A busy few days at the office. To privatitize, or not to privatitize the NHS, that is the question . . .?

The last few days here at ND Central the King Canute like tide of wellness has been well and truly lapping at your average Northernshire GPs’ throne like a tsunami.

A combination of a shortage of doctors and a huge surge of alleged illness has resulted in the number of extras per GP spiralling. Coupled with our ever loving, and increasingly abusive, patients the few doctors and reception staff still standing on the frontline are struggling to cope.

We think the last time it was this busy was in the mid nineties but at least then most people we saw were actually ill and polite with it in contrast to now where very few are. As an example at last night’s surgery 9 extras demanded to be seen in one GP’s branch surgery session. The alleged “emergencies” broke down as follows:

Number of life threatening conditions seen = 0.
Number of ill patients seen = 0.
Number or prescriptions issued = 0.
Number of self limiting minor illness seen requiring no treatment = 9.

At the same time as the local healthcare markets are burning with alleged illness, but with no extra resources to quench the fires of demand for instant medical care, our political masters are fiddling away and tell us how competition and markets are the way forward to improve healthcare. Hmmm.

As very simple grunts on the frontline we thought about how would we cope with the situation of too many (allegedly ill patients) with too few doctors. We present 3 options based on current, and past Za Nu Labour/ConDem, policies:

Option 1:

In a true market the patient as the consumer would pay directly for healthcare. The healthcare provider (GP) could then charge the market rate. If demand = illness was high and healthcare provision = supply was sparse then the laws of supply and demand would dictate that in order to see a GP costs would rise as demand does in order to reduce GP workload.

Examples might be you can see a GP for a routine appointment in a couple of days and we will charge you £20. If you, as the customer demand that your illness is an emergency, your NHS Choice, we will charge you £50.00 to be seen the same day. If you feel that you cannot possibly come to surgery then we will charge you £100.00 for a home visit.

To reduce unnecessary demand in a free market then A&E departments if busy could up their charges to say £70 a shot. £250 if you call an ambulance.

Think about which of the above options you would choose and whether the cost would determine whether your condition was a true emergency or could wait. At the moment if we were on piece rates we would be more than happy to cope with demand as it is now for our extra effort, and that of our staff via overtime, would be richly rewarded.

Works well for lawyers, accountants and, possibly, consultants too?

Option 2:

In the pseudo free world Soviet regulated by the internal (non) market, a Soviet institution called a PCT agrees a contract with a private provider and limits the number of patients they are allowed to see. In other words there is a cap on how much illness the private provider can see and treat. This we have commented upon before.

“Oh no comrade patient you are illness case 101,326 this month but the Party’s contract allows us only 101,325 illness commissioned events by your preferred contracted provider this month so you cannot be treated until next month. We do have a contract you know regardless of your illness.”

So the private sector treats as per contract, gets rich and then what? Stops seeing patients even though there is still demand and worse still local spare capacity to see and treat them that is not being used. The world-class managers who “commissioned” this spare capacity are preventing its use at a time of need.

Who then mops up the rest of illness? Local GPs and A&E?

Option 3

The current NHS nGMS contract is a godsend to both the private sector and Government for it allows unlimited dumping on GPs (and A&Es) regardless of capacity. We note that GPs do not have any fixed capacity in the way that Darzi centres have and so workload is potentially infinite but resources very finite.

So we have seen a 50% increase per GP in workload but we do not get paid anymore but still have to absorb increased demand and costs associated with meeting this demand.

If you are, as all GPs in Northernshire are, so heavily over doctored that we export them overseas by the container load, and spend more time on the golf course than in the surgery, this scenario will never be a problem. You just drop a round, or two, of golf.

This will of course only ever happen in PCTs such as ours due to their world-class commissioning activities by their Harvard and Yale educated PCT commissars, who were never so dumb as to agree an option 2 Darzhole centre currently absorbing NHS funding while delivering bugger all.

