Another great piece of research from the NHS....

Apparently, some boffin in a lab has worked out that patients who clench and unclench their fists a lot when getting blood taken can have falsely raised potassium (K+) levels.

Fucking brilliant. She only had to look at 200,000 patients to work this out.

Let's make this very simple for the boffins:

1. We've known this for decades.

2. We only ask people to clench and unclench when we can't get a sample any other way.

3. Patients who we can't get a sample out of usually also have the tourniquet on for ages (raising K+) and have more bruising from the difficult attempt (raising K+).

4. You don't get a choice between taking blood with clenching/unclenching and taking blood without. In these patients, you get a choice of getting blood with clenching/unclenching or not getting blood at all.

5. K+ is not the only think we are testing for.

6. Don't you have something better to do with your time?

7. Er....

8. Actually, that's it.

9. No. Really.

Still, the author did manage to get one fabulous quote out:

"It seems to be hit or miss whether they get trained to avoid using this procedure."

Hit and miss? Taking blood? Nice one, Vanessa. What's next, following 200,000 bears into the woods to see if they shit?

Trust me - I'm a GP

Early research into the Doctor-Patient relationship and the concept of 'trust'.

Have a look at this abstract from the illustrious New England Journal of Medicine, which is not exactly known for it's pro 'socialised medicine' editorial policy. It looks at the concept of 'gaming' to hit targets in order to achieve financial gain - i.e the New Labouresque tactic of removing people from the statistical count if the don't conform to your targets.

Conclusions - Exception reporting brings substantial benefits to pay-for-performance programs, providing that the process is used appropriately. In England, rates of exception reporting have generally been low, with little evidence of widespread gaming.

So if we're not defrauding the system, and we're not playing golf all the time, then what the fuck are we actually doing?

It's obvious that he government and 'liberal-elite' chattering classes don't trust GPs, despite the fact that that our patients do. This article is as about as hard as the evidence gets, and shows that GPs are not systematically cheating to earn money - we are actually hitting these targets, and that the patients are the one's benefiting as a result. If someone can provide me with evidence that something similar has happened, in anything other than the most heavily regulated, free market system I'd be quite interested. Now fuck off Toynbee, here's a good girl....

Saving lives, and saving money: What primary care is good at doing.

David Haslam: An organ grinder surrounded by deaf monkeys.

David Haslam is a GP in Cambridgeshire and President of the Royal College of General Practitioners. He’s also a really likeable bloke, and if I was ill he is the kind of GP I would like to meet.

He’s written a superb article here which describes the importance, the low cost and the effectiveness of primary care. Good primary care saves lives, as Barbara Starfield has demonstrated.

Dr Rant hopes that Lord Darzi and team are not going to destroy the great primary care system that already exists in the UK.

However as a friend of mine put it to me,

“Haslam has always been an intelligent and stylish commentator. The task however is hopeless. GP is, and has always been, undervalued. The achievable task is to lobby the ear of the powerful and try to mitigate the endless tendency towards dramatic and high tech medicine. Success will only ever be partial.”

On here we believe in the strength and importance of primary care. Voltaire once accused doctors of, “giving pills of which they knew little, for diseases of which they knew less, to patients of whom they knew nothing.” Politicians and their ministrations to the body politic are even less informed that this.

The longer I live and practice medicine the more I realise just how demanding a rubric “First, Do no harm” is to actually achieve.

Anyway read David Haslam’s article and you’ll get a glimpse of what primary care can do for patients.

We will, we will, MOCK you!

Click image to enlarge

I thought it was about time that we visited the subject of the latest, and stupidest, most hare-brained scheme of the creator of Doctors Net UK: www.iwantgreatcare.org

You may have heard the russet tones of Neil Bacon all over the meeja over the past couple of days lauding his new love-child. Crippen's already touched on this subject here, here, here,here and here, but I wanted to draw your attention to the delightful screenshot at the top of the piece, which is well worth a click and reading in detail.

No doubt single issue loons and self obsessed tossers (like some of our correspondents) will love this opportunity to snipe at doctors that they perceive are getting between them and what they want from the NHS. However, they are unlikely to take the opportunity to credit the same doctors for giving them what they 'need' in preference to want they 'want'. Doctors will of course have no right to reply.

As you may have gathered, every non self flagellating/satisfied doctor without a vested interest is pretty pissed off about the whole thing, as is evidenced by this story.

