NHS hits the news again

After a lull in which there was talk of "clinical engagement" and getting staff back onside, the DH reveals its true colours again. And they are not nice.

Nurses were overpaid and under-reformed under Agenda for Change. NHS got poor value from a botched and rushed process according to Niall Dickson.

Managers are now blocking GP referral decisions at referral management centres.

There may not be enough doctors in post on Wednesday 1.8.07 and operations will be cancelled as a consequence.

Difficulties with trauma care: Doctors try to do whilst managers squabble.

So we have a botched, rushed reform, we have an absolute lack of doctors on 1.8.07, operations cancelled, evidence of poor trauma care, evidence of referrals being blocked by managers.

So with all this news, of events that matter directly to patients emerging what do you think the government and its media acolytes do?

They spin against GPs!

The Sunday Times leads the way with a right hook editorial.

Needless to say that old bullying and toadying rag the Dail Mail (sticking to type, is ever so fond of Big Chief Clunking Fist) joins in on Monday.

The spin against GPs gives the lie to any chance of constructive clinical engagement with the disastrous NHS reforms. We can trust the DH to do nothing other than kick us periodically, and plot to achieve our detriment. Let’s not fool ourselves that NHS management is anything other than a DH outpost. Remember that primary care trusts are not primary, don’t care, and aren’t trusted. Any member of the Twaterati who collaborates with them deserves much odium.

Keep this up Gordon Brown and Alan Johnson (you looked nice, but clearly are not) and you won’t have any doctors left in the UK, and we’ll spread the word that so that even the Poles won’t want to come here any longer. This year GPs income is being kept the same, but our expenses are rising so this year GP profits will fall significantly. £250K is but a distant dream for my earnings via the NHS- even if I put every hour possible into my practice. If I want that sort of earning I’ll need a private business outside the NHS.

Let’s speak the truth. The Government fucked up the new GP and consultant contracts. It fucked up Agenda for Change. The Government has fucked up the NHS internal market and is now desperately casting around for “ clinical engagement” to bail out Practice Based Commissioning. It knows its managers can do nothing themselves that works.

The state of the NHS after too many years of New Labour is bad, and getting worse. Hospitals are now dangerous and failing to deliver basic care. They risk making things worse with high rates of hospital acquired infections. Like the days my teachers thought they would not see again patients are now fearful of going into hospital and coming out with something worse.

On 1.8.07 the after effects of MTAS will hit the front line rotas of hospitals near you. There will be many gaps, covered in desperate ad-hoc ways to try and keep the service going. Managers and senior doctors are struggling to keep the service going through this DH generated and mismanaged crisis. Surely Some senior DH officials such as Sir Liam Donaldson will have to go soon. Dame Carol Black left PMETB quietly recently.

The NHS is a new Labour disaster zone. Keep going like this and the staff will desert it. The public will get treated by foreigners and the less experienced staff. The rest will all get out of NHS as soon as possible.

If New Labour keeps going with this kind of spin how long before GPs do a dentist and go into the private sector? The question is “Will the NHS support doctors and nurses to help patients?” The current outlook is that the NHS will actively hinder doctors and nurses from doing their job. That has to be bad news for patients and voters.

NHS Internal Locum Agency Meltdown

NHS Professionals (NHSP) was set up as a huge internal locum agency several years ago. The idea was to save money, but the pay being offered in many areas meant that few doctors were willing to sign up with the agency. This meant that in large parts of the country, NHSP was simply passing requests onto commercial locum agencies - thereby adding an extra layer of costly management with all the costs and problems that go with that.

So Dr Rant was interested to read the following comment from Raymond on the recent Darzi story:

I don't suppose any of you good people are aware of the NHSP (NHS Professionals) monopoly that has been granted in several [NHS Acute Hospital Trusts] including mine - a huge trust with 1100 beds?

This weekend has seen a fair bit of medical sickness, including the day [Senior House Officer] in my speciality this morning. I rang the manager on call to inform them of the situation and was told that similar requests for locum cover had been made to NHSP. NHSP responded by informing the management team on call over the weekend that they still had no doctors on their books that had been processed and were legally ready to work.

Well there's a good two days to go till the handover, everything shoudl be fine! Anyone got the number for Medacs...?

STOP PRESS! The Daily Mail has printed something remotely sensible on this issue.

The Promised Land

Alleluia. Amen. Alleluia, Praise the Lord Darzi for he is great, and Practice Based Commissioning will take to the Promised Land of Polyclinics.

Tis the season of great hope, of revival, of the resuscitation of the moribund carcasss that is the NHS. The dry bones of structural reform are all going to leap together and the sinews will be reclothed with just the right balance of muscle and leverage. These dry bones, these wizened old hags, these melancholic managers, these despairing doctors, these nagging nurses, these pusillanimous pharmacists, these putrefying politicians, these perishing patients. All of you. Stop and listen. Repent. Be transformed as I tell you of the route to the promised land.

Beware the naysayers of doctors.net. Beware the medical bloggers of doom. Beware the generally negative ones in the corner. Damn the ferrets, and that monk is a heretic. Look neither to the left nor to the right, but follow only the positive ones at the front.

Harken to me, the Messiah of Practice Based Commissioning.

Under this all will be well, and all manner of things shall be well. The hospital will sit down under the bampot tree with the general practitioner and parley. Swords will be sheathed (safer sex) and discharge summaries will magically be written and arrive on time. Patients will be admitted and discharged then admitted again before you can even type “Dear” on a discharge summary.

