Timber.r.r.r.r.r.r.r.r

Everybody and his or her dog reckons they know how GPs work. They don't need to ask us before providing new systems 'cos they already know what we do. They don't need to ask us if the new system will work. Of course it will work. Could anything be more simple? Well let's see.

The "Choose & Book" system had a cleverly designed form that it printed for us to give to patients. It provided them with their reference number, the information they need to contact the hospital of their choice and finally their password. The minimum amount of information requires about eleven inches of text. For those of us in the world of "A4" that's one sheet of paper for the first nine inches of text plus one sheet of paper for the remain two inches. There's lots of white spaces so it could have been condensed with a just molecule or two of design. Now after five hundred referrals and five hundred sheets of (almost) blank paper, we were delighted? to see that they have redesigned the form. Some bright spark at CfH has discovered Text Boxes. Yippeee.

Now two sheets of paper have become three. The second has a little bit of writing. The third has a couple of lines or so.

Timberrrrrrrrrrrrrrr.

I See No Ships

Dear Patsy,

Thank you so much for all your recent communications to us lowly people who look towards you as their leader. My word you have been busy but through this maelstrom of media engagement your new organisation has triumphed. I haven't actually seen the Powerpoint presentation as yet; our PCT's IT department is busy taking down the Christmas decorations at their shiny new offices in Marie Celeste House. Nevertheless I think I have the gist of what you had done. Perhaps you could confirm my understanding?

Your new communications team (the Strategic Press Information Network - "SPIN") have already scored some notable goals for the good guys. Clearly it helps to have a clear and unabiguous target (and what government has more impeccable credentials when it comes to targets?). Having said that, why not come out into the open and say exactly who you mean instead of hiding behind a code name of Greedy Pigs (or "GPs" as they are already known amongst the congoscenti). Let's name and shame. After all, these GP bastards have a lot to answer for.

There's that awful PFI or "Perpetual Financial Indebtedness". I was about to say that only GPs could have come up with so financially awful but then I remembered ENRON who did try the same thing. Still your solution is a master touch. "Put the Blame on Contractors" or "PBC" has solved the problem in one simple yet ever-so-stylish stroke. Of course, PBC only works when viewed against "PBR" (the "Public Sector Borrowing Requirement"). This clearly is no impediment since our almost Prime McMinister seems to have no problem in shuffling the numbers around with the leger de main of a Mancunian croupier.

As any good admiral, you are now reaping the benefit of having thought ahead and deployed your reserve troops ready to deal with the situation as it has unfolded. Operation "Blame" ("Bring in Lots And lots of Management Experts") is as much a triumph as Nelson's was at Trafalgar. Everyone expected you to cover up the mess made by these GPs but oh, no! You simply came right out and did it. "It's all the GPs fault. They have taken all the money."

Brilliant!

I can't wait for next week.


p.s. Just remind me - who were those GPs exactly?

Wow! What a response!!

Patsy,

The speed of your response is breathtaking. Thank you.

Thank you for the names I requested as examples of very bestest practice. I'm ashamed to admit that I thought you might find it a little difficult to find a name but so many?? That's truly impressive stuff. I've already had a preliminary chat with most of them and will update you further once I 've had the chance to absorb the 28-carat nuggets that were forthcoming. However, these are my first impressions:

John Prescott was really helpful (I think). It was a little difficult to find him at first. I wasn't sure which car he was in and to which of his government-provided houses he was being driven but I am nothing if not persistent and, like the mounties, got my man. He had much to say. I must confess that I did lose the thread occasionally but this is only to be expected when dealing with a man who runs much of the country when TB is away (which seems to be rather a lot these days). (Off the record, he really is worth more than the £150,000 a year plus expenses plus cars plus offices plus staff plus pension etc. A bargain if you ask me). Lord Prescott will only add lustre to the upper house (should he need a third).

Next came John Reid. I really struck gold here since he was able to arrange a "four-way" teleconference between the two of us AND Charles Clarke and David Blunkett. This I was able to get the collective wisdom of all the players who had delivered a Home Office which frankly is an example to us all. It also completely clarified what is meant by "fitness for purpose". Gosh, don't we have a long way to go?

