I know, I know, I'm fat!

On UK television this evening, we watched an episode of a documentary series about Whipps Cross Hospital ( a large general hospital in north-east London). One of the featured patients was a man suffering from the usual complications of heart failure, odema, breathing difficulties, impaired mobility, etc. He was a very sick person and he freely admitted that his current plight was a result of years of over-indulgence.

At this point. a kindly volunteer arrives wheeling a mobile shop from which patients can purchase some 'treats'. Our patient buys Coca Cola, chocolate bars and other assorted confectionery that, if someone else had fed them to him, they would be at risk of being charged with attempted murder.

You might think that a rant now follows - you would be wrong! But ...

Next year, my GPs are almost certain to be given some targets for controlling obesity in our patients. I have no idea why the Department of Health thinks that we can make a difference. Who doesn't know about fibre, fat and five-a-day? Who always looks sheepish when their weight is mentioned? Who doesn't know all about eating less and exercising more?

In case you're wondering, my BMI is nearer thirty than twenty and my waist is only just surviving. Few of us do what we know to be right even when the chicken (and chips) have come home to roost like our Whipps Cross patient who confessed to sneaking into a cupboard during the night to top up his cocoa and refined sugar levels.

Alice in Budgetland

The NHS year runs from April to the following March. Over the past couple of years, we have been encouraged to take a greater interest in the cost of the medicines we prescribe for our patients. You might think that such interest would be a "given" but it is not so. The NHS relies on doctors to "do the right thing" when choosing which drug to prescribe. At the same time, these same doctors are the targets of the intense promotional activity by the drug companies. Busy doctors have little time to take a calm, measured look as the latest drugs on offer.

One positive move was the allocation of prescribing budgets to GP practices. The carrot has been the offer of allowing practices to keep a proportion of any savings they make providing these savings are reinvested in improving care for patients. At the moment, there is no "stick"; there are no sanctions for exceeding budgets but it is hard to believe that won't come in due course. Last year we saved £70k from our budget. We look forward to using these savings to add to our services. An in-house physiotherapist; an acupuncture clinic, and the like. Our budget this year is £1.33m. That's our share of a total budget of £32m for the PCT as a whole. We have worked hard to make further savings and at about the half-way point (the latest figures available) we have increased our savings to an annualised £130k. Great! We can continue to offer these extra services and add to them.

This week I received a letter from our PCT. They have finally incorporated the changes in payments to community pharmacies. These changes will have to be funded from this year's budget. It means that £1.8m additional funding has to be found. Thats about 5% of the total budget and it will have to come out of all our budgets.

Let me see. Five per cent of our budget is £66k. Gone! Half the savings we have worked hard to achieve. It is the end of month nine of our financial year. What is the point?

It's raining money

You might remember the "shock/horror" headlines of a couple of years ago when many NHS organisations were finally forced to declare their hidden deficits. Our then illustrious leader, the glorious Patsy Hewitt, forced trusts to do all the unpleasant things they had tried to avoid such as getting rid of surplus staff, becoming more efficient, etc. However, the knee-jerk actions of the NHS bureaucracy reached all the dark corners of the service and we had "realignment of services" (ward closures); "streamlining" (nursing staff were made redundant); and "financial re-focus"(budgets were suddenly reduced). Our own primary care trust was one of the few that had stayed within budget up until then. Suddenly, their budgets were "top sliced" and abracadbra - we were £30,000,000 in the red.

That's the good bit! Next, because the trust couldn't work out how to recover all this "overspend" a pack of management consultants was forced upon us (at our trust's expense) to tell us how to run more efficiently. (I don't know why but it reminds me of the old army joke: "all leave is cancelled until morale improves".

Life has moved on. Our trust has now had much of that top-sliced money suddenly returned. It is falling out of trust headquarters by the day. On my desk are three new incentive schemes that seem amazingly generous after the recent sparse past. I am trying to work out how to recruit (expensive) agency staff so I can grab this dosh before the meter stops (March 2009). My primary care management team was reduced to two people during the lean times. There are now at least ten of them floating around, some of whom are tasked specifically to help me spend money.

Meanwhile, back in the real world, we are hurtling towards a recession. This government is forecast to borrow £100,000,000,000 next year. somehow, I don't think that the next cuts are likely to be another unpleasant top slice. They are more likely to be financial castration.

I'm keeping everything crossed.

Yes I am just being a pedant

Our Primary Care Trust has, as one of its objectives, "that the health of its residents is as good as other Londoners by 2020". As things stand at the moment, this is near nigh bloody impossible.

