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?

Liberating the NHS: some thoughts on the Great Patriotic White Paper 006 of 007.

Well comrades, still awake? We are now onto the penultimate battle of the Great Patriotic White Paper of liberation of the NHS entitled : “Cutting bureaucracy and improving efficiency”.

Images of the team at ND Central walking around our local Soviet with chainsaws sprung to mind at our regular resistance meeting but then we must on and read.

A short spiel on economics follows but then: “Cutting bureaucracy and administrative costs.”

We are told that the new Party’s “ . . . first task is to increase the proportion of resource available for front-line services, by cutting the costs of health bureaucracy”.

Read on dear reader for “Over the past decade, layers of national and regional organizations have accumulated, resulting in excessive bureaucracy, inefficiency and duplication”. We won’t say we told you so but just read UK General Practice and medical bloggers to see how it is.

Onto the second paragraph 5.4 which says that “PCTs – with administrative costs of over a billion pounds a year – and practice based commissioners, will be replaced by GP consortia”.

An interesting statement that which shows those who wrote it have not got a clue. PCTs = crap and expensive yes but “practice based commissioners” have cost local practices a fortune to do nothing so how does that save the NHS? And who are the practice based commissioners?

None other than the self same GPs who will be in GP consortia. And who do we think they are going to employ to do the commissioning while they do their day job? So clearly lots and lots of central Government “savings” farmed out elsewhere. Or did we miss something?

“The Department will shortly publish a review of its arm’s length bodies. . . . we abolish organizations that do not need to exist.”

Anyone need any help? Just read a few medical blogs for starters. Have chainsaw will travel.

Lots more flannel follows but in para 5.6 a small glimmer of realization “But it has rapidly become clear to us that the NHS simply cannot afford to afford to support the costs of the existing bureaucracy; and the Government has a moral obligation to release as much money as possible into supporting front-line care.”

We cannot argue that last one with the good comrade Marshals but we have a sneaking suspicion as we probe further behind the White Paper that bureaucracy is going to increase via the NHS Commissioning Board and all 150 of its yet to be announced 150 “outcomes” which we suspect will enable GP consortia to swim the 100 meters in a “record” time while weighed down with a huge millstone of bureaucracy tied around their neck from central Government regardless of any moral obligation they may feel.

“At present, there are over 260,000 data returns to the Department of Health . . . we will consult on the findings . . .”

Another done deal?

“The Government will cut the bureaucracy involved in medical research”.

What does that mean it will take less than a year to get approval for a medical research project? Can you imagine Alexander Fleming advancing medical science in today’s climate? A potential yes from the team at ND Central although it does involve a “review” = another committee.

Para 5.10 scuppers out limited joy re medical research with the following words:

“We are moving to a system of control based on quality and economic regulation, commissioning and payments by results, rather than national and regional management”.

The words "payment by results" have dashed all hope as another attempt to resuscitate the long decayed corpse of the NHS internal market appears to be on the cards here.

“ . . . we are committed to reducing the overall burdens of regulation across the health and social care sectors. . . . undertake a wide-ranging review . . . with a view to making significant reductions.”

Starting to recognize the pattern? Cut costs so have a review establish a committee but then:

“The reforms in this White Paper will themselves have one-off costs. We shall ensure these are affordable . . . while ensuring funding is focused on front-line patient care.”

Which bit of the chicken and the egg did we miss here. We will spend more on the frontline but in order to do so we have to spend more money on a review. Guess which, comrade patient, will come first to you and your family? The chicken, or, the egg?

Still do not be dispirited for read the next bit “Increasing NHS productivity and quality.” It starts with the following battle winning sentence:

“The reforms in this White Paper will provide the NHS with greater incentives to increase efficiency and quality:”

for such words have motivated NHS staff for generations to shout the following encouraging words urging their fellow comrade workers onto victory:

“On no not another set of reforms”.

Another cuddly grey box from NHS La La land follows full of patient words and pseudo market language.

Para 5.13 states the “Taken together, these ten changes will bring about a revolution in NHS efficiency.”

And so after ascending onto Mount Sinai the latter day prophets Dave and Nick (Davnic?) did descend and bring down carved on 2 pieces of silicon chip the new 10 commandments of revolutionary NHS efficiency.

Para 5.14 starts with “Enhanced financial controls” which starts with “As well as providing incentives for greater efficiency, the new arrangements will provide for greater financial control:”

And is followed but a second cuddly grey box. And look who pops up yet again? The NHS Commissioning Board with yet more responsibility. This is surely going to be a very small Board at this rate of knots?

“Making savings during the transition” follows on with “We will implement the reforms in this White Paper as rapidly as possible”. Always a worry as how rapidly is rapid to the political classes? “But the NHS cannot wait for them all to be in place to begin to deliver improvements in quality and productivity”.

“Patients are rightly demanding the former and the national economic position requires the later”. Patient usually want to see good medical care and care bugger all about the costs as they don’t pay up front and Governments have used this fact for years to bugger up the Health Service with numerous failed reforms.

And finally on to the last 2 mammoth paragraphs of section 5. The first of these starts with a QIPP = “The existing Quality, Innovation, Productivity and Prevention initiative will continue with even greater urgency, but with a stronger focus on general practice leadership.”

Lots of buzz word bingo words follow including reference to such QIPP successes as the “productive ward programme” = how to clean out broom cupboards, “increased self care” = stop eating/smoking/drinking you fat b*stards and the use of new technologies for people with long-term conditions = more nurses in call centres. All "proven" successes from a bygone Party.

A little nod to the Greens with some “improving energy” and “working with the Carbon Trust” should see all our patients healed remotely by an energy efficiency remote access call centre which is cost neutral.

The final paragraph is good for a few laughs as it would appear that “SHAs and PCTs have a current role in supporting QIPP”. This is sounding somewhat Soviet but read on:

“In discharging this, and to pave the way for the new arrangements, they should seek to develop leadership of QIPP to emerging GP consortia and local authorities as rapidly as possible, wherever they are willing and able to take this on.”

So things that are to disappear are to take on leadership and then more worryingly:

“The Department of will require SHAs and PCTs to have an increased focus on maintaining financial control during the transition period, and they will be supported in this task by Monitor, The Department will not hesitate to increase financial control arrangements during the transition, wherever it is necessary to maintain financial balance; in such instances, central control will be a necessary precursor to subsequent devolution to GP consortia.”

Someone once said “No one would remember the Good Samaritan if he’d only had good intentions. He had money as well”. So if we tell the public that GPs are in charge but in reality we maintain the ancien regime and when Johnny GP starts to try spending money we stop him via central control who will be at fault?

Does this sound familiar?

Praise be to the Party for is that last paragraph another way of saying the Party is dead long live the Party? And blame the GPs when it goes wrong for they have the “control” but we have the money?

Liberating the NHS: some thoughts on the Great Patriotic White Paper 004 of 007.

Uri, Sergei, wake up fellow comrade GPs. We have a war to fight. The war to liberate our NHS. We have to work as GPs during the day and now run the rest of the Health Service in our spare time. Wake up Comrades, liberation from the scourge of more work may be upon us . . .

Quiet comrade soldiers for Marshals NC/DC have said the following so listen up.

We are now into section 3 of the war of liberation called “Improving health outcomes”.

We are told that the “The primary purpose of the NHS is to improve the outcomes of health for all:”

Funny that, we thought its primary purpose was to treat patients.

“We will start by discarding what blocks progress in the NHS today:”

Does this means an end to constant Government interference with the NHS?

Sadly no, it means:

“the overwhelming importance attached to certain top-down targets”.

