“Quality” and money grabbing bast*rds.

The word “quality” as defined by the Shorter Oxford English Dictionary has many meanings. It can relate to both people and things but we shall use the meanings of excellence or superiority as in a “quality newspaper” as our benchmark for this little ramble. We appreciate that “quality also can be used sarcastically but we are simple folk up here in Northernshire and will stick with the excellence and superiority definitions in their literal sense.

Most, if not all, GPs we suspect are sick of hearing the word “quality” spouted by NHS mandarins for whenever it precedes anything medical it usually means that something which is really poor, time consuming and completely useless to anyone called a patient is coming our way to increase workload in order to tick someones’ box when a steel toe capped boot would do better placed in the same manager’s/politician’s “quality” box.

When used by anything NHS “quality” usually has the same meaning as the Late Modern English word “crap” or, in grunt speak, a word from a Mid Low German origin, and we are sorry for a couple of very naughty grunt expressions “sh*t” or its derivatives pile of s. or croak of s. both of which can be used with the c. word.

You can very quickly think of things with the Q word in the NHS just think QOF (Quality and Outcomes Framework) which is so excellent and superior that it isn’t working.

We are sure many readers will have their own little local Q word initiatives which like the Q-ships in WW1 were thought of as being a good idea at the time but which were superceded by better things than anyone at an average PCT could think of on a good day on a down hill run with wind assist ditto politicians.

Na Zu Labour’s endless persuit of Soviet style bureaucracy for the NHS led to the formation of the Care Quality Commission which like the Q-ships of old appears to be an innocent vessel striving to save others from harm and charged with maintaining standards but in fact like any poorly built tramp steamer is struggling to do its job and already cannot meet its own deadlines such is the quality behind it in terms of thinking and personnel.

Now where do the money grabbing bast*rds come in?

Well the CQC being a benevolent caring organization existing purely to serve the patient will happily relieve any GP practice (and others too) of £ 1500+ to be registered with it for you have no NHS “Choice”. Not registered can’t work, fail inspection cannot work well shafted whatever the outcome of any inspection cough up or else.

So this Q-ship is not charged with preventing harm it is in fact a source of harm and will no doubt shoot and hole many practices below the water line not with a ship terminating Exocet but with something far more deadly like you didn’t have gerbil wipes in your washroom (CQC “quality standard 57.997.47.1101.gerbil.9/11). Bear in mind that the captain of this Q-ship has much experience of being a U-boat, sorry hunting U-boats . . .

One of the members of the alleged listening exercise a once a week man aka part time GP called Professor Field has clearly embraced the market so much that he has given GPs the opportunity (to lose a few grand) to improve “Quality” via something called the Quality Practice Award (QPA).

Notice the little Q word at the front? Impressed are we?

Try googling “quality practice award” as we did as part of our research and see what, and who, else runs “Q” word practice awards and like the Royal College of GPs there are some excellent and superior organizations which put Northernshire’s Harvard and Yale MBAs to shame for not having put forward a Shiteton QPA of intergalactic quality.

We digress for the CQC are prepared to relieve practices of a mere £1500 (a year we believe) for registrartion and inspection by inspectors who we are sure will be our “equals” or betters in terms of qualifications and abilty for something which is a legal necessity and a nice little deficient balancer to boot for any Government in power. Can you imagine Pol Pot inspecting Harvard and Yale medical schools and what the outcome would be but remember we are talking NHS “quality”.

If you look in the small print of the Royal College’s Qboll*cks page, sorry about the offensive grunt speak the Q word slipped out by accident, here you will find out how much Professor Field and his back slapping government stooges would like to relieve their fellow hard working GPs actually on the real frontline, on a full time basis, as consultable GPs a few of whom are not members of the Royal Gentlemen’s club but do exactly the same work.

Have a look at the little red words on the first page (the italics are ours) which say that evidence obtained for certain QPA/mQPA (Version 14) may help providers demonstrate complainace with the Care Quality Commissions essential standards.

Have a look at how much quality has gone into the preparation of the web page and how “quality” means that the word United Kingdom is severely displaced by “quality” and the quality of the logo which looks like it was drawn by a nine year old. Or perhaps someone drunk hit the enter key more than needed? And note version 14 – does that mean someone got the quality not quite right 13 times before this one? We hear rumours that even version 14 is being redone.

We know of some commissioning groups (RCGP mafiosos) that are taking “may” to mean “will” meet CQC registration and thinking of imposing it on practices but the old expression caveat emptor applies. But if you are MRCGP you don’t do Latin or Windows when in collegiate mode for this usually involves real general practice avoidance aka commissioning.

