Top tips from a money saving GP expert.

We thought we might have a laugh and introduce a series of ideas on how the NHS could save loads of money for very little effort and perhaps as a side effect, in contrast to central Party diktats, improve patient care. Here is our first (possibly of a few?) GP money saving expert top tips.

When we were junior grunts the diagnosis of angina was clinical. This meant talking to patients and examining them without ticking any boxes and coming up with a differential diagnosis or list of things that you thought as a professional, rather than a Party tick boxer, the patient might be suffering from.

In the case of angina, classically described as central crushing chest pain occurring on exertion radiating into the neck and down the left arm causing the sufferer to slow or cease exertion and the pain resolves with rest, all one needed to try was a trial of a few pence worth of a drug to see if this eased the symptoms. If it worked the diagnosis was likely and then other more expensive drugs could be added to control the symptoms.

With advances in pharmacology the control of symptoms by drugs was added to by the use of preventative drugs like aspirins and statins. All good old fashion general practice and clinical medicine – simple, cheap and safe.

For more difficult cases, or where the diagnosis was not clear cut, then referral to a general physician or a cardiologist might be required who then might order an exercise ECG or stress test or proceed to more invasive tests if bypass surgery was considered. However most cases could be managed cheaply in general practice.

Such medicine was not considered good enough by the Party who via the QOF (Quality and Outcomes Framework) introduced the “quality” angina framework which if you wish to you can read it here.

So now instead of simple cheap GP management between 40-90% of patients are now expected to be referred to a hospital. Not the minority who used to be referred there but the majority will have to be referred in order to maximize GP income and tick the QOF boxes to show how "good" a doctor you are.

So now for every patient with angina either £ 93 of exercise ECG or £ 215 to see a cardiologist (click 2 Outpatient attendances) will be incurred to ensure that the GP is Party compliant and gets paid. And that is in addition to what was done previously.

If you look here you can see some figures for how many people in the UK have angina. So if you round up the figure to 2 million the costs of treating angina have gone up from a few pounds in general practice per patient to a few hundred pounds per patient if you follow the Party approved protocol.

Our former leaders felt that this cheap and cheerful approach which helped patients was not worthy of those who had not had the misfortune of ever working in medicine and so these wise idiots overnight increased the need for unnecessary investigation of the majority of those with angina by introducing centralized QOF control of medical practice. Even the Party’s tame GP attack muppet does not approve.

This is akin to looking in a field and saying there is a four legged animal with a white fleece, a black face, that chews grass and emits baah sounds and this looks like a sheep. It is indeed likely to be a sheep and does not require further investigation unless you suspect that the 3 foot long creature might be a blue whale in disguise as a sheep in which case far more expensive tests than the mark one eyeball might be required for example DNA analysis to determine if your case of angina was in fact a case of blue whale in sheep’s clothing. Such DNA testing is now required for all sheep by the Party to exclude the odd blue whale out there.

Medical training in the NHS has generally tried to minimize over investigation in order to get a result but Za Nu Labour’s QOF has probably increased over investigation with no discernable benefit in terms of “outcome” but as long as targets and tick boxes are met we know that “quality” care has been given.

Clinical medicine is ever changing and what might be de rigueur today could be heresy tomorrow. Ticking QOF boxes restricts clinical freedom and imposition of centrally dictated “outcomes” and economic control will severely restrict medical advancement and compromise patient care. For if in order to get paid the doctor has to tick the box as opposed to give a patient a better treatment than QOF allows this will clearly compromise patient care as QOF takes time to change.

Praise be to the Party for dictating how we should waste money. This is the sort of thing that GP consortia should be tackling but they can only do this if they come up with some NICE ideas that are Monitored and approved by the Board and its ultimate controller.

So we must now be looking forward to a new GP led free from central control NHS and money saving ideas like this will be so simple to do, won’t they?

The top down noose gets ever tighter.

One of the team saw this little gem on the web this morning. Quite frightening if true for it means that GPs will no longer be able to resist the will of the new Party for they will have to obey its new set of organs the consortia.