Services will be delivered closer to home and burial in the back garden is a possibility for some. West and co will be proud contractors for this service.

I, the Messiah of Practice Based Commissioning have spoken, and now I will appoint my apostles from amongst the shining wits who infest this clapped out (Sorry about the GUM cutbacks, perhaps we’d better commission some?) skeleton service that we call the National Health Service.

I may have a weird and far away look in my eye as I call you all to follow me, into the promised land of polyclinics and plenty, but I know a great reform when it happens. Follow me and look neither to the left nor the right, nor to the negative ones, as we enter our promised land, our birthright, our perfect NHS.

What joys await us there? We will provide great care to our patients ever closer to home. It will be a pleasure to live there, in good health until the time is right to depart.
Like the parrot, the NHS is not dead, it is merely resting, and we shall see it flapping its wings again soon, although the psittacosis may take longer as we haven’t yet commissioned an appropriate service for its treatment. But we shall. Oh yes, believe me when I say, “WE SHALL.”

We shall do and do and do. Ever more proactivity, and none of this stupid medical reactivity that bedevilled us in former years. We’ll treat diseases before they even occur.

Repent all you cynics and scoffers, you pedlars of piffle and balderdash, you abominations who doubt the wisdom of the Department of Health and the Messiah of Practice Based Commissioning. We shall see your ruination and well deserved destruction, crushed under piles of ministerial directives you never read. (We would have preferred to burn you, but it’s a carbon heavy process and the papers are so dense they won’t burn properly)

Repent and believe in the power of the Great Commissioner, (even though the last one was sacked for leading us in the wrong direction.) Hospitals are idols, and truly they have feet (and sometimes foundations) of clay. Their destruction and desolation will be perfect, as we destroy the disease palaces, those blighted MRSA and Clostiridum difficile breeding grounds, that nest of the vipers of the BMA and RCN that speak with forked tongue.

The Messiah of Practice Based Commissioning continued in this vein for many days. A flood of paper soon covered the land, and reached every corner so that local decision making, in a responsive and patient centred way became the norm in every hospital and clinic and surgery in the land. All was well. All became well. All became whole again.

And then the serpent entered the Garden and whispered, “Vanity, vanity, all is vanity. And perhaps an apple a day will keep the doctor away. I have a special one here” And lo the Devil became a mangagement consultant.

And now, some survey results

Here at the Ranting House we have been on tenterhooks wondering about the results of the GP Patient Experience Access and Choice surveys. We thought that £11million’s worth of research would surely unveil some new truth, and teach us something that we didn’t already know. Laurence Buckmann’s statement hits the nail on the head.

Another £11 million down the pan. And we had already predicted the results here and answers to stupid questions here! The DH could have had the results for nothing.

And after spending all that money the results still aren’t even what the DH wanted to hear. They can’t even be spun without major distortion into an anti-GP story. Most people are satisfied with GP opening hours. There is a significant minority (and no service will please all its users all the time) who find our opening hours difficult but there are mechanisms (such as national or locally enhanced services) within the current GP contract. So the government and PCTs have mechanisms, and resources, to negotiate with GPs and commission services into place for those who are struggling with current GP opening hours.

The results of these surveys don’t really support what the government wants to say, nor do they give the government leverage to force major changes onto GPs. Indeed they actually help the negotiating position of GPs more than that of ministers. This is why the DH has sat on the survey results for several months, and decided to release them as non-news stories in the middle of a good week to dampen any stories down.

There are some improvements needed to GP access, but the DH and GPC will probably now start a sensible negotiation to sort these out.

Meanwhile the rest of us can get on with our work, and try to help some patients.


Other useful articles on here related to this topic:-
OOH services

Extended opening hours:-

NHS IT system in trouble?

Our regular reader, Morgan, has pointed out two interesting articles on the troubled, hugely expensive NHS IT (NPfIT) system.

One is an interview with Dicky Granger, in which he shows no insight and continues to blame everyone except himself [are you sure this is news? - Ed.].

The other is the question of whether NPfIT is being dropped.

Journal of Nurse Quacktioner Madness (Volume 47, Issue 7, p1311)

Dear Dr Rant,

I feel I need to bring something to your attention.

I refer to this job advert on the stupid NHS jobs website.

I am/was a Plastic Surgery trainee, untill my medical career was modernised. I, and almost all of my peer group, have not obtained training posts. I know you have heard this before, but I know many people with 5-years at medical school, an extra two years of intercollated BSc, a Junior House Officer year, three years of basic surgical training, a three year PhD, and up to five years of plastic surgery experience who didn't get jobs. And yet, trusts are advertising for fucking nurses to effectively be surgical trainees.

Note the the advert clearly states that this will involve being first assistant during 'complex reconstructive operations' and will include microsurgery [fucking hell! - Ed.], as well as seeing patients in clinic. These are the unique features of a plastic surgery training system: this is what senior SHOs and junior Registrars are supposed to be for.

These jumped up nurses are being used to fill a perceved service gap. But this gap has been created my MMC/MTAS. Don't get me wrong, I fully subscribe to your stance that this is not the fault of the individual nurses doing these jobs, but the fault of the government, the trusts, the colleges, and that slimy bastard Liam Donaldson.

Further, this advert has a pay scale attached. These nurses aren't even going to be that much cheaper than us - and they will being doing fewer hours [By my calculation, that makes them more expensive - especially when you factor in their lack of training and experience, which will make them slower and more error-prone - Ed.]