“In future, performance will be driven by patient choice and commissioning; as a result there will be no excuse or hiding place for deteriorating standards and our proposals will drive improving standards.”

At last patient “choice”?

I have a sore throat give me antibiotics. Excellent. Medical science out of the window patient choice and commissioning is now the new science of medicine.

“We will replace the relationship between the politicians and professionals with relationships between professionals and patients”.

Nice thought but whenever politicians offer bread and circuses it is always by offering the NHS as their Games. Healthcare professionals are sacrificed as gladiators in the Politicians’ games.

“Instead of national process targets, the NHS will, wherever possible, use clinically credible and evidenced-based measures that clinicians themselves use.”

Never? A Government relying on doctors and nurses to tell them what should be done next? They will be asking airline pilots how to fly aircraft next but for some reason you never hear of politicians telling airline pilots how to fly the planes they fly in. They do, however, always tell doctors and nurses how to treat their patients.

“In future the Secretary of Sate will hold the NHS to account for improving outcomes.”

Maybe we are a bit thick here up North, but is the word “outcome” the new word for “target”?

“The NHS, not politicians, will be responsible for determining how best to deliver this within a clear and coherent policy framework”.

But who, or what is the NHS?

Are GPs as “independent contractors” the NHS?

Or is the “Department of Health” the NHS?

Anyone know the telephone number for “the NHS”?

So we move onto “The NHS Outcomes Framework”.

“The current performance regime will be replaced with separate frameworks for outcomes that set direction for the NHS.”

At last targets are replaced and now we have a “current performance regime” replaced by “separate frameworks” for “outcomes” that set “directions” for the NHS.

Just look at how many words have replaced targets, the things “that blocks progress in the NHS today”.

“A new NHS Outcomes Framework will provide direction for the NHS”.

A new set of targets, sorry comrades, outcomes. Outcomes are not targets in the same way that commissioning is not fundholding.

“It will include a focused set of national outcomes determined by the Secretary of State against which the NHS Commissioning Board will be held to account . . .”

Focussed, national outcomes all new words for new central Soviet style “targets”, sorry outcomes?

Onto “Developing and implementing quality standards”.

Listen to this one comrades:

“Progress on outcomes will be supported by quality standards. These will be developed for the NHS Commissioning Board by NICE . . .”

So no moron medicine here directed by politicians just “real world” science modified by “evidence-based” medicine “politically influenced” by the “independent nice people” at NICE.

NICE expects to produce 150 “standards” = targets or outcomes, dumbed down medicine for the thick and they will develop “authoritative standards setting out each part of the patient pathway”.

“Pathway = journey”. More word tinkering “To support the development of quality standards . . . "?

Furthermore “NICE . . . will advise on research priorities”.

We look forward to NICE research on is the Earth flat for this is surely nothing more than political control of the NHS by failed academics wanting a gong?

More frightening is the “We will expand the role of NICE . . .The Health Bill will put NICE on a firmer statutory footing . . . ”

Za Nu Labour reborn with legal clout? Sound familiar?

Central control on professional thought and independence leading to its being outlawed?

Think outside the new Party (grey) box comrade GP and the jackboot will get you but it will be a NICE and a legal jackboot too.

There then follows another cuddly grey box all about how the new Party thinks one should prevent DVTs and PEs.

Bet they have never spoken to any Coroners that realize that death happens regardless of guidelines followed or not.

However, if a Party puts “guidelines” or “outcomes” or “targets” in place, the Party can prevent all known deaths from DVTs and PEs. Coroners can now safely retire as from now on there will be no DVT or PE deaths because everything will be NICE.

We like the “Patients/carers are offered verbal and written information on VTE prevention as part of the admission process.”

Bet that will frighten off evil Johnny DVT and save countless lives at the cost of a few hundred hectares of Amazonian rain forest and the employment of not one extra nurse on any understaffed ward who might be able to mobilize a patient.

Clearly Marshals ND/DC like NICE as they think that “NICE quality standards will be reflected in commissioning contracts and financial incentives.”

Once again no political interference here, comrade, just NICE, simple medicine.

Onto “Research”.

Research has usually been independent of Government so unless you are going to fund it, keep out. DNA and splitting the atom were not discovered by Government or anything NICE.

We now come to “Incentives for quality improvement”. Start rubbing your hands with glee for this surely must be where we, the evil under worked, overpaid GPs find out how much huge wonga wads are coming our way for our additional commissioning work.

“The absence of an effective payment system in many parts of the NHS severely restricts the ability of commissioners and providers to improve outcomes, increase efficiency and increase patient choice”.

Does this mean an end to the flawed Soviet style market system where all prices are fixed nationally? Read on:

“In future, the structure of payment systems will be the responsibility of the NHS Commissioning Board and the economic regulator will be responsible for pricing.”

How are they going to cope, those busy little boys and girls at the NHS Commissioning Board, with it being so much bigger with each paragraph we have read thus far?

A new Department of Health 2 - The Sequel being born? And where did the economic regulator come from?

It is clear that the failed internal market is not dead it is a case of long live the “market” as “money follows the patient and reflects quality”.

Notice the subtle changes in wording so that what was once the NHS tariff is now “a set of currencies”. Does that mean health tourism is to be developed as a new income stream?

But Uri, Sergei come here quickly for para 3.22 tells us how we can make loads of money:

“ . . . we will introduce a new dentistry contract . . .”

We must go away to dental school for if it is as successful as the last one there will be an even greater need for private dentists!

Praise be to the Party for giving us more of the same with different words. This war of liberation seems uncannily similar to what happened at the end of the Second World War in Eastern Europe.

Will our liberation now, be the same as theirs, was then?

Health Policy: fundholding reborn per chance?

Yesterday the current UK coalition love in published their The Coalition: our programme for government.

Now normally we don’t have much interest in matters political but we thought we would have a read. To say we were disappointed would be an understatement but we are also waiting for next week’s financial review to see if certain white elephants in health care might be scrapped.

We thought there were lots of woolly ideas but little detail but one paragraph caught our eye.

It reads:

We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf.

You will notice the C word there. A return to fundholding anyone but of course commissioning is not fundholding?

Those of us old enough to remember fundholding realize that if this is devolved to practices, or possibly groups of practices, this will inevitably lead to the employment of more managers and administrators just as it did first time round.

However another paragraph reads:

We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line.

Sounds good doesn’t it?

We suspect that NHS administration might be cut but, just as with fundholding, and with rumours of GP practices getting individual “real budgets”, this “cut” will lead to GP costs rising as “resources are transfer to support doctors and nurses on the frontline”.

We love support on the frontline. It usually means more work dumped onto primary care for little, if any, gain or improvement.

These costs cuts will appear to disappear from the NHS budget.

Just as with the end of fundholding when all the fund managers and admin staff were redeployed it might be that all the “cuts” in NHS admin costs will be but smoke and mirrors and history will repeat itself but in reverse.

So will all the cuts in NHS administration by a third result in needless NHS managers and administrators being paid to do the same thing with a different name in General Practice?

Praise be to the Party for possibly reinventing the wheel. The future of the NHS is bright, the future is possibly coalition green?

Where is the patient in all of this?

Choice.

For the first time in at least 5 years today patients, and those who work in healthcare, are being given a real “Choice”.

It is called a General Election.

We, the United Kingdom electorate, have a choice and what a choice it is.

All politicians use the health service as a football to kick around as they please until the football is punctured, deflates and does nothing useful and then like delinquent youths they find something else to trash or have a fight over.

So for those of us in healthcare we now have a real “choice” that we can exercise and hope to influence possible “change” as those in the US have recently done.