Fine if you have enlightened forward thinking intelligent GPs in charge but if your consortia GPs are at best a quarter of a century out of date being led by PCTs who don’t even know the Berlin Wall has come down where does that leave the individual GP? Can you see the GMC being lenient on a GP who cocks up and uses the “I was only following consortia orders” excuse? Didn’t work that well at Nuremberg did it?

Praise be the Party for liberating GPs and the NHS from top down reorganization and Big Government. Things can only get better?

The third of possibly many ways?

A few days ago the good Dr Grumble reproduced an article which pretty much sums up what many feel is slowly happening to the NHS. The Ferret Fancier, welcome back you have been missed by we heathens up North, also commented on the piece. Now there is a phrase called the Third way (possibly more in this process?) and we wonder if this is already happening within the NHS.

Imagine a scenario where a PCT devolves responsibility for a service to a sub section of its staff and puts them in a separate unit let us call it Bletchley Park and runs it for a while. If the PCT decides as a result of “budget constraints” or a “service redesign” it can no long afford to run it what does it do then?

Perhaps it could set it up as a private concern using a variety of guises for example a limited company or a corporation or a federation. This "private" entity could then run the same service while being paid by the PCT and later even have it bid against a “competitor” by submitting a tendor which the PCT would consider.

If this “independent” business entity wins then they hold the contract. All good and ethical business’ practice.

Now consider the state of PCTs which will be disappearing soon. Their staff will be fearful of their jobs. What better way of preserving some of them than by farming out certain services to this “private" sector?

Consider next what will happen when GPs start commissioning. If there are good local services up and running cheaply GP consortia will properly use them rather than go through a long and complex commissioning process.

There is another aspect in that it might be conceivable that the true private sector might want certain services in a particular area and might offer to buy out the “private” former PCT provider.

Look carefully at your own area for this process may already be occurring albeit slowly and by stealth, or as the Witch Doctor blogger puts it by “creep”.

Could it be a case of PCT self preservation by creep and in doing also the selling of the family silver?

Praise be to the Party for giving us the Third Way but where that Way will lead nobody knows. Or do they?

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

Well comrades we are almost at the end of the Great Patriotic White Paper and like all those involved in wars of “liberation” are tired. But we must get up and go onward to the final section where hopefully all the threads and loose ends will no doubt come together as do all NHS reforms to produce a “better” and in this case a more “liberated” NHS.

Whatever that will be.

And so we begin section 6 the "Conclusion: making it happen". Onward to “Engaging external organisations”. Does that mean us as GPs by any chance?

It begins with a statement of the obvious and follows with a statement of the less obvious saying that “It provides clarity of purpose: a more responsive, patient-centred NHS, which achieves outcomes that are among the best in the world”.

Sounds like care on the cheap through an increase in bureaucracy that as we write is still being decided (invented?).

“It provides certainty, through a clear policy framework to support that ambition, with increased autonomy and clear accountability at every level in the NHS.”

Did we miss this bit? The NHS Commissioning Board and NICE giving us all of the above?

For what follows is “Much work now needs to be undertaken over the next two to three years, both to manage the transition, as well as to flesh out the policy details”.

So the liberation of the NHS is not being thought of on the hoof?

Oh no for words like “partnership”, “external organizations”, “ shared decision-making” and “choice” follow. Sound familiar?

More “consultation” follows, always a good way of saying the decision has already been made, and look what they will consult about “. . . on strengthening the NHS Constitution . . .”.

Brilliant! Consulting on something that is meaningless to those grunts on the ground. The NHS ran for decades without a meaningless “Constitution”, aka Charter in old money, while certain countries were founded on one. Compare and contrast anyone especially when it comes to quality (not availability) of healthcare.

The new Party goes onto say it will be:

“ . . . seeking views on commissioning for patients (the implementation of the NHS Commissioning Board and GP consortia) . . .”

Curious that when we see patients we are never asked about commissioning by patients only about where can they get the best healthcare.

“. . . local democratic legitimacy in health . . .”

