Missing the point

Stick to making the tea love...

Is it really worth it? What is the point of hard work? Should one bend over backwards to try and help patients, or the hospital one works for?

Obviously not, thinks Sarah-Kate Templeton. This particular 'health journalist' has come to Dr Rant's attention in the past. She also managed to piss off a few thousand doctors on Doctors.net by abusing her access by printing 'quotes' from doctors, out of context and without their permission. A more vacuous, unethical, gin-soaked two-bit hack would struggle to find.

Dr Rant wonders - just what the fuck does this wailing gobshite want?

The story boils down to this: There is consultant in Morcambe Bay who specialises in breast surgery. This work will be mainly breast cancer. This surgeon is probably very good. He has probably done a lot of research into breast cancer, and is widely regarded in his field. He is probably very good at his work, which is operating on patients with cancer. His basic pay is probably around the same as his dentist.

Now he seems to have done a lot of overtime, both while 'on-call' and doing extra waiting list sessions. In fact, he has done £80,000 worth of overtime, which is probably an awful lot of work. On people with breast cancer.

So, Sarah-Kate Templeton seems to want to expose the fact that a top cancer surgeon does a lot of overtime, and gets paid for it.

Just what does this vexatious gorgon want?

Or would she rather make the patients wait, or even not have their cancer operations?

Would she rather the NHS waiting list goes up, and the surgeons cleans up at the private hospital like 'back in the day'?

Would she rather a less capable surgeon attempted the work?

By paying a local specialist to extra work as it arises is a fuck site cheaper than taking on a new permanent consultant, for whom there would be no guarantee of work the following year.

But then, if anyone else did over time they would expect to be paid would they?

I mean seriously, wouldn't they?

The story then wheels out Katherine Murphy, director of the Patients association. She declares:

“It is unethical for the medical profession to line their pockets in this way knowing that NHS trusts are being forced to cut services. Patients are being left in pain. Doctors are being given bonuses for what should be part of their day jobs.”

Comments like this make Dr Rant want to vomit out of his nose. When a rat-faced harpy from an unelected quango spews out uninformed bullshit in a paper such as the Times, something has gone very wrong. The very statement is gibberish. If trusts are cutting services, why are they paying people overtime? If consultants are doing extra work, how exactly are patients being left? If there are waiting lists that require extra sessions, how is that covered by a day job? Funnily enough, Katherine Murphy is a former nurse, who has left nursing for a non-clinical position.

The seething jealousy from chicken-shit journalism and Quango-Evny^TM is almost palpable in pieces such as this. A 'health journalist' who probably got a B in her O-level biology and a failed nurse should never dictate what the NHS spends its money on. There is always debate about the appropriateness of merit awards. They are one way of rewarding and retaining specialists in their field, and stopping them fucking off abroad.

However, when an expert chooses to do extra work in their time off, to operate upon patients with breast cancer, it is sheer fucking insanity to start belittling them in the public press for doing so.

Anyway, Gordon Brown has seen to it, and it won't happen again. The new tax changes mean that these surgeons might as well play golf or spend some time with their families, as his latest tax changes will mean that there will be no point in doing extra work as it will be taxed at 70%*. Just hope you don't get cancer at a busy time, because the surgeon won't be putting in as much overtime.

* After new 50% rate, national insurance and loss of basic rate tax relief, there or there abouts - Ed

Swine Flu: We're all doomed!

Referrals Mismanagement

Well Fuck Me. The Fucking fuckwits who manage the NHS have managed to fuck it up again!

This time it’s on referrals. Referrals are a basic necessity in any healthcare system such as the NHS as one doctor passes on a patient to another.

Now the idiots who run the NHS think that GPs refer on:-

• To save themselves a job
• To bankrupt their PCT
• With no regard for guidelines
• Needlessly
• For things which could be managed closer to home, within primary care
• For things which don’t need referring at all.
• Too often
• and of course GPs refer far too many patients.

And these fuckwits with fuck all knowledge of medicine, and rather less of people and patients take it on themselves to adjudicate on “best practice” and set up useless extra layers of bureaucracy such as “Referral management centres” to second guess doctors who actually know some medicine and something about their patients and their needs. They fool themselves into thinking that they know what the appropriate rate of referrals is for populations by some misapplied basic maths. The result is of course a false measure, and another league table.

