As we rapidly approach the General Election the main political parties seem to be trying to out do each other with their spending plans (or non-spending plans to be more accurate). I read that the NHS is expected to save £4bn in the next couple of years and up to £20bn by 2014.
Thats a lot of pennies. Of course the politicians hate to talk in terms of cuts to spending so its called 'efficiency savings'. Surely this then implies that they have been throwing money at the NHS without bothering to check if its spend efficiently? Curiously this seems to happen all the time at the Ministry of Defence. They always seem to pay far too much, get the items (planes/helicopters) far too late and then their not even fit for purpose. I must confess I don't understand funding billions for the killing industry but then cutting funding for the life-saving one?
Anyway, I'm not a politician - thank God. I don't have to worry about balancing the books. But what if they decided to make the NHS independent of political control, like the Bank of England (fat chance)?
If you had to cut the NHS budget by £4bn what would you target?
Choose and Book? Where most patients want to choose their local hospital and the booking process is unnecessarily complex? Well that’s £200million, of course you have to replace it with something - which will have its own costs. What about the entire National Programme for IT? That’s meant to have cost £2.3bn over 3 years, now £12+bn and its still not finished. I don't think you can get a refund sadly so it may not actually save that much by scrapping it.
Homeopathy on the NHS - clearly a waste of money but would only save £4m. Independent Sector Treatment centres - ah, now that scrapping area might save a fair few quid seeing as they seem to get paid regardless of whether they do the work or not. What about the Private Finance Initiative scheme which is funding over 100 hospitals? That’s a whopping £10.9billion but by the time the final payments are made in 2048 that will be £62.6bn - again, can't get a refund and can't pull out of existing schemes but stopping wasting money on future schemes would seem sensible. How about restricting prescribing to a limited list of cheap and cheerful generics? Or is that a step too far?
Of course you could go to all this trouble by shafting the NHS and then bankers waste billions on some hair-brained-get-rich-quick scheme, need another bailout and then we are back to square one again.
Ultimately I know what will happen. GPs will get it in the neck. Funding will be reduced, we'll be berated in the press for being greedy bastards and its only a matter of time before our pensions are plundered. None of this will fix the problems but it takes the heat of the MPs and we are an easy target as we never seem to do anything about it.
Tuesday, 30 March 2010
Tuesday, 16 February 2010
Death becomes her
As a locum GP I think I am getting better at spotting money making opportunities when they turn up. I note that the public seems to be changing its opinion on assisted suicide, or active euthanasia to give it its proper term. No doubt this will eventually be made law as politicians have an annoying habit of passing populist laws based on opinion rather than fact or worst still hiring experts and then firing when they don’t agree with them. It does seem a curious vote winner but we live in curious times I guess.
Anyway, back to my first point, how can you (or the NHS) make money out of assisted suicide? It seems clear that this will eventually become law so I suggest brushing up on ways to kill your patients. No doubt the Shipman Guidelines will need to be drawn up to decide what drugs are best at bumping patients off. I’ll hazard a guess and say that not every doctor is entirely keen on the idea of euthanasia or variants of it. Well, its no time to be displaying a backbone or relying on your moral guidance.
As a large number of doctors will not want to take part in the selective reduction of vulnerable patients it could mean a big cash bonus for those of willing to wield the scythe. I’m sure you can think of a number of your elderly patients who don’t want to be seen as a burden or make a fuss, well now you could finally have the opportunity to help them shuffle off this mortal coil. You no longer have to worry about such trivialities as palliative care and all those fiddly drugs. A quick consent form, needle in the arm or pills in a cup and hey presto, one assisted suicide cash bonus and perhaps even a cremation form fee if you are lucky.
Its only a matter of time before it becomes part of the QOF targets. Just think of all the money it could save the NHS! ICU bed numbers could be slashed, hospices could close and we’d have another treatment option for our severely depressed or heartsink patients. Hopefully the money saved will be reinvested in other areas of the NHS but don’t hold your breath. The Government is pretty short of cash at the moment and needs every penny.