Curious that in a NHS run along Soviet lines since its inception.

“ . . . freeing providers and economic regulation . . .”

No free market agenda here eh comrades?

“ . . . the NHS outcomes framework.”

The care on the cheap new alternative to the former targets now known as “outcomes”. Yet to be decided so no commissioning yet comrades just sit on your hands . . . and wait . . . and wait.

And look at para 6.5 “To support the ownership of the strategy within the NHS . . .” which no doubt means the same “. . . series of consultation activities . . .” as would have happen before the Charge of the Light Brigade in that our comrade Marshals feel that collective “ownership of stratergy” is different from top down imposition of political policy.

Para 6.6 is more management brown smelly bovine excrement until you read “The proper management of financial risk will be of particular importance.”

Someone finally realised that Houston we may have a problem?

On now to “Proposals for legislation”. Another of those cuddly grey box follows which gives a summary of all those layers of bureaucracy that are to be dissolved and all those that will take their place.

In brief no less than the creation a “Public Health Service”, a transference of “local health improvement functions” to “local authorities” known here in the UK as councils with “accountability to the Secretary of State for Health” so once again no Soviet centralized control of NHS plc.

Placing the “Health and Social Care Information Centre”, currently a Special Health Authority on a statutory footing.

Making the “National Institute for Health and Clinical Excellence” a non departmental public body which means no political control on the new 150 targets, sorry “outcomes” comrades.

Establishing the “independent” “NHS Commissioning Board” who just happen to be accountable to the Secretary of State and if you have fought thorough the White Paper thus far you may have wondered how it will manage all its new found roles without the establishment of more bureaucracy than you could imagine.

Establishing a statutory framework for a “comprehensive system of GP consortia”. An excellent idea if as we have here in Northernshire more GPs than can actually find enough work to fill a morning let alone a full day and if every employee of the local Soviet is at worst a Harvard or Yale MBA with distinction as we have locally.

GPs cannot deliver both without compromising either their face to face healthcare or their efficient management of healthcare provision.

And finally establishing “Health Watch”, no passing similarity to a popular crime solving program in the UK to be part of the Care Quality Commission whose first head’s credentials in terms of missing poor quality care are alluded to here by Dr Grumble.

“Reforming the foundation trust model”, “strengthening the role of the Care Quality Commission” and “developing Monitor” anyone see several subtle links to the establishing of Foundation Trusts and events in the county of “Staffordshire” here?

We think there will be a lot of work for toothless tiger orthodontists in amongst these organizations and the mad grab for Foundation status.

And para 6.8 invites you the public to be consulted about how best to manage the changes which brings us on to the next section “Managing the transition”.

The first paragraph states the bleeding obvious that change is a coming big time but for once they:

“ . . . will happen bottom-up, for example GP consortia having greater say and responsibility as rapidly as possible . . .”.

Nice thought but it ain’t happening. Most PCTs, Northernshire’s “enlightened” ones being obvious exceptions, are very conservative and won’t do anything until someone up high says it can happen. They are already blocking any changes for the better for they are still in control.

Para 6.10 is a big one and it illustrates the problem that will inevitably happen more management although it implies less. But then so often is the case that less is often more. Think of fundholding where practices often employed a fund manager in addition to a practice manager.

But commissioning is not fundholding so that will never happen. Or will it?

Section then follows entitled “Timetable for action” which despite all the hype about GPs spending billions really says that nothing much will happen until about 2012. Just look at how long it takes to reinvent the NHS tariffs or are they now currencies? Good to see free (Soviet) markets will flourish under the liberated NHS with centrally fixed pricing to continue.

That will really encourage the GP entrepreneurs or will it be the private sector?

So until autumn 2012 when the NHS Commissionning Board makes its allocations for 2013/14 direct to GP consortia GPs in consortia will be going to lots of meetings but they will have no money to pay the piper.

Worse is that GP consortia cannot hold contracts with providers until April 2013 and as commissioning is said to be based on NICE produced outcomes all 150 of them which won’t be ready until July 2015.

