NO, NO, NO to current NHS reforms

There seems to be a widespread view that the NHS needs reform and that all the current NHS reforms are good, and that only antediluvian “vested producer interests” of doctors, nurses and other unions are holding them back.

To these commentators who all seem to be politicians, health economists or management consultant types reform is a great good in its own right, and all who stand in its way are some combination of:

Lazy
Overpaid
Overprotected
Anti-competition
Anti-choice
Non patient-centred
Slow
Backward
Scared
Self serving
Vested producer interest
Knaves

As Richard Vize, the HSJ editor, puts it, “In the struggle to improve health services the only easy part is finding someone to say 'no'.” Well we’re certainly happy to oblige him with this piece.

Actually I have got news for them. We are none of the above. We think that the current NHS reforms are just WRONG, both IN PRINCIPLE and IN PRACTICE. New Labour has been a total disaster in its running of the NHS and relations are worsening again.

There is a real feeling of us versus them and for all the talk of “clinical engagement” most doctors are ever less involved in service design.

Let’s look at Labour’s record on health:

A fortune has been spent on the NHS.

However, it has not gone on anything sensible such as extra GPs, longer consultations, better access to investigations, speeding up discharge summaries, improved primary-secondary care communications. In short patients still encounter a system working under resource and severe time pressure at every point they meet it. Patients, doctors and other health service staff are run ragged and frazzled, and somehow still keeping a smile on and a service running despite management hindrance and interference. Clinics run late, and get overbooked. Notes are lost, letters get mislaid, or never typed. The doctor-patient consultation is still only a few minutes in an experience that may have taken several hours of travel and waiting. The patients still don’t fully understand what the hospital doctor says and go to the GP only to find that the consultant’s letter is not yet there…4 weeks later.

Admission wards overflow, and back up back into A+E departments. Winter pressures could easily overwhelm most local hospitals. Bed occupancy in UK is appallingly high, and MRSA, and clostridium difficile are rife. Wards are easily closed when there is an outbreak of norovirus. NHS long term care for older or young disabled people has been destroyed and NHS dentistry is becoming rarer, and harder to access. GP premises have been run down, and cost rent scheme stopped.

And the NHS is such a “world class service” that only Cuba has anything like it. But what would Johny Foreigner know?


Where has the money gone?

-On a grandiose computer system- imposed top down, with no regard for confidentiality, or for what would help doctors manage patients better.
-On choose and book- needless, slow, offering the wrong choice at the wrong time
-On reorganisations and structural changes- same old face, nice new desks, nice new titles, bugger all done.
-On management consultants Know alls who know nothing, who have never met a patient and would faint with dread if they did.
-On NHS Direct and NHS 24 Stand apart facilities, drawing money and staff away from other areas. Same money could have been spent on giving GPs more practice nurses and improved phone access to GP surgeries. Nurses could then have worked alongside GPs and used a shared database and so had some background on patients they were speaking too. Would have improved the GP service, made patients lives easier and been safer for patients too.

-On Payment by results (which should really be known as payment per activity) a national tariff system that does not really allow for complexity and case mix.
-On practice based commissioning introduced too late and too timidly to be useful. More slippage announced this week. Likely to be scrapped or renamed soon.
-On appraisal- a system that takes doctors away from front line practice to “reflect”
-On ISTCs ministerial vanity to destabilise local hospitals
-On Mergers- ever larger hospitals- The DGH is now seen as an enemy to be destroyed
-On PCTs the most useless organisations ever invented
-On Walk in centres Useless, and money would have better been spent on improving local GP services or negotiating a deal for commuters to be seen by GPs near their workplace.
-On new contracts that deliver what neither doctors nor patients really want or need.
-On sacking medical secretaries and outsourcing the typing to agencies in India
-On management pet projects rather than locally needed projects
-On competition in what is fundamentally a co-operative and collaborative venture
-On PFI and 'LIFT' projects- the true cost of which was dragged out of a civil servant this week

The key flaw in all the reforms suggested for the NHS over the last 20 years has been the notion of an “Internal Market” It’s a totally flawed analogy, that does not, and never has, matched NHS reality. Any solution based on it is wrong de novo, and the NHS’s record on implementation of anything is a dire warning to other organisations.

So when people say “It’s easy to find people who say NO to reform” Dr Rant shouts back, “Yes, here we are, and we have something valid to say. And we start by saying “NO” to what’s going on now.”

An abortive misuse of the GMC

Abortion is a subject that evokes strong feelings on both sides. It is an ethical minefield, and both sides (pro-life and pro-abortion) can be well and sensibly argued. Basically the pro-life side say that the fetus is a human being from conception, and therefore abortion is murder. The pro-abortion side say that the fetus is not fully alive until “viable outside the uterus” which is currently at about 24 weeks gestation. The pro-abortionists tend to see the decision as “the mother’s right to choose” and to give no rights to either the father of the baby (the sperm donor)or to the unborn child. (The foetus, just a collection of cells, not yet fully human etc) To many pro-abortionists the only correct medical response to a request for an abortion is for the doctor to say, “OK, when?” Some argue that the doctor is not a moral agent in such cases but merely a technician to deliver the mother’s "rights."

Therefore to some pro-abortionists a doctor like Dr Tammie Downes is a vile, unethical beast who should be struck off. She has the temerity to ask patients questions along the lines of, “Why do you want an abortion?” and “Are you sure it’s the right decision for you?” How awful. How dreadfully unprofessional and how clearly disrespectful to patient autonomy. Well, at least that seems to be the apparent basis of an unnamed doctor’s complaint to the G.M.C. about Dr Downes. The complaint seems to be based on what Dr Downes said in a newspaper interview rather than the complainant’s personal knowledge of a specific case, or any evidence of a specific patient having been harmed.

Now whatever your views on abortion, and whatever your actions in a particular case as doctor or patient, I hope we can agree that complaining about what a doctor has said rather than arguing the case positively is shitty behaviour.