Let’s get real on referrals. GPs refer to specialists for several very good reasons. These are for specialist knowledge, specialist diagnosis, specialised treatment, more detailed review of a patient’s symptoms than can be achieved in a GP’s surgery.
GPs ask specialists to see their patients as they believe that the specialist’s knowledge will help the patient. GPs refer to help the patients.

Now there are as yet no criteria which reliably distinguish a good from a bad referral. Indeed no one even knows what the criteria to make such a judgement would be. We can make general statements such as “a good referral gets the right patient to right specialist for the right reason” but the devil here comes in defining the “right” not the participants.

GPs have for many years kept referral rates in the UK down. Indeed GPs are often criticised for failure to refer and failure to diagnose. In the UK GPs historically have underused rather than overused specialist services. This has some good effects- too much high tech hospital intervention is harmful…unless you are ill enough to make the alternative riskier still!

The increasing medico-legal risk that GPs suffer from will erode this under-referring and may lead to extra “defensive” referrals.

Referrals are going to be a battleground between primary care doctors and cost cutting managers. The doctors have to win this one- we know the medicine, we know the patients and we have a duty to care for patients, not figures or finances.

Sorry NHS managers. For many years you have had the NHS on the cheap. (you weren’t around then to squander money by making the doctor’s job harder) The drivers in the GP consulting room (medico-legal fear, GMC guidance, NICE guidance, drug company datasheets etc) and in patient demographics (older, more treatments possible, more needed, patient demand etc) are all towards ever more referrals, more treatments, and less risk sinking done by primary care. This may even be an improvement in medicine. It’s going to be expensive, and it’s not clear the NHS can afford it.

But in current climate of NHS delay, diminish, deny and blame no doubt the managers will find some false measure with which to taunt the doctors. No one will actually be looking at what the patients actually need and matching it with what the system can deliver.

Oh my prophetic soul

Recently Dr Rant blogged on medicine by dictat. We included this line, meaning it as a joke. “All diabetics are so well controlled that they never get out of hypoglycaemic coma”

Reality it seems is ahead of art this weekend. This piece in the BMJ raises a serious question over the value of extremely tight glycaemic (blood sugar) control in older type 2 diabetics, and all the extra costs of insulin and blood testing and monitoring and hypoglycaemic episodes that go with it, not to mention the unpleasantness of injections.

The QOF targets have been tightened this year, instructing GPs to achieve very tight glycaemic control in their diabetics…just as the evidence suggests it may not be the right thing to do.

How ironic. A target based system leads professionals to do the wrong thing for money. How very new Labour, as Hugo Rifkind shows as he separates sheep from goats this week.

Hippocrates said, "First, Do no harm." The longer he goes on in medicine the more the misleading simplicity of this great instruction strikes Dr Rant. How much harm will the NHS force doctors to do to meet targets rather than treat the patients right? Answers please on a postcard from Staffordshire.

Whistleblowing: Why its dangerous

Don't even blow there!

Alan Johnson is quoted as saying, “"I don't understand why clinicians whose primary role is the safety of their patients are somehow concerned about whistle-blowing. I can't understand it, quite frankly."

Well let’s answer him.

In the NHS the senior management of trusts now have the right to sack doctors, and use this right freely. It happens abroad too.

Senior management regards the bearers of bad news as unwelcome, disloyal, and untrustworthy. They are not “one of us” They are one of them, and dangerous. Trust managers fear the DH or exposure in the local newspaper. Nothing else. The kindest term they will use for a whistle blower is “nuisance.”

Give a little whistle!

The default style of NHS senior management is bullying (shut up), bluster (talking is communicating) and bravado (hope I don’t get found out before I get parachuted out of here).

NHS senior management wants everything to look Ok, to get its foundation status, and not to get found out as incompetent. As all NHS management is incompetent maintaining the illusion of competence is difficult, but a top priority. Whistle blowers threaten this and must be eliminated.

That’s why Dr Steve Bolsin ended up working in Australia.

That’s why Dr Pal now cries in the wilderness.

Whistle blowers are not welcome in the NHS, the no-blame culture means keep quiet and we won’t blame you…unless it’s convenient for us, and that patients continue to be harmed.

The no blame culture, and the organisation with a memory, that makes amends, and learns from mistakes is a total fiction.

In the NHS there are vicious blame games afoot, and shooting the messenger is one strategy the management use to get unwelcome information off their patch.

And professional bodies such as GMC and GTC will not stand up for whistle blowers, nor allow a public interest defence.

