The Secretary of State’s Dream

Once upon a time the Secretary of State for Health for England had a dream. He shared this dream with his foreign counterparts and they too had had the same dream for their own countries.

In his dream the Chancellor of the Exchequer handed him all the resources he could possibly need to get the National Health Service working. He set to work with his civil servants and together they drew up a Great Plan to galvanise the Sleeping Beauty of the NHS into action. It was the equivalent of a 360J shock, going straight to the heart of the organisation!

Doctors and nurses were recruited. Hospitals were well managed and well equipped. They even got new stuff before the Americans did! The cleaning was done properly and so MRSA disappeared. Momentum was generated, flip charts did not just flip but somersaulted in springs of ecstatic action and the morale of managers, doctors and nurses rose mightily. They had never been so empowered before and relished their opportunities. Heigh Ho! Heigh Ho and off to work they went!

And what a lot they achieved. Patients were seen promptly and every one of them received all necessary treatment quickly and courteously. In some cases it was so quick that the treatment was given before the patient even knew they needed it! What a change from the bad old days of waiting lists and prolonged suffering.

It had cost a lot in staff overtime to get the waiting lists sorted but it had all been money well spent. And even the treasury were not concerned about the cost, so great and good was the accomplishment. This was just what a good health service should be like.

The Secretary of State basked in well deserved public adulation. He had achieved the seemingly impossible goal of getting the National Health Service to work. The Prime Minister was soon retiring and with his great track record he was sure to be asked to step into his shoes, nemine contradicente!









Tomorrow:

The Secretary of State's Nightmare

Eye don’t see

You might think that Dr Rant is written out of raw anger. It isn’t. It’s actually written out of grief. We have a tremendous sadness that something that is good, effective and useful, and which could and should have been improved further is being dismantled and replaced with a complete mess of stupidity. We are in the end times of the NHS, and the forces of good need to re-establish themselves.

Just a brief example of stupidity here. It arises from the great success that is known as Choose and Book (aka Chaos and Bullshit, Booze and Chuck).

It comes from the excellent local ophthalmology department.

“Dear Dr Rant,

Thank you for your letter about this patient and I apologise for the fact that the management here have seen fit to ignore your letter to Dr Eye and deposit him in one of my clinics which meant that he took time off his work and came all the way over to St Faraway’s.

As you know Dr Eye had wanted to follow him up in the clinic in St Faraway’s because she needed to see him early in the morning. According to our records he failed to attend on two occasions and Dr Eye made no further appointment to follow him up and wrote to you. However on talking to the patient the first failure to attend was not a failure to attend. He has a letter at home from the Trust telling him to ignore that appointment and to keep an appointment that they sent as a replacement in November. He then tells me then that he only received the letter for my clinic yesterday morning. I really feel quite upset that patients and GPs are being treated in this way in the new wonderful “Health Service”

[he then goes on to describe the clinical scenario and why Dr Eye would have been clinically more appropriate for this patient than himself]

Yours sincerely

Dr Wisdom,
Consultant Ophthalmologist”

We have much prattle by pratts about 'a patient centred health service'. Yet here we see it in action getting the wrong patient to the wrong doctor with a struggle and with stupidity. The patient’s time is wasted, clinic time is wasted, and the doctor’s blood pressure goes up. Heaven knows how many admindroids it took to generate this muck about. And how few it would have taken if it had been dealt with right first time.

Just another example of day by day NHS organisational mismanagement.

The management’s panopticon has a cataract in every lens.

“That is an absolute insult……”

Liam Halligan, in today’s Sunday Telegraph, is spot on in his diagnosis and description of NHS changes. The Telegraph's graphic (above) shows what you need to know.

The NHS Titanic has gone round in circles, and got nowhere. The captain on the bridge has changed, but none of them have had any understanding of what they were doing or why they were doing it.

New Labour has squandered medical and NHS staff goodwill almost as fast as they have squandered money. They have totally betrayed the nhs founding principles, and put nothing in their place other than an expensive mess. The private sector vultures are hovering over the NHS carcass and may well get it if the public come to believe the NHS is irredeemably inefficient, whichever party is in power. Sadly I doubt the private sector will do any better than the NHS, and may in fact be worse still.

Dr Rant recommends Liam Halligan's analysis. In his interview in the same paper with the Secretary of State for Health, Patricia claimed that the suggestion that she has harmed patients just to save her job was 'an absolute insult' to hard working NHS staff. Nice try, Patsy. Dr Rant believes it is an absolute insult to patients, doctors, other NHS workers, and anyone with more than one functioning neurone, that Mrs Hewitt is still in office fiddling the books whilst the nhs is privatised and destroyed.

Her civil servants have no confidence in her NHS managers.

The doctors want her to go too - in fact Dr Rant challenges you to find me a front-line doctor that doesn’t.

Let’s hope the public and Mr Blair (or Mr Brown, bearing in mind Patsy's a Blairite) decide her time is up. Ms Hewitt may not be planning on failure. But then again, she doesn’t need to, she's already achieved failure.

Let’s push her out as quickly as we can. This is one place to start.


Liam Halligan's Dispatches investigation "NHS: Where did all the money go?" will be shown on Channel 4 on Monday 26th February at 8pm.

The Daftest NHS Survey Ever or I'm a Little Teapot!

see full size image

The above Chose and Book survey is being conducted, at taxpayer's expense, across GP surgeries
in England.

What information can possibly be gleaned from it?

The doctors are handing it out to patients........just AFTER we have done a referral via choose and book in surgery (or if we we are smarter, we give it to them while we are doing a Choose and Book appointment). So the patient can only answer "Yes".

And the survey does not even apply if we do a referral to specialities not covered by Choose and Book!

So we have a survey, with one question, expecting the answer 'Yes!'.

Do we need to explain how stupid, daft and invalid this is as a measure of anything?