Sorry Neil. It's a shit idea and you are behaving like a total twat about the whole thing. Carter Ruck's letter has been partially funded by the team, and we will not be passive in our defence.

In the meantime, let the ridicule of 'I want great care' continue. I must say, I particularly enjoyed the review of the psychiatrist who put his 'wanger' in the patients' ear. Neil has made his position clear - that internet criticism of doctors is a good thing and immune to legal comeback..........

Rotten veg to the ready.......

Brown’s losing it

The marvellous Peter Brooks of The Times cuts to the quick.

From Thursday’s Mail

“Last night it was revealed the Prime Minister was confronted with growing complaints about his leadership when he summoned MPs to private talks about his future.
Mr Brown was asked by anxious backbenchers what he was doing to counter public doubts about his fitness to be Premier at a meeting in Downing Street.
In reply, a frustrated Mr Brown 'thumped the table' in the Cabinet room and urged his MPs to tell voters about the Government's record on health and education.”

OK, lets then look at Labour’s record in education and health.

In education it’s obvious to me that:-

• Teachers are thoroughly stressed out and pissed off.- The stream of them to my surgery shows no sign of abating.
• That teachers would retire early if able to.
• That degrees are a devalued currency- more expensive to buy, and less distinctive than they once were.
• That grade inflation renders A grade A levels less valuable than they once were. This is even more obvious to university admissions officers. To me it’s obvious that today’s students are neither brighter nor dimmer than my generation…so the proportion of A grades should stay about the same as it was.
• That we still have adult illiteracy rates of about 20%- in my surgery I found this was the shame that drove a patient of mine to alcoholism, that one illiterate young man regarded me as a genius for quickly looking up a drug in the BNF (“Can you read so fast doctor?”). What were these people doing whilst at school? What were their teachers doing with them? What did SATS measure? It certainly wasn’t reading ability!
• That most of the British people are innumerate. They cannot work out percentages, do mental arithmetic, or work out when credit cards are charging them a lot of interest. Hence fantasy island economics. I’m sure at least 80% of British MPs are below average at maths, hence why they won’t get this joke, nor did they spot the flaws in Gordon Brown’s economics.
• Inclusivity effectively excludes everyone. Ed Balls may prattle on about “excellence for everyone” but excellence by its nature is an exclusive concept. It’s defined as excelling above some baseline standard. Not everyone can get to excellence, nor in every field. If he aimed for a high basic standard he might be more sensible. And keep the basics to getting able people able to read, write and add up. It may not sound much of an ambition- but it’s probably what can be, and is worth achieving. It’s a bit like “First do no harm” in medicine. It sounds so easy, and so little. And then you practice medicine for a while, and realise how much medicine you need to know to live up to it.

Anyway that’s enough of dissecting Labour’s higher nonsense on education. Let’s finish this section with the great quote;

“Nothing you will learn in the course of your studies will be of the slightest possible use to you in after life; save only this; that if you work hard and diligently you should be able to detect when a man is talking rot, and that, in my view, is the main, if not the sole purpose of education”

By my reckoning, that makes me on of the best educated people in Britain, because I smell bullshit. There’s more than a few Brits left who are sufficiently well educated to spot that Labour talks rot on education. So perhaps their MPs are not so keen to be picked up for speaking rot as Mr Brown would have them be.

And what of Labour’s record on health?

Well on here we think it’s worse than its record on education. We see rising inequalities of health, wealth and education. We see rising numbers of bureaucrats and fewer hospital beds. We see ever more guff about “care pathways” and ever fewer coherent routes for our patients to go down. We see more management, and activity, but less actually getting done.

We think that the money spent by Labour on the NHS has been pissed away. We are sad and angry that Labour is so keen to destroy the NHS and deliver it in tasty chunks to Neil Bentley, Richard Branson and others.

Anyone who knows anything about health whether from left or right wing must realise the sheer stupidity, and gross ineffectiveness and huge expense of this government’s health policies.

The answer is some competition, and sooner the General Election Competition starts one the better.

Mr Brown:

I don’t think Labour’s record on either health or education will get anyone to vote for you. Your MPs are right to question your “fitness for purpose.”

The Darzi Report

An Empire building, robotics expert, 'Doctor' opponent, yesterday.

We resisted an immediate reaction to the Darzi report. (Actually we were all busy elsewhere, or just too lazy.)

But the national press have been active on the issue and the overall impression is quite funny.

