Life after Retirement

This my first post since retiring after fifty years employment, self-employment and then employment again. It has been "interesting" as in the Chinese curse version of that word. On our first day of retirement, and driving out of London to our country retirement idyll, we got only as far as Hammersmith Flyover before the results of my recent PSA blood test resulted in a phone call urging me to see my GP as matter of urgency. For all my whinging about the NHS, what happened thereafter, my patient journey, was a example of text-book excellence.

I registered with a local GP and saw him the following day. My "two-week wait" referral resulted in a urology appointment at my local district hospital (DGH) in seven working days.

What I Thought Would Happen

After watching patients endure the local DGH where I had worked, I warned my wife that I would probably see an SHO or, if I was lucky, a registrar who would decide to ask for a repeat of the PSA, order an ultrasound and make a follow-up appointment a couple of weeks later to review the results.

What Did Happen

My 10am appointment was with the consultant. First, the ultrasound machine which was next to his desk. Completed by five past ten. Good news: didn't appear enlarged.

Next, the dreaded gloved finger did the necessary. Ten past ten. Mmmm... there's some sort of nodule there so we'd better get a biopsy. Can you come back at three o'clock?

Biopsy completed by half past three.

Now for The Bad News

Seven days later, back for the results. Adenocarcinoma of the prostate. Advanced. Aggressive. Oh bugger. Left hospital with first batch of drugs. Radiotherapy started on the first possible day after allowing the drugs to do their stuff.

And finally The Good News

All clear.

So dear reader, it can be done well. I asked the specialist nurse why it was so good. She told me that the whole team had sat down together and worked out how to do it all better. What an amazing thing .. asking the people who know how it works (and doesn't)  and who need to make it work better.

A&E Treatment Targets

It's been an "interesting" summer (as in the Chinese curse "interesting"). One of my more forgettable moments was taking myself down to St Thomas's one Wednesday evening with what I suspected was an unwelcome return of the double pneumonia episode a couple of months earlier.

I arrived into a pretty quiet waiting area at 20:45 and was booked in almost immediately. A few minutes later, I was taken into the treatment area and into a cubicle. Routine obs were taken and after a while the new JHO - Junior House Oficer (it was week one of the great August musical chairs) learned of my previous bout. She said she'd arrange an x-ray and this was done within the hour. Pretty good ... so far!

About 23:15 JHO returns and says chest is clear so they're going to take some more blood for some tests. Blood duly extracted. I wait in cubicle.

23:45   Still sitting in cubicle
00:15   Still sitting in cubicle.
00:30   I say to my wife: "You watch; in the next fifteen minutes all sorts of stuff will happen".
00:40  JHO returns and says they're going to admit me.

Me:   Why?
JHO:  Pardon?

Me:   I've been sitting here for the past 1½ hours. Why have you suddenly decided to admit me?
JHO:  We're still waiting for results of your blood test.

Me:   Can't I wait here?
JHO: No.

Me:   Why not?
JHO:  My care pathway coordinator won't allow it.

Me:   Well how long will the results be?
JHO: About an hour or so.

Me:  Well I'll wait here then rather than take up a bed.
JHO: You can't.

Me:  Why are the results taking so long?
JHO:  Um, um, actually there was a problem with path system.

Me:   What problem?
JHO. Er, we forgot to send them to the lab.

Me:   You are not admitting me to adhere to some arbitrary four-hour target which you will exceed because you made a cock-up.
JHO:   You can't stay here.

 Me:  Then I'll go home. I live over the road less than five minutes walk and you can phone me when you have the result.
JHO:  Oh, you'll need to fill in the self-discharge papers.

Me:   OK.

Two hours later the phone next to my warm comfy bed rings.

JHO:  The results are back. You need a CT scan. You need to come back straight away.
Me:    Does that mean I have the CT scan when I get there?

JHO:  No. They don't open until nine o'clock.
Me:  Then I'll come back then. Good night.

If I'd agreed to be admitted, St Thomas's would have charged my GP's commissioning budget because they'd cocked up their management of my treatment by forgetting to send my bloods to the lab. The likely cost to the GP's budget would have been hundreds of pounds because of the way it would be coded with my advanced years and a non-related chronic disease.