Up until now both sides of the abortion have debated loudly, and the rest of us have tried to find a sensible way through it, and help women come to as good a decision as they can. Abortion is an act with consequences, and so is a pregnancy taken to term. In the old days you’d have women going through IVF next door to women having T.O.P.s on a gynaecology ward, and sometimes fights broke out between them. Women are both blessed and cursed by fertility, and of course they are the ones left holding the baby, or the after effects of the termination. Women often have very mixed feelings towards pregnancy especially in the early stages when they first discover it. Some are delighted, and some prefer their other roles at work or elsewhere and a child could ruin their career. Others re-evaluate their career when pregnancy comes.

To some extent women are damned if they do and damned if they don’t with a pregnancy. They may feel guilt and depression for ending the baby’s life, or they may feel guilt and depression for keeping a not fully welcome child. The decision to terminate or not is a permanent decision, life changing, responsible and made fast, often at a time of heightened emotions. Surely it is a decision to get as much help as possible with before making?

From the Mail interview it seems that Dr Downes is fully aware of all this and helps women review their situation and make the best decision they can. This is actually good medicine, helping patients to review and understand their predicament, and then make as good a decision as they can. She says, “I don't try to persuade anybody. I give them the facts and allow them space to think through the decision that they are making.”
She also says, “Some of my colleagues are happy to sign an abortion form without helping a woman to think the decision through, which is such a tragedy.” Dr Rant would agree with this. Abortion is not a minor decision, with no consequences. Treating it as merely a minor technical procedure is to diminish totally our respect for the value of each individual life.

She also says, “But I won't stand in a woman's way if she wants a termination.” So it appears that she is talking sensibly to women in early pregnancy about whether abortion is the right decision for them or not. The women think, and either keep the baby, or they go and see one of her colleagues if they decide to go for abortion. This is actually very fair medicine, and despite Dr Downes’s strong views on the issue it sounds that the women are getting a fair service, and the ultimate choice on whether termination is right for them or not. In other words the women’s autonomy is being respected, and Dr Downes is not imposing her moral views on the women she treats. Dr Downes says she is “pro-informed choice” and this is fair. Indeed doctors are usually criticised for giving too little information about procedures and their risks and consequences. It may be that abortion is currently being done in the UK with only partially informed consent.

In short there seems nothing in the interview to suggest Dr Downes is a bad or uncaring doctor, and nothing that suggests she is in breach of any G.M.C. guidance in Good Medical Practice. I think Dr Downes will see off any G.M.C. complaint easily.(with the usual caveats that this is said on basis of the data in the Mail and Observer reports and if G.M.C. finds additional evidence things could look different.)

To use the G.M.C. in this way, to complain about what a doctor has said, as opposed to what they have done, to the G.M.C. is shitty behaviour. It is a double edged sword. All doctors hold opinions and we all disagree with our colleagues on things. This is part of the fun of medicine (and life in general) It doesn’t indicate bad medicine. Taking part in the debate actually indicates commitment and engagement with our patients and our profession. Being on one side or another of a debate is not evidence of malpractice.

So to try and silence opponents by running off with whinges “She said the wrong things” and "She thinks the wrong things" to the GMC is shitty behaviour. It reeks of intolerance and heresy trials rather than reasoned debate.

The G.M.C. is there to arbitrate on bad behaviour by doctors, and whilst it tries to keep its procedures fair, robust and consistent, it doesn't always achieve this. The G.M.C. is no arena for arbitrating on general moral questions even if they are exemplified in one particular doctor. To its credit the G.M.C. is usually quick to spot agenda driven complaints and separate them from serious concerns about a doctor's performance in practice.

I hope that the unnamed pro-choice doctor who initiated this complaint will think again about his behaviour and drop the case. Dr Rant wishes Dr Downes well as she answers her accusers.

And he wishes doctors would not even think of using the G.M.C. to settle an argument with another. He regards that as very unethical and dangerous and disrespectful behaviour.

Crockard : "I blame everyone else"

Dr Rant taken it upon himself to completely murder this piece in Hospital Doctor this week about our old friend, Professor Alan Crockard, erstwhile chief apologist for murdering Modernising Medical Careers. This is by no means an indictment of the original piece, just it's subject:

***PUERILE PARODY ALERT***MAY CONTAIN TRACES OF NUTS***

The former national director of Modernising Medical Careers (MMC) has denied responsibility for the shitting his own pants, pinning the blame instead on the Government and doctors.

In his written evidence to the Health Select Committee inquiry into pant-shitting, Prof Alan Crockard, who resigned in March, claims that the DoH repeatedly undermined the authority of his anal sphincter.

He alleges his anal tone was 'reduced' from late 2005 and says that politicians and senior DoH officials did not heed warnings issued by the team about problems with his arsehole.

Moreover, Prof Crockard says that the disastrous leakage was not co-ordinated by his rectum, but developed in the DoH's workforce directorate under a separate senior officer.

The former director also blames the profession for not giving his ring-piece sufficient backing. According to Prof Crockard, the team had proposed a number of alternative bowel-motions, similar to those now in the Tooke review, but received 'little support from the profession to consider an alternative defaecation'.

Okay. Maybe this isn't the exact article. Maybe the article wasn't about Crockard shitting his pants.

But consider this - Dr Rant has replaced only twenty words in the above article. When you throw your toys out of your pram in public, you end up looking like an incontinent, whining toddler. In fact, you rather end up looking like one who has just shat their pants.

DISCLAIMER: The Dr Rant contains some of the victims of MMC. People like Crockard pushed ahead despite years of warnings about the inevitable  consequences. Sometimes sensible satire seems futile.

Medics Slam MP Pay Deal

by Steven Forde, Westminster Correspondent for the Daily Rant

An influential committee of doctors has slammed the pay deal granted to MPs as offering poor value to the taxpayer. MPs earn 250000 a year* yet constituents cannot visit them in their surgeries on a Saturday morning or in the evening. Despite record pay rises (voted for by themselves) they have failed to make themselves more available. Changes to their contract in recent years have seen a dramatic reduction in OOH (out of hours) sittings in the Commons yet their salaries have risen at the same time. The committee was dismissive of claims that the reduction in OOH was to make the job more family friendly.