Change is a great word but only if it is for the better. Most grunts on the ground know that subtle change (if ever allowed by politicians) can sometimes make a huge difference in healthcare. Unfortunately politicians do not do subtle they do sound bites.

The patient and their care should always be our priority and not a political football.

It is a choice to vote, or not, and it is a choice that the Party cannot determine.

We will use it and we would urge those who have a vote to use it, please. If you have never spoken to those who do not have a vote who envy those that do, you do not realize how valuable a thing it is however much you may despise politicians or feel that your vote is worthless.

Whatever the British public decides today those in healthcare will still deliver a service to the patient as an individual to the best of our ability tomorrow.

In the same way that if you handcuff a boxer’s hands behind their back that might influence the outcome of the fight the only thing that by and large will influence your healthcare is your choice of politician.

Please choose wisely but, given the recession, regardless of the outcome things in healthcare can only get worse. It is not much of a choice but it is still a free choice that we can, if we choose, exercise.

Praise be to the Party for finally giving us real choice.

Tomorrow will tell us our choice but today we shall go to work as usual with a slight detour at some point to put an X in a box.

Snow in Northernshire some practice points.

Snow is white rain or frozen water that falls from the skies under certain atmospheric conditions. In terms of its impact on United Kingdom there seem, based on our cumulative experience here at ND Central, to be certain patterns that occur each time we get a bit of the white stuff.

The first is when more than a centimetre or in old money about half an inch falls in an hour or so all businesses shut up shop and decide they have to drive home. In doing so all roads become congested and traffic grinds to a halt.

Full surgeries result in no more than 3 patients turning up in 3 hours and local politburos whose function is vital to the smooth running of the NHS shut up shop too and vanish.

We here in GP land wait until the last patient is due to have left and then spend 4 hours in traffic doing the normal half hour commute.

The next 2 days virtually no-one ventures out, local PCTs declare public holidays for all their staff for increased efficiency while GPs open and most staff manage to get in after the first day of disruption. Initially few patients turn up and home visits decline to almost zero as people realize that they can’t get out so their GPs can’t in either as opposed to the normal GP visit request of we can get out but can’t be bothered.

Surgeries experience new hazards.

When one walks into reception it looks like it has been a convention for incontinent geriatrics as in front of each desk is a large, and increasingly larger each hour “wet patch”. The entrances to the building look like a rugby team after 8 pints of lager has decided to let rip in the same spot and there is an even bigger wet patch that squelches under foot and water is visible either side of your boot. And that is with the extra carpet on top of the wet patch to absorb the water deposited by all the patients’ footwear.

Footwear also changes with most now wearing Wellingtons. For those of us that have to do visits a good pair of Italian made mountaineering hiking boots capable of taking crampons combined with Yeti gaiters are essential for visits off the main roads where the hazards of compacted snow and ice and a foot of uncleared snow present the combined hazzards of slippage and very wet trouser legs (well you did ask!). One does not wish to land up in A&E as a GP wearing a pair of normal leathered soled shoes in these winter conditions as we can hear the laughter now.

The interior of the car after a few days develops a new damp odour due to the deposition of snow from boots and the daily commute starts with 10-15 minutes of clearing any new snow off the vehicle and de-icing the windows on the outside and increasing removal of water vapour from the inside before one can safely drive off.

Although the practice has grit bins these empty rapidly and soon grit becomes unobtainable.

As the roads become clearer surgeries start to become full again and visits increase although the hazards do not disappear once one leaves the safety of the main gritted routes. Taxi trips increase as people cannot get their own vehicles out and although a lot of people do walk some fear the risk of falling on iced pavements outweighs the cost of the taxi fare.

Examinations take longer as patients arrive looking like suburban Yetis in increasing numbers of layers and bizarre South American woollen headgear to protect them from the bitter cold of the walk from the house to the car and then the second exposure to the Arctic conditions from the car to the surgery.

In rooms with poor heating electric fires appear in order to prevent the occupants’ hands turning blue during the course of a surgery and the sight of patients in Yeti wear recoiling from the first touch of real cold from a doctor’s, or nurse’ hand which has been in the cold for more than a couple of minutes.

One of us went to a local hospital yesterday and made a very pointed observation that while the local supermarkets. which don’t charge for parking. had managed to grit and clear large areas of their car parking space the hospital had only cleared a small part at the front main entrance and, despite charging for parking, had done nothing to clear the roads or parking areas.

We did note that they were starting to put some grit down using a makeshift hopper on the back of a van but we suspect this will have little effect on the 2-3 inches of compacted snow and ice that had developed after several days of no treatment. The local shopping malls’ car parks were snow free oasis and well gritted by contrast and still they offered free parking and make a profit.

People have been so much nicer too. One of us was helped by a complete stranger to dig a car out after we had to abandon it on the first day of the snow. We were digging away merrily on our own when suddenly a second shovel starting working. Neighbours have been helping people with their cars too. A patient told us that most of the residents of their close on a housing estate, 9 in all, came out to help an ambulance that could not get up onto a main road for 20 minutes.

So here are a few thoughts and observations from the winter wonderland that is Northernshire at present. Hope our readers wherever they are in the world are enjoying their version of our winter wonderland. And some forecasters are predicting up to 2 weeks more of this.

We will cope we have done so before it just makes life a little harder that is all.

Praise be to the Party and all its wise managers who will be coordinating the war on winter with the same efforts used to fight the deadly swine that is the ‘flu. We are in all in such good hands.

Right checklist: boots, gaiters, crampons, ice axe, shovel, window scraper, rope rucksac with emergency kit, snow chains, lashing and lashings of Kendal’s mint cake, flask of warm cocoa and most importantly, for emergency use only, the hip flask and its off back to work we go . .

Something for the weekend sir or madam?

Za Nu Labour’s NHS for the old this Xmas.

This week, having had to dig ourselves out of snow at ND Central to get into work while on call, an hour of hard graft with a shovel followed by another hour’s worth of driving on congested roads, we encountered one of the many benefits of NHS reforms for the worse.

We will call it the rotating door of being old.

During our professional lifetime the population has increased by 10 million from 50 to 60 million, got older and more debilitated. Despite this the Party has ensured a decrease in resources to cope by decreasing hospital beds by possibly a 100,000.

Hence, in a grid locked Northernshire town in winter, due to 2 inches of snow, the local hospital discharged a patient who could not walk, lived on their own and was incontinent all of a sudden. The patient was admitted to hospital by us the day before in the exact same state.

Today we had a call to visit the same patient who could not walk, was still incontinent and lived on their own and who had not moved since their early morning discharge from a local hospital funded by a “world-class” PCT.

Lots of lots of phone calls from local care agencies insisting on a home visit.

There was no need. Care in the community could not cope. This was a direct failing of centralized NHS control and pressure on less hospital beds with more elderly needing to use them.

The patient needed care. This was being compromised by prats.

Some were talking Mental Capacity issues who were afraid of doing anything quickly for fear of impinging their “client’s human rights” (like being able to go to the toilet or walk without a carer) versus a patient’s need for acute hospital care.

Other prats, called “modern” matrons, aka work avoiding administrators incapable of do any real nursing, were trying to clear (sorry “manage”) hospital beds and bouncing anything that flickered an eyelid back home as by doing so they had passed a mobility assessment.

More elderly = more illness = more dependency leads to less beds = more care in the community = less resources for an aging and more dependant population. A classic success story unless you work in the real world and see its inevitable failure.

Net result: an old, incontinent, immobile biddy sitting in chair and admitted to hospital, assessed and returned to the same chair as the same old incontinent biddy sitting in a chair came from. Clearly 12 years of bringing the UK health expenditure up to the rest of the European GDP expenditure has achieved what?

