“all’s spent, nought’s had, if our desire is got without content” - Lady Macbeth
“Sometimes if God really dislikes you he gives you everything you pray for!” - Dr Rant
I thought of these two quotes as I settled to write this piece. The NHS has had cash poured into it, beyond the expectations of those who worked for the service. The UK now spends about £90 billion per year on the NHS and this works out as about £1500 per patient per year in the UK.
Yet dissatisfaction with the service is never far from the news. Patients are unhappy, doctors are unhappy, the SoS for health is unhappy, Grant Shapps is unhappy.
There is much claim and counterclaim going on at present. There are glowing official statistics and then there are examples on the ground. The Doctor Rant team regard the present NHS reforms as fundamentally wrong, and as a danger to the NHS we know, love and hate. Rudolf Klein, a well seasoned NHS observer, describes the current reforms as being like a bobsleigh run. Bobsleighs have no brakes, and once you’re on the run, you have to keep going. Most of the Doctor Rant team wish we had never gone down this very slippery slope.
So how do we resolve the paradox of increased funding coinciding with increased discontent?
I think there are several things going on here.
Firstly the 'Rationing' word functions like Lord Voldemort, in that it must not be named. Yet resources are at the heart of every argument about the NHS. When all is said and done the NHS is effectively a £1500 a year compulsory insurance scheme for all the people of this country. It works, as Julian Tudor-Hart explains, on a basis of pooled risk. The underlying assumption is that any patient with an illness is a person worthy of treatment in their own right, on the basis of the medical practicalities in their case, and not on any social or political criteria of worthiness.
Disease can strike anyone. It is a great leveler. The lord dying of cancer in his mansion is just as much ill and struggling and in need of treatment and compassion as is a miner dying of pneumoconiosis in his terrace house. The NHS provides to both without fear or favour. This equality is actually one of the nice parts of being a doctor in the NHS, and I value deeply my ability to relate flexibly to people from many different backgrounds. Through the NHS we all put in to draw on the fund when illness strikes. In practice we know that there is a social gradient in health, and that poorer people get ill more often than richer people. The fundamental equality in the NHS is that of access to treatment, not of outcome from treatment, nor of the risk of experience of illness.
Once we admit the necessity of rationing the finite resources of medical and social care (and indeed of the country itself) we can then start to pick our way between conflicting claims on the service. However until we admit rationing we have to talk about all sorts of rubbish when we pretend not to ration resources, as this Labour MP has discovered painfully and directly. I hope her treatment succeeds. In this context I welcome the Public Health Directors suggestion that some services will have to be paid for. To my thinking this is just obvious, but needless to say the DH have denied it immediately.
The NHS will go so far - but only so far. As long as it covers the basics (illnesses causing morbidity or mortality) that’s probably as much as we should ask of it. This may involve some rough justice, but at least it means ill people should get treated. If NHS limited itself to this aim there would be enough in the pot to achieve this. The alternative of ill people unable to get treatment would be a disgrace, and is not an avenue we want to go down. Even writing from a position that sees little merit in egalitarian arguments in other parts of the economy, I cannot see myself being comfortable in a society that lets those unable to pay for treatment die at the side of the road. I do not want a completely egalitarian society, but I am aware that a severe degree of inequality if pushed too far leads to very unequal, unhealthy, crime ridden societies that lack social capital.
But the NHS has not contented itself with this aim of providing a basic sound level of service. Even to achieve this provision would be a major achievement for social justice in itself. This truth would set the NHS free, but instead we cannot admit there is rationing and so we dance around trying to pretend it’s not happening.
What we see happening in the NHS at present is tragic. We see complex structural solutions being introduced, that will damage the service, destroy cohesion, increase transaction costs and reduce the ability of doctors to deliver services to patients. The system needs to be built around the doctor (here standing for all health professionals) –patient encounter, and do everything it can to support this.
If we did this we would aim to get lots of care, for very little administration or management. What we see happening is reformation by shredding. The metaphors are of shredders, destruction, vertigo, dizziness, fast pace of change, no foundations being put in, nothing having time to bed down. Disasters such as this and this, happen, and the NHS manages not to manage.
The current NHS reforms are expensive, complex, misguided and disastrous. They take what should be a basic competent service, working to defined minimum standards (and remember that all standards set minima, not maxima) and convert it into a playground for Private Financial Investment, and Management for Idiots. The current NHS reforms are driving up transaction costs, whilst not delivering much increase in health care output.
We need doctors and patients working together, insisting that good medicine comes from relationship, and mutual respect and is developed over time, mostly without rushing. (Obviously in A+E dept or on coronary care things happen quickly)
The current NHS reforms do not recognise this and instead seem to think that what Raymond Tallis calls “sessional functionaries robotically following guidelines” are a good substitute for properly trained and educated professionals. In medicine, and in other professions, we are going to see the folly of this belief being enacted. Professions may be conspiracies against the laity. However would you like me to look at “court procedures for beginners” and then lead your defence at your trial? No you’d want a proper barrister to do it, no matter how many law books I’d read. Likewise for all patients can get plenty of information off the internet, they still need medical help and advice to make sense of it in their case. And remember that the physician who treats himself has a fool for a patient. Same applies to a member of the public trying to google themselves better. As Red Adair put it, “If you think professional advice is expensive, see how much an amateur costs you”
Practice based commissioning (PBC) and payment by results (PBR) are the two new pillars of New Labour’s attempts to run the NHS. Rudolf Klein is the only man I know who claims he can see the coherence in the DH vision. However he has already described the ride as being like a bobsleigh, and I don’t recall any of us giving our informed consent to take part in such a dangerous game! PBC and PBR are somewhat solutions in search of a problem, being needless distractions from the NHS core job of bringing doctors and patients together as necessary.
The battle for the future of the NHS is going to be fought this year. Doctors will have a role whatever happens, but here on Doctor Rant we want a niche that supports and trusts well qualified professionals to get on with their work for the benefit of patients.
We see good medicine as consisting of a co-operation between doctor and patient, to achieve sensible outcomes for the patient. The relationship is based on mutual respect, and draws on the resources of both doctor and patient. Julian Tudor-Hart described doctors as co-producers of health, and it is this kind of collaborative thinking we would want to encourage and support.
I have used a lot of Professor Klein’s insights in this piece and I am going to finish with this quote,
“The government's dependence on the medical profession collectively will increase as the new model NHS emerges, as the success of the model depends largely on the profession's active commitment to managing resources and introducing new patterns of service delivery. Yet at the same time, the government seems set to challenge the notion of collective autonomy by implementing Donaldson's proposals for substituting appointed members for those at present elected to the General Medical Council by the profession and for hiving off the educational role of the GMC to a separate body.3 This would greatly dilute the notion of professional self regulation—not a strategy calculated to generate enthusiastic cooperation. The way in which this paradox is resolved—whether policy makers come to see doctors as the solution to or the cause of the NHS's problems—may well decide how the perilous run down the icy track ends.”
I think the current NHS reforms could end up with no gain, a disenchanted profession, and a hacked off and over taxed public. Truly, for the UK, for the politicians, the patients and the staff, “all’s spent, nought’s had, if our desire is got without content”
Wednesday, January 31, 2007
Tuesday, January 30, 2007
Doctors! Your Profession Needs YOU!
Well, it seems the BMA has been infected by some of the 'fuck you' mentality that Dr Rant lives for.
On Sunday, Dr Rant suggested:
- Belatedly, the BMA are showing signs of recognising the error of assuming they are dealing with the well-intentioned. They are beginning to realise that the piper calling the tune is a tone-deaf psychopath with no musical or medical knowledge and highly questionable friends.
And right on cue the BMA leader, Hamish Meldrum (pictured above, to the right of Lord Kitchener's arm), issues a press release billed as a 'rallying call to family doctors'.
In a letter sent to 42,000 UK GPs, Meldrum says “At a time when GPs and the wider NHS should be celebrating the achievements of general practice we seem to be facing a constant barrage of unjustified and at times malicious criticism”. Exactly what we've been saying for some time now. The lying evil fucks.
He goes on to point out that "The profession is under threat from local NHS deficits, private sector encroachment and an unprecedented volume of misinformation, including, what appears to be, politically-inspired doctor-bashing." and has included a leaflet rebutting the government propaganda and lies.
Meldrum accuses the government of attempting to blame GPs to "will divert attention from where the real blame lies" [I wonder where that could be? - Ed.], which is spot on.
Most importantly, says Dr Meldrum, “general practice is judged by what we do, the way we treat our patients, the consideration, dedication and compassion of a caring profession. I am confident that these values remain as strong as ever but it is vital that we don't allow the present distractions to affect the core values of the work that we do.”
Thank fuck the BMA are finally beginning to understand what is going on, and that appeasement and Quisling collaboration is not working.