For well over half of the patients who register with us, we are their first general practice in the United Kingdom. They come from all over the globe and mostly from areas where their "health" is nowhere near as good as other Londoners: high rates of Diabetes and Hepatitis B from Eastern Europe; Maghreb Arabs seem to have more than their fair share of severe mental illness; refugees and asylum seekers possessing the physiological legacy and mental scars of hardship, abuse and deprivation. We will do our best to care for them all but, for some, good health has receded out of reach for ever.

The high-sounding objective may play well to the gallery but I really dislike it. My PCT tells me that objectives must have a reasonable chance of being achieved. The only way to overcome the arithmetic impossibility of this one is to imitate Dame Porter's style when she ran Kensington & Chelsea: import good health and ban immigrants. No? I don't think so either!

The best we can strive for is to ensure that we have provided excellent primary medical care to all our patients, irrespective of how well or not they are when they arrive on our list. We should all meet a defined high minimum standard of service that would provide the right care to people irrespective of their circumstances. We can then be confident we have done all that is reasonable for our patients even if the outcomes don't reach an irrelevant point on a meaningless graph.

It's official. A ruler can kill you!

My own primary care trust has long been careless with the term "Health Inequalities". They always include within their strategic plans the lofty aim of: "eliminating health inequalities within the trust's area". They also have another lofty aim of making sure that our resident's health is at least as good if not better than the London average. To me, the first aim misses the point and the second is at best contradictory and at is also illogical (if we get better then we have shifted to inequality somewhere else).

Whenever someone sees some else getting a better NHS deal elsewhere, they trot out the "postcode lottery" weapon and fire it off in all directions. Well, in terms of primary care, we like differences. We like to think we do things better than average. We like to think that when we refer a patient to hospital, we arrange for all the tests that the hospital are likely to need to have done so that the hospital diagnosis and treatment is not unnecessarily delayed. We know (from feedback) that we are reckoned by hospitals to be one of the better practices. That means others are not as good.

This is an "health inequality". The cure is to set sensible minimum performance standards and then ensure that all of us maintain them. It would be even nicer if they then recognised those that exceed them and held the underperformers to account but I'm not holding my breath.

Now the WHO has passed its ruler over "health inequities" and found out that these measurements can be lethal. Their report contains much sense although some of their conlcusions are less than revolutionary:

"The Commission found evidence that demonstrates in general the poor are worse off than those less deprived, but they also found that the less deprived are in turn worse than those with average incomes, and so on. This slope linking income and health is the social gradient, and is seen everywhere – not just in developing countries, but all countries, including the richest. The slope may be more or less steep in different countries, but the phenomenon is universal."

God alone knows how much it cost to reach that conclusion!

I just get an awful feeling that somehow using the jargon phrase makes easier reading for those who hold the public purse strings. "Health inequity" is a measurement. It doesn't kill anyone. The actions and inactions of policy makers and politicians lead to changes in mortality (for good and ill). Yet somehow "health inequity" doesn't have the same ring as unhealthy housing, hunger, ignorance and waste. It's softer.

With the best of intentions

I am one of only two people to whom an elderly distant relative can turn for any contact in her ever-shrinking world. Elsie is ninety years old and currently in a general hospital "somewhere in England". That "somewhere" is two hundred miles cross-country from both me and also the other relative. Her latest crisis started some months ago when the accumulated effects of her self-imposed social isolation finally caught up with her. Since then she has been resident in three places:

• The psycho-geriatric assessment and rehabilitation unit;
• A local care home;
• Back in the general hospital.

Elsie is not much better than she was in the spring and I am really fed up about it. I don't expect the NHS or her local authority social services team to turn the clock back but between them they have failed to deliver the care she needs. The "between them" bit is the problem. I find it difficult to find too much fault with any one particular body but somehow in this instance "the whole is less than the sum of its parts".

Caring for the elderly is done by people many of whom should receive some form of endurance medal. The elderly can suffer from any number of physical ailments the treatment of which is made more difficult by them being difficult, vague, uncooperative, confused and confusing.

In Elsie's case, each team has done everything that it "says on the tin". The hospital have cured her UTI. The psychogeriatric services took her, assessed her with social services funded a place for her in a care home. The care home tried to cope with her, but she seemed to be too ill for them so she ended up back in hospital. The hospital says they can't see what is wrong so can't treat her. The psychogeriatric unit say they have already done what they are supposed to do. The home won't have her back because they say she's too difficult for them. Everybody I speak to is really nice. They all seem to care and they all do their bit. The bits simply don't add up to a solution that sees Elsie being treated or cared for effectively.

Conversations with friends in similar situations reveal a common experience. They also reveal a common conclusion: unless there is someone whose job it is to act as advocate for the individual irrespective of which agency they are dealing, then Elsie and others like her fall into one or more of the many gaps that exist between these agencies.