Smile: You're on Candid Camera!

It's not just doctors is it? Anyone, who's not spent the last week in contemplation of their own haemorrhoids, will have heard about the 'Panorama' nurse who got struck off. The irony is that her striking off has garnered more attention from the press than the disgusting abuse that she uncovered in the places where she worked.

So, hidden camera work might not be listed in the 'professional duties' of a nurse, and she might have jumped a few rungs of the ladder (perhaps the fact that she felt such a lack of confidence in the 'proper pathways' should be the most telling aspect of this sorry affair) , but sometimes the ends do justify the means. After all, isn't that how modern politicians reconcile their nauseating, self-interested, subservience and lack of independent thoughts or actions?

Alan Johnson wonders why whistle blowers are scared. Come on Alan. You are an ex-union man and you know the games employers play. The NHS shows all of them how to play at the highest level, and can rightfully revel in its status as one of the worlds most opaque, arbitrary and vindictive employers.

Are you showing false naivete here? Or are you simply turning into another dissembling boss?

The NHS Plan: Ten Years on

This year the Commons All Party Parliamentary Group on Primary Care and Public Health is running an enquiry with the title? "Was the NHS Plan really a blueprint for the NHS - 10 years on?" You can contribute via this link.

There’s nothing quite as sad at looking back at the wreckage of grandiose plans. They sounded good at the time. They had full stakeholder support, and “user buy in.” The Lancet and BMJ had been co-opted to the cheer party. A bright new government was in office, and the dinosaur Frank Dobson had been retired to the Natural History Museum for a spot of taxidermy.


So in 2000 the NHS plan was launched.

And each of its aspirations sounds so reasonable and obvious that you’d have to be against motherhood and apple pie to reject them. We now recognise this as New Labour mood music, which is designed to unethically hypnotise its hearers, and destroy all critical faculties in rather less than 45 minutes. It’s worked rather too well for too long, but soon they’ll pay for their mendacity and incompetence at the polls. I suspect we could forgive their incompetence (marks for effort etc) but we won’t forgive them for taking us for mugs… barbecues …plugs… second homes etc.

Dr Rant thought it would be fun to see how well the ten core principles have stood up to the last ten years. The original DH text is in ordinary type and our comments are in italics.

“We the undersigned” Some of the medical great and good were far too easily taken in by the New Labour spin machine, and deserve castigation for their gullibility.
support these principles, and commit ourselves to a modernised (one of the great weasel words of our times. Dr Rant calls for a national debate on a new modernised word going forward into future documents. Why does everything have to be modernised? Why is the old so in need of reform? What if it wasn’t broken before? What if the fix is really a fix for administrators, not patients? What if change is worse than what already was? New Labour’s falsest assumption has been that “new” and “modernised” is automatically good, and that change towards this must therefore be good in itself.) NHS on the basis of these principles reflected in this NHS Plan.

1. The NHS will provide a universal service for all based on clinical need,
not ability to pay.
Healthcare is a basic human right. Unlike private systems the NHS will not exclude
people because of their health status or ability to pay. Access to the NHS will continue to depend upon clinical need, not ability to pay.

Great but:-
Dr Rant, and many other taxpayers, now have to pay for their dentists privately.
Demented patients have to sell their house to get residential or nursing care.
Infertility treatment is not covered by the NHS
Erectile dysfunction- the NHS failed to rise to this opportunity.
Cancer treatment- some not available- personal and postcode lotteries.
Many clinical needs go unmet.
Mortality rates are worse
Mortality amenable to healthcare is higher under our system

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.

Private systems- that great old bogeyman, that entirely justifies the NHS as “the envy of the world.” Of course. And let’s not look across to Europe to see how anyone else might have got it better organised. They’re all out of step and unethical except our NHS.

2. The NHS will provide a comprehensive range of services
The NHS will provide access to a comprehensive range of services throughout primary and community healthcare, intermediate care and hospital based care. The NHS will also provide information services and support to individuals in relation to health promotion, disease prevention, self-care, rehabilitation and after care. The NHS will continue to provide clinically appropriate cost-effective services.

The NHS probably manages to provide this…mostly because of the internal motivation of doctors and nurses, and despite the poor quality of management.

3. The NHS will shape its services around the needs and preferences of
individual patients, their families and their carers
The NHS of the 21st century must be responsive to the needs of different groups and
individuals within society, and challenge discrimination on the grounds of age, gender, ethnicity, religion, disability and sexuality. The NHS will treat patients as individuals, with respect for their dignity. Patients and citizens will have a greater say in the NHS, and the provision of services will be centred on patients’ needs.