Yet another way for Patsy to fiddle figures whilst hospitals close, staff are laid off and the patient centred NHS takes ever greater steps not to ask the questions that matter to patients.

Primary Care Trusts: who needs the fuckers?

Brothers and Sisters,

Rev Dr Green has chosen John Chapter 11 and verse 35 for my sermon today: "Jesus wept". And well he might.

Isn't it amazing? Successive cycles of reorganisation of the NHS have reached their apogee with the formation of these organisations that were supposed to take on the acute trusts and run the NHS "properly". What are we left with now? A sad ragbag of organisations that are busily merging because they were not big enough to take on the acute trusts (whoever conceived of the idea of the NHS being a boxing match anyway? What a dumbfuck idea).

The little vermin that inhabit be burrows of these "organisations" (using that term as loosely as the English Language allows) are so busy chasing after new sinecures that Planning Blight has now descended on the NHS, with no one willing to plan or carry out anything.

All over the country 'Practice Based Commissioning', which was the PCTs' favourite buzzword for about 18 months, is just not happening. (This was another idea of the Ven Anthony Bliar to save the NHS - get GPs to commission care on the cheap, by doing it for free. Hardly surprising then that the GPs said, "Fuck Right Off Patsy".) Of course, the PCTs didn't really want the GPs to do it, because if they did manage to run it successfully, they would find themselves out of a job, and no one, but no one, gets sacked in the NHS (except for doctors and nurses in the more bankrupt acute trusts, but who gives a fuck about them, right?).

Strategic Health Authorities are also merging because they weren't big enough! Nothing at all gets done, except, of course, the bloated parasites suck the blood of front-line NHS workers. They sit in their offices in front of computer screens looking at porn, managing to attend meetings, carrying briefcases full of papers so that they look important, and draw their inflated salaries, whilst all they do is to think of increased targets and obstacles to put in the clinicians' way (greedy GPs? Look at the doctors' cars in Dr Rant's practice - Fords and Honda's, none of them new - then look a the the PCT managers' cars: Mercs and BMW's - need one say more?).

The NHS is an inverted pyramid with the hard, and important work done at the narrow, sharp, end, with all the freeloaders sitting above, in increasingly wide layers.

Don't believe me, brethren? Just try sending an e-mail to the scum this week at your local PCT. It's half-term, remember? They've all got their 'out of office' on. 'I'll be back in the office on Monday'. Yeah? Well who gives a fuck? The NHS coped for a week without you. It could cope for 10 years without you.

"Do not pass Go. Do not collect £200. Instead, go and collect your P45".

And now, the Rev Dr Green asks that we offer one another a sign of peace....

Fuck choice. Choose MMC (again)

I'm reposting this because I came across a link to it from this blog which merged it with the MMC monopoly board which was published earlier by Dr Rant. I wish I'd thought of that.

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Choose MMC. Choose MTAS. Choose a region. Choose a career. Choose a fucking big lottery. Choose portfolios, on-line application forms and years of uncertainty. Choose a cut in training posts, career choice and job security. Choose FTSTA’s no one knows anything about, middle grade rotas being run by juniors who’ve never worked in the specialty before, foundation programmes you have no control over, and hospitals you don’t want to work in. Choose being treated by ‘trained doctors’ rather than ‘doctors in-training’, even though the average consultants training hours have been cut from 40,000 to 10,000. Choose Hospital At Night and no-one knowing the patients anymore. Choose being an SHO lost in the middle of it all, with nothing but a sparsely updated web-site to inform yourself. Choose seniors who know nothing about the system and seem powerless to influence it. Choose an internal office with no windows in your brand new PFI hospital while the doors fall off and middle managers sit in their swanky boardrooms munching on biscuits that your taxes are paying for. Choose paying £10 a day for the privilege of parking at your work-place while you work non-compliant rotas and get bullied into lying on your EWTD monitoring forms. Choose sitting at that PC filling-in mind-numbing, spirit-crushing objective assessment questionnaires. Choose PMETB-approved curricula and competency-based assessments no-one has properly validated. Choose your third choice career path and wondering who the fuck you are on a busy post-take ward-round. Choose rotting away at the end of it all, pishing your last in a miserable Non-Consultant Career Grade post, nothing more than an embarrassment to the under-experienced, ‘fit for purpose’ FY’s you’ve trained to replace yourself.

Choose not to choose your future.

Choose MMC.


Dr Rant loves this - sounds great when done in a strong Ewan McGregor accent. It was first posted on DNUK, and Dr Rant would like to thank the original author for permission to republish it here (and the original artist for the image too).

Why Dr Findlay Doesn't Do Out of Hours Any More

More controversy has erupted about GP services and the new contract.

The responsibility for Out of Hours (OOH) services was removed from GPs and given to Primary Care Trusts [PCTs Perfectly Crap Treatments? - Ed.] when the new GMS2 contract came in April 2004. For many GPs this was the best part of the deal. GPs are no longer responsible for the standards or provision of OOH services.

Indeed any current complaints about OOH services cannot be laid at the GP’s door. They must go to the PCTs charged with providing them. The fact that PCTs are struggling to do this, as demonstrated by SERCO vs KERNOWDOC in Cornwall is a problem for the PCTs [and the patients - Ed.], not GPs.

The DH and PCTs thought they could provide doctor lite services - doctors are so expensive, overpaid, and over-rated they felt. They thought Red Adair was wrong - “If you think professional advice is expensive, try taking advice from an amateur”. They thought advice from non-doctors would do just as well for colds and sniffles.

This policy is crashing down around the DH and its PCT lackeys today. Yet another great piece of New Labour management.

Why were GPs so keen to give OOH work up?

We’ll start with the obvious fact that unsocial hours are unsocial. Having evenings and nights disrupted by calls is disruptive. When you have to do this and work the day after then it starts to take a toll on you.

But this wasn’t the biggest problem.