I am certain that on paper there is a clear definition of boundaries and there are no gaps at them. However, once an agency thinks they have done their bit, they pass Elsie over to the next agency. This next lot don't think they should have been given Elsie so they tell the first lot that Elsie belongs somewhere else. And so it goes on. Fridays come and "they didn't get back to me." Meetings take place where "the person that usually deals with this case is on leave and I don't really know Elsie". I once travelled up to the hospital for a "case conference". Waited three hours ("doctor is on his rounds at the moment") to be told that the doctor had gone for lunch. Waited two hours and was told the doctor had been called away on an emergency. "Could I come back next week?" You get the picture, I'm sure.

So here we are. Elsie is "on everybody's radar". She's costing the NHS and social services loads of money. Over the past few months they have managed to lose all her clothes and the replacement personal supplies we bought for her. Her medication records have huge gaps in them ("they don't seem to have told us who stopped her diazepam" or why). Elsie is frightened and lonely. I feel guilty that I cannot do more, shout more or visit more.

Everybody has done their job but somehow Elsie has got lost in their efforts.

The Lowest Common Denominator - again!

There are good doctors and there are some that are not so good. A few are dreadful. Such things are inevitable when there are so many of them and none of them every get younger. GPs are not except from this. In fact, given that most of them run their own businesses (i.e. their practice) the opportunity for variation is all the bigger.

Enter the "primary care trust". The job of a PCT is to be the part of the NHS with responsibility for signing contracts with these GP practices to deliver the services that the NHS wants delivered. Our contract is three inches (7½ cms) thick.

If you suffer from insomnia, you might leaf through the odd tonne of gumph spouted by the NHS about " ... devolving power to ensure local services reflect local needs, blah, blah, blah ..." It seems such lofty aims stop at the PCT. They simply cannot cope with lots of practices each doing things in their own way, especially when some of them don't do it properly or well enough.
Their response to such variations?? Simple!

Make everyone do it the same way, irrespective of whether or not that is better or worse than what was going on before in the non-problem practices. In other words, find the lowest acceptable performance level that everybody can meet and then make all do it, irrespective of how well they were doing it already.

Bad, like Tesco?

I attended a presentation yesterday about "Practice-based Commissioning". If you don't understand the term, may I suggest you click the "Next Blog" link at the top of the page? It would take too long ...

Anyway, one of the speakers was a passionate GP who explained what he and his colleagues were doing to ensure that the big, bad, Tesco/Boots/Sainsburys axis of evil didn't invade primary care. Why is this so bad?

Well, conventional GP thinking runs alongs the lines: They will open early and late so they will deal with our least-troublesome patients: the young, working people who don't want to take time off work to sort out their minor ailments. Under the present system of funding, we receive annually an equal amount of money for each patient. It doesn't matter what age they are, or how often they use our services. Since children and the elderly use us most, the loss of our least demanding patients mean we will find it hard to fund the same levels of care for these more vulnerable groups. GPs throughout the country are busy defending the status quo. I help ours to do so.

But before signing up to the received wisdom of the evil of Tesco et al, I think we all need to ask ourselves a number of questions about these companies and the services they provide:

1. Would you like your local McDonalds to be as clean as your local hospital?
2. Would you like to wait as long at the checkout as you do at your local GP?
3. Where do you buy fuel for your car and why?
4. Who deals better with complaints; Sainsbury or the NHS?
5. How much does it cost to park at your local supermarket and at your local hospital?
   

If you think I am being unfair, you are probably reciting a long list of the fundamental differences between a retail operation and a hospital. I don't see that cleanliness, punctuality, effective demand management, customer service and smart procurement should form part of that list.

Just Who Is This "Public"?

I live in a small rural village. It's lovely. It has a post office but not for long. Following a "public consultation" our post office will close at the end of the month. A lot of our neighbours submitted their opinions to the Post Office. Every one of them said "please keep it open". The only person I know who wants it closed is the man who owns the shop and post office in the next village five miles away. His post office is closing too! I can't imagine any sane individual saying: "close my local convenient post office (even though I only use it on 'high days and holidays')". Can you?

At the moment, the NHS is spending millions of taxpayers' money on a public consultation of the "Darzi report" on the future of NHS services in London. The big change in primary care is the idea of "Polyclinics". The consultation is about to be completed but no findings have been published yet our PCT has now published its plans for the first two polyclinics. The tenders are going out soon. Six more are in the second stage of detailed planning.

I hope the consultation agrees with Lord Darzi but somehow I don't really think it matters. Do you?