This was sound good fluff then, and is now exposed as utter bollocks. Patients have never had less say on their local services than now. The government abolished Community Health Councils, and replaced them with a mishmash of talking shops. (A typical new Labour modernisation- take something that at least works partially and totally bugger it up)

Local services are decided from the centre, cooked up in PCT plans agreed with DH and SHA beforehand. No public voice present in any of them. Fake consultation and grand listening tours ensue. But let’s be clear. These consultations ask a question “Just how good do you think these plans are?” and the answers range from, “Whatever, you’ll do it anyway” to “Agree” to “that’s the greatest new paradigm in health service management since the last one. Go straight to beaconicity status” Read Michael Mandelstam’s excellent book if in any doubt about this.

Dr Rant’s patients go to the local foundation trust centre of excellence and come back saying, “They altered my appointment four times, they ran late, they weren’t interested in me, I couldn’t understand the doctor, I was too scared to ask the doctor, you’re just a number to them”…etc. Dr Rant’s patient centred response is “Tell me more, it gives me grist for my blog!”

4. The NHS will respond to different needs of different populations
Health services will continue to be funded nationally, and available to all citizens of the UK. Within this framework, the NHS must also be responsive to the different needs of different populations in the devolved nations and throughout the regions and localities. Efforts will continually be made to reduce unjustified variations and raise standards to achieve a truly National Health Service.

That’s why the Scots and Welsh get free prescriptions and free car parking at hospitals, whilst the English taxpayers subsidise the Celtic fringe.

What about responding properly to the one population who are properly the concern of an illness treatment service- the sick? What about treating people on grounds of illness, not on basis of ethnic origin?

What about providing enough beds in clean hospitals?


5. The NHS will work continuously to improve quality services and to
minimise errors

The NHS will ensure that services are driven by a cycle of continuous quality
improvement. Quality will not just be restricted to the clinical aspects of care, but
include quality of life and the entire patient experience. Healthcare organisations and professions will establish ways to identify procedures that should be modified or
abandoned and new practices that will lead to improved patient care. All those
providing care will work to make it ever safer, and support a culture where we can learn from and effectively reduce mistakes. The NHS will continuously improve its efficiency, productivity and performance.

This is the biggest failing of the lot. Donaldson is supposed to be an expert on this kind of thing. He set up, “the organisation with a memory.” One of Dr Rant’s biggest frustrations is that the NHS has still no system for learning from its errors. It just doesn’t take safety as seriously as the airline industry. There is a cynical theory that it is easier and cheaper to pay out a few indefensible cases, run many into the long grass, or six feet under, than it is to spend the same money on getting the system right in the first place. Maybe a few damaged or dead patients, and a few ruined medical and nursing careers are an affordable price to the administrative mind? Or at least that seems to be the risk management calculation the NHS is often making.

Negligence is paid out…with no one giving details of cases, or any discussion of what is learnt from the episode. Individual patients and doctors suffer, and the compensation agreement always has a “confidentiality-no publicity” clause built in. At one level this keeps everything quiet, and avoids adding public embarrassment to professional chagrin, and at another it just seems that medicine deals with individual tragedies and no overall lesson is learnt.

Lots has been spent on audit, and clinical governance, and quangos such as the “care quality commission” and “NICE” and “NPSA” but the relationship of these organisations to coalface workers is distant at best and antagonistic often.. NICE is arrogant and NASTY and thinks it knows how to do other people’s jobs. It has so many hidden assumptions and false values and false valuations behind its pronouncements, that it deceives itself that it has any value. NPSA has never yet made any difference to patient safety, and no one ever reports anything to it…and even if we did no one is certain anything would follow from so doing. Another expensive quango that takes in time money and data….and successfully produces another glossy report. The Healthcare Commission finally barked on Staffordshire…and so is about to be abandonded and merged into the “Care Quality Commission” run by…the former SHA chief exec for NHS West Midlands…who denies she could possibly have realised there were problems at Stafford…as has the coroner…and Monitor.

GPs have their “Quality and Outcomes framework” which distorts their work, and purports to measure quality.

