Better late than never?

This morning we watched this item on an otherwise news depleted Saturday morning.

It seems that A&E departments are being misused. Never! Must be those idle GP scum again not the ignorance of the British people. After 60+ years of the NHS someone thinks perhaps people, in this case children, need to be taught how to use it.

Well dudes they have already learnt how to both use and misuse the NHS for however many times you misuse it there is no sanction. They have been well educated by their great grandparents, grandparents and parents on how to use the NHS for decades.

So if Tarquin Jr. or Chantelle Jr. get ill they ring the GP for an emergency prescription of paracetamol because the kid is disrupting X-factor or Strictly Come Dancing. If their GP is shut, or they are not considered an amergency (case for a paracetamol prescription) by thier own GP or an out of hours call handler, or doctor, they explore the local NHS “market” and try the local Darzi centre or walk in centre but guess what the market does not allow them to use it!

Chuffing hell somemic will be doing Tarquin or Chantelle (seniors’) heads in, they will have got through a pack of fags, cheaper than the Paracetamol they want from the NHS, so they will be well stressed and will ring NHS reDirect and explain their problem and might, big might, be advised to go to a pharmacist and purchase some paracetamol.

Eventually Tarquin or Chantelle (senior)and “will have no (f**king) choice” but to dial 999 “it is an (f**king)emergency” and get conveyed by the free, no questions asked, executive taxi service to an A&E department.

And get some Paracetamol but at what cost?

This process has been going on for decades and to try and address such behaviour as a healthcare worker will result in complaints against anyone who tries it for the non paying, totally unresponsible NHS customer is king.

Even if you misuse your GP enough you can only get booted off the list. And you can still go onto another GP and so on. Misuse the ambulance service and they still have to attend. And so on.

At least now after 60 years our secondary school children will get lessons about the NHS. This will be useful for given the paucity of sex education in secondary education they will probably need to use it when their kids become ill 2 or 3 years after their NHS sexless education lessons.

Praise be to the Party who no doubt will be preparing lesson plans for a few years time about the fact that smoking is harmful to health some 50+ years too late. Talk about slamming the stable door shut when the horse has bolted all over the UK and is still running unchecked 24/7.

At least the stable door will now be finally shut. Isn’t UK education wonderful?

Memory.

One of the great things about a health service where nobody pays the doctor directly is the effect it has on our patients. We had a discussion at our weekly resistance meeting at the Café Michelle about our collective experiences at one of our more “exclusive” rural branch surgeries.

At this surgery you are immediately out numbered in the car park by the scores of Range and Land Rovers driven by our patients as well as their employees’ tractors and various instruments of agricultural production.

Given that the Ferraris driven by all UK GPs and their staff, are low riding beasts compared with those above us, this is a truly hazardous place to be in. One misplaced dung dispenser dispensing could seriously damage the shine on the average UK GP’s Ferrari.

Still that was just the car park. Worse is yet to come when we deal with the owners of these vehicles our patients whom we allegedly serve. For some unknown reason when a patient sees their doctor in the UK, the National Health Service manages, at no cost to the patient or the State, to perform a partial cerebral lobotomy the minute they walk into their GPs’ consulting room.

Our patients are in effect rendered brain dead but unfortunately still breathing, walking and worse still talking. After their NHS “free at the point of care” partial lobotomy the response to open questions such as “what is the problem?” or “how can we help you today?” is:

“I don’t know? You’re the doctor, you tell me!”

Oh so original, you can tell a farmer a mile off. They’ll talk to their vet ad nauseam about a speechless animal whom they pay for but come to a doctor, whom they do not pay for, and they will expect a full tank of diesel and a diagnosis before they go off to spend their EU subsidies.

A quick “if you want to play stupid see your vet (they charge)” usually results in the realization that it is not the doctor who has the problem but the patient and the doctor needs something called a history in order to do their job.

In other words talk to us (you dumb animal).

The NHS “free at the point of care” lobotomized patient then usually goes onto refer to their problem as “it”. Even when questioned about every standard symptom of disease for example is “it” chest pain, or shortness of breath and so on the problem is still “it”. What “it” is we sometimes never know especially in the demented when they attend sans relative, an increasing phenomenon.

We are not veterinary surgeons for in the UK they are usually much brighter than we doctors. Their patients do not talk but their owners do in order to get value for their money. However, when patients present to their GPs without their pets which cost, they are allowed to be dumber than your average vets’ patients (the animals that is).

At this stage in the UK, a GP presented with their lobotomised patient inability to communicate may then have to examine their patient. This always presents further problems. Simple instructions like lie on the couch on your back can result in the lobotomised patient assuming a knees elbow position on the desk or lying sidewise facing you in the room next door for reasons beyond our comprehension.