If you became a Specialist in Regulated Euthanasia Assisting the Passage to Everlasting Rest (R.E.A.P.E.R) you can forget about the need for basic life support skills (unless you ‘assist’ the wrong patient!). I would expect that it would be unlikely the patient complains but its possible that the family might if their dear relative didn’t die peacefully or if you declined to ‘assist’ their granny who lives in mansion that’s far too big for her.
Seems like a win-win situation to me, what could possibly go wrong?
Thursday, 4 February 2010
To jab or not to jab?
A patient came to see me the other week and asked me about the swine flu jab for her children. Should she get her children vaccinated?
She had two healthy children under five with no pre-existing illnesses. The media had helpfully pointed out that the children who had died from swine flu had pre-existing illnesses, although rather more unhelpfully no one was saying what these illnesses were.
Being a locum, I thought I had missed the official information to give to parents about the jab. I checked in with Dr Google but couldn’t find a thing. A few papers here and there, but nothing that had meaningful numbers in it. I was surprised as there is a wealth of very good information for parents about other vaccines but nothing that I could find for swine flu.
Eventually she decided that she wasn’t going to bother as she thought it was all rubbish. Not exactly the informed choice I was hoping for, but it’s her choice nonetheless.
Then the invite came through for our children, I was faced with the same choice: to jab or not to jab? I won’t bore you with medical papers that I read to see if was really necessary to vaccinate an otherwise healthy child for a mild illness (in most) that she may have already had or may not even catch.
Click here to find out more!
But what I wasn’t prepared for was the amount of hand wringing and floor pacing about the decision to potentially stick a needle in my child’s arm. Previously the wife had taken the children to their jabs so she had to endure the sight of a needle piercing their flesh, the looks of betrayal on their cherub-like faces and the inevitable ear piercing shriek that followed.
The daughter was sick the other day, and three weeks later she is still harping on about how she puked – God knows who taught her that word. Would I be prepared for her constant whining about how Daddy let the nurse hurt her and the years of counselling she would no doubt need afterwards? Not to mention the fact that it’s not nice to see your child in pain. Would I get emotional? I couldn’t blame it on the hayfever as it was winter. Perhaps blaming the dusty environment might help.
It made me realise that what we might regard as trivial – a quick jab, or a blood test - can be very upsetting for the child and parent and that might discourage them from attending or going along with the management plan. How do you explain to a 3-year-old what is about to happen? It's no wonder children bawl their eyes out when they attend the doctors.
I’ve asked colleagues and friends about the swine flu jab and it's been more or less a 50:50 split over whether their children have had it or not. The uptake is poor in the otherwise healthy, which has got me wondering whether it was worth offering in the first place?
The government wasted million on Tamiflu, which was largely useless. Have they done the same for the swine flu vaccine?
She had two healthy children under five with no pre-existing illnesses. The media had helpfully pointed out that the children who had died from swine flu had pre-existing illnesses, although rather more unhelpfully no one was saying what these illnesses were.
Being a locum, I thought I had missed the official information to give to parents about the jab. I checked in with Dr Google but couldn’t find a thing. A few papers here and there, but nothing that had meaningful numbers in it. I was surprised as there is a wealth of very good information for parents about other vaccines but nothing that I could find for swine flu.
Eventually she decided that she wasn’t going to bother as she thought it was all rubbish. Not exactly the informed choice I was hoping for, but it’s her choice nonetheless.
Then the invite came through for our children, I was faced with the same choice: to jab or not to jab? I won’t bore you with medical papers that I read to see if was really necessary to vaccinate an otherwise healthy child for a mild illness (in most) that she may have already had or may not even catch.
Click here to find out more!
But what I wasn’t prepared for was the amount of hand wringing and floor pacing about the decision to potentially stick a needle in my child’s arm. Previously the wife had taken the children to their jabs so she had to endure the sight of a needle piercing their flesh, the looks of betrayal on their cherub-like faces and the inevitable ear piercing shriek that followed.