The same but worse. Care on the cheap and the crap.

This will get worse and winter has not yet officially begun according to the Met Office but the Thickerrazi are hard at work blaming everyone and ignoring the one person that should be sorted by all of their ever increasing numbers.

The patient.

We wish this were just an isolated incident but we will each here at ND Central see several this winter. All will request home visits for patients who need hospital care but have been denied it. We used to visit but this is increasingly a complete waste of time as all you do is see the patient in the same state you saw them in the day before, unable to cope and needing care in a hospital.

We just sent the patient straight back in via A&E and via 999 ambulance to avoid talking to the bed managers who had already refused social services request to readmit the patient. Not the best use of resources but at least 2 lots of doctors (A&E and medicine) will look at the patient and hopefully one of them will realise that the patient cannot manage at home. It is usually easier to get into hospital than to get out (unless there is pressure on beds when the reverse applies).

The managers will not see this pattern as they do not see patients. They will see increased turnaround of patients in terms of admissions = income but will chastise GPs for 1) increased use of ambulances and 2) increased use of A&E services.

Such is the “joined up thinking” of current NHS managers they fail to see that early inappropriate discharge of patients actually leads to more expenditure and harm to patients.

They, however, do not see real patients only spreadsheets. They have tunnel vision and see only that early discharge saves money via the NHS Tariff whereby if old bid is admitted with a condition with a “trim point” * of 10 days for say £ 3,000 then 24 hours in a hospital = 9 days profit and a double whammy as there is an A&E Brucie bonus and a new admission tariff as well.

*(Our understanding is that the trim point is management speak for number of days a patient can stay in hospital for a given condition).

They will be wetting themselves with excitement in the same way that our patient was wetting themselves in their chair. All that profit and all that patient experience of the new improved “world-class” NHS.

Praise be to the Party and welcome to the “world-class” Northernshire NHS. “World-class” it is not unless crap is now the “world-class” NHS.

Plus ca change plus c'est la meme chose? Plus ca NHS change plus c'est la meme malhereuse chose?

(With apologies for our poor use of French.)

NHS “Consultation” and Parking.

When most people use a market they pay for a service.

For example, if you go to a shopping mall you pay for what you buy and you park for free even if you don’t buy anything.

Compare that with the current NHS “market” where the service is provided for free, namely your treatment, but “co-payment” link is not allowed so hospitals can continue to charge you for parking, television and phones for patients but comrade patient your treatment, whatever that is, free.

All the above are examples of the current NHS internal “market” which costs each of us a fortune in taxes but delivers no real healthcare benefit which is what the NHS is supposed to be there for – real healthcare, for all.

If you have paid taxes you have already paid for your treatment, already paid for the hospitals and already paid for the car park to be built that you are now being charged to park in.

If you go to a shopping mall the private sector have paid to build it, have paid to provide parking, provide parking usually for free and make a profit.

The NHS “market” struggles to break even.

So imagine our joy when we heard that our beloved health secretary, Andy Burnham, say there will now be an eight week “consultation” regarding NHS parking charges as they had “caused great resentment” to “ensure that plans were affordable at a time of pressure on NHS finances”.

No way man, surely not? Andy Burnham, the only politician in touch with the people after all these years.

What joy! Another NHS consultation which means they have already made up their minds and want a public “consultation” to rubber stamp their plans.

Parking charges are the only part of the NHS “market” that works i.e. makes a profit from a small initial outlay to provide a “service”. In this case the “service”, namely screwing the public and its own staff to pay for the privilege of using something the vast majority of them have already paid for, is now to be “consulted” about. Great.

Praise be to the Party for shopping malls. Parking is free, we usually get what we want on the first visit, and, apart from Christmas, there isn’t usually much of a wait.

Why hasn’t the NHS “market” done the same? Still after more than 12 years of both Parties charging for parking and talking markets at least someone has the decency to “consult”.

Don’t hold your breath too long. We are in a recession after all and 8 weeks on the National Debt will have grown some more. Anyone guessed the outcome?

Tales from the Outpatient Gulag – an update on current “world-class” cancer care in the UK.

Earlier this year we wrote about our experiences regarding cancer care in the UK NHS for an older relative.

The surgery was a success and so was the reconstruction needed for our relative and they were very pleased. They were particularly impressed by the consultant who did a whole day’s work and had almost got home when a complication set in and they returned for another working day, this time in the evening and early hours to ensure a successful outcome. The following day they spent another 6 hours in theatre in ensure a successful outcome not just one consultant but two both surgeons.

Unfortunately in the recent past our relative has developed pain in one of their limbs which might, or might not, be due to a possible recurrence.

For those of us with the benefit of a first world education the investigation of this pain would have been simple and would have required initially 2 different types of scan of 3 different areas of the body in order to determine any possible cause and determine treatment.

However UK healthcare is no longer world-class it is “world-class” a throw away expression beloved of NHS managers and politicians to try and convince the public that crap care is something else other than crap. In this instance a world-class healthcare system would have done 3 scans in a morning seen the consultant with the results and sorted out a treatment plan based on the results. Simple.

Now the NHS does not do simple but it does do bureaucratic, institutionalized incompetence par excellence so how many scans do you think our relative had and how long did it take to get them? Have a guess.

Well in the end it was a total of 6 scans instead of 3 in a morning spread over 6 weeks. Of the 6 only 3 were actually needed the other three were “mistakes”.

No doubt the local Thickerazzi will say well you got scans what more do you want?
The right ones, quickly, perhaps?

Of course not comrade, the “market” will not allow such over production. One tractor per week is your lot comrade. Take it or leave it.

This is the response of the ignorant who know nothing of medicine until it affects them. Those of us with the misfortune to having been using the relevant scans 25+ years ago expect people in the 21st century to be using them better than they were then but having scanners is not the same as having the ability to use them properly.

The results (eventually) suggested the clinical diagnosis (which is that of doctors based on history and examination alone) that there was a recurrence. The recommendation was for further chemotherapy something our relative dreaded. Two options were outlined one less aggressive the other more so. If you have ever had the misfortune to have had chemotherapy then less is better so this was opted for.

By now our relative had had enough of “world-class” care and transferred to a local teaching hospital, still relatively in the Dark Ages, and their scans were seen and a further scan PET (Positron Emission Tomography) scan suggested.

This type of scan has been available in some of the more forward thinking teaching hospitals in the UK but not in Northernshire until recently. In the same way that consultants with a first world training would ship patients 30 years ago down South of Northernshire to get CT and MRI scans today’s first world graduates struggle to do the same.

Our relative was greatly impressed with their PET scan for they were treated as a human being for the first time in weeks at a private installation but paid for by the NHS with the only wait being a weekend (by chance only). One scan was requested and only one scan done.

Now remember dear reader the diagnostic delays due to more scans than needed equalled weeks of delay and uncertainty (did we mention pain and fear as well?) and on the advice of the oncologists our elderly relative wanted to go to a social gathering which they felt was OK and so the chemotherapy was differed for a further week or so.

Unfortunately the sudden development of the inability to properly move a limb revised all these plans considerably. The tumour had invaded the nerves that supplied this limb and reduced its usefulness considerably. The oncologists were contacted, seen the next working day and IV chemo was now considered more appropriate.

Praise be to the Party for dumbing down medicine to the point that even local consultants cannot logically determine how to scan a cancer patient and for the systemic incompetence that means 3 scans in a morning equals 6 scans in as many weeks. Still our relative lives in a “world-class” PCT so should expect, and get, no more than this.