Perhaps the most difficult interview was with Frank Dobson who as your predecessor in 1997 can take all the credit for demolishing those appalling Tory gimmicks such as internal markets, devolved budgets, etc etc. It is still a puzzle to see why he came a bad third to Ken Livingstone and Steve Norris in the London mayoral elections. Clearly it has left its mark. Still he did have some words of praise for the Treasury who have always been so supportive of his efforts.

I've left a message for Ruth Kelly at Education but she's not taking calls. I don't have a number for Margaret Hodge so all-in-all Education is a proving a tad tricky.

Steven Byers suggested floating our surgery on the stock market and then cancelling the shares but was a little vague on detail. David Miliband at Defra suggested I could learn a thing or two about making every penny count by looking at his department's work on the common agricultural policy.

I've left the best until last. Our beloved London Mayor was unsparing in his help and was generous in providing me with a text-book study on spending £800+ millions that wasn't in his budget on buses that now run every ten seconds in packs of five meanwhile taxing the overpaid bourgeoisie swanning around London in their 4x4 tanks to pay for it. Surely there is no better example on how to soak those rich GP bastards. You can rely on Ken.

I am so totally energised by your timely response. You have only increased my determination to prove that we in the health service can do just as well as our beloved leader has done for the people of Iraq.

What a team! What results! What an example to us all.

Your greatest fan

p.s. my thanks to my good friend Dick for his input.

An Appeal

Dear Patsy,

I am writing to say how sorry we are to have been the cause of so much inconveniece to you and your team at the Depratment of Health. How could we have been so inconsiderate? How could we have so exceeded your performance expectations and quality targets. Please, please calm yourself. The solution is at hand.

Our partners have cancelled all their sessions for this week in order to focus on re-establishing the "cost trajectories" that had been established in your original plan. In doing so they are helping in two ways: firstly, it will lower our quality indicators scores and start us on a firm trend towards the 777 points you assumed we "average" practices would achieve. Secondly, we will stop registering new patients which will lower our totals thus directly reducing our income. It has been most pleasing to help you achieve these most important objectives. Of course, we need to look to the longer term. God forbid that we should ever be accused of short-term thinking.

We will be issuing redundancy notices to the two health care assistants that we recruited to shoulder much of the administrative and routine monitoring tasks. Such actions have both good and bad outcomes with which we are
wrestling: we will achieve less and thus earn less which surely is a good thing? The trouble is we will spend less so we will still appear to be the same greedy money-grabbing bastards you have led with such grace, such aplomb since your appointment. Our nurse practitioner has now finished her nurse prescribing course and which for the past four months we have been trying desparately to get our PCT to authorise so she could use the knowledge she has worked so hard to learn. We didn't realise that their gross inefficiency is part of your master plan to reduce our prescribing spending. So, our pursuit of the appropriate signature will cease immediately.

Reducing our staff brings other benefits. We now have some spare equipment so if you know of anyone who wants two Celeron P2 PCs with less memory than the average Alzheimer victim, together with two HP 959c printers with worn print heads and wonky power lead sockets and who provided they can outbid our local museum, then they are theirs for the asking.

However, let's not be negative. There are some real win/wins on offer. We have decided only to refer patients if secondary care can be booked via your wonderful Choose and Book system. Thus you will soon be able to claim that everybody is using Choose and Book successfully and you never know, one day it might actually be true. What a day that will be. In the meantime, we continue to enjoy the built-in restrictions that slow down the whole process thus in turn reducing spending. We especially like the way you have camouflaged these sophisticated barriers as technical problems, slow connections and inexplicable log outs. Darned clever those computer boffins.

I'll need your help on the next one. Could you point me in the direction of another government-led organisation that has been too successful and resulted in over-generous incentive payments? I would like to have a "heads up" with your opposite number in whatever ministry they work to get the griff on how to claw back the money whilst maintaining morale and improving output. One will do, although two names would provide me with more depth of experience. No rush on this one.