For there is not just one RCGP QPA that might just get you QPC registration scam there are in fact two. Did you notice the subtle mQPA that you can take longer to get? And can you guess who devised this?

So yet another set of different Q words from different organizations but they all have two things in common. No quality and money grabbing bastards. One is the Party's the others are just advising them.

Praise be to the Party for using the Q word as freely as tinpot dictators award themselves medals and charging the punters for the privilege of wearing their baubles as well.

Now will those commissioning groups wanting the RCGP bauble be able to justify to their patients why they spent more than £ 3,900 on a Q word when £ 1500 was all that was legally required especially if the CQC don’t accept it and they still have to pay the government’s income generating lackey as well?

It appears that certain Royal colleges and their members don’t just shaft their trainees they are more than prepared to Qrap on their colleagues too.

As directed.

Writing a prescription is a relatively simple exercise provided one knows a bit about drugs, can read and write and most importantly can do it safely. There are lots of short essays on how to do so and if you haven’t already done so, and believe us many doctors have never done so, the British National Forumlary is a good place to start. A few years ago the Medical Protection Society published a booklet on prescribing.

These were full of common sense things like don’t use Latin initials for example t.d.s. instead write it in English as “three times a day”. A lot of doctors still use the Latin abbreviations which are useful as a form of medical shorthand but can cause confusion in certain situations.

Another top tip was to only use the abbreviation mg (milligrams) and not use the abbreviation μg for micrograms which the article showed various ways that handwriting could convert the symbol μ into the letter m. Not to dissimilar to look at but a thousand fold variation in a dose that with some drugs could be very lethal so this was a good one to avoid.

For many years these simple principles have kept us going but in the recent past two organizations, both non medical ones, have decided like all impudent and ignorant children that they know better and would learn us doctors to do proper like what they does.

The first shot across the bows of HMS Smooth Prescribing was from the Al Quaeda school of radical pharmacists. On one of their many visits to educate those more knowledgable than they, they had decreed a jihad after issuing a fatwa against the term “as directed” (a.d. to use its Latin short hand) appearing on prescriptions.

This simple term had become verboten in radical pharmacist circles and as such was now the source of a witch hunt as all true religious and science based zealots do embark on after reading holy scrolls from a Midlands “University” famed for the production of many social service graduates and media studies types all highly useful in healthcare.

The zealots persevered but those of us with memory and experience played them at their own game. What about patients on insulin who may need to daily change their insulin based on current blood sugars?

No “as directed” is not acceptable the scripture says so. So we will need to write a prescription with a specific dose for each insulin injection 4 times a day for every diabetic on insulin every day when we do not know their blood sugar readings?

Yes the prophet Keele is most precise on the interpretation of the holy scriptures for “as directed” is now heresy and the prophet is all wise. OK lets play the prophet’s game and guess what?

Eventually when it became unworkable the radical pharmacists accepted that the term “as directed” might just be useful. For thing like insulin and warfarin and bum cream and a whole load of other things where regular doseage is not required, cannot be predetermined and is dependant on variable feedback from blood tests and worse still the needs of a patient according to their lifestyle.

Patients involved in selfcare prescribing using their own judgement who needs them went the zealots of radical pharmacy all that is required is that the label is written as per the prophet’s will. We do not involve patients in “academic” pharmacy.

Unfortunatley we do involve patients for it is their symptoms that often determine when a drug needs to be used and unlike “academic” pharmacists we do not have the luxury of being able to sit next to each and everyone of our patients so that if they develop an itch, or rash or a pain we can instantly write a prescription dictating when, where and how often to apply a medicine. This is why the term “as directed” is useful and if a patient is sensible, rational and understands what the drug is used for there is rarely a problem.

Scratch one revolution. The revolutionary zealots crawled back into their tents in a far desert and we thought sense had prevailed until this week when the fedayeen branch of radical pharmacy reared it increasing ugly and gorgan like head when a colleague in a neighbouring practice, while the on call doctor, was requested to visit 27 patients to do urgent medication reviews at a residential home.

Could this be that a chance inspection of 27 inmates in one the Grim Reaper’s departure lounges had noticed that 27 of their residents had stopped breathing 3 weeks ago and there was a needle and syringe and an empty ampoule of 100mg of Diamorphine by the side of each decaying corpse? Were the last doctors to have visited none other than Dr H Shipman and Dr Ubani?

Of course not it was far more serious than your average day in GP land. Apparantly the home concerned had had an inspection by the Blair Quality Commission C(B)QC and someone had been upset by the fact that a few patients dared to have the blasphemous words “as directed” on their medication.