There were other underlying dynamics that combined to really make many GPs detest OOH work. Any job is a combination of satisfaction, salary and support.

The Department of Health valued OOH work at around £6000 per year per GP in the new GMS contract. Before this, GPs essentially did the work for free. If they wanted to offload this work say to a deputising service or OOH co-operative then they had to pay, and ended up losing money. So the service started from poor pay.

Then the support element was minimal. OOH services were supposed to be for emergencies only. Sadly the definition of emergency proved elastic and having answered calls about head lice at 3am and spoken to sad, drunken alcoholics at 1.30 a.m. my tolerance wore thin. If the OOH service had been kept to genuine emergencies then GPs would have had to lump it and do it. But it wasn’t. The call rate rose steadily throughout the 1980s and 1990s.

And politicians kept on encouraging people to call whenever and whatever they wanted. No politician can utter the R word:

RATIONING

and so no one had the courage to back GPs in their attempt to keep demand down. Added to this the increasingly jittery public, that want everything checked just to be sure, and who think all rashes are meningitis, then the support for GPs was minimal at a time when demand was rising. Also society was becoming more violent and the risk of attacks on lone, especially female GPs operating in rough areas was growing. Who wants to save lives by putting their own in danger routinely?

This led to the development of GP OOH co-operatives which proved successful organisations pooling GP resources, providing drivers, and security. They provided good service and got most calls sorted within an hour. Phone advice, OOH centre appointments, or visits, were provided according to need.

Needless to say the Government couldn’t give these organisations any credit, and so set about duplicating these services with the dire NHS direct (or NHS Re-Direct as it is known in the trade). Rather than having experienced doctors, nurses who are inexperienced at diagnosis were given algorithms to follow. And of course, algorithims are so much better at diagnosing things than doctors.

Fundamentally there was no support for GPs doing OOH work in terms of income, appreciation or safety.

The third nail in the coffin of GPs and OOH work was lack of satisfaction. The demand were rising, the support dropping, and then the risk of complaints got ever higher. OOH was only a small fraction of GP workload but by far the most dangerous in terms of medico-legal risk. Strange as it may seem, doctors hate medico-legal risks. They will do their best to avoid situations likely to expose them to these risks. In OOH work it was easy to make mistakes, and patients complained and sued us frequently. Local papers loved stories of “bungling doctors” and, with their duty of confidentiality, GPs have no chance of defending themselves against lurid allegations splashed across newspapers. The fact most complaints are answered satisfactorily or dropped never gets a mention in the papers. We were tired and stressed enough at the end of a full day’s work (0830 to 1830 approx, 35-50 patients seen). To then go and see patients was a recipe for trouble, grumpy doctors, and stressed out patients. It was a combustible combination and bad for doctors and patients alike.

Can you see why doctors were keen to avoid work that is poorly paid, unappreciated, physically risky and medico-legally risky?

These are the reasons why GPs cheered the OOH opt out in the new contract.

Any attempt to make us go back to it is unlikely to be successful. GPs were resigning and retiring to get away from OOH work. Partnerships were having internal rows about OOH work. Partnerships were unable to recruit new partners as they would not take on OOH commitment.

The new contract has bolstered GP partnerships, and made GP again an attractive job. Any attempt to foist OOH back onto GPs could see a rush of GPs either to the barricades or the exit.

Please don’t admit anyone….the hospital cannot cope

Staff hard at work in a Flagshit PFI NHS hospital

Latest missive from Dr Rant’s friends at the PCT (Problem Creating Tumour, Primary Cause of Trouble):

“Escalation update.

We have had notification this morning that both local acute hospitals, St Here’s and St Elsewhere’s are experiencing huge pressures and are currently struggling to cope with the increased demand.

There are high levels of sickness amongst medical and nursing staff: you may therefore face problems in admitting patients to either site. Please consider referrals to Intermediate Care, District Nursing Teams, Community Matrons and Specialist Nurses for support during these difficult times.”

Now Dr Rant is puzzled by this pointless missive.

Firstly he is not aware of any particularly unusual patterns of illness in his area. There’s the usual number of winter colds, but it doesn’t seem anything unusual for a winter. And this seems a very mild winter so far.

Secondly he cannot reduce his number of admissions. If a patient is ill the doctor is honour bound to admit him or her to hospital. It’s simple. The GMC correctly says that “You must make care of the patient your first concern” and:

"Good clinical care must include:
a. adequately assessing the patient's conditions, taking account of the history (including the symptoms, and psychological and social factors), the patient's views, and where necessary examining the patient.
b. providing or arranging advice, investigations or treatment where necessary.
c. referring a patient to another practitioner, when this is in the patient's best interests.”

So Dr Rant must refer patients to hospital for urgent admission when their clinical condition demands it. It is the duty of the NHS to provide such facilities so that I can carry out my duty.

The basis of the NHS is access to treatment on basis of clinical need, not on any grounds of capacity, cost, social status, moral worth or any other prejudice that might get in the way. Rule one of medicine is that if the patient is severely ill you admit them to hospital. Rule two is that if you think the patient is severely ill you admit them to hospital. You don’t take risks with patients just to save the NHS a few quid. Sure GPs often admit cases where the diagnosis turns out to be less serious than first thought (e.g. suspected appendicitis turns out to be bad irritable bowel syndrome, or period pain), but medicine constantly catches even the best doctors out, and diagnoses are often obvious only in retrospect. It's just not acceptable to make routine use of post mortems for diagnosis.

Every year aggrieved and grieving relatives sue GPs over missed diagnoses and delayed referrals. Accepting medico-legal risk is part of the role of GP, but the GP’s job is to try and lessen this risk, and the NHS must help by putting in fail safe systems to back GPs up. One of these fail safe systems is hospital back up when the GP needs it to secure the best and safest treatment for the patient.