Finally I do feel the need to confess that we may unwittingly provided ammunition to those who feel that your views on general practitioners may be anything but entirely well-informed and wholly accurate. So, with immediate effect, we are withdrawing our labours from our local out-of-hours service so that we cannot be accused of earning too much from private fees. I have to confess that we failed to opt out and reduce our income by the fifty-odd thousand quid our partners could have spent on you rather than on themselves but it's no use crying over spilt milk. I don't like a "blame culture" any more than you, but quite frankly, it wouldn't have been a problem if our local GP co-op wasn't so damned efficient. Then out-of-hours cover would have cost us the fortune it seems to cost in most other places. Still, I have now hit our co-op manager round the back of the head with a plank and let the air out of her tyres and this should do the trick.

Please find enclosed a cheque from the practice which represents a downpayment on the repayment of the scandalous Tsunami of cash that has come our way. More will follow I am sure. Perhaps we should send it direct to Accenture who nearly lost so much money on NPfIT? Didn't you used to work for them? Perhaps you could let me have the address of one of your colleagues?

Always here to help,

Bestest wishes

A Letter to my MP

Dear Dianne Abbott,

After much consideration, I have decided that it really is about time that you, as my MP, put my interests at the forefront of your thinking. Gone are the days when every four years or so, you could break off from your busy schedule of evening television programmes to remind us all just how great you have been at doing whatever it is that you do. I think it's about time that you put us, your constituents, at the heart of your thinking.

Recently, I got together a group of citizens and we held a "Citizens Summit" at 'The Fox Reformed' on Stoke Newington Church Street. I asked them what they would like to see from you, their MP. Their responses were interesting and I have sifted through them to find those that are neither physically impossible nor morally repugnant. There were a few left.

First of all, we want to see you at a time and place that is convenient to us. I work away from Hackney so I expect you will make reciprocal arrangements with your Newham colleague so I can visit him during my lunch hour. Also, I'm taking the mother-in-law to Prestatyn in the new year, so I would be grateful for contact details of your colleague there just in case I feel like an evening chat.

Now your website doesn't actually give details of your constituency "surgeries" (I think that's the term) but I do have a number of irritating minor ailments, so I need to know where I can make several appointments stretching through Christmas and the New year. At the same time, I wish to be reassured that should I have a short-term crisis with my brown recycling bin, you will be on hand to get things done. Now I just thought I should warn you that I may, or may not keep these appointments.

When I do visit you, it may be that I will need to speak to someone else as well. I would like you immediately to make me an appointment with that person, again at a time and on a date of my choice. Of course, I would expect you to confirm it in writing.

Finally, I am enclosing my proposals for "Payment by Results". This exciting and radical plan represents the biggest shake up in parliamentary procedure since Dennis Skinner said something constructive and no more that mildly offensive. Quite simply, MPs will be reimbursed on the basis of "outcomes" rather than at present. I suggest fifty five quid for a consultation; twenty pounds for writing a letter; let's say thirty quid for each day in excess of fifty days a year that you actually turn up at Westminster and say something .. ( I was about to say "useful" but let's not run before we walk).

Even more exciting will be the Enhanced Payments to which you will be entitled once we have completed a survey of your constituents. We will mail a number of them at random and ask them questions about what they think of you and your effectiveness as their democratic champion. I attach a sample questionnaire but suggest that you pay it little heed. It's not the one we will actually send out to people.

Finally let me offer you some soothing words about those dreadful rumours that have been circulating. Of course at this stage, nothing can be ruled out but I am happy to reiterate that at this moment in time we have no plans to introduce private contractors into the House of Commons to take over constituencies where performance may be below par. That doesn't mean to say that we won't be pushing to expand those parliamentary walk in centres. You know the ones. You turn up; they listen attentively; and then they tell you that you need to see your own MP for that particular problem. Whilst they don't actually add much value, we do think that they sound good and we'll get lots of brownie points from our friends and neighbours.