The doctors were also highly critical of the long holidays that MPs take. They sit in parliament for only 208 days a year, and don't work weekends. A spokesman for the BMA (British MPs' Association) claimed that much of the remaining time was spent dealing with "administrative" duties in their constituencies, but the committee suspected that it was more likely that they spent it doing private practice as paid advisors and company directors. The gold plated pension scheme, which sees MPs retiring on full pensions after only 20 years' service, was also felt to be a further unnecessary contribution to their excessive remuneration.


*the sum of the basic salary of an MP and the highest expense claim of any MP last year is £245698, but why not round it up to 250000, since that sounds much more dramatic, and not bother to mention that actually, most MPs don't claim this much, and they don't spend all of it on themselves.

ISTCs have crash landed

Roger that Capio, you're cleared to fuck things up completely

It appears that the government's illogical and ideologically driven policy is running aground, ISTCs are the latest to be finding the going more than a little thought. Dr Rant has obtained a leaked email that was sent out by a PCT, that may or may not be somewhere near Oxfordshire, in order to 'encourage' trade in the direction of a failing ISTC:

"I am working with the PCT to look at ways to increase the utilisation of the Treatment Centre.

There are a number of new initiatives underway which you and the team might want to hear about.

I am however more concerned to hear your views and ideas concerning this facility, and would like the opportunity to visit with you and your clinical team.

Please advise some suitable dates.

In the meantime if you would like to discuss any aspect of the ISTC do please call me - 0845 PCT-NUMPTY."

It seems that the PCT are desperate, the ISTC is desperately unpopular with patients who would prefer to use the excellent local NHS services; thus the PCT is trying to force trade in the ISTC's direction in a rather underhand manner. The behaviour of the PCT is starting to appear rather pushy, if not aggressive, whatever happened to that thing called 'choice™'?

Maybe this is because the PCT was pushed into an expensive contract with the ISTC by its top-down fathead controllers at the DoH, as part of the government's dogma driven reform agenda. However this does not excuse the shockingly bad value for money that ISTCs represent, not to mention their unknown and unaudited safety records; certain anecdotal cases are actually rather scary. The way in which the DoH's little PCT monkeys are behaving cannot be condoned as they may just be doing what they are told; however throughout history this kind of nonchalant compliance has resulted in great crimes being committed. The greatest evil may be resident in Whitehall, however PCTs are certainly providing a local resident evil of sorts.

MTAS - It's Raining Shit

MTAS is now well and truly dead. The last death throes finished at the end of October, and junior doctors are now more-or-less stuck in whatever employment they have been able to obtain. A bomb has gone off in the cess pit of medical worforce planning, and small particles of shit are still drifting down from the sky.

Eminent Surgeon, Mr Salmon, has noticed a problem at his department. Junior doctors used to be called SHOs. He is not sure what they are supposed to be called now, so will continue to call them SHOs, even though their job titles are a mixture of terms such as 'trust grade', 'FTSTAs' and 'ST2s'.

In his department, there used to be eight SHOs. Now with the advent of MMC and MTAS, there are five. They no longer work speciality night shifts. Instead, they are part of a pool of 14 SHOs who work as part of 'Hospital at night'. So, usually, every other week, the department is down to four SHOs to get all the work done formerly by eight SHOs.

One of the SHOs was lucky enough to get a locum registrar job at the same trust. It will not help his career prospects much. However, it will earn him a little more, and he will enjoy his job more. However, medical staffing have found it difficult to fill his post. So, for a lot of the time, his department are down to three SHOs.

Two of the other SHOs were working three month contracts, offered as part of the MTAS round 2 deal. One of them found a job elsewhere. Medical staffing did not realise that he would walk out after three months. And he did. So the department was down to two SHOs.

One of those SHOs is an sensible ST2, who booked all of his study leave on the first week of the job. He is currently on a course for a week. So the department is currently down to one SHO, who is doing all the jobs that eight SHOs used to do.

Now, what have medical staffing been up to, Mr Salmon hears you ask? Well, they have been trying to obtain a locum. Except there aren't any. They've all fucked off.

The doctors who used to do locum shifts no longer exists.

Those in research have realised that MMC / MTAS does not reward them. A year doing an MSc or and MD counted as much as a one day computer ECDL course. So those research doctors have fucked off.

Those doctors who had come from a non-EU country to do locum shifts have realised that the UK does not value them. Locum experience will not get them a proper training job in the UK. Despite years of subcontinental doctors propping up the locum sector, the NHS has given them the cold shoulder. So these foreign doctors have fucked off.

And what about the doctor 'in-between' jobs? Some doctors were prepared to go without permanent work for a couple of months, and do locum work for a short spell. They waited for an ideal job to come along, in order to obtain a desirable CV. Well, that is no longer an option. Under MMC, the situation is 'a job in August, or bust'. No one really wants to hang around for FTSTA or trust grade jobs. They count for fuck-all on a CV. So, with the choice of go abroad or leave medicine, this group of doctors have fucked off.

And lastly, a year ago, it was easy to get locum work. You needed a GMC certificate, occupational health clearance, a CRB check and some decent references. Now, as well as the above, you need to complete a 'solo-practice' course (£14 please), a manual handling course (more dosh, please), sort out locum appraisal (guess what?) and complete further mountains of paperwork. Of course none of these improve patient care or safety one iota, nor would they prevent another Shipman type psychopath from having some fun. For those who would normally do a couple of weekend locum shifts to help pay the bills, well, they find the extra hassle not worth the effort. In other words, they ARE fucked off.

So, one of the results of MTAS is that medical staffing departments are trying to pour a quart into a pint pot. Or rather, pour in a whole fucking bathtub. It just cannot be done. Some things just do not fit.


Professor Crockard, Professor Heard, Patsy Fuckwitt and Tony Blair - why did you not foresee this problem?

Oh yes, it is because you are all fucking idiots.

