The Brown Stuff

PFI - we did tell you at the time.

2011-08-19T14:31:00.001+01:00

http://www.parliament.uk/business/committees/committees-a-z/commons-select/treasury-committee/news/pfi-report/

The Treasury Select Committee has published the report of its inquiry into PFI, available. Many of the Committee's concerns echo those raised in the BMA's written evidence to the inquiry, particularly around the inflexibility and lack of value for money of PFI projects. A summary of the key points is below, prepared by the BMA's HPERU unit.

Analysis undertaken by the Committee’s Specialist Adviser suggests that, all else being equal, paying off a PFI debt of £1bn may cost the same as paying off government debt of £1.7bn. This would mean that a 70 percent increase in investment could be achieved for the same long term cost if government funding were used instead of private finance.
Allocating risk to the private sector is only worthwhile if it is better able to manage the risk and can pass on any subsequent savings to the client. The main benefit highlighted by PFI providers was the transfer of construction risk. However a PFI contract which lasts for 30 years is not necessary to transfer this risk.
In the area of design innovation and building quality there is some evidence to suggest that PFI performs less well than traditionally procured buildings.
The fixed nature of PFI contracts means they are likely to provide more certainty regarding price and time. However there is no convincing evidence to suggest that PFI projects are delivered more quickly and at a lower out-turn cost than projects using conventional procurement methods. On the contrary, the lengthy procurement process makes it likely that a PFI building will take longer to deliver, if the length of the whole process is considered.
PFI contracts are inherently inflexible. There is little evidence of the benefits of PFI arrangements, but much evidence about the drawbacks, especially for NHS projects. The inflexibility of PFI means that any emergent problems or new demands on an asset cannot be efficiently resolved.
The Value for Money appraisal system is biased to favour PFI. Assuming that there will always be significant cost over-runs within the non-PFI option is one example of this bias. There is an incentive for both HM Treasury and public bodies to present PFI as the best value for money option as it is often the only avenue for investment in the face of limited departmental capital budgets
For too long PFI has been the ‘only game in town’ in some sectors which have not been provided with adequate capital budgets for their investment needs. This problem is likely to get worse in the future with capital budgets cut significantly at the Spending Review. If PFI is the only option for necessary capital expenditure then it will be used even if it is not value for money. A much–needed reappraisal of PFI needs to be accompanied by a similar reassessment of its effects on overall capital spending in the public sector
The price of finance is significantly higher with a PFI. The financial cost of repaying the capital investment of PFI investors is therefore considerably greater than the equivalent repayment of direct government investment. The Committee has not seen evidence to suggest that this inefficient method of financing has been offset by the perceived benefits of PFI from increased risk transfer. On the contrary there is evidence of the opposite. The Committee does not believe that PFI can be relied upon to provide good value for money without substantial reform.
Owing to the current high cost of project finance and other problems related to PFI, there are serious doubts about such widespread use of PFI. There are certain circumstances where PFI is likely to be particularly unsuitable, for example, where the future demand and usage of an asset is very uncertain and where it would be inefficient to transfer the related risks to the private sector.

Central servers

2010-07-06T09:03:00.002+01:00

Is it just me? I fell distinctly uncomfortable with the prospect of universal, centrally held servers.

Oh, I can see the advantages, sharing info between practices, easy transfer of records etc.

However, as the data controller, how can I guarantee control when I don't physically have access to the server? I am less than reassured by the presence of robust audit trails etc, as that sort of thing is very useful after a breach has occured but useless to prevent such a breach occuring in the first place.

http://www.ehiprimarycare.com/news/6054/inps_wants_vision_360_to_be_gp_system

That is the article that has got me thinking (again) about this. I understand that EMIS Web will be the only EMIS product with accreditation for EPR2. That is a shame, as many practices will not wish to change just for that, and EPR2 is one part of the CfH schema that may actually be of use and benefit to practices. It appears that INPS will be keen to see a move to their new system, though of course Vision 3 will remain compliant.

There is a part of me that hopes that IT spend will be part of the devolved budget that comes through with the commissioning changes. GPs could once again then start driving the process of development rather than reacting to it.

Another example of where control needs to be wrested from the PCOs.

Practice Boundaries: a proposal

2010-01-26T08:59:00.000Z

Text of a press release follows:

BMA sets out its proposal for how to reform general practice boundaries

The BMA today (Tuesday 26 January 2010) sets out its solution for how to reform GP practice boundaries* and make it easier for patients to see a GP in a place and at a time that is more convenient.

The government wants to abolish practice boundaries by October 2010 and the Conservatives have said they want patients to be able to register with the practice that best suits them (near their home or work). A government consultation on practice boundaries is to start shortly.

The BMA paper, Reforming General Practice Boundaries, explores the possible consequences of completely abolishing practice boundaries and suggests a solution which, while not a total abolition, would significantly improve choice and access for patients without the huge cost, upheaval and unintended consequences that completely free registration would cause.

Dr Laurence Buckman, Chairman of the BMA’s GPs Committee, said:

“Complete free choice of registration is a good idea in principle and we want patients to be able to choose the GP surgery that is right for them. However, we don’t want it to come at the expense of continuity of care or for it to lead to increased risks for vulnerable patients and a widening of health inequalities.”

The BMA believes that total abolition of practice boundaries could have a number of unintended consequences. Examples of issues that would need to be addressed in advance of completely free registration include:

* How to reform the home visiting system so continuity of care for patients, who are registered with practices far from their home, isn’t affected
* Current IT projects, such as the electronic patient record transfer project, would need to be accelerated so GPs could have access to full patient records in order to make safe clinical decisions
* How to avoid widening health inequalities – this could happen if frail people or those without access to private or affordable public transport are not able to access practices further from their home, while others can
* Systems would need to be put in place to protect and track ‘at risk’ patients who could be vulnerable if they are regularly re-registered at practices not within their social services boundary
* Funding arrangements for GP practices would need to be reformed to ensure that, with increased movement and changing patient demographics, funding for all practices is fair and equitable
* Popular practices that had reached the limit of physical capacity would need to be helped to improve their premises in order to match patient demand
* Primary Care Trust (PCT) funding would need to be completely changed in a way that would take into account the impact on hospitals and social services. This would be extremely complex if the patient lived in one trust but registered in another.

The General Practitioners Committee’s solution is to combine a series of local improvements with a national change in the current “temporary resident” arrangements. Local solutions should include permitting the widening of the boundaries of all practices in an urban area so patients have greater choice, the introduction of videophone and webcam consultations, as well as formally allowing patients who move outside a practice boundary the option of staying with their GP. The change in the temporary resident arrangements would mean unregistered patients could be treated by a distant practice on an ‘ad hoc’ basis whenever necessary, while their normal GP practice would still oversee their care. It would have the added benefit of encouraging patients, who might otherwise inappropriately attend A&E, to go to the nearest GP surgery instead.

Dr Buckman added:

“Getting rid of practice boundaries altogether is fraught with difficulties. Having worked through various alternatives, we believe this solution is the best option for the health service at this point in time. Not only will it be the most cost effective solution, it will also serve patients far better. They will get more choice and are less likely to be adversely affected by the new set of problems that total abolition would create.”

An explanation

2010-01-04T13:51:00.003Z

Hello, been a while.

Someone noted that I haven't blogged for a while. I thought I should explain.

I have been busy. I am now very much part of the establishment, being Chair of East Sussex Local Medical Committe. Additionally, in June of last year, I was elected to the General Practitioners Committee of the BMA for a year. I am not sure whether I will get re-elected this year, time will tell.

As a result, given I do not (and have never) blogged anonymously, I partly have no wish to cause our negotiators difficulty by commenting publically on matters political, but mostly I have less time to post and comment.

Consequently, my blog has fallen by the wayside almost entirely. I spend sufficient time discussing medico-politics during the day, one way or the other!

On which note, I'm hoping to start using my camera more as a means of relaxation, so you might get some photos on here, interspersed perhaps with the odd bit of politics.

(By the way JD, it was nice to be missed. Thank you. That also to the few dozen people (or at least aggregators) who have persisted in checking my blog every week.)

Flickr

2010-01-04T13:50:00.001Z

This is a test post from , a fancy photo sharing thing.

Darkness at the Heart of the Labour Party

2009-04-15T09:03:00.002+01:00

I don't normally re-blog what others have, but this one is illuminating.

A greek chap I read pointed me to the blog of Frank Field MP.

"Harold Wilson asserted that the Labour party was a moral crusade or it was nothing. The McBride affair has left Labour members looking at nothing. That is the reality check that McBride has wrought on the party.

The whole of the government's energy should be spent on governing now and building a programme from which, within and year, we will be seeking permission to rule for another five years.

Far from helping sketch out a new roadmap, the McBride activities shine a searchlight on the paucity of the government's programme."

Please, go and read the rest.

How to work out your increase in funding

2009-04-14T08:49:00.007+01:00

This one is for GMS GP readers (and possibly practice managers, I've no idea if any of those read my blog).

What does the DDRB recommendation mean for your practice? I was rather confused initially, so after working it out (with some help including an illustration by Dr David Shaw on DNUK) I wrote a very short paper to share with others.

So here it is. A quick guide. Except that I wrote it in Word to start with and discovered that copying and pasting from Word into HTML is an interesting experience, one that I will try and avoid in future. Anyway, I retyped it here.

How to work out your GMS funding

There are 4 components to it:
Global Sum (GS) increases by 2.4%
Global Sum Equivalent (GSE) which equals the GS plus your correction factor (if you are an MPIG Practice). This increases by 0.7%
QOF points increase by 1.7%
Enhanced services (ES) funding increases by 1.7%

For non-MPIG practices, your GS goes up by 2.4%, QOF and ES go up by 1.7%. Simple.

For MPIG practices, it is slightly more complex. Obviously the QOF and ES bits are the same, increasing by 1.7%. But for the rest of it, keep reading:
Calculate both your new GS and your new GSE.
If the uplifted GS exceeds the uplifted GSE, you move off MPIG (congratulations).
If not, the GS component of GSE is uplifted by 2.4% and the CF is likely to drop to give an overall increase in GSE of 0.7%.
What this actually means in practice is that your Practice Manager will be able to see if Primary Care Support Services are paying you what they should each month.

Obviously your QOF and Enhanced Services monies will vary from practice to practice, but you should (at least) be able to work out how much each QOF point is worth to you practice. Ask your LMC rep if your PCT is uplifting the Enhanced Services Floor by 1.7%. They should be.

A couple of worked examples to illustrate differing magnitudes of CF:

Practice 1
GSE £101,000, made up of GS £100,000 and CF £1,000
GSE increases by 0.7% to £101,707
But GS uplift gives £102,400
This is bigger the GSE, so you no longer have a CF and you move off MPIG.
Practice 2
GSE £110,000, made up of GS £100,000 and CF of £10,000
GSE increases by 0.7% to £110,770
GS uplift is also £102,400
CF=GSE-GS, so =£8370
So the net effect is an increase of 0.7% with a decrease in reliance on MPIG with a reduced CF (goes down by £1630)

Addendum: the CF is recycled into the GS, so as more Practices move off MPIG, there is no loss of money from the overall pot.

A decade

2009-04-08T16:37:00.003+01:00

I really haven't been very good at keeping up with this blogging lark.

Part of the problem is my decision at the outset NOT to be anonymous. Consequently, much of the material others publish is not possible here as I have no wish to identify anyone, even if inadvertently, that I have seen in surgery.

Nevertheless, this week marks my tenth year at Manor Park. I think that deserves a mention.

I initially wrote a long piece about my time at the practice so far but frankly it was boring. However, the fact is that it can be summarised quite briefly: The patients keep coming because they need us, we are seeing more and more people all the time, I am still enjoying the clinical side of things greatly. The admin side of things gets increasingly onerous as time goes by. The "light-touch, high-trust" contract which was brought in in 2004 has proven to be anything but, though we are much luckier in our relationships with our PCT than many.

I have seen many changes in the last 10 years, some of which have happened to me and some of which I have been instrumental in.

The gradual adoption of our computer system's facilities has been a very significant change, one which I initially led. We now have a website as well, where patients can pre-book appointments and request repeat prescritions.

The new contract in 2004 was an eye-opener. Initially I can confidently say it improved matters in Primary Care. However, as is the nature of these things, the consequences (intended or otherwise) are playing havoc with General Practice, not helped by a predatory and antagonistic Government who seem to feel the need to grind us into submission when all we want to do is do our job. This despite our patients constantly supporting us in whichever survey you care to mention.

I have also been an active member of the East Sussex Local Medical Committee since 2000. I suppose this makes me a politician. I try my best to contribute in a meaningful way, though it is for others to say if I am successful. Whether any of those others read this blog, though, I have no idea. I can't see the pointing in whinging about things if you're not prepared to do somethig about it. So I try to.

I've also changed in the last decade. My experience base has grown. My practice has, too. I've been divorced, remarried and made a father again. I swear (a bit) less, laugh as much as I ever did (quite a bit) and I think I am both more considered by more adamant in my viewpoint and espousals. I guess I've grown up some more.

Anyway, I'm starting to ramble.

I will try and post more frequently...

Self confidence

2009-03-19T10:37:00.000Z

"I'm a Normandy veteran you know. Yeah, I won the war.

Well, me and another bloke, but he was rubbish."

I love these old veterans.

Darzi and coffee

2009-02-10T12:17:00.002Z

Honestly, he really has no idea, does he.

(With thanks to Hairy Aerosol for the image)

Scarey stuff

2009-01-22T13:46:00.000Z

Pandemic flu planning.

I'm in charge for my practice. I was quite relaxed until I started reading the official planning docs. Don't mean to worry you but thought you might be interested in some official figures. These are being used as a basis for planning and for once planning is on the basis of a worst-case scenario. But that shouldn't reassure you. That ranges are actually not that broad.

When it comes (as it inevitably will, we just don't know when) 50% of population is likely to get it (either in one or more than one waves, each wave lasting 8-15 weeks, with first wave peaking 50 days after the virus arrives in the UK, which in turn will be about 4 weeks after it erupts wherever). That's 30 million people.

25% will get complications. 7.5 million people.

4-5% will need hospitalising. 1.2 million people if its 4%. The UK has about 390 beds per 100k population, so about 234k beds.

1-1.5% will need intensive care. 300k. There are only 3500 ITU or high dependency beds in the UK including the specialist beds in cardiothoracic centres, trauma beds and the like. There a re a small number of paediatric ITU beds in addition to that.

2.5% potential mortality. That is three quarters of a million people.

Staff absence at any time (including health workers) expected to run at 25% (closer to 35% for smaller businesses) so fewer nurses/medics, tanker drivers, electricity engineers etc. Schools will be closed reducing the number of people able to work further. Of course, some people will not go to work to try and avoid exposing their families, which will make matters even worse.

Lets hope it doesn't come till the next century.

On a happier note, Panama by Van Halen is currently playing on Planet Rock...

