Murkeet musings # 1.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Maybe some more murkeet musings to come?

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

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

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

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

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

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

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

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

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

More reductions to come comrades, toodle pip!

Big Brother’s members continues to get bigger.

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

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

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

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

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

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

Improved clinical involvement in commissioning.

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

Stronger patient involvement through shared decision making.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The QraP 6 indicator is as follows:

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

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

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

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

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

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

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

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

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

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

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

Some thoughts on the year 2011 from up North.

Traditionally at the year’s end people reflect backward on what has been and think about what they hope will be. Most humans are optimistic but as one ages in general practice one becomes more pessimistic with each change of Government or “new idea” that comes out of the Department of Health or local PCT.

As GPs we should treat patients. We are trained and able to do so and by and large we do. We are not so dumb that we believe that all those in jails or politicians are saints but overall most people in medicine care and try to do their best to the best of their abilities, their training and knowledge which we know varies from individual to individual and from place to place.

In 2010 the great Marshals NC/DC launched a war of liberation of the NHS something we haven’t quite got yet. It was sold as a “bottom up” liberation as opposed to a “top down” reorganization which has become even before the relevant legislation is passed a bureaucratic quagmire going nowhere fast.

Every GP is in this quagmire to some extent treading water and wasting time and money away from patient care to deliver Marshals NC/DC dream of liberation which increasingly looks like the Red Army’s advance into Eastern Europe at the end of World War 2 looked to those dreaming of democracy in countries occupied by the Nazis.

The “bottom up” reorganization with the clinician in the consulting room being in charge is prevented from doing anything useful by the (non) top down reorganization dictating the rules of engagement (ROE) while the real ROE are still being thought up on the hoof and modified on a daily basis. And that is before its codification into legislation and thereby enforceable diktat.

As a result the real net reform of NHS to date is business as usual at the frontline. A centrally, politically controlled Sovietized medicine of tick boxes that deliver piss poor patient care by ensuring that your GP gets paid to tick patient useless boxes at the expense of treating patients.

Preventative medicine is easier to control and reward. Life saving medicine is acute real time and unrewarded.

As a GP if you resuscitate a 3 month old child successfully from a cardio-respiratory arrest in your surgery or a patient of 45 who walks in feeling unwell who has a VF arrest using a defibrillator you purchased yourself because you thought it was a good idea to have one this is all available to the government for no charge. No box ticked but a clear benefit for the patient.

Do a cholesterol on a stable diabetic/angina patient or a patient with mental illness every year which is normal and requires no treatment and you are rewarded for doing so. One intervention makes a clear difference the other intervention’s benefit is of debatable benefit but rewarded.

Patients want care especially when ill and this is what most of us are trained to do. Increasing they are getting care not for acute illness which is unpredictable and therefore not Party controllable but for Party determined “illness” in the form of boxes to be ticked.

The need for boxes to be ticked to generate income, for we all need money to live, has led to more and more of our surgery time being filled by reviews of well patients and of us seeing less and less illness. Party determined “illness” is taking priority over real acute illness.

This is not medicine it is a retarded bureaucracy of medicine determined by politicians’ needs and not by patients’ real illnesses. It is said if you want to learn surgery go to war. If you want to learn bureaucracy go into general practice.

Praise be to the Party for pursuing policies of reform which are nothing more than command and control of patient care by politicians at the expense of real hands care of patients and their actual illnesses. Commissioning is not about getting good care it is about controlling costs and will be centrally controlled.

A Happy 2012 to you all and to use an expression from one of the teams’ previous lives - stay frosty. We suspect this year in United Kingdom general practice will be a bleak one with every more expected for ever less and even more interference from on high that will not benefit patients - only politicians and their friends.