Yet in this letter we have the NHS management almost begging doctors not to admit patients to hospital. The manager is subtly suggesting that admissions should be referred to alternative places but without any real idea of whether the local services have the ability or capacity to handle the problems. Now I am very fond of my district nursing and intermediate care colleagues, and they have their place in the portfolio of options available to GPs (Community Matrons are about as effective as chocolate fireguards, but that's a different rant).

However, when the patient is ill enough to need admission it is my duty as a GP to send the patient in to hospital. And I’m sorry that the hospital is struggling to cope with demand. I know the staff are working hard. The hospital in question is PFI and so a size too small for the area it serves. But the bottom line is that as a GP if my patient is ill enough I must organise the treatment he or she needs, in hospital if needs be.

The NHS is currently trying to subvert this medical role, whilst not removing any medico-legal or disciplinary responsibility from me. In this instance the letter shows managerial despair as the local service is struggling even to provide basic care for acutely ill patients. If this is the state of the NHS after billions of pounds of extra investment then where has the money gone? It’s no wonder that neither the doctors, nor Patsy’s own senior civil servants believe in her working any longer.

What the Secertary of State for Health does not seem to understand is that a £20 billion computer, £billion management consultants, and £40 billion of NHS-money-turned-profit -for-PFI-banks, doesn't treat a single fucking patient.

Mad As Hell

There are many good things about this country and now but some madness is let loose.

The main one of these is the almost gleeful rebellion from the stereotyped reserved, stoicism of old Britain.

Now it seems as if there is a culture of psychopathy, short term, hedonistic, egotistically vain and imbued with a sense of exaggerated entitlement.

Grinning morons spending huge amounts of time and money on superficial matters of appearance. Be it cosmetic surgery, tattoos, haircut, foolish sartorial affectations. All this under the pretense of a functionless value system such as the tyranny of cool.

Irresponsibility in financial matters. Spend, spend , spend. Acquire, accumulate, consume.

Be it shitty chav uniforms, 10 cm hooped earings or pansy holidays in
the destination de jour where little Tristam can swim with the fucking dolphins.
Recycling pseudohippies travelling Boeing 4 times a year. Fake friggin creeps.

Replacing phones twice a year. Men with highlights. Incredibly dense adolescents sitting in Starbucks with Che Guevera T-shirts.
Literature students who can't punctuate.

The majority of UK society pretending to be working class, despite 2 cars, 3 foreign holidays and a mortgage. The mocking of intellect and detailed analysis. The glib preference of superficial vacuity.

The false praise for meritocracy, where to prefer the meritorious is seen as crusty, snobby elitism.

Politicians pretending to like soaps and football. Glottal stops affected in sentences to be "one of the people".

Educated people reading, value sapping cancerous gossip magazines in an "ironic" manner (don't get me started on these pretentious cunts). The value of individuals with no demonstrable talent, for simply broadcasting their troubles and being "one of us". The relative disrespect and resentment for those who consitently show ability, skill or brilliance.

Ludicrously shameless, naked ambition, self promotion and spiritual debasement all in the name of acheiving the empty kudos of celebrity.

Insane fixation with physical appearance with a 3 kg window of healthy weight and the entire value system challenges of those who traverse this window.

Loud demands of outrage before verdicts are reached. Instant suspicion of every male who works within 50 metres of a child he has not fathered.

Males, no longer "emotionally repressed" now hugging and crying in the arms of any short term acquaintance, acting in an emotionally labile manner of such excruciatingly egotistical superficiality. Unable to cope with normal life pressures.

Fat bastard children gorging their corpulent faces on sunny D, drooling onto their playstations showing their expertise of virtual soccer. Never having owned a football.

Crazy parents, getting tutors for their kids, doing their projects, banning them from failing. Filling their timetables, yes timetables, with all sorts of extracurricular activities, lest they fail to fullfil their wonderful potential. Growing up as neurotic wrecks, fearing any failure and unable to cope with rejection, loss or any setback.

Incomprehensible, violent, scum males, whose only modes of existence are drunkenness and violence.

Wanky pretentious modern art twats whose collusion in mass self deception would be hysterical were it not a tragic waste of kidneys.

Mocking disregard for anyone whose values put duty, kindness and quiet determination before ambition and appearance and extroverted emotive boasting.

A complete demand for every one to have an equal opinion irrespective of their merits and skills on the pertinent subject, with an absolute distrust of any "expert".

Egocentric feelings of stifled entitlement, everyone thinking they can do better than their boss, superior. Unable to consider experience and skill of others as potentially being more developed.

The bullshit language of modern politics. Cancerous guff, bland platitudes, blue-sky-thinking, management speak.

All parties "delighted" to announce every new initiative or "revolutionary" concept.
Deceit, lies, scapegoating, discrediting. Hiding and burying inconveniences.

Inability of this country to manufacture mechanical items. Relying on pubs, coffee shops, media and advertising. In fact, don't get me started on advertising. A malignant industry, riddled with morally bankrupt ideas and rotten fuckers, whose pretense at being "creative types" masks the fact that they are the most despicable disciples of capitalistic expropriation, producers of nothing other than fear and vanity tricks.

Ignorant baying press pontificating from a position of arrogant incompetence and stupidity.

Lazy acceptance or consensus prejudice yet public disgrace for anyone who courts controversy on a "bad" prejudice.

There are so many good points abou this country but there has been a mass change in the value system. This country, under consumer capitalism, has almost acheived the collective personality of a psycopath.

There is a sickness at the moral core of this place, I just hope that the inherent goodness of people is enough to balance this collective stupidity.



[This first appeared on the doctors-only discussion forums of DNUK - thank you to the original poster for permission to reproduce it here - Ed.]

Communication Skills

I've had to go into hiding.