National guidance and evidence base

2009-01-06T10:16:00.001Z

I've been reading this:

http://jac.oxfordjournals.org/cgi/content/full/61/5/976

Just out of interest really, as there seems to be a belief amongst certain noctors in secondary-care-land that GPs are filthy creatures who are responsible for a fair few MRSA infections.

Two main thoughts came to mind on reading the document.

Firstly, that most community acquired MRSA seems to be in people who've had recent contact with secondary care in some manner. Which is odd, as we seem to have a pelthora of posters up at the moment advising us to wash our hands at every available oppotunity so we don't kill people. I'm not aware of any evidence to suggest that GP surgeries are foci of infection, which this guidance would seem to support.

Secondly that the evidence base for this guidance is so poor. The vast majority of the recommendations throughout the document are graded as D (in other words, they are based on the opinions of the great and good rather than sound scientific data).

I can't help wondering whether HMG should be spending money on acquisition of reliable evidence for things like this rather than wasting it on white elephants (by which I mean NHS Direct, rating GPs on NHS Choices, Darzi centres and the like).

Dementia

2008-12-22T09:46:00.003Z

Lots of fuss this morning about this.

Apparently all us GPs are to receive training to recognise dementia much, much earlier. Once we've diagnosed it we will send people with it to memory clinics for treatment.

Right.

Well, I've been diagnosing dementia for years.

I've been referring for years.

Support services for people with early disease are rudimentary. Most people with early disease are able to live completely independently.

The disease is characterised by an inevitable and inorexable decline. There is no treatment that works and even the treatments which are said to slow the progression of the disease have recently been said by the government to be too expensive. Just talking about the possibility of having it scares most people rigid. The vast majority of those with it die of something else well before the dementia itself gets severe enough to carry them off.

Which rather leaves me wondering what the point of this announcement is.

Oh wait: Parliament is in recess and Christmas is coming up...

Oh dearie dearie me

2008-11-12T13:10:00.001Z

http://www.theregister.co.uk/2008/11/12/dr_scot_gmc_probe/

The saga continues.

Other blogs have covered this in much more detail.

I would expect the investigation to be robust, but we will see.

Bless her.

2008-10-30T11:35:00.001Z

6 years old, known her since birth (the joys of GP).

Flare up of eczema since the heating went on. Not too bad, but obviously irritating.

I say to Mum "Increase the frequency of the diprobase to three times a day."

Little one pipes up, very loudly: "Oh Doctor Brown, I HATE diprobase!"

"Why's that then?"

She of course goes bright red and looks at her feet.

"S'itchy on my back mumblemumblemumble"

"Want to try a different cream?"

"Sss, plsss..."

"Ok, lets try something else than diprobase then."

Cue big grin and another satisfied patient.

Her first steps into an independent relationship with her health.

Great job this, innit?

Sick notes

2008-10-13T09:21:00.007+01:00

Specifically with reference to getting them from hospital doctors. The guidance is available here.

This is NOT a rant against my colleagues in secondary care. Hopefully some of my readers are secondary care docs. Some of them may learn something from this post. Or they may not. (grandmothers, eggs, natch...)

There are 2 main types of sick note patients will come across. The Med3 and, less frequently, the Med5.

The Med3 is the white certificate you might obtain from your GP if you need more than seven consecutive days off work. Its duration can be open (specified typically as "two weeks" for example) or closed (when a specific return to work date is recorded). It cannot be backdated. The patient must be physically seen, in the flesh. Telephone consultations, although they seem to be ignored by the DWP, actually fall outwith the regulations governing these certificates

A Med5 has two possible functions. One is for a doctor to backdate a certificate, but only if he or she has seen you in the recent past and for upto only a month from the date of signing. The other is to provide a certificate (without necessarily seeing a patient) on the basis of a recently received (within a month) letter from another doctor. In this instance, the certificate cannot be backdated (again the DWP seems to ignore breaches when this inevitably happens).

As a GP I do a lot of these.

Not infrequently, patients come to see me after operations or hospital stays to get one because they have not been furbished with one at the time of discharge or they have been given one for a shorter period of time than will obviously be necesary (for example 1-2 weeks after a hysterectomy rather than the 6 weeks virtually everybody needs).

This irritates me. Greatly.

I would imagine it occurs mostly because of ignorance of the regulations by hospital junior doctors. I would hope that it isn't just laziness.

Because you see the guidance is quite clear:

The duty to provide a statement rests with the doctor who has clinical responsibility for the patient at the time. Hospitals are required to provide all certificates for social security and Statutory Sick Pay purposes and doctors' statements for both in-patients and outpatients who are incapable of work. The Med 3 should be issued on discharge from hospital where a hospital doctor advises a patient to refrain from work, and the doctor was attending and had clinical responsibility for the patient at the time this advice was given. In such cases the Med 3 should be issued for an appropriate forward period. Responsibility for issuing further certificates rests with the doctor who assumes clinical responsibility for treating the incapacitating condition. In cases where the GP has not taken over responsibility for the incapacitating condition, responsibility for issuing further certificates will rest with the treating clinician.

I am sure that, at times, junior doctors are advised by others (perhaps administrators or nursing staff on the wards) that sick notes are not available, or that "we haven't got any". It certainly happened to me when I was training.

I have written twice this year to senior colleagues at my local hospital advising of these regulations. The second time I offered to go and do a session at their twice-yearly inductions for the junior doctors. I didn't receive a reply to my second letter, but there you are, some people are just rude. Such is life.

However, given all the problems around the accountability of the GMC (as well as to it) together with increasingly draconian messages regarding probity coming from it, I suspect that in future, I will be regretfully apologising to patients as I do now. But the focus will shift from an apology that my secondary colleagues have somehow abrogated themselves of responsibility for the sick note and provide it whilst steaming quietly in my chair, to apologising that I may not provide a note for them and directing them back to the hospital consultant. I will show them a copy of that paragraph, and will give them a copy to show the consultant.

Hopefully the message will sink in, bit by bit. I will repeat my offer to educate if the opportunity arises (which sadly, I suspect it will). Letters will be written, patients will be inconvenienced.

Does that make me stroppy? I don't think so.

Doctors and freedom of speech

2008-08-11T16:55:00.004+01:00

Story here.

This has been covered by other medical bloggers. I don't blog as much as I used to because I often feel generally pissed off with the way the NHS and the Medical Profession generally seem to be heading.

But I am really very cross about the way that the events leading to the Pulse story have been dealt with. Go on, click on the first link in this post if you haven't already read it. Professor Paice's comments about free speech are quite enlightening.

The Jobbing Doctor has also posted that various out-spoken bloggers have gone quiet. That worried me. But I'm not anonymous, never have been.

So we can say what we like, as long as we mind how we say it, or by implication, who we say it about?

Well, as an alternative, how about I say what I like and you put up with it?

This isn't Stalinist Russia. It isn't even the USA. If you don't like it, I do believe you can bloody well put up with it.

Despite the fact I am a professional, I am also a citizen of this country and am entitled to express my opinions to whomsoever I choose in whatever way I see fit within the bounds of the law.

Not the bounds of others sensibilities.

I haven't really said much about MMC/MTAS and the utterly ridiculous and reprehensible way in which our junior colleagues have been dealt with, and I specifically include the young surgeon in Scotland in that comment.

Someone should be held to account.

It will be interesting to see the GMC's attitude to the reporting of Donaldson to them by RemedyUK.

And I don't think its any coincidence that iwantgreatcare.org is out now. I would very much like to see a definite statement about it from both the Department of Health and the GMC, specifically with regards to their level of involvement in the project.

But I won't hold my breath that anything of any substance will occur.

Apologies

2008-07-23T13:45:00.000+01:00

I've just realised that I haven't updated my blog-roll for ages.

I tend to use Google Reader to keep up to date with those I read. Many of my favorite blogs are not listed on my roll.

If that's you, sorry.

I will try and update the roll soon...

News today

2008-07-23T09:55:00.003+01:00

Several front page-type news stories today.

The main one is the release of a report by the Chief Medical Officer, Sir Liam Donaldson, on revlaidation of doctors. In principle, I think is a "good thing". But I am a little worried about the details, because that is where the Devil is. And, in my (not so) humble opinion, Donaldson has failed the profession several times in recent years, the most reprehensible episode involving his lack of accountability for the MTAS/MMC debacle.

What I would support is an annual exercise to check that we are keeping up to date that is more robust than the current system.

What I would have difficulty supporting is anything which involves excessive paper chasing. We GPs are already "answerable" to a couple of dozen different organisations and quangoes, from the PCT, to the Health Care Commission to the GMC, never mind the fact that people can also take us to Court, separately and additionally to all the other ways they can have a go at us.

And I'm not even going to mention the abomination that is Iwantgreatcare... (bugger, I did, didn't I?)

The next story is about GPs prescribing antibiotics: again, I'm in two minds about this one.

I don't prescribe antibiotics at the drop of a hat, and guidance will add to the credibility of my already rather paternalistic and uncomrpomising argument when a patient is insistent that they need "something or I'll get pneumonia" ("You'll need them when you have pneumonia, at the moment you don't.")

On the other hand, the premise that GP prescribing is part of the problem with the rise and rise of the so-called superbugs such as MRSA doesn't have a lot going for it. Dr Grumble and the Jobbing Doctor have already blogged about this failry recently, so I won't bore you further (though I do commend their blogs to you, go and have a read). Suffice to say that the Government should be looking elsewhere for solutions, rather than looking for scapegoats.

Finally, this story: I (and my colleagues) am (are) missing the diagnosis in patients presenting with HIV. Apparently there should be more widespread testing (well, I can't argue with that). But I should also be considering it in anyone presenting with a flu-like illness.

Do these people have any idea whatsoever how many people I see with just that story every week? Even in a good week its half a dozen or more. In a bad week it'll be in the fifties or sixties.

There are 7000 new case of HIV diagnosed every year. That compares to almost 114,000 deaths form heart disease, over 33,000 deaths from lung cancer and a prevalence of diagnosed diabetes of almost 4% of the population (not counting those patients who we don't know about yet).

This suggestion by the National Aids Trust, while laudable, is another example of Ivory Tower speak: they may be experts in their field, but they are patently not experts in mine. It would make much more sense to me to be dishing out free condoms and promoting safe sexual practices.

Finally, I am grateful to the Jobbing Doctor (good grief, 2 mentions in one post. I'm not stalking you, JD, don't panic...) for bringing to my attention something that isn't my fault.

Access and Choioce survey 2007/8

2008-07-16T12:37:00.002+01:00

Results are out for this survey, available here .

You can search for your own surgery by post-code or street name.

Here's a brief summary of our results (bear in mind that this survey predates the start of extended hours and also predates us setting our website + services up, total respondents 269 out of 5950 patients, so 4.5% of our list):

Happy with phone access 96.6% (last year 92, PCT average 90.4, number happy/number not happy 255/less than 10)
same day or within 48 hour access 98.1% (94 and 92.5, 157/ <10)
Advanced booking more than 48 hours away 58% (29 and 70.7, 47/34)
Book with specific GP even if means waiting longer 89% (84, 88, 105/13)
SAtisfaction with opening hours 90.6% (87, 83.4, 241/25) (although thats 9.4% of sample, that's less than half on one percent of list)

The questions with smaller numerators were usually asked after a different question, so eg my number 3 was after this question: "In the last 6 months, have you wanted to book ahead for an appointment with a doctor?" and only those people who had wanted to, had had to answer the book ahead question.

I'm really pleased, especially with the pre-booking figures. Thats a big improvement, just from telling people as they come in to the surgery. That should improve even more over the next few months; for example, since we launched the website in March, almost 200 people have signed up for the EMIS Access services we offer. We should be at or beyond PCT average by the time of the next survey.

And 5 simply justifies our stance of not doing extended hours, in my opinion.

Of course, the redoubtable Mr Bradshaw thinks otherwise:

"The survey results are a real measure of success for those GPs and their staff who have listened to what their patients think and who have responded with even better access to GP appointments. I congratulate those practices.

"I also want to thank the two million patients who took the time to respond to the survey as these results show the difference patients' feedback can make to the services they receive.

"The NHS now needs to respond to what this latest data is telling us. It is clear patients increasingly need access to primary care at more convenient times. Since the survey took place over a quarter of GP practices have begun to offer extended opening hours and from 2009 the 152 new GP-led health centres around the country will continue to improve provision."

I'm not entirely sure how one can suggest that "it is clear patients increasingly need access to primary care at more convenient times" when obviously so many people are ALREADY VERY HAPPY!

But then, that's why people trust me and not you Ben. You are a politician, whereas I am (now, what was it you said? Oh yes...) mendacious and misleading.

Having a laugh

2008-07-15T11:32:00.003+01:00

I've just seen Doug. Doug is 79 and has COPD. But that isn't why he came in today.

Doug has had non-specific back pain for some time. No worrying features, other than the fact it isn't resolving. He tends to manage it with simple analgesics.

He has seen a chiropracter recently. The chiropracter thinks Doug may have osteoporosis, based (I assume) on the X-rays that he took. So I'm arranging a DEXA scan to see if he does. He doesn't have any risk factors, but its possible.

The chiropracter also found what he thinks is an abdominal aortic aneurysm. I hadn't had reason to examine Doug's belly before, so I did so today. Sure enough he has a small pulsatile mass just below the belly button.

The trouble is, Doug is tall and skinny, So I'm not sure that this mass is of any significance. S I've requested an abdominal ultrasound scan. I explained what I'd found and why I think we should scan it. I also advised him that I might want to refer him to our excellent local vascular surgery clinic if the result shows it is larger than 5cm.. If not, I will just keep an eye on it myself. For the time being anyway.

Then Doug said something which surprised me a little: "Well, that's a relief."

I asked him what he meant. I thought perhaps that I'd explained something badly. But I needn't have worried.

"I thought you were going to tell me I was pregnant!"

We shared a snigger. He left happy.

GPs to blame - again

2008-07-03T08:48:00.002+01:00

Ben Bradhsaw has accused me and my colleagues of operating a gentleman's agreement to stop patient's having the choice of practice.

Of course he doesn't actually offer up any particular evidence of this.

But he's a Minister, so it must be true.

Quite why he hasn't advised the Competition Commission of the facts that he obviously has to hand I don't know. Agreements of that nature would be a serious breach of the law. Indeed our current contract regulates us such that, assuming we have an open list, we must register anyone within our practice area who wants to register. If our list is closed, we can't take on new patients. That's it, nothing complicated.

Unfortunately the BMA response has been less than robust, describing his comments as "nonsense", rather than "libellous" which is probably what I would have said.

Its all part of the "choice" agenda that they are pushing so hard. If patient's have choice, all will be well with the world. I keep saying it, but patients are less concerned with choice and more concerned with good, local services.

But that doesn't fit in with the current agenda to get private companies involved in health care, particularly Primary Care (for which read General Practice).

And as for the practice in the South of England with only 2 patients.

Really, Ben?

Where is it then?

No?

Put up : evidence in public of these agreements, evidence that GPs are restricting choice, give it to us, make it public.

Or shut up.

BMA position statement

2008-06-30T17:01:00.001+01:00

http://www.bma.org.uk/ap.nsf/Content/Darzipositionstatement

Downloadable pdf.