As long as this goes undetected. There is no incentive on hospitals to be more efficient when treating A&E patients long as they can be admitted, even without a diagnosis, after 3h:55min. In theory the tariff allows a set number of days for particular episodes but this was an episode that could have been completely unnecessary (e.g. my first ever attack of gastric reflux - which it wasn't).

Dr Lansley's Brave New World?

We are now well into the convulsions caused by Andrew Lansley's radical reorganisation of the NHS in England. Already, the NHS senior management establishment is undermining much of what he set out to achieve. We were told that it was expected that there would be about 550 consortia formed. Clearly this is far too anarchic for the bureaucrats and they have fought back with dogged determination to ensure that the "new" NHS structures retains as much as is possible of the "old" NHS structures (that got us where we are today).

Now, the NHS hierarchy seem determined to create much bigger consortia than was originally envisaged. They are suggesting that in East London, the minimum size they see as sufficient to create the necessary economies of scale is about half a million patients. That is roughly the combined populations of the London Boroughs of Newham, Tower Hamlets, Hackney and The city of London. Amazingly enough (or not), that is precisely the description of the existing "cluster" formed by the amalgamation of the three PCTs last year. If you divide the poulation of England by half-a-million, that would mean about one hundred consortia for the instead of the 550 suggested by Dr A and his merry men. This is all a far cry from the original plans as they were explained to us.

Meanwhile, the PCT/Cluster seems determined to fashion things as it thinks they ought to be rather than what the commissioning groups think or want. Since it is these same PCT managers that got primary care where it is today, they’re mostly the people I would rather were NOT designing their replacement. However,  turkeys rarely vote for Christmas and here in East London, the turkeys still reign.

I now longer have either the energy or the enthusiasm to try and change things.

At a personal level, I am saddened by how little of the energy that is being expended is making any difference to patient care. Things are being rearranged, usually at some considerable cost, but rarely to make things better. We have been tricked into doing the government’s dirty work for them presiding over significant cuts in funding despite all the rubbish that ministers spout about “spending in real terms”. Primary care is 90% of the care and 10% of the funding. Giving us amateurs the budget for the other 90% whilst slashing it can only be poor value for taxpayers and poor value for patients. The answer to the problem of NHS managers that clearly can’t manage is to find managers that can, not give it to GPs who have no training or experience.

I am glad I will have retired by the time that our local general hospital announces firstly that it will have to close its A&E service (probably done in stages by first reducing opening hours), and then that it is closing most of the rest of the hospital too. For consortia, they should realise that the politicians will be quick to point out that this will be a commissioning decision so it will be their fault.

Dr Lansley or Dr Pangloss?

In a little under five months, GP commissioning groups are supposed to take over the reins of most of the prodigious NHS budget £106 billion for 2011/12. If you have read previous entries, you know I like the real numbers:

So that's one and and six, thousand, thousand thousand pounds. £106,000,000,000. Even the Greek economy doesn't need that much (this time round).

Well, MrTaxpayer, how do you feel about handing over control of this much money to a complete load of amateurs?

NPunFIT

Probably because it got off to such a poor start, the National Programme for IT ("NPfIT") got a rebranding and became "Connecting for Health". Several billions later, we are still light years away from any system that delivers good quality decision support so I prefer to call them NPunfIT since that is exactly what we've got: a system that is definitely not fit for purpose.
I suspect that people operating in the commercial arena assume that we have functioning management systems to control such a collosal organisation consuming over £100,000,000,000 each year.  We don't!
I think "the management" gets away with it because they operate the most byzantine of systems, usually at least three months behaind the event, and often with little resemblance to financial reality.
We are supposed to taking over commissioning budgets (the financial responsibility for funding a patient's hospital or specialist care).

• There is no financial system in place that provides any accurate information that is less than ten weeks old.
• There is no system in place that can accurately price the actual costs being charged to us by hospitals (since they are so often subject to local variations).
• The same patient can have the same procedure twice in the same hospital but we could be charged different amounts depending on which order they hospital codes the record of treatment (i.e. if they put "old" before " depressed" it might be a different charge to being "depressed" and them "old".)
• There is no system that accurately identifies whose budget should be deducted for which patient.so we are supposed to spend time working out whether we should have been charged for the treatment for that patient on that date.
• There is absolutely no forecasting system that monitors actuals against forecast against budget.
• Budgets are frequently set well into the year to which they apply. The record for us was November for a year starting the previous April.

