BMA position statement

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

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

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

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

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

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

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?

(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


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


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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...