Now pharmacists and C(B)QC employees live in a magical world of excellence where nothing wrong ever happens. This is why we need more and more inspections by the local villages idiots who have failed throughout their lives to do anything useful and no-one liked at school.

We have seen the local parmaceutal advisers at work locally now their fellow zealots are at work with the C(B)QC. Worse still the zealots had affixed parts of their holy scriptures to the offending prescriptions saying that there were no directions as to how often to administer the medicines or even to which part of the body.

The first few of the presriptions so purified and freed from mortal sin by the zealots’ inspection were for creams. One was for a patient with widespread eczema which varied on a day to day basis both in terms of location and intensity and was treated with a mixture of steroids and moisturizers. The patient had had eczema since childhood and although physically infirmed was mentally able to dictate how to use the creams for best effect.

A disease that is variable in time, location and severity requiring differing amounts of medication at different times and locations cannot be prescribed for on every single occurrence in today’s NHS but despite this self evident truth attached to the offending prescriptions was the holy scriptures dictating that as directed should be removed and precise locations and timings be written instead.

Several other creams had been similarly cleansed by the zealots and all were conditions that varied as above.

So what did our professional colleague do in the face of the terror of the new Spanish Inquistion? Well they considered their professional responsibilities remembering that they were responsible for any prescriptions they signed. Those who did the inspection had long since galloped off and their faces were hidden under pointed hats with only their eyes visible and so there was no idea what qualifications (if any) they had.

The prescriptions had all be written correctly from a medical point of view, the staff at the home knew what they were doing and so did the patients and so passive resistance was employed.

Praise be to the Party for ensuring that no-one is too thick to fail and if you do you can always inspect something and take full no responsibility for your inactions. If you prescribe and make an error it comes back to haunt you. The ability to prescribe is hard won and carries with it responsibility.

The ability to prescribe responsibily to meet the needs of patients not those of protocols must come first for it is they that we as doctors are there to serve and protect. Of course if you want doctors to spend all day writing prescriptions and not seeing you just dial CQC PHARMACY for instant help.

Muppets.

Bank holidays, dogs, dentists and the coming of CQC.

The recent spate of bank holidays has given a few of us the chance to travel to places new and talk to others involved in medicine. One of our travels involved a chat with a dentist.

Dentists deal with mouths and teeth and have done very well out of NHS dental reforms. This have resulted in most dentists earning far more by doing less and have created the phrase of “doing a dentist” which if GPs did the same as a result of market led NHS reform would lead to very long queues outside those GPs who could afford to work for very little for the NHS as per the NHS dentists. A clear victory for NHS market led reform in increasing provision of dental care to those best able to afford it at the expense of those who need it most. Still toothache = see NHS GP.

We chatted to this dentist who asked of us how we GPs were affected by the Care Quality Commission (CQC). The overwhelming impression we got was that this was bureaucracy gone mental. In 20 minutes of a quite in depth discussion, for dentists are ahead of GPs here, one of us was reminded of an expression that one of the team who used to help out in remedial classes recalled being shouted out loud when one of the class couldn’t spell a word one of their peers thought was easy to spell.

The word was “retard”. As we spoke it became apparant that a lot of general practice time will be spent on matters of retardation rather than anything to do with medical care. Remember retard and retardation were words used to insult those who could only just spell 5 letter words better than their fellow pupils in a remedial class. Old words were revisited in the context of what crap, nay in grunt speak sh*t, is about to be inflicted on professionals by the Care (Blair) Quality Commission C(B)QC.

As we spoke more to this dentist about the C(B)QC process the word retard got louder and louder in our brains until we were told about the section dealing with dogs when an atomic explosion of retardation gone mentally ballistic occured.

Now forgive us for being thick at ND Central but when did dentists do dogs? Err perhaps we ought to rephrase that as to when did dogs become big issues in your average dentist’s clinical practice other than blind or support dogs? But we forgot there is a war on terror and as a result in the search for weapons of mass destruction as a large government “organ” the C(B)QC may be ahead of the game.

Maybe as part of the defence of the realm all dental practices are the new Home Guard and therefore have to have a policy on provision of rest rooms for bomb disposal dogs (Armed Forces Dogs section A), enemy combatant sniffer dogs (Police Dogs section B) as well as substance misuse sniffing dogs (Drug Enforcement Dogs section C). All essential for your average dentist’s quick look in your mouth, scale and polish and charge you service.