Where will the doctors be while these pretend doctors are performing their fiftieth free flap? [Presumably some uberclever plastic surgeon technique. See how complex this stuff is - even Dr Rant has no idea what they do! - Ed.] We will be in the fucking ward, clerking in the patients, taking blood samples, and doing ECGs on perfectly health 20y olds because some nurse manager in a black SS uniform wrote a fucking 'Patient Admission Protocol'.

Where will it end.

Yours,

Dr A. Rantett

Kelvin MacKensie - Thick as Pig Shit

Fig 1. A nasty little cunt, yesterday.

Apparently, this has recently appeared in that well known and august organ of righteousness that is The Sun:

"But one astonishing fact reemerged during the inquiry into how all these foreign doctors got here in the first place. Did you know that in the past 3 years 22,500 doctors have found jobs here. Why doesn't our medical system create more jobs for our people? A consultant friend explained that this Govt has shut 3 medical schools and 2 dental schools over the past decade. Wouldn't it be better to keep the terrorists out - to simply lower the original education barrier slightly to the med schools and then we won't need so many foreign doctors. Perhaps I'm being doctorist-and I've already reported myself to Trevor Phillips- but it seems that certain overseas doctors take advantage of our women patients and appear regularly in courts charged with indecent assault. The patients came in for a bad back and they got told to get their breasts out. You know the story. And at that point I must say I was delighted at Jacqui Smith's statement to the house as Home Sec. after the failed bombings."

The Author and former editor, Kelvin MacKenzie (above) has never been encumbered by a desire to check his facts, and indeed certainly isn't one to let the facts get in the way of an opinion. The Government has actually opened new medical schools in the past few years. The rest of it is just shite.

Dr Rant will leave the last word on this topic to a good friend of his:

"Just for Kelvin MacKenzie - I am a white, English born Oxbridge graduate, and my knowledge of anatomy isn't perfect. However, I know a cunt when I see one."

Daily Mail: the lying bastard ex-nazi sympathizers are at it again

“Many GPs now earn £250,000” shouts the Daily Mail’s front page under the headline “The Rise of the £250,000 GP”. These two leader-lines were based on the statistic that 150 out of 100,000 UK GPs earned £250,000 or more. I make that 0.15% of GPs. Message to the Daily Mail sub editors: all is 100%, most is more than 50%, many is between 30% and 50%, some is less than 30%. On the other hand, 0.15% is ‘a tiny fucking proportion’.

And we’re not talking just NHS income only here, either. We’re talking about businessmen who happen to be GPs as well – they guys who run Out of Hours companies, who have set up IT companies creating GP software, write best-selling books on fad diets (see Diets), spend a lot of time on daytime telly, that kind of thing. Even the £100,000 average income that is bandied about is misleading, as it refers only to partners that own their own practice – it doesn’t include the large number of salaried and locum GPs that earn only a fraction of this.
Compare that to the recent profit announcement from a successful legal firm that worked out at around £650,000 per partner. I don’t remember seeing that headline in the Daily Mail.

Interestingly, in the same edition, they were announcing their FREE DVD The World at War, Part Nine: Genocide. Turning to page 27, as instructed, there is a précis of the available episode:

FROM 1941-45 the Nazis were responsible for genocide of unimaginable proportions throughout occupied Europe. Jews were not the only victims of Hitler’s meglomania. Gays, the mentally ill, the disabled, Romany people, Freemasons and Jehovah’s Witnesses were all exterminated. What happened during these years remains the darkest period of 20th-century history- and one which still stands as a dreadful warning to humanity.

Blimey, they’ve changed their tune. What the Daily Mail has strangely omitted to mention the darkest period of the Daily Mail’s history: such as the Daily Mail’s support of Oswald Mosley’s home-grown facism up until 1927, and its pro-Nazi stance throughout the 1930s which was unique amongst the British press, and was in large part due to then-owner Lord Rothermere’s friendship with Hitler. Rothermere’s last visit to the Fuhrer was in mid-1938, by which time his true nature should have been obvious to anyone.

But then if fascists have one thing in common, it’s their incredible ability to believe absolutely that they are always right at the exact same time as they are busy hiding away all the shit they got wrong in the past. That must break some law of physics, surely.

If there are any dim-witted jihadist doctors left in the NHS with a clapped out L reg jeep and some matches, you might want to check out if the main office of the Daily Mail has reinforced bollards outside. You know, like the ones at Glasgow Airport. That way you could at least mount your jeep on the Daily Mail bollards and set fire to yourselves at their front door. Your deaths would then not be totally pointless: having a few days without the Mail being far preferable to having lots of cancelled holiday makers milling around airports.

The Myth of Full Employment: My part in its creation.

Lloyd-George has much to answer for, and possibly his biggest contribution to indolence, want, ignorance, disease and squalor was the humble “Med 3” certificate.

Now for many years this relatively innocuous piece of paper played a fairly minor role in UK social policy and allowed benefits to be administered.

But in my generation of doctors it has been the weapon of choice for bringing down unemployment. New Labour boasts of the UK having “full employment” The last Conservative government used it to get the unemployment figure down.

There is a well trodden path from losing one’s job to ending up on long term incapacity. It’s easy.