I don't know how they first found out.
It's a secret I've kept all my working life.
I have pretended; I have lied; I have born false witness.
And I was caught.
I still don't know what gave me away.
The Paramedics were terminal, tossing prevaricators.
The Community Matron did need her bleedin' neurones looked at.
The CPN had never contributed to the Nutters in his nurture.
Somehow everyone came to know.
Management(and there's a bunch of mindless, minted morons)were informed.
Appointments were made, meetings were held.
Soundings were taken(though I would have called these fucking secret recordings and had done).
And I was caught
So I tried, dear Reader, I tried.

It was not my fault.
How could I know the Facilitator would turn out to be a rat bastard?
I should never have agreed to go.
But it was "Communication Skills(Beginners)" or parcel tape over the mouth.
So I went.
They felt I was not engaging, was not on board(Sooorry, simply hadn't noticed the bleeding gangplank).
With humility, I reflected, I respected, I genuflected and I stood corrected(not exactly a cakewalk with my knees, at my age).
It was not enough(and so boring my bloody mind melted).
One careless moment, two double Espressos and it was, "How's this for a buggery mission statement then?"
And I heaved the rat bastard over the balcony at break time.

Some things aren't worth the learning.
I've managed without Communication Skills before and I'll manage again.

If he lives.

Fuckin' twat.



[Great minds must think alike, Dr Rant. Just before I received this piece I noticed that HospitalPhoenix has posted on the same topic today - Ed.]

Don't just do something, sit there!

I've been mulling over my Quality and Outcome Framework, performance review. Yes I am a sad git, perennially on-call and committed to work avoidance as default.

I have just noticed, "We found an organised proactive practice".

Ever ready to learn, I looked up "proactive" in the Oxford English Dictionary: "Of a person or policy creating or controlling events, ready to take the initiative, a tendency to make things happen".

Reader, it froze my blood. I cannot imagine how I became such a monster. You couldn't be proactive when I was a ladette: it hadn't been invented and would likely have earned you a well-deserved clog round the head. Now - reflexly applauded, encouraged and rewarded - is proactivity, particularly as applied to health, really such an unalloyed joy?

If everyone was proactive, what would the world look like...apart from less ugly with the plastic surgery and all?

In a Health Service, Ultimate or Extreme Proactivity would necessarily entail a thorough application of the precautionary principle. Don't smoke leads inevitably to "Don't cross the road you may be run over by a bus".

Plainly silly. How would an ordinary bloke and his bimbos get from the corridors of power to Number 10?

Scoping the bus problem(a new skill I picked up during my Contract Review) we would obviously require risk-assessment, population screening, remedial health education, training programmes, testing procedures, enforcement orders....where are we with the GP contract review for 2007/8. Wouldn't this fit right in as a quality target or something....we could measure reaction times, visual fields, check bus cognition, develope road-crossing avoidance strategies for the totally inept, maybe a buddy system or an expert road-crosser scheme ...??? Probably have to involve a few other agencies...schools, social work, community care...





Sorry, drifted off there. Scarily easy to do when you're being proactive. And there's the rub, the good old horse-liniment of life.

PROACTIVITY does exactly what it says on the tin; it favours activity, any activity however moronic, at any expense.

Extrapolate "Bus Avoidance" measures to every aspect of life and you have, well, pretty much how we live now.

A harrassed, frightened populace, pervasively invaded by fungating bureaucracy and terminally distracted from the pursuit of happiness and buses.

And I, and my practice, would appear to be part of the problem.
I have decided I must change.
I must proactively seek to be REACTIVE
I must become a nuclear reactor.
And that's the Quality and Outcome Framework out the window.

Memo to man recently run over by a bus in Islington:

"As you had failed to attend the recommended pedestrian training course on three occasions prior to your close encounter with a number 33 in Upper Street, you will be billed for the entire cost of your stay in Intensive Care. Should you regain the use of your legs, you are reminded that attendance at the nearest Pedestrian Centre for Training(PCT) within six weeks of discharge is mandatory. Failure to comply with this order will lead to all road-crossing privileges being withdrawn without further notice. Future incidents would therefore not be covered by the Health System."

Get well soon.

Data spine continues to implode

The groundbreaking National Data Spine being put through its paces by an NHS boffin.


The National Patient IT Framework (National Data Spine to you and me) lurches from iceberg to iceberg.

Henry Morgan has drawn Dr Rant's attention to this article in which Fujitsu says that what is being done is not working, and is not going to work.

We'd ask the Secretary of State for Health, Commissar Spewitt, for a comment, but we already know what she'd say:



DR RANT: Commissar Splatzy, the IT framework continues to implode. It is projected it will cost £20,000,000,000. Even if you can get it to work, it's handling of confidential patient data is both illegal and unethical. Doctors no longer have faith in it, most say they don't need it, and you are closing wards and shutting hospitals because of an NHS defecit that is only 5% of the projected cost of this project. Are you on drugs, and if not, why not?

PATTY SPATTY (Secretary of State for Misinformation on Health): The NHS has had its best year ever. Less money for patient care is a good things, because it means there is less illness to cure. Less food for starving third world children is a good thing, because it means there is less hunger. More nurses than ever before, more doctors.........blah.....lies.......blah.......spin.......bullshit......blah........

DR RANT: [turns flamethrower on the SoS for Health.......]

PATSY FUCKWIT: I'm melting.......I'm melting......

What we have in today's NHS is an unholy seething quagmire of the worst in public sector bureaucratic excess, and the worst in private sector opportunistic greed in symbiosis.

I can't think of a single example in the last 10 years where health policy has reflected 'perceived wisdom' as recognised by the front line medical profession.

Discuss......

Fuck choice. Choose MMC.