And they did.

Licence to kill? We busy doing nothing . . . .

For most of the British public the decision of the General Medical Council to introduce a licence to kill, sorry practice, will be of as much interest as a parson’s burp on the island of Tokelau.

In summary the GMC (all praise to them for whatever it is they do with our 410 sovs (or £ 410) registration fee a year has decided that you can now as a doctor be:

1) unregistered but useless = cheapest
2) registered and unlicensed = expensive (£145) and useless
3) registered and licensed = more expensive but able to work as a real doctor so possibly on balance a tad useful for those that earn their living this way.

An aside dear reader regarding option number 2, if you are desperately lonely or bored have a look here at question number 4:

“Holding registration without a licence allows doctors to show to employers, overseas regulators and others that they remain in good standing with the GMC.”

We like that phrase “good standing with the GMC” it reminds us of showing “respect” in The Godfather movies. An intersting turn of phrase for having paid their (reduced bung) registration fee. But enough and onward that was the boring but an educational bit for our readers over with now onto the real point of this post.

The date for being licensed was 16 November and if you ever visit the GMC website and some of us do mainly to check if dodgy doctors who are working are actually registered you will have read, assuming you are able, a note saying that after the licensing date this information will appear on the GMC website for free, gratis, nothing.

With us so far?

So if you want to find out if a doctor is registered, licensed and therefore legally able to practice do you know how you may be able to find this out?

If you cannot work this out we suggest you leave now and enrol in your local junior school for the start of a lifetime’s education that you have missed. Or work for the local Politburo they need class acts like you and it is a job for life.

A good 6 weeks before the LEGAL need for a licence an elite branch of the local Thickerazzi sent a letter out locally to each GP asking them if they:

1) had applied for a licence

and

2) would the doctors send them a copy of the letter saying they could have a licence.

As with all the important and highly useful Politburo requests there was the usual “urgent” deadline. Vitally important as any employee of a local Politburo has to finish work by 13.00hrs every Friday. What they do the rest of the working week is a complete mystery.

In other words are you still legally able to practise medicine now (yes we don't need a licence) and more importantly WILL you be able in a few weeks time when licensing comes in?

This was so that the local Politburo could ensure that all the performing seals on the local Politburo’s (GP) “Performers’ List” were able to practice medicine with a licence that you hadn't got, didn't need and was not legally needed at the time of asking .

Well done comrade managers we are sure you will have had a triple vodka and caviar for this completely wasteful use of public money and a waste of GP time to achieve what?

A list of doctors who may have a licence to practice medicine a few weeks before they are legally required to do so?

And if one of them had been struck off would they still be on the Performers list when licensing comes in?

Several of us here at ND Central found that due to our age we could not remember if we had applied for a licence, or if the dog had eaten the letter for the licence, or if it was in the back pocket of our jeans that went into the washing machine. Still if you are senile you can still be on a Performers' list as long as you send your letter in.

Given what we said would it have not been cheaper for one NHS comrade manager to spend an hour on the GMC website when licensing was ACTUALLY introduced and LEGALLY required to ensure that the performer’s (seals) list was UP TO DATE?

Of course not comrades, as any Soviet system has full employment of comrade workers busy dong nothing. They are not that bright. What are these people doing with our money and more importantly what do they actually achieve?

Nothing perchance? You decide this was not made up.

Praise be to the Party who protect the Public from “dodgy doctors” by squandering the Public’s money on useless exercises in incompetent bureaucracy.

What will they be asking for next?

Doctors’ death certificates from all those currently employed by the local Politburo to enable them to plan workforce requirements for the next century? Jest ye not, it might be next, dear reader given the current state of NHS Management . . .

More Education, Education, Education? Medicine and Education a few parallels.

While driving home earlier this month a few us “customers” of state funded education heard that the Party feel that parents who “cheat” should be penalised for advancing their children. When we say cheat we mean trying to get their children into the best schools. Not too long ago the Party felt that co-payment should be verboten and so we here at ND Central started to note a few parallels between education and healthcare.

No surprise here given that one of us at ND Central was a victim of the “Old” Labour Party educational policy which dictated that all comrade serfs’ children, regardless of their ability, should be downgraded to a Party sponsored education, called comprehensive schools.

At the same time that the Old Labour Party elite, sorry they were called MPs then, who were the “true socialists” in those dim and distant days, felt it was totally acceptable for their children to be sent to Public schools (no doubt on MPs’ expenses). At that same time they, as parents, sorry political commissars, insisted that other parents’, their serfs’, children should be given the same “choice” that they had and given a true Soviet equalitarian comprehensive based education as opposed to a State funded (via MPs expenses) private or Public school education.

Such disadvantage is continued in this country in the course of “socialised medicine” and “socialised education” so that any black, inner city child with the intellectual ability to be a doctor will be denied a chance of a decent education, not because of race sex gender etc for these forms of discrimination are now outlawed, but because they live in the wrong street and because their parents cannot afford it.

This is fundamentally wrong.

Ability should be fostered, rewarded, encouraged and not penalised. A poor child who becomes a doctor will more than pay for their education via taxes (we estimate about 70% of their income per year will go to the State if that child becomes a GP) and the admission of people from various backgrounds will help enrich medicine by providing a rich vein of social experience as well as intellectual excellence and ability.

It was the same 30 years ago that one of us experienced “socialized education” but manage to rise above it even though it meant leaving the shores of Northernshire to experience true world-class education. Things are worse now due to the numerous reforms denying advancement via education to those gifted and the need for a large financial input in order to afford education. And that is if you have to live in the right area with access to good schools to start with.

Remember that everyone in the UK pays for state sponsored education and medicine via their taxes but not everyone gets a decent education (or healthcare) despite paying for it.

Given the “market” economy so beloved by the current Party Commissars in healthcare surely the fact that schools that are popular should mean that the money follows the patient, sorry pupil?

Oops we think there may be a cock up there. We think there may even be a slight “market” cock up here? The ZaNu Labour “market” theory would dictates that the consumer, the taxpayer, would have choice. We pay our taxes (our money as customers of the State) we want to go to school X or hospital Y.

Doesn’t work fellow comrade workers as the Party, all powerful, dictates your “choice” of healthcare (via “Choose” and Book run by the local commissars at the PCT), and your education (via local commissars at local Councils), in the same way it denies your children Blair care and Blair education using the well known Socialist Principle of all Gordons and Tonys are equal but some are more equal than others.

So No Joe the Plumber care here in the UK. No Joe the Plumber education here either. But Joe the Plumber (UK) works in a real market and charges what the hell he likes and gets his healthcare for free and knows his rights. You dear patient, or parent, operate in a true Soviet, or “socialized” market called the health service or school system. You can have any “choice” of school or healthcare as long as the Party approves.

Dissent, try to use your nouse, money or private healthcare and the Party disapproves and you will be penalized. Try to get your child into a good school and the Party will get you. Try to get your patient to see the right consultant and the Party will get you.

Old and Za Nu Labour are the same Party separated by a few decades but some of the names and most of the ideas are the same bar some mild tinkering with words and ideas and suits replacing donkey jackets.

Anyone see a headmaster refusing a Prime Minister’s child education based on his address? Doubt it but it is not the same for you or I comrade? We don’t get Darzi care when we are ill we get whatever cheap crap the people in the lower streams of a Northern comprehensive think is right for you based on their huge inability.

For some of the people running local healthcare now weren’t bright enough to hack it in the private sector or get into a University or medical school. They went into NHS management after failing several times in other jobs first.