Maybe as part of the “patient experience”, a new C(B)QC retard buzz word for the buzz word bingo card, there has to be a policy on provision of crèches for dogs at dental surgeries?

With sub sections on provision by dental surgeries for dogs’ urinary excretion needs (quality care for clients’ dogs section 1.1.a), dogs’ faecal excretion (quality care for clients’ dogs section 1.2.1a), needs with special reference to disabled dogs excretory needs (quality care for clients’ dogs section dogs 1.2.1b), and special provision for dogs with Zimmer frame needs(quality care for clients’ care for clients’ dogs section 4)?

All essential layers of retardation for the provision of “care” and “quality” assured dental services (perhaps with a little red lion mark too?) at your average general dental practioner’s surgery. Ditto the same to come for GPs?

Now GPs are not immune to the layers of retardation that have come the dentists’ way for we have already seen the 6 inches thick of ring binders full of paper that needs to be completed. We can take comfort from the fact that if all those at CQC piled their brains up we would still be able to see these ring files from space with a magnifying glass for there would be no meaningful obstruction to the passage of light as that usually travels in a straight line unless it encounters a large quantity of dense matter called a black hole in which case the light might curve and render it invisible. (In our dreams).

It would only take 4 GP’s brains to hide them from view. If the C(B)QC lost their brains they would still be able to function unhindered and deliver world-class retardation and zero patient care but completing this monster pile of retardation gone wild sh*te will lead to many GPs losing their minds in the cesspit of alleded quality and care that is C(B)QC.

No doubt for general practice the C(B)QC will be more “rigorous” and “robust” and the layers of retardation will extend to cover other areas of Linnaeian classification so no doubt hamster and gerbil policies will be de rigor to ensure a “good patient experience” and maintain alleged “quality” and “care” as per the new Soviet style commissariat?

Figures we have seen suggest that 90 hours of work will be required to complete this monsterous pile of rain forest deforestation and intellectual retardation. If you are a single handed GP that equates to almost 3 weeks less medical care in order to demonstrate “care” and “quality”. Do patients want to see a completed C(B)QC folder or a doctor when ill?

Heaven forbid if a spot CQC inspection found that little Joanna’s visit to their doctor with a minor self limiting illness was compromised because the practice did not provide gerbil wipes for little Misha their pet gerbil who happened to do a whoopse in their travel cage in their 4X4 wally wagon parked in the practice car park and poor Joanna were to be distressed as a result of the lack of provision of a rodent rest room at the practice with gerbil friendly changing facilities (red gerbil mark anyone?).

They will be in therapy for years unless the C(B)QC and it fully retarded personnel are there to maintain high “quality” medical “care” standards via the important task of completing a tick box and devising “action plans” for the provision of rodent rest rooms and all things C(B)QC led improvement.

Now the dentists seem have got their act together in contrast to the Government stooges called the BMA and are helping their members (in contrast to the BMA). The Blair Quality Commission has powers without ability (sounds familiar) but is coming our way as GPs.

It is retardation gone wild and enables all of those who failed in the UK education system to get their own back on those who were bright. For there are not enough qualified people to inspect all those even more well qualified people who provide healthcare without compromising the provision of healthcare itself.

Instead it will be the job of those who have failed. Only those who are expert in providing layers of retardation can do this and there will be plenty of people made redundant from PCTs and SHAs who will be up to the mark and they will do so to the best of their exceptionally limited abilities but at least your gerbil will be well cared for as a result. Your grandparents will die as a result as their current leader is well qualified in not registering multiple deaths on their radar.

The CQC is not about care, it is not about quality, it is merely another layer of retarded bureaucracy and in having to fill in its mind destroying paperwork it will distract those who actually provide quality care from doing just that.

For if we, in healthcare do not fill it in “properly” to retard levels of “quality” and to retard “care” levels the retards can and will shut down the asylum and be totally unaccountable but at least we can take comfort from the fact that the gerbils will be well looked after as a result of the moron generated retarded enforcement notices and action plans if you pass.

Praise be to the Party of free enterprise for ensuring that with each Party the layers of retardation increase year on year despite their increasing promises of red tape reduction.

If it carries on at this rate the weight of the (gerbil friendly) protocols and bureaucracy will crush your average GP’s practice under their weight more efficiently than any Japanese tsunami and aircraft will never fly for the weight of pilot ticked retardation will be greater than the ability of the plane to take off.

And if the plane never takes off and the patient is never treated then no-one comes to any harm but rest assured all the boxes are ticked and all the policies are there to prevent harm (or treatment?).

Now that is important, isn’t it?

(We know we missed a doggie i before you start!)