Dr Rant likes to join the BMA from time to time in order to resign in disgust when the occasion justifies it. But, if we are going to save any of the NHS. If we are going to save the patients from lying in their own shit and vomit while the Royal Bank of Scotland and the other PFI fat cats laugh all the way to the...er...bank. If we are not going to be afraid to be admitted to our own hospitals. Then we need to all work together to get rid of the lying, evil fucks who are gutting our public services with their crackpot schemes and corporate cronyism.
Doctors! Your profession needs YOU!
Sunday, January 28, 2007
Patsy OUT!
Dr Mustard would like to draw your attention to the existence of a so-called 'e-petition' on the Downing Street website. This petition calls for the sacking of Patsy Hewitt. It was started by a young Doctor called Ben Taylor who is to be commended for his audacity. Please sign it:
Click here to sign.
We hope that this petition is more succesful than another recent petition calling for the Prime Minister to display his penis in public once a month.
Hang on a minute, he lets John Reid out at least once a week already!
Picture courtesy of Beau Bo D'Or.
The War on Error
I have nothing against Neville Chamberlain.
Contrary to the ugly rumours put about by Dr Mustard, I did not actually know him personally. I admit that his nickname, "The Coroner", has occasionally given me pause for thought, and "Approaching dissolution brings relief" as a deathbed contribution to debate, given what was happening in Europe in 1940, was maybe a tad insensitive.
However, let's cut the man some slack. He had just singlehandedly proven, beyond reasonable doubt, that personal diplomacy and appeasement as negotiating tools are the useless last resorts of the fucking moronic.
Don't misunderstand me. I do not believe that Neville could have in any way avoided the carnage of the Second World War. True, he might just as well have taken a Community Mental Health Team to Munich and relied upon a touch of multiskilled crisis-intervention, as attempt to become bestest friends with Herr Hitler. I DO think that a swift sledgehammer to Adolf's Uniball may well have helped matters, particularly if this could have been made to look like an accident, but I can see the problems with this approach and anyway, basically we were stuffed.
The whole unhappy incident did have one solid-gold, no-shit Sherlock outcome. It established for all time that appeasement cannot work. A millisecond of analysis suggests it never could. Used transitively the verb assumes an aggressor; it means "making concessions to an aggressor in an attempt to preserve peace". Its logical extensions are subjection and surrender.
So why has this discredited, suicidal approach been adopted by the GMC and the BMA as their policy of choice in dealing with a blatantly, rabidly anti-doctor government? Why am I always being told that "He who pays the piper calls the fucking tune"?
My theory...and didn't you just know I was going to have one...is that appeasement is hard-wired; it is the reflex response of the well-meaning but weak-minded to terrorism. It surfaces particularly when those being terrorised are slow, or unwilling, to wake up and smell the shit.
Consider if you will the definition of terrorism, "The systematic employment of intimidation (and/or violence) to coerce a community (or government) into acceding to specific political demands". Now there's a process anyone working in the beleaguered NHS has to recognise.
A few years ago, during the protracted Consultant and GP contract "negotiations", those of us with "reservations" were routinely dismissed as paranoid, non-believers in the good faith and good intentions of Tony and his less than Merry Men. We were alarmists with attitude and trust (or perhaps Primary Care Trust?) issues, pitifully unable to accept it would all be alright on the night.
Well, Hello?
Medical Education has been comprehensively hijacked. Modernising Medical Careers is effectively disempowering existing potential dissenters. It has been made all too clear to any SHOs with a mind not to join the Hitler Youth, that they can just fuck off. The pogrom against International Medical Graduates was swift, silent and shamefully unremarked. On a personal level, my pension is being held hostage and has just had its bleeding head cut off.
And, most importantly, our pitiful capitulation and disempowerment means that the NHS, and all who fail in her, is about to be handed over to United Wealth as our REAL final payment on the Marshall plan. This at a time when the great health divide in our rich country is assuming Grand Canyon proportions.
Belatedly, the BMA are showing signs of recognising the error of assuming they are dealing with the well-intentioned. They are beginning to realise that the piper calling the tune is a tone-deaf psychopath with no musical or medical knowledge and highly questionable friends.
But really they, and we, have no more right to be surprised at the catastrophic, destructive chaos enveloping our Health Service than Neville Chamberlain had to wonder, and I paraphrase here, "What the fuck are those tanks doing in Prague?"
Saturday, January 27, 2007
An Ode to MRSA
Who spread MRSA
Why and what's the reason today
"Don't blame me" chimed Tony Blair
Who denied it all with his usual flair
"We've put in the cash, give me a break
My political history won't be at stake"
Find a doctor we can get onside
Whispered Patsy with a smile so snide
"Blame us blame us" said Joplin with glee
"We earn to much and I feel guilty"
Underplay it all sigh the management
In the end we're all crooked & bent
Make them wash their hands & give them soap
It's the only way out of this tight rope
The relatives scream "the nurses, blame them"
with an ignorant rage; dripping phlegm
"I once saw one walk past the sink"
"I did that too. I did not think"
"We sacked the cleaners" cried the backabench MP
Before the Whip's deathstare made him flee
"Don't speak out. I'll end your career"
"Remember the rent boy, only last year"
Come speak to us spout the BMA
We've always got something pompous to say
We're a trade union, that may be true
but useless vacillation is what we do
Get Tony out, groan the old Tories
We're sick of the lies. sick of the stories
The backbiting starts on the hour.
We just want to get back in power
The reasons from the micrbiology bore
Were drowned out in a global snore
"I can't quite put it in a soundbite
I've never been good at talikg shite"
With threatening tones claim the GMC
We'll find a martyr; we'll do it for free
It's the doctors not the system yawps Graeme Catto
With a bulging head like a sweaty tomato
Hear my news cried the journalists
as they publish many misleading lists
"We've been writing truth since the time of papyrus"
Shame they still call the thing a bloody virus
Blame the NHS say Milliband & Mandy
If we sell it off it'll all be dandy
Fear not my friend, he's what we'll do
Bury it all whence come the bird flu
The plan's so great it cannot fail
The foreign virus'll get us out of jail.
Who spread MRSA
Why and what's the reason today.
Dr Rant would like to thank the original author of this Ode, first posted on the doctors-only discussion forum DNUK earlier this year
Asking the deck chairs to rearrange themselves
Maidstone and Tunbridge Wells NHS Trust management are asking staff to work for free so they can pay for a PFI contract. That's right - the poor are being asked to make sacrifices so that the banks can make even more profit.
Let's just compare those figures:
Royal Bank of Scotland - record profit of £6.2 billion last year
D Grade Staff Nurse - makes around £0.000018 billion per year
Thats a profit ratio of 344,444:1.
So, the answer is obvious to any NHS manager. Steal from greedy Nurse Nancy to give it to needy Wanker Banker.
The PFI deals already done (where private companies build and then run and lease back hospitals to the NHS) will cost £53 billion over the next 20-30 years. Yet, the value of the builds is only £8 billion.
Dr Rant went to the RBS Mortgage online calculator. An £8 billion '2 year tracker' mortgage, repaying the capital over 20 years, would cost a total of £13.15 billion. So, that's an extra profit of around £40 billion that the banks are taking.
The governments and the banks claim that this extra money pays for support services and maintenance. Really? That's a hell of a lot of support services.
Let's do the sums.
£2 billion extra profit for the banks per year, every year, for 20 years.
That's the cost of 100,000 full time D grade Staff Nurses (including their pensions etc). Every year. For 20 years.
Or 20,000 GP principals (including their pensions etc). Every year. For 20 years.
Or 20,000 Front Line 999 Ambulances (including kit and crews). Every year. For 20 years.
That would QUADRUPLE the number of front line 999 ambulances in the UK. Or boost the number of GP principals by around 50%. I'm pretty sure an extra 100,000 staff nurses would not go amiss either.
So unless cleaning a few new hospitals costs 4x as much as the entire NHS Ambulance service, clearly this money does NOT pay for 'support services' .
Dr Rant thinks these huge sums of extra money is a way for the Totalitarian Capitalist Bastards at the banks (who are, after all, the last great monopoly) to make a killing by taking money from the poor, the sick, and the weak. Money that they then hand out in huge bonuses so they can eat out in expensive, exclusive restaurants and clubs. While the poor patients lie in their own shit, vomit, and piss while the few nurses that are left work their arses off for little or no pay.
We have had all of these nurses, ambulances, and doctors STOLEN from the front lines by cheating, lying, scum. The evil fucks running the country did this.
Not only is this obscene, but it threatens democracy. If a Labour government can help in the looting of public services and funds by the fat cats in big business (the new 'ruling class'), then something has gone horribly wrong. If this continues, then violent rebellion is increasingly likely as the poor get poorer and the rich get richer. 'Let them eat cake' is as unnacceptable today as it was in 1789.
Friday, January 26, 2007
Yorkshire is now a Doctor-Free-Zone (DFZ)
As reported by Dr Crippen here and here, Yorkshire
is now becoming a Doctor-Free-Zone© (DFZ) where patients, if they are seen at all, will be seen by cheapo-cheapo Doctor Lite™s. These Non-Doctors are often nurses. They have almost no training or experience in having the final responsibility for diagnosing illness. As the nurses in NHS24 (the Scottish version of NHS Re-Direct™) are discovering, patients die when you don't know you don't know. When this happens, patients sue. The nurses in question are liable to face more manslaughter charges than the proper doctors that they are pretending to be. This is likely to result in a collapse in the Angel image of nurses. I'm not sure the nursing profession understands, or is ready for, the change to being a group that patients automatically blame when their loved ones die.