Patients abusively demand of our staff “urgent” appointments and then do not show. When they do show it is virtually never urgent e.g. constipated for a month in a 7 year old busily trashing the surgery toys or I have had this unchanging mole for 40 years and thought I would get it checked NOW (bad night on telly) or I want my blood pressure checking (which was OK this morning when nurse checked it?).

There is no responsibility for the patient to attend their appointments, to use healthcare responsibly but their god given right to bear arms, oops wrong country, to abuse daily the NHS is used without any fear of sanction or cost across the land. Even dentists can charge for missed appointments but not GPs or hospitals or A&E departments and remember dentists were allowed to do this when they were once part of the NHS.

If you are really genuinely ill and need to be seen which model do you think you would serve a genuine need best?

Would you be prepared to pay £50 to be seen as an emergency or go for the no charge to be seen and wait option 3? The future of the NHS as we know it?

Option 1, currently not widely available, but allows the “customer” the market choice of putting their money where their currently abusive mouths are.

Option 2 GP commissioning which will make the private sector rich at your expense and for more cost will provide you with less care. This is current NHS “world-class commissioning” by morons on your behalf.

Option 3 the current situation where you will get care on the cheap and quality to match. You also have to wait but then you are not paying the piper directly so you have no choice of tune, quality or speed of access which is centrally controlled not locally determined.

Everyone says they would be prepared to pay more for a better NHS but talk is cheap and increasing taxes is never popular but abuse towards our reception staff is a democratic right and free to all who wish to use it.

Praise be to the Party for giving the NHS a market. At present our staff would embrace the free market and invest in shares given the current demand for they would be rich given the workload and abuse they are enduring.

Unfortunately the NHS market means we are all the poorer for pandering to the pathetic the most pathetic of which are the politicians. Bet you none of them are BUPA positive?

For BUPA positive press option 1 . . .for NHS press option 3 . . . for no, or limited care try option 2.

Where have all the ill patients gone?

We at ND Central had a crap day last Friday. We have spent more time waiting than we have working a clear benefit of Gordon (the MoreOn)’s NHS “reforms” for General Practice.

If we had actually spent our whole day working, we could have seen and dealt with all our patients in it in just over 3 hours rather than the long drawn out, agonisingly boring wait for patients that stretched it out and took almost 9 hours to finish.

This morning we worked from 09.00-11.30hrs and spent an hour and ten minutes seeing patients. The rest of the time we spent waiting for patients to arrive (1 hour twenty minutes). If you cannot see a doctor read on to work out why. The Fat Controller’s influence is all pervasive in healthcare as it is in our increasingly affluent economy over which he presides.

In amongst this morning’s waiting, sorry work, was a patient who brought their child in and proceeded to moan about how they and their family could not get a same day appointment at a GP Practice in the English NHS and had to go to A&E to be seen straight away. They felt that this was wrong (as they paid a lot of tax to the Fat Controller) and also they asked about any local private GPs (of which there are hundreds in our affluent neck of the woods).

They contrasted their experience to that in Southern Ireland and in Europe where they have had to pay to see GPs but could always get same day appointments. The law of supply and demand at work, perchance?

We know from the A&E discharge summary that the patient had a GP treatable condition but due to Party reforms and a “World Class” Commissioning PCT, they cannot get a GP appointment. But the Fat Controller rewards local idiots for their incompetence and they and he think they are doing a good job. Neither ever talks to patients so they know better than do we.

We then sorted out visits for the whole of the practice on our own that weren’t needed and then signed 350 urgent repeat prescriptions before moving on to minor administrative queries and problems that did not involve any direct patient contact.

This afternoon on an emergency appointment list we saw 17 patients in 1.5 hours in the only time in the week we don’t do a Gordon or centrally dictated surgery.

Amazingly, this non Party prescribed system works well, but when you leave work people are staring daggers at you for seeing sometimes 8 patients in the 20 minutes plus they are waiting to see a doctor doing 10 minute Gordon appointments.

In a whole day no one had any illness that was life threatening.