Here’s how it goes:

Patient (man aged about 50) loses his job in factory. Not hugely well educated, a bit past it, a bit too senior, a bit too stuck in one line of work etc. He’s getting on a bit, and doesn’t like being out of work. He misses the company- can’t always live with it, can’t live that well without it. He’s got bored and done all the jobs round the house and garden and allotment. He’s a bit aimless. His status has dropped. His circle of mates has gone. The house isn’t big enough for him and the wife. His temper gets a bit shorter. He goes to sign on and man at UBO spots this and goes, “Are you a bit depressed mate? Perhaps you should see a doctor.” UBO staff have a target to get people off unemployment register, or job seekers or whatever else it’s called in future.

This story is starting to sound strangely familiar........

Patient goes to doctor and says, “The man in the UBO told me to see you for a sick note” Doctor asks why and uncovers litany of sadness of man and his loss of job.
Doctor labels what is a normal reaction to shit happening as the medical illness depression. Lo and behold man is now turned into patient on incapacity benefit and removed by medical magic and a Med 3 from unemployment total.

Doctor thinks he has treated previously unrecognised disease. Man now has a “label” UBO staff have one less signing on each week. Politicians say “claimant count has dropped, we therefore have full employment.” Sales of prozac have gone up. It’s a win-win deal for everyone (EXCEPT THE TAXPAYERS) and all achieved via one stroke of the medical pen.

Other classic scenarios are smoker’s cough turned in to asthma or furor therapeuticus. Brian Haynes’s well known study on steelworkers in Hamilton taking more time off work (for all illnesses) after a diagnosis of hypertension is worth revisiting. It’s something to do with perceived vulnerability.

We don’t have less than one million unemployed in this country. We have about 1 million on jobseekers allowance and about 3 million on incapacity benefit. That’s an awful lot of economically inactive people. People not contributing, people taking out of society, people who probably want to do something, but finding themselves trapped on benefits.

Truly as doctors we have connived in a major government sleight of hand.

Engagement or divorce?

Well New Labour seem at last to realise that they have fucked up on the NHS. They also seem to have realised that they cannot get their reforms through without “Clinical Engagement.” Soulless acquiescence will not do it. Sessional functionaries robotically following guidelines won’t do it.

So there’s a new note emerging from DH and its apparatchiks.

David Nicholson was at the King’s Fund this week. His mood music was superb. However this piece in the Times on the same day shows just why the conference was so necessary- the more clinical engagement is discussed the less is actually happening.

Some highlights were, (quotations not verbatim)

“Within five years I want there to be a credible clinical manager as a candidate on every shortlist for an NHS chief executive’s job.”

“We are on a journey” (so was the Titanic)

“Create a compelling patient centred vision that clinical staff will sign up to.” (We used to know this and the goodwill in it has been squandered)

(the vison) “would need to have traction within the service” (but there’s no sign current health policies have any great credibility at all, and Alan Johnson seems to think they are right, but were just presented badly. Gordon Brown apparently thanked Mrs Hewitt for a job well done when she left.)

“creating the environment within which this (engagement) can happen”

Now I don’t want to rain on his parade but in medicine we have:-

12000 junior doctors unemployed on August 1st. Fudges and short term contracts will paper over the cracks.
Doctors have been routinely abused by ministers and their press poodles as
“overpaid”, “not-patient focused” ,“vested producer interests”, and so forth. The managers then have the chutzpah to accuse the BMA and Unisons of being the worst name callers.

Doctors have been sidelined as doctor lite services have been tried to provide services such as out of hours more cheaply.

Doctors have been sidelined as parallel services such as walk in centres and NHS Redirect have been opened. The regular service still has to pick up the pieces afterwards but at least the pushy and the neurotic can be seen more quickly.

Doctors have been sidelined as ISTCs are opened staffed by foreigners from far away countries, about whose clinical standards we know little but DH will still let them out to experiment on the natives. Meanwhile NHS consultants and GPs (properly) have to be trained and qualified to meet specific standards.

We have seen circular structural changes that have achieved nothing for patients.

We have managers and doctors who do not trust each other, and who both who trust the central credit, local blame DH even less.

So forgive me for not immediately accepting Mr Nicholson’s offer to get more engaged with his department. But I still don’t trust it, or its policies.



And the shiny happy people on this brochure are probably actors:-

Consultants paid properly scandal!

The BBC is reporting that consultants now earn £110,000 per year.

But, "Earlier this year, the National Audit Office (NAO) said the new consultant contract had not improved patient care".

Let's follow what happened:

1. Consultants were working far more hours than they were contracted to because they are caring professionals who put patients first.

2. Evil, lying bastard politicians said "Oi! Consultants! You need to stop playing golf and seeing private punters and do more NHS work, you lazy fucks!".

3. Above mentioned bastards decided they would show the consultants who was boss by setting up a new contract which payed them for the actual hours they worked.

4. Doctors pointed out that this would mean a big pay rise for consultants because they were working far more hours than they were contracted to do.

5. The fuckwit politicians didn't believe this and were convinced the consultants were swinging the lead.

6. New contract comes in, consultants get paid for all the hours they are doing, their pay shoots up, no change to the service because the consultants were already working very hard.

7. Fuckwit lying bastard politicians start bleating about 'greedy' doctors.


Note to the lying evil scum running our country: you are too stupid to be classed as a form of life.

Drug crazed addict speaks

Another nicotine-crazed crazy in the Guardian ('comment is free', which is a section of the Guardian that should carry a health warning to anyone with high blood pressure).

You know those people who try and keep quiet the fact that their psychotic 13 stone fighting dog ripped a baby to pieces because Killer 'didn't mean no harm, he's good as gold normally'. That's Simon Jenkins on smoking.