 No we're taking the responsibility away from the so called "professionals" and handing it over to the "amateurs". GPs.


Be scared. Be very, very scared.

Obesity - Illness or Just Plain Stupid?

If you click on the title of this entry, it will take you to a BBC news article about Professor Tony Leeds - an obesity guru at Central Middlesex Hospital. His underlying concern is that "The impact of Britain's obesity epidemic continues to increase, and so does the cost, both human and financial. Obesity now costs the NHS around £4.2bn annually, and the wider economy a frightening £16bn."

Though it's not why I feel compelled to put pen to paper, I do wish people would say "it costs YOU and ME £4.2bn (assuming YOU like ME are a taxpayer). He argues for an "fully-funded army" of obesity specialists in every GP practice. He talks about "obesity management", "surgery" and a "fully-integrated national scheme" and much more.

Apart from the fact that Professor Leeds obviously lives on another planet as he has no idea what's going on with NHS funding here on Earth, I am growing ever-more exasperated by the NHS's preoccupation with helping people to lose weight. Whatever we do and however much we spend, I reckon over 90% of it is a complete waste of time and YOUR money.

How many overweight people do you know who don't also know:

• about healthy eating?
• about the risks of excess weight?
• about the benefits of exercise?
• somebody with diabetes?
• somebody with heart disease?
• other people who are overweight?

Exactly. We all know what to do and how to do it. Most of us simply don't! It's a choice we make and I don't see why spending even more taxpayer's (yours and my money) will make the slightest difference.Don't get me wrong - I am worried about obesity. I am 14st 10lbs (92kgs) and underneath my well-built exterior is a skinny bloke. I reckon my healthy weight should be 26 lbs (12kgs) lower than that. Clearly I am not that worried!

Both of my offspring are overweight and they know it too. Where I work, half of the staff are overweight and some of them meet the (BMI>30) definition of obese. We cannot claim ignorance - we watch patients arriving everyday seeking help for the damage caused by years of over-indulgence.- and most of our team talk about their concern but clearly they are not that concerned.

Looking around us, London seems to me to be the crap food capital of the world. We seem to have more places to eat fatty, greasy, and decidedly dodgy fast food than anywhere but the United States (and look at what's happening there!). These outlets wouldn't be there if they didn't make money but they do, especially immediately after school finishes when they are filled with the next generation of podgies stuffing chicken 'n chips, coated in salt, dipped in sugary ketchup and washed down with a sugar-filled carbonated drink.

Our PCT spends over £2 million a year on "weight management and obesity" which includes prescribing orlistat and then bariatric surgery (gastric banding). Only the latter works; the rest is a complete waste of time and money. Our patients tell us they want to lose weight, and next time they come they might have lost (or gained) a kilo or two. We rarely succeed in helping anyone do anything significant about their weight.

What do I think we (i.e. the NHS) should do?

Nothing!

I think our job should be to treat the symptoms and leave dealing with the causes to somebody else. Somebody else that is who has a billion or three that their government is prepared to cough up.

We could also:

• apply a supplementary levy on all fast-food outlets;
• discriminate against fat people in the workplace (they cost employers a lot more than skinnies);
• price transport tickets by passenger weight;
• ban unhealthy foods in places in schools, hospitals, government offices;
• insist that all radio and TV broadcasts a set amount of anti-obesity propaganda;
• fine parents that don't feed their children properly.

Too radical for you? Well, I guess so.

But the problem is not medical,; it's social and that's where we need to supply the solutions. The best thing that GPs can do is scare the pants off fat people but too many GPs are way too squeamish for that.

Don't believe me. Those of you who remember Harry Secombe will recall him as the jolly, rotund "Goon". Suddenly he lost a lot of weight. A LOT!

Why? Because a doctor (not in UK) told him if he didn't, he'd be "dead in six months"! He freely admitted that up until then, despite being told about the consequences, nothing had worked.