Also the text of aletter from the BMA's patient involvment group:

Letter from Juliet Dunmur re. Privatisation of GP practices:

Dear Hamish
Privatisation of GP Practices

After comprehensive discussion by the members of the BMA PLG, I am writing to you about our fears as patients, and on behalf of patients, about the changes being implemented in the way General Practice in England is organised, funded and run.

Our concerns are based on the change from self-employed GPs and partner-led practices to market-controlled, profit-driven clinics; on the issues the DH has chosen to prioritise when commissioning and remunerating General Practice services, and in the way it has chosen to address these issues. We are apprehensive that these changes and the new focus of Government will lead to a decline in the quality of patient care for all patients in England.

The PLG has identified a number of major concerns, many of which we believe you will share, and also makes some proposals on what the BMA might do to address them. Our main concerns are:

The voices of older, less able, more ill and less vocal patients and carers are not being heard.

The current Government focus on longer opening hours masks and ignores the needs of many patients who, ironically, are the people who are more likely to be ill, make more use of NHS services and more likely to cost the NHS more if their needs are not addressed early on.

Opening hours is an easy goal to measure, cheap to provide and amenable to private providers. However, this focus gives the appearance that patients’ needs are being addressed while ignoring patients’ other needs and preferences. Evidence from the Picker Institute shows that continuity of care and confidence that your GP will act as your advocate are vital for patients, particularly those with long-term conditions, and elderly and disabled people. We are concerned that government is selectively focusing on objectives that serve their political goals and are pushing forward service redesign based on this, rather than on what patients want and need.

Our proposal is that the BMA should challenge the government to develop policies for providing general practice services that meet the needs of the all patients, using evidence from the Picker Institute.

The unilateral imposition of change, instead of flexibility according to needs in a particular area.

We are concerned that government is increasingly imposing a ‘one-size-fits-all’ pattern of service delivery instead of allowing local variation according to local need. The BMA often quotes the figure that 84% patients are content with practice opening hours. However, this overlooks the needs of some sections of the population for whom current opening hours are inappropriate, and who do not use General Practice as a result, giving the potential for ill health through late diagnosis and intervention. Similarly, the policy to compel every PCT to set up a polyclinic, regardless of what services currently exist in the area and their acceptability by and convenience for the local population, shows a blatant disregard for patients’ needs, and the needs of the general community served by general practices.

Our proposal is that more evidence of how GP practices are already being flexible, meeting the needs of local communities and engaging with their patients should be made more public. We feel there should be more public acceptance of variability of service provision in general practice by the BMA: promote the good practice and be open about the areas where it is not so good.

The new GP arrangements are a step backwards for community health and participation and a psycho-social approach to care.

The consolidation of GPs into large, anonymous clinics, and the move towards private companies running GP services is likely to lead to a significant reduction in the development of initiatives to involve local communities in improving their health. As Sam Everington has demonstrated, GPs who see themselves as much a part of the community as their patients and the other residents are more likely to make a commitment to that community and develop innovative means of improving public health. Those patients less likely to use conventional services, who are also of lower socioeconomic status, non-English speaking and who have long-term conditions are likely to suffer as a result of reduced community commitment from profit-led provider companies.

Moreover, care focused on fulfilling the minimum requirements of a low-cost tender and subsequent contract will almost inevitably lead to a more biomedical model of care rather than a rounded, medico-psycho-social approach that is accepted as necessary to improve health and encourage people to participate fully in their health care, their families, jobs and communities. The issue of increasing health inequalities needs to be made forcefully.

Our proposal is that the BMA should engage with patient and consumer organisations also concerned with health inequalities, offer your support to their efforts to make such needs known and campaign with their support. The voice of the powerful doctors’ organisation along with them would make a real impact.

GPs will lose even more clinical autonomy

We fear that GPs operating in new profit-driven and cost-sensitive private companies that are commissioned to run clinics and practices will have less autonomy to utilise their clinical training and judgement when offering care to their patients. Referrals to secondary and tertiary providers are likely to be even more curtailed than they are now through PCTs.

We also worry that these new healthcare corporations will not want their employees (GPs) to prescribe expensive drugs or treatments, even if the GP feels that it is the best decision in her/his clinical judgement. This scenario is likely to lead to a more widespread postcode lottery when it comes to referrals and treatments, and the gradual decline of clinical freedom as more ‘expensive’, clinically-led GP practices are replaced by profit-driven and cost-dependent corporate medical employees.

Travel and access to general practice

One reason why patients like a local GP surgery is that travel to them is short and easy, a particular concern for people with long-term conditions, older people and people with young families. The proposal for universal polyclinics is likely to take away this neighbourhood access and continuity of care. The RCGP’s recent briefing by their PLG sets this out clearly.

Our proposal is to join forces with the RCGP and their PLG on this. The RCGP has sent out some excellent factsheets on Lord Darzi’s review of the NHS which give an overview of the benefits of GP surgeries from both the doctors’ and the patients’ points of view.

In conclusion

We believe that services can be improved by building on the strengths of general practice: on personalised care; healthcare close to home in the heart of the community; co-ordination of care; GP practice teams able to deal with multiple conditions and integrate different types of care; aftercare for patients after discharge from hospital; lifelong care; prevention of illness.

At present patients have free access to their GPs under the NHS. We have seen what happened to NHS dentistry: when top-down measures were imposed on dentists, many abandoned NHS service completely and chose to work privately in order to provide the level of service they valued. This resulted in half a million people losing access to NHS dentistry since the government introduced reforms in April 2006, figures from the Information Centre suggest. Only 50% of all adults in England were seen by an NHS dentist last year; the rest either having to pay for their care, or going without any care. This has resulted not only in a two (three)-tier system but in a consequent build-up of health problems for those denied access to dental services, leading to the development of more serious conditions, and therefore extra distress for the patient and potential extra expense for the NHS. We do not wish to see this happen to access to general practice but fear the potential outcomes highlighted in this letter may leave few other options. This would be a tragedy for the NHS, especially as we celebrate its 60^th anniversary.

We look forward to hearing from you, and are happy for you to circulate this letter or to quote from it as seems appropriate to you.

With best wishes,

Juliet Dunmur,
Chair BMA Patient Liaison Group

Darzi links

2008-06-30T16:25:00.003+01:00

Not had time to read them yet (obviously, being a full time GP) but here are some links to the various documents.

The Report.

The Proposed Constitution.

A High Quality Workforce.

Louise Boden

2008-06-06T13:15:00.004+01:00

An email has come to my attention. It is from Louise Boden, the Chief Nurse at UCLH, and so she is no longer a clinician at all of course, but a manager, paid for out of tax payers money.

The email is full of hyperbole and half-truths, insults and implications about GPs in general. It is really very insulting about GPs. She obviously is very jealous of us.

Here is the text:

-----Original Message-----
From: Boden,Louise=20=20
Sent: 06 June 2008 07:54
To: Divisional & Senior Nurses; Nurse/Midwife Consultants; Clinical Nurse
Specialists/Practitioners
Cc: Heads of Nursing
Subject:Don't be fooled: this doctors' protest is all about profits, not patients

GPs are fighting the new polyclinics for the same reason they refused to join the NHS 60 years ago: to protect their businessThe British Medical Association has declared war on the government. Nothing new there, as the doctors' trade union sends out several press releases a day crying wolf about anything the government does. Next week is polyclinic protest week, with posters and leaflets in every GP practice encouraging patients to sign a petition doctors are taking to Downing Street.

The ideas of surgeon-turned-minister Lord Darzi mutated through various models - but finally emerged as 152 new clinics (London) or health centres of flexible size (everywhere else), which each primary care trust designs to suit its most needy area. But the BMA says they will "fragment care and destabilise existing services. Some surgeries may have to reduce services for patients while others could be forced to close." Scary warnings abound tha
t the era of the GP is over, bureaucracy will rule and your beloved local surgery will go the way of the post office. The BMA told PR Week it is digging into its war chest for a national poster campaign. The Conservatives have jumped on the Save Your GP campaign - something they may regret. So what's the problem the new clinics seek to solve? Although the nation's 8,500 GP practices do 90% of NHS work, hospitals take 80% of the cash. For decades
Labour and Tory governments have striven to get resources out of hospitals and back into the community, with more early prevention and less emergency repair. The other reason is to get a grip on bad GPs, which is difficult as they are private businesses. Most are good, but up to 15% are seriously inadequate - often single-handed practices in shabby premises in the neediest areas, in stark contrast with some of the most hard-working and idealistic GPs.

Polyclinics are only destined for London: elsewhere there will be health centres grouping several GP practices with new facilities. Lord Darzi's London model will be a hub around which are grouped existing local GP practices, often in the same premises - or new ones that fill in gaps. The hub will offer diagnostics and specialist clinics of all kinds; patients can walk in and see a GP, or be referred by their own GP. These clinics come with new
money from the centre and just two universal rules: they must be open from 8am to 8pm, and must see any patient who walks in. Does this sound like a threat or a promise? That may depend on whether you are a patient or a GP. It's hard to see a downside for patients. They will have access to a host of services nearby instead of in a distant hospital - and, joy of joys, at any time from 8am to 8pm. Where new health centres have opened recently - I
saw a beautiful one in Crewe - there has been a stampede of patients to join.

In one of their few firm policy commitments, the Conservatives seem to be making a bad error. They say they will stop the polyclinic and health centre programme - and, even more surprising, they won't make GPs open their doors outside office hours. Andrew Lansley, the shadow health spokesman, told Pulse magazine they would restore GPs' control over what hours they open, which oddly puts the Tories on the side of the union against patients' interests.However, the BMA draws its power from the trust people put in doctors but not in politicians, which may be why Cameron reckons he should hang on to their coat-tails as they march on Downing Street, pretending that "patient care will be damaged" whenever anything threatens their own terms of service. Cameron should ask Kenneth Clarke for his unfond memories of BMA tactics. Many decent doctors blench at the crude and dishonest shroud-waving
carried out in their name. The BMA fought tooth and nail against opening GPs' doors at hours to suit working people: the government won only a meagre three extra hours one evening a week, and no weekends. This is despite a 58% increase in pay when their brilliant negotiators pulled the wool over the eyes of John Reid and Alan Milburn - whose 2004 contract let GPs off all weekend and evening work for a puny =A36,000. (BMA negotiators could hardly believe it: they were expecting to lose =A315,000). The contract paid them if they hit 75% of their targets: they pretended that was tough but when they easily reached 92% they hit the jackpot. The National Audit Office said it cost =A31.78bn. Unsurprisingly, GPs have had no pay rise in the four years since, and that's part of the grumbling grievance behind this current campaign.

The BMA's petition to Downing Street will be shaped as a giant birthday card for the 60th anniversary of the NHS, so let's remember what happened back then. Aneurin Bevan failed to get GPs to the join the NHS, so they remain to this day private businesses. They have life-long contracts that can't be removed, with a guaranteed income, and large increments for doing things that should be part of their job. They own their businesses - and usually
their premises - and sell them on when they retire. As a result the NHS hasn't been able to ensure GP practices are spread to where they are needed most. The fact GPs are not direct NHS employees has always worsened inequalities in health provision as they congregate in richer, leafier spots. This BMA protest has nothing to do with patient care - and everything to do with jealously protecting what they see as a threat to their business model. So
it's hard to keep a straight face when the BMA scaremongers about "the threat to your surgery" from "commercial providers" who "will be more interested in their shareholders than patients". The BMA expresses indignation that more GPs might become directly employed by the NHS - but forgets to mention that a growing 35% of GPs are now directly employed by other GPs who meanly refuse to make them full partners in their businesses. Some contracts may
go to private providers - but the first has gone to a group of local GPs, and that is expected to be the model, except in rare cases. The new clinics will be built with various financial partnerships between the NHS, private funds and GPs' own investments. In the London borough of Camden and Derby, whole GP services have been contracted out to a private health company, causing consternation about creeping NHS privatisation - but these will remain the exception. In Camden the practices were already being run by the loca
l primary care trust and now open long hours, attracting more patients. But anti-privatisation campaigners are right to be wary: it is typical Gordon Brown triangulation that a mention of using the private sector has to be injected into everything to show he's a Blairite reformer at heart - as with this week's announcement that, as a last resort, failing hospitals could bring in private managers - though few expect it to happen: it was tried at Birmingham's Good Hope - and failed.

Of course polyclinics could go wrong. They could be underfunded and badly run. PCTs are not always good commissioners and could choose the wrong models in the wrong places. Clinics attracting patients may destabilise other practices - but frankly, that's the point. GPs who can't be bothered to join something offering new services for their patients are the very ones who may need a bit of destabilising. For all the fuss, London's 152 new clinics
will cover only 3% of GP services. But if they are half as good as promised, they may blaze a trail so that soon every patient will want one.

I will be passing this to the BMA as I suspect that a robust defence will be forthcoming (who am I kidding?!). There are many statements in this email which I suspect are not evidence based, for example that 15% of GP surgeries are seriously inadequate.

With colleagues like these, eh?

I have just discovered that this is a cut and paste job from Polly "I love Labour" Toynbee in today's Guardian.

Fuel poverty plan being unveiled

2008-05-30T08:52:00.002+01:00

This issue is perhaps more social than medical, but it impacts on me every year.

BBC NEWS | Business | Fuel poverty plan being unveiled

Lets get people out of fuel poverty. Good idea!

Lets collect and share data with the power companies so they can identify who to help. Then they can offer to insulate their lofts, make sure they are on the cheapest tarrifs, check the draft excluders on the windows.

Not so sure on that. You want to collect data identifying people who are at risk of fuel poverty. How would you do that? I can only imagine the Government would make use of data derived from pensions somehow.

Or (now wait a moment!) could this just be another way to try and persuade us of the merits of national ID cards?

I've just heard a minister on the Today programme, Malcolm Wicks I think it was. He was explaining why the Government thought this was a good idea. He began with the data sharing idea, which made me feel uneasy. I'm on record as to how I feel about ID cards. Given recent episodes of data insecurity I have no faith whatsoever that the Government would keep my data secure. But then he compounded the problem by stating that changing the Pensions Bill, the Government could give itself more "powers".

Government seeking more "powers".

Seeking yet more control over our lives.

Once again they forget that they are our servants, not our masters.

But there is no point in me being critical without suggesting alternatives. Of course, I speak from a position of relative ignorance, in that I am neither an expert in fuel poverty nor a Government minister (who are of course by definition infallible, like the Pope, until they decide to spend more time with their familes).

So how about this as a relatively easy, cheap to administer idea: anyone over 65 on income support gets sent a voucher to give to their energy company. No data sharing, its up to the individual to decide whether to engage with the scheme or not as they see fit. Consequently there is no need to change the Pensions Bill, with a commensurate saving of both Parliamentary time and tax-payers money (no changes/revisions means less working hours spent on it). I can't see that it would cost more than the suggested increase in executive powers. I can see that it doesn't make the Government any more top heavy. More legislation does.