We have a Stalinist government, run in a highly centralised and paranoid way. (By the way yes we are all out to get you out!) Private Eye’s caricature “From the Desk of the Supreme Leader” captures Brown beautifully. Then we get the fun of the Broons, reborn to scunner Broon and his depleted and deserting army.

The Russian Empire was brought down ultimately by the unsustainable farce/tragedy of trying to maintain an illusion. Eventually empty supermarket shelves spoke louder than “Tractor production quotas achieved” and all the efforts of Comrade Stakanovich. As Robert Conquest puts it, (The Dragons of Expectation: Reality and delusion in the course of history p47, Penguin edition)

“The crux is less intelligence than a failure to confront that intelligence with reality-and even a drive to use that intelligence to deny or pervert reality.”

We seem to be getting the same sort of reaction to Darzi. Firstly medical leaders haven’t flown off the handle at it, and have commented, “it’s good in parts” Even Remedy UK have found something to welcome with the repairs to the MMC/MTAs system that has failed so badly (that's state central planning in action for you).

Something much more subtle seems to be happening. The report has been greeted quietly, and the responses seem to vary from “another government report” to “might be good, if ever implemented.” However some most welcome, splendid ridicule is emerging:

Oliver Pritchett does an excellent demolition job on the notion of patient choice in the Telegraph.

Brendan O’Neill at Spiked lays into the illusion of choice New Labour offers. (well nothing new Labour has said is real is real is it?)

Simon Hoggart has a fit of the visions, and sees jargon from top to bottom.


The Public no longer trust the government on NHS reforms. The Telegraph suggests that the NHS might be right for retirement. A bit early perhaps, but it’s an old system, and not up with modern ways.

Harriet Sergeant weighs in the Mail today. The NHS will end not with a bang, but with a door being closed quietly on the last bureaucrats meeting as the agreement to close the last bed in the last hospital is reached. This develops her previous authoritative report “Managing not to manage” for CPS.

Dr Crippen finds the report “offensively inoffensive”

Daniel Finkelstein in the Times finds the whole report to be a dangerous document, because it has nothing to say about reality. It promises much, but it’s unlikely it can deliver anything. Under performing and over promising is a desperate political strategy, rather than any way to run a business or organisation.

Somewhere behind the vision is a realm of fog, where the way forward is entirely unclear. And there is no honesty about this unclarity. The word “Rationing” looms up in the mist, and present fears are less than horrible imaginings such as top up fees. Karol Sikora may be the man to insist we find a way through it.

Meanwhile the ever awful Ben Bradshaw pops up to insult GPs, and accuse us of “gentleman’s agreements” between practices, and other shenanigans. Ben Bradshaw is rapidly becoming as loathsome as Patsy Hewitt remains. About the only thing we don’t hold against him is his homosexuality. He’s plainly lost his connection with reality as this quote shows. On the subject of the National Programme for IT, a scheme dogged by cost overruns, failing public confidence, delays, and doubts over its benefit to patients[6][7], he commented:

"Our use of computer technology in the NHS is becoming the envy of the world. It is saving lives, saving time and saving money. If you talk to health and IT experts anywhere in the world they point to Britain as example of computer technology being used successfully to improve health services to the public."[8]Credo est, quia absurdum.

This government has two years left before we can boot them into touch. They have had to U-turn on many policies recently. Let’s hope we can stop them doing too much damage to the NHS before they go.

Next to no GPs, except the now discredited David Colin-Thome, will support Labour at the next election. Any Labour MP wanting to visit the Ranting House Surgery will be persona non grata.

New Labour are currently ridiculous. History repeats itself, first as tragedy, then as farce. In this government’s case we are suffering a tragedy, and their efforts to sort it are farcical.

The NHS at 60: It’s great…BUT

It’s the 60th anniversary of the great institution we both love to love and love to hate. Dr Rant couldn’t resist a birthday card to the dear old NHS. So here it is:

The NHS is great because it provides care free at the point of need, to the whole population of the country. All health systems have to be paid for somehow, and paying tax is as good or bad as paying an insurance premium.

The NHS is great because it takes monetary considerations away from the immediacy of the doctor-patient consultation…but this is bad as it simply makes rationing covert.

But once we have stated the good in the NHS we need to acknowledge the significant downsides of the NHS.



1. The NHS is such a good system that no other advanced industrial economy has one.

In the old days we were taught to see the irony in “They’re all out of step except my little Johnnie!” It seems we have a blind spot about the merits of American and European systems. Must be the great education we all get under Commissar Balls-Up.