Clearly in this respect Old and New Labour have succeeded. Don’t foster and encourage ability penalize it. You get what the Party provides and it is presided over by the least able of all, the NHS manager. The ones we know of were in the bottom third of a mixed ability comprehensive school in a large Northern industrial town.

Try to do better and you are penalised either financially by having to pay for better healthcare and education, or by the State denying you better care or education, that you have paid for by taxes and taking you to Court if you try to better your child.

So much for the every child matters agenda and the Children’s Act putting the child’s interests at the centre of any decision making process. So much for the mantra of “education, education, education” so often quoted from a former Party leader.

Education is the current way to advance oneself in our society and it should be provided on the basis of merit. If a child from an inner city school has the potential to be the next Einstein is recognized he or she should be sent to the best schools locally based on ability not location. If that child’s parents recognise this fact they should be encouraged in the same way that if they wanted to see a better surgeon at another hospital for a particular condition rather than a less good one locally they should be given real choice to do so.

Praise be to the Party who provide “choice” as a word but not as an option. Thirty years ago choice was limited in education locally but in healthcare it wasn’t. Now both are limited more than every before and more “choice” is in fact less.

No wonder the Americans are worried. More management means less progress and choice. Pay more get less. More Choice anyone?

Regardless of the politics who loses? The patient and their kids.

NHS Flu Resource Desk. A vital component in healthcare in a “crisis”?

The world’s best prepared country to counter swine flu has just got even better. One of our team, the on call doctor no less, went to an “emergency meeting” to brief local GPs about how the plan is coming together even though it should have been seamlessly rolled out due to the advanced knowledge of all those involved in its implementation like we GPs on the frontline.

We were told that there was a Flu Resource Desk that had been operating ever since the pandemic was declared. This would cease its vital and well valued operations when the Flu Lines opened on the 23rd of July somewhat earlier than October when they were expected to be available so no panic here just excellent forward planning by the Party.

Flu Resource Desk? Must have been a closer guarded secret than the Manhattan Project but even the Russians knew about that one and they were several thousand miles away before the Internet. How come despite Connecting for Health we did not hear about this valuable resource?

Their exact terms of engagement are unknown locally and whether they could issue Tamiflu prescriptions is also unknown. But nonetheless it was there and with the advent of the Government’s Flu Line Service the “excellent” local planners who set it up can now shut it down happy that it has served its purpose. Whatever that was?

There will now be appointed by the local Politburo thickerazzi a group of 4 wise dickweeds, sorry Party stooges, sorry wise GPs (remember here in Northernshire we have more GPs than we ever need and that was before Lord Darzi) to ensure that the local underworked, overpaid GPs have come up with a contingency plan or sorry “a business plan” to cope with the Flu pandemic.

So taking 4 local GPs from a heavily “over” doctored area out of medical practice to individually visit practices and check that they have a flu crisis “business plan” is an efficient use of resources? What about in under resourced areas?

Now tell us dear reader, if people do not pay to use a service is there any need for a “business plan”? Or is it NHS failed management speak for we have a problem Houston get us out of it. Lets pretend to do something (useful?).

Listen up soldiers while managers have to develop business plans we just have to cope. Did their flu plans and flu “crisis” plans offer any help to us when every Tom, Dick and Harriet who was mildly unwell decided to phone their GP?

NHS managers flu plan = panic.

GPs flu plan = cope as best you can even if you are ill yourself.

Some more observations from the frontline of the phoney war against Swine flu which is still a relatively mild and self limiting illness in most people who have it although a small number will die. More will die on the roads each day at present. Should we be panicking about this and ringing our local Volvo dealers for their toughest tank just in case we have to go on a car journey?

Praise be to the Party without whom we would never have coped. They did so much to generate a crisis when there was none and so little to help with the problem they created. The grunts just worked on.

If the big one happens this winter we know we will be able to cope don’t we? 1919 the sequel, if it happens, will just be a re run with a few minor plot changes for example 1919 no intensive care units, 2009 no intensive care beds. And so on.

Salve Medice. Latin a dead language? Long live Latin!

We at ND are quite proud of our collective life experiences in various parts of the medical, social and wider world(s) which we share with each other.

We believe we have a “skill mix” to “support and foster” the “primary health care team” and “its diversity” so lead us to a “gold standard general practice” with “equitable access” in Northernshire and hence provide “world class commissioned services” that involve the patient at every “key decision” on their “patient journey” to “empower” them to make the right “ NHS choice” for them and their family.

OK let us cut the bull and come to the point we do after all live in the real world of NHS General Practice.

One of the old fart school of medicine among our team went to a Northern state school where they were taught Latin by a teacher called Big John. This was a few decades ago and while Latin, like any language has different forms, for example medieval and ancient our team member had not used it since pre grunt training.

Imagine our collective response when this “well” educated member from the Northernshire state school told us that they had been presented with an MRI scan by a patient from an Eastern European country formally part of the Soviet Union. The patient had in broken English said:

“I have this report which you will be able to read . . .”

They then presented the MRI scans and the report to our team member. The scans we could have a guess at given our training.

The x-ray report, however, was typed in Latin in an Eastern European type font!

Titter ye not, it's wicked to mock the afflicted! Well it might be one of your own!

A first in Northernshire for the team!

Anybody else know better?

Praise be to the Party for Latin x-ray reports?

Thanks to teacher Big John all those years ago for allowing us to translate it and for our team member who had worked in an area of the world that had MRI scans many years before “world class” commissioning PCTs thought these might be useful for doctors. They were able to interpret both the scan and the report without using a language line.

The Party continue to use a modern variant of Latin and teach it to their managers which is why few understand a word they say. Bit like the Catholic Church in the Middle Ages before the Reformation? Use an incomprehensible language to confuse the peasants and maintain power via fear and ignorance?

Therefore it is back to the books: Grumio est in culina . . .

A Tale of Two Worlds

A previously healthy woman notices some shooting pains down her arm and thinks nothing of this as she has had them intermittently before and they have gone off after a few days. One morning she gets up and find that her arm is not working properly in that she cannot lift her shoulder up or move her elbow but can move her wrist, hand and fingers.

Thinking that something is wrong she rings her family physician, Doc Northern MD, and is seen that afternoon. She consults with her family physician who talks to her, performs an exam and suspects that she may have a disc in her neck pushing on the nerves to her arm.

Doc Northern rings the local neurosurgeon who sees the lady the same afternoon and arranges a whole series of tests including a MRI scan of her neck. The scan reveals no disc problem but further tests on her nerves reveals that she has a condition called mononeuritis or inflammation of a nerve that affects its function. It should recover given time and help from a physiotherapist. The neurosurgeon passes his patients care on to a neurologist whom she sees the next day and he then arranges further follow up and treatment.

This is a tale from one world. Let us though the wonders of imagination now travel to another world and start the story again.

A previously healthy woman notices some shooting pains down her arm and thinks nothing of this as she has had them intermittently before and they have gone off after a few days. One morning she gets up and find that her shoulder is not working properly in that she cannot lift her shoulder up or move her elbow but can move her wrist, hand and fingers.

Thinking that something is wrong she rings her GP, Northern Doc, to ask for an “emergency” appointment but there are none. All the emergency appointments are now “open access” and not limited to emergency only consultations and so are taken by people needing contract review appointments to ensure that their GPs will get paid.

She then attends the local A&E department, something she shouldn’t do as it costs too much according to the local commissars, where she is seen by a junior doctor who tells her to go and see her GP as there is no neurosurgeon at this hospital. The A&E doctors cannot refer direct to a neurosurgeon as it is not an emergency and therefore the neurosurgeon would not get paid under Payment by Results as it is a consultant to consultant referral (rather than a GP to consultant referral which will lead to payment).