The current government has increase the financial pressure on the NHS that was first exerted by their predecessors. Don't you love creative English? For "financial pressure" read REDUCED FUNDING. So we have less money to care for more people, living longer and getting ever fatter. If it was your money and your relative that needed a hip replacement, spinal surgery or renal dialysis, or it was your local A&E that was closing, I'm sure you wouldn't mind that part of the reason was that while you and I just kept on eating chips, health bureaucrats kept spending money on you and me, even with the knowledge that £90 million in every £100 million was a complete waste of money.

Let's think the unthinkable - smoking

In the 1970s, I spent a great couple of weeks in Bristol learning about "Operational Research". This was the original name of what is now called "Applied Statistics" - using statistics to solve a specific "here and now" problem. The course lecturer had formerly worked on the great technological white elephant that was Concorde.He explained that he watched the Concorde project abandon financial commonsense as delays, overruns, modifications all added to the bill. That's the trouble with big numbers. They start to reach a size where we loose our grip on reality. Once you start talking "billions", then £0.05 billion seems like petty cash.

But it isn't. It's fifty million quid!

Our lecturer explained that he kept his sanity by converting all these overspends into Mars Bars. He knew the volume of a Mars Bar and how much it cost. It was fairly simple arithmetic to represent the "latest cost overrun on the Concorde undercarriage system" into enough Mars Bars to fill three aircraft hangars - floor to ceiling .. wall to wall! You may think he was potty but it kept his cost accounting feet firmly rooted on the ground instead of in project-financial fairyland. I have taken advantage of his wisdom ever since. It helps me to ensure that cost projections, financial forecasts, etc. can all stand up to real world scrutiny.

Which leads me to the NHS expenditure on helping people to stop smoking. Why are we forking out MILLIONS of pounds for smoking cessation treatments? People smoking a packet of fags a day are spending £42 a week on the habit. They could afford to buy any of the various OTC patches and potions for a fraction of that. I've checked on Amazon and patches vary in price from £1.05 each up to £1.75 or in cigarette terms that's between six and eight ciggies a day. If they do give up, then they will reap the financial benefit for the rest of their lives.

By this point, any "health professional" reading this will have marshalled the forces of righteous indignation to attach me as an inhumane and illogical idiot (which may be true but that's not the point). Helping people to stop smoking saves the taxpayer money. You've all see the headlines. Smoking costs the NHS £1.5bn, £3bn, £5bn a year (what's a few billion matter here?). Don't believe me? Just click on this link to Google and see what numbers pop up for "smoking costs NHS". Read the headlines for yourself.

Increased likelihood of coronary heart disease, lung, throat and mouth cancers, respiratory disease, etc.etc. are all consquences of smoking. However, there are also savings to the NHS and the taxpayer.

• The excise duty on cigarettes is vast: excise duty in 2010 is estimated at £8.8bn and VAT is a further £1,7bn. (Tobacco Manufacturers' Association). That's ten percent of the total NHS budget of £103.8bn
• The biggest cost to the NHS is in treating the effects of getting old. If smokers (on average) die sooner, then whilst they still incur the costs of their chronic conditions but save on the costs of elderly care.

If the NHS wants to have a financial debate about smoking, then perhaps it should consider encouraging us to smoke. It looks as though there's a net gain in terms of revenue and expenditure here! Even if I'm wrong, about the big picture, I still don't see why we should be subsidising people who want to stop smoking any more than we should subsidise people who want to stop biting their nails or sucking their teeth.

The NHS is running out of cash. We have more important things to do than this.

(for the record: I use to smoke - sixty-a-day in fact. So did my son. He now runs marathons and I get my exercise watching him occasionally).

Lions Led by Donkeys?

The title of this posting was first applied to the allied soldiers rotting in the trenches in the first world war. It is a phrase that often haunts me when I collide with NHS management. I am weary of sitting with groups of managers and those GPs that get involved in management and hearing them defend the NHS as something that is far too good and noble to be tainted by the whiff of commercialism or those with a "profit motive". From where I sit, the NHS isn't very good at all. It is grossly inefficient; appallingly profligate with taxpayers money; and it delivers a large amount of mediocre care in buildings that would be the subject of criminal prosecutions if they were not the responsibility of the government.