Even if you can get your patient into the correct position you are then faced with the fact that the patient cannot remember what clothes they put on in which order and so 5 minutes can be spent trying to get to an upper arm released, with help from a relative/carer/friend, from the unique combination of bra, bodice, corset, suspender belt, vest, incontinence pad(s), catheters and thermal long Johns. Did we forget the body warmer and hat too and to remove your glasses as well when the ankle is being examined?

And that is just in those patients called John. Jane Does are worse. Which bits of the English language they missed at school we know not but our medical students frequently comment on how thick our lobotomised patients are. For even as medical students they know the difference between up and down, left and right, arm and leg. Remarkable.

Following the “history” and “examination” part, one may then have to prescribe a treatment.

This is fraught with hazards as such questions as “Do you have any allergies to any medications?” will result in answers such as “Yes it is something with an A in it. Or is it a C?” or “Are you on any other medication?” are usually met with responses such as:

“Yes I am. You will know what I am taking.”

You are asked to prescribe a drug, a poison, which they take regularly but don’t know what it is? The hospital, or you, “just” gave it to them and “it will (always) be in the letter” you have not yet got as they only saw the consultant yesterday.

Notice the “it” word again?

If this isn’t the case they will have of course taken all the tablets and disposed of all boxes, any discharge letters or prescriptions but the patients and their relatives will always say:

“You will know what it is it will be ON YOUR RECORDS."

Whatever a patient does not know it is always ON YOUR RECORDS.

“You will know my case. I am a new patient it will be ON YOUR RECORDS”.

“I have seen a doctor at the hospital and rang the labs and they tell me the results are there. Can you get them for me? It will be ON YOUR RECORDS the hospital said so”.

Top tip if a doctor in hospitals says a letter will be with your GP in less than 2 weeks ignore it.

2 weeks is a BARE minimum so don’t waste an appointment try, if you can bringing the drug boxes, or the discharge letter for the helpful phrase heard so often in General Practice of “They are THE little white tablets” is about as helpful to a GP as “it was a blue car with wheels on” is to a Police officer.

Which doctor, which hospital, which department? Which car?

"I don’t know? It will be ON YOUR RECORDS."

In reception you will hear the following “I would like my tablets”.

“Which one? (of the twenty you take)”

"I don’t know it will be ON YOUR RECORDS." Now this is the NHS, which is free, but try asking the same lobotomised patients what car they drive?

They will have already clocked your car, told you how Top Gear have rated it and how their relatives have something so much better than your NHS Ferrari. They can complain about how much petrol costs per litre to the nearest tenth of a penny when its MOT is due and how much a full service costs. You will get the full spec and any problems they have ever had with their vehicle without you ever hearing them say “I don’t know it is ON YOUR RECORDS”.

The amazing thing about the NHS “free at the point of care” partial lobotomy is that once the patient leaves the surgery they suffer from instant recall about the whole of the consultation and leave with super uber enhanced memory powers. You then hear them saying in the supermarket:

“My doctor could not tell me what was wrong with me and I told them everything . . .”

“My doctor did not even know what tablets I was on . . .”

“The doctor didn't have a clue I don’t know what they are paid for. . .”

This is especially so when they sniff the quick buck of litigation and enhanced memory goes into overdrive. People who could not remember the 1 times table at school can suddenly quote pi to a billion digits to a lawyer.

We have been trying to find the origin of a quote we once heard that we thinks may explains this (almost) universal amnesia of the UK population when it goes to the GP and we think it goes something like this:

That which you do not pay for, you value not.

That which you value not, you respect not.

That which you respect not, you despise.

That which you despise, you abuse.

Anyone working in healthcare disagree? We bet none of you have had patients like ours?

Praise be to the Party for free healthcare and education. One of them works despite the other failing completely. Problem is we at ND Central can’t remember which is which.

Curious that? Must have breathed something in, it must be very infectious . . .

PS Anyone who can help us with the original quote above we would be grateful. Over a century of collective medical experience gets a bit forgetful . . . you will know what it is doctor it will be ON YOUR RECORDS!

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?

The guilt of the sum is greater than that of all of its parts?

Once again this week the tragic case of Baby P(eter) is on the news screens of the UK and once again the Press screams about individual’s incompetence as the failing(s) but it may miss the collective target in terms of overall responsibility.

Imagine if you can a situation in the UK where a group of GPs work closely with a group of health visitors in a practice setting. Over the years they develop a rapport where each knows the strengths and weaknesses of each other and also they know their patients.