Government IT fiasco (again)

A bit delayed and ever so slightly over-budget: Another government IT triumph

Again, and again, and again. Well today we have finally found one civil servant is honourable enough to resign after a massive cock up.

We now know that the government is fundamentally incapable of managing data securely and safely.

What will this mean for ID cards? What about Connecting for Health and the privacy of your medical records or MTAS and its great computer security?

This government’s reputation for competence crumbles quicker than Northern Rock’s solvency.

Would you still trust this lot with anything?

PCTs and gunpowder

Damn the smoking ban! Anyone got a light?

Since November the 5th, I have been keeping myself amused with a little game of 'fantasy gunpowder plot' and the maxim 'What would Guy Fawkes do'? Well, after literally 5 minutes agnonised deliberation, I realised that there is one candidate in Rantingshire that is head and shoulders above all the others.....

I do not see the point of PCTs, and not once have I seen onedo anything that has helped improve health care in this country. They are top heavy bureaucratic structures staffed by many people with very little brain or talent. They are the apotheoisis of the way that the NHS under Labour fails to work. They are the beacons of our incompetent government's over interfering, top down health care, freak show. (The recent news about Birmingham PCT and their McMedicine franchising fuckwittery will be visited by us in detail in the near future.)

The PCTs do what their bosses tell them. They inefficiently plan health care and move funds around in the most time consuming and drawn out ways possible. They produce endless reams of meaningless management-speak and force feed it to clinical staff, people who are trying to actually do some proper work, like they are a gaggle of French geese. They produce glossy pamphlets that tell GPs how to deal with heat waves of 20 degrees. They are staffed with no one who knows anything of medicine or public health, yet they feel they are able to order highly skilled professionals to do things that have absolutely no evidence base behind them.

The PCTs waste money trying to shut down good GP practices and replace them with Walk in Centres run by nurses who can barely take a manual blood pressure. They waste millions on ISCTs and then bribe local GPs to feed work away from the local NHS to these ISCTs, despite the fact that these treatment centres are death traps with no solid clinical back up. They waste thousands of tax payer's money on schemes with no evidence behind them, such as giving fat people vouchers to spend at slimming companies.

I could go on and on because PCTs get my goat. They represent the disempowerment of highly trained professionals, in favour of the empowerment of brain dead cretins who can barely tie up their own shoe laces. They represent the abuse of good solid evidence and science, in favour of the peddling of nonsensical propagando-mumbojumbo. They represent the focus that this government puts on bullying downwards to meet stupid targets, instead of focusing on trying to improve the service for the tax payer. I was chatting to a visiting consultant from overseas the other day who remarked:

"It's amazing over here, I just can't believe how far ahead your clinical work is ahead of the management."

More amazing is the fact that so many excellent NHS staff have not yet thrown in the towel. The PCTs are certainly doing their best to force talented assets out of the health system. The lunatics have certainly truly taken over the asylum.

How not to get past the round circular file

“Remember Graves, the waste paper basket is always your best friend”

So said Robert Graves’s housemaster when he discovered Robert Graves was writing poetry. As I grow older I also think the waste paper basket is my best friend. (And I fantasise about sending Darzi down the Khazi…but maybe I shouldn’t.)

Dr Rant has an overdeveloped internal crap detector, and loves getting rid of crap in all its forms. He thinks the shredder is the greatest invention of the last 100 years. Anyway some crap arrived today and although it’s crap, it’s all grist to the ranter. Be assured this merely delayed its journey to the bin by a few seconds.

The crap this time was a silly survey from some academic centre of excellence (click on survey to enlarge). It had everything about it guaranteed to get a busy GP offside and wanting to throw it with force into the bin. It wasn’t actually the subject of the survey that was the problem- that was valid enough. It was the phrasing of the intro letter that annoyed me.

Academics amaze me. They seem to have no idea about how little we care for their pet projects, their current theories. Nor do they quite realise how dissociated they are from reality of NHS general practice. So when they write assuming that their projects matter to me they assume rather too much.

It was a very busy day at the Ranting House. I did not have a spare ten minutes, and even if I did I was not going to use it on this survey. It has everything in its approach that actually illustrates lack of understanding and indeed a lack of politeness to busy people.

“You are being invited” as I am several times a week by too many people. It doesn’t make me feel special.

“We realise that answering this survey will take some time (10 minutes)” I may or may not be willing to give this. Time management is about priorities, not minutes, and this wasn’t about to become my priority because...

“However it is vital” Oh no, it isn’t. At least not to me it’s not. It might be to someone, but it’s probably only to some academic who wants to get his papers published.

“in a peer reviewed medical journal” I do hope I get to review this one! Dr Rant regularly peer reviews papers for various journals. I’ll pay close attention to the response rate. And Carey Cardigan is not really representative of his profession.

“we greatly value your opinion” No you don’t- you’ll take the answers and put whatever spin you were going to put on them anyway. Insurance companies value my knowledge properly…and pay for it. A £10 M+S voucher would have helped…and the project was Pharma sponsored.

"A charitable donation to Depression Alliance for every completed questionnaire"
But this is not my favourite charity, and it's one of those silly campaigns with no obvious enemy. Where's the pro depression campaign that opposes it?

I can give my opinion for free any day I want. This blog is rather good evidence of that!

Actually if they had sent the survey and said “Please help us” I would have been more inclined to say, “yes.” If they had not said “It is vital” I would have been more sympathetic.

They broke rapport because they focused on what was vital to them (to get lots of responses) rather than on what was vital to me (getting through the day). This broke rapport and left me feeling that the survey mattered a whole lot more to them than it did to me.

So it went straight into the bin. Aren’t time management skills wonderful?

Levelling the playing field

Dr Rant has been reliably informed that a certain PCT not far from Oxford has been up to some rather mischevous work. To set the scene, Oxford has an excellent Orthopaedic specialist centre in the form of the Nuffield Orthopaedic Centre which has some of the best surgeons around and an outstanding record of clinical care. However as part of HMG's reform program an Independent Sector Treatment Centre was set up in Banbury, about twenty miles north of Oxford. The PCT, probably due to pushing from the government, signed up to a long contract with this ISTC that paid large amounts of money up front for a quota of work that has not been completed; a familiar tale for an ISTC, burning money again.