Choose MMC. Choose MTAS. Choose a region. Choose a career. Choose a fucking big lottery. Choose portfolios, on-line application forms and years of uncertainty. Choose a cut in training posts, career choice and job security. Choose FTSTA’s no one knows anything about, middle grade rotas being run by juniors who’ve never worked in the specialty before, foundation programmes you have no control over, and hospitals you don’t want to work in. Choose being treated by ‘trained doctors’ rather than ‘doctors in-training’, even though the average consultants training hours have been cut from 40,000 to 10,000. Choose Hospital At Night and no-one knowing the patients anymore. Choose being an SHO lost in the middle of it all, with nothing but a sparsely updated web-site to inform yourself. Choose seniors who know nothing about the system and seem powerless to influence it. Choose an internal office with no windows in your brand new PFI hospital while the doors fall off and middle managers sit in their swanky boardrooms munching on biscuits that your taxes are paying for. Choose paying £10 a day for the privilege of parking at your work-place while you work non-compliant rotas and get bullied into lying on your EWTD monitoring forms. Choose sitting at that PC filling-in mind-numbing, spirit-crushing objective assessment questionnaires. Choose PMETB-approved curricula and competency-based assessments no-one has properly validated. Choose your third choice career path and wondering who the fuck you are on a busy post-take ward-round. Choose rotting away at the end of it all, pishing your last in a miserable Non-Consultant Career Grade post, nothing more than an embarrassment to the under-experienced, ‘fit for purpose’ FY’s you’ve trained to replace yourself.

Choose not to choose your future.

Choose MMC.


Dr Rant loves this - sounds great when done in a strong Ewan McGregor accent. It was first posted on DNUK, and Dr Rant would like to thank the original author for permission to republish it here.

The Sunday Mirror leads the way

At last! A newspaper editorial from the right angle, and columnist that hasn't simply decided to recycle the DoH's lies and misdirection about GPs earnings being the root of all evil and a threat to Liberal Western Democracy. Carole Malone of the Sunday Mirror has shown that you don't have to work for a self proclaimed 'quality' tabloid to see the bigger picture.

HEWITT WASHES HER HANDS OF NHS
Carole Malone
GOD knows what the qualifications are these days for a Government Minister but Health Secretary Patricia Hewitt ain't got 'em.

And judging from some of her recent pronouncements, she must be raiding NHS coffers for mind-altering drugs if she actually believes the patronising tripe she came out with last week.

First, her advice to anyone panicking about bird flu: Wash your hands regularly as people apparently underestimate the value of this.

OK, so we could be on the verge of a worldwide pandemic and the advice from Britain's Health Secretary is to wash your hands! Then, to compound her idiocy, she claimed that closing NHS beds is actually a sign of success because it means fewer people need care.

Does she think we're all as daft as she is? Does she think the people of this country, who sadly can't afford private medicine - unlike our politicians and our GPs - are likely to swallow that nonsense?

Does she think we don't feel the effects of ward closures and thousands of NHS staff being given the boot on a weekly basis? I wonder if Mrs Hewitt has ever actually visited any of our cash trapped hospitals. More importantly, has she ever been turned away from one of them because there are no beds and no staff?

Have any of her children died, I wonder, having been taken to one of our inadequately-staffed A & E units and told to go home because there's nothing wrong with them? Only to find a few hours later the child is dead because doctors hadn't had the time to examine them properly.

I suspect the answer is a big fat no to all of the above. Yet this Government - which seems incapable of making possible the relatively simple task of keeping hospital wards clean - is at great pains to tell us that bed closures are something to be celebrated. " The NHS is changing," says Mrs Hewitt.

"People's needs are changing."

No, Mrs Hewitt, people's needs remain constant. They need to feel that when they or their children or the people they love are taken seriously ill there is a hospital bed for them, a hospital that isn't 200 miles away.

And they need to know there are enough competent doctors to treat them. It's hardly a comfort to know that in the last 12 months the NHS has announced 24,000 job losses - 900 of which are in Mrs Hewitt's own constituency.

Still, if we all just keep washing our hands everything will be fine!

Well done! I just hope Carol Sarler and Karyn Miller are taking note.

The Rant Diaries 2007 (63)

Not quite Hyde

Monday 5th February

'John' came to see me. He is 56 and doesn't like taking tablets, and takes great care to remind me of this at least five times during each consultation. This is the third time that I have seen him this month. John has high blood pressure, everyone in his family since the Norman Conquest has had a heart attack before retirement age, and a recent check of his blood lipids indicated that he has liquid black pudding coursing through his arteries. He Smokes 20 a day, and he describes his main interests in life as 'Benson' and 'Hedges'.

The last time I saw him, I prescribed him antibiotics for his chest infection. Two days later he's back complaining that he 'rattles like a pill box' when he walks. Intrigued by his 'concerns', I decided to explore his health 'ideas' by asking him to strip to his underwear and jump up and down on the spot. Despite holding my stethoscope to his epigastrium (above his stomach), I was unable to hear any pills rattling. I'm not quite sure what his 'expectations' were. He did however develop left sided chest pain after 5 minutes of jumping up and down.

I'd better run that one past Dr Cardigan.

++++++++++

On a lighter note I noticed, in a discarded copy of the Daily Mail in the waiting room, that a lady who has been taking those statin tablets that we've been dishing out for years noticed that her 'one of her knees was a different colour to the other one', and that this means that she might have 'bird flu'.


Tuesday 6th February


Bloody Daily Mail! My first 10 patients this morning, let's call them 'John', were complaining that one of their knees was a different colour to the other one, and asking whether this means they have bird flu. Only one of them was on a statin. I spent the rest of the morning looking for the read code for 'asymmetric patellar-chromatism'. It's a good job there isn't QOF points riding on this one.


Wednesday 7th February

'John', the registrar (trainee monkey-boy) in our practice is a law unto himself. The cheeky bastard always knows best, because he's latest 'evidence' for absolutely bloody everything. He could probably produce evidence that bears don't shit in the woods if he had to - smart arse! His latest crusade has resulted in most of my patients being diagnosed with Chronic Kidney Disease (CKD) and he's referred them to the local hospital's kidney department. I happen to play golf with the head consultant (let's call him 'John' as well) of the kidney department in question - and he's mighty pissed off I can tell you! He was mumbling something about 'sodding guidelines' as I slotted in a handsome 18 foot putt on the 18th green to win the game. The registrar will no doubt sail through the Royal College exams this summer.


