

So after a great deal of thought on this we have to apologize to any patient who has a mental illness for wasting their time. We have to apologize for being GPs who sometimes treat real patients for real illnesses for which we receive no extra payment and for wasting our patients’ time collecting information for administrators. We are also ashamed to have to prostitute ourselves on the altar of p*ss poor medicine in order to earn income called QOF.

Doctors are meant to be responsible people and it is said that all that is needed for evil to succeed is for good men (and women) to do nothing. Medicine is full of loads of good people and you can spot the most godly of these by the number of QOF points they have. Especially in mental health.

Praise be to the Party for stuffing the faces of GPs with gold to provide “quality” care. When it comes to stuffing the faces of GPs with crap medicine to provide substandard patient useless care we take exception.

Is there a QOF code for that?

Wednesday, 4 April 2012

Some thoughts on fuel and appointments.

On a regular trip to our local pathology museum, some may prefer to call them supermarkets, one of the team after their sortie there drew up to the supermarket’s petroleum station and said onto the attendant as they usually do:

“My good man, will you be so kind as to fill up my tank with my usual aviation grade 5 star extra leaded petrol and don’t forget the ice, cherry and umbrella in ones glass too as it is a rather warm day”.

We were distraught when the curt reply in a Mister Sidney James’ voice came back saying:

“No can do guv we ain’t got any, will normal unleaded do?”

“It certainly won’t! How many more people have got Ferraris in these parts now?”

“None mate only you rich geezers called GPs and PCT chief execs although they go more for lambos idle rich gits and drug dealers.”

“So where has all the aviation grade 5 star extra leaded petrol gone?”

“Don’t ask me guv ask those in charge.”

So where has it all the gone?

To those cars that need it to function correctly?
To those in panic?
To those who don’t need it but think they do and will pay to get something they don’t actually need to have?

Bit like the health service. Where have all the GP appointments gone?

To those patients who are ill and need (unleaded) care?
To those who aren’t ill and but in panic and demand (aviation grade 5 star extra leaded petrol) care?
To those who aren’t ill and cost the health service a fortune because they don’t have to pay for something they don’t need?

While motorists have thought nothing about draining petrol stations dry for something they have to pay for our patients think even less of the health service which they can drain dry on a daily basis without even thinking of paying for it.

Patients use the NHS just like they do petrol stations. If they can’t get fuel at one petrol station (a doctor) they try another petrol station (a nurse). If that does not work you try a walk in centre or A&E until they get what they want not necessarily what they need.

In the same way as panicking for petrol has led to an increase in demand for things you would not normally need but had to pay for the same occurs on a daily basis at every GPs surgery and every A&E department in the land for appointments at absolutely no charge to a patient.

So the NHS meets patients’ wants for free but not necessarily real patients’ needs while the oil industry fails to meet punters’ wants for fuel at the expense of other punters’ needs.

So if you think petrol think health.

If your tank is full and your motor running fine do you really need a top of (unnecessary Party) healthcare?

If your tank is half full and your motor is running fine do you really need a top up of (unnecessary Party) healthcare?

If your tank is empty and the motor is not working do you really need a top of (unnecessary Party)  healthcare or would you prefer real healthcare?

If you are genuinely ill what do you actually need? Treatment or a top up?

Think about it.

And a big thank you to the minimum four patients per doctor who have booked on the day appointments on several mornings in the last 2 weeks and did not show up for them only for the same four patients to book another four appointments on the day for the same afternoon with the same doctor.

Can’t get an appointment or fuel? Who do you blame?

Praise be to the Party for ensuring that supply is always outstripped by Party generated wants in contrast to the Party providing supply for real patient needs.

Now where we can get some aviation grade 5 star extra leaded petrol just in case our full tank runs out? Or should we book an appointment next week with our GP just in case we are ill and if we don’t show whatever?

We jest not this is happening and it won’t cost you a penny.