At a recent PCT Practice Based Commisioning (PBC) meeting it was made clear that certain rather large and unfair incentives were being offered to whoever was willing to refer patients to the ISTC. The cost of all referrals and treatments at the ISTC will not be charged to the GP practice's budget, in an attempt to boost the trade of the flagging treatment centre. Patients would also be reimbursed all their travel expenses for making their way to the ISTC. Other policies were also brought through at this meeting which look to waste even more tax payer's cash on anti-obesity schemes with a zero evidence base of their efficacy.

This example perfectly demonstrates just how much damage the government's poorly thought out reform program is causing. The Nuffield is a brilliant tertiary referral centre that has been struggling financially of late; largely thanks to a Payment By Results (PBR) system that does not reward the units that do the trickier more complicated work, work that is in fact too hard for other units to even consider undertaking. The government's fisherprice payment system rewards easy work and gives no incentive towards doing good work; this means that a hip replacement that lasts only three weeks because it was wrongly positioned makes as much money as one that lasts for twenty years.

The PCT's actions are yet another kick in the balls for excellence in the NHS, and show that in reality this rigged internal market is acting as a catalyst for needlessly burning tax payer's money. Money is not only burnt running the highly inefficient PCT bureaucracy, but it is also burnt bribing GP practices to send patients to the flagging treatment centre. Even if the Capio treatment centre was able to provide as good a standard of treatment as the NHS' Nuffield, this would be an incredibly wasteful scheme. However when you hear that local medical staff refer to the Banbury treatment centre as 'Crapio', one soon realises why the patients flock to the Nuffield.

I wasn't expecting the Spanish Inquisition

Nobody expects the General Practitioners Committee............

Dr Rant's recent piece about the 'mole' inside the GPC seems to have touched something of a raw nerve. We have heard from at least two members of the GPC (neither of whom is our mole!) that there is currently something approaching a witch hunt trying to identify our source..........

In retrospect, our description of our source as 'actually being an actual member of the actual GPC' may have been a touch ambiguous and a bit of an exaggeration and could well be the source of the confusion. For that we humbly apologise, and you can rest assurred that will give ourselves a very stern talking to indeed. Slipping to Daily Mail standards of journalism is unforgivable.

However, the GPC's reaction to the story shows that it must in fact be 100% true!!

Cardinal Buckman - Fetch: The Comfy Chair!

If Dr Rant were being mischievous, he could use this method to confirm the truth or otherwise of any future hunches or mumblings by claiming it comes from our mole......if they bite it must be true!

It is deeply flattering to have attracted the attention of such an august and influential body as the GPC, and it would be churlish indeed to pass up an opportunity to whisper in their collective shell-like. Our message to the GPC is:

Do you not find the complete lack of surprise about the DDRB amongst doctors on DNUK and on this blog strange? This jaded cynicism and contempt for the government and their hollow threats should set alarm bells ringing in Tavistock Square.

Keep it up - you have our support. Fight fire with fire with fire, and do not underestimate the profession's stomach for a fight.

Access: For what price?

We wrote recently about the 'why' of 'access'. However the government is desperate to get GP opening hours extended into the evenings, and within “the same overall cost envelope”.

So the government is so really keen to get better access that it is willing to spend nothing to achieve it. The NHS alliance has put out a useful press statement.

As we revealed this week, the negotiations between the BMA and the DH have shown what the government might be willing to trade, and how they intend to threaten us, to get it. It seems that the government would value one hour of late evening surgery as being worth twice a daytime surgery. So a practice could open once a week to say 9pm, or for an hour on a Saturday, and close for twice as long another day. In other words we could open less and earn more. We’d have to pay our staff for funny hours, but we’d get someone in and manage it.

Would this be a good deal for patients?
NO- they’ll overall lose GP availability. The people with major illnesses, the retired folk with co-morbidity, the ones in whom most medical work is needed would get less access. The office worker with minor viral infection, and the girl who’d run out of her pill would do better. Medically such a trade would represent taking resources away from the sick and towards minor illnesses.

Would this be a good deal for taxpayers?
NO- you cannot get something for nothing, despite what PBC is supposed to achieve.

Would this be a good deal for doctors?
Not really, but we would adapt as always, to severely skewed incentives.

Is the DH going to get a good deal for patients and taxpayers here?

Like fuck they will. Of course not.

Access: Why?

There is much bleating and gnashing of teeth at the DH as they cannot deliver access to dentists and/or GPs. If they’d stop gnashing their teeth they wouldn’t need either of course.

Now I know that the access at my practice is not as good as it could be, but I’m not sure this matters.

This may strike readers as non-patient centred and not politically correct thing to say. But I’ll say it again- I’m not sure it matters.

Not at least in the grand scheme of things that do matter.

It matters at the trivial levels of convenience, time off work, personal impatience and so on. But these are base consumerist notions, and the phenomenon of supply induced demand will soon swamp any improvement we do make.

But at the level of seriously ill patients going untreated I’m not sure access does matter that much. If I thought seriously ill patients were unable to get treated at my surgery I would be worried. But I see no evidence of this, and I read the hospital letters, casualty reports and other messages carefully. (They’re not going elsewhere)

At the level of what really matters in medicine such as cancer treatments and other serious illnesses their claim on limited NHS monies is greater than that of patients wanting GP access now matter how shrill the siren voices are. At the end of the day the main job of the NHS is to treat serious illnesses well, not to give empathy to IBS patients, or attend yet another meeting.

So let’s look at what patients will bring to GPs if access is increased:-

1. GANFYD requests- get a note from your doctor- for housing, school, work, prisons, and any one else who thinks that “a doctor’s note” (Middle C anyone?) will allow some minor bureaucratic admindroid to do something sensible, but not of their own volition.