So unless the rules of engagement change dramatically, it looks like for the vast majority of GPs and consortia it is business as usual. Sit in meetings and do nothing useful. The current raft of NHS managers have a 3 year retreat during which they could handicap GP led commissioning for years to come.

Praise be to the Party for its plans to liberate the NHS. He who pays the piper is said to play the tune. Money is also said to be the sinews of war.

Our reading of this is that GP consortia will wait a long time to fight any wars or play any tunes while the Old Guard carry on as usual, and, when we finally get to play, we could be left with a mess by a defeated and by then disbanded Old Guard?

Still fighting the war is often easier than winning the Peace that follows. Back to the day job for quite a long while to come for despite all the hype it looks like business as usual.

We in healthcare on the frontline are going to wait a long time for liberation based on this White Paper and so will our patients.

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 005 of 007.

Well fellow comrade GPs we are now engaged in a war of liberation for “our” NHS. The nights are starting to draw in, and temperatures are starting to drop up North, but still our all wise and knowing Marshals NC/DC shall ensure our victory in the Great Patriotic War of Liberation of the NHS via that most powerful of weapons the White Paper.

Let us mount up and rally onto chapter 4 “Autonomy, accountability and democratic legitimacy”. More stirring words of freedom for all NHS comrade workers from our leaders. Read on.

“The Government’s reforms will liberate professionals and providers from top-down control”.

Fantastic we can stop reading and go home and do our job for the first time in 13 years.

Sadly no for we are due “Greater autonomy . . . matched by increased accountability . . .”. More regulation anyone?

Onto “GP commissioning consortia” which we think are the ConDems new version of multifunds which arose during fundholding - the prequel to Commissioning the Movie III outlined in the next few paragraphs.

Lots and lots of buzzword bingo words follow like “patient pathways”, “clinically-led”, “. . . crucial role that GPs already play in committing NHS resources through their daily decisions. . .”.

Is that the same as GPs treating patients?

“GP-led purchasing has history”. It certainly has 20+ years of failure not our words but that of the House of Commons Health Select Committee.

“Our model is neither a recreation of GP fundholding nor a complete rejection of practice-based commissioning.”

Is that the same as the previous Party’s commissioning is not fundholding idea for “Fundholding led to a two-tier NHS; . . .” but the ConDems version will not cause this as all GP Consortia will be created equally good comrades?

Another cuddly little grey box follows full of La La land happy thoughts and oh look the NHS Commissioning Board has yet another job to do.

“A number of PCTs have made important progress in developing commissioning experience . . .”.

Quite right comrade Marshals. NHS management has increased at a far greater rate than frontline healthcare provision and we suspect will continue to do so at an exponential rate from what we have read thus far.

“Primary care trusts will have an important task in the next two years in supporting practices to prepare for these new arrangements.” We would like to think up North that this important task would be to disappear completely but we fear this means that the idiots running the current local healthcare system will lose their jobs at the local Soviet and some will be reemployed via GP consortia.

Comrade workers paragraph 4.9 must reassure all those fighting the liberation war for the NHS as it says “The final shape of these proposals will depend upon our consultation findings . . .”.

We all know that consultation means the decisions have already been made.

Now comrades we must not be dehumanised or brutalised by the fight to liberate the NHS for just working for it does the same so let us move onto “An autonomous NHS Commissioning Board”.

You can skip the next few paragraphs as it sounds like the reinvention of the Department of Health by another name despite another cuddly grey box and the rather worrying words “It will not manage providers or be the NHS headquarters”.

It will just “ . . .hold GP consortia to account for their performance and quality”.

Worryingly is the start of “Establishing the Board and managing the transition” section which starts with the words “The Board will be established in shadow form as a special health authority from April 2011 . . . it will be converted . . . into a statutory body . . .and will go live in April 2012.”

So until this body goes live and NICE has its 150 outcomes what happens to local GP consortia? Well thought through this liberation war looks like the motor has stalled until at least 2012.

The NHS Commissioning Board it would appear will not just be the Department of Health 2 but a SHA (special health authority aka strategic health authority) as well para 4.13.