4 out of the afternoon “open access” (to meet the 48 hour Gordon access target) wanted (non) urgent blood results.

Another 4 had booked into get a Party prescribed (Gordon) annual medication review for a (non) urgent annually needed hay fever treatment

4 came back to ask for repeat sick notes which they knew they would need when they got the first one but they did not book an appointment at that time.

Oh yes and one patient did not show (but we still had to wait 10 minutes just in case they did).

So most of the same day (urgent) Gordon appointments were for things that did not need to be seen within 48 hours or even that week based on MEDICAL priority or need but Gordon knows best as he never went to medical school.

We used to use this “something for the weekend surgery” as “emergency” only appointments to try to see acute illness but now they are open to whatever crap wants to come in thanks to Gordon and Tony. And it does and in doing so blocks illness.

What used to be an “emergency” surgery has now become a “I can’t be bothered (to plan my life) surgery but as it is free I will (ab)use it”. Our reception staff have noticed that there is a hard core of patients that always (ab)use these surgeries which occur twice daily every working day. Some patients will use the afternoon surgery if they are unhappy that they didn’t get want they wanted in the morning and worse than this even the next days surgeries as well.

Where has all the illness gone? We know it is there but we are not seeing it.

This worries us.

A former comrade at arms who works in the other front line of NHS care, Accident and Emergency medicine, noted that their workload at night went up by 20% in the first year of the new GP contract. It has got worse since our comrade tells us as if people can’t get an appointment with their GP they go straight to A&E. They are seeing less Accident and Emergency medicine but more general practice “because I can’t see my GP”.

At practice based commissioning meetings the local Thickerrazi tells us that A&E attendances are going up and they want us to stop people going there to reduce costs. Is this were all the illness is going?

We know not but, if you see almost 30% less patients then you used due to Party reforms then, if illness is distributed randomly, it will take you longer to see it. Maybe that is why we are seeing less illness because we are now seeing less patients and taking longer to do so in order to meet government targets?

Of course illness could be struggling into the extended hours surgery that Gordon thought was a good idea. All those early morning surgeries for busy commuting pensioners and children and the Saturday mornings where often a third don’t turn up as they are busy sleeping off their intensive health promotion Friday night workouts (8 pints, a curry and a glassing). Is this where all the illness has gone?

We doubt it as all of these are pre booked appointments so no acute illness. The extra surgeries do not make up the appointments lost by the Party’s insistence that all consultations should be 10 minutes long, comrade. Still the Fat Controller thinks our staffs’ weekends should be disrupted to try and keep him in power. (We like true socialists who look after the workers, comrades).

Could it have gone to NHS (re)Direct? We don’t think so as a third of their workload is bounced back to GPs or A&Es so we should eventually see some of it?

Could it have done to the Darzi centres or rather the Equitable Access centres or whatever other name is currently applied to the squandering of finite NHS resources on the private sector regardless of need?

We don’t know as yet but our patients are not leaving in huge wildebeest like droves to join these expensive white elephants so it is just possible they may be seeing all the ill patients we are not?

We drove past a GP Walk In centre in one of the largest cities locally yesterday at 17.00hrs and saw one patient in the waiting room when ours would be full. That is one more than we have seen the last 3 times we have driven past it.

Might illness have gone to other Walk In (get nothing done and then see your GP) centers?

Same logic as here as with NHS (re)Direct.

So where has all the illness gone?

Praise be to the Party for reducing illness by its health policies. Make GPs do less, spend more time waiting than working, and then blame them when patients moan.

Anyone else struggling to see illness or is this phenomena peculiar to the ever over affluent North? More pork scratchings and chips anyone?

NHS Efficiency

ND’s team is getting increasingly bored in surgery which is in part why the team have taken to blogging after many hours of reading other more established bloggers. But hang on we hear you say, how come you have so much time to do these things after all the health service “reforms” and “efficiency savings” that have been achieved?