2. Acute minor illnesses. GPs are being (rightly) castigated for giving out too many antibiotics for these. If people can get to us very early in their illnesses you end up seeing minor viral illnesses 3 or 4 times in one week. If you see your GP too often they will eventually give out ADT (Any Damn Thing) to try to get you out of the door. If GPs are full the patient arrives a week later and says, “It was bad last week but it’s gone now” The GP thinks, “You never really needed to see me at all…and anyway there’s next to nothing we can do for minor viral coughs and colds…and you’ve shown you can fight it off yourself… so you are wasting your time around here mate” (Exit patient stage left)

3. The neurotics “I have no life…and my atypical chest pain…or is it my irritable bowel…is giving me lots of pain.” The doctor is thinking, “Yes dear, you’ve had a bad day at work, you always get these funny pains…and have been for years…and you have dealt with them before…and you’re only here now because I am open now.”

As you can see opening up our surgeries longer is really going to get serious illness better dealt with. It will pander to the worried, the neurotics, and the feckless, and it will reduce people’s abilities to cope with illness even further.

Supply induced demand will emerge and the patients will turn up and pack out the surgeries. I just think I won’t see any more real major illness than I do already. I think I’ll see the usual suspects, later at night, and more times a year. Pandering to sympathetic nervous system hyperactivity disorder (Copyright Dr Rant) is a waste of time and money.

Gordon Brown, Alan Johnson and Lord Darzi have no clue about really matters in medicine, and are currently stoking up a consumerist madhouse. They have the political power to get their way, but I predict it will come back to haunt them.

The problem is that symptoms are common. (Symptoms are sensations that a patients thinks may be related to a disease and might need medical help) Most of us have two or three symptoms every day and rightly judge them as harmless. Disease is actually quite a rare cause of symptoms.

So there are many people with symptoms and yet few with serious illness. So doctors spend a long time sorting out the worried well, the neurotics and the hypochondriacs from those with real illnesses (on whom they should spend more time money and attention). The aim of a good GP appointment system is to keep the neurotics wailing at the door and get the seriously ill ones seen and sorted. And to keep the neurotics away from potentially dangerous and harmful interventions at the hospital. The longer Dr Rant practices the more he realises just how demanding a commandment “First Do no harm” is to achieve in practice.

Simply increasing access will open the door to the neurotics and the polysymptomatic symptom generators and entitled demanders. They’ll love it…but it’s a waste of medical time and NHS resources and our tax revenues pandering to this group.

The NHS needs to ratchet down demand, and focus more on the most serious illnesses well. That actually means making it less easy to access doctors, and drugs, and tests, and doing less medicine overall. Much of what is done in medicine is already over cautious, defensive and fear driven. And antibiotics are given out as GPs and patients are nagging each other to pieces.

Of course if I was working entirely privately I’d be as nice as pie to well heeled neurotics, double my fees, and test to my heart’s content. I’d be richer than I am, and my ethics would have gone to pot, but I’d be ever so patient centered and customer focused. The patient would be worse off, financially and medically, as a result.

I know UK GPs tend to be rushed and a bit irritable. But if you give patients and GPs too long together they find far too many things that need investigating and testing and prescribing for. And so costs rise.

One of the great achievements of NHS (Treasury are you listening?) has been to keep doctors so busy that mostly they don’t do too much unnecessary investigations and treatment- indeed if anything UK doctors under investigate patients) This has kept patients away from an excess of incidentalomas (minor, irrelevant,non-serious lesions found on unnecessary MRI scans) and serum hyperrhubarbaemia. (a funny chemical that clever doctors measure…and then have no idea what to do about…and patient is no better off as a result of the knowledge…but now they have a condition with a label. Better not eat too much custard, or the rhubarb level will rise still further.)

One of my psychiatric profs said, “Anyone who wants to see a psychiatrist must be mad” I’d agree with him, and enlarge it to “Anyone who wants to see a doctor must be mad” You should want to see a doctor only if you are seriously ill, and the alternative of not seeing a doctor and taking his poisons is worse. That is that the NHS should respond to NEED, and not to WANT.

The first duty of the doctor is to educate the public not to take medicines…and in the name of good medicine we should abandon the access demands.

However the great clunking politburo chief wants to squander taxpayers pounds on a showpiece improvement and he seems to have found GP access as his vanity project. God help us all, and save the country from bankruptcy, and the patients from an excess of medicine.

The Twaterati in action

Yesterday, the Parliamentary Health Select Committee got a chance to grill the fuckwits who were largely responsible for the computerised career genocide that is MMC and MTAS. Watch the twaterati in action here if you can bear it. It really is nauseating stuff. Having watched it, Dr Rant was reminded of a song called 'World Leader Pretend' by R.E.M.

This is my mistake,
Let me make it good,
I raised the wall,
and I will be the one to knock it down.

How can these wankers feel safe in their jobs? Or will Chief Clunking McBroon-Thug continue to support incompetence?



Time for Donaldson and Marshall to go............

Are you still here?

Sir Liam Donaldson: Going nowhere fast

The BMA has become unrecognisable of late. Since Nosher Meldrum has taken over from Wee Jimmy Johnson, gonads have been paraded with comparatively reckless abandon. The new chairman of the BMA's Junior Doctors Committee, Ram Moorthy, is also proving to made of considerable more prickly stuff than the lacklustre doormat that he replaced. Here's today's press release your your delight and edification:

Junior doctors repeat call for Chief Medical Officer’s resignation

The Chief Medical Officer for England, Sir Liam Donaldson, today (Thursday 15 November, 2007) said he would not resign over the failed Modernising Medical Careers training reforms.

Mr Ram Moorthy, chairman of the BMA Junior Doctors Committee, says:

“The CMO is supposed to be the link between the government and the medical profession. He can’t fulfil that role effectively any more because doctors have no confidence in him. He was one of the chief architects of these reforms and it’s time for him to take responsibility.

“The government is belatedly acknowledging that they rushed in a new system that messed up thousands of doctors’ lives. What happened this year must never be repeated, and that means that doctors have to be listened to.”