But they won't listen. They never listen. They consult. They decide what they are going to do, decide on a timetable, go through a public consultation exercise (which is to inform, not seek views from, the public) then do what they decided to do. Then they pass laws designed to do what they want without thinking about the difficulties that those laws might cause. This Government is forever having to deal with the Law of unintended consequences. They usually seem to do this by retrospectively changing what they set out to do and saying that it had been their intention to do that all along.

By all means help the poor, Mr Brown. But you don't need "powers" to do that. You just need common sense.

Save Your Surgery

2008-05-23T15:26:00.004+01:00

The NHS is 60 this year.

That means that my predecessors and I have been looking after your family from cradle to grave, personally and with knowledge about your health and illnesses built from the familiarity that comes with a relationship that may well span decades.

Gordon Brown wants to change that.

He doesn't want you to see the same doctor each time you need some help. He has bigger plans. He wants to introduce commercial companies to the sector.

"So what?" I hear you say. "You GPs are private, you just work for the NHS."

Perhaps. But who am I accountable to (exclusding for the moment the couple of dozen Quangos which can also make my life busier than it needs to be)? My patients. I have a GMS (General Medical Services) contract. It is a long term arrangement to provide care.

What about a commercial company? They have a responsibility to their shareholders, first and foremost. They will likely have something called an APMS (Alternative Personal Medical Services) contract. APMS contracts will likely be for 3-5 years maximum. so what happens when the contract runs out? Will you lose that service as well? Perhaps. But don't worry, some other company will be providing the service if the first one isn't. It really doesn't matter who you see.

Does it?

What about polyclinics, walk in centres and the like? The Government have said there will be up to 250 large new health centres. Great! More services! Sounds super! And what's that? It'll be up to local PCTs to decide if they need one? Wonderful! (Oh no it won't, they've all been told that this is a political "must do", whether they need it or not.)

Except the money that is being spent on those (around £1 million per centre I would guess) could be spent investing in the current service being provided by people like me, for people like you. That money has to come from somewhere. I am not reassured at all by Ministerial reassurances that they have no plans to disinvest in GPs. They think we are superfluous and that what we do could be done more cheaply by nurses, paramedics and pharmacists.

These polyclinics will have many more doctors than the current style of GP surgery, maybe as many as 25 doctors. Great! Easy access! It doesn't matter if you don't see the same person twice.

Does it?

If this concerns you as much as it does me (and I'm concerned equally as a patient of the system as I am as a GP) then please go to the website and sign the petition. Or visit your local surgery and sign.

Write to your MP and the local papers, the Nationals even. Espeically write to your local council, address it to their Overview and Scrutiny Committee.

But please do something.

When we're gone, it will be too late.

Musings of a Dinosaur: Why Breastfeeding is a Bad Idea

2008-05-23T08:37:00.000+01:00

Musings of a Dinosaur: Why Breastfeeding is a Bad Idea

Please, go and read this.

It made me snort coffee on my keyboard.

Crewe and Nantwich

2008-05-23T08:31:00.000+01:00

Schadenfreude - Wikipedia, the free encyclopedia: "Schadenfreude (IPA: [ˈʃaːdənˌfʁɔʏ̯də] Audio (German) (help·info)) is enjoyment taken from the misfortune of someone else. The word has been borrowed from German by the English language[1] and is sometimes also used as a loanword by other languages. German philosopher and sociologist Theodor Adorno defined it as 'the largely unanticipated delight in the suffering of another which is cognized as trivial and/or appropriate'.[2]"

Time to start a campaign?

2008-05-09T10:16:00.002+01:00

(With thanks to Prit Buttar and colleagues on the BMA Communications team)

This one is mostly for my GP readers, but here is a transcript of an email I've just sent to my LMC mailing list.

I listened to Darzi on Radio 4 this morning. If anyone missed it, use
the BBC website 'listen again' thingie, it was at about 0712.

He was explicitly asked whether PCTs would be able to choose NOT to
have a polyclinic if that was what the locality decided. He said that
they would be allowed to make such a decision.

Annual budget for one of these places is going to be somewhere in the
region of £800k-1m per year.

Using PBR tariffs and the BNF, I estimate that this could be used to buy:

1,139 cataract operations
154 hip replacements
113 courses of Herceptin
or 36 full-time district nurses

Perhaps we should therefore be undertaking a survey of our patients to
find out if they want a centre of some of the above. We should then
pressurise the PCT boards to accept our findings. especially as Darzi
specifically said that PCTs should take into account local
preferences.

This could be run along side the BMA campaign (see Laurence's email of
yesterday or press release on BMA website).

Window of opportunity here I think.

Any other GPs reading this: Get up and start making noise. Now is not the time to knuckle down and get on with it, or the rug will be pulled from under you. Talk to your patients. Read the bumph from the BMA which will arrive next week.

If not us, then who? If not now, then when?

I don't believe it

2008-05-02T14:10:00.002+01:00

Last year I posted this.

She's back.

I have just had the SELF-SAME CONVERSATION with her!

Thank goodness its Friday.

Hendrick's, Fever-tree tonic and cucumber await...

George Monbiot tells it as it is.

2008-04-29T09:05:00.002+01:00

An excellent article has been written by Mr Monbiot, a Guardian journo who is unhappy with the political direction the NHS is taking.

His article is well written and contains much insight into the current threats to YOUR health service.

Required reading, especially with local elections coming up.

http://www.guardian.co.uk/commentisfree/2008/apr/29/nhs.health

Compliments

2008-04-28T10:43:00.002+01:00

I have just been described as "a lovely bit of stuff" by a female patient*. To my face.

So how should one deal with this sort of thing? Complaints are dealt with in a structured way, utilising our Practice's complaints procedure as a first step. The huge majority are dealt with in this way, insofar as no further action is taken by the complainant. Presumably most are satisfied by the resolution of the problem. Sometimes the complaints are trivial, other times more serious. Some are patently vexatious, though they are few and far between thank goodness. All complaints are dealt with as significant events in our practice, which effectively means we try and learn from them. That sounds rather "cardy" (by which I mean "cardy-wearing, leather elbow patches, touchy-feely") but generally there is something which we could change. At the very least we discuss it (partners, practice manager and if appropriate other staff). All the details are recorded and kept.

I sometimes think, though, that we don't deal with compliments as robustly as we might. I receive compliments fairly often in the form of thanks (for doing my job!). Sometimes, especially around Christmas I receive small gifts, often of the imbibing variety. Soemtimes, I receive letters or cards. I keep the cards. A few years ago I put them in my appraisal folder as I thought they might help show that my relationships with patients contributed to the evidence that the GMC should continue to register me. I no longer do that. I now keep them in a different folder, for my own benefit. I don't look at them often but I know they are there. Perhaps we should be logging all of these episodes as we do with complaints. That seems a little excessive but I suppose it would allow a veriafiable balance against the complaints.

But there is a part of me that feels that doing so might cheapen the intentions behind the gestures.

As for the ribald comment I have just been both the subject and recipient of, well, I take it as its intended and wink.

*Ok, she's 74 and partially sighted...

Tax cuts

2008-04-25T09:24:00.002+01:00

Losing the 10p tax band has hurt my staff. not badly, but all of them.

They have each lost about £15-25 a month (they are all part-time). Those paying pension contributions have seen those drop by about £10 a month as well. None of them will be able to recoup this money as their husbands/partners are all in work as well, so no tax credits.

Thanks Gordon.

Extended hours - some random thoughts

2008-04-24T09:43:00.003+01:00

Still no sign of the specification of the DES to provide this apparently vital service. There has been some interim guidance published (here)by the Department of Health to allow the development of LES's by PCTs and LMCs. I noticed that our illustrious Health Secretary, Postman Pat, is now talking about "Family Doctor Services" rather than "General Practice" and that Laurence Buckman is being described as an Arthur Scargill figure (good for you Laurence). I was also disgusted to hear AJ say that he was pleased that 92% of GPs accepted their proposals, but not surprised. Firstly, 92% didn't, it was 92% of those that voted. I bloody well didn't. And the 92% had little choice, did they Alan? What was the alternative?

Anyway, back to extended hours. I can't see why anyone would want to commit to a system which has yet to be agreed, or at least published, which will result in more work for less money, for minimal benefit for a minimal number of patients.

Some GPs will it seems do anything for money. I fear a lot of GPs will just keep their heads down and get on with it anyway, even if it ends up costing them money. Some I'm sure would argue they can't take the financial hit of not doing it. Although quite how you get your practice finances in to such a state that the loss of £6000 per partner (approximately, maximally and gross) can be so catastrophic is something I struggle with.

But it isn't about the money as far as I'm concerned. Its about the hours. I have a contract. Well, I call it a contract, it can be changed at will by the Government at 3 months notice.

Some extra background about me. I'm a full timer. I work 4 and a half days a week. My half day not infrequently ends up being a "finishing a couple of hours early" day instead. I recently worked out my hours of work for my appraisal. 47 hours a week, in 4.5 days. More than most I suspect. I don't mind my hours. I'm a GP, its what I do. I'm also a married, family man.

The government reckons that 6.5 million people want us to open longer hours, an analysis of a survey which even the most ignorant of people must realise is a bogus extrapolation. For my practice of just under 6000 patients, only 42 people who were surveyed (out of 330, so 13% of those surveyed but only 0.72% (that is, not quite three quarters of one percent) of our entire list) were unhappy with our current hours. 3 felt we didn't open early enough in the mornings. 2 were unhappy that we weren't open long enough at lunchtime, although we don't actually close during the day, unlike many other surgeries. 9 felt we needed to open longer in the evenings. 15 wanted us to open on Saturdays. 4 had what is described as "other reasons", undelineated.

If we were to open for 1.5 hours in an evening and 1.5 hours on a Saturday, that would provide 12 extra appointments in the week. Bear in mind that this would be for routine, pre-booked appointments. Home visits would not be on offer. Emergency care would not be on offer (although quite how we could morally turn away someone who turns up acutely unwell is unclear to me, apparently it is not a major problem from the politicians' point of view). I would be very surprised if that service was utilised fully for some time. Indeed, the people who would eventually make use of the service on the whole are very likely to be the very people who come during the day at the moment. So the people who might "need" (for which read "want") the appointments in the extended hours would be unlikely to be able to access them because they would get filled by other people.

And we are back to square one.

And I don't wish to repeat my divorce experience, thank you very much.

Of more concern to us, in actual fact, was the perception by those surveyed that patients could not prebook appointments. Only 29% of those surveyed thought they could. In actual fact people have been able to prebook for several years. We did have a period of time where we adopted so-called Advanced Access, in other words, day only booking, to reach a target. When it became clear (within a few months) that it wasn't suiting some of our patients we started to allow a limited amount of prebooking. We are trying very hard to advertise the fact that people can. Part of that work is that we have set up our practice website. Registered patients can make appointments and request repeat prescriptions through the website.

We are actually quite pleased. The system has only been up and running for about 4-5 weeks. We already have 71 patients registered to use it. 10 patients have made appointments. We are starting to get repeat script requests through.

So things are improving. I think.

But we have no wish to open longer hours. We don't think that there is actually any demand for it.

Teachers

2008-04-24T09:31:00.002+01:00

The NUT has my support, for what it is worth.

Think about it: a 3 year pay deal which is below inflation (as per RPI, rather than the completely useless CPI) and depends on Government plans for the economy coming to fruition.

The BBC annoyed me this morning (for a change) by comparing the "average teacher's salary" of about £34k with nurses' and police constables' starting salaries, figures which they acquired form that font of all accuracy, the Government. So of course the figures are not comparable. Idiots (and Voltaire had a thing or two to say about idiots...).

The fact that the NUT and its members felt that a strike was needed speaks volumes to me. The first national strike for over 20 years by a teaching union.

(Apologies for the lack of links. Lazy perhaps, but I'm in the middle of surgery. This post is what Neighbour would describe as "housekeeping", to aid in the maintenance of my (in)sanity.)

Bad news

2008-04-22T10:37:00.003+01:00

Sometimes a patient comes along who reminds me why I'm here.

Ettie is a lady of 82 years. She's been widowed for almost a quarter of a century. Apart from high blood pressure and quiescent ischaemic heart disease she is relatively fit and healthy. I've been her GP since I joined the practice in 1999. She only sees other GPs rarely, usually if I am on leave.

But Ettie wasn't well recently. She had what appeared to be a chest infection with some pleurisy. I treated her with antibiotics. She felt better in herself, but the pleurisy didn't settle so she came back to see me a month later. Although her chest was clear I arranged a chest x-ray.

The x-ray showed a shadow in the top of her right lung. It also showed some destruction of two of her ribs, just where she was still getting discomfort. Ettie probably has lung cancer, almost certainly in fact. It would also seem to have spread beyond her chest to her ribs. This is bad news.

I have seen Ettie this morning. I have spoken to her at length about what is going on, what the likely problem is, what will happen next. I have referred her to our excellent local lung cancer rapid assessment clinic.

Ettie is devastated. She is scared. She is sure that this means the end for her. It may well do. But I will be there whatever happens. I will treat whatever symptoms she develops to the best of my ability and will enlist the help of our local palliative care team if I need to (or if Ettie needs me to).

I would prefer not to have to, but I will coordinate her care, to what will hopefully not be the bitter end, but a dignified, peaceful death.

Who better than me, who has known her for so long, who she has a relationship with, who she trusts?

I am her GP.

Enough said.

New practice website

2008-03-04T09:10:00.003Z

Apologies for the lack of posts.

I've been rather busy trying to make some headway against the destruction of General Practice.

Sadly I think that we (the public) will lose our Primary Care service. Even more sadly, many people won't realise that the replacement is less good than the current system until it is too late to go back.

I suspect that within 5 years the current model of partnerships providing continuity of care for patients will be largely defunct, replaced most likely by Polyclinics with some shift-working salaried doctors but mostly with non-medically trained staff such as nurse practitioners and nurses.

On the up-side, we have spangly new practice website at www.manorparksurgery.com

Have a look if you like.

And to the 50-60 or so people (according to site monitor) who view this website a week despite the lack of posts, thanks for keeping an eye out for so long.

Letter to MP

2007-09-25T10:05:00.000+01:00

Peter Holden, GPC negotiator and jobbing GP, recently wrote to his MP regarding the current attack on GPs.

I was so impressed by his letter that I wrote my own MP (David Lepper(lab) in Brighton) and the MP (Norman Baker (lib.dem) in Lewes) in whose constituency my practice lies, using some of his information.

Below is a transcript of my letter.

Perhaps Peter and I can persuade more of you to do the same.

Norman Baker MP

23 East Street

Lewes

East Sussex

BN7 2LJ

Dear Mr Baker

I am a GP and am not one of your constituents, although my practice lies in Polegate. However, I am responsible for the health of approximately 2000 of your constituents. I am however sending a similar letter to David Lepper, the MP in whose constituency I live. I am also a member of the East Sussex Local Medical Committee, representing GPs.