The average NHS manager has no real grasp of financial management and no grasp whatsover on the real meaning of cost. Few managers have any formal training for whatever role they assume. My son is a project manager for an international telecomms giant. His team are experienced in project management and work effectively in every corner of the globe. I dare not recount to him how my PCT is (not) managing our NHS broadband connection whilst he's eating as he could easily choke whilst laughing. Few if any of our local managers have the faintest idea how much the services they manage actually cost and there is no accurate means of measuring forecast vs actual costs. Our prescribing budget is usually set six months into the year. Mind you, there is no point having a real management information system. The management couldn't work it nor usefully interpet it anyway.

Before you all start shouting at me, let me acknowledge the tens of thousands of workers in the NHS trying their best to deliver good care to sick people. There are many small islands of excellence. I am grateful to live in a country where I will get treated if I am ill even if I can't remember the PIN on my credit card. However, these facts have nothing to do with the way the NHS is run. In fact, shouldn't it be these people shouting the loudest?

Blair and Brown inherited an NHS that was leaking vast amounts of money (billions!) through waste and inefficiency. It was grinding to a standstill with waiting times, poor access and declining hygiene. This dismal catalogue was the evidence of NHS management outcomes. Blair's prescription was to throw money at the problem. Even our village idiot could tell you that whilst you might eventually fill a leaky bucket if you poured enough water in, the moment you stopped pouring it, you will be back at square one.

And so we are!

Even as I speak, the same management is now working out how to cut spending in real, historic and any other term you wish to use. The bucket still leaks as much. The level will drop. Waiting times will creep back up. Hospitals will close and management will blame it all on the government and most of you will believe them.

The Buck Stops Here

The TV programme was all about the experiences of an undercover reporter in hospital and the subject was the awful food. I have no idea why this reporter felt the need to hide under the covers; hospital food is almost invariably awful and everybody knows it to be so. Anyway, having puffed up his feathers into a fit of righteous indignation, he confronts some poor hapless politician to demand what is to be done? After floundering around talking about anything but money, this drowing MP reaches for the usual "get out of jail free" card:

"Your local GP" says he, " is the chap to sort this out! We are giving them the budget and they are in the best position to drive up standards and make sure you are a happy bunny."

Oh really?

Here's a question for the reporter: how will you feel if the next time you need to see your GP, you can't get an appointment because his morning surgery is full of people angry about hospital car park charges, the lack of a direct bus to the surgery, the district nurse arriving late, the curtain pattern in Nan's sheltered accommodation, young Henry's lack of choice for designer prescription spectacles and all the other things with which the "I want it all and I want it now" brigade can fill their spare time?

Lots of managers but not much management

The meeting had lasted 1½ hours and was drawing to a close. We had been discussing the improvements in performance of a screening service that our PCT had taken over and then completely buggered up. Right at the end, they produced their performance report and in it were two graphs (which I have combined into one shown on the right).

You will see that routine referrals by the service to hospital consulants (the top line) oscillated between 38 and 225 a month. Urgent referrals also varied between 1 and 39 a month.

Everybody was really impressed with the report but then I spoilt it. I asked why there were such large variations from month to month.

Not a bloody clue!

The Elephant in the Room is a Drunk!

The current mantra of our healthcare policy makers is "moving care closer to the patient". The reason (excuse) for this catchy little phrase is money. It is now assumed that moving care out of hospitals and into community settings is cheaper and on paper this is entirely reasonable. That's the "what" and the "why". It's the "how" that always terrifies me.

As a taxpayer, I wan't the NHS to be looking to ensure it doesn't spend money unnecessarily. There is one area where it could save itself a fortune if there was anyone brave enough to grasp the mettle. It's drunks!

Before shaving threepence off the community chripody budget, all politicians should be required to spend a Saturday night in the casualty department of the general hospital that serves their constituency. What they will see is an NHS emergency service overwhelmed with young, drunk, vomitting, often-aggressive pillocks who think that ending up having the contents of their stomachs vacuumed is a sign of a good night out.

Our risk-averse managers ensure that we care for these tossers with skills that are in short supply and very expensive to provide overnight and at weekends - how much would extra you want to be paid to be puked over on your Saturday night?

I think the answer is to adopt one of the United State's more sensible policies - the "drunk tank". If you're drunk and incapable, then get shoved in a large cell with all the other serial idiots until you sober up. In the morning you can pay the spot fine and find your own way home. Make sure the cell is tiled so it can be hosed down easily in preparation for the next batch. I don't wish to be uncivilised about it. Female drunks should have their own cell next door.