The daughter was sick the other day, and three weeks later she is still harping on about how she puked – God knows who taught her that word. Would I be prepared for her constant whining about how Daddy let the nurse hurt her and the years of counselling she would no doubt need afterwards? Not to mention the fact that it’s not nice to see your child in pain. Would I get emotional? I couldn’t blame it on the hayfever as it was winter. Perhaps blaming the dusty environment might help.
It made me realise that what we might regard as trivial – a quick jab, or a blood test - can be very upsetting for the child and parent and that might discourage them from attending or going along with the management plan. How do you explain to a 3-year-old what is about to happen? It's no wonder children bawl their eyes out when they attend the doctors.
I’ve asked colleagues and friends about the swine flu jab and it's been more or less a 50:50 split over whether their children have had it or not. The uptake is poor in the otherwise healthy, which has got me wondering whether it was worth offering in the first place?
The government wasted million on Tamiflu, which was largely useless. Have they done the same for the swine flu vaccine?
Tuesday, 3 November 2009
A day in the life of a salaried GP
I am no longer a salaried GP, but I thought that you'd enjoy this article I wrote for Pulse magazine - it shows a day in my (old) life.
I could tell you about a normal day in the life of a salaried GP but it would be really rather dull.
This Monday, however, was a rather unusual day - the first day in our new building. The partners had been sweating bullets over it for the past few months and the big day was finally here. We had a sneak peek on the day before to find our way around and marvel at the nice new desks, smooth floors and curious locking mechanism on the doors. Keys are a thing of the past, instead we have a new little key fob that you wave at the handle and the door unlocks. The fob looks alarmingly rather like a shiny black suppository.
0800 I arrive half an hour early to set-up, and find out whats going on. I have the pleasure of doing our rapid access clinic on the first day. It’s a clinic with 5min slots designed to see all the minor complaints – like sore throats, colds, earache – so the complex stuff goes to the normal clinics. There is not much room for pausing or having chat, it’s a fast clinic and if one patient takes too long it very quickly over-runs. I predict problems, it’s in a new building that’s a bit maze-like and a doctor that doesn’t know where anything is.
0805 The trays we use to store our sick notes, forms and such like have quadrupled in size. I don’t have one or a name plate. Sadly I still have to work.
0810 First things first, time to check the most important room in the building. The tea point. So far so good.
0820 Receptionist informs me toilets are not flushing as the water hasn’t been switched on yet. Wish they had told me before I had a sit down session. Feel sorry for whomever uses it after me…
0830 Clinic starts! Patient is told they are my first patient in the new building, the patient doesn’t seem impressed and just wants their sick note.
0845 Hear the water has been switched back on. Run back to loo and flush the evidence.
0915 Need to weigh a patient. New scales not calibrated yet. Only one set of scales working, on other side of building. In a nurses room.
0950 First patient to complain about the car park being too small.
1000 Patient who doesn’t speak English tries to do consult with relative translating via mobile phone. No mobile reception in the new building. Oops.
1026 Notice that we have soft-close bins. Very nice. Patient feedback about new building generally positive
1030 Emergency case turns up needing my help and eventually an ambulance. Clinic running behind now.
1100 Total of 1 hour of urgent extras to see. Most are not urgent.
1215 1 home visit hasn’t been taken. Down to me to argue with doctors to see who is going to do it. Phone patient but they have gone out, informed they will be back from the shops soon.
Politely inform family that we will not be doing a home visit for them. Total of 24 visits today, split between 13 Doctors. Notice that a Partner did an early morning pre-booked clinic between 7-8am. Not a single patient turned up.
1250 On the phone and it starts ringing – it has more than 1 line! No idea how to swap calls so ignore ringing.
1256 Rapid access clinic finally finished. Just a mountain of paperwork to do now and script signing. Room is freezing so wear my coat.
1325 Paperwork finished. Should have been in a meeting that started at 1300. Turn up late, not missed much. Jealously spy the fancy new coffee machine in the corner of the meeting room. Can’t use it though as one of the Partners said it costs a small fortune to use. (Last week one of the Partners did get a coffee out of the machine. Shortly afterwards a sign appeared on it saying Out of Order – awaiting connection to water supply. To discourage anyone else from using it? Who knows.)