I look forward to seeing you next Saturday afternoon at about six-ish. I have this nasty rash on my front drive .....

Do shoot the messenger. Just make sure it's the right one.

The real problem with a well-functioning democracy is that our representatives need you and me to re-elect them every now and again. This would be more than a tad difficult unless he or she can convince you that: (a) they're doing a good job; and, (b) their opponents would do it worse. Recent governments have perfected the art of making all news sound good or as we all know, "finding good days to bury bad news".
The NHS has been until now a rich vein of positive-sounding anecdotes. So it should be considering how much of our money they've thrown at it. I just wish they would act more responsibly and consider the wider implications of the claims they make.
It's all very well managing patients' expectations to make it sound as if things are now under control - "the NHS is safe with us" - "an appointment when and where you want". The whole "spin thing" depends on Joe Public not reading the small print and by and large he doesn't. At least, not until he walks up to the GP reception desk and asks for a hospital appointment on Thursday at the hospital near his Mum in Cardiff where he's staying for a week or so. It's left to us to explain the small print.
You can understand why Mr Public is puzzled. He's been told: "when you want it". He's not been told that he can choose, but it is only from any one of a number of appointments all of which are three months or more from now. He's also more than little pissed off that he can choose to go where he wants but only as long as it's to any one of four local hospitals. Cardiff is in another country as is Edinburgh and Belfast. As usual, it's the GPs' reception team that have to explain the precise realities and how they vary from the crowing and the disingenuous claims being made for purely political gain.

Good Housekeeping

Imagine you are manager of your household's finances. Your spouse tells you that you will receive £xoo each month to keep you both in food, bog rolls, cleaning stuff as well as pay the gas and electricity bills and all the other domestic minutiae. The amount on offer is barely sufficient but, with careful management and a keen eye on the money-off bargains and the dented tins shelf at your local supermarket, you reckon you'll get through the month.

With me so far? Now imagine it's the twentieth of the month.

Your spouse tells you that it isn't £x00 pounds after all. It's £x00 less £250. Oh and by the way, that applies to last month as well so you owe £250 in arrears and the housekeeping fund is empty.

How do would you feel?

Welcome to the wacky world of NHS financial planning.

Free for All

It seems to me that taxation is a kind of unwritten agreement between me and the politicians. I agree to give the money and in return they give me and mine with all the sorts of stuff that can only be provided by pooling my money with every other citizen's money. Our A&E services are available free to anyone who really needs them and this is a very good thing. I wouldn't want it any other way. GP services are another matter entirely.
GPs are there to provide the basic support for our residents in the management of their healthcare and to help them when they need medical help. It's "free" but only to the individual. The NHS bill in our borough alone is well over a billion pounds a year. That's funded by our taxes (I actually wish people would call it "paid for"). As I said, I am happy that they use some of my money to provide emergency medical services to anyone in need. I am less than happy that these same politicans seem quite happy to provide the full range of NHS benefits to anyone that walks up to the counter and asks for them.
Before you jump to label me some sort of fascist, racist uncaring hard-hearted xenophobe, let me acknowledge that if someone is in our country and is unwell, I am glad that we are compassionate enough to ensure that they are treated.
I am a relative newcomer to the NHS - I'm over half way through my fourth year. I work in a GP practice that is popular with most of its patients and our GPs are an amazingly dedicated bunch of extraordinarily nice people. From my perspective, our patients are really fortunate in healthcare terms to be living in our neck of the woods. When I first started working for them, I found it almost impossible to comprehend how easy it was for anybody, and I really mean anybody, to obtain NHS care from them. There is no working system that checks to see if a person is entitled to NHS care. I found it incredible at the start and still do.
The only real determinant of entitlement is whether or not the applicant is "ordinarily resident". This is a common law term which is the Government explains: "The term “ordinarily resident” is not defined, but its established meaning is that a person is ordinarily resident if they are normally residing in the United Kingdom (apart from temporary or occasional absences), and their residence here has been adopted voluntarily and for settled purposes as part of the regular order of their life for the time being."
In other words, you can turn up at our reception and say that you have come here voluntarily and for settled purposes etc. Nowhere does it say that you are entitled to live here. Nowhere does it say that you have to work, pay taxes, be a citizen of the European Union.
It didn't seem fair to me then and doesn't feel fair now. I know that we register "medical tourists" all the time. We provide NHS prescriptions for people with long-term chronic conditions who have arrived to stay with relatives or friends and who have no medication and no medical insurance. All they have to say is that they have come to live here. I am not allowed to check their immigration status and I have no way of checking their entitlement. Health service regulations on the subject provide complete "decision tree" guidance at the bottom of which is "if the person still appears not be entitled, the person can still be registered at the GP's discretion". In these litigious times, witholding medical treatment can be ruinous to a GPs bank balance so the medical insurers tell us to register them.
The upshot is that if you can get through immigration at Heathrow, you will get "paid for" NHS care. It's as simple as that whatever the government might say otherwise.