To start with, some cities will need something the size of an aircraft hangar (and there are plenty of those lying around) but once the message gets through to what's left of their brains, demand will surely lessen?

Your trusted GP?

Back in January this year a young baby, one of our patients, died whilst waiting in A&E. It was unexpected but actually no great surprise. The poor mite had been born with a number of severe heart defects which skilled surgeons were doing wonderful things to fix but only a few at a time.

I have just received "Form B" from them upstairs.

On the front page it says:

"Each agency representative is to complete this form by summarising information available within their agency. Each representative should complete only those sections for which they have information. The CDOP manager will collate the information from the different agency reports to provide an overall case record. This collation will be agreed at the local case review or by the individual agency representatives in consultation with the CDOP manager.

You can see where this is going.

Let's fast forward to page 4:

"Factors in the family and environment:

Include comments on family structure and functioning; wider family relationships; housing; employment and income; social integration and support; community resources.Include strengths and difficulties."

Had enough yet? No?? Page 8 then ...

Is either parent a smoker? Was the baby an asylum seeker? Are the mother and father related to each other (excluding marriage)??

It stops at page 10.

After the death of Victoria Climbie, the NHS spent millions and millions on a massive change on child protection procedures in GP surgeries, most of which would not have stopped Victoria's "aunt".

After Shipman, the NHS spent millions and taking Class A drugs out of GP surgeries because they made the paperwork so awful that it was easier not to bother. Another huge system upheaval not because the system didn't work, but because individuals in the system failed in their duty of care. I can only surmise that this form is a result of the baby P case.

Officialdom's response to a failure is to change the system but it's the people that don't do their jobs that's usually the problem.

Everybody knew.
Anybody could.
Somebody should.
Nobody did.

Here's a suggestion: save the money spent on completing this form (which is arse covering in triplicate) and spend on on front-line social care that might just reduce the incidence of further Baby Ps.

Sacred Medical Records

You are currently spending lorryloads of money creating the ability for clinicians everywhere in the NHS to view your summary care record ("SCR"). Whenever this investment is challenged and for whatever reason, the shroud wavers emerge to say that it will save lives. They give examples of people who would suffer a severe anaphylactic shock if given drugs to which they will react badly. They are correct but that must not be the end of the argument.

Medical records as we maintain them are mostly utterly irrelevant to present or future health care.

Elderly patients have letters in their records telling me that in 1955 they had a baby with a normal delivery at a hospital that long ago became a luxury apartment complex. That baby is now collecting their old age pension.

I know that's an extreme example but very little of what has gone before has any relevance to urgent care or current management.

You are spending billions moving paper and electronic versions of all this medical ephemera between GP practices and from practices to hospitals and back again.

Instead of upgrading the NHS wide area network, let's buy some shredders.

Targets Are Not Management

The Government has made much of its decision to scrap a couple of NHS targets: the "48 hour target" within which time a patients is guaranteed to see a GP; and the "18 week rule" within which time a patient should have been treated in hospital following a referral from a GP. I really disliked these targets but perversely, I am sorry to see them go.

Firstly, what didn't I like?

Well, let's start with the 48-hour target. The way in which GPs fiddled their appointment systems didn't really sort out the structural confilct between seeing the GP when it suits (a future appointment) and seeing the GP "now - it's an emergency" (even though it almost never is!).

Some of the outcomes of the 18-week rule were frankly, bizzare. If a patient tried to change a hospital appointment, they were "discharged back to their GP" (NHSspeak for taken off the system) and invited to join the queue from the start when a further 18 weeks could be counted. This is clearly poor care and there is no excuse or justification for it.

So, why am I sorry to see them go?

I should explain that I am not opposed to quantitative measurements of performance to inform management. Looked at in isolation, these targets are reasonable; if you in some distress it is reasonable to be able to obtain medical help within two working days. Four months ought to be enough time for a patient to pass through the hospital system and be treated (providing there have been no unforeseeable delays).

The problem is not the targets but the way in which The Health Kremlin uses them.