Thursday 8th February

Bloody Daily Mail again! Today's headline screams: "Everyone should be on Statins". This evening's surgery comprised a succession of people (let's call them 'John') demanding to be put on Statins immediately. Apparently they can make you live to 120 and have been shown to alleviate third world poverty. It's a good job that I've got a decent Single Malt under my desk; it numbs the pain, and it reminds me that if I'm nice to people they give me bottles of booze at Christmas.


Friday 9th February

It's a well known that the fact that because it's Friday it means that 'niggles' and 'aches' that have been around since 'just before Christmas' suddenly become life threatening. One of my patients today, let's call him 'John', is due to go on holiday to Lanzarote next Saturday. He's got a bit of a sore shoulder, and 'can't do this'. I offered him a choose and book referral to the local intensive care unit because they might be able to find someone who 'cares' more 'intensively' than I do. Apparently I have a 'sarcastic tone of voice', but I think it's just hoarseness actually. Come to think of it, I might have contracted bird flu from those Statins I've been taking. I wondered what that rattling sounds was on Wednesday afternoon..........

Snow

Everyone thinks it's an excuse not to do any work. Sort it out you lazy bastards.

What are you waiting for? Dr Blue to come round with a shovel and dig away all 5cm of it for you?

You can rest safe in the knowledge that the Dr Rant Team will not let disease and suffering take advantage of the weather. There are still Blood Pressures to measure when the QOF computer says so you know.

We're fighting for YOU!

Now let that be the end of the matter. (Any referrences to 90s white-boy rapper 'Snow' will be dealt with swiftly and efficiently. You have been warned).

Carol Sarler is Fucking Ignorant...

...in her article in the Times yesterday.

I mean, what a fucking moron.

Not only does she regurgitate the well known lie about GPs earnings, but she thinks that in Dr Findlay's day things were better.

A quick glance at From Cradle to Grave: 50 Years of the NHS would show her that that generation of GPs had thousands of patients and would have up to 60 patients waiting in large waiting rooms, often to be seen at a large desk at the end of the room. Examination was cursory or absent, and workload was understandably horrific. A doctor could do 50 visits a day, often on a bicycle.

And her idea that technology can replace a good clinician would be laughable if it were not being given space in a broadsheet daily. In fact, she talks about how wonderful 24hr walk in centers are, yet she criticises GPs because she cannot see the GP that 'knows her best' within 48hrs. Is the poor fucker not allowed a holidy? Selfish bint.

And the reason, my dear moron, that "appointments are only available during daylight", is because that is all the government will fund. Fuckwit.

If you are a GP, you'd better sit down before you read the next bit:

My family’s GP does nine two-hour surgeries a week; those 18 hours aside, a large building on a London high street sits empty, humming quietly with the running costs for which we pay.

What a fucking retard! Do you honestly think that ALL your GP does is see patients face to face? I mean, how fucking stupid are you, Carol?

GPs do results handling, reports on their patients, letters to specialists/other GPs/government agencies, education, practice meetings etc., etc.. This is normal for any professional, and means that they work 2-3xd as long as the consulting times.

And Carol, I can safely call you an ignorant tosser when you say that:

The supposed merit of GPs’ “filtering” patients to save specialists’ time is done better by triage nurses.

Dr Rant has never heard anyone make this claim before. The available evidence, common sense, and the very process of medical triage (sorting done by the most experienced person available - which, for primary care, is a GP you fuckwit!), all tell us that this is not the case.


And the rest of this dribble is just rambling masturbatory tosh. Like this:
Which would you prefer? To hope that the local chap is sufficiently on the ball to spot a future problem and sufficiently up to speed to deal with it? Or to get a polite note saying that your data suggests you are at risk — but there is available the most up-to-date treatment, so would you care to pop in, time and place of your choosing?


What the fuck are you talking about? How is the 'local chap' going to have any different chance of being 'on the ball' than the person sending you the polite note.

If anyone sees Carol Sarler's brain, they can return it to her c/o The Times, London.

Off course A&E waiting targets are fixed

City University Cass Business school has worked out what Dr Rant has known for some time. The waiting time targets are a fix. Cass worked out that it was impossible to meet the targets without cheating.

Lets look at some of the tactics Dr Rant is aware of having been deployed:

1. Move the fuckers to another area to make them wait. Call it 'Assessment Unit'. Hey presto. In fact, I'm just waiting for hospitals to rename their A&E departments 'Canteen' so they can bypass the waits alltogether (presumably, this would cause them to breach some other target, like maximum servery wait, or whatever).

2. Don't let the fuckers in. Simply keep seriously ill patients in ambulances outside A&E. The clock only starts when they come through the door. This is particularly fuckwitted because it means that the most seriously ill patients, who are most likely to be in an ambulance, wait longer. Meanwhile the sore toe patients wait less long. And, the ambulances cant reach emergencies because they spend hours queued outside A&E. This is probably the best example of targets making care worse that Dr Rant has ever encountered.

3. Admit the fuckers. Genius! Can't send them home until their blood result comes back? Going to breach the target? Admit them! Then they get to spend more time in hospital, pick up MRSA, and block a beds that, quite frankly, are in short supply.

4. Get extra staff in on the day of the test. Since the unit knows which day they are going to be assessed, they simply buy in expensive locums and bank staff to hit the target on that day. Fucking cheats.


The conversation goes:

DoH: I'm going to ask you next Monday how long your A&E Wait is. If it is more than 4 hours I'm going to fire you. But I'm not going to do any surprise inspections, or check up that you are telling the truth.

Manager: Er....Ok...