Well as Dilbert puts it in a cartoon, “Nah, don’t bother with real quality. Just invent a meaningless metric and call it an industry gold standard.” Well our three star, green light, red rosette and gold swimming award foundation trust and their high quality Blue Riband Quality Medallion management manage to achieve this objective completely. The NHS must be a world leader in meaningless metrics. “World class” commissioning surpasses them all. Perhaps I should set up a Meaningful Metrics Consultancy and measure just how much money I could make in exchange for baloney.


6. The NHS will support and value its staff
The strength of the NHS lies in its staff, whose skills, expertise and dedication underpin all that it does. They have the right to be treated with respect and dignity. The NHS will continue to support, recognise, reward and invest in individuals and organisations, providing opportunities for individual staff to progress in their careers and encouraging education, training and personal development. Professionals and organisations will have opportunities and responsibilities to exercise their judgement within the context of nationally agreed policies and standards.

I wish I felt valued by the NHS but I don’t. Staff now are disposable elements, who are motivated by vested producer interests, who need to be regulated, and if any of them speak out they should be struck off. The NHS is wonderful so anyone who points out any flaws in it is clearly deluded, wrong, and in need of re-education.

Quite clearly all faults in the organisation are due to character flaws in employees. As one manager summed it up, his biggest fear for the NHS was that someone would try to improve it. I don’t think anyone as staff gets a particularly good deal out of NHS. (though in these recession times the available alternatives look rather worse)

Bullying is rife, with passive aggression the preferred option.

But managers are so wonderful they need no regulatory body, and a quick golden parachute out of trouble, and a sideways move sorts out any problems. From such attention to detail we get the new chief exec of the Care Quality Commission from the SHA which turned a blind eye to failings in Staffordshire.

Expect floggings to continue till staff morale improves.



7. Public funds for healthcare will be devoted solely to NHS patients.
The NHS is funded out of public expenditure, primarily by taxation. This is a fair and
efficient means for raising funds for healthcare services. Individuals will remain free to spend their own money as they see fit, but public funds will be devoted solely to NHS patients, and not be used to subsidise individuals’ privately funded healthcare.

I wish we could describe the spending of taxpayers money on needless computer initiatives, bollocks management consultancy, ISTCs that don’t deliver, Darzi policlinics, dumbing up staff (nurse practitioners, GPwSI etc) redisorganisations, renaming failing organisations from Rantingshire PCT to NHS Rantingshire, chiropody to podiatry, fitness for purpose exercises, payment by results, world class commissioning, pathway redesign teams, PFI hospitals, LIFT(ing the budget deficit higher)primary care premises and other such wastes as “successful patient centred reform.” Sadly honesty forbids us from doing this…but new Labour apparatchiks will feel no such concerns.

The NHS funding increase in the last ten years has largely been pissed away on government vanity projects, managerial conceits, and structural meddling in the NHS. The focus has been on internal objectives, not on delivering what patients need and want.


8. The NHS will work together with others to ensure a seamless service
for patients.

The health and social care system must be shaped around the needs of the patient, not
the other way round. The NHS will develop partnerships and co-operation at all levels of care – between patients, their carers and families and NHS staff; between the health
and social care sector; between different Government departments; between the public
sector, voluntary organisations and private providers in the provision of NHS services
to ensure a patient-centred service.

Don’t make me laugh. A carrier pigeon with a concrete block round its neck could get letters from hospitals to GPs quicker than the hospital mail and van systems. Letters from our local centre of excellence take over 4 weeks to arrive. Letters from a famous National Centre of Excellence take over 3 months to arrive. Interfaces of care are dangerous places for patients, and failures of communication here are legion. The issue isn’t on hospital star ratings yet, so no one is that bothered about it. The medical defence organisations are acutely aware of this as they defend (or more likely settle) the claims that arise from poor communication.

Communications with social workers are rare and patchy.

The battle over bed blocking geriatric patients and limited council funds for residential and nursing care are still huge. Care about the patient’s need for care? Who are we kidding? The game here is snag shifting of the old crumble and the budget cost from one agency to another.

Patients do not experience a seamless service. Doctors are forced to work in their silos, and no one seems to have a grasp of the whole. I think that’s the kind of problem John Seddon’s systems thinking might address, but which therefore won’t be tried in the NHS.


9. The NHS will help keep people healthy and work to reduce health
inequalities
The NHS will focus efforts on preventing, as well as treating ill-health. Recognising that good health also depends upon social, environmental and economic factors such as deprivation, housing, education and nutrition, the NHS will work with other public
services to intervene not just after but before ill health occurs. It will work with others
to reduce health inequalities.