Look comrades there may be light on the horizon for the next section is entitled “A new relationship between the NHS and the Government”. Could this be one where healthcare professionals are allowed to work free of political interference in order to provide the best for their patients?

Another cuddly grey box follows which outlines the Secretary of State’s relationship with the new Department of Health, sorry NHS Commissioning Board, but we can’t see the words healthcare workers anywhere within this box.

Onto “Local democratic legitimacy”. This predicts the demise of PCTs but more worryingly suggests the transfer of “ . . . PCT health improvement functions to local authorities . . .”.

So the ConDems now see your local council as the new PCTs? Better start looking at the school league tables to see what your healthcare is likely to be like “ . . . the power of the local authority to promote local well being . . .”.

Grammar school good, comprehensive bad? Another cuddly grey box follows outlining the role of your local council, we think, in providing your healthcare. Given that they are probably cash strapped and short staffed can we guess who might just be joining their payroll at no expense to central government?

GPs working with local councillors? Interesting.

We march on across the steppes to the section “Freeing existing NHS providers”.

“Autonomy in commissioning will be matched by autonomy for providers”. This can’t be a hint that privatisation via commissioning is about to loom on the horizon of the war of liberation of the NHS? We are too cynical we must return to just cleaning our weapons and let the comrade commissars do the thinking, Sergei.

We are onto a new concept “Our ambition is to create the largest and most vibrant social enterprise sector in the world. The Government’s intention is to free foundation trusts from constraints . . .”.

What the hell is “social enterprise”? We first heard this phrase when we played a video on the most excellent Ferret Fancier’s blog site.

Read para 4.21 for we think mixed left and right wing messages here. Suggests the coalition ain’t got a clue about healthcare.

“Economic regulation and quality inspection to enable provider freedom”.

“Providers will no longer be part of a system of top-down management, subject to political interference”.

Does that mean we as GPs can do our own thing? Somehow we doubt it for whenever freedom is offered unconditionally it is always followed by loads of conditions. Enter stage right Monitor “. . .the current regulator of foundation trusts . . .” whose sterling work in Staffordshire will no doubt mean some honours going their way.

Combined with added power from the Care Quality Commission whose first leader also had some Staffordshire involvement we know we are talking toothless tiger regulation by whom and for whom?

Who are the providers?

Another cuddly grey box follows about the role of the Care quality Commission. In the same way that a soldier on the ground takes comfort from their weapon and body armour the average NHS patient will be well served by these 2 pieces of NHS Personal Protection Equipment (Care Quality Commission and Monitor)for both should be awarded the Congressional Medal of Honour for their sterling service to patients to date.

Onto “Monitor’s scope and powers”. Mixed messages here some suggesting a possible free market laissez faire approach other hinting at a “market” with regulated prices. A little diagram follows and guess who is at the bottom of the pile? None other than the patients and public.

Onwards to para 4.31 “Valuing staff”.

The biggest cost to any organization is only now recognized with 6 lines of corporate bullshit. Why not just say you are all going to be shafted and ignored rather than use non words like “ . . . staff engagement, partnership working . . . improve staff health and wellbeing.”

And for those of us who do not know who Dr Steve Boorman here is a link. Looks a bit like Al Borland from the TV series Home Improvements. You know we are well cultured in our TV watching habits here at ND Central.

The last three bits of section 4 actually relate to things that matter to NHS staff.

The first is “Training and education”. Lots of fine words and again the NHS Commissioning Board has it hands in education. It would seem that there will be “education commissioning plans” which will be “led locally and nationally by the healthcare profession through Medical Education England”.

In case you hadn’t heard of this organization here is a link.

The second is “NHS pay”. Don’t hold your breath regarding any increases or an end to central regulation we are in a recession with crippling National Debt as well. A few woolly words re need to end national control and move to local terms and conditions so no great changes.

The third is “NHS pensions”. If a government doesn’t like something you can bet it will order a review. So the words “. . . ensuring that pension solutions are found that are fair to the workforce in the health service and fair to the tax payer” properly mean we are all going to work longer to get less if we live that long.