Why do all addicts talk shite?

Selfish right winger: troll or saddo coward?

Regulars to Dr Rant will notice that we get a lot of hits from a rabid right wing nutter who bangs on about buying his own health care and how the NHS is crap and the market will solve all the problems.

He also hits the other medical bloggers (and he may in fact be a regular in other sectors, who knows).

Let's see what we know about Anonymous:

1. His posts are all very similar (?cut and paste)

2. He ignores all evidence against his beliefs (?troll, ?fanatic)

3. He never signs any posts, but uses the 'post anonymously' button (?troll, ?coward, ?passive aggressive)

4. He posts dozens of times a day, yet claims to have lots of money and a very important job (?troll. ?fantastical story teller, ?sad fuck with low self esteem)

5. He is impossible to bait (strong evidence for a troll that)

So he is either a troll (most likely) or paid by someone to cause trouble (interesting, but if I was paying someone to cause trouble I'd find someone better), or is a lying, sad, overcompensating, freak sitting alone somewhere posting all day to feed his own sick ego (ie: a troll).



Should we:

1. Simply ignore him?

2. Dlete all his posts?

3. Switch off the anonymous posting option?

4. Track his IP address and send the heavies round?

5. Continue to shoot him down in flames several times a day?

Dr Rant Quiz Question #1

The Guillebaud Report into the NHS was commissioned by the Conservative government in 1951, three years after the introduction of the free-at-the-point-of-need NHS, and was published in 1956.

Did it find:

A. That the NHS was a bottomless pit facing infinite demand because there were no patient charges.

B. That there was no real evidence of inefficiency in the NHS.

C. That the NHS was an inefficient communist monolith set up by pinko-commie lefties and it needed to be opened up to the free market to make it work.

Dr Rant Quiz Question #2

The administrative cost of the US health care system is 31% of the total health care budget (reference).

When the NHS was introduced in 1948 it spent 2% of its budget on administration.

In 1974 this rose to 6% when tighter management was introduced.

In 1984 the conservatives introduced market reforms, and administration costs....

A. fell to zero.

B. stayed the same.

C. rose to 12% and continue to rise in line with the degree of marketisation of the NHS.

D. The NHS is a communist monolith, so who cares how much money it costs to turn it into a market economy.

Dr Rant Quiz Question #3

Regarding research on not-for-profit verses for-profit health care provision.

A. You are less likely to die if you are treated in a for-profit hospital.

B. You have about the same chance of dying whatever hospital you are treated in.

B. You are more likely to die if you are treated in a for-profit hospital.

C. Not-for-profit is for lefto-pinky commies, so who cares if you are more likely to die in a for-profit hospital.

Dr Rant Quiz Question #4

In the US...

A. For-profit hospitals spend about the same on administration as not-for-profit hospitals.

B. For profit hospitals spend 23% more on administration costs than not-for-profit hospitals.

C. Not-for-profit is for lefto-pinky commie faggots, so who cares how much money they save giving better health care.

Dr Rant Quiz: Answers

Question 1.
B. That there was no real evidence of inefficiency in the NHS.

Question 2.
C. NHS administration costs rose to 12% and continue to rise in line with the degree of marketisation of the NHS.

Question 3.
B. You are more likely to die if you are treated in a for-profit hospital.

Question 4.
B. For profit hospitals spend 23% more on administration costs than not-for-profit hospitals.

A step in right Johnson

From today's Guardian:

"Mr Johnson's only departure from the course set by Patricia Hewitt, his predecessor, was to downplay the role of the private sector. He said he would only sign contracts for more independent sector treatment centres if they were needed to fill gaps in NHS capacity. He appeared to abandon the Blairite view that private involvement helped spur competition, whether or not extra capacity was required."

Do you think that Johnson reads the medical blogs, or do you think that the fact that Hewitt used to work for the management consultants - who had so much to gain from privatisation for the sake of privatisation - had anything to do with this difference of ideology?

Whatever, it's good timing because privatisation is this theme of this week's Dr Rant Quiz.

Free market medicine

We get a lot of this at Dr Rant:

"Open health care up to the free market and that will solve everything".

Dr Rant has played Monopoly: it starts off nicely enough, but it always ends up with one rich fucker gloating about owning everything while a bunch of pissed off losers fight over the left over crisps and snacks.

Julian Tudor Hart in his book 'The Political Economy of Health Care' says:

Economists cannot point to a single real example of any nation that has depended entirely on a competitive market economy for health care of its entire population.

Discuss.

Excessive Adjectival Aggregation

Just when you though it couldn’t get any more clichéd, it does. Deja-vu all over again.We badly need some new clichés. When do we want them?- at le moment juste!

This is becoming almost too easy. And never being one to miss an open goal Dr Rant rushes forward valiantly to score here. Strangely if we’re thinking in foot balling terms Dr Rant thinks defender Norman Hunter would be a better role model for us. Let’s hack some shins.

Here’s another conference for managers. At least it will keep them away from work for a while and so boost productivity. Managers are to the productivity of the NHS what an atherosclerotic plaque is to blood flow.

Anyway now they are going to “achieve a paradigm shift” to provide the 18 week patient pathway. A paradigm is a big concept, such as gravitation, the laws of thermodynamics, the discovery of Jupiter’s moons, circulation of the blood, homeostasis, Pasteurisation, clean water, smallpox eradication, the recognition of the significance of Helicobacter pylori. They usually come from powerful scientific and technical work. They cause major shifts in thinking, and happen only rarely. They are rarely fully appreciated at the time.