Dear Secretary of State

Dear Alan,

I write to congratulate you on your shrewd career move away from the post office, completed before your colleagues presided over the disintegration of the Post Office network. At the same time, I wanted to warn you about some worrying symptoms that might give you pause to consider whether Health Secretary is quite the place to be just now.

Who am I talking about here? As you will be well aware, the government is in the process of streamlining the delivery of many of the services once the preserve of a national network of small but local community-orientated outlets offering a wide range of products especially valued by the least mobile amongst us. Adaptable to local needs, these were not necessarily the lowest-cost options but taken "in the round" they have helped to sustain a focus for many of our small communities. Vulnerable people were known and their individual difficulties readily taken into account when national procedures or a one-size-fits-all bureaucracy might have caused distress. Such things were hard to measure but that should not have meant they were not factored in to any business rationale. I get the feeling that someone made a grand "back of a fag packet" plan and everything after that was squashed and squeezed into the resultant planning straightjacket. There were of course winners as well as losers. Supermarkets were able to win some of the business taken from these outlets. Other services were made available via government web-based products (I hope you weren't too disheartened by the appalling write-up by your [close] friends at the NAO about what poor value-for-money many government web sites have turned out to offer).

I am, of course, talking about the Post Office. I live in a small village on the Hants/Wilts border. We have a village post office (but not for much longer following public consultation - nudge nudge, wink, wink, say no more). I can't buy my TV licence there (although I can at Sainsbury or Waitrose). Last week a card from our postman fell through the door whilst we were out about a letter that needed a signature. Paul (our postman) delivers our letters and then calls at the post office next door to collect outgoing mail. He couldn't leave the letter there. Instead I had to drive the twenty-four mile round trip to the Polyclinic (oops sorry - main office) conveniently located on t'other side of Salisbury city centre where there is no free parking and the post office is surrounded by double yellow lines and an exuberant clamper. Nevertheless, I do understand your rationale - really, I do. Vulnerable and immobile people in small rural locations aren't likely to be swing voters in marginal constituencies. Young, healthy working people usually have access to the Internet and were always least likely to make use of their local post office so it is a matter of priorities. In this case the overwhelming need to secure those swing voters.

Maybe it's time you made yet another move (you've been at Health HQ quite a long time when examining your rapid progress up the greasy pole). Breaking up the branch network? Getting rid of loads of local contractors? Moving yet more government services into supermarkets? How about the Foreign Office?

p.s. glad to see your getting rid of those nasty 0844 telephone lines. By the way, do you have any other number for the NHS Pensions Stationery Order line other than 0870 1 555 455 or the NHS Pensions Help Line 0870 0 117 108? Just thought I'd ask.

Bureaucracy vs Reality

Just before closing time, the mother of a 14 year-old girl phones us and is very anxious about her daughter's "funny breathing" and chest pains that she had had all day at school. She is asked to bring daughter to surgery where GP examines the lass. As a result of the examination, the GP decides that there is no cause for alarm and that with the medication prescribed, she should soon be well again. However, if Mum is at all worried during the night, then she should not hesitate to call the out-of-hours service.

On the way home - GP is giving me a lift to the station - he says that he won't be at all surprised if Mum calls the OOH doctor although as far as he could tell, there was no cause for alarm. We then talked about the uncertainty inherent in many GP diagnoses and the "ninty-nine times in a hundred" they would be correct. Especially in today's medico-legal climate that leaves me worrying about the other "one in a hundred". I reflected on the two different approaches to such a dilemma: the doctor's versus the manager's.

The GP knows that if he or she refused to take probability into account, our hospitals and emergency services would be overwhelmed within a day. He/she takes responsibility for managing the flow of patients to the next stage of medical intervention be it hospital treatment, medication, or perhaps diagnostic testing. It doesn't get noticed because it isn't a tangible activity; but it is a real benefit of having a well-trained and well-motivated "gate keeper".

The manager is likely to try to remove all risk, if not from the system, at least from that part of it for which he is responsible. His approach will be: "if in doubt, refer". I have some sympathy. After all, he is the one that will have to deal with the "one in a hundred" should it result in a formal complaint.

I don't have a neat solution. Homo Sapiens rather inconveniently presents in an infinite variety of shapes, sizes and combination of physical and psychological variations, most of which are tucked away out of sight or reach.

The NHS only works because doctors assess probabilities and having done so, hope for the best. You may not like the sound of that, but in essence, this is what happens. We can rightly demand that this assessment is skilled, appropriate and that the evidence supports the conclusions that are then drawn. If the assessment is proven to be deficient, then let justice prevail. But, providing it is reasonable, our society and its legal processes should support such doctors and resist the demands of those seeking perfection. The costs to us all would be catastrophic.