Their social intercourse on a daily basis means that little snippets of information are passed between them. For example there might be a family of concern about whom a conversation similar to this might take place en passant:

"Hello Northern Doc, you mentioned the other day that child X had condition Y."

"Yes I did. What of it?"

"Well did you know that their Mum was assaulted last week?"

"No, I did not. Who by? "

"Her new partner."

"Who’s that?"

"Dicky W*nker. "

"Really? Didn’t he do time a few years back for indecent exposure to minors in the local park?"

"I didn’t know that Northern Doc but I am now on the case. . . "

A simple sharing of information like that combined with follow up by those concerned might just lead to the exposure of a Schedule 1 sex offender who had been beneath the radar for years.

Now the Party does not do information sharing between professionals although it wants you to share all of your information between Party members via the Summary Care Record. Information is often the key to protecting children but information in isolation is often useless.

Protecting children, and the elderly, is like a jigsaw puzzle. If you hold a small piece of the jigsaw in isolation you do not see the whole picture. The ability to share the pieces may give you an increased chance of seeing the whole picture.

Which is why the Party took away our health visitors and reorganised the way in which we now work. What used to take one conversation like the one above now takes several phone calls and days of waiting just to identify the responsible individual. Having identified them you then have to find them to actually talk to them and share the information.

The current state of NHS health visiting means that trying to complete the jigsaw as a GP is hampered by the NHS adopting so called “silo working”.

The sum, here the protection of the individual, is greater than all of its parts, for all of the parts are usually there. They, as usual, are not shared. So the sum fails but the individuals are blamed. They are blamed for the failings of those who instituted the sum.

The sum was devised by our politicians and all their little local commissars. It was they who ultimately employed all those who failed and it is they who also dictated their terms of engagement.

Praise be to the Party for they are once again all wise (after the event). The problem with the Party is that when the system fails all fail for they cannot without the system.

The depressing thing is that it is said it will happen again. Unfortunately it will and all of the NHS reforms of the last 13 years have made it easier than ever to happen for they have destroyed the information sharing that is vital if these tragedies are to stand a chance of being avoided.

Rats leaving the sinking ship?

Well the change in the UK Government and its great White Paper of NHS liberation has locally led to the very loud sound of the scurrying of claws being heard on the wooden deck of the super liner that is NHS management.

In our local shires loads of rats are apparently leaving, nay, high jumping and triple jumping away from their ships and looking for pastures new. They continue to deposit their droppings for as they scurry away their underlings are being promoted above and beyond their limited incompetence. Lots of their junior offspring are struggling to function for NHS management is a rigid Soviet style dictatorship and no-one dare make a decision without the say so of the local Great Leader(s).

New junior rats, in the same way as in war field promotions are rapid, are crawling up the stairways of the sinking ships of local PCTs. While grandiose titles are being bestowed upon them and may sound good they are merely the equivalent of being promoted to being the executive officer on the RMS Titanic.

The captain of the Titanic at least had the grace to go down with the ship he had mismanaged. The rats however are climbing the greasy pole in the hope that if they sh*te hard enough on their colleagues they may just reach the heady heights of the as yet undefined new super carrier of NHS management called the NHS Commissioning Board.

The rats that are jumping the sinking PCT/SHA ship may yet live another day and unfortunately populate the new SS NHS Commissioning Board when it is finally launched. This means that however good GP consortia may become those who have mismanaged the local Soviets for years may scupper any improvements that might come out of GP consortia when they are finally allowed to do something.

We thought, after talking to some colleagues from other Northern shires, that this process was just peculiar to the local and neighbouring Soviets but it would appear that the rats are now more like lemmings if this article is to be believed.

Praise be to the Party who will ensure that the new NHS Commissioning Board will be full of great captains like Admiral Nelson. Or will it be more like the Caine mutiny?

Defence reviews, the NHS and who is the real enemy?

This week in the UK there has been published a defence review which is a euphemism for defence cuts against a background of a bankrupt economy which must see things go.

Certain things here at ND Central struck us at how defence and the NHS ride a similar route to obtain the same result. While defence is about protecting us from without should we not be looking at the enemy within namely Government and Party ideologically driven incompetence?

One of the biggest things in the defence review is that the UK will spend £ 6 billion on 2 new aircraft carriers. Most excellent news apart from the fact that they will have no jet aircraft on them for many a few years to come.

This would never happen in the NHS. No-one would be daft enough to spend £ 12 billion on a failed computer system meant to do 90% of all NHS referrals by December 2006 that only now just manages 50% of referrals. Would they?