Dr Rant applauds the new BMA's tougher line, but would put it slightly differently himself............

FUCK OFF LIAM AND FUCK OFF NOW!

The case of the independent DDRB that wasn't

Dr Rant has friends in places both high and low, but few are more strategically placed than our friend on the GP Committee of the BMA, the body that is a responsible for directly negotiating with the government when it comes to GP contract issues.

It will come as no surprise to you that the government employs shady practices and exerts undue influence on supposedly independent public bodies, but it gives us great pleasure to give you some specific details.

For the past two years, GPs have received a 0% annual increase in their total (gross) income in a shameless claw-back after the freely and fairly negotiated new GP contract was introduced in 2004. Out of this generous 0%, GPs are expected to pay their staff annual increases and meet the rising costs of running a business and heating a building etc.

The annual pay rise for doctors and dentists in the NHS is decided by a body called the Doctors and Dentists Review Body (DDRB). This body is supposed to consider evidence from the government and the BMA before coming to an independent decision which should be then accepted by the government.

It has become abundantly clear that the Government thinks that they will win the next election if they have force GPs to offer routine appointments at weekends and in the evenings, despite the fact that 84% of people are happy with their surgery's opening hours. The government is also determined that this increased access with come at no extra cost to the DoH - i.e. for free.

Here's what actually happened:

Government Fuckwit (DoH): Right you Bourgeois pigs - we think we'll win the next election if we can get you to open at the weekends and evenings, so that the worried well don't have to miss the Jeremy Kyle show. Trouble is, we not going to a pay a penny for it to happen. We're going to reduce the amount you get paid to do things that you do already, and you can only have it back if you open extra hours. Pass the caviar Quentin.

GP Committee (GPC): What? So you want to pay us less for doing things that have been proven to make people with chronic diseases live longer, less miserable lives, just so a few Daily Mail reading reactionary shit for brains can whinge at us in the evening. Isn't it their employer's duty to let them have time off to see during normal hours anyway?

DoH: Well, we are prepared to let you shut during normal hours - let's say 2 hours for every one hour extra you do.

GPC: Wait a minute, you want us to reduce the quality of care we provide to people who really need it and make it harder for acutely unwell people to see a doctor whilst at the same time giving the Daily Mail a opportunity to whinge about us earning the same money for fewer hours? Anyway, have you actually ever been to a General Practice? There's no way we can shut during the day because we're already working flat out and you will create additional demand (rather than redistribute it) by opening later. You know that GPs will end up staying open anyway without getting paid.

DoH: (knowing smile)

GPC: This is a shit deal, that will actually be bad for patients and create demand that isn't actually there now. If you want us to open extra hours, we're happy to do it, but we need to be paid fairly for this. It will still cost less per consultation than your useless NHS Direct and Walk-in centres where there isn't a doctor in sight.
To be honest, we're inclined to tell you to go fuck yourselves.

DoH: Alright then, how about we'll look at some of your priorities like actually having buildings that are fit to practice medicine in. If you play nicely, we won't interfere with the DDRB recommendation for this year. How does 0% for the third year on the trot sound?

GPC: What the fuck? The DDRB is an independent body. You can't do that, and it would be an abuse of political power for party political means.

DoH: (smirk)

Don't you just love open and accountable parliamentary democracy?

Practice Based Commisioning

An Ivory Tower yesterday.

Of all the misinformed, misbegotten and ill implemented changes that have been inflicted on the NHS this could be one of the worst.

I’d better start by saying what it is supposed to be, at least as far as I, or anyone might know- the details are sketchy and the practice patchy and inconsistent. The official links are here and here and here
and here

“We believe that Practice Based Commissioning will produce the following positive outcomes:
• A greater variety of services, from a greater number of providers in settings that are closer to home and more convenient to patients.
• Increased support of clinician-to-clinician dialogue about improving and developing care processes.
• Early and continuing involvement of practitioners in service development
• An additional set of levers to aid demand management.”

Additionally PBC may solve the long standing problems of health inequalities according to this piece in HSJ

“One of the stated aims in the Department of Health's vision of world class commissioning is to eliminate health inequalities. Not to reduce them, but to get rid of them altogether.”

Oh and all this will involve world class patient engagement as well!

“Picker Institute chief executive Angela Coulter said engaging patients would be vital. 'Commissioners need to get beyond talking to the usual suspects,' she said. Rotherham PCT chief executive Andy Buck said: 'Probably the greatest challenge for PCTs is to find radically better ways of seeking out and acting on public and patient expectations and experience.'”

The document envisages PCTs with high levels of clinical engagement, which it says is 'integral to the process of commissioning'. Dr Rant has commented on world class this before- Our engagement with it is of course world class!)

Finally I love this recent quote from NHS Confederation PCT network director David Stout 'This is the first time we have had a coherent sense of what commissioning means and where we are trying to get to.'
I love the fact that he now (October 2007) has a coherent sense of what commissioning is. (First launched about 2004) I doubt anyone else does yet, and I doubt his current clarity will last for long.

The PBC enthusiasts are an odd lot. They have a messianic fervour, and believe great things will be achieved by PBC. They have a variety of motives.

Some are former GP fund holders and want to get their hands on budgets again. Some imagine that primary care will improve by getting its hands on “all that money going into secondary care.” Dr Rant thinks that beggaring secondary care will do nothing for primary care.

Some don’t like patients, or doing surgeries, and prefer twateratus type work on committees. They talk about ever more “patient centered services delivered closer to home” but actually you’ll never catch them delivering it themselves. They like patients so much that they don’t like seeing them. They may however exploit, sorry employ, a salaried doctor to provide the service and take the profit.