For managers to use the term in relation to administrative changes in an organisation where the basic structure and purpose- namely patient will meet doctor - will be unaltered is to diminish the term to the point of absurdity.

Anyway the excess of adjectives flowers most abundantly and fragrantly and I now present a montage and collage of them for your delectation and delight.

“radically transformed and redesigned” What change is not radical? One or other of transformed or redesigned is redundant.
“overstretched and financially challenged NHS” At least two out of these four words add nothing here.
“practical ‘take home' tools”
“the patient pathway” Journey is so passé a term. It went to the Rose Cottage for retired and redundant clichés.
“paradigm shift in thinking is essential” I’m sure, and no doubt Thomas Kuhn himself will appear at the conference to lead it.
“deliver care closer to home” There won’t be a hospital left to go to.
“signpost mutually accepted goals”
“incentivise collaborative working”
“support cultural change” The most cultured thing we grew at med school was Staphylococcus Aureus. It wasn’t methicillin-resistant then.
“Director of Commissioning and Performance” What on earth is this Mr Rafferty?
“drive forwards change” There’s no reverse gear on this beast
“implement new service models and maximise efficiency” The new is always better, NHS managers are neophiliacs.
“cohesive working relationships” Ahh, and then engagement leads to an enhanced relationship too.
“Clarifying national guidelines” I can see clearly now the retirement home
“Co-ordinating professional role redesign” Shall I become a nurse now?
“Upskilling and reskilling clinical staff” Where’s the retraining centre? In the paddy fields?

Actually there are some good bits to this conference:-

“However, limited finances and resources, poor communication across the interface, and a lack of shared vision, are significant obstacles to progress.” (entirely true)
“recognise the diverse consequences that the restructure has for different parts of the NHS” (We live in interesting times)
“Aligning Choose & Book and PAS to ensure efficient patient flow” (Another great success of NPunFIT is that GPs and hospital computer systems don’t talk to each other.)

There are also some threats hidden in the detail:-

Lead appropriate transfer of secondary care services and diagnostics into primary care, to optimise resource management and reduce steps in the patient pathway
(We’re closing some clinics and the GPs and District Nurses will have to pick up the pieces)
“Maximise referral management to reduce demand on secondary care outpatient provision and streamline patient journeys”
(This is dangerous- it’s where the managers want to try and block or deflect patients after GP has decided to refer them to a consultant. Very patient centred. Patient will not be consulted about this act of blocking or deflection- it will just happen. )
“need to manage demand on acute services”
(We know they are limited but we don’t people to know we know. And we don’t want the patients to know this as they might be frightened, or demand more.)
“Engaging administrative staff to accurately input data”
(Why would they not be doing this already? And if they are not how we can trust the figures produced? The story of the Indian Civil Service and the civil servants analysing figures in great detail not realising that their primary data was all written down at random by the village headmen comes to mind)
Exploring the potential of referral management centres to manage patient flow
Developing consistent referral protocols to ensure appropriateness of referral
(We don’t trust GPs to do this, despite the fact they are mostly actually good at it, and so we’ll put an extra layer in to second guess their decisions)
Strengthening patient-practitioner communication to secure compliance and trust (Compliance - Of whom? With what?) (Trust in whom? Of what? By whom?)

I doubt there’ll be any scales falling from eyes at this conference. However I hope that there will be a cataract of new ideas as myopia is corrected, and squints corrected.

For the record Dr Rant saw his optician recently and had perfect eyesight.

The State of the NHS One: The chief executive’s view

The NHS is surreal at present. We have several competing narratives in play. The difficulty is to decide which bears any relation to reality.

We’ll start with David Nicholson’s magnum opus, his annual report. As is common now with DH publications it’s on shiny paper with shiny happy people inside. Is this really how NHS is or is this risible with Nicholson carrying as much authority as Biggus Dickus. Weally wisible. Or as Billy Connolly might put it "A monumental erection"

According to Nicholson the NHS is on a journey. “Changes and improvements for patients will accelerate” Here we see the false equivalence being drawn between “change” and “improvement” At least some people are beginning to see this according to this poll.

“We won’t succeed unless we take our patients, staff and public with us.”
Well there’s doubt whether the NHS has any of these groups fully onside. The profession is now totally offside, and by default regards any emenations from NHS management as rubbish.

“We won’t succeed unless NHS leaders start to look out toward their patients and populations as a guide to action, not up toward the Department of Health”
There may be some sense in this but the idea that the centralised Stalinist monolith will become a smooth local provider of services seems very unlikely indeed.

“Patient expectations are rightly high, but public perceptions
and confidence are low.” Again sensible people set their expectations low and then get surprised when they are exceeded. One of the biggest problems the NHS has is that it cannot admit that it is finite, and cannot possibly conceivably ever meet every demand that could be placed on it. Good businesses are realistic with people about how far they go, for how much money and in what time frame. If anything they under promise and over deliver, thereby pleasantly surprising customers. The NHS under delivers whilst over promising hence most of current frustration with it.

“Why do things feel so difficult? Why does it feel so uncomfortable? It is because we are about half way through a massive change programme, and we are where we should expect to be at this point in the change process. We are trying to transform the NHS on two levels: firstly at a systems level, from a monolithic provider of care based on organisations, to a more plural and open system, using reforms such as choice and contestability; and secondly we are driving through transformation at a structural level – our model of care – by shifting the care we provide for patients outside of hospitals and into the community, closer to home.”