No-one would top slice budgets to fund privately run ISTCs (Independent Sector Treatment Centres) which run at below capacity but, at which whatever level they run, still cost the tax payer 100% of cost regardless of numbers of patients treated (or aircraft taking off from them?). Would they?

New defence threats have been identified like that of an influenza pandemic. Did we not have one of those PanicDemics last year whereby the collective incompetence of Government invented a nonexistent threat that almost took down general practice due to goading of the Public to panic in mass numbers? Nobody would be that daft, would they?

Cyber terrorism is identified as a “new” threat to the UK. This is made so much easier by incompetent but expensive IT provision at the behest of the State. NHS IT is a victim of its own incompetence as the drive towards centralisation of medical records leaves it open to being crippled by a few well placed pounds of explosive or a local IT idiot who knows nothing. No-one would design a central medical records’ system that vulnerable to being crippled on a regular basis by its own, would they?

All of these of examples of how poor the NHS/Defence departments are. All of the above of examples whereby there is an enemy which impacts on those on the front line.

Who is that enemy? Well in general practice it is the Department of Health and the local Soviets aka PCTs who for years have been mismanaging locally central policy and whenever they cock up it is our problem to sort out even though it is their responsibility.

And the MOD? Well far be it for us to comment given that locally jobs will go.

Praise be to the Party for all of their reviews. They serve us all so well.

We in general practice, and our colleagues in secondary care, will carry on picking up the pieces. The Party may not be happy for some “aircraft” may be forced to land on "aircraft carriers" that they should not be allowed to.

And that is less expensive and better than ditching in the drink . . . but GP commissioning should stop all of that by delivering empty carriers like the defence department?

The absurdity of the NHS internal “market”.

A while ago one of the team flew a sortie to another part of the UK for a meet with fellow comrades from grunt school some of whom had come from other countries. As with all reunions it is a time for catch up, compare and contrast individuals’ experiences and consume a few naturally fermented organic chemical containing beverages.

Specialities tend to congregate and after a while the conversation turned to GP commissioning and what was happening locally. What was interesting was the compare and contrast element against a worldwide background.

One of the squad told us that in their patch a Darzi practice, paid for from the public purse to benefit the private sector had been so “successful” that it had been told to stop “treating” patients. Others said that those Darzhole practices on their patch(es) were being terminated due to the fact that they cost more than local GPs but then the lawyers became involved . . .

Despite the fact the collective IQ at this point was in the thousands, the individual blood alcohol levels were well above local legal driving limits, everyone had a Homer Simpson “D” word moment as these issues were discussed. A heated conversation followed and there was a diverse nature of opinions about this situation, always the case when more than 2 doctors meet and talk especially when they were from different specialities and parts of the world.

One group said this made no economic sense for although a Darzhole centre was successful it was public money paid to the private sector and the private sector should be exploited to the full.

Another group said can you imagine if this was McDonalds who had opened a new restaurant that had exceed targets would they shut it down? Hell no they would chuck more money at it and milk their success.

A third group (way?) said this is the current NHS “market” whereby contracts operate within the framework of the alleged free market but the NHS commissars who administer them are former Soviet Bloc Party driven target obsessed commissars who cannot see that what they have done is a) successful b) an efficient use of public funds and c) that by their actions and inabilities they are actually denying patients healthcare which is what they are charged with to provide and were actually meant to provide as comrade commissar NHS “commissioners”.

There was a lot of input from those overseas saying that they wished they were in that position for they could use the increased success to improve capacity and therefore income while increasing the provision of service to patients albeit at a price. There were also a lot of opinions at this stage of the evening that were unprintable.

This led onto a discussion about GP led commissioning as proposed by the current Party(s). Fine in principle, the alleged free market one, but if applied against the background of a (failed) Soviet styled centrally fixed price market and heaps and heaps of paper shifting between bureaucrats as opposed to hands on patient care will generate what exactly?

The same but different?

Will the White Paper improve things or will it drown us as GPs in a sea of mountainous bureaucracy while denying us seeing any patients? The overwhelming opinion based on this discussion is that it will.

It is like trying to break the 100m spirit world record while wearing leg irons. However much you talk it up you will never succeed under the current rules of engagement.

But then it will all be the GPs’ fault won’t it?

The market. Certain elements are successful for example private medicine and McDonalds and then there is the NHS “internal” market.

Our patients tell us which they would like and also which one they actually get, and will get, as they tell us we currently have billions to spend (not).

Praise be to the Party for all new NHS reforms. We are lucky to have once again met up with our colleagues from grunt school. The debate will continue. And what of patient care?

Whatever. Politicians come, bugger up the NHS, and go. Doctors and nurses pick up the pieces time and time again. It will be no different this time.