Health is proportional to wealth, and to wealth distribution across a society. This government has overseen and encouraged the biggest growth in wealth, education and class differentials in living memory.

The NHS is like a pea shooter against a bazooka in fighting the ill effects of these increasing differentials. And fuck New Labour’s “Tory Toffs” game. The newly entitled twaterati are not old landed gentry but public sector managers, and their co-dependent management consultants who between them siphon the public purse into their own pockets all the while talking the mantra of, “we (pretend) to care about health inequalities” and “opportunity for all.” (especially our own)

Meanwhile New Labour has continued selling off public space such as school playing fields and old hospitals to builders, thereby reducing the opportunity for exercise in schools.

Health and wealth inequalities have grown as a result of New Labour’s economic policies.

10. The NHS will respect the confidentiality of individual patients and provide open access to information about services, treatment and performance. Patient confidentiality will be respected throughout the process of care. The NHS will be open with information about health and healthcare services. It will continue to use information to improve the quality of services for all and to generate new knowledge about future medical benefits. Developments in science such as the new genetics offer important possibilities for disease prevention and treatment in the future. As a national service, the NHS is well-placed to take advantage of the opportunities offered by scientific developments, and will ensure that new technologies are harnessed and
developed in the interests of society as a whole and available to all on the basis of need.

Well, that’s all right then. It tells no one what it is up to and then Abracadra, wow, ker-bang, ker-plunk, all our medical notes are uploaded without personal consent onto the National Spine. So much for respecting confidential medical information, and the right of invididual patients to decide how their information will be used.

This Labour government of control freak, micro-manager snoops wants to know everything about everyone. Well there’s enough evidence out there- we hate you- please fuck off. Get out of our light, and stop wasting our oxygen supplies you wasteful, hateful bastards.

The only protection from New Labour’s database state is that it cannot get the computers to work. This government is less respectful of individual people and their right to privacy and confidentiality than any in recorded history. It is trying to make the NHS like this too, but is running into stiff opposition.

So as we can see the NHS is failing to deliver on pretty well all of the ten principles of the NHS plan.

There is nothing patient centred about it. There is nothing in it, or any of New Labour’s reforms that really helps me to get patients seen and treated better.

Doctors and nurses saying this is a damning, and rather sad, indictment for anyone in the NHS to make in describing the effects of a huge cash injection into the NHS. This is New Labour at its best. It can produce a glossy brochure, and a nice newsletter, but it has no idea what is actually needed, or is happening, and even less wish to find out.

The NHS plan is a failure on its own terms.

The Tories under Andrew Lansley seem to have no apparent specific plans about the NHS. Looking back at the failures of the Labour monsters this lack of a plan may be Mr Lansley’s most sensible decision of all!

Happy 10th Birthday NHS plan.

Great Minds Think Alike.

It’s always good to see when the Mainstream Media catches up with bloggers. This week three welcome pieces have appeared, two in BMJ, and one in the Times.

Tony Delamonthe this week in BMJ has a good piece on “What to cut?” It’s suggestions for what spending the NHS should cut when the cash runs out. If the credit crunch forces some sanity on public squandering (investment?) then some good may come out of it.

It’s great to see ideas similar to ours being taken on board. It shows that those who know anything about medicine are beginning to form a firm view that the last 12 years of New Labour meddling with the Health Service have achieved nothing, and that most of their changes could be stopped with no loss of function.

We’ve been saying that loudly and raucously for some time now as you can see in the links here and here and here. It’s great when a prophet no longer has to cry out in the wilderness.

In the Times this week Camilla Cavendish has drawn a useful distinction between the two types of public service worker. These are firstly the direct, frontline public sector staff who have simple job titles, and you know what they do. Doctor, soldier, teacher, receptionist, nurse, street cleaner, fireman, policeman. The second category are the mostly useless managerial cadre, twaterati and the clipboarderati, who give themselves long job titles, rearrange the department, liaise with all stakeholders, and call more meetings whilst wondering why no-one wants to engage with them. This second category is mostly a hindrance to anything other than buffing the figures to make it look as if all the targets have been met, which can then be spun as “improved performance” to the public by mendacious Labour politicians. Cutting this second category would be a blessing to service users, service providers, and the taxpayer. Things would improve, and cost less if we decommissioned this second category.