From the above we can see that PBC is trying to achieve many things at once.
• A greater variety of services, from a greater number of providers in settings that are closer to home and more convenient to patients.
• Increased support of clinician-to-clinician dialogue about improving and developing care processes.
• Early and continuing involvement of practitioners in service development
• An additional set of levers to aid demand management.”
• Also an end to health inequalities
• Also full clinical and patient engagement

Now there are many problems with all this. Firstly the agenda is too huge. PBC is becoming seen as a panacea for all NHS and the NHS as a panacea for all society’s ills. Inequality is a fact of life in UK for at least the last 2000 years. Edwin Chadwick and team first documented the problems…or was it William the Conqueror with the Domesday Book? The fact that wealth inequalities show up as health inequalities is well known. The medical system can only deal with the casualties of this, not the causes. The medical system in any country is not a mechanism that can or will reduce health inequalities, although hopefully it will give equal (equally bad) access to treatment to all classes on basis of need.

Secondly PBC is currently a mechanism for taking money off “over funded expensive hospitals” and giving it to “other providers” Who the other providers might be is not clear, but current government plans for GP in Tesco and Boots show that existing GP services are out of favour. Also these new services look likely to be set up with no local consultation with GPs or patients, and PCTs will probably consult central government diktats so they don’t get clunked by the Great Clunking Fist. Local decision makers will be ever so empowered by strong central direction.

Thirdly there is a worry about the ability of trusts to manage existing budgets, let alone to set up a new way of commissioning services. Apparently this worry is so great that “external expertise will be needed” (The management consultants again). How they know any more about commissioning than anyone else is a mystery to me and anyone else…and probably to them…but as long as they keep on spinning the yarn the emperor’s clothes will look ever so grand. Won’t they? CLUNK.

PBC as currently set up is a mishmash of conflicted politically correct sounding, nominally patient centred initiative that is supposed to get more and better services by spending less money. Actually it is a time consuming excuse to go to meetings rather than actually see any patients.

Dr Rant agrees there are efficiency savings that could be made in the NHS. Stopping PBC would be one of his suggested cuts, along with closing down PCTs. PCTs are not primary, not caring, and not trusted by doctors, patients, or government.

I think PBC could be dead in the water, but no doubt it will get resurrected into another form or incarnation. I told you the messiah has spoken…

Highly ineffective and highly defective: The State of NHS 12.11.07

The State of the NHS, and unflattering international comparison across Europe rear their heads again today. For us the key problem in the NHS is that bureaucrats are running it to their agenda,and getting in the way of doctors and patients working together on sensible solutions to medical problems.

In the NHS you can regularly see meetings called where combined salaries of over £1,000,000 sit around a table for hours debating expenditure of £15,000. The game will repeated again and again, week in week out and no decisions will be reached but hours will be reduced to minutes. The whole edifice is top heavy, and hinders the primary service deliverers (Doctors, nurses, physios etc) from getting on with their job. And the £1,000,000 worth of salaries committee just demands ever more information so that “fully informed decisions” can be made by “due processes, fair and transparent”. If any of the £,1,000,000 of salary ever got out and saw what was happening they might learn something…but of course no management ever wants that kind of real information do they? Didn’t the founders of M+S at one stage visit one or other of their stores each Saturday and listen to the sound of tills going, to check their sales and cash flow for themselves? And to make sure that the figures subordinates presented them with matched what was actually happening.

One of the men who helped get us into this mess rears his head again today in the Observer. It makes us SICKO with rage to think that the man who advised Phoney Blair has actually gone and joined one of the NHS’s natural enemies. If the captain of the ship is planning to join the opposition what hope has the ship? This is basically treason to the ideals of the NHS.

(Even the Chinese this week thought Blair was an expensive fake who spoke only “platitudes and empty generalities”)

On Dr Rant we hold no respect for current NHS policies which we think are expensive, valueless, misdirected and ineffective. We would start our NHS policy by stopping all of them entirely and sacking all those involved in creating them, and all those who willingly collaborate with them. We would scrap all the crap about the internal market which has created the worst problems the NHS has seen. This view will see a lot of people out of work, and would save the taxpayer a fortune.

I think Simon Stevens, Blair, Julian Le Grand-Prat, Alan Maynard, Kenneth Clarke, Alun Milburn, Patricia Hewitt, Liam Bryne, Liam Donaldson, Andy Burnham, Lord Warner, Alain Enthoven would be the amongst first to named, shamed and sacked. However their name is legion, and all their departures are long overdue.

Lord Darzi, David Colin-Thome, Dame Carol Black, and many others would go as medical collaborators. The keenness with which many senior medics have become spokespeople representing the government to their members, rather than their members to government is sad to see.

The whole lot of PCTs could be closed down and never missed.

Most of the managers in NHS acute trusts could be sacked and never missed.

All the management consultant parasites could be sacked and never missed.

The big American healthcare corporations should never be allowed anywhere near these shores. Seeing people like Richard Smith join one of these is just revolting. Another twateratus to enjoy booting out.

What would we put in place of current management?

Well firstly we would want local democratic accountability. So maybe local councils to run the hospitals and GP surgeries? And with locally elected officials as they have in USA so how about local elections for hospital chief execs, and fixed terms of office?

And the government’s role would become one of service specification, standard setting and regulation, rather than that of centrally directed provision. Bevan’s biggest mistake was ever to allow the clattering bedpan in Little Middlecombe to be heard anywhere other than Little Muddlecombe. On the other hand when nurses tell patients “just to go in their beds” you know that there has to be something very wrong in the current setup.

Above all the new service would have just enough management to support the front line personnel, and no more. The managerialist agendas of the last too many years are what cause most of the current NHS problems.

A Slimmed down NHS is entirely possible and indeed desirable. The bureaucratic fat is ripe for total destruction. Is Andrew Lansley brave enough to go for this?

There are some encouraging signs. The taxpayer’s alliance is getting more vocal. Nigel Hawkes in the Times has picked up well, “The NHS used to be underfunded and ineffective. Now it is only one of these”

People are going to start asking what value they have got from the massive squandering of public resources by new Labour over the last ten years. The answer is clearly far less than they have paid for. The answer is not more taxes and try again. The answer is local services, local discretion and far, far less bureaucracy.

As GPs the government may find us revolting. We ne