Anyway, the actions of Dr Janet Soo-Chung CBE fill Dr Rant with rage. It is a rage that is hard to express in words, but perhaps the following images may give you some clue as to what went through Dr Rant's head when reading Dr Crippen's articles:
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is now becoming a Doctor-Free-Zone© (DFZ) where patients, if they are seen at all, will be seen by cheapo-cheapo Doctor Lite™s. These Non-Doctors are often nurses. They have almost no training or experience in having the final responsibility for diagnosing illness. As the nurses in NHS24 (the Scottish version of NHS Re-Direct™) are discovering, patients die when you don't know you don't know. When this happens, patients sue. The nurses in question are liable to face more manslaughter charges than the proper doctors that they are pretending to be. This is likely to result in a collapse in the Angel image of nurses. I'm not sure the nursing profession understands, or is ready for, the change to being a group that patients automatically blame when their loved ones die.Anyway, the actions of Dr Janet Soo-Chung CBE fill Dr Rant with rage. It is a rage that is hard to express in words, but perhaps the following images may give you some clue as to what went through Dr Rant's head when reading Dr Crippen's articles:
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Monday, January 22, 2007
Patzy 'NHS Best Year Ever' Hewitt found alive deep inside patient's arse
As reported on Dr Crippen:
The squeamish should be particularly careful not to look directly at Patricia Hewitt's face. Only view using tinted glasses and a mirror. Or, for maximum safety, get a friend to tell you when it is ok to open your eyes again.
The squeamish should be particularly careful not to look directly at Patricia Hewitt's face. Only view using tinted glasses and a mirror. Or, for maximum safety, get a friend to tell you when it is ok to open your eyes again.
The Neurotic’s Health Service
Bloody neurotics. AAAAAAAARRRRGGGGGGHHHH!
I have had enough of them today. I need to say something. VERY CLEARLY.
Shit happens, and worrying about won’t stop it, prevent it, head it off, anticipate it or do anything useful about it whatsoever. In fact it will make it worse. Now as well as the shit itself, there’s shit for brains (Krapposcephalos to give it its improper medical name) having a panic about it rather than sorting it. 90% of what we worry about never happens, and - even worse - other stuff will come and catch us unawares. Harold McMillan’s classic phlegmatic response about what really worried him, “Events, dear boy… Events”, captures the essence of British Stoicism. Neurotics are the antithesis of this; worrying about phantasmagoria, rather than reality. “Sufficient unto the day is the evil thereof,” but not for the neurotics.
Several neurotics were in full flow in my surgery this afternoon: “If I only had a whole body MRI scan”, “If only I had this investigation”, “Perhaps it’s nothing, but just to be on the safe side”. There’s only so much of this rubbish I can listen to this before I go mad, and tonight my limit was well and truly passed. Think doing 140 m.p.h.on a motorway to realise how far over the limit this was. The total search for reassurance that there is nothing wrong is the hallmark of a good neurosis. The neurotic wants to hear that they don’t have cancer or multiple sclerosis. The patient’s chance of having cancer is usually no worse than mine. The patient hasn’t given me any symptom that might be worth an MRI scan. Some patients may well go off and pay for a private whole body MRI scan. I wish them many incidentalomas for their trouble.
The neurotic is really scared about error, mistake, the possibility that we are missing something. Well of course all those things are possible, and medicine is not 100% sensitive or accurate. Any symptom may be due to cancer. That tingling sensation may be multiple sclerosis, and that twitching muscle may be motor neurone disease or Parkinson’s. Electromagnetic radiation is probably frying your brain, your headache from your mobile phone is probably a sign of a brain tumour, your swelling abdomen is maybe not due to eating too much over Christmas. You can’t be too careful with all these things about nowadays, can you? Actually, yes you can, and our current inability to live with uncertainty will paralyse the NHS if we don’t stop it. There’s a lot of neurosis about, you know. I think I may rename it Sympathetic Nervous System Hyperactivity Disorder (SNSHD © Dr Rant, 2007) and grow rich on the patent. Grow up, live with it, and accept that life has its uncertainties.
And don’t ask your doctor if you are worried about it, as we’ll probably make your worry even worse. Neurotics drive most of the excess expenditure in the NHS. They get over worried, attend more frequently, get investigated more often, get referred more often, get more tubes up more orifices, make more follow up visits, complain more (especially if they cannot see their favourite doctor - “The only one who understands their case”), and so on. They build up fat files, and they drive everyone mad. They get to know the system and somehow always manage to get an appointment, even though they moan that the time is not convenient. They take time away from the treatment of those who are truly ill with severe pathology [Reverse Robin Hood Syndrome - taking time from those that need it, and giving it to those that don't - Ed.], and slow down access to investigations.
They scramble logic, and mistake and misunderstand everything said to them. The more you say the worse they get, and the more visits they need for “clarification”. If a statement needs clarification they haven’t got the message clearly enough: Get out of my consulting room! Nice cardie* doctor turns back into normal ranting self.
Medicine generates neurotics. Doctors pride themselves on being reassuring. This is daft. Medicine is not a reassuring subject. Life is a 100% fatal sexually transmitted disease. There’s as much death about as life, or more if you remember that the dead outnumber the living by about 30:1. As doctors we know many, many ways in which the body and the brain can, and will, go wrong. Sometimes quickly, sometimes slowly, but always we are progressing towards death. Everybody is either ill already, about to become ill, or recovering from an illness (so they can then get another one). Even if we don’t know what’s wrong now, we probably will after the post mortem. To a doctor the only patient who is entirely normal is one we haven’t examined thoroughly enough. Fundamentally doctors are trained in dealing with sickness, not wellness. We are better at saying what is wrong with you, than what is right with you. I hope all this is reassuring to know. Fortunately there probably is more right with you than you realise.
Simon Drew has produced a superb painting - “At the tomb of the unknown worrier”. One of the thoughts emanating from the tomb is “I always told them there was something wrong with me”. Yes, there was. And the final illness wasn’t it. It was the 40 years they spent previously telling all who would listen about this, that, and the other symptom or dread disease they had. A clock that has stopped is right twice a day. There’s enough illness around that eventually even a neurotic will get a diagnosis right.
I think I’m going to start using nocebo (“I will harm" - opposite of placebo, "I will placate”) tactics on these people. I’ll make every scan out to be dangerous, and bad for their claustrophobia. I’ll make every scope bigger, every orifice smaller, and every test more uncomfortable for them. I’ll tell them my colleague Dr Carey Cardigan is ever so much better at this kind of thing than me. (Actually he isn’t- he’s a stressed out passive aggressive who’ll eventually crack. For now however he can fake it.)
I want these people out of my consulting room.
I want them back out in the community.
I want them away from hospitals and dangerous tests.
I want them to realise that I am trying to keep them away form iatrogenic harm.
I want them to realise that medicine can be dangerous to patients, and that you should only accept medical treatments if the illness is sufficiently severe as to render the risks of medicine acceptable.
I want them to realise that hanging around doctors for too long is dangerous.
I want them to realise that presenting too often will destroy their medical credibility rating. Crying wolf will mean we miss their one serious symptom amongst the thousands of symptoms they distract us with.
I care for these patients best when I do nothing at all.
The Pareto Principle applies here with a vengeance. These patients take up about 80% of my appointments for relatively little juicy, real medicine. The remaining 20% who attend sporadically get the left overs. They are often the iller ones, who actually I should be seeing and treating. The same lament would be made by many specialities in medicine. Of course if we worked in a private service we would pander to these people all day and all night, and get rich, as long as we didn’t do anything too harmful. The Fat Man in the House of God (q.v) described this as “The bowel run of the stars.”
A huge amount of NHS cash is being spent on investigating and treating our neurotics, often for little diagnostic or therapeutic success. I have a concern about this. You may be worried about it. As for the great collective, they....well, they are just neurotic.
And this afternoon I met just too much neurosis to tolerate.
Musn’t grumble, better rant!
* Soft, touchy-feely, over-caring doctors are referred to as Cardigans in the medical profession, or Cardie's for short (see Dr Cardigan) - Ed.
Sunday, January 21, 2007
Cull or be culled
Gerry Robinson took six months to establish that if the NHS had a saviour it probably wasn't him. Not a major surprise, but there were interesting incidentals in these programmes.
Everyone remembers the Consultant apparently the proud holder of five degrees, pitifully protesting the 3-GCSE managerial morons? Many of us reflexly cringed, some of us disassociated ourselves, a few toerags apologised, and Patsy Twatsy's spin doctors rubbed their hands with glee. Well, that Consultant was unrepresentative. Widely seen as scoring a spectacular own goal, he had in fact briefly discovered his balls and was making a very valid point. He was also understating his case.