Such is the nature of wars of liberation and so ends battle 4.

Praise be to the Party and its war of liberation. Only 2 more sections to go and it will soon be Christmas. Who knows we might then get a banana, or an orange, this year, if we are good little comrade serfs?

We certainly won’t get anything else other than unpaid work from what we have read thus far and our patients? What will their reward be for funding all of this liberation?

Liberating the NHS: some thoughts on the Great Patriotic White Paper 003 of 007.

Recovered yet from the last chapter of the NHS “Liberation” War? It is hard work comrade and many will suffer as we fight to achieve the true liberation of the NHS Motherland on the orders of the new comrade Marshals NC/DC.

So mount up as we go onward to the second battle “Putting the patient and public first”.

Stirring words from our comrade Marshals and they should know given their collective humble upbringings about comrade Joe Public and their healthcare needs.

Don’t forget your bingo card so let us begin with the first section of this battle of liberation: “Shared decision-making: nothing about me without me”.

Notice the start of possible subtle recurring themes? “Nothing about me without me”. Seen this before?

“The Government’s ambition is to achieve healthcare outcomes that are among the best in the world. This can only be realised by involving patients fully in their own care, with decisions made in partnership with clinicians, rather than by clinicians alone.”

Sounds good a bit more flannel and then:

“But compared to other sectors, healthcare systems are in their infancy in putting the experience of the user first”.

They certainly are for when you are a politician or a manager who might speak to one or two patients a week, if they are lucky, in one of their “surgeries”, see how much time they spend listening to the experiences of the user.

If you guys came and spent a couple of weeks in an A&E department, a general Practice surgery and an acute hospital admissions unit you would realize why. For none of your advisors have ever been there. The troops on the ground know what the problems are there and their managers and politicians ignore them or deny them.

Still we know when grunts and patients on the ground complain that there is no ammunition,beds or nurses there will be more pearl handled sidearms for the managers as a result.

They will look into the problems, do nothing and pat themselves on the back for doing so well.

“The new NHS Commissioning Board will champion patient and carer involvement, and the Secretary of State will hold it to account for progress. In the meantime, the Department will work with patients, carers and professional groups, to bring forward proposals about transforming care through shared decision-making.”

Not the NHS Commissioning Board again? Its responsibilities mushroom every few paragraphs. How will it cope? Is the buzz word “champion” the same as the word “ignore”?

“Shared decision-making” is that the same as more "consultation exercises"?

Onto “An NHS Information revolution”. More good Soviet top down words here “revolution”. Jo S would be so proud of his new boys.

Information is not knowledge or experience. You can read a book on how to drive a car, fly an airplane but still that is theory. Information in isolation is not experience or necessarily how to do something.

“The Government intends to bring about an NHS information revolution to correct the imbalance in who knows what. Or aim is to give people access to comprehensive, trustworthy and easy to understand information from a range of sources on conditions, treatments, lifestyle choices and how to look after their own and their family’s health.”

That paragraph is clearly written by someone who has never worked in frontline healthcare as you would be amazed by just how much information, and disinformation, is out there. Just try listening to patients. Information is not the problem, quality care is.

Read on:

“The information revolution is also about new ways of delivering care, such as enabling patients to communicate with their clinicians about their health status on-line. We will provide a range of on-line services which will mean services being provided much more efficiently at a time and a place that is convenient for patients and carers, and will also enable greater efficiency”.

Now we like technology, well some of us do here at ND Central, and have had a Eureka moment after reading that paragraph.

For example: why not let surgeries and patients book hospital appointments on line and call it Choose and Book?

Or why not let patients be able to ring a call center 24/7 to discuss their symptoms and let us call it NHS Direct?

All examples of centrally imposed NHS IT driven efficiency? Excellent bring it on (line) we love progress. All of the above ideas have been tried, failed increased GP workload and patients hate them. They want to see real doctors and nurses.

Spend more to achieve less? Been there done it and all we get is more “efficient” square wheels.