Targets are not management or a substitute for management yet this is precisely how they are used. The orthodoxy is that we set these targets and leave the front-line to reorganise themselves to meet them. What doesn't happen is sensible pragmatic supervision and management of the behaviour of GPs and hospitals that are aspiring to these targets. Providing the PCT or Hospital can let their local Politburo tick the correct box, then the target has worked, even when a short stroll around the patch would reveal some of the nonsenses that have been carried on since the targets first appeared.

Another classic: the "no more than 4 hours in A&E target".

Introduced after countless lurid headlines of patients left lying on trollies in corridors for hours, days, weeks, etc. The target has resulted in a huge surge of patients admitted as in-patients because the precautionary test results (x-ray, whatever) wasn't available within 4 hours; all of this at considerable additional cost and inconvenience to everyone.

Before we had targets and no management.

Now we don't even have the targets!

It Only Works because It Doesn't

In the left corner:

Our PCT, insisting that we provide ever more appointments that have to be bookable two weeks in advance; also insisting that we see patients immediately when they say it's "urgent" even when it's clear it isn't; and also providing minimum number of appointments each GP must provide each week. Their targets are ambitious but we do our best.

In the right corner:

The BMA Guidance on child Protection which says amongst all the other excellent advice: "Doctors have a key role to play in child protection (case) conferences and the BMA considers it important that , as far as possible, doctors attend in person, in addition to sending in a written report containing relevant information such as ..."

In the middle:

The GP. We usually receive less than 48 hours notice of a case conference (that's because best practice is to convene it a.s.a.p). So the GP has usually already got fifteen or so patients each with a ten-minute appointment booked up to two weeks in advance, exercising their right to see the doctor of their choice.

The Outcome.

We rarely attend case conferences and until someone works out the realities of the conflicting demands made of GPs, that situation won't change.

The Moan

It's one of the things that really gets my goat. Managers have produced glossy (and expensive) books containing impressive procedures that are faultless in ambition, aiming for very best practice and overflowing with care. They simply don't work and nothing will change until they look at the realities of general practice. Try asking us - that would be a start.

Uncle Noel RIP

Yesterday I went to the funeral of the last of my mother's seven siblings. Uncle Noel died peacefully at the splendid age of 93. He started as a miner at the age of 14 but continued his education and after the war became the Deputy Master of Worcester Workhouse. What a splendid title! Pure Dickens, porridge and all. For the rest of his working life, together with my aunt, they cared for old people and they did it really well. My Aunty Mair's cooking was legendary!

When Mair sank into the swamp of dementia, it was all the more frustrating (polite version) to see the lack of care that she received despite the determined afforts of a feisty eighty-odd year old husband. Hospitals trying to discharge her because she "wasn't ill as such" and local authorities acting with a complete lack of urgency. After all, Uncle Noel could help (no, they hadn't noticed he was crippled by two very arthritic hips).

After Mair's death, Noel moved into a care home run by MHA (a methodist charity). At last, he received the sort of care that he and Mair had given to others. So thank you to MHA, the staff at Norwood, Ipswich and to Noel and Mair for lives spent providing real care for people not clients.

Is This The Real Meaning of "Efficiency"?

"Phlebotomy" = extracting blood for testing and monitoring patients. Some GP surgeries do it but mostly it's done either in the local hospital or a large health centre.

A few weeks ago we were informed that the afternoon opening hours our local phlebotomy clinics would be reduced.

"Why?" I asked (since afternoons were especially popular with people with jobs). The answer came back:

"The activity within the phlebotomy service has been increasing year on year since it transferred to the Community Provider from the local hospital in 2004/05 with very little increase in funding. We had managed to sustain a quality service within the financial constraints over the years. However with further financial reductions across all provider services it has become necessary to ensure the service that is provided remains of good quality and all governance risks are reduced which has unfortunately resulted in a reduction within the service for some of the afternoon clinics.

We had approached our commissioner colleagues for additional funding last year which was initially agreed for 6 months whilst they reviewed the service, allowing us to resume a full service. Unfortunately the funding agreed this year is not sufficient to provide the same level of service."

I always have trouble with "officialese" so just to be sure ...

"Thank you for your reply which leaves me rather baffled (nothing new there then)!

May I paraphrase?

(a) Demand is increasing
(b) Funding is decreasing
(c) The level of service is therefore reduced.

Or have I missed something?"

Clearly I hadn't and the further response had me reaching for the benzopump.