You don't in fact need any qualifications to be an NHS manager...all you need is a progenitor. Then, as we know to the NHS's cost, managers are the fastest replicators on the block. Doctors are ludicrously slow replicators at best (if MMC goes ahead unchanged, we won't replicate at all) and the difference DOES lie in the respective qualifications required for the tasks.
This is a problem, and the uncomfortable truth that 3-GCSE man was pilloried for pointing out.
In the same programmes, bints with questionable intentions, bad clothes, lousy hair, and shit-for-brains, repeatedly referred to Consultants as "difficult" and "obstructive". They bigged up their own martyred heroism, and skills in dealing with doctors at all, by describing them as routinely having tantrums and the playground mentality of primary school children. These unstudied insults produced no outcry in any quarter. Somehow their slanderous behavior was seen as totally acceptable. Why?
Well the bints were unashamedly crapping upwards (the Consultants were repeatedly accused of being "in charge"), and in our sad society this is more than all right. It is encouraged. It is the norm. We have allowed ourselves to be managed into a rabid anti-meritocracy. The message is, "Hide your light under a bushel baby or you will burn".
I was reminded of all this by the self-confessed "25th most influenshall person in the world", Jade Bloody Goody. How ironic is that for a surname?
Dutifully watching last week's Celebrity Big Brother I was nagged by a sense of deja vu, a certainty that the horrible dynamic unrolling before me was all-too-familiar. As the attempted massacre of the innocent unfolded, all became clear. This was not CBB management, this was NHS management, as brought from the DoH to doctors, with love. An ignorant, self-seeking git was going for the throat of a perceived threat and relying on the sense of fair play of her target to get away with it.
True to type, Jade self-replicated within seconds; she gathered her empty-headed coven around her and they sat belching and bitching while the target cooked and cleaned. Worked, my lovelies. Worked in a sad attempt to please and appease. Sound familiar?
But stupid Shilpa (money, brains and beauty notwithstanding) couldn't even get the cooking right. She didn't understand that she wasn't about to get anything right. Jade couldn't afford that she should. If Jade had been a better "manager", or had her spin-doctor in the house rather than her monosynaptoid mate, she could easily have capitalised upon her initial success. Having encouraged the hapless Shilpa to self-question and self-immolate, all she really needed to do was hold the party line and wait.
Happily, the victim in question was Indian, the Big Bad Bitch went over the top, the race card came into play and the mob shamelessly turned. But what about that mob? And what about the neutral, neutered housemates? They stood by, obviously appalled and horrified but, to a man (just a coincidence I'm sure), they remained firmly above the blatantly abusive fray. All the usual excuses for inaction were rehearsed, some of them with the victim. Just a bitch-fight, personality clash, territorial issue between the alphas. Well all power to you bunch of numbnuts. Perhaps no-one has ever mentioned that standing on your dignity for too long does tend to fucking destroy it.
For those of you entirely lost in an overstretched analogy, we have now moved from hideous Jade/Patsy chimeras, to the BMA and our respective, respected Royal colleges. The received wisdom is that the usual suspects who appease, accept and accelerate the profession's decline are in search of money or medals [See Dr Pink, perpetuating that myth earlier on Dr Rant - Ed.]. The truth is much more scary...they are just typical bloody Shilpas, sorry doctors, or clones of her quiescent, ineffectual allies. Like most of us, they are quite prepared to take "reasonable" to suicidal extremes. They stand on our dignity, fatally compounding our original sin, and the game is lost, we are lost, the NHS is lost.
On Newsnight, when Paxo 'controversially' asked Gerry Robinson, "How do we put these arrogant Consultants back in their box?", the boy wonder had the grace to protest that he didn't want to put them in their box. Well comrades, that the question can be asked means that we have already squashed ourselves into boxes, quietly, sadly protecting the inner baby-seal that made it so easy to put us there in the first place.
If the NHS and our profession are to survive, it is time to stand up and club those cuddly, useless fuckers to death. It will be bloody; it may hurt; we may lose some of our special, loveable quality. But we stand to gain some clout.
And Christ knows there are a few Jade Goodies wrecking the NHS that could really benefit from a good clout.
Everyone remembers the Consultant apparently the proud holder of five degrees, pitifully protesting the 3-GCSE managerial morons? Many of us reflexly cringed, some of us disassociated ourselves, a few toerags apologised, and Patsy Twatsy's spin doctors rubbed their hands with glee. Well, that Consultant was unrepresentative. Widely seen as scoring a spectacular own goal, he had in fact briefly discovered his balls and was making a very valid point. He was also understating his case.
You don't in fact need any qualifications to be an NHS manager...all you need is a progenitor. Then, as we know to the NHS's cost, managers are the fastest replicators on the block. Doctors are ludicrously slow replicators at best (if MMC goes ahead unchanged, we won't replicate at all) and the difference DOES lie in the respective qualifications required for the tasks.
This is a problem, and the uncomfortable truth that 3-GCSE man was pilloried for pointing out.
In the same programmes, bints with questionable intentions, bad clothes, lousy hair, and shit-for-brains, repeatedly referred to Consultants as "difficult" and "obstructive". They bigged up their own martyred heroism, and skills in dealing with doctors at all, by describing them as routinely having tantrums and the playground mentality of primary school children. These unstudied insults produced no outcry in any quarter. Somehow their slanderous behavior was seen as totally acceptable. Why?
Well the bints were unashamedly crapping upwards (the Consultants were repeatedly accused of being "in charge"), and in our sad society this is more than all right. It is encouraged. It is the norm. We have allowed ourselves to be managed into a rabid anti-meritocracy. The message is, "Hide your light under a bushel baby or you will burn".
I was reminded of all this by the self-confessed "25th most influenshall person in the world", Jade Bloody Goody. How ironic is that for a surname?
Dutifully watching last week's Celebrity Big Brother I was nagged by a sense of deja vu, a certainty that the horrible dynamic unrolling before me was all-too-familiar. As the attempted massacre of the innocent unfolded, all became clear. This was not CBB management, this was NHS management, as brought from the DoH to doctors, with love. An ignorant, self-seeking git was going for the throat of a perceived threat and relying on the sense of fair play of her target to get away with it.
True to type, Jade self-replicated within seconds; she gathered her empty-headed coven around her and they sat belching and bitching while the target cooked and cleaned. Worked, my lovelies. Worked in a sad attempt to please and appease. Sound familiar?
But stupid Shilpa (money, brains and beauty notwithstanding) couldn't even get the cooking right. She didn't understand that she wasn't about to get anything right. Jade couldn't afford that she should. If Jade had been a better "manager", or had her spin-doctor in the house rather than her monosynaptoid mate, she could easily have capitalised upon her initial success. Having encouraged the hapless Shilpa to self-question and self-immolate, all she really needed to do was hold the party line and wait.
Happily, the victim in question was Indian, the Big Bad Bitch went over the top, the race card came into play and the mob shamelessly turned. But what about that mob? And what about the neutral, neutered housemates? They stood by, obviously appalled and horrified but, to a man (just a coincidence I'm sure), they remained firmly above the blatantly abusive fray. All the usual excuses for inaction were rehearsed, some of them with the victim. Just a bitch-fight, personality clash, territorial issue between the alphas. Well all power to you bunch of numbnuts. Perhaps no-one has ever mentioned that standing on your dignity for too long does tend to fucking destroy it.
For those of you entirely lost in an overstretched analogy, we have now moved from hideous Jade/Patsy chimeras, to the BMA and our respective, respected Royal colleges. The received wisdom is that the usual suspects who appease, accept and accelerate the profession's decline are in search of money or medals [See Dr Pink, perpetuating that myth earlier on Dr Rant - Ed.]. The truth is much more scary...they are just typical bloody Shilpas, sorry doctors, or clones of her quiescent, ineffectual allies. Like most of us, they are quite prepared to take "reasonable" to suicidal extremes. They stand on our dignity, fatally compounding our original sin, and the game is lost, we are lost, the NHS is lost.
On Newsnight, when Paxo 'controversially' asked Gerry Robinson, "How do we put these arrogant Consultants back in their box?", the boy wonder had the grace to protest that he didn't want to put them in their box. Well comrades, that the question can be asked means that we have already squashed ourselves into boxes, quietly, sadly protecting the inner baby-seal that made it so easy to put us there in the first place.
If the NHS and our profession are to survive, it is time to stand up and club those cuddly, useless fuckers to death. It will be bloody; it may hurt; we may lose some of our special, loveable quality. But we stand to gain some clout.
And Christ knows there are a few Jade Goodies wrecking the NHS that could really benefit from a good clout.
White Light, White Heat.....White Noise
Dr Rant just got bigger.
I'd like to welcome our newest member, Dr White.
I've known Dr White since I was a brand new GP doing locums. She is well known for her dry wit, and her views on weeding out and dealing with the collaborators, Quislings, and suckup gong-merchants in the medical colleges and BMA.