We bet no-one in frontline healthcare wrote that pile of smoking dung which smacks of something repeating itself comrade for the clear “benefit” of the comrade patient.

“Information generated by patients themselves will be critical to this process, and will include much wider use of effective tools like Patient-Reported Outcome Measures (PROMS), patient experience data and real-time feedback.”

Amazingly frontline healthcare professionals like doctors and nurses already do this on a daily basis with no fancy initials and without having to go to a PROM.

It is called talking to, listening to and learning from patients.

If several of them say to you “I have seen surgeon Y and they were crap”, and they have complications you can report this and nothing happens.

You then stop referring patient to that surgeon and thereby improve healthcare without involving useless management “tools” and abbreviations.

Read on and see that the rise of data collection management via already failed methods e.g. patient experience surveys and real-time feedback which results, as it does now, with patients being completely ignored.

Imagine a health service manager listening to Ferdinand Magellan saying “I have sailed round the world?” He would have been told his metrics did not meet the patient experience survey results and therefore the world was still flat.

Read paragraph 2.8 in its full but only if you are having difficulty sleeping and want a laugh. Look at the last sentence and what we said 2 paragraphs above.

The last sentence says “The Department will seek views on how best to ensure this approach is developed in a coherent way”.

Not that difficult but you might have to start by talking to people who probably already have the information you want for the first time.

Paragraph 2.9 starts with “Information will improve accountability”.

We think you can ignore the rest of that long paragraph as historically whistleblowers who point out something is wrong have been persecuted. We respectfully draw your attention to this site (slow to load).

We see only the creation of more useless and expensive management who will be unable to see a Gulf of Mexico sized oil spill on a sheet of A4 paper even when someone tells them “there is something seriously wrong here”.

“More information about commissioning of healthcare will also improve public accountability”.

And who’s going to provide this?

The GPs who are being GPs now, who will soon be working on commissioning, and also having to produce reports about their commissioning, or possibly a new type of manager to improve accountability?

In another little cuddly grey box there are a few more bits of common sense that have been frequently ignored. It says that “In future, there should be increasing amounts of robust information comparable between similar providers on:

Safety with no doubt added matron power for example about levels of healthcare-associated infections, adverse events and avoidable deaths, broken down by providers and clinical teams.

Effectiveness: for example, mortality rates? does this mean deaths possibly on a ward by ward basis to not doing . . . and patient-reported outcome measures. Is that another tacky stretch limo trip to a local PROM or are we just thick up North?

If you are concerned regarding the liberation of your own personal medical details, a keystone to the doctor patient relationship for centuries, then hold on to your hat for the Parties of the individual are about to possibly show their commitment to you.

Paragraph 2.11 starts benignly enough:

“We will enable patients to have control of their health records. This will start with access to the records held by their GP and over time this will extend to health records held by all providers. The patient will determine who can access their records and easily be able to see changes when they are made to their records. We will consult on arrangements, including appropriate confidentiality safeguards, later this year”.

Sound familiar? Looks like the online transfer of medical records will continue even though it is totally unnecessary for the treatment of patients and will cost a bomb.

2.12 “Our aim is that people should be able to share their records with third parties. . . .We will make it simple for a patient to download their record and pass it, in a standard format, to any organization of their choice.”

But then the next paragraph shows the underlying reason for NHS computerization of records the “Making aggregated, anonymised data available to the university and research sectors . . .” and how long before the private sector gets its hands on all this information and exploits it? Think it hasn’t already been doing this for a while? Click this link.

Ask your doctor if you have given your consent to take part? And Big Brother wants more.

There will of course be robust safeguards “. . . to protect personally identifiable information. We will consider introducing a voluntary accreditation system . . .”.

“Patients and carers (and hackers?) will be able to access the information they want through a range of means . . .”

Now we would not suggest that Big Brother is going to become bigger just read further:

“We will ensure the right data is collected by the Health and Social Care Information Centre to enable people to exercise choice.”

Old Party out New Party in, spot the difference? Déjà vu? NHS IT looks like it is going to get bigger like it or not. And it continues in a similar vein until the excitement of “Increased choice and control .”