Which brings us onto the death knell for Practice Based Commissioning (PBC). Dr Rant has never thought much of PBC. We’ve always thought that its messiahs were somewhat strange, and that it offered nothing of real significance to already too busy GPs. Seems now that even people who are nominal enthusiasts for the policy are damning it.

Officially it’s a policy being “reinvigorated” this year. Gillam and Lewis basically raise the question of whether it should be a resuscitation or palliative job, “But if tangible results remain elusive, evidence based policy makers will wonder whether this patient needs palliative care not reinvigoration.”

A bit like the British Economy really. Apparently an unnamed minister has suggested that a visit from the IMF should be thought of as a “recuperative exercise”, and not as a sign of economic near death.

Credo est, quia absurdum. Bit like the whole government and all its policies at present.

Remedy UK: Thunderbirds are go!!

"F.O.A.D Liam!"

In february, we posted a a message from Remedy UK detailing their appeal to raise funds for a judicial review of the GMCs decision not to investigate the 1600 signature referral of the architects of 'MMC'.

We are pleased to tell you that the appeal has raised enough money to proceed!

Click Here for more on the 'Double Standards Challenge'.

Medicine by Dictat

Unfortunately NICE hasn't yet evaluated 'a spoon full of sugar'. More and more medicine will have to find its own way down.

Computer says that for this condition you must be treated with this drug. So I will prescribe it for you. No exceptions will be allowed. Clearly the evidence for this policy is very strong which is why NICE tells us that it is good for you.

Who is your GP to disagree with the experts at NICE? Who is your GP to do anything other than what we tell him to?

So, following orders to the letter the following results will be obtained without exception. (as all these things are good for people, and represent good public health outcomes, and are measurable targets):-

-No one will ever have a cholesterol molecule in their bloodstream
-No one will be left standing after hypertension is treated so far that all the patients have fallen over and got fractures.
-All diabetics are so well controlled that they never get out of hypoglycaemic coma
-Everyone is on aspirin and gets ulcers
-Treatment is uniform and consistent everywhere in the world
-The patients are all dead well.

Exception reporting is about to be banned.

Well it would be if the DH could get its way. They see exception reporting from the quality and outcomes framework (QOF) as cheating, as gaming, as a way of lazy GPs making it look as if they had hit the targets. (You wouldn’t catch ministers or health service managers doing this would you?)

Now the actual evidence is that GPs use exception reporting reasonably sensibly. QOF works on generalities- it is on the whole, in most cases, a good idea to reduce people’s blood pressure back to normal levels. So encouragement towards this is a sensible incentive. But there will always be some exceptions, as the DH itself realises- for example a lady who is intolerant of many anti-hypertensives, a patient who faints when the BP drops anywhere normal, and up till now QOF has allowed exception reporting in such cases.

To keep QOF ethical, and effective, exception reporting must remain as an option. And the DH must trust GPs (I know this breaks their hearts and explodes their command and control thinking) to do this appropriately. The alternative of treatment of the whole population by NICE guidance written into computer algorithms on GP computer systems with no allowance for the personal peculiarities of patients is just too awful to contemplate.

Sorry DH but patients and GPs are variable, and so some variation in exception reporting is to be expected, and you need to learn to tolerate it. Fuck off with your annual quibbles that “GPs exceeded expectations” and “earned too much” and “show unacceptable variations.”

Do you want chronic diseases managed well? Do you want to start reducing the inverse care law and reducing inequalities? If so leave QOF alone, allow GPs to implement it, and to get patients onside on an individual basis, and with some exception reports when necessary.

If you want robots…well I suppose Lord Darzi could tell you all about them.

A lamentable lack of curiosity, Oh Coroner.

Cause of death: 1a) Moyda!

There used to be an old medical joke. It went, “Don’t worry, we’ll soon know what’s wrong with you…just as soon as we’ve got the autopsy findings.”

It’s silliness is matched only by this joke,

Q: "Do you recall the time that you examined the body?"
A: "The autopsy started around 8:30 p.m.."
Q: "And Mr. Dennington was dead at the time?"
A: "No, he was sitting on the table wondering why I was doing an autopsy."

And then there’s this classic lawyer joke,

Q: "Doctor, before you performed the autopsy, did you check for a pulse?" A: "No."
Q: "Did you check for blood pressure?"
A: "No."
Q: "Did you check for breathing?"
A: "No."
Q: "So, then it is possible that the patient was alive when you began the autopsy?"
A: "No."
Q: "How can you be so sure, Doctor?"
A: "Because his brain was sitting on my desk in a jar."
Q: "But could the patient have still been alive nevertheless?"
A: "It is possible that he could have been alive and practicing law somewhere."

