Farewell Lord Darzi

Lord Darzi: Back in the clinical saddle yesterday?

So, farewell then Lord Darzi. You were once described as a well tethered goat. No longer. You seem to have gnawed through the ropes binding you to your ministerial desk.

Or maybe you have just seen the light that this government is falling apart and you are deserting the wreckage, like so many previous health ministers are doing. Labour health reforms seem to be going backwards now with you and Britnell leaving. Soon we’ll have a government of no talents at all.

Or maybe you want more time with your robots and other family?

You did a great review of the NHS that had the great insight that, “"At the core of my report was one simple yet radical idea: to put quality - defined as patient experience, clinical effectiveness and patient safety - at the heart of the NHS."



Then you got slammed as Clive Peedell and everyone else asked, “What else has it ever been about?” thereby exposing the idiocy that has being going on as the government hashes up health policy even further with you as the useful idiot providing camouflage for its machinations.

I think your review will come to be seen as the worst kind of old fashioned managerial butchery- like a laparotomy- and with many, many complications.

Dr Rant notes that you are not planning to stay around to sort them out, and wishes you well in your forthcoming 'advisory' role to a private sector company hoping to cherry pick some profitable nuggets out of the mess that you know intimately well (because you made it).

Labour: always the wrong sort of choice

Here’s a brilliant example of a government repudiating its own record. This piece in the Guardian could be summarised down to,

“Labour OFFICIAL: We fucked it up. We got it wrong.”

However the more choice version is that Liam Byrne now admits that the choices Labour has offered have been somewhat empty.

“Byrne makes clear that the new approach is a big change from that adopted over the past 10 years under which Labour said it was offering the consumers of public services a choice. He says that has often been "an empty choice".”

"We need to give people real choices by locking down rights and entitlements and giving people fast means of redress ... In recent years power was basically pointing in the wrong direction. It was pointing up to senior civil servants and ministers in Whitehall and not pointing out to people. That helped create in too many places a culture of heads down, get the job done, deliver on the targets and tick the boxes."

A government making a big change in its policies after 12 years in power says that what has gone before was wrong. Well, we’d certainly agree with him on that.

It’s nice to see Labour are at last beginning to understand how badly its policies have done. Shame they didn’t realise it for Baby P, Staffordshire hospital and all the other “isolated” disasters that have occurred because of this governments ability to blame the staff rather than run services. Central credit and local blame again.

We, and other bloggers in fields of health, teaching, police, army and so on, will continue to help them to see exactly where they are going wrong.

The country will administer euthanasia and the (utterly undeserved) last rights to this dishonest, decrepit and disreputable government as soon as it possibly can.

Gordon Does The Five-Knuckle Shuffle

New Personnel at the Department of Health

So, we now welcome another reshuffle. We get our sixth SOS for Health in 12 years. The cadavers on the Labour front bench will get polished up and moved sideways, but nothing will really alter. Dr Rant says leave the dead to bury the dead, and the Conservative victory gets bigger the longer the public’s choice is delayed.

Farewell then, Alan Johnson. You were the postman who failed to deliver the one message necessary to Gordon Brown this week. By this failure you become yet another MP running at full speed away from the electorate and towards a better retirement pension.


You can at least claim the credit for being the least awful SOS for Health this government. You had the sense to do nothing, and you were not as obviously odious as Mrs Hewitt. We’ve got the measure of you now as you stick by the decrepit and disreputable Prime Minister, rather than do anything decisive to help your party or your country.

Farewell too to your oleaginous understudy Ben Bradshaw. You are going to the Department of Culture. Dr Rant says you are the kind of cultured being who would not look out of place on an agar plate, or maybe as the mould upon the odd little brownie or two. You can sing for your supper there, but it looks as if the people of Exeter will have nothing to do with you after the next election.

As doctors we are delighted to see you go. You have done no good, and caused needless harm at the DH. You will not be missed.

And we welcome back to the DH Andy Burnham, this time as SOS for Health. Oh well, at least you only have a year to do anything before you and your government are annihilated next year. As doctors we currently owe the DH no political favours, and if you spin against you we will hit back. You may find you’re as welcome as as a Government Minister at Anfield. Perhaps an early election will spare you further misery.

PE7 and PE8: More Government Lies to come

In the Autumn the government announced it planned to do a survey of patients to assess many aspects of primary care, including access to GPs. The survey was going to be independent and of a random sample of those on GPs lists, rather than of surgery attenders as had been done previously. The BMA objected sensibly and vociferously at the time, but the government ploughed on anyway.

Now Dr Rant had a professional statistician as a patient once. He said that the first thing a statistician asks whoever is paying for his services is, “What would you like the statistics to show?”

I think that the government wanted this survey to show that:

• GPs are crap
• GPs are not accessible

With the result that their QOF scores would drop, and they would earn less, and it would then be easier to justify selling off bits of general practice to “our friends in the private sector.”

