Time to start a campaign?

(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

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.

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

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

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

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

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

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

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

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

"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

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...

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...

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

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...

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.

More Spinal Privacy problems

As if we haven't got enough to worry about with our own national scheme, now someone in Brussels wants us to share all pour medical problems with most of Europe as well! According to the report, there are 5 million health workers across the EU, so if there is anyone who won't be able to access medical records at the drop of a hat, could they raise their hand now please?

No? Oh.

I've already posted about this twice (and on a related matter here, here and here).

Its bad enough that billions are being wasted on the UK scheme which, after £12 billion (at least) and several years, is still charitably describable as an insecure waste of money with a long term usefullness rating that most health professionals aren't convinced about.

How much will a pan-European scheme cost us and who is going to make the most money from it?

Oh, yes.

Who will benefit from the scheme?

Sorry. Forgot that one.

"The data that will be shared will include some kind of emergency care records and patients' medication histories. The aim of the scheme is that if, for example, a UK citizen falls ill while in Spain, doctors there will know what medication the patient cannot take or what existing conditions they already have."

Right. So instead of asking the patient, they can Google the patient. Great.

Still, what do I know?

Sack Patsy

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)

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

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

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

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

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

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"

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)

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

Yours truly is mentioned!

Check it out...

Over-performance

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

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...

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

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

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


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


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Trust me, I'm a Doctor

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

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

Decisions, decisions...

Options:

1. 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.
2. 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.
3. Radio 2. Wogan. Music from elevators, humour from the 1970's but without the slapstick.
4. 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).
5. 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).
6. 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

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

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

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

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...

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

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

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

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

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

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

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

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

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:

1. 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.
2. 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.
   
3. 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).
4. Try having some sort of bland carbohydrate before you get up (crackers or toast).
5. Don't get hungry: nibble snacks throughout the day and see point 1.
6. 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.
   
7. 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).
8. Ginger in various forms may help. Of course, it makes some people worse.
9. If you're prescribed medication, please use it. We don't prescribe for fun. You never know, it might help.
10. See points 1 and 6 again.
    

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

1. Be sympathetic. Its not nice. Jokes will not go down well and do not make your wife/partner/girlfriend/lover feel any better.
2. Cuddles are good, but don't squeeze. You will regret it.
3. Try and think ahead of yourself. Keep fresh water handy. Try flavoured electrolyte replacement or rehydration salts (such as dioralyte). Buy crackers.
4. 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.
5. Wash up before you go to bed. You won't have time in the morning.
6. 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."
7. 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.
8. Just because she isn't eating her broccoli doesn't mean you shouldn't.
9. Beer and whiskey smell. You should be aware that women with pregnancy relates sickness are often made worse by certain odours. Ask first.
   
10. Remember, things will get better. (Probably in about 18 years.)
    

Flea: When Daycare Calls - Part I

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

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....

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...

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.