1400 Meeting finished. Got 30mins before afternoon clinic starts. Decide to walk to shops for sandwich as not sure I’ll get a parking space on my return.
1430 Afternoon clinic starts
1600 Angry email from reception manager moaning about the new tea point being dirty and no-one is washing their own mugs
1630 Feeling generous and see 2 patients who are both 20mins late each. Would normally ask them to rebook but as it’s the first day in the new building I let them off.
1700 Informed that last patient has gone to the old building. See them 10mins later
1715 Done. Leave after washing up my mug. Race across town to pick up daughter before nursery shuts at 6pm.
All in all the day went well, apart from the workload. Might try and get a cup of coffee out of the machine upstairs next week when no-one is looking.
I could tell you about a normal day in the life of a salaried GP but it would be really rather dull.
This Monday, however, was a rather unusual day - the first day in our new building. The partners had been sweating bullets over it for the past few months and the big day was finally here. We had a sneak peek on the day before to find our way around and marvel at the nice new desks, smooth floors and curious locking mechanism on the doors. Keys are a thing of the past, instead we have a new little key fob that you wave at the handle and the door unlocks. The fob looks alarmingly rather like a shiny black suppository.
0800 I arrive half an hour early to set-up, and find out whats going on. I have the pleasure of doing our rapid access clinic on the first day. It’s a clinic with 5min slots designed to see all the minor complaints – like sore throats, colds, earache – so the complex stuff goes to the normal clinics. There is not much room for pausing or having chat, it’s a fast clinic and if one patient takes too long it very quickly over-runs. I predict problems, it’s in a new building that’s a bit maze-like and a doctor that doesn’t know where anything is.
0805 The trays we use to store our sick notes, forms and such like have quadrupled in size. I don’t have one or a name plate. Sadly I still have to work.
0810 First things first, time to check the most important room in the building. The tea point. So far so good.
0820 Receptionist informs me toilets are not flushing as the water hasn’t been switched on yet. Wish they had told me before I had a sit down session. Feel sorry for whomever uses it after me…
0830 Clinic starts! Patient is told they are my first patient in the new building, the patient doesn’t seem impressed and just wants their sick note.
0845 Hear the water has been switched back on. Run back to loo and flush the evidence.
0915 Need to weigh a patient. New scales not calibrated yet. Only one set of scales working, on other side of building. In a nurses room.
0950 First patient to complain about the car park being too small.
1000 Patient who doesn’t speak English tries to do consult with relative translating via mobile phone. No mobile reception in the new building. Oops.
1026 Notice that we have soft-close bins. Very nice. Patient feedback about new building generally positive
1030 Emergency case turns up needing my help and eventually an ambulance. Clinic running behind now.
1100 Total of 1 hour of urgent extras to see. Most are not urgent.
1215 1 home visit hasn’t been taken. Down to me to argue with doctors to see who is going to do it. Phone patient but they have gone out, informed they will be back from the shops soon.
Politely inform family that we will not be doing a home visit for them. Total of 24 visits today, split between 13 Doctors. Notice that a Partner did an early morning pre-booked clinic between 7-8am. Not a single patient turned up.
1250 On the phone and it starts ringing – it has more than 1 line! No idea how to swap calls so ignore ringing.
1256 Rapid access clinic finally finished. Just a mountain of paperwork to do now and script signing. Room is freezing so wear my coat.
1325 Paperwork finished. Should have been in a meeting that started at 1300. Turn up late, not missed much. Jealously spy the fancy new coffee machine in the corner of the meeting room. Can’t use it though as one of the Partners said it costs a small fortune to use. (Last week one of the Partners did get a coffee out of the machine. Shortly afterwards a sign appeared on it saying Out of Order – awaiting connection to water supply. To discourage anyone else from using it? Who knows.)
1400 Meeting finished. Got 30mins before afternoon clinic starts. Decide to walk to shops for sandwich as not sure I’ll get a parking space on my return.