2. The NHS has no co-payments. It just prefers people to die!


3. The NHS results in terms of successful treatment of serious illnesses are less good than those of our European neighbours.
Somehow our system isn’t getting the sickest patients the best treatment. Somehow the Europeans and Americans have got things better organised than we have. We still have much mortality amenable to healthcare.


4. Despite the NHS, health inequalities in the UK are worse than in past generations.

This is not a failing of the NHS itself- Medical treatment only patches up the casualties of the battle, it doesn’t stop the battle going on. In this battle health is more or less an outcome of education and wealth, and ill health a consequence of poor education, poor housing, and lack of money. The failure of Government policies to do anything about this is well illustrated by the health statistics from Glasgow East. The role of the NHS in keeping unemployment down by classifying everyone as incapacitated is also well shown there.


5. The NHS treats everyone…eventually

The NHS works as a sausage machine production line. We treat everyone, but the service to patients is far from great. Consultations are rushed, and we regularly order tests to get people out of the door. The NHS is becoming ever more efficient at throughput measurement, but is steadily destroying the therapeutic alliance (a relationship of respect, listening and trust going both ways) between doctor and patient. The NHS prattles a good deal about “ patient centeredness” but this is simply becoming a term of rampant consumerism. “ I pay my taxes, and you Dr are my servant and must do what I say” Most of the people who praise patient centeredness see very few patients. We see the idiocy that those people, who can actually do the work and see patients, are accused of not being patient centred…by twaterati who will do anything else other than see patients!


6. Access and convenience

These are far from great. People like NIKU would have you believe that doctors make patients wait for the fun of it. Actually we don’t. We’d actually prefer to run to time. When doctors are running late it’s actually not because we are having a cosy chat with our favourite nurse over coffee whilst leaving 40 patients fuming in the waiting room. The NHS has never been run to the convenience of doctors.

Doctors in primary and secondary care are usually attempting to do too many things too quickly, as routine. Then extras are added in.

And the NHS superstructure is so efficient that getting patient, doctor, notes, and results together in one place is far from guaranteed. So more delays, and more waiting, and time wasting for both doctor and patient. Fortunately most patients are tolerant…and sometimes I have been grateful to patients for reducing my frustration. They have maybe done more for me than I can for them some days.

And patients often want and need more than the allotted time. So we overrun, and get delayed, and so frustrated. Forgive us that we get rushed, frustrated, fed up, and sometimes this shows. We sometimes use arrogance to shut people up. It’s not actually that we are uncaring. It’s that we are using our defence mechanisms to prevent ourselves from being overwhelmed. Ultimately there are more symptoms in the world than we can ever hope to properly deal with.

The NHS arrangements for bringing doctors and patients together are time poor, awkward and militate against good medicine. They prevent the development of relationships, and of mutual understanding and learning between doctor and patient. The fact doctors still get on well with most patients despite the handicaps the NHS generates is a tribute to resilience and good sense of doctors and patients.

Even so the obvious problems here are:

• Poor communication
• Poor understanding
• Poor compliance or concordance with treatment plans
• Risk of complaints and litigation over “failure to explain risks fully”
• Excessive testing
• Loss of follow up
• Patients not knowing whether they are coming or going
• Important results going unacted upon
• Collusion of anonymity- the buck is passed between several people but never actually stops anywhere.
• Much rushing, too little listening.

These can be observed any day in primary and secondary care settings. They cost the NHS a lot of money, and they show the system not making care of the patient its first concern.


Managers only care about throughput figures (18 week target etc) The Darzi report on raising quality may help a bit…but it still does not get into the basic clinic or surgery environment and look at what needs to improve to enable better doctor-patient communication. It’s sad, as improving this would significantly reduce the need for tests and investigations, whilst increasing patient satisfaction. But tests are cheap, and doctors are clearly obstructive, overpaid skivers as any fule such as Ben “Fotherington Thomas” Bradshaw kno.


7. Comprehensive coverage

The NHS provides great comprehensive coverage unless:-

• It’s a dental problem.
• It’s dementia: your needs are social and not medical you see, and be a good taxpayer and sell your house to fund your nursing home bill.
• Fertility- we’ll pay for contraception and abortion…but we don’t to create new babies.
• It’s a new cancer drug.
• You need rehab rather than curative treatments.
• You need adaptations to your house.
• You don’t want to wait.
• You have a mental health problem.
• You want a permanent and recognisable psychiatrist.