(Yes closing down hospitals does rather leave patients with nowhere locally to go doesn’t it, especially if they are in tory areas?)

“If we want the reforms to be implemented in a way that improves the patient experience, then we have to connect the reform tools and levers to the needs of our staff, patients and the public. And for that to happen, we need a deep understanding of what matters to each of these groups. What do they want from the NHS? What is the distinct offer the NHS can make to them? We need to be able to describe very simply how they will support our staff to do what they come to work to do – save and improve lives.”

Well he would only have to read the blogs we link to (right side column) to see how far he is from achieving staff buy in.

“But we are in a peculiar place, where despite these objective measurements of improving patient experience, public perception by comparison is negative, and some staff groups report low levels of morale and engagement with the reform agenda. For example, although regular Ipsos MORI polling for the Department of Health shows that patients report over 80 per cent satisfaction with the services they have used, when the public are asked how satisfied they are with the NHS overall, this falls to below 60 per cent.

We need to get much better at identifying what matters to staff, patients and the public, and communicating what the NHS ‘offer’ is to them, and how the changes we are introducing will help better meet their needs. This is not about spin, it is about core delivery. All my experience teaches me that we simply cannot deliver the reforms without the understanding and support of our staff”

The place is not peculiar. The staff are disconnected from the reforms. They are nothing to do with us in Rantingshire. They have been delivered from top down by a doctrinaire group of bureaucrats, aided and abetted by medical and other professional quislings. There was no staff or public clamour for the current set of reforms. There was a clamour for a better NHS, but as patients and as NHS staff we should be careful what we wish for. Our biggest fear now is that Brown will “try to improve it”

“Since becoming NHS Chief Executive I have made clear that my number one priority is to establish clarity of purpose about what the NHS is for – what are our values? Not as a piece of theory, but as a guide to understanding and action. If we are clear about the values of the NHS, and how they connect with the reform programme, it will provide the basis for a successful strategy to transform the NHS. It also provides a clear and common purpose for our most important asset –the people who work for NHS patients. We are embarking on a bottom-up approach, in partnership with NHS staff, patients and the public, to establish not just what the purpose and values of the NHS are, but what the NHS offers to patients, staff and citizens.”

It sounds good, but the key phrase is “we are embarking” The force comes from the DH, not from the staff, most of whom want to get home, or get retired. There is no current common purpose that unites doctors with managers who are basically DH narks, sneaks and appartchiks.

“I have described perhaps the biggest reform programme for the largest publicly-funded health care system in the world. How can you drive this degree and nature of change from the centre? The simple answer is that you can’t. The simple answer is that you can’t. Neither I nor Ministers can make a £90 billion system, with over a million staff, be responsive to patients from our offices in Whitehall.

On the first stage of the reform journey, which was essentially about expanding capacity and reducing waits, central targets could be set and driven nationally.

In the second stage of the journey, reform policies were initiated and developed in Whitehall, drawing on the lessons of other sectors and countries.

But the third stage, using the investment and reforms to drive transformation, can only be delivered through successful implementation by our staff working in the many NHS and NHS-funded organisations across the country.”

I think the problems of the NHS are laid bare here. Dr Rant is beginning to see monopoly provision as a problem in its own right, and maybe the monopoly is what needs tackling. A disaster for doctors and patients such as MTAS could not have occurred in a pluralistic health system.

If David Nicholson and Gordon Brown want staff engagement in reform they will need to give some sweeteners at least to selected quislings, and maybe more widely. Actually Dr Rant is thinking the NHS may not survive this round of reforms, and may be a deeply unhappy family for many years to come.

Doctors among detained terror suspects

Dr Rant is relieved that the recent terrorist attacks were thwarted, and is saddened to find out that most of the suspects who have been arrested are doctors. One, Dr Mohammed Asha, would appear to be a Senior house officer in Neurosurgery (not a neurologist as mentioned in the Telegraph or a 'brilliant neurologist' as claimed by This Is London - brain surgeons are...well, surgeons....neurologists are not, and 26 year old SHOs are about as junior as you can get, so 'brilliant' would seem a tad over the top).

It would be childish to point to the rank incompetence of these thwarted attempts and try and link it to the dumbing down of medical education in the UK, and suggestions of the formation of a Real Remedy or Provisional BMA in response to the MTAS/MMC debacle would probably only be valid if Patricia Hewitt was still SoS for Health.

If the allegations are true, then it will be a tad ironic after Hewitt, callously and with little warning, threw out most of the hard working non-EU doctors recently - many of whom had given years of their lives to the NHS - but she managed to miss an entire terrorist-doctor sleeper cell.

One helpful suggestion on DNUK was that The GMC should update its Good Medical Practice guide pronto as the section on doctors' conflict of interest might have been mixed up with doctors' interest in conflicts.

I, however, think we need to be very thankful that the perpetrators were both incompetent and unlucky. Parking a car bomb badly is a basic error, which helped the wonderfully observant LAS ambulance crew spot the first bomb. If the allegations are true, then potential patients of Dr Asha should also be thankful because - lets face it - the average teenage joy-rider can kill more people and cause more damage in a stolen-SUV than Asha and co managed at Glasgow Airport. Would you really want someone that incompetent unscrewing your skull and having a poke around? If he had really wanted to kill innocent British people, surely he could have had more success by just doing his job really badly. You know, the odd un-noticed scalpel slip while working near a Really Important Brain Thingy (excuse my technical jargon), or he could have occasionally screwed the patient's head on backwards when the consultant wasn't looking. Or he could even have just had his team drive the 12 year old, gas guzzling, Jeep Cherokee around the M8 until its 20 mpg emissions melted the ice caps, killing millions. But how exactly do you crash a huge SUV into a crowded street without killing anyone except yourself? (I've seen the photos of the man who was on fire, and I wouldn't hold your breath on him seeing next week.) I mean, who hasn't nearly killed some daft drive-on-the-right tourist looking the wrong way coming out of a UK airport terminal?