1430 Afternoon clinic starts
1600 Angry email from reception manager moaning about the new tea point being dirty and no-one is washing their own mugs
1630 Feeling generous and see 2 patients who are both 20mins late each. Would normally ask them to rebook but as it’s the first day in the new building I let them off.
1700 Informed that last patient has gone to the old building. See them 10mins later
1715 Done. Leave after washing up my mug. Race across town to pick up daughter before nursery shuts at 6pm.
All in all the day went well, apart from the workload. Might try and get a cup of coffee out of the machine upstairs next week when no-one is looking.
Thursday, 29 October 2009
Free at last!
By the time you read this I will be a free man. Free from the shackles of being a salaried GP! I will have stepped out into the big wide world and blinked at the bright sunshine. Much like the old chap, Brooks Hatlen, did in The Shawshank Redemption, (hopefully I won’t end up the same way he did). I will join the ranks of locum GPs and pimp my skills to any practice that wants me.
I think I have become a bit institutionalised at my current practice having been there since I gained my GP qualifications. It was actually a big shock to go to other practices to see how other doctors work. I was actually shocked to see that in some practices the doctors meet up regularly and talk, divide up visits fairly and seem happy. I forgot that there are better jobs out there. It is not as scary as you think. Being a locum gives you a lot of freedom and a set workload (a novelty indeed).
It also made me realise how hugely dependent some practices have become by relying on salaried GPs to do the bulk of the work. If more salarieds say no and get up and leave, or become locums then perhaps things will change as some Partners don’t seem to listen to our concerns unless it affects them where it hurts, in their pockets.
I’d like to claim that I got so fed up of being dumped on and taken advantage of, that I stormed into the practice managers office and slapped down my resignation letter on the desk and bellowed a few choice words at him. Sadly the somewhat unglamourous truth is that I was too cowardly to do the above. My fellow salaried colleague did actually do something similar to the above and I don’t think any of the partners forgave him and didn’t speak to him after that. I hid behind my wife’s career. We have to move so she can complete her training so that was my excuse for leaving. I didn’t want to make waves and I need decent references (my colleague didn’t as he became a Partner at another practice). Things have got quite strained at work – 4 salaried GPs leaving over the next few months – and I didn’t want to add to the shitstorm
Monday, 26 October 2009
Medication pic n mix?
(taken from Pulse magazine blog)
We have a number of non-English speaking patients and I’m not sure I’m really getting through to them about concordance with their medication. I’ve had several patients who happily take a prescription for their illness, then travel abroad and see a ‘doctor’ who gives them a variety of potentially dangerous treatments. They then pop back a month or two later and see me and complain they are not better, having stopped the original treatment and tried something else entirely. I’ve seen patients who have been given methotrexate, psoralins, roaccutane and a wide variety of topical super potent steroids without any supervision or monitoring whatsoever.
Do I decline to see them again until they do as they are told? What if they continue taking these treatments without any monitoring? Worse still, what if they give these treatments to their friends or children? I’ve had patients accuse me of being tight-fisted for not giving them the incorrect and dangerous treatment they have got from abroad. Warnings about potential serious side-effects fall on deaf ears.
It does make me wonder why they bothered seeing me in the first place if they won’t use what I gave them, but try some dodgy pills from a person with dubious qualifications. It is quite frightening what odd treatments patients can get hold off via a variety of means. Any time a patient sees me claiming a ‘special cream’ has cured them of their eczema or psoriasis I can be fairly confident the mystery ingredient is dermovate.
It’d be interesting to know how many patients use their medication for something other than what it’s prescribed for. I know of some elderly patients who have been sharing their medication, god knows what sort of interactions have been going on. I wonder if it’s a bit like pic 'n' mix?
We have a number of non-English speaking patients and I’m not sure I’m really getting through to them about concordance with their medication. I’ve had several patients who happily take a prescription for their illness, then travel abroad and see a ‘doctor’ who gives them a variety of potentially dangerous treatments. They then pop back a month or two later and see me and complain they are not better, having stopped the original treatment and tried something else entirely. I’ve seen patients who have been given methotrexate, psoralins, roaccutane and a wide variety of topical super potent steroids without any supervision or monitoring whatsoever.