Next Monday:
DoH: Hello. How long is your A&E wait.
Manager: It's 3 hours and 45 minutes.
DoH: Excellent. The PM can tell the nation at PMQs how the NHS is having its best year ever.
Passing Patient: But I've been here for 92 hours......[gets bundled off by clipboard wielding managers, who outnumber the clinical staff 2:1].


The managers know they are lying.
The politicians know the managers are lying.
The managers know that the politicians know that the managers are lying.
The politicians know that the managers know that the politicians know that the managers are lying.

Its all one big fucking con.

Sign of the Times

Our guest columnist, Dr Mustard, offers a radical remedy for British journalism that has become a sick joke.

It would appear that the someone at The Times thought that it would be a good idea to invite Carol Sarler, who normal 'writes' for the Daily Diana to 'express' her opinion about GPs as a 'Guest Columnist'.

In a belated attempt to leap onto on the 'GP bashing' bandwagon, that has already been jumped on by so many journalists that it resembles the Delhi to Mumbai express, Ms Sarler shows that utter ignorance need not necessarily be a bar to becoming a successful journalist in today's egalitarian Britain.

Read it, it's a hoot!

I'll leave the counter argument to a doctor posting on Doctor's Net. He writes in reply:

Ms Sarler: You are an ignorant bigot.

On average, a GP costs £50 per patient PER YEAR! That is extraordinarily good value. Whether or not we as a nation invest enough to get the most out of the service is however doubtful. It seems to be journalistic high fashion at the moment for those with the inability to differentiate their gluteals from their olecranon to have a pop at GPs.

Time after time journalists trot out this £118k average wage for GPs figure, despite the real figure being available instantly to any one who can be bothered to look.

Further more, a 'two hour surgery' takes on average 3 hours at least, and generates an hour's worth of paperwork......so that's 4 hours (advanced maths I know, but you managed to cope with 9 x 2 = 18 earlier). Chuck in a few home visits and the odd mandatory meeting and that's yet another lunch time missed during the course of a 10 hour day. But then again, not actually having a clue what you're talking about precludes you from passing informed sensible comment.

The plural of 'anecdote' is 'anecdotes' - not evidence. Why not change your GP and stop whingeing?

I'd also ask your GP for a 'Choose and Book' referral to sort out that chip on your shoulder if I were you.

Here's my advice to certain jumped-up vacuous tabloid journalists:

Figure 1: Carol Sarler yesterday

I think that puts an end to the matter. My advice would be to add Carol Sarler to the 'ignore list' along with Polly Toynbee and Karyn Miller.

Targets fall on deaf ears

Another example of how NHS priorities get skewed comes from Scotland.

While lots of money is being spent getting GPs to chase spurious targets of dubious value, people who need a hearing aid are having to wait an average of nearly two years.

What's that? NHS's best year ever? You'll have to speak up, Splatzy Fuckwit! I'm a bit deaf, and my fucking hearing aid won't arrive until 2009......

Shit care for patients shitting blood

Our esteemed blogger colleague, Dr Crippen, performing a blood transfusion as a junior doctor.

Dr Crippen recently posted about the fact that the treatment seems to have changed for patients who are shitting blood (altered blood, called melaena, which indicates bleeding from the top end of the gastrointestinal tract).

Dr Crippen was asking if he had missed something, as when he was a junior doctor, all such patients were admitted and endoscoped urgently. Dr Rant remembers this too. We remember it because it was the correct management.

What happens is someone bleeds from an ulcer in their stomach. The blood comes out the other end 'black'. The patient appears ok because they only lost a pint or so. The blood tests are normal initially because they have not had a chance to 'dilute' their blood with clear fluids (water, cups of tea, whatever). However, a few days later they have haemodiluted, and are now anaemic. The bleeding then starts again, and, because they are anaemic to start with, they become much more unwell. Sometimes they bleed to death in minutes.

For this reason, the correct management is to admit them and do an urgent endoscopy within 24 hours. This is official. It saves lives.

There is a formal scoring system called the Rockall Score which is used to work out who is at higher risk of dying. However, this score is based partly on the endoscopy result (for obvious reasons - without an endosocopy you have fuck all idea what is causing the bleeding).

The New NHS We Have No Beds So Fuck Off and Die approach is to send the fuckers home if they 'look ok'. So some of them die later, shit happens!

Who gives a fuck if patients die? Who gives a fuck? Not Patricia Hewitt, apparently. Or she would not have put all the hospitals under such financial pressure to 'balance the books' (what the fuck does that mean? The budget is just some arbitary number she made up, for fucks sake!).

Doctors need to stop being such saps. They need to stop agreeing to provide bad care just because useless managers tell them there is 'no money'. Doctors need to start saying 'No, this is not good enough!'.

In the mean time, if you are sick, be afraid.

Be very afraid.

Training the Zombie Sheep Doctors of the Future

The doctor of the future passes its 'Nurses are the bees fucking knees, and doctors are the root of all evil' assessment with flying colours (courtesy of Bastard Management Ltd.)

Dr Rant thinks the changes to medical education are a fucking disgrace.

We need doctors who have a good medical knowledge, can deal quickly and confidently with medical emergencies, and who are safe and experienced in practicing their art (be it diagnosing, cutting, putting to sleep, or prescribing medications). We used to be pretty good at this.

What we don't need is a bunch of undertrained, underpowered, saps who are popular with nurses and cleaners but are no fucking use if you are actually, heaven forbid, ill. But that's the way things have gone.

We now have the educational high achievers being thrown out of medical school because they failed their Licking Nurses Boots module. Aparently, if you know fuck all about medicine and the bodies are stacking up all around you from your mistakes, then that's ok. But, if you can't get your head, and possibly most of your torso, all the way up Staff Nurse Chiponhershoulder's arse, then you are clearly not fit to practice.

The postgraduate deans are behaving like a bunch of spineless, spongebrained, Quisling, collaborators and Dr Rant wants them to know that we know.

Dr Rant has recently received this email from a medical student in Scotland:
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