So we are all looking forward to some excellent new rants on how we can save the profession and its poor patients by forming an orderly lynch mob.
I'd like to welcome our newest member, Dr White.
I've known Dr White since I was a brand new GP doing locums. She is well known for her dry wit, and her views on weeding out and dealing with the collaborators, Quislings, and suckup gong-merchants in the medical colleges and BMA.
So we are all looking forward to some excellent new rants on how we can save the profession and its poor patients by forming an orderly lynch mob.
Saturday, January 20, 2007
Question Time!
This question is for The Rt Hon. Patsy Fuckwit MP:
"Who does the Secretary of State for Health believe should be allowed to make 'a profit' from the NHS?
a) The private companies that are set to share a risk free bonanza of £23 billion for being awarded contracts through the private finance initiative (PFI).
b) The 'management consultants', many of whom work for your old company, who deliver nothing yet cost the NHS more in total than the medical consultants who deliver the actual 'service' bit (as in National Health Service).'
c) GPs who run their own businesses and manage 90% of day to day NHS activity, and who were were given a legally binding contract to deliver extra work for the benefit of NHS patients.
Patsy talks bollocks
Who the fuck does this crazy woman think she is?
Has she ever run anything herself? If she has ever run anything has it ever run anywhere than into the ground? Do her ideas have any more flight than a block of concrete? Is she to business management what Saddam Hussein is to the Nobel peace prize? Is she to honest dealing what Enron was to accounting?
She surpassed herself on Friday, aided and abetted by Toynbee. Here we have two women neither of whom has any idea how to run anything. Now they think they can tell GPs how to run their businesses.
Patsy’s wrong to attempt this for several reasons:
Firstly, there’s no evidence she can run anything well.
Secondly, there’s fuck all evidence that anyone in her party can run anything well. John Reid “Oh fuck, not health” and now “oh it’s a fuck up at the home office”. They run fitness for purpose exercises but neglect to run it on themselves. Shame.
Thirdly, there’s no evidence that the expensive management consultant fuckers she employs can run anything at all. The fact that Patsy emerges from such a background shows just what poor value management consultants really are. They know everything, until it comes to implementation. Then they try the King Charles 2nd exculpation:
Rochester "We have a pretty, witty King, Whose word no man relies on. Who never said a foolish thing, Nor ever did a wise one"
King Charles II: Be just, Rochester. The wise words are my own, the deeds are my ministers'
Sadly Hewitt has never even got as far as saying any wise thing.
Fourthly, she has no knowledge of how to run general practice
Fifthly, GPs are mostly actually very good at running general practices. We’ve been doing it for a long time and we have worked out some of the pitfalls.
Sixthly GPs are independent contractors. This means we are tasked to do a job, not told how we should go about a job. We are not employees, and if we were we would be appalling employees as we like to think for ourselves, not simply obey orders. So if we want to employ extra staff we can. If we want to keep our costs down we can. If we make good profits we keep them. If we employ too many staff we have to pay them.
The new GP contract was meant to be an adult deal. As GPs we have over delivered on the new contract (ministers believed all the stories about GPs being on the golf course, and not being very good at medicine spread by researchers and specialists who should know better). Ministers should be celebrating our achievements and saying thank you to us. Instead they are berating us for the consequences of us running our practices well to achieve those outcomes they wanted us to achieve. This is incompetence and base ingratitude.
If you asked for your front room to be decorated would you say to the decorator, “Well we agreed that price but we’re disappointed you didn’t do the bedroom as well”, or “Well you can do the job but you cannot hire any one else in to help you”. You just wouldn’t do this. You’d specify the job and the price and trust the decorator to get on and deliver the job, by whatever fair means he wanted to use.
The practice receives the income and uses it sensibly to achieve a good service for patients and a good profit for the partners. The government has a duty to see the money is well spent, and services delivered, but has no right to meddle in the internal management of practices.
Seventhly, [Is that a real word, Frank? - Ed.] this government is actually in deep doodoo over health. They have poured billions in with bugger all idea about what they were buying. They have got next to nothing for their efforts although the taxpayer is picking up a huge bill. They thought doctors were lazy, idle shysters, when in fact it was their researchers who relied on false, lazy, flawed assumptions.
Patsy is trying to deflect blame for the state of NHS onto GPs. Apparently she’s going to try and blame us for the failure of out of hours (OOH) services as well on Monday. Yet it was the DH that thought it could run OOH better than GPs despite the successes of the GP OOH co-operatives.
Patsy suffers from the delusion of all new Labour and management consultants that they know better than the people who do the work how it should be done. It’s bollocks. We need to stop accepting external wisdom as being better than internal wisdom. It usually isn’t for reasons that David Craig and Jim Collins explain.
The NHS is suffering from Medicine for Idiots at the DH.
The NHS is suffering a financial haemorrhage as money disappears into the pockets of:
- Management consultants (More than is spent on medical consultants: so we pay those who tell us how to do the work, more than we pay those who actually do the work. This is lunacy.)
- Perfected financial idiocy
- Choose and Book (aka Booze and chuck, Chaos and Bullshit)
- The NHS computer system
- Measuring everything that everyone who sees patients does
- Payment by results
- Outsourcing of support staff
- ISTC
- NHS Direct and NHS 24
- [Don't forget GPWSIs - Ed.]
At least the GP service in UK works. If the rest of NHS was as well run as general practices it would be far better.
To Patsy Hewitt: Fuck. Off. Let us run our practices. We do it far better than you can.
And please do not be as daft as to try to dictate our income vs expenses ratios.. They are OUR business, not YOURS. You don’t try this game with any other NHS contractors do you? You’re quite happy for private companies to make as much profit as they want aren’t you? Whilst hospitals go bankrupt and cut services.
But suddenly it’s new when GPs earn well. Anyone can make money out of the NHS, but not GPs. You bloody hypocrite.
We’ll get our income/expense ratios right according to the contract in place at the time. And we’ll look after the patients well.
Wednesday, January 17, 2007
The "unacceptable face of cronyism" in Labour’s NHS
When are the medical profession, the media and the public going to wake up to the outrageous relationships between big business, management consultancies, Whitehall politicians and the disastrous NHS reform agenda?
This is just a taster of some of the issues and personalities involved. Most of this information is from David Craig’s book, “Plundering the Public Sector”. [My copy just arrived in the post today - Ed.]
In 1997 when Labour took office, Gordon Brown (one of the few Labour politicians that had not criticised PFI under the Tories) immediately embraced the PFI to keep down public sector borrowing, which was one of his prudent “golden rules”.
The famous Geoffrey Robinson (new Paymaster General) was put in charge and 6 days after the election victory, Robinson announced a review of the PFI emphasising the importance of the PFI to New Labour.
A further 6 weeks later and the review blueprint came out. Out went the Tory bankers and builders and in came The Treasury PFI Taskforce, essentially a Labour run quango of management consultants, lawyers and industry specialists.
This taskforce made the PFI process much easier and more attractive to private companies by essentially minimising financial risks an increasing the chances of profitability. The PFI immediately became very lucrative to private companies and not surprisingly has spiralled out of control ever since.
The Taskforce used complex calculation methodologies to show that PFI was more cost effective than public procurement. A BMJ article in 2002 showed the public-sector comparator (PSC) always came out cheaper than PFI, but methodological tweaking and biases then put PFI projects at least on a par. This coupled with Alan Milburn saying “PFI is the only show in town” ensured PFIs won out.
Amazingly, the same management consultancies who had developed these methodologies and enshrined them in the Taskforce guidance were also employed by public bodies to advise on the procurements. Surprise, surprise PFI repeatedly came out on top for building and running public infrastructure!
The initial bad publicity that followed the rip off nature of PFIs was countered by an Anderson Consulting study which said that PFI was 17% cheaper. No sooner had this been rubbished by its obvious biases, then PwC came in with another pro-PFI report. HMG ignored rigorous critical reports by Pollock and Shaoul and stuck by the PwC report. Even the National Audit Office (NAO) was made to be pro-PFI by appointment of a “head of PFI development”
It is quite amazing to see the web of involvement in numerous PFI schemes the various companies have. The big four management consultancies seem to continually assess, audit and advise on each others messes and come out with the “right answers”. The web of involvement with HMG is also very interesting. We as taxpayers are all now paying a very heavy price for "the unacceptable face of capitalism". The PFI is unsustainable and killing NHS Trusts up and down the country.
To illustrate the web of personalities and cronyism involved in the privatistion of the NHS take a look at the following list:
Consultants turned public servants:
1. Richard Abadie: former Price Waterhouse Coopers (PwC), now Head of PFI policy HM treasury (excellent name by the way!)