Do I decline to see them again until they do as they are told? What if they continue taking these treatments without any monitoring? Worse still, what if they give these treatments to their friends or children? I’ve had patients accuse me of being tight-fisted for not giving them the incorrect and dangerous treatment they have got from abroad. Warnings about potential serious side-effects fall on deaf ears.
It does make me wonder why they bothered seeing me in the first place if they won’t use what I gave them, but try some dodgy pills from a person with dubious qualifications. It is quite frightening what odd treatments patients can get hold off via a variety of means. Any time a patient sees me claiming a ‘special cream’ has cured them of their eczema or psoriasis I can be fairly confident the mystery ingredient is dermovate.
It’d be interesting to know how many patients use their medication for something other than what it’s prescribed for. I know of some elderly patients who have been sharing their medication, god knows what sort of interactions have been going on. I wonder if it’s a bit like pic 'n' mix?
Tuesday, 20 October 2009
What makes a perfect patient?
A quick bit on GP funding before we begin so you know what I am talking about in the future - QOF stands for Quality Outcomes Framework - its a points based system for GP funding. You get points for managing certain conditions, managerial activities and other things. For example for a patient with heart disease you would get points for checking they are not depressed, on certain medication, blood pressure is below a certain value etc... Its designed to increase the level of care a patient receives by ensuring certain targets are met. It does mean that there is a tendency to concentrate on getting the points and nothing else however. Also some points are based on dubious targets or near impossible to get (the recent biased and poorly designed patient questionnaire released by the government was a good example). We have a few nurses who's sole job is to go chasing QOF targets to make sure we score as many points as possible
In exchange for not doing out-of-hours care anymore GPs had a paycut of about £6000, QOF targets were also introduced. At the time there was a recruitment crisis in General Practice so the government hoped getting rid of Out-of-hours care for GPs would make it more family friendly and changing the funding would raise pay a bit. When the QOF targets first appeared the government assumed most GP practices would reach about 70-80% of the total. Infact most Practices got 100% so received a bumper amount of funding. This is why Partners salary went shooting up. It wasn't that they were greedy it was that they were doing their job well!
The government ever since has been trying to claw back some of this funding ever since by changing targets on a yearly basis or forcing GPs to do extended hours again without giving them back the original money they took from them. There has also been a smear campaign against GPs as the government was more than a little embarrassed at cocking up the GP contract negotiations and giving too much funding to General Practice. QOF targets have had negative and positive impacts on General Practice, I'll talk about them more in the coming months but that was just a brief run through to bring you up to speed. Any questions send me a tweet via @GPforhire on twitter.
(below is taken from my blog on Pulse)
I guess it depends on you want out of them, at its most basic could the perfect patient be the one who is registered but never turns up and lives a happy healthy lifestyle with no need for a GPs input? Perhaps but with my QOF chasing hat on you can’t score that many points from them. Maybe a few points as they are a non-smoker, non-drinker and normotensive. But not many.
Perhaps if they had a few chronic diseases that would be better, could get a few more points out of them. What about if they are a depressed obese asthmatic with epilepsy, diabetes and heart disease? Could score a lot of points there! But to be a good patient they would, of course, have to turn up for regular review and take all the medication you throw at them. Ideally you want to be able to score as many points for as little work as possible I suppose. Maybe patients could be trained to chase their own QOF points? What if a cohort of diabetic patients touted their QOF point potential to low-scoring practices? Could they hire themselves out by registering with a different practice each year?
You could have some sort of QOF über-patient but it’s just a tad dehumanising to only view them for their QOF scoring potential. For me personally I like patients who turn up on time, don’t stink of fags, booze or sweat, don’t have a vast list for me to try and sort out in 10mins, do what they are told, and most importantly send me cards saying thank you so I can put them in my appraisal portfolio to show what a wonderful doctor I am as it seems nowadays if its not written down it doesn’t count.
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