If only all terrorists were this stupid and unlucky. The world would be a far better place.

You might as well emigrate

Dr Rant's accountant, John Cash, was round this week. Sadly John's mother has been unwell in hospital, but Dr Rant was pleased to hear that she has made an excellent recovery.

Anyway, when John went to visit her after her first night in hospital he was attempting to prop up her pillows when one fell down between the bed and her bedside unit. John didn't want to move any furniture to retrieve it, and since the hospital was grotty he didn't know what he would have done with the soiled pillow if he had retriived it.

Apparently neither did the cleaning staff, as several days later when his mother was discharged the pillow was still where it had fallen. Meanwhile, the cleaners had been overheard outside the room:

Hospital Cleanliness Consultant #1: So, Jimmy up' stairs had his wee op last week, and the cheeky wee bastard wanted me to sign him af a' work.

Hospital Cleanliness Consultant #2: No! Wee fucker!

Hospital Cleanliness Consultant #1: Aye. He told me 'But you work at the hospital', and ah' told him tae get tae fuck. Ah can diagnose yae an tell yae whit's wrang wi you, but I dinnae dae any oh that paper shite. Git yer GP tae dae that crap for yae".

Hospital Cleanliness Consultant #2: Tae fucking right.

So, clearly they didn't have time to clean the hospital because they were too busy providing primary care services to the denizens of their tenement. Which kind of explains the MRSA rates, the fact that our hospitals looks like a pile of dog's vomit, and the random appearance of Jameses the country over sullenly demanding medical lines (presumably pissed off that their multi-tasking Moplady-come-Medical Care Practitioner wouldn't save them the trip).

John wanted to know why the consultants, for example his pal who was a consultant in the City Hospital, doing the rounds didn't tell the cleaners to do their job properly. In his view, the consultants were culpable for letting this stuff go on.

Ah, says I, I can tell you exactly how that would go:

Hospital Cleanliness Consultant #1 [deep in conversation with colleagues]: .....fuck......wee shite.......bastard.....

Consultant [seeing patient on ward round]: Excuse me, my good lady, but might I point out that this ward looks like a pile of dog's vomit and ask that you stop gabbing and do something about it.

Three Hospital Managers [appear as if by magic, carrying clipboards]: Hospital Cleanliness Consultant #1 has made a formal complaint about your conduct, Dr Consultant Physician. She is alleging bullying behavior, and her union rep claims that she has failed to receive dignity at work. She is making a separate complaint to the GMC alleging that you are too evil to be a doctor and should be barred from ever seeing patients again because you are a quote 'wee shite, so you are' end quote. There is no place in the modern NHS for arrogant doctors who think they are more important than other members of the Health Care Team, so we are suspending you on full pay for several years after which you will either kill yourself of emigrate or get struck off and die in penury. [managers vanish, leaving consultant - now looking old, haggard, and unshaven - to do a silent Munch Scream to camera].

And that ladies and gentlemen is why doctors are scared, hospitals are dirty, and patients are fucked.

Here's our special 'Best Baked Product in the Hi...

As part of the Dr Rant Goodbye and Good Riddance Patricia Hewitt Tribute Week, we're putting up some of the pieces that we had in our sandpit that didn't make it into the blog (ie: we were too lazy to get this stuff out on time, but we don't want the work we did do to go to waste - especially when it involves pictures of Nigella Lawson). This piece was planned for the 7th of June.


Here's our special 'Best Baked Product in the History of the NHS' recipe in celebration of the fantastic news that the NHS has balanced its books this year. We're especially delighted that the lovely Patricia Hewitt will not be honour bound to fall on her sword as she threatened to if there was another deficit this year.

Start with you usual cake recipe, but follow my advice.

Ingredients:

1. Measure out your usual amount of flour, and throw 30% of it away.
2. Don't bother with the yeast as we wish to avoid inflation in the size of the cake.
3. Butter is optional, and depends on whether your postcode falls within a Labour-held constituency.
4. Plenty of icing - your cake must look good you those you don't need to actually eat it.
5. 'Top Slice' the Cherry fund to make sure everyone else's cake has at least half a cherry.
6. Use a computer to randomly select the filling.
   

What to do:

• Heat the oven to ambient room temperature to avoid unnecessary CO2 emmisions, and grease your cake tin with a knighthood.
• Allow the ingredients to mix themselves so that they can be blamed if the end result isn't what your guests are quite expecting.
• Place in the oven for 11 months.
• Employ former chefs to say how great you are and that everything is hunky dory.
  
• Serve up the result to great fanfare on a day when lots of other things are happening. Ignore everyone's opinion, answer no questions.
  

Mmmmmmmm.........

She did it with mirrors

As part of the Dr Rant Goodbye and Good Riddance Patricia Hewitt Tribute Week, we're putting up some of the pieces that we had in our sandpit that didn't make it into the blog (ie: we were too lazy to get this stuff out on time, but we don't wan