I am heartily fed up with the current vogue in Government to blame GPs for the ills of the NHS. The recent media circus promulgated by the Prime Minister (among others) does nothing to actually alleviate the problems faced in Primary Care today. It serves only to cause a significant increase in the stresses of the job and consequently is directly responsible for the dramatic reduction in morale I see in my colleagues.

There has been a concerted government and probably No. 10 inspired campaign for several months about access to GPs, extended hours opening, and out of hours services. They are 3 different things but the government is trying to coalesce them. Part of the campaign has been to smear GPs by constant reference to their performance related pay earnings which are referred to as net earnings. Such net earnings are not take-home pay but net of practice expenses before tax, national insurance, sick pay insurance and surgery mortgage capital repayments.

At no stage during the current media onslaught against GPs has the government in the shape of No.10, the DoH or ministers contacted the General Practitioners Committee of the BMA - the body with whom the deal was done- about extended hours of service. They have received not one phone call, no letter, no email, no communication about extended hours. None of the negotiating team, nor the chairman of the GPC, Dr Laurence Buckman, has even had any informal approaches concerning extended hours from senior civil servants or ministers in their day to day business, including when paths have crossed. I have that on good authority from Dr Peter Holden of the GPC, one of the original negotiators (one of only 2 of the original team, including Dr Buckman; in contrast the NHSE/DoH team has none of the original team who engaged in negotiations).

Out of hours services (services outside of Mon-Fri 0800-1830)

The continuous and erroneous intimations that somehow GPs are responsible for the level of service provision in the out-of-hours period are nothing short of risible. It is widely ignored by Government spokesmen that responsibility for out-of-hours care has lain squarely with the PCTs since 2004, and not, as is so often stated, with the GPs. The NHSE, Treasury and DoH underestimated the cost and complexity of a service which GPs had provided at an uneconomic cost and a massive personal price since the inception of the NHS in 1948. For years the DoH officials had been denying the GPs assertions about the burden and the costs. For them to subsequently blame us for the inadequacies of a service which they are responsible for commissioning and managing is nonsense. In addition, there are frequent assertions that over 90% of GPs have opted out of providing out-of-hours cover. While in itself, that statement is true, the actuality of the situation is that many GPs still do work out-of-hours, but we have ceased to be the body responsible for the commissioning and running of the services, and so any inadequacies must be laid at the feet of the PCTs and the Department of Health. Their attempts to save money are what has led to the out-of-hours horror stories which occur from time to time, not the lack of GP involvement.

Extended hours is about the provision of NORMAL General Practice into the evenings and weekends. As I am sure you are fully aware modern General Practice requires receptionists, phlebotomists, Health Care assistants, practice nurses, district nurses, pathology services (such as blood testing), access to social services , X-ray facilities and the ability to discuss findings with a consultant. With the new contract we took on 52.5 hours of opening based on 37.5 hours of staffing and funded the difference from our "over-performance". PCTs have always been free to commission extended hours and some GPs may be prepared to provide it if commissioned at a commercially acceptable price. We are not prepared to simply be a "GP with a prescription pad" working alone, with patients having to return to complete the consultation, just so that the government can have a soundbite. I have asked my staff if they would (for pay obviously) be prepared to work extended hours and to a woman they said not at any price. In any event, in order not to breach the EWTD, some of us would have to take on and train yet more staff, something which would take considerable time and resource.

GPs are tired of the "banks and supermarkets opening argument". The longer banks and supermarkets open, the greater their profits. What is more, it takes at least 5 years to train any of my professional staff to work independently and up to a year for my non-professional staff. Shelf stackers and checkout operatives take a matter of weeks to train and the operation of the store does not require the continuous shop floor presence of the board of directors. The only people banks employ are sales people and money counters, who again take little real training. Indeed medicine, dentistry and veterinary medicine are the only professions where nothing can happen without the actual presence of the most highly skilled and trained individual member of the team working on the shop floor or immediately available to do so.

Access

This is about the ease with which patients can make and obtain an appointment. A national survey costing £11 million has been undertaken recently and there is a satisfaction rate of 84% of patients with the current access arrangements. Analysis of this survey results in politically difficult messages. Most of the 16% of patients expressing dissatisfaction are registered with practices of a particular type, in particular geographical locations, serving a particular type of population, with services delivered by a doctor qualified from particular parts of the world. I know of many leading edge practices where they refuse to try to meet the 48 hour target (and forgo the resources) where the urgent and emergent are dealt with today but a routine appointment is 15-17 working days away.

Doctors have always struggled with their appointments systems. We are now on the 5th version since I joined the practice in 1999 and much of the problem concerns workforce resources and increasingly surgery space! The de facto moratorium on practice premises funding (unless you are in a Labour area LIFT scheme) means that we cannot increase our staffing as we are hot-desking already! We have always seen anyone with a clinical priority the same day and a clinical emergency on an immediate basis. Mr Blair's interference over the 48 hour access target (which we by and large meet) has meant that we cannot forward book significant chunks of the appointment book. I DO recognise the problems which working people, especially those who commute have in gaining access, but they are the very same people who do not want taxes to rise! Of course I could operate (and actually would take pride in) an 0700-2200 ROUTINE service 6 days per week (provided nobody was required to work compulsorily more than a 40 hour working week) but that is neither affordable nor cost effective. Even if we have the resources the staffing is impossible on current workforce Levels (GPs, never mind other staff).

The most recent straw contributing to the creaking in the spine of British General Practice has been the appointment of Ara Darzi to review General Practice. What does a tertiary world class surgeon know about general practice or primary care?

This crude attempt to blacken GPs for the political prize of 16 hours per day of routine general practice, even if does mean a return to paid slavery for GPs personally, is despicable. Irrespective of the financial facts, the government have conveniently forgotten the long term health gains already accruing from that performance related practice resource deal - the Quality and Outcomes framework. Doing this by means of fomenting public envy and disapproval of our earnings is beneath contempt and is hypocritical. Ministers in addition conveniently omit the facts that GPs still have to provide a service for a 40% longer working week than the norm. GPs still exceed the EWTD. 40% of GP income is performance related pay. GPs are stunning value for money. It is fascinating to note that the new accession states in the Baltic have adopted the British primary care system because of its cost effectiveness.

The new GP contract was negotiated and agreed with the knowledge, influence and intervention of No.10, HM Treasury as well as all 4 Departments of Health. It was further endorsed by the independent Doctors and Dentists Pay Review Body whose recommendation was not amended by the Prime Minister or the Chancellor at the time and they did not see fit to interfere with its findings! Gordon Brown and Tony Blair therefore had at least two opportunities to veto this deal if they felt that it had been too generous. The GP pay rise was deliberately substantial in return for substantial extra work and to correct the massive workforce crisis in General Practice. It was designed to correct 15 years of pay drift from repeated interference with DDRB reports. Remember that GPs were only required by Ken Clarke's contract to do 26 hours over 42 weeks per annum. You now get 52.5 hours of responsibility a week, with an actual average of 44. The fact that out of hours was priced by the independent DDRB as late as 1997 at only a few thousand pounds meant that the loss of it could only cost us a few thousand pounds.

You need to know that the massive relentless adverse and unfair media onslaught of the past few months against GPs has demoralised them hugely. Causing this much ill-feeling in GPs will damage the NHS because of the corrosive effect it has on morale. We have a massive GP retirement bulge looming in the next few years and the UK needs as many GPs as it can find. The government assertions border on lies and they are distorting the truth in such a manner that if I indulged in a likewise fashion in my practice I would be struck off.

I hope that this information helps to inform debate and I am happy to elaborate further, or direct you to other colleagues representing GPs if you wish. I do not wish to receive a reply from the Minister, as it will answer none of my points or concerns.

Yours sincerely

Russell Brown MB ChB

Go on. You know you want to.

Circituitous conversations

2007-08-07T10:55:00.001+01:00

"Doctor, I've got this very itchy rash on my arms, look! It appeared over night!"

"Oh yes, those are bites of some sort."

"No they're not, I haven't been bitten."

"Yes, they are. I'll give you some antihistamines to try."

"They're not bites you know..."

"Ok, what do you think they might be?"

"You're the doctor, how should I know?"

"Fair enough. I think they're bites."

"No they're not."

"Try the tablets and see how you go."

That was 3 days ago.

This morning:

"Doctor, that rash on my arms is better, look!"

"Oh yes. Good, glad the tablets helped. Anything else?"

"What do you think it was?"

(Sighs) "Insect bites."

"No they're not..."

Thank you Andrew O'Hagan

2007-05-15T10:05:00.000+01:00

I tend not to read newspapers. I don't have time.

But I do browse their websites from time to time, especially when health stories are prominent in the news.

An article in today's Telegraph (or rather on its website) has for once made me something other than angry.

I don't know who Andrew O'Hagan is, or what his usual political "colour" might be. But his comments about the NHS were an eloquent testimony to what I suspect is the view of most health professionals, whether medics or not.

So thank you Mr O'Hagan. Your concerns about political interference are recognised and shared, and your good wishes are appreciated.

Been a while...

2007-04-27T08:45:00.000+01:00

Morning all.

Not blogged for a month or so. Been rather busy, what with the end of the financial year and a new baby (who is coming along nicely thank you).

So this is just to say I'm still alive (if anyone was wondering) as sitemeter tells me I have about 140 visits a week, even if I don't post (which is nice, thank you!)

Once I'm getting abit more sleep, I'll probably start getting cross again, so keep an eye out...

Kind of puts it in perspective...

2007-03-28T18:07:00.000+01:00

So, GPs are overpaid according to Patsy, right?

Loads of stuff in the news over the last six months about it.

Look at this.

Says it all really.

Bastards...

GP OOH

2007-03-14T11:10:00.000Z

Well, the newish system of providing out-of-hours (OOH) care hasn't benefited anyone except doctors.

Could have told you that...

The BBC this morning reported on the Parliamentary Select Committee's report on the rehash of OOH care. Apparently it is "shambolic".

What a surprise.

Well, we did tell them that it would be expensive. We did point out that market forces would take over.

But I was cross when I heard some MP from the Committee (and I'm afraid I'm not sure who he was) say on air that GP's were "Laughing all the way to the bank".

WHAT?! We give up 6% of our budget to opt out of OOH care provision, and we're laughing all the way to the bank? How do work that out, idiot?

Despite the fact that the BBC were quite clear that the responsibility now rests with PCTs, that one comment at the end of the report on the Today program once again tried to make it seem as though we are money grabbing unscrupulous shysters.

Well, shame on you in Westminster. Get your own house in order before casting aspersions. And put the blame where it lies: on the Department of Health and its Secretary of State.

And in further news...

2007-01-29T12:58:00.000Z

Patients will be able to boycott opt out of the uploading of their medical records.

Report in the Register here.

Well, that is a result.

The Information Commissioner's report can be found here. Astonishingly for a governmental report, it is only 4 pages long.

I especially like the following excerpt, with my own highlighting:

NHS Connecting for Health has confirmed that people living in areas
introducing Summary Care Records will be contacted before any of their
medical records are uploaded on to the NHS Care Record Service. They will be given information about their options to limit the future scope of the
information on the Summary Care Record or the option not to have one at all and they will also be given the opportunity to make arrangements to view their information before it is uploaded. They will have a specified period before
their information is uploaded to consider their options.

The initial upload will take place without explicit consent on the specified date unless you choose to utilise one of the options mentioned above. Explicit consent is only one of the conditions for processing sensitive personal data referred to in schedule three of the Data Protection Act 1998 and NHS
Connecting for Health are confident they are able to meet the requirements of
one of the other conditions.

Once the basic health information referred to above is uploaded on to the
NHS Summary Care Record:
• you will be able to choose to remove some or even all of the
information initially uploaded
• you will be able to keep the uploaded information but make the
Summary Care Record invisible.

Any further information will not be added to your Summary Care Record
unless you have agreed to it in discussion with your GP. The
Commissioner understands that these types of discussions will take place
at the next consultation you have with your GP following the initial upload.

Later on, you will have another choice. Instead of the whole record, you
will be able to choose to prevent specific information from being visible
without your consent by utilising what will be called a ‘sealed envelope’

Please note the highlighted bits. If you are in one of the pilot areas and you share my concerns about what might be termed information governance I suggest you make use of these options. As far as I am aware, I will not be in an area of "early adoption". But they can't have my info if I am.

Thank you to the BMA who were lobbying hard behind the scenes to get this sorted. Your efforts are, as always, appreciated.

Sack Patsy

2007-01-29T08:35:00.000Z

There is a petition here to urge the Prime Minister to get rid of Patsy.

I urge you to read and consider whether to sign (I have).

My only slight concern is who would replace her...

(With thanks to Dr Ben Taylor for starting the petition, and Dr John Crippen for bringing it to my attention.)

Its all our fault (again)

2007-01-19T10:15:00.000Z

Patsy is at it again.

Apparently, my pay should have been capped. I earn too much.

Given how the GP contract was negotiated, that of course implies that the quality of care which I am providing is of an excessively high quality. I will not however desist from providing good care. Its what I was doing before, and I see no reason why I should stop.

Ms Hewitt said: "I think if we anticipated this business of GPs taking a higher share of income in profits we would have wanted to do something to try to ensure that the ratio of profits to the total income stayed the same and therefore more money was invested in even better services for patients."

Right. So, as a self-employed, independent contractor, I may not take as much profit as I wish from my business. I have to reinvest the money into services which are otherwise inadequately funded, I have to effectively bung the DoH a sub.

"Now it is quite true that neither the government or BMA anticipated how much GPs would do in response to performance-related pay."

Well, not quite, Patsy. If you check the memo's from your negotiating team, you'll see that Dr Fradd et al did warn you that we would strive to maximise profits and do as well as we could. We are business people you see. Our business is health and illness management. That's what we do.

And then there's someone called Joyce Robbins, from Patient Concern:

However, Joyce Robins, from the health watchdog Patient Concern, told BBC News that the new contract did not represent "value for money".
"I do think that the doctors' unions took the government to the cleaners with that contract because, I mean, nobody's mentioned that in fact they do a great deal less work," she said.
"They no longer do evenings, no night work, weekend work - this has all got to be paid for somewhere else.
"And yet their money has gone up quite enormously.
"In fact, I understand that far more GPs are actually retiring early because their pensions have gone up so much that they can afford to do that."

Well, she's obviously speaking from a position of knowledge about these issues then, isn't she?

Ms Robbins, we still work about 50 hours a week, we are doing more and more during the day, and we didn't get paid for doing out of hours work before the new contract, indeed we used to pay for the privilege of working, and since the advent of nGMS, the government take 6% of our core budget off us if we opt OUT of providing out of hours services.

(Quite who Patient Concern are, I'm not sure. According to their site, they've been going for 6-7 years, but I've not heard of them before now. I'm also not sure that their agenda is as transparent as they would wish. Certainly to my mind some of their "Campaigns" are a little naive, though I agree with the principals behind some of them.)

Anyway.

If the Government aren't happy, they should try to renegotiate the contract with our representatives. All this spin is not helpful. Patients (and voters, lest we forget) don't believe it anyway, from the comments I've been getting from my patients.