2. Liame Byren: former Anderson Consulting, Labour MP and Health minister
3. Paul Corrigan: former indepedant consultant managing public service change, became Special Advisor to health secretary (architect of ISTCs and Foundation Trusts)
4. Dr Penelope Dash: former McKinsey consultant, became director of Monitor (independent regulator of Foundation Trusts)
5. Richard Grainger: Deloitte partner, became head of NHS IT programme
6. Patricia Hewitt: Director Anderson Consulting, became SoS for Health!!
7. Paul Jones: Director Atos Origin, became Chief technology officer for CfH
8. Simon Leary: Consultant PwC, became head of DH strategy unit
9. Adrian Masters: Consultant with IBM and PwC, became director of health team in PMs delivery unit, then head of strategy at Monitor
10. Sheila Masters: KPMG partner, appointed to public services productivity panel looking at performance, estates and IT in NHS
11. Dr Timothy Stone : Chairman KPMG PFI advisory services, became member of the DH commercial directorate advisory panel amongst other HMG advisory roles in health, farming and MoD!
12. Tony Whitehead: Coopers and Lybrand Consultants, became member of Treasury PFI Taskforce
Public servants turned Consultants:
1. Baroness Jay: Health minister, became senior advisor to Currie and Brown, construction consultants active in PFI
2. Lord Barnett: Labour Peer, became Charmain Atos Origin
3. Alan Milburn: SoS for Health became paid advisor to parent company of Alliance Medical
These are not exhaustive lists and only covered Health!
I am not the “stereotypical Consultant” portrayed by the media and politicians as a “force of conservatism” against reform of the NHS. I’m a “hungry for change” youngster and believe in modernising but not in the New Labour meaning. I believe in value for money for the taxpayer, but not in the New Labour meaning. I believe in taking sound advice from the private sector and industry, but not in the New Labour meaning. I believe in a role for the private sector in healthcare, but not in the New Labour meaning. I believe in the existence of the NHS, but not the New Labour meaning.
I apologise to all taxpayers for voting Labour in the last 3 general elections. I hope you will accept that apology and join me in ridding ourselves of this menace to our country.
Finally,
Read the blood boiling books by David Craig: “Plundering the Public Sector” and “Rip Off”.
Also “NHS Plc” by Allyson Pollock [As recommended by Dr Rant - Ed.]
Join Keep Our NHS Public Now!
Originally posted on DNUK 13.01.07 by Clive Peedell, Consultant Clinical Oncologist, James Cook Univeristy Hospital. Thank you Clive for letting Dr Rant post it here.
Conflict of Interest Declaration: Colin Peedell: Taxpayer, member of Keep Our NHS Public
This is just a taster of some of the issues and personalities involved. Most of this information is from David Craig’s book, “Plundering the Public Sector”. [My copy just arrived in the post today - Ed.]
In 1997 when Labour took office, Gordon Brown (one of the few Labour politicians that had not criticised PFI under the Tories) immediately embraced the PFI to keep down public sector borrowing, which was one of his prudent “golden rules”.
The famous Geoffrey Robinson (new Paymaster General) was put in charge and 6 days after the election victory, Robinson announced a review of the PFI emphasising the importance of the PFI to New Labour.
A further 6 weeks later and the review blueprint came out. Out went the Tory bankers and builders and in came The Treasury PFI Taskforce, essentially a Labour run quango of management consultants, lawyers and industry specialists.
This taskforce made the PFI process much easier and more attractive to private companies by essentially minimising financial risks an increasing the chances of profitability. The PFI immediately became very lucrative to private companies and not surprisingly has spiralled out of control ever since.
The Taskforce used complex calculation methodologies to show that PFI was more cost effective than public procurement. A BMJ article in 2002 showed the public-sector comparator (PSC) always came out cheaper than PFI, but methodological tweaking and biases then put PFI projects at least on a par. This coupled with Alan Milburn saying “PFI is the only show in town” ensured PFIs won out.
Amazingly, the same management consultancies who had developed these methodologies and enshrined them in the Taskforce guidance were also employed by public bodies to advise on the procurements. Surprise, surprise PFI repeatedly came out on top for building and running public infrastructure!
The initial bad publicity that followed the rip off nature of PFIs was countered by an Anderson Consulting study which said that PFI was 17% cheaper. No sooner had this been rubbished by its obvious biases, then PwC came in with another pro-PFI report. HMG ignored rigorous critical reports by Pollock and Shaoul and stuck by the PwC report. Even the National Audit Office (NAO) was made to be pro-PFI by appointment of a “head of PFI development”
It is quite amazing to see the web of involvement in numerous PFI schemes the various companies have. The big four management consultancies seem to continually assess, audit and advise on each others messes and come out with the “right answers”. The web of involvement with HMG is also very interesting. We as taxpayers are all now paying a very heavy price for "the unacceptable face of capitalism". The PFI is unsustainable and killing NHS Trusts up and down the country.
To illustrate the web of personalities and cronyism involved in the privatistion of the NHS take a look at the following list:
Consultants turned public servants:
1. Richard Abadie: former Price Waterhouse Coopers (PwC), now Head of PFI policy HM treasury (excellent name by the way!)
2. Liame Byren: former Anderson Consulting, Labour MP and Health minister
3. Paul Corrigan: former indepedant consultant managing public service change, became Special Advisor to health secretary (architect of ISTCs and Foundation Trusts)
4. Dr Penelope Dash: former McKinsey consultant, became director of Monitor (independent regulator of Foundation Trusts)
5. Richard Grainger: Deloitte partner, became head of NHS IT programme
6. Patricia Hewitt: Director Anderson Consulting, became SoS for Health!!
7. Paul Jones: Director Atos Origin, became Chief technology officer for CfH
8. Simon Leary: Consultant PwC, became head of DH strategy unit
9. Adrian Masters: Consultant with IBM and PwC, became director of health team in PMs delivery unit, then head of strategy at Monitor
10. Sheila Masters: KPMG partner, appointed to public services productivity panel looking at performance, estates and IT in NHS
11. Dr Timothy Stone : Chairman KPMG PFI advisory services, became member of the DH commercial directorate advisory panel amongst other HMG advisory roles in health, farming and MoD!
12. Tony Whitehead: Coopers and Lybrand Consultants, became member of Treasury PFI Taskforce
Public servants turned Consultants:
1. Baroness Jay: Health minister, became senior advisor to Currie and Brown, construction consultants active in PFI
2. Lord Barnett: Labour Peer, became Charmain Atos Origin
3. Alan Milburn: SoS for Health became paid advisor to parent company of Alliance Medical
These are not exhaustive lists and only covered Health!
I am not the “stereotypical Consultant” portrayed by the media and politicians as a “force of conservatism” against reform of the NHS. I’m a “hungry for change” youngster and believe in modernising but not in the New Labour meaning. I believe in value for money for the taxpayer, but not in the New Labour meaning. I believe in taking sound advice from the private sector and industry, but not in the New Labour meaning. I believe in a role for the private sector in healthcare, but not in the New Labour meaning. I believe in the existence of the NHS, but not the New Labour meaning.
I apologise to all taxpayers for voting Labour in the last 3 general elections. I hope you will accept that apology and join me in ridding ourselves of this menace to our country.
Finally,
Read the blood boiling books by David Craig: “Plundering the Public Sector” and “Rip Off”.
Also “NHS Plc” by Allyson Pollock [As recommended by Dr Rant - Ed.]
Join Keep Our NHS Public Now!
Originally posted on DNUK 13.01.07 by Clive Peedell, Consultant Clinical Oncologist, James Cook Univeristy Hospital. Thank you Clive for letting Dr Rant post it here.
Conflict of Interest Declaration: Colin Peedell: Taxpayer, member of Keep Our NHS Public
Patient choice is a dangerous myth
A long, long, time ago, there was a village in a far away land.
In this village there were two GPs. They had gone to medical school together, and they had moved to the village about the same time. Each had their own practice in the village seeing their own patients. The patients in this village were free to join whichever of the two practices they chose.
One day, when the two GPs had been in the village for several years, one of the GPs was browsing in the market at the center of the village. He spotted his fellow GP buying some goods, and decided to ask him a question that had been playing on his mind for some time.
"Dr Nicebutdim" said Dr Good.
"Ah, hello there Dr Good" replied Nicebutdim.
"You know, we've known each other a long time, Dr Nicebutdim, and I have something I need to ask you." Continued Dr Good. "I was top of my class at school, and top of my class at medical school. I'm an excellent GP, I rarely get my diagnoses wrong, and I always prescribe the best medicines for my patients."
"All true" smiled Nicebutdim.
"You, on the other hand, Dr Nicebutdim, were a chancer at school, and barely escaped being thrown out of medical school. You frequently get the wrong diagnosis, and your patients are lucky to be alive with your terrible prescribing."
"All equally true" admitted Nicebutdim with a smile, for he truly was very nice, but very dim.
"So why is that 95% of the people in this village are your patients, and only 5% of the people in this village are my patients" asked Dr Good, bemused.
"Come with me, Dr Good" was the only reply. And Dr Nicebutdim led Dr Good over to a nearby door, through it, and up the stairs of the tallest tower in the village.
"Look down and tell me what you see" said Dr Nicebutdim, pointing down to the marketplace below thronged with villagers buying and selling goods.
Dr Good looked down for a moment, and then said "I see a bunch of idiots".