Now it seems as if the lawyer joke might apply to the coroner in Staffordshire. And the old medical joke may as well be a throwback to an earlier age as no one’s doing PMs any more.

One of the strengths of medicine is that ultimately we learn from death. It’s called pathology, or morbid anatomy, and the sad fact is that much medicine has been learned from studying patients who have died. It’s the ultimate audit of medicine- we can directly see the path to and the consequences of our mistakes.

Nothing quite replaces the post mortem as a venue for direct hard factual learning about medicine. It’s not pleasant, but it’s real death in all its glory. It’s also sobering for doctors as they realise how little of the pathology present they had discovered in life. In addition, any pathologist will tell you that the percentage of post mortem examinations that find a cause of death that is very different to the suspected cause at the time of death, is highly statistically significant. The true value of pathology is lost behind the TV glamour of sexy young pathologists doing the Police's job and solving murders whilst swimming in a sea of gonadotrophins. The truth, as any doctor will tell you is more like a combined Asperger's/OCD drop-in clinic at a Star Trek fans' convention than Silent Witness.

And so to hear about the excess mortality rate in Staffordshire, and then to realise that the local coroner is being awkward about helping with the enquiry, and prides himself on not doing many post mortems ("I see it as a good thing rather than a bad thing if you can reduce autopsy rates”) adds to Dr Rant’s pessimistic assessment as to whether anyone in the government, NHS or legal hierarchies really gives a damn about anything to do with people dying or quality of life and care.

If we want to start picking up patterns of mortality, then we need each death to be examined independently, and to do more post mortems. At present it seems as if coroners notice nothing, (and will notice even less if they reduce their numbers of post mortems), the hospitals have no overall view, and doctors produce bland certificates, which conceal as much as they reveal. It’s as though we are all in a masquerade dance in which all deaths are entirely natural, and we mustn’t upset the relatives.

It’s a lamentable lack of curiosity, and it’s time that doctors got less squeamish about asking relatives about doing PMs, and that relatives got less squeamish about agreeing to PMs, and that coroners started to show a bit more curiosity into how and why the patients really died. And the Home Office needs to be willing to fund coroners to get post mortems when necessary.

If we actually want to know about the quality of medical services we need to look at deaths closely. Perhaps it is time for a medical coroner to be appointed? After all Julian Tudor-Hart only suggested such an idea 22 years ago.

But he was a real doctor, and such are no longer welcome in the NHS.

New Health Minister Announced

I've just seen this press release, and for once I think that the government has actually got it right for a change. I feel a rosey glow coming over me, and I'm even starting to have benign non-violent thoughts about Ben Bradshaw.............

BANKER TO BE HEALTH MINISTER


Downing Street has confirmed that Sir Fred Goodwin, former Chief Executive of the Royal Bank of Scotland, is to join the Government as Minister of State for Health. He will receive a Life Peerage and will enjoy a full ministerial salary. Sir Fred is expected to be tasked with accelerating the privatisation of the NHS, and promoting total lay input into medical regulation.


Avril Singleton, a senior Press Officer for the Prime Minister said, “We value the commercial experience that Sir Fred can bring to the NHS at a time of necessary economic stimulation to combat the global downturn. We view NHS privatisation, especially of primary care, as a key part of our fiscal stimulus and wish to fully utilise Sir Fred’s talents in this respect.”

It is anticipated that Sir Fred will be asked to oversee further changes in medical regulation. The Prime Minister has reportedly asked him to bring about 100% lay membership of the General Medical Council’s governing body by 2013. The Downing Street Press Officer commented, “Sir Fred has built an extremely rewarding banking career upon having no relevant qualifications. We look forward to the same principle being rolled out to medical practice, as the modernisation of the former profession is advanced in the Age of Change.”

Ironically, Sir Fred will not have direct ministerial responsibility in his native Scotland as Health is a devolved area of government. The Scottish Government has resisted NHS privatisation to date. However, his responsibility for regulatory matters will carry influence in all of the UK countries.

Sir Fred was unavailable for comment but was reportedly looking forward to taking his seat in the House of Lords early next week. Downing Street refused to give further information about the date, citing security reasons.