In the mean time, I will continue to maximise my income to the best of my ability by caring for my patients to the best of my ability.

If its all the same to you, Patsy...

Safe Arrival

2007-01-07T15:41:00.000Z

I am delighted to announce the safe arival of our new daughter Willow Rose on December 28th, at 0742, born at home (about which more in a future post), weighing in at 7lb 10oz.

My wife is doing well, so is Willow and we're smitten.

Patsy wishes you a merry Christmas

2006-12-22T09:45:00.000Z

I have no idea who to credit for creating this, but thanks to Dr Evans on DNUK for posting a link for me.

http://www.elfyourself.com/?userid=ef6da7db05b5fd4e056385aG06122200

Wonderful!

Coincidence

2006-12-15T10:51:00.000Z

Ok, I said I'd take a break, but nothing's happened yet, so here's another one for you.

NHS deficit: Approx £500 million

Amount spent on management consultants in the NHS last year: Approx £500 million

For fuck's sake Patsy, do the bloody sums.

In the Guardian...

Last post for a bit

2006-12-14T11:50:00.000Z

Lord Warner is going. Will he be missed?

Lets hope he gets a good pension for his stirling work totally bollixing up the NHS finances.

The BMA is seeking a Judicial Review regarding the legality of the governments retrospective slash-and-burn of our pensions. How the hell they think they can get away with a gross breach of contract I don't know. Idiots...

As to why this is the last post for a bit:

Mrs B will imminently be having the baby, any time in the next 1-3 weeks. So I might be a bit busy...

(I will however post an announcement when I get chance!)

So, dear readers, take care and have a good Christmas or holiday-season-of-your-choice.

Pension Cap

2006-12-07T18:22:00.000Z

I don't have full details yet, but it appears that bastard Lord Warner has written to the GPC to say that he will cap GP pensions.

Here is the text from a BMA press release:

Immediate release : Thursday, 7 December 2006

BMA to challenge the imposed cap on GPs’ pensions

Dr Hamish Meldrum, chairman of the BMA’s GPs Committee, denounced Lord
Warner’s decision to cap GP pensions as reneging on a contract agreement and
denying doctors the pensions they have already paid for.

“Most GPs are self-employed. They pay both the employers’ and the employees’
contributions into the NHS Pension Scheme. The pensions they have accrued
are in fact delayed pay resulting from a contract agreed by the government
with the profession. For Lord Warner to say they cannot have the pension
they have earned and paid for is a denial of their contractual rights. We
will be challenging his decision” said Dr Meldrum.

While family doctors have seen a substantial rise in income under the new
contract, the BMA believes the earning figures announced last week by the
government are wrong. Dr Meldrum said: “Because of a significant error, the
quoted figures are pitched at too high a level. We understand the 14%
employers’ pension contribution has been mistakenly included in the income
figures. The error means the average GP pay for 2004-05 is well below
£100,000, not the six figure income as reported. It also means the
percentage rise in pay is substantially below the 32% claimed by the
government.” Clarification of the error is being sought by the BMA.

Dr Meldrum said: “Lord Warner’s offer of a 48% rise in the pension
dynamising factor* over five years may seem superficially generous but it is
not the deal we negotiated and will seriously disadvantage GPs nearing
retirement and those who have recently retired. Those doctors retired
believing in good faith that they would receive the pensions they had earned
and paid for. Moreover, we believe the timing of the announcement is
premature, is based on estimated figures of doubtful accuracy and,
therefore, we do not accept the assertions that honouring this deal would
take money away from patient services.

“The government’s decision is a betrayal of good faith and is depriving
doctors of a pension we believe they have a legal right to receive.”

The BMA’s GPs Committee will now seek further legal advice on mounting a
challenge to Lord Warner’s announcements on capping of pensions.

Ends

This has got to be a breach of contract, never mind comp[l;etely removing any chance of healing the rift between the politicos and medics.

I will await developments with interest...

Follow up to "Spinal Privacy"

2006-12-04T09:00:00.000Z

There have been further developments in the matter of Spine vs Everyone else.

Clarification has been issued to those who sent in coupons expressing a desire not to be included, here. Apparently the Department of Health "does not believe that processing their information in this way is a genuine reason linked to substantial and unwarranted distress." But I thought that distress was in the eye of the sufferer? Obviously only if the DoH thinks so to.

As a GP I'm now damned if I do, and damned if I don't.

If I do "allow" (and it doesn't look like I'll have any choice in the matter) the uploading of people's information, I could be held accountable for the breach in the confidentiality. In other words, I (as data controller for my practice) will be in Breach of the Data Protection Act and I suppose could be legitimately complained about to the GMC.

If I don't, I'll have everyone from the Health Minister (so-called) down trying to bend me over my desk...

This is also picked up today in the Torygraph.

I suspect that Tony and cronies will continue to ride roughshod over everyone, until either someone hacks the system or the opposition get of their arse and cause a fuss.

Watch this space...

The BritMeds 2006 (1)

2006-11-27T16:17:00.000Z

John Crippen has started up a weekly collection of the best of British medical blogs.

Yours truly is mentioned!

Check it out...

Over-performance

2006-11-23T16:34:00.000Z

Oh dear, oh dear, oh dear...

Hospitals in the South East are being told to delay routine patient appointments for eight weeks, otherwise they will not be paid for them.

Here's the link.

So, fail to achieve government targets and be damned.

Exceed them and be financially crippled (albeit temporarily).

On the other hand, I can see the Strategic Health Authority's point of view: the PCTs have to contract for an amount of "activity" and then pay for anything which exceeds that anyway (under Payment By Results, the national tariff). There's a big deficit heading Patsy's way, and of course she said that she'd take personal responsibility for achieving financial balance. Lets hope she isn't allowed to dodge it.

Although I personally thought that a bit of an oxymoron, a cabinet minister taking personal responsibility for their area of responsibility...

What about the patients? The only people who are talking about them are the consultants. But what do doctors know about health care, hmmm?

And there was me thinking the political silly season had passed already.

Redundant advertising

2006-11-20T11:40:00.000Z

I read this story a couple of weeks ago. It was also posted in various other places, including the BBC, most of the national press and other media. I didn't comment on it at the time because I thought it pathognomic of the difficulties the NHS is facing, and that further comment was not necessary.

But now we have this.

So lets compare these two stories, shall we?

On the one hand, the NHS workforce has reduced in the last year by about 20,000. There are an indeterminant number of compulsory redundancies, which the Government says are just under a thousand. Yeah, right...

On the other hand, hospitals will now be able to advertise their services. who to? Not to patients, oh no. To doctors. Yes to GPs like me.

But hold on a moment. Don't I already refer to hospitals? Am I not already obliged to refer to someone I at least know of and trust to do the right thing by my patients? To quote paragraph 55 of Good Medical Practice:

Referral involves transferring some or all of the responsibility for the patient's care, usually temporarily and for a particular purpose, such as additional investigation, care or treatment that is outside your competence. You must be satisfied that any healthcare professional to whom you refer a patient is accountable to a statutory regulatory body or employed within a managed environment. If they are not, the transfer of care will be regarded as delegation, not referral. This means you remain responsible for the overall management of the patient, and accountable for your decision to delegate.

My highlighting, by the way.

But the Government is already trying to force me to abrogate my responsibility for ensuring that I know what service my patients can expect with Choose and Book: I can't refer to a named consultant, if I can refer at all!

But back to the point at hand...

So, lots of people out of work (however you want to define it), so cutting costs.

The money saved can now be invested in advertising a hospital's services to the GPs who are already referring to it, likely involving the recruitment of advertising and marketing managers. Of course that means less money for patient care. I suppose the idea is that advertising will increase the number of "service users", thus increasing income under the "Payment by Results" tariff.

What kind of buggered up system is this? That money should go towards patient care.

I'm 36. I can't wait to retire.

Five weeks to go...

2006-11-15T16:56:00.000Z

There will soon be the patter of tiny feet in Chez Brown.

Mrs B is expanding on a daily basis, I'm sure she will explode soon. The baby likes Strictly Come Dancing, we can tell because she has a dance when its on. My other 2 kids are excited, we have arranged for them to be the first to meet their sibling (after us of course).

I can't wait...

Mind you, we're only just getting organised with baby-grows, nappies, clothes, etc. We were much better organised with our wedding last year at Newick Park.

And I've still got loads of painting to do :-(

I still can't wait to meet the thing that's been booting me in the ear while I'm reading or singing to it.

Of course, we still have to decide on a name...

Spinal Privacy

2006-11-07T09:39:00.000Z

There is an interesting article in the Guardian today. I suggest you read it. It refers to the security (or otherwise) of the NHS spine, the computer system which is being built to house the medical records of all UK residents.
And therein lies the problem.

Given the Governments track-record on IT projects, given the fact that you can either have a functional or secure system (but for a project this size probably not both) the question you have to ask is:

"Do I really want my personal and confidential details available to any of the 250,000 staff in the NHS who have currently been given smart cards? Oh, and the police, security services, and anyone else who might have the technical skills to hack in or money to buy information from the spine?"

Speaking as a medical professional, I don't.

The Governments constant mantra of reassurance and complacent murmurings that security will be adequate completely fail to make me feel better about the scheme.

For a start, you won't have a choice about whether to be involved or not unless you opt out right at the beginning. Once your info is on the spine, its there in perpetuity (and lets not even start talking about civil liberties and the Data Protection Act).

Sadly, this scheme is just another manifestation of the current Government's inclinations to control us all. There is no safeguard with this. If it is "in the public interest" your records will be viewable by whomsoever the authorities deem. Right now, if the police want me to show them your records, they need to either provide me with your consent (in writing, and even then I usually check with people to make sure they understand what it is they've consented to) or ask a Judge to issue a Court Order (and although it has never happened, I would probably then wish to speak to the Judge myself anyway to clarify what exactly they want to see: it would be most unusual for someone's appendectomy in 1954 to be of any relevance to anything at all, really).

The Guardian also provide a page (here) with a draft letter to the Secretary of State for Health instructing that you don't want your data added to the spine. I will be writing.

The decision whether you should as well is not one I can make for you. But consider carefully before imagining that New Labour will treat your most intimate personal details with the dignity they deserve.

Disclosure statement

2006-11-02T15:45:00.000Z

After the nonsense about PayPerPost, which although I am not signed up to is still in my view a bloody good idea, I thought a disclosure might be a reasonable idea. This is available for viewing here.

It is also replicated below.

This policy is valid from 02 November 2006

This blog is a personal blog written and edited by me. For questions about this blog, please contact drbrown at gmail dot com.

This blog does not accept any form of advertising, sponsorship, or paid insertions. We write for our own purposes. However, we may be influenced by our background, occupation, religion, political affiliation or experience.

The owner(s) of this blog will never receive compensation in any way from this blog.

The owner(s) of this blog is not compensated to provide opinion on products, services, websites and various other topics. The views and opinions expressed on this blog are purely the blog owners. If we claim or appear to be experts on a certain topic or product or service area, we will only endorse products or services that we believe, based on our expertise, are worthy of such endorsement. Any product claim, statistic, quote or other representation about a product or service should be verified with the manufacturer or provider.

This blog does contain content which might present a conflict of interest. This content will always be identified.

To get your own policy, go to http://www.disclosurepolicy.org

Trust me, I'm a Doctor

2006-11-01T12:22:00.000Z

Well, it seems people do.

In that case, why don't the politicians listen to us?

Because they want their reforms to go down as an historical achievement.

Great. Dismantling the NHS will be such an achievement, won't it?

I'm a bit busy today, but for invective about politicians generally and the health service in particular, try clicking on some of the links listed over there ->

Enjoy!

The cost of litigiation in the NHS

2006-10-18T11:09:00.000+01:00

Whilst indulging in some forum posting on DNUK (no you can't have a link, unless you're a registered doctor in the UK) I came across a link to a question posed in the Lords yesterday (Hansard).

NHS: Compensation and Legal Costs
Lord Steinberg asked Her Majesty's Government:
Whether the cost to the National Health Service of £175 million for compensation and legal costs as stated by the National Health Service Litigation Authority includes all outstanding cases to the end of the past financial year. [HL7454]
The Minister of State, Department of Health (Lord Warner): The NHS Litigation Authority 2005-06 accounts report expenditure of £591,586,000 on clinical and non-clinical negligence claims in the past financial year. The accounts include a provision, as at 31 March 2006, of £8,344,980,000 for all outstanding cases including an estimate for incidents that have occurred but not been reported.

Yes, you read that right.

The government have put aside £8.344 billion pounds to cover negligence claims against the NHS, both clinical and non-clinical. Doesn't say how much is put aside for non-clinical negligence though. Nor does it define what non-clinical negligence is. (Anyone fancy a Freedom of Information request there?)

Eight. Billion. Quid.

One thing that does surprise me is that no further questions were asked. Even in the current climate of rather defensive medicine (though not as bad as the USA) this figure is staggering. To put it in perspective, that would be a year's income for over 330,000 new police officers.

Yet so far, the Government (Lawd bless 'em!) have spent over £20 billion on a computer system which isn't fit for purpose and probably won't be.

God help us all...

Listening habits: the drive to work

2006-10-18T09:17:00.000+01:00

Decisions, decisions...

Options:

CD. Good music (IMHO), I can sing along without discomforting anyone else (believe me, with my voice that's important) BUT I tend to play it too loud and end up with tinnitus byt the time I get to work, I don't hear the news before work.
Radio 1. I'm sorry, but Chris Moyles is just a big fat git who lots of teenagers finds funny. The music is at best variable, and most of what I get is actually inane drivle interspersed with occasional jingles, with the odd track of music thrown in.
Radio 2. Wogan. Music from elevators, humour from the 1970's but without the slapstick.
Radio 4. The Today show. I get the news and weather. The 0810 interview is sometimes ok, but generally just gets me angry with the vagaries and downright bastard lies from politicians (of all colours).
Southern FM. Really irritating adverts, not much music (and the same stuff over and over and over...), chirpy presenters (far too bright, eff off you bastards, its first thing in the morning), traffic reports every 20 minutes (but they make you listen to the bloody adverts first).
Southern Counties Radio. Decent traffic reports which have the advantage of being RDS, but OH MY GOD the shows are soooooooo boring I'm in danger of falling asleep at the wheel...

What to do, what to do...

Forms of nursing

2006-10-11T10:15:00.000+01:00

It seems a week can't go by without yet another form appearing that I am supposed to use to refer patients to a particular service. I totted up how many different referal forms I have in my box file the other day: 22 . Yes, twenty-two different forms to refer patients to different NHS departments. Alot of these forms have similar information requirements: they all need demographical details of course, as well as a few details of the presenting complaint leading to the referal. Some of these forms we have managed to get in electronic form from the originator, which we can then adapt so our clinical software can automatically fill out at least some of it. Of course, we need to ensure that the forms' authors are happy with it before we can start using them. Others, we can't, for one reason or another.