A recent statistic shows that each year the NHS becomes 2% less efficient. Someone put it that if the Party spends £1 this year on the NHS then next year that £1 is worth 98p in terms of what it buys from the NHS and so on year on year.

Why is this so?

Well let us look at some of the reforms that the new General Medical Services contract has inflicted on one of the two front lines of the NHS = General Practice. Let us look at GP appointments and access.

Our last glorious Party leader Tony, currently struggling through the economic crises on a true socialist income of £12,000,000 a year lecturing to Americans wanted people to have access to a GP in 48 hours as all good but, paying, Americans do have?

Remember the famous “why can’t I see my GP with a booked appointment?” incident?

This hand bagging of a Prime Minister who is happy to inflict his policies on his people without knowing its impact on the front line is so typical of NHS reform and a direct result of a centrally imposed target driven culture driven by people who have never worked in healthcare. In order to get everyone seen within 48 hours some surgeries had to scrap booked appointments because of demand or lose money.

At ND Central we used to have a mix of pre booked appointments and a daily “emergency” surgery where patients were given a card and told that this was for acute illness not for things like sick notes, medication reviews, follow ups, getting results etc. We had a degree of control over what an “emergency” was.

ND Central after a couple of years also introduced ten minute appointments for purely financial reasons as despite Party Central hype income was falling. Under the rules patients could come in with any crap not with acute illness just ring up and get an appointment no questions asked. Therefore there was no control on demand. And the effect of this was?

A direct reduction in General Practice efficiency due to Party Central. Why?

The Party “working day” for a GP is 10.5 hours from 08.00hrs -18.30hrs = 52.5 hours for a five day week vs the European working time directive that the Party has signed up to of 48 hours per week.

Suppose that you could see 24 patients in 3 hours under the old system. This would give you a morning and evening surgery of 3 hours each with a gap in between of some 4.5 hours where you could fit in visits, paperwork, meetings, clinics, sign several 100 prescriptions, read hospital consultant letters, answer phone calls, supervise trainee doctors etc.

Apply ten minutes appointment to 24 patients and you get two 4 hour surgeries a day and a gap in the middle of 2.5 hours. So in order to meet the Party target you have increased the time to see the same number of patients and decreased the time available for other GP jobs unless of course you increase your working day by 2 hours (and your week to 62.5 hours) that you would not get paid for. (However Government is holy and does not believe in contracts and feels that increasing GPs' working hours without pay is an OK thing to do.)

Now doctors are human. They have families and outside interests and like a little R&R. They also get bored sitting down for 4 hours and this increases the risks of DVT by doing a trans Atlantic flight every day of the week. So after much discussion the ND team decided that 3 hours was the most it could stand and so we reduced the numbers seen to fit two 3 hour slots and not reduce the other minor things that GPs do in between surgeries that do not count towards Party tick boxes.

(Numbers used are for example not actual before the local Politburo Stasis’ start sniffing and to make the mathematics easier for any innumerate Stasi snoops reading).

Thus we are spending more time and meeting a target but doing less work as a result. If someone comes in for a simple sick note this might take 2-3 minutes leaving 7 minutes spare per appointment. If this is repeated several times a surgery then there is a hell of a lot of (unpredictable) spare time but not time that can be applied to complex tasks.

A good example of this was the first extended hours surgery the ND team did which was 4 hours long and of that 1 hour and 55 minutes was spent waiting for patients. Last extended hours surgery was 3 hrs 40 minutes of “booked” appointments with only 1 hr 46 minutes working. So a GP was waiting, not working, the best part of 2 hours on a political whim.

This is what happens when the Party Central imposes targets that have to be met so Doctors and their staff get paid. Local flexibility and doctors’ knowledge are over ridden by the superior knowledge of the Party. The end result?

A decrease in efficiency.

ND suspects that they must be using British Leyland as their model for running the health service efficiently. Maxi or Micra anyone?

So if you can’t get a GP appointment do not blame the receptionist blame the Party for they set the rules. GPs only play by them.

Praise be to the Party.