So they got Ipsos-MORI to write them a long and detailed questionnaire (all eight pages of it) that no one except a disgruntled obsessive would complete. The survey was long and most people who got it threw it in the bin. The national response rate has been about 38%. The findings are embargoed for now but they will probably be magically released just before the LMC conference which starts on 11.06.09.

Many practices have lost out under this new arrangement. We have lost money on QOF. And we have also lost a valuable source of patient feedback as we now only get our scores and QOF points, not the full patient survey results.

The PE7 and PE8 scores are a false measure of the accessibility of general practice. They are based on an unrepresentative subset of patients, and the response rate for the survey at 38% is too low for its results to be representative of the population of people surveyed. In short the survey has managed to mismeasure what it purports to measure. This won’t bother our innumerate politicians who are still surprised to find that 50% of them are below average, and the rest of them are worse.

But here’s the modern NHS in all its glory, mismeasuring what it does, undermining existing providers, poisoning relationships between its parts, and generally making the job of GPs harder rather than easier. It will result in less well funded local practices which will then provide poorer care to patients.

But for the DH it looks like the survey is a complete success fully delivering on all its objectives...none of which are patient centred or to help doctors.

What does your own medicine taste like?

Poor little Tory MP (and former nurse) Nadine Dorries has been bleating about the effect of the recent expenses fraud furore is having on the MPs themselves. They don't like being tarred with the same brush as everyone else, and she's worried that some might commit suicide.

Let's recap shall we?


Over the years there have been a number of medical scandals (Bristol, Alder hey, Shipman, Stafford). Often MPs and ministers have been the first to leap onto the bandwagon, condemning everyone involved BEFORE all of the facts are known. There has then usually been a knee jerk reaction 'to stop it ever happening again' which has been invariably ill thought out or positively bad for medicine, research and the public. The Human Tissue Act and the introduction of a 'license to practice' are cases in point.

Doctors have all been tarred with the same brush and some have cracked under the strain, given up jobs or left the country. Some have committed suicide.

Whilst Dr Rant has thus far declined to enter into the fray on the expenses scandal, preferring to sit back and smuggly watch the Schadenfreude unfold, the tempation to stick a pin the walking voodoo doll that is Nadine Dorries was just too great.

However, I would like to offer a word of advice to Ms Dorries - Don't expect much sympathy from your GP.

NHS Progress this week

CfH trials it's new portable communications system, yesterday

1.PBC is dying on its feet. It has a much life in it as the parrot in Monty Python’s sketch. It will have even less when it is used by PCTs as a means of keeping their budgets secure, rather than as a means of improving services and making savings which could be redeployed.

"Now Dr David Jenner, GMS contract lead at the NHS Alliance, has said he is 'seriously worried' about the future of the initiative.
'I've seen PCTs reclaiming all the savings made,' he told last week's London conference. 'So the trust has gone and the incentives (to take part) are gone.' Such clawbacks seem to be happening in many parts of the country, he said."

David Jenner is, or at least was, one of the enthusiasts for PBC. If he’s giving up on it…

2. Choose and Book is the great success of the National Programme for IT according to health minister Ben Bradshaw, and to CfH at their conference in Harrogate last month. Lib Dem MP Mark Hunter has a rather better understanding of the reality. As he says,

"In November when I asked the Minister to review the system in light of the many complaints received he replied that it was 'one of the great success stories of the national programme for IT'. If the Minister calls "choose and book" a success I'd hate to see what he considers to be a failure!"

3. The NHS Plan is coming to be seen as an utter failure as Dr Rant said recently. Now the delivery of the APPG report is awaited. There's a summary of the evidence it received here. How will Dr Stoate allow his party to weasel their way out of their failures? Just how much “tweaking” will be necessary? As much tweaking as CfH will need if it is to avoid being ditched by the Tories?

4. You just cannot get Chief Execs for acute trusts these days can you? To paraphrase Lady Bracknell, to lose one CEO is bad enough, to lose two is careless. And to lose more than that is systematic failure of the kind only this government can manage. Dr Rant sympathises with Chief Execs- they get the blame for everything, and now they don’t even get a pay out.

Richard Vize at HSJ is trying to swing the blame pendulum back towards doctors and away from management. I can see why he’s trying this…but it rather illustrates that the culture in the NHS is not one of reflection and learning, but actually one of aggression, bullying, back stabbing and blame deflection.

5. Will Alan Johnson still be SOS for Health? Might he be called to a higher place? Of course, like the cabinet, we all still do have full confidence in Gordon Brown and his government. Mrs Blears the Labour’s Party’s problem is not that we don’t get the message- it’s that we hate the message, and most of the messengers, and we hate the fact that you think we’re dumb enough to accept your party’s combination of arrogance, mendacity and incompetence any longer.

Jobbing Doctor comments on the fin de siecle feel to current politics and Dr Rant is looking forward to the end of this particular government. Dr Rant hopes that Mr Lansley will be a high phosphate enema for the NHS getting rid of the policies and people who have failed it severely in the last twelve years.

Never has so much money been squandered by so many politicians and managers for so few health gains.

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.