A particular bug-bear I have is the fact that we now have to communicate with the District Nursing team by writing them a note on a specific form and faxing it to their offices. They have been expecting this for the last 2 years or so, ever since they were reorganised so that they were no longer attached to a specific surgery, but in a "locality". Before this, if Mabel developed a leg ulcer, we would speak to the District Nursing Sister when she came to the surgery (usually a daily occurence to collect supplies). She would check to make sure there were no matters to be discussed before she left. In addition we had a weekly Primary Health Care Team meeting in the surgery.

Not any more. Oh no.

Now face-to-face communication is non-existant. I don't know most of the nurses who visit our surgery to run clinics. You can phone, but its just an answer phone. And if you do leave a message, you get a message back saying that they need a referal form. So you send the form, they see the patient (one assumes).

Of course, we don't get one back when they discharge patients from their case load. Neither do they keep their records anywhere near ours: they have their own folders, kept at the patient's house, which are later archived somewhere mysterious, never to be seen again.

And I haven't even mentioned the referal/discharge criteria which are being introduced by the management teams.

I'll give you 3 guesses how much consultation there has been with other ~~professionals~~ stakeholders as to whether this is necessary, never mind a good idea. And the first 2 guesses don't count...

Where the driving force behind these changes comes from is a matter of further irritation. Yep, the good old Department of Health. Bless 'em. Except of course that the decisions where made locally, not centrally. Except of course that the decisions were basically forced upon the local health economy by financial decisions further up the food chain. Decisions made in London. See how that links up? Clever, innit?

I could go into why these changes are apparently "good for patients". All I know is that the patients complain to me that they don't see the same nurse more than two or three times. The nurses are getting more and more officious (a sure sign to my mind of the stresses they are under and their levels of dissatisfaction with the way they are working). Inevitably, there are the usual recruitment freezes periodically (though, to be fair, recently there seems to have been an influx of community nurses, less well qualified than District Nurses, though forced to do the same job).

Gets right on my wick.

Bring on Practice Based Commissioning. Care to hazard a guess at one thing we're contemplating taking over from the PCT?

Dr Rant

2006-10-10T09:51:00.000+01:00

Oh my goodness.

Please please read this blog. (Click on thread title, it links to the Dr Rant blog.)

It is so right.

If I had more time, I would tell you more, but I haven't.

Go read it.

And then laugh.

And then wonder if you should actually be crying instead...

Entrepreneurs

2006-09-21T14:40:00.000+01:00

My mate Pete has himself a new job as Director of Software Development for PayPerPost.com.

I worry about Pete: he's living several thousand miles away and can't buy me beer anymore.

So I checked out the PayPerPost website at http://payperpost.com/ and they seem to be a very interesting company, just the sort of thing that will help Pete keep his mojo going.

It seems a very sensible way for people to do business, you sign up and get paid by companies who want to advertise on blogs by writing posts about the subject they ask of you.

As Pete says in his blog:
"...despite what some would have you think, blogs are not journalism. Blogs are personal, and PayPerPost's model is a very real financial enabler for a huge portion of the Blogosphere; the single-mom trying to raise a small family, the student trying to make ends meet, the video game junkie looking for a means to fund his ever growing game collection. In fact, if you're human and have a blog, PayPerPost probably has something you can write about for cold, hard cash."

So good luck Pete, and good luck PayPerPost. More power to you...

Waste in the NHS

2006-09-19T09:12:00.000+01:00

I've come across two posts on blogs which I enjoy. I commend both to you if you are curious as to why people like me think New Labour are full of shit when it comes to public services, being more concerned with their historical legacy than actually providing good services.

The first is an example of how pointless some of the exercises which take place in the NHS really are, from the estimable Dr John Crippen at NHS Blog Doctor, and is basically "How to have a crap, a user manual".

I kid you not.

The second is from Shiny Happy Person at Trick-cycling for Beginners. SHP describes the waste that is rampant in the NHS using a specific example.

Well, I say specific. This sort of thing goes on all the time.

I shall refrain from mentioning what others think of the way the Government spends billions on while hospitals and PCTs struggle to make ends meet.

Up the Revolution (and here's looking forward to the next election)!

Its all back to front...

2006-09-11T12:49:00.000+01:00

A busy Monday morning today, as you might expect.

One of my nurses gave a print out of an email a friend sent her which she thought might tickle me. I assume its one of those things that goes round the internet every so often like a cold, which everyone in the wolrd gets, only to see it again a few years later. This one was new to me.

She was right about it tickling me (actually I snorted a half-chewed plum all over my keyboard), so here it is for your delight and delectation:

_______________________________________________________________

"You should start out dead and get it out of the way.

That way, you wake up in a retirement home feeling gradually better every day.

You get kicked out eventually for being too healthy. You go and collect your pension, then when you start work after a decade or two you get given a gold watch on your first day.

You work for 40 years until you're young enough to enjoy your retirement.

You drink alcohol, smoke, party and are generally promiscuous and you get ready for school.

You eventually become a kid, you play, you have no responsibilities, you become a baby and then...

You spend the last 9 months of your life floating peacefully in luxurious, spa-like conditions: central heating, room service, larger living space every day.

And then, you finish off as an orgasm."

_______________________________________________________________

Wonderful!

I like my job

2006-09-04T10:27:00.000+01:00

Well, I've had a week off but today I'm back at work and running late already...

It seems the more things change the more things stay the same: same old faces, same old problems. A bit like a favorite old jumper.

My most recent patient (whom I shall call Daphne, as that is of course not her name) has been suffering from anxiety. Doesn't sound too major, does it?

Except that Daphne has had symptoms for years. It stops her going out, predominantly because she gets diarrhoea whenever she gets anxious. It makes her go home early for the same reason. She avoids doing things she used to enjoy just in case she gets diarrhoea while she's out. She suffers palpitations on a regular basis, which make her feel even more anxious in case there is something wrong with her heart. Her appetite could best be described as "variable", which becomes a problem when you realise that she hovers at a BMI of 19-20 (so any weight loss makes her underweight, although there are of course arguments about the validity of Body Mass Index as an appropriate measure of health in isolation). She smoked to help herself cope. She used to argue frequently with her husband and felt abandoned by her friends. She couldn't sleep because she kept mulling things over in her mind.

Three months ago, Daphne came to see me about her tummy problems. It had taken her a long time to summon up the courage to do that. After all, she said, I'm a very busy man. I don't need frauds like her taking up my time when there are people who are actually poorly who need me, rather than just people like her, "being stupid". She was sure that it was "just nerves". She asked why she couldn't just pull herself together. She asked me if there was anything I could give her and then followed that question immediately with a statement that there was nothing that could be done for her as she was just a pathetic waste of space. She didn't want a sedative or an antidepressant or anything like that, apparently.

I felt very sorry for her. Given she had said she didn't want anything which would actually help, I explained that she might like to reconsider, but that in the mean time we could try an antispasmodic.

She came back to see me about a month ago. The antispasmodic hadn't worked. She was now prepared to try something else.

Anxious people often have poor self-esteem. They sometimes don't come to see me when they should because of this. Which is a shame. Sometimes (as with Daphne) they come with something else, an excuse if you like.

Anxiety is usually very treatable. There are a variety of non-pharmacological therapies available, some with an evidence base, some without. However, in todays NHS, certainly where I work (at the moment, but there may be a post on this at a later date), the only readily available therapy involves pills on prescription from me.

Mind you, that isn't necessarily a bad thing.

Daphne, for example, left me after about 25 minutes with a prescription for a few diazepam and a month's supply of citalopram. I asked her to come back after a fortnight to see how she was getting on. When she came back, things weren't quite so bad, but she still couldn't go out for fear of an episode of diarrhoea. She was sleeping better though. Oh, and she'd stopped smoking.

She came back to see me this morning, after a further two weeks.

She tells me she hasn't felt so good in years. The diarrhoea has gone. She went into the local shopping centre early in the morning with her husband over the weekend for the first time in several years and apparently burst into tears because she was so relaxed. She feels normal again. Her husband says she is the calmest he's seen her in years, much more like the woman he married 40-odd years ago. She had a new hair-do. She is also wearing a new smile.

She's not there yet. But she is getting there.

I like my job.

The Now Show

2006-08-03T14:15:00.000+01:00

A topical news show, broadcast on Friday evenings at 1830 UK time.

Worth it for Mitch Benn alone.

And now a podcast!

Give it a rest Tony

2006-08-03T14:04:00.000+01:00

For goodness sake.

Its dead.

Leave it alone man.

You won't even be in the country then, you'll be on some lecture tour in the US.

Link to story.

Nursery rhymes

2006-08-02T10:13:00.000+01:00

Let me ask you a question: Do you prefer "Baa Baa Black Sheep" or "The Ugly Duckling"?

Those of you who know me will remember (I'm sure) that I am noted for my melodious tones, although generally not the ones emanating from my larynx. I have a repetoire of nursery rhymes inherited from my family which I have sung to my other children to soothe them (with varying success).

Mrs B is 20 weeks now. Bumpy Brown is kicking for England. So I've started talking and singing to it. Rather bizarely, it seems to ignore Baa Baa Black Sheep, Jack and Jill or Half a Pound of Tuppeny Rice, whilst consistently becoming still if I sing The Ugly Duckling or Twinkle Twinkle Little Star, only to get going again once I've stopped (after a suitable pause for reflection and appreciation of its father's performances).

Hopefully, the little mite will recognise my voice after its been born. At 20 weeks gestation, it can already hear things in the womb. My singing will be audible to it, and although the hard consonant noises won't get through the softer vowel sounds and general tone will. Given it already seems to settle with certain songs, I suppose its possible we already have a baby with favorite nursery rhymes.

The alternative is that Bumpy is quivering in the corner or the uterus with it's fingers in it's ears, hoping the caterwauling will stop soon...

Orwell (can hopefully now) RIP

2006-07-12T12:03:00.000+01:00

I've spoken about ID cards before.

There were various news articles yesterday (here and here).

The Register's John Lettice reports further today: John Reid, who I have always considered to be a ignorant prat of the highest order (and you know what they say: "Jack of all trades, master of none"), may actually be doing something sensible and kicking this riduclous Big Brother idea into touch (in effect if not officially).

This is most out of character for him. I can only assume he is trying to keep damage to a minimum...

Anyway, labour goons notwithstanding, thank goodness this form of identity management seems to be going away...

Your right foot

2006-07-12T11:08:00.000+01:00

This is so funny that it will boggle your mind. And you will keep trying at least 50 more times to see if you can outsmart your foot, but you can't.

1. While sitting at your desk, lift your right foot off the floor
and make clockwise circles.

2. Now, while doing this, draw the number "6" in the air with your right hand.

Your foot will change direction.

And there's nothing you can do about it!

Lack of space

2006-07-06T15:22:00.000+01:00

Had a bit of a blog break recently, what with Mrs B being ill and (ahem) other things going on at home, as well as having to go through the trauma of recruiting a replacement for my senior partner at work.

Could do with a holiday to be honest. I hear New Zealand is nice this time of year....

Anyway, to the purpose of this post.

It has become clear to SWMBO* and me that we really can't continue to live in our current domicile once Bump Brown arrives: it is a small Victorian terraced house. Fitting in 3-5 humans (depending on the time of the week) and 2 felines is going to be impossible in the medium term, though we might be just about able to manage for a few months. But where do we put the buggy, or hang the washing?

We've had a traumatic 18 months, what with one thing or another. Our lovely little house has been outgrown. And so we are examining our options: move or stay?

If we stay, we'll have to seriously consider a loft conversion. We are fairly sure that this is unlikely to be possible: the house is just too small. We're also unlikely to get our money back from the investment needed to get the work done.

If we move, we'll have to do it soon. Mrs B is 16 weeks in, so we'll need to be in a new house by the end of October at the latest, or she won't have time to plan the decorating before nappies intervene. But that has its own problems: the windows need refurbishment or replacing, our soffits need repairing, the place could do with a repaint. There are lots of other little and not so little jobs that need doing. Finances will need to be considered carefully as well. We'll probably need a second car (and even if we decide to stick with one, we'll need to replace mine which is too small for a baby carrier/car seat and two booster seats). And of course, where do we move to? Closer to my place of work and family, or stay near where we are, where we've been very happy?

So lots of thinking needed.

Watch this space, it might turn into a moving-house-blog.

*"She Who Must Be Obeyed"

Morning sickness

2006-05-23T14:34:00.000+01:00

I've had reason to review my knowledge of morning sickness recently. Most women get this to one degree or other in pregnancy in the early stages of pregnancy. Most don't require treatment and it usually settles around the three month mark.

Some don't settle however. I suspect those women probably don't enjoy being pregnant as much as they were hoping to.

A few unfortunate souls suffer hyperemesis gravidarum. That is more serious and sometimes requires hospital admission, especially if the mother becomes dehydrated. But there are degrees of hyperemesis. Someone close to me has it at the moment (in my completely unbiased and objective opinion). I thought she would require admission last week, but luckily we've avoided that.

The constant nausea and repeated vomiting brought on dehydration and an extreme malaise and lethargy. She is currently not working, which is just as well because I don't think she would be able to anyway. This week, she is coping a bit better. In part this is due to the phenergan she has been using on and off. The only trouble with that is it causes sedation and gives her a headache, which in turn makes her feel nauseated.

See the problem there?

There are other drugs which help some people: prochlorperazine, metoclopramise, cyclizine. None of these drugs are licensed for use in pregnancy related sickness. But numerous studies have been performed which have not shown any adverse effects on the baby. The Prodigy website was one which I have found helpful as a revision, though it hasn't helped Mrs Brown very much. She is trying accupuncture, having already (unsuccessfully) tried the accupressure bands you can buy in any pharmacy. Accupuncture has not been shown to be helpful in 2 randomised controlled trials. But if it helps her, I'm certainly not going to argue.

So in case you've come across my blog because you're suffering from pregnancy related sickness and you've googled it, here is my suggested managment plan:

Sip frequently, don't drink large volumes. The quicker you drink a large volume, the more likely you are to throw up. Try using a straw.
Drink and eat whatever you feel like. Don't worry about whether the baby is getting enough vitamins because your previosuly healthy diet has been reduced to mashed potato and baked beans. The improtant thing is that you avoid dehydration and manage to get food in to yourself. The baby will take what it needs from you, at your expense.
If you can't stop vomiting, seek help from the health professional of your choice. Midwives may have some sensible suggestions. GPs certainly will and can prescribe certain drugs (though be aware that many GPs will prefer to avoid them if they can).
Try having some sort of bland carbohydrate before you get up (crackers or toast).
Don't get hungry: nibble snacks throughout the day and see point 1.
Rest. You're not superwoman, and the world won't fall apart because you're knackered. If you have other things that need looking after (like other kids) enlist help from family and friends. Do not try and do it all yourself. You don't have to.
Despite the fact that most alternative therapies have not been shown to be of benefit, that doesn't mean they won't make you feel better. Any cynical GP (like me) who says anything other than "If you say it helps I won't argue" shouldn't be told (as long as it won't do any harm of course).
Ginger in various forms may help. Of course, it makes some people worse.
If you're prescribed medication, please use it. We don't prescribe for fun. You never know, it might help.
See points 1 and 6 again.