A few days later she gets to see her GP “as an emergency” (something she was loathed to do as she does not wish to abuse the health service) who talks to her, examines her and suspects that she may have a disc problem in her neck. Her GP, Northern Doc, knows she has been to A&E and not been referred to a neurosurgeon because of funding issues.

Northern Doc could refer her by Choose and Book but the local neurosurgeons do not use this system. They like to screen referrals to prioritise referrals themselves rather than see non urgent cases first if they are booked by Choose and Book. Any paper referral would take days or weeks and the only other option would be a possible emergency admission to a far distant neurosurgical centre which the patient does not want because of family commitments.

Therefore, the doctor and patient decide to go for a private referral direct to a consultant neurosurgeon a couple of days later to ensure a prompt review by an appropriate specialist and circumvent the management structure that delays health care called World Class Commissioning.

The neurosurgeon admits the patient straight away and does all the tests over a couple of days that reveal inflammation of the nerves or mononeuritis as the cause of the lady’s problems.

He refers on her onto a neurologist who tells her what the problem is that she will need follow up including specialist neurophysiotherapy which he then asks her GP to arrange (to ensure that funding for this specialist service is preserved) as his referral was from a consultant not a GP.

She is discharged and goes to see Northern Doc to ask for the physiotherapy.

Northern Doc asks his secretary (for GPs in the UK rarely have enough time to use the snail like computer system that is Choose and Book) to try and arrange a neurophysiotherapy appointment.

Northern Doc’s secretary hunts high and low but can not find the hospital where the patient was treated on the Choose and Book system as the local Choose and Book Commissars will not allow this service on their local Politburo controlled Choose and Book system.

They do allow several local tractor plants which claim to offer neurophysiotherapy but the GP knows that these physios at the tractor plant know nothing about neurology. They cannot recognize worsening paralysis in patients they treat for bad backs, in place of real orthopaedic surgeons, who are too expensive for local management commissars to allow local GPs and their patients to use them.

After a long time trying to use the new and improved Choose and Book system, which just shows what is available, not its quality, the dedicated secretary rings the hospital where the patient has been discharged from to ask if they know where to refer the patient to?

She speaks to several people who know the department exists and is eventually told to send a paper referral to the physiotherapy department who will sort it.

After 2 weeks the department phone and say because the patient does not live in the same town as the hospital they cannot have this service even though they have been treated at the same hospital and there is an alleged National Health Service.

This is the tale of two worlds. The first 3 paragraphs detail what would happen to the patient in any first world country and it does as our patients tell us their tales of illness abroad or how their (and our) relatives get treated overseas.

The susequent paragraphs (14) relate the second world's story of the "patient journey" (=management speak for treatment why use one word when 2 meaningless ones will do?) in the wonderful world that is local NHS World Class Commissioning one of the (alleged) best in the country.

If your arm did not work one morning which world would you like to live in?

Praise be to the Party for the wonderful world of World Class Commissioning the 21st century equivalent of the Youth Opportunity Program (YOP) from the 1980s. Jobs for the otherwise unemployable and an artifical bureaucracy serving no useful purpose than preserving its own existence.

Welcome to the fourth world that is medical care under the current NHS in Northernshire and this is not a made up story. We really wish that it was but it isn’t.

The patient is still waiting and getting worse with each day of World Class Commissioning in action. Perhaps they should go private but then is that not what the Party wants?

Can they afford to? No, so they continue to worsen despite paying their taxes.

And our heads are sore from banging them against the brick walls of institutionalised management incompetence.

NHS Dentistry a report

A while back we did a post about the fact that the Party thought there might just be a tad of a problem with NHS dentistry as after their new Party NHS dentistry contract came in at least a 1 million fewer people were registered with NHS dentists. This isn’t usually a problem if you are a caring Party (as it costs less and is therefore prudent) until pictures of people queuing to register with newly imported (from the EU) NHS dentists were a little embarrassing given their successful dentistry policy and a certain Mr Blair’s pledge of NHS dentistry for all within 2 years in 1999. We are still waiting 8 years later.

Unusually for the Party we noted that rather than employ an Armenian born Irish trained surgeon to reform NHS General Practice they would employ a UK born and trained dentist (albeit Scottish trained?) to tell them what they had done wrong. Professor Jimmy Steele has now published his report.

We are sure that like most GPs who used to see a couple of dental emergencies a year pre Party reforms but now we see anything between 2 a month to 2 a week all saying they cannot get to see a (free) NHS dentist or asking us to refer them to the hospital for (free) NHS dentistry because they cannot see a (free) NHS dentist.

If patients are to be believed no NHS dentists are taking patients on and there is even a waiting list to see private dentists. If you get on a private dentists’ list you have to take out a monthly private dental insurance to stay registered so local golf club car parks here in Northern shire are now filled by NHS and private dentists rather than industrialists.

(An aside dear reader. If the same happened in general practice and we kept our current list size and you were charged £100 a year for registration we would earn as much as we do now without doing any work. Charge for treatment on top and we would be doing a dentist and earn more than we do now! It has worked so well in dentistry why not do it for general practice? Then we could join a golf club and find out where all the missing dentists are!).

However the Party has provided a new free accessible NHS Dentistry service called NHS General Practice. In the same way that they can replace real doctors with nurses at NHS (re)Direct they can replace real dentists with GPs.

This is done in the same way that witches were condemned to death in the Middle Ages using the sink or swim principle.

If you chuck a witch into a pond and she sinks she is innocent. If she floats to the surface she is guilty and is therefore burnt at the stake for surviving. Either way she is dead.

The Party applies the same principle to NHS dentists. If you cannot see a dentist you approach your local PCT who are responsible for providing NHS dentists which they don’t. They cannot do so and so they send you to NHS (re)Direct who will tell you to see your GP.

If your GP fails to treat you then they can be penalized for failing to give immediate emergency treatment even though GPs are not qualified dentists. If they decide to treat you, based on their lack of a 5 year dental course and dental qualification, and something goes wrong they can be sued. Either way you are stuffed as a GP like the medieval witches were.

Let us look at some bits of the report as heard on the BBC while we drove home through the now pleasantly warm but thundery Northernshire.

The main thrust of the report seems to be a move away from a payment for completed treatments towards a payment based on registered patients. One of the big flaws of the current contract was that payment was made only when a treatment was finished. A filling is quick to do but corrective orthodontics for children may take years before it is finished and you get paid. So a lot of dentists doing this treatment had no choice but to go private. A lot of dentists did corrective and cosmetic dentistry which took time and so went private as for some reason people like white teeth.

Hence quick and many = money. Long and slow = waiting ages for money.

Furthermore the number of treatments was fixed by the Party and it managers who are so good at predicting illness while they work 09.00-17.00 Mon-Fri and 11.00-13.00 Fri so once you had done your Politburo quota no more money which meant some dentists stopped working for a few weeks/months in a year when they had done all the treatment they were going to be paid for. If you are doing nothing for the NHS you may as well go and do a little private work in that down time and get paid for it. Central planning at work again?

The report suggests piloting change before implementing it. Now that sounds sensible as long as the pilots are real dentists and not heavily subsidised Party stooges. Not entirely in keeping with current NHS top down Soviet centrally managed one idea suits all. Of course the report is accepted in principle by the current health secretary which means it may not be turned into practice or ignored by any future Government which actually started the rot of NHS dentistry.

More worrying is the fact that administration may get more complicated as instead of 3 bands of payment there would now be 10. No prizes for guessing what that means in practice? More administrators to manage a more complex payment system?