Yes the NHS is a very comprehensive service…that over time has comprehensively and covertly reclassified problems so that they are not medical any more but social…and so come out of a different budget.


8. High quality service

Except that:-

• It ignores foreign comparisons.
• It actively manages against its staff achieving this.
• It sets targets for quantity not quality, and refuses to admit that there is a trade off to be made here.
• The criteria for high quality are poorly defined.
• Pretends that “excellence comes as standard” which, as any fule (except Alan Johnson, Ed Balls, Darzi, Bradshaw and Donaldson) kno, is an oxymoron.
• Pretends that guideline implementation and measurement and compliance is an assurance of quality.
• Dreams that a computer (or nurse drone) could replace a thinking human being.
• Believes that rationing is merely a technical issue rather than a moral issue.
• NHS direct still exists (see below).
  

NHS Direct: A bit shit and not cheap

9 A cheaper pooled service

“The NHS used to be underfunded and inefficient. Now it is only one of these”

Nigel Hawkes' succinct summary captures this well.

The NHS is now expensive, ineffective and inefficient. It has squandered a fortune on a useless computer system, botched management reorganisations, increase internal transaction costs, management, and management consultants.

Yes the whole of the NHS funding increase has pretty well been wasted entirely. Gordon Brown had no idea what he was buying from the NHS and it shows.

Clinics and surgeries are in poor state, new builds are PFI or LIFT on the never, never and the barbarians of private profiteers are at the gate. The CBI is frothing at the mouth, and Sir Richard may drop by as well…as long as he only treats the young and healthy patients that is. He doesn’t want any of those old so and so with multiple problems- not worth the capitation fee you know. Not a viable business proposition to anyone.

So there we have it. We love our NHS but it is failing to deliver on:-

• Finance
• Cost control
• Clinical effectiveness
• Accessibility
• Computing and record keeping
• Quality
• Comprehensive coverage
• Relationship based care to patients
• Staff satisfaction

It is delivering on:-

• Corporate bullshit
• Redisorganisations
• Meaningless waffle
• Meaningless meetings
• Visions into vapour
• Squandering money
• Laying up future debts under PFI
• Paying more heed to management consultants than medical consultants
• Staff disengagement
• Bureaucratic processes
• Increasing negligence bills

Happy Sixtieth Birthday NHS!

Virgin on the Ridiculous

Bringing 'Spanish Practices' to General Practice

Thank the lord for the miracle of markets and free enterprise. Dr Crippen has beaten us to it again, but this one is too important not have a rant about.

Dr Rant has been alerted to Branson Pickle by whistle-blower John Spencer. Have a good look the website, and this bit in particular.

It is abundantly clear that Virgin Healthcare see ethics and legislation as a bit of an inconvenience, and they will circumvent these irritations in every way possible in pursuit of profit. They will also use clumsy and incompetent threats of legal action along the way to bully anyone who doesn't have several billions pounds worth of funding in their back pocket.

It would seem that the bearded one is an even fatter cat than us GPs are supposed to be. He'll be making a bit more than £250,000 per year and playing a whole lot of golf if his Virgin Healthcare shower of shite get their foot wedged in the door.

It is important that both patients and staff understand this:

Patients will be worse off because continuity and quality of care will fall.

The staff will be worse off because your contracts will be inferior and you will loose control over what you do and the clinical decisions you make.

The tax payer will be worse off because they will cream every penny they can out of this and IT WILL COST MORE.

Richard Branson and his daughter will be better off.

As a taxpaying doctor who also relies exclusively on the NHS to look after myself and my family, I'm pretty fucking pissed off off I can tell you.

Polyclinics? Oligoclinics more like!

Darvos Says: Exterminate 'That fantastic relationship between the GP and the patient'!

Has any one else noticed the distinct lack of mention of the fabled 'polyclincs' in Lord Darzi's report? We have. Back-tracking? Surely not!

Anyway, apologies for the distinct lack of action on here recently. That's the problem with the summer - the Dr Rant Team are either on holiday, or they're having to work twice as hard because half their colleagues are!

The fact that fewer people get ill in the summer, doesn't seem to translate into reduced demand for GP appointments or home visits. Funny that isn't it?

I'm bloody knackered. The Darzi report will have to wait.

Here's another photoshop to be getting on with.......

Lord Darz Vader