And here's Russell's management plan for husband's/boyfriends/whatever:

Be sympathetic. Its not nice. Jokes will not go down well and do not make your wife/partner/girlfriend/lover feel any better.
Cuddles are good, but don't squeeze. You will regret it.
Try and think ahead of yourself. Keep fresh water handy. Try flavoured electrolyte replacement or rehydration salts (such as dioralyte). Buy crackers.
If you're worried, seek help. That can be your Mum, her Mum, your doctor, her midwife, anyone you like. If you don't ask, you won't get.
Wash up before you go to bed. You won't have time in the morning.
Don't feel guilty. Its not (just) your fault. Two people had sex. At the same time however, accept any and all criticism with that stock phrase: "Yes, dear."
Don't forget to tell her you love her either. That will help, because the way she is feeling, she is unlikely to love herself at the moment.
Just because she isn't eating her broccoli doesn't mean you shouldn't.
Beer and whiskey smell. You should be aware that women with pregnancy relates sickness are often made worse by certain odours. Ask first.
Remember, things will get better. (Probably in about 18 years.)

Flea: When Daycare Calls - Part I

2006-05-09T10:09:00.000+01:00

Flea: When Daycare Calls - Part I

Flea posted this recently. It seems they have GANFYD's in the States as well.

If you don't know what a GANFYD is, well, hopefully you'll never need one. All they do is create work for people like me.

The number of different notes people ask for never seeks to amaze me: examination board notes, holiday notes, simple "been to the doctor" notes and yes, "safe to return to nursery/school" notes.

Flea is absolutely right: no-one seems to use their common sense anymore. Perhaps more to the point, no-one is happy for anyone else to use their common sense anymore either!

Anyway, I'd better get back to work and stop reading blogs...

Dame Janet slams docs again

2006-05-03T09:37:00.000+01:00

Ho hum.

Dame Janet Smith is perturbed by the lack of progress shown by the Government over her recommendations after Harold Shipman's crimes.

Talk about tarring everyone with the same brush...

She made this comment: "There are doctors who still think that everything is fine and that there is no need for change. There are still those who think Shipman was a one-off villain."

Well, wasn't he? Is there any evidence that there are more mega-serial killers in the current medical workforce? No?

Thought not.

I do think that some of the changes she has proposed in one of her many reports are sensible: the proposals about changing death certification and cremation administration; the need for a system to ensure doctors' skills remain up to date; her criticism of the GMC's procedures for monitoring doctors (although that led to the GMC embarking on disciplinary proceedings when perhaps it should not have).

But it seems to me and I suspect many of my colleagues that she would rather have us all shot. That would certainly prevent any more Shipman's.

But there are other things about her rampant anti-doctor attitude that concern me more. I can't help but wonder how many patients have been left in unnecessary pain because doctors have been concerned that adequate pain relief may result in an earlier demise than might otherwise have been the case and that that demise may then be subject to vexatious scrutiny. Certainly I've been aware of a lot more post-operative patients are being discharged by surgeons with simple, less powerful analgesics. Perhaps they don't need anything stronger. Palliative care also feels a lot more defensive in the last few years, or perhaps cautious would be a better word.

Perhaps this caution is for the best. Perhaps doctors do need more monitoring to ensure public safety. But I certainly came in to this career because I wanted to help people through their lives, from beginning to end. I suspect the same is true for most of my colleagues. Dame Janet's viciously negative attitude does nothing to help avoid another Shipman. It just makes doctors feel vulnerable and defensive and that cannot be good for patients.

If I was a rich man....

2006-04-18T10:33:00.000+01:00

Apparently, as a GP, I'm very rich. The BBC investigative team have discovered the scandal that some GPs (less than 5%) are earning over £250,000 a year, after expenses.

Well, most aren't. I'm not. Wish I was...

Apparently "Experts have said the contract was ill devised and is partly responsible for current NHS deficits."

Not quite sure who these experts are, of course, that's not stated. And why are us GPs being pilloried for the NHS deficit when the Government negotiated our contract? It was NEGOTIATED!! We're now being paid for things we were already doing. Our pay had fallen behind comparable professions, and its almost caught up, thank you very much.

As far as the guys earning a quarter mill are concerned, good on them. They will be managing businesses (as do I) to the best of their ability, to get maximum bang for buck, and in the process taking a profit. I wonder if there would be so much fuss if it was some private company making a profit from the NHS, perhaps from following an American model of some sort (which Our Glorious Leader seems to want to emulate).

Well, wake up BBC: GPs are private companies. If you think you're not getting value for money, start comparing us to other countries, see how much we spend per head of population on GPs and the services they provide.

Idiots.

Orwell eat your heart out...

2006-04-03T10:02:00.000+01:00

Well, when George Orwell wrote 1984, I'm sure he didn't think that we really would end up with a totalitarian regime. And so far, we haven't got one. But that could change.

Our Glorious Leader has done a fair amount to erode our freedoms in this country, usually under the guise of ensuring our safety, protecting us from terrorists and the like.

The main thing is of course Identity Cards. These will apparently "keep us safe". Yeah, right. They really would have stopped the Tube bombings by British subjects, wouldn't they? They'll really stop people getting into the country we don't want, won't they?

A google search of "Identity cards UK" immediately pulls up several websites who are basically against them. they summarise nicely what is wrong with the scheme as is suggested by Tone and cronies. NO2ID are a pressure group whose news letter provides updates on where the legislation is at. After the recent Lords climbdown and "compromise" over the compulsory nature of the scheme (and make no mistake, it is compulsory), we will all over the next 10 or 20 years have to have a card. Then, the police will be able to insist on seeing it on demand. In other words, in a fundamental shift, British citizens will have to answer to the State about their identity.

WHY SHOULD WE?

And now we have more concrete plans for SOCA. This Agency, going "live" very soon, will be a rough equivalent to a combination of the American FBI, DEA, Justice Department and Customs. This one I have less of a problem with.

BUT. What happens if in 20 years we end up with a government led by some sort of megalomaniac, possibly a right wing xenophobe? It could happen, all it would take is a few more terrorist attacks, a whipping up of the populace by the likes of the BNP, an exageration and a playing on of peoples' fears. All of a sudden, we could be in a position of having to carry the cards to prove we are who we say we are when the SOCA officers stop and search you. If we can't, we'd be dragged off to chokey until, well, until who knows when.

The Nazi's insisted on ID cards. Especially for Jews. I don't want to live in that sort of world. I don't want my children growing up in that sort of world. But currently we are being "managed" by a Government more concerned with leaving something for posterity than in the actual well-being of us, the Great British Public. Think about that at the next General Election.

Despair

2006-03-28T09:38:00.000+01:00

The latest in demotivational accessories for your company. Just click on the Thread title to go to the web page.

Despair, Inc. are based in the US. They do, however, ship worldwide. With regard to international shipping, their website says the following:

"Despair ships to most international locations. Most orders to most international locations are delivered within 1 week, however- larger-sized orders often can take 4 to 6 weeks (and in a few cases, even longer) to deliver. For faster shipping, we recommend moving to the United States."

The rest of the website, and indeed the whole company ethos, is centred around the principle of demotivation, in juxtaposition to the huge market there is for motivational literature and products.

But I personally recommend the video podcasts, available through the website or iTunes Music Store.

Flame of the week

2006-03-27T10:10:00.000+01:00

The Register has published a "how to" for flaming the ultimate flame.

Wonderfully apt, given some of the flamings I've read over the years, and I'm surprised I didn't come across this before.

Mind you, I only really started browsing the Register a few months back, and then fairly intermittently.

So a competition for anyone reading my blog: flame me.

Best flame wins a prize, though I haven't decided what yet.

What kind of coffee are you?

2006-03-27T08:59:00.000+01:00

You Are a Frappacino

At your best, you are: fun loving, sweet, and modern

At your worst, you are: childish and over indulgent

You drink coffee when: you're craving something sweet

Your caffeine addiction level: low

What Kind of Coffee Are You?

I am sooooo not a Frappacino...

Flickr sorted

2006-03-23T10:34:00.000Z

Not sure what they did, but I can now access my account. Received an email telling me how to log in (which was what I was doing) and all seems fine.

Mind you, haven't added any more pictures to it as yet...

Problems with Flickr

2006-03-22T12:13:00.000Z

Getting lots of problems when I try to log into my Flickr account from work. It keeps telling me that my Yahoo id is already associated with a Flickr account, and I need to merge the acounts.

Fine. So I follow the links and instructions, only to be told that the email address I supply is linked to a Yahoo account and I need to log in there.

Fine. So I log into my Yahoo account and then try to access my Flickr acount, only to be told that I need to merge the accounts.

Guess what happens next?

I've emailed Flickr support, but I guess they'll be on US time, so I will have a bit of a wait.

I've tried to resolve the issue using both Firefox and Internet Explorer, no joy and consequently not many pictures as yet. The funny thing is I can access the account without any problems from home using both safari and Firefox.

It's very fustrating.

Global Warming

2006-03-06T13:11:00.000Z

Following on from my last post, and by a strange quirk of coincidence, the Sustainable Development Commision, chaired by Jonathon Porrit and reporting directly to Our Glorious Leader, have released a report into whether the UK should invest in nuclear energy.

And the answer is: No!

Surprise, surprise.

A press release is available here.

We all need to reduce, reuse and recycle much more than we are at the moment. That is well known. Developing countries carbon output will inevitably go up over time, so we need to lead by example. If you haven't got a compost bin or water butt, why not? Go and buy one next weekend, or start a wormery. If you need a new boiler (unlikely, granted) get a condensing boiler. Use the car less, walk or cycle more.

Mind you, renewable energy has a long way to go before it can hope to provide us with the energy we need. Wind farms are unpopular, solar water heating is one thing, but photovoltaic solar panels are not as cost effective as they need to be to generate a mass market. It can take many years to recoup your investment.

But, and its a big but, the current Government are only interested in votes, especially those from Middle England. If Colonel Bluster (rtd) from Greater Whinging in Surrey says "No!"*, the politico's wobble and rethink. Sound bites are all. They have to start paying attention to the long term needs of the country. Of course TB says he is. But if that is the case, why is the nuclear option being considered with such alacrity?

Personally, I think the Government should move away from a centralised energy grid towards a more flexible, locally delivered system concentrating both on big power stations and small microgenerating schemes (such as solar energy, small wind turbines on everybody's roof next to the TV aerial/satellite dish). Grants are already available in the UK to help get your roof insulated, even to get solar panels of one sort or another put up. But the Government needs to improve the structure of these mechanisms, making it easier for householders to have the work done, and easier for planning authorities to ensure that developers build in a more sustainable fashion. Why not insist that all the new houses that are being built in the south east of England have either solar water heating, or photovoltaics, or both? Build in water capturing technology to reduce the amount of rain water that goes into the drains, there to the sewers and so to waste. It can't be that hard.

So come on, people. Have a think. And this weekend, do something green.

*Col Bluster is fictional and any relationship to any figure in life or imagination is unintentional and your own problem.

Planet Earth

2006-03-06T10:22:00.000Z

There's no getting away from it: Sir David Attenborough has done it again!

The first episode was aired last night and already you can see that the show will be a tour de force in the genre.

Stunning landscapes, beautiful animals and state-of-the-art videography and filming have become de rigeur in wildlife filming but, in my humble opinion, there is no organisation who bring it together as well as the BBC.

That it also makes people more aware of the damage we are doing to our home can only be to the good. This post is not the place, however, to go on about global warming. I'll do that at a later date...

Doomed!! We're all doomed!!

2006-03-02T08:54:00.000Z

It never ceases to amaze me how the media affects people. Bird flu is a case in point.

This morning a patient contacted me to say she had seen a dead duck the day before yesterday. Now she is feeling unwell. She is worried she has contracted bird flu. I take a deep breath, explain that she hasn't got it, and give the usual advice on how to deal with the symptoms of the common cold. But I don't blame her for being worried. How was she to know?

Only recently have the press started being less sensationalist about bird flu and its possible effects on humans. However, somewhat over-egged stories can still be seen in numerous tabloids such as this story in my favorite paper. The BBC has generally been more circumspect, providing a more balanced view of things.

For myself, I am more sanguine: bird flu will inevitably reach the uk. This is not the disaster people think. It is part of the natural order of things. At some point, this virus or another will make the transition to human from whatever it's current host is and we will see another global pandemic.

But there is no need to panic. Admittedly they started slowly, but worldwide, governments are finally starting to take the threat seriously. There have been moves afoot to develop a vaccine for some time, but only recently have governments started to take an interest.

So what can you do to stop yourself getting bird flu? Not much to be honest. But don't worry. At the moment you are significantly more likely to die as a result of an asteroid strike on the Earth.

Normal flu on the other hand is doing the rounds. Advice on flu and managing the symptoms can be found here.

Next patient please...

NHS blog Doctor

2006-02-27T09:31:00.000Z

I've just discovered this blog.

Very funny, and I commend it to you, one and all.

I only wish I'd got my act together sooner and thought of this first. I could have made a mint from the advertising...

2006-02-26T16:52:00.000Z

I've just discovered that Safari (the web browser on my iMac) doesn't have as many options on the compose bar when composing posts for the blog. :-(

This means I can't do some of the formatting automatically, which is another reason for me to get to grips with html tags sooner rather than later.

Oh well, what doesn't kill you makes you stronger. And I can run Firefox (which does support the extra formatting options) along side anyway!

You should probably be prepared for odd posts occasionally, as I don't think its fair to keep all my elementary html errors from certain of my viewers. (Pete, you could probably do with a laugh, am I right?)

More posts at a later date...

2006-02-24T21:28:00.000Z

Me!
Originally uploaded by Russ and Julie.

Well, here's my first attempt at a flickr-esque blog posting.

Direct from flickr, no expense spared! (Hope it doesn't make you gag)

Wedding DVD

2006-02-24T19:14:00.000Z

Well, finally got round to sorting out Nick's video so we can create a DVD of our wedding.

If anyone wants a copy, mail me and I'll send one to you in the post.

We've even figured out how to print out the innards of the |DVD case (though we haven't managed to get hold of printable DVD labels yet through sheer can't-be-bothered-ness).

Its been great fun learning how to do it all, using our iMac to copy the film into iMovie, then creating a DVD movie, then finally ripping it.

In between times, I've started learning a bit about html tags, but unfortunately none of you will be able to see as you're not doctors as I've been practising on my profile entry for DNUK, which you can't access unless you're a GMC registered doctor!

Unless of course you've come here from my profile in DNUK, in which case you've already seen it!

Next blog posting will hopefully incorporate some images. Once I get some on flickr of course.

Welcome to The Brown Stuff!

2006-02-22T14:45:00.000Z

Hello!

I thought I should finally get a blog going for all those little thoughts that I want to share with the world.

I've been reading my mate Pete's blog for ages (http://peterwright.blogspot.com/), and from his I've navigated to other blogs of people all over the world.

So if you've already found the blog, watch this space, you never know how many pearls of wisdom you might find here.

Or, of course, not!