"Correct.
Whilst funding following the review increased our establishment by 1 phlebotomist only to be then used for efficiency savings. Leaving us with no choice but to provide a service within the envelope of money we have been given."

Just in case you have some difficulty in comprehending the sane and rational world in which I work, allow me to summarise:

1. Demand for the service has increased and thus so have the costs of maintaining the same service levels.
2. The provider asked the commissioner for more money and this was given but only why the commissioner reviewed the service.
3. Having completed the review, the commissioner agreed to increase funding to increase capacity.
4. The commissioner then took the money away again and called it "efficiency savings".
5. As a result, the service levels have been reduced.
   

Be Careful What You Wish For!

I guess everybody now knows the "old Chinese proverb":

Be careful what you wish for;
it may be granted.

A fair number of people must be hoping that the Tories do win the election that can be no more than six weeks away. Let's just suppose they do. Then what?

Trouble, that's what!! Big trouble.

The present lot have presided over and implemented the most right-wing policies ever experienced since the NHS was founded sixty two years ago. They have done so consistently ever since Tony Blah "discovered" health in 2000 (when a junior minister lost a "safe" seat in Kidderminster to a doctor who campaigned solely on keeping the local hospital open).

Now think of Charlie Whelan (a.k.a. Charlie Marx) running the Unite trade union and close fried of Gordon (you know ... "the safest pair of hands we've ever known as a Chancellor" - that Gordon).

Add these all together and you may understand why Labout have got away with it; the biggest privatisation of healthcare and lots more of it already signed and sealed if not delivered. Now fast forward to the second week in May ..

David Cameron walks into 10 Downing Street.
Andrew Landsley (presently shadow health sec.) walks into Richmond House, 79 Whitehall.
Guess who will be walking out?

• nurses
• porters
• technicians
• cleaners
• maintenance people
• drivers
• etc

The "free ride" enjoyed by Labour will be over. Any cuts will be an immediate political cause celébre.

I know several people who will vote Labour not because they admire them but because:

• the country cannot be ungovernable at such a time;
• they should be forced to have clear up the mess they've made.
  

Care in the Community - Been There - Got Nothing

The sudden burst of posts might lead you to think that I have suddenly become more agitated of late but you'd be wrong. It's just that the year end in public accounting is when we all get inundated with requests for "stuff" - I won't bore you with the trivia that is much of my working day. The worst of the storm has passed, so I can attempt to benefit from the catharsis from shouting at the world-wide webosphere.

The current DH obsession with "moving secondary care into a community setting" brings back both some sad memories from my own childhood and also my own view of the last time we heard "care in the community". This was a dominant mantra of the Thatcher years. Why sad?

Well, my elder sister was born brain-damaged and remained a young child for the twenty one years she spent on the planet. At the age of twelve, in the early fifties, she was sectioned and sent to St Lawrence's Hospital in Caterham. She wasn't a danger to herself or to anyone. It was simply because my parents couldn't care for her due to my mother's failing health. Every other Sunday, we visited for two hours (having to queue outside the main gate until precisely 2pm). The journey was bus, train and then bus again and it took two hours each way. The wards were crowded and the nurses were amazing. Most of the inmates were there because that was the only structure in place at the time to provide such care. Once admitted, the "patients' " chances of leaving alive were almost nil since there was no rehabilitation; just detention. You might think then that I would be "Care in the Community's" greatest fan? If only!

The reality was different to the hype. Who can argue that my sister and most of the other 2,499 prisoners would have been better off if the vision of Care had been delivered?

Instead, the whole strategy was used by central and local government to leech money from the system to meet their short-term financial imperatives. St. Lawrence's was closed the government pocketed the proceeds of selling prime Surrey commuter belt development land. Local authorities were left with inadequate budgets and insufficient experience to absorb a wholesale shift to them of people who had spent their lives in such institutions with complex health needs and no clue of how to even help in their own care. It was ten shameful years of waste, unnecessary bewilderment and confusion.

The problem was not the intention. it was its implementation. If I could lay my hands on the mandarin that executed this appalling act, I would cheerfully throttle him.

Polyclinics - An Elegant Summary

George Monbiot writes for The Grauniad. his article on polywotsits is a standard of writing to which I can only aspire with little confidence of achieving.

Do read it here