"That's correct, Dr Good. 95% of those people are idiots. They're my patients"
This story first appeared in the New England Journal of Medicine some years ago (sadly I have lost the original, and can't find it on the NEJM site, so apologies to the original author).
The moral of the story is not to insult patients, but to point out that even fellow professionals have trouble working out which doctors are duff. Usually, we simply go with people we like. Research has shown that litigation rates against doctors are not linked to their error rates, but to their communications skills.
This is a big problem for patients who think that being given choice will solve the problems of poor care. What it will do is solve the problems of ugly hospitals. We can all appreciate a shiny ward with Sky TV and good food.
However, Dr Rant once worked (very briefly) in a lovely shiny private hospital. The only problem was that the staff had little training in dealing with emergencies, and the resuscitation trolley was in a frankly dangerous state.
Had any of the rich clients actually become unwell in their comfy beds, there would have been fuck all Dr Rant could have done about it with one rubber glove and an antique defibrillator which lacked a screen. Perhaps they expected me to be able to divine the heart rhythm - or perhaps I was supposed to just give electric shocks and adrenaline on the off chance that (1) that was the correct treatment, and (2) the antique defibrillator actually was capable of delivering an electric shock.
Fucking scary stuff. And did the satisfied customers realise how close to death they had come, silently cruising the Titanic within sight of icebergs? Did they fuck.
Patients are not morons. But neither are they medical professionals. What they need is to know that their local hospital will provide good quality, safe, care in a clean and pleasant environment.
What they don't need is to play Russian Roulette with Choose and Die or whatever other pretend capitalist shit idea is flavor of the month.
In this village there were two GPs. They had gone to medical school together, and they had moved to the village about the same time. Each had their own practice in the village seeing their own patients. The patients in this village were free to join whichever of the two practices they chose.
One day, when the two GPs had been in the village for several years, one of the GPs was browsing in the market at the center of the village. He spotted his fellow GP buying some goods, and decided to ask him a question that had been playing on his mind for some time.
"Dr Nicebutdim" said Dr Good.
"Ah, hello there Dr Good" replied Nicebutdim.
"You know, we've known each other a long time, Dr Nicebutdim, and I have something I need to ask you." Continued Dr Good. "I was top of my class at school, and top of my class at medical school. I'm an excellent GP, I rarely get my diagnoses wrong, and I always prescribe the best medicines for my patients."
"All true" smiled Nicebutdim.
"You, on the other hand, Dr Nicebutdim, were a chancer at school, and barely escaped being thrown out of medical school. You frequently get the wrong diagnosis, and your patients are lucky to be alive with your terrible prescribing."
"All equally true" admitted Nicebutdim with a smile, for he truly was very nice, but very dim.
"So why is that 95% of the people in this village are your patients, and only 5% of the people in this village are my patients" asked Dr Good, bemused.
"Come with me, Dr Good" was the only reply. And Dr Nicebutdim led Dr Good over to a nearby door, through it, and up the stairs of the tallest tower in the village.
"Look down and tell me what you see" said Dr Nicebutdim, pointing down to the marketplace below thronged with villagers buying and selling goods.
Dr Good looked down for a moment, and then said "I see a bunch of idiots".
"That's correct, Dr Good. 95% of those people are idiots. They're my patients"
This story first appeared in the New England Journal of Medicine some years ago (sadly I have lost the original, and can't find it on the NEJM site, so apologies to the original author).
The moral of the story is not to insult patients, but to point out that even fellow professionals have trouble working out which doctors are duff. Usually, we simply go with people we like. Research has shown that litigation rates against doctors are not linked to their error rates, but to their communications skills.
This is a big problem for patients who think that being given choice will solve the problems of poor care. What it will do is solve the problems of ugly hospitals. We can all appreciate a shiny ward with Sky TV and good food.
However, Dr Rant once worked (very briefly) in a lovely shiny private hospital. The only problem was that the staff had little training in dealing with emergencies, and the resuscitation trolley was in a frankly dangerous state.
Had any of the rich clients actually become unwell in their comfy beds, there would have been fuck all Dr Rant could have done about it with one rubber glove and an antique defibrillator which lacked a screen. Perhaps they expected me to be able to divine the heart rhythm - or perhaps I was supposed to just give electric shocks and adrenaline on the off chance that (1) that was the correct treatment, and (2) the antique defibrillator actually was capable of delivering an electric shock.
Fucking scary stuff. And did the satisfied customers realise how close to death they had come, silently cruising the Titanic within sight of icebergs? Did they fuck.
Patients are not morons. But neither are they medical professionals. What they need is to know that their local hospital will provide good quality, safe, care in a clean and pleasant environment.
What they don't need is to play Russian Roulette with Choose and Die or whatever other pretend capitalist shit idea is flavor of the month.
Tuesday, January 16, 2007
Billy's Dad's Job
Billy was at school one morning and the teacher asked all the children what their fathers did for a living.
All the typical answers came: fireman, policeman, salesman, chippy, captain of industry, doctor, etc.
But Billy was being uncharacteristically quiet and so the teacher asked him about his father.
"My father is an exotic dancer in a gay club and takes off all his clothes in front of other men. " said Billy. "Sometimes if the offer is really good, he’ll go out with a man, rent a cheap hotel room and let them sleep with him."
The teacher quickly set the other children some work and took little Billy aside to ask him if that was really true.
"No" said Billy. "Dad is a senior health minister in Tony Blair's government but I was too embarrassed to say"
This was originally posted as a comment by Cynical NHS Manager on the Karyn Miller Talks Shite post, but Dr Rant liked it so much he felt it should have a post of its own.
All the typical answers came: fireman, policeman, salesman, chippy, captain of industry, doctor, etc.
But Billy was being uncharacteristically quiet and so the teacher asked him about his father.
"My father is an exotic dancer in a gay club and takes off all his clothes in front of other men. " said Billy. "Sometimes if the offer is really good, he’ll go out with a man, rent a cheap hotel room and let them sleep with him."
The teacher quickly set the other children some work and took little Billy aside to ask him if that was really true.
"No" said Billy. "Dad is a senior health minister in Tony Blair's government but I was too embarrassed to say"
This was originally posted as a comment by Cynical NHS Manager on the Karyn Miller Talks Shite post, but Dr Rant liked it so much he felt it should have a post of its own.
Tory Woman Opens Mouth and Swallows Foot
Conservative London Assembly Member Professor Elizabeth Howlett must have felt rather chuffed with herself, whilst checking the Letters to the Editor in The Times Yesterday, to once again see her name emblazoned in newsprint. The former International Opera Singer turned Conservative Deputy Chair of London Assembly Health and Public Services Committee thought that this was a good idea at the time presumably:
Sir, Time and time again the Department of Health promises action and delivers nothing, but the news that the Government will not reach its target of halving the MRSA rate is particularly shocking.
With the relentless drive to deal with the NHS deficit, hospitals are being forced to slash training budgets, yet improving staff training is one of the most basic things the Department of Health needs to ensure, so that best practice can be spread to each local hospital.
This was one of the recommendations contained in my 2005 London Assembly Report, MRSA in London. With other viruses like clostridium difficile on the rise, effective infection control is more than just a matter of making people use alcohol gels.
Hospital infections are not inevitable: adopting better procedures around staff uniforms and bed-crowding, as well as tackling consultants’ self-belief that they are germ-free, can be done and must be done.
ELIZABETH HOWLETT
Conservative Deputy Chair, London Assembly Health and Public Services Committee
London SE1
This is the problem with 'democracy' isn't it? Any old Tom Dick or Harriet feels empowered to thrust their ill considered prejudiced half-baked 'opinion' upon anyone who will listen in the mistaken belief that it carries some merit, yet people who know what they're talking about are usually ignored. The above letter contains a basic and fundamental mistake, betraying the writer's astounding lack of basic scientific knowledge and rendering herself and her opinion utterly irrelevant in this debate.
MRSA IS NOT A FUCKING VIRUS!
Neither is Clostridium difficile! They are BACTERIA. If you do not understand the difference, then you are utterly unqualified to comment on the very real problem of hospital acquired (nosocomial) infections. I can assure you that doctors and nurses are anything other than cavalier when it comes to hand washing, but until you've done worked under the kind of kind of day-to-day conditions they have (which are the cause of the problem), then I'm afraid you should shut the hell up. Professor Howlett can also shove her comment about consultants’ self-belief that they are germ-free RIGHT UP HER ARSE! - that is ignorant and self important bullshit beyond the stratospheric standards set even by the Daily Mail (to which I expect she subscribes). Isn't it also strange how the press fails to discuss the fact that often the patients bring these bugs into hospital with them, and sometimes it's their relatives? Oh no! Beastly doctors not washing their hands is the sole cause of problem. (Listen love; we're not perfect but we're trying really hard and we really do care about it - but you sticking your oar in hasn't helped!)
Basically, as far as Elizabeth Howlett's contribution to this debate is concerned The Fat Lady's Singing! (and she should stick to opera)
Monday, January 15, 2007
Tomb or Womb
Does medicine need the NHS or the NHS need medicine?