Are we having another flash back here? The choice word again but here with the control word. New Party same as Old Party for they admit that “The previous Government made a start on patient choice . . .”.

It certainly did it, denied it par excellence. You could have any choice as long as it was that chosen for you by the local Party and its commissars.

Of course the implication is that the failure of choice is the GPs’ fault “just under half of patients recall their GP has offered them choice”. Could this be because there was no choice or is that people don’t remember much?

Can you describe what your other half is wearing today? Try it, it might be important if there were to be a disaster and you would want to try and identify someone over the phone. Were they wearing their pink or grey shirt with their jeans or where they wearing slacks? Try it.

There is another little cuddly grey box full of nice things a bit like a child looking in through a sweet shop window at lots of nice things but knowing also that nice things are expensive. “You can even register with any GP practice with an open list without being restricted by where they live.” Familiar?

Another long boring paragraph but alarm bells ring when the words “. . . maximising use of Choose and Book.” Why? This is centrally controlled denial of Choice by morons who claim you have a choice.

Talk about resuscitating dodos, we have said before no-one writing this White Paper has been in Front Line medicine for decades.

“The previous Government recently started a programme of personal health budget pilots. International evidence, and evidence from social care, shows that these have much potential to help improve outcomes . . .”

In other words if you have to pay for something you might not use it so much but read on:

“ the Department will encourage further pilots to come forward and explore the potential for introducing the right to a personal health budget in discrete areas such as continuing care.”

We like the word “discrete” Does that mean a wad of twenty pound notes in a plain brown envelope passed under the desk to a patient with a certain illness? “Don’t tell anyone I am giving you this money or they will all want it.”

“We expect the choice of treatment and provider to become reality for patients in the vast majority of NHS-funded services by no later than 2013/4. The NHS Commissioning Board will have a key role . . .”

Haven’t we already had “choice springing out of our eyeballs? And the NHS Commissioning Board following the end of the SHA/PCTs how are the 5 lowly paid members of this board going to be oversee yet another task?

Onward comrades, and remember this is a hard war of liberation, to the next section. Stay awake for we would hate for our NHS to be overtaken by evil Soviet forces called Government so let us rally and read “Patient and public voice”.

Sounds so lovely but Uri do not listen to your sergeant when he says no-one listens to the patient or the public voice.

But onwards we must not tire for the good comrade Marshals ND/DC say:

“We will strengthen the Collective voice of patients, and we will bring forward provisions in the forth coming Health Bill to create Health Watch England, a new consumer champion within the Care Quality Commission.”

In the same way that criminal gangs introduce their own street speak so does any new Government possie introduce a whole load of ghetto speak like this possibly more quangos:

“Local Involvement Networks (LINks) will become the local Health Watch, creating a local infrastructure, and we will enhance the role of local authorities in promoting choice and complaints advocacy through the Health Watch arrangements they commission”.

Presumably under the Big Society all these new organizations will be staffed by local volunteers?

Brace yourselves comrades for what follows may be a work of fiction para 2.26:

“All sources of feedback, of which complaints are an important part, should be a central mechanism for providers to assess the quality of their services. We want to avoid the experience of Mid-Staffordhsire, where patients and staff concerns were contunally overlooked while systemic failure in quality of care went unchecked.”

The words bull and excrement come to mind and if you want to see how this works in practice check out the Ward 87 blog. There is a lot there regarding events in Staffordshire and it will take a lot of time to read but it is very enlightening.

Still it might all get mentioned on the “Local Health Watch” TV program investigating crimes against local health care.

Skip the cuddly grey box it is merely brown and smelly and another layer of bureaucracy to replace the SH/PCTs that will disappear.

And at long last we reach the end with a nice little “onion” picture of the new cuddly NC/DC version of healthcare for the future.

Praise be to the Party for once again putting the patient first behind the Party and all its new quangos. Are we just dumb oop North or have we just had a mega déjà vu moment from Za Nu labour in terms of health policy?