Interestingly there is a guarantee that any dental work that fails within 3 years would be replaced for free. It would appear that the current system encouraged second rate workmanship presumably because failures could be charged to repair the “fault”.

Praise be the Party for succeeding in increasing NHS dental provision for all those who can afford it and for its report which shows how well it has succeeded and the way forward?

We shall see but meantime we will continue with NHS GP Dental care = antibiotics and painkillers, try and see a dentist and we’ll keep our fingers crossed nothing bad happens to you.

A new form of stimulator?

While reading one of the GP rags we noticed a very small article about the development of a Practice Based Commissioning (PBC) simulator. Now some of us here on Northernshire enjoy using flight simulators to help maintain and hone certain skills (mostly long distance navigational ones) and there are even simulators that enable you to design and fly aircraft which have been used to develop real aircraft which got us thinking about what (flight?) model this PBC simulator would use.

After a hard symposium of work at the Café Michelle on the “model” we present an artistic summary of our thoughts above.

No doubt desperate and incapable NHS managers will see the word “simulator” and think that a “simulator” will do a "Jim’ll Fix It for them" and be booking in droves seminars for them and local GPs hoping that something that sounds like a “flight simulator” will encourage their ideas to fly above the plummeting failure that is called PBC.

Some quotes from a more detailed article:

“The Practice Based Commissioning Simulator has been developed in conjunction with the primary care body the NHS Alliance and Swedish-based BTS, a provider of customised business simulations.”

Who?

“Humana Europe said the PBC Simulator combines hand-on learning, including role play and business simulation, with predictive technology in which the conditions and variables of PBC are replicated through a computer simulation.”

Most of our medical students are so peed off with role play that this is a guarenteed turnoff with doctors to start with. They like to see and help REAL PATIENTS and despise role play which is in contrast to managers who constantly pretend they are doing something useful on a daily basis.

“The company, a subsidiary of the American health benefits giant Humana Inc, said the simulator was designed to inspire primary care clinicians and practice managers to improve health and cost outcomes through advanced PBC techniques.”

See above image. Which is the more inspiring? What are “advanced” PBC techniques and do they work any better than the failed “basic” techniques?

“Dr Peter Reader, head of the PBC programme at Humana Europe, said the simulator was designed with the particular skill sets of GPs and practice managers in mind. He added: “Over the course of the simulator programme participants get to see the impact and outcomes of the decisions they make whilst building a greater understanding of the implications that practice based commissioning has on improving health outcomes.”

We are out to make a fast buck out of the suckers using this pile of horse manure.

“By using the resources available to them wisely GPs can empower their patients to live healthily and reduce their susceptibility to disease and in turn ensure that services reach those people with real need.”

Hmmm. So if I spend 4 hours on a simulator we will stop our patients smoking, using heroin, getting fatter and drinking themselves to death? And we still can’t get an urgent MRI scan for a patient with a life threatening condition despite PBC?

“Dr Michael Dixon, chair of the NHS Alliance and a Devon GP, said the onus was increasingly on GPs and practice managers to commission services in an intelligent way to meet the health needs of their patients.”

We could do that but the power is with the idiots called commisioners, sorry World Class idiots, that you are clearly pimping this “simulator” to?

Praise be to the Party who continue to flog a long dead horse in the hope it might get up and win the Grand National for them. The horse is dead let us hope no other fools attempt to revive it in the near future.

Choice gets better in “World Class Northernshire”

ND being a grunt periodically patrols the perimeters of our Practice and talks to fellow grunts and asks how things are going (or hanging). An essential part of maintaining a lean mean fighting machine is identifying weak points in contrast to top down PCT managers which are the major weak point in UK healthcare getting better as they never engage the enemy called illness and never talk to patients or staff. Hence they are all wise (and therefore powerful) as they know not for they see not or hear not.

Today we spoke to our two loyal secretaries who were trying to do their best for one of our patients but were being countered by the “World Class” idiots in a “World Class Commissioning PCT” which boasts that it offers “Choice”. (Not).

The words world class and choice have meaning elsewhere in the world as per the Oxford English Dictionary but in the NHS they are meaningless sound bites which are mutually exclusive and equate to crap health care anywhere else in the world other than on planet NHS. Planet NHS is currently like Moon Base Alpha in the 1970s Space 1999 TV series moving uncontrollably out of any solar system known as rational and good healthcare due to years of huge uncontrollable gravitational forces mismanaging it called politicians and NHS Managers.

Enough of our childhoods for now. Those of you who remember David Hasselhoff, and his part in the fall of the Berlin wall, may know what we are talking about how a once great “Party” gave its people “choice”. The wall came down and these people who were detained behind it now have choice as opposed to “choice” which is that now offered to NHS patients by the current Soviet style NHS management structure.

This is the problem our secretaries encounter when true patient choice is controlled by the Party’s NHS “choice”.

Our secretaries’ problem was that they wanted to do the best for a patient as do we as doctors. Our patient is currently working with an increasingly worsening shoulder problem that if, they can see the right surgeon can be cured, and so return them to being an economically productive person at work and also, as a minor side effect, give them better health. Surely an ideal in a National “Health” Service? One would hope and think so.

The patient had seen their GP who knew what the medical problem was and what the correct treatment was and had discussed NHS “choice” and said Mr X can fix this for you but you need to go to hospital Y which you allegedly can do because you have NHS “choice”.

You see now that we are really good little comrades here at ND Central honest. In fact we offered choice before there was ZaNu Labour “choice” since at least the 70s. But we digress.

The patient has a problem with their arm that might be fixed by an upper arm joint replacement or corrective surgery it is so severe. They can’t lift their arm and so cannot work.

Simple problem you might think, use “Choose” and Book to find a local upper limb surgeon and send the patient to see the local upper arm joint replacement specialist.

Our secretaries tried seeking real choice to look for the locally respected upper arm specialist surgeon suggested by their GP and can find that this local specialist only does hip or knee problems on the “Choose” and Book NHS computer system where “Choice” is determined by local idiots working for the local Thickerazzi.

The specialist is a well qualified and very experienced orthopaedic surgeon whom we know can deal with most orthopaedic problems especially upper limb problems.

So our secretaries refer our patient to see this named consultant and book the patient into a “hip” or “knee” clinic the only ones available for this consultant on the “Choose” and Book computer system knowing that the patient will see the same consultant as these clinics are all that is offered for this expert consultant under the “Choice” agenda even thought the consultant’s main interest is upper limb work.

The referral is rejected because the local Politburo managers want the money to go locally to the local idiot hip surgeon who thinks he can operate on a shoulder but only if you want your feet facing in opposite directions after your shoulder surgery.

The idiot managers also see the word “shoulder” which is a much bigger word than “hip” or “knee” (more than one syllable in fact) and so they don’t understand why the word “shoul” is not the same as “hip” (or knee) and so the referral must be wrong. Instant rejection.

This is acceptable if you are a “World Class Commissioner” but not if you are a patient who would after surgery like to go back to work able to use his shoulder again rather than split his pants every time he takes a step after his shoulder surgery at the local Tractor plant.

Praise be to the Party. Less and less choice with each day that passes as the increased use of “Choose” and Book is used by the idiot managers to manage costs and waiting lists not patients.

How can we correctly treat patients when there is no choice?

The only way we can access this surgeon is to send a paper referral to his secretary or the patient pays to see him privately and then transfers to his upper limb NHS list.

We are not allowed to send paper referrals as these are intercepted by the local referral management center and the patient cannot afford to go private.

Looks like the return of the dead letter drop for referrals will be coming soon to Northernshire. Where are our Harry Palmer specs we feel a return to Berlin is coming . . . ?