Consider the womb. It is a secret world, only partially observed by outsiders. The life developing inside it is not yet conscious of itself. The organism within the womb is developing being nourished and supported as it grows.
The womb is a useful temporary home. It is never a final destination. Staying in the womb too long risks the problems of post maturity, with a dying foetus and a failing placenta.
I wonder if the NHS has been like a womb to the British medical profession for too long now. The NHS may have given the medical profession a lifeline when it was set up, but it may no longer be capable of being a supporting structure for our profession.
There’s a part of me that thinks the NHS rather cocoons doctors from the harsh realities of life. National pay scales and an attitude of “you won’t have to worry about your salary or redundancy” were widespread when I was learning medicine. I am now seeing them as false. Like Descartes I have been struck by the number of falsehoods I had previously accepted as true. I am becoming ever more aware of how many more falsehoods people are still trying to sell to me, in this “best year ever for the NHS.”
The government and other medical bodies often portray the NHS as the whole of medicine in the United Kingdom, and behave as if there are no other options for British doctors other than the NHS. This is clearly a false concept as although the NHS does about 90% of the medical workload at least 10% is done within the private system and this proportion looks set to increase.
Beyond these percentages however there is a deeper flaw in the habit of ministers and others who falsely conflate medicine and the NHS into one entity.
We need to remember that medicine is actually an ancient and learned profession, with its own distinct epistemology. I am a doctor because I know about the world in a particular and useful way. Although I use this knowledge in service of patients, the knowledge has to precede the service.
The NHS provides a delivery system for my knowledge, but it does not have my knowledge. Without the knowledge of doctors the NHS has nothing worth offering to patients, especially as it has so reduced its commitment to long term care and the associated nursing input.
The question that arises is, “Is the NHS a suitable delivery system to get medical skills and talent to where they are needed?” The answer to this question seems to be “No.” The number of British graduates who have left these shores bears testimony to that. Some have gone for better lives abroad, but a larger number have gone to get away from the NHS. The willingness of many consultants to take early retirement, and the angry comments of senior consultants such as Theodore Dalrymple, Raymond Tallis, Robert Winston and others is evidence all is not well with how doctors relate to their roles within the NHS. The problems with modernising medical careers may well drive many junior colleagues abroad next year.
As a profession we are slowly waking up into a painful self-awareness of ourselves and of the system that both contains and constrains us. The system both nurtures and kills us. The NHS is a gilded prison for British doctors, convenient, available, well paid, but at a price of sacrificing quality to quantity, process to throughput, and standards to expedience. The NHS suffers from that Socialist flaw which is that levelling down so that everyone gets the same may be fair, but is actually a lose-lose scenario for many involved.
The latter day attempts to remedy these defects by talking a lot about quality whilst still insisting patients are pushed through the sausage machine of an outpatient clinic too quickly is the confirmation that the NHS is chasing two objectives at once. The NHS is a house divided against itself, trying to straddle the divergent demands of quality and quantity simultaneously. That its managers and ministers seem not to realise (or perhaps are not able publicly to admit) that these are in deep conflict is a sign of NHS management’s inability to think through problems clearly. The manager’s restless pursuit of ever moving targets is an example of activity as a substitute for thought.
I know what I should be doing in my job. Does any manager know what he or she will be doing next week? Or what next year’s great initiative will be?
However I look at it, and although grateful to some extent to the NHS for early on the job training, from my current knowledge I think that the NHS is in danger of becoming a tomb for the medical profession. Unless British medicine either delivers itself, or is delivered from, the NHS it will die smothered in the womb. And without the profession the NHS too will die. The NHS needs doctors more than the doctors need the NHS.
The womb is a useful temporary home. It is never a final destination. Staying in the womb too long risks the problems of post maturity, with a dying foetus and a failing placenta.
I wonder if the NHS has been like a womb to the British medical profession for too long now. The NHS may have given the medical profession a lifeline when it was set up, but it may no longer be capable of being a supporting structure for our profession.
There’s a part of me that thinks the NHS rather cocoons doctors from the harsh realities of life. National pay scales and an attitude of “you won’t have to worry about your salary or redundancy” were widespread when I was learning medicine. I am now seeing them as false. Like Descartes I have been struck by the number of falsehoods I had previously accepted as true. I am becoming ever more aware of how many more falsehoods people are still trying to sell to me, in this “best year ever for the NHS.”
The government and other medical bodies often portray the NHS as the whole of medicine in the United Kingdom, and behave as if there are no other options for British doctors other than the NHS. This is clearly a false concept as although the NHS does about 90% of the medical workload at least 10% is done within the private system and this proportion looks set to increase.
Beyond these percentages however there is a deeper flaw in the habit of ministers and others who falsely conflate medicine and the NHS into one entity.
We need to remember that medicine is actually an ancient and learned profession, with its own distinct epistemology. I am a doctor because I know about the world in a particular and useful way. Although I use this knowledge in service of patients, the knowledge has to precede the service.
The NHS provides a delivery system for my knowledge, but it does not have my knowledge. Without the knowledge of doctors the NHS has nothing worth offering to patients, especially as it has so reduced its commitment to long term care and the associated nursing input.
The question that arises is, “Is the NHS a suitable delivery system to get medical skills and talent to where they are needed?” The answer to this question seems to be “No.” The number of British graduates who have left these shores bears testimony to that. Some have gone for better lives abroad, but a larger number have gone to get away from the NHS. The willingness of many consultants to take early retirement, and the angry comments of senior consultants such as Theodore Dalrymple, Raymond Tallis, Robert Winston and others is evidence all is not well with how doctors relate to their roles within the NHS. The problems with modernising medical careers may well drive many junior colleagues abroad next year.
As a profession we are slowly waking up into a painful self-awareness of ourselves and of the system that both contains and constrains us. The system both nurtures and kills us. The NHS is a gilded prison for British doctors, convenient, available, well paid, but at a price of sacrificing quality to quantity, process to throughput, and standards to expedience. The NHS suffers from that Socialist flaw which is that levelling down so that everyone gets the same may be fair, but is actually a lose-lose scenario for many involved.
The latter day attempts to remedy these defects by talking a lot about quality whilst still insisting patients are pushed through the sausage machine of an outpatient clinic too quickly is the confirmation that the NHS is chasing two objectives at once. The NHS is a house divided against itself, trying to straddle the divergent demands of quality and quantity simultaneously. That its managers and ministers seem not to realise (or perhaps are not able publicly to admit) that these are in deep conflict is a sign of NHS management’s inability to think through problems clearly. The manager’s restless pursuit of ever moving targets is an example of activity as a substitute for thought.
I know what I should be doing in my job. Does any manager know what he or she will be doing next week? Or what next year’s great initiative will be?
However I look at it, and although grateful to some extent to the NHS for early on the job training, from my current knowledge I think that the NHS is in danger of becoming a tomb for the medical profession. Unless British medicine either delivers itself, or is delivered from, the NHS it will die smothered in the womb. And without the profession the NHS too will die. The NHS needs doctors more than the doctors need the NHS.
Sunday, January 14, 2007
Karyn Miller Talks Shite
Whilst the Sunday Telegraph has the distinct advantage of not being associated with Wooly Pinko Liberals and Champagne Socialists, it does occasionally print some astoundingly crap journalism.
This Sunday’s example of Publish First Think Second column filling drivel, comes from Karyn Miller and Jasper Copping. (It’s a good job that the Dr Rant doesn’t stoop to the puerile level of making fun of someone’s name, otherwise Jasper would be ‘copping it’ right now).
The Healthcare Journalism Revelation of the Weekend® is that ‘GPs are like, basically, right, totally like diagnosing loads of people with chronic diseases, right, you know, so they get paid loads of money like’ (paraphrase).
Unfortunately, Karyn and Jasper don’t get off to a flying start by getting the name of the new GP target-based payment system wrong. ‘QOF’, Karyn, stands for Quality and Outcomes Framework. It does not stand for Quality Of Framework, as you refer to it repeatedly in your article [Quality of Framework isn't even proper English and doesn't mean anything - Ed.]. The discriminating reader could be forgiven for turning the sports section after that unforced error, but I’ll go on for your amusement.
I don’t know about you but, if I had a chronic disease like hypertension, I would want it diagnosed and treated early to significantly lessen its effects on my future health. The efficient identification and management of chronic disease promoted by the QOF targets have been more successful than anyone predicted. The aim is that people will live longer, and stay healthy for longer.
It appears that Ms Miller’s aim, however, is to imply that there is widespread fraud being perpetrated by GPs in the pursuit of financial gain. She alleges that this is achieved by GPs diagnosing a greater proportion of their patients as having chronic diseases. Unfortunately, the QOF doesn’t actually work like that, and doing what is suggested would create a significant amount of extra work for the GP for little or no extra money - ie: they would lose money. [By my calculations from the figures in the article, even if 20% of GPs were carrying out such a deception, they would need to have diagnosed every s