Let's All Focus

You will pleased to note that the NHS decided to concentrate its efforts.

"Other key themes to emerge (sic) from the consultation process were: " ...investing in services for people whose health and well-being may be at greater risk, for example: minority ethnic groups, teenagers, and people on low income."

Well let me see. The population of England and Wales in 2001 was recorded as 49,138,831 people.

• Sixteen percent of these are aged 65+ and we can hardly leave them out. That's 7,862,213 pensioners.
• Add to that the thirteen percent of the population who are teenagers and that's another 6,642,321.
• That leaves 34,634,405 of whom eight per cent come from ethnic minorities - 2,770,752.

I could go on but simply add on pregnant women and those in post-natal care, the long-term chronic sick, victims of accidents and crimes and somehow the focus starts to become a tad blurred.

Dont forget that since 43% of UK NHS spending goes to the elderly, that leaves just 57% of funding for the rest of us 84% of the population.

It's the sort of gibberish that is pleasing to the ear and meaningless to the wallet. Do we really live in a society where teenagers are counted as " ... people whose health and well-being may be at greater risk"? If so, we are all deeply in the proverbial.

"Your health, Your care, Your say" but who PAYS?

Read the new government White Paper? With its zippy touchy feeley title, it can only be a political winner. This government "listens". It puts us first. It drives me bonkers.

The whole "listening exercise" with its preposterous "citizens summit" and its "panels of stakeholders" seems to me to be a complete abrogation of strategic management by the Department of Health and the National Health Service. Don't tell me that it was worthwhile because it was important to listen to what the public wants. That has as much value as asking my granchildren to design the menu for school dinners. Perhaps I can suggest a new title? "What shall we promise you to get your vote?"

If the mercury wasn't already popping out of the top of the sphygmomawotsit, to conveniently forget to ask these wise public people to consider costs makes me really angry. Of course I want to visit my doctor when I'm ill, any time day or night, weekends, bank holidays, when I'm doing the weekly shop. Of course I want all the services I might need all installed nearby just on the offchance I have a knee strain or a rather unsightly rash. I'll take it all as long as it doesn't cost me anything.

Staying open a bit longer is simple. All you need to do is .... well, stay open a bit longer? Oh, you then have to either recruit additional staff or pay overtime. Then there's the security guard since there are some strange night dwellers where we live. Oh and since we are a service, we have to provide sufficient staff to guarantee the service despite sickness, holidays and absenteeism. So where's the problem? A receptionist or two, a security guard, a doctor and a nurse should do it. Oh and a cleaner. Maybe the caretaker might not like working longer hours but it's probably OK.

The whole thing is a disgraceful piece of political posturing done at the taxpayers expense and which has served to raise expectations without proper regard to the sensible use of NHS funds. We need an honest and open debate about the true and ever-rising costs of providing complex and costly drugs and treatments and how this can be properly funded. Just like twenty years ago we needed the same thing about pensions. We didn't get it then and it isn't happening now. Instead we get platitudes, slogans and expensive and meaningless Labour propaganda dressed up as national policy.