NHS White Paper

(For an article in Pulse Magazine)

Just read the NHS white paper and it looks like we GPs can finally stop being back seat drivers of the NHS and have a go at the wheel. Well I say we, I really mean GP Partners. Salaried GPs will still be trying to fill the whole left by the GP Partners who have gone on to become new NHS managers, play golf or sit in the staff room with their feet up. Locum GPs like me will fill the whole left by all the burnt out salaried GPs who can’t take it anymore, and the gaps left in the rota by GP Partners playing golf.

Of course I am being my usual cynical self, its not all bad. I am sure great good can be achieved over time but the level of re-organisation required for the NHS mark II (as I like to call it) is quite terrifying. It won’t be cheap so how we can save £20 billion and reorganise the NHS simultaneously is anyone’s guess. I’m hopeful that GP Partner numbers will increase fairly dramatically as I don’t think salaried GPs will want to get hands dirty without a hefty pay rise.

I’ve heard other GPs talk about it being a bit like fund-holding all over again, but this it is compulsory. All GP practices will be forced to be part of a GP consortium. There they will have to fight it out, argue, arm-wrestle or do whatever GPs are going to do to decide where the money goes to. No longer can you fob off your patients and say the PCT has pulled the funding for tummy tucks, it will all be your fault. Now when you see a patient needing an operation you’ll be thinking how much this is going to cost and how much abuse will I get at the next GP consortium meeting for referring them.

Patients are meant to have control over their medical records and can go to whomever they want, wherever they want for an opinion. Practice boundaries are to be abolished - its nice to see the government listened carefully to all the objections to this problem, then ignored them, screwed up the bit of paper it was written on and then burnt it.

You’ll be over-joyed to hear patients will have choice, choice and a bit more choice with added choice on the sides and sprinkled on top. Apparently patients like to choose. It doesn’t matter that all that choice is expensive, unnecessary and a bureaucratic nightmare. Almost always when I’ve asked patients about where they would like to go to its wherever is nearest. Regardless of the fact that the nearest place doubles as a butchers shop at the weekend and offers a 2 for 1 special on MRSA and C.dif infections

Of course there will be some GPs who will be positively tumescent at getting their hands on a big pot of cash to play with. I wonder how quickly their tumescence will shrivel when they realise they’ll get the blame if it all goes breasts skyward.

However, GPs are well known for agreeing on everything, their lack of financial motivation and running multi-billion pound budgets. I honestly can’t see anything that could go wrong.

NHS or RHS?

I have realised that we don’t have a National Health Service. We have a regional one. Its only since I’ve been a locum and worked in 3 different counties that I’ve realised this. What do I mean? Well let’s take admitting a patient into hospital for a start. Each hospital has its own rules for admitting a patient. Some have a GP hotline, some have a switchboard may or may not answer and when they do they can’t find the doctor you are looking for, and some have their own team who negotiate on your behalf with the admitting doctor. I don’t get it. How hard can it be to have a common admission pathway to hospital? Very hard it seems. In the end you get fed up trying to work out what’s going on and the patient gets bounced to A+E with a letter.
What about paperwork? Each hospital has its own paperwork to be filled in, different colour schemes and boxes to be ticked. Is it too much to ask to have one set of universal notes? They would look the same for every hospital and could be easily read through, filled in and relevant section found? Far too sensible. Each hospital has to have its own identity so someone somewhere in an office can justify their salary. Universal notes would save on stationary costs, improve patient care (as everyone knows where everything is) and you could even audit things easier if you were so inclined. Hell, if every hospital stuck to this you could even begin to attempt to computerise it. There could even be a standardised admission letter that GPs could use so the admitting doctor could read our ineligible scrawls.
Mind you I can’t be too critical of different hospital records seeing as I have had to train in 5 different electronic record systems to be a GP locum. Some of the systems I’ve used a truly rubbish, God only knows why the GPs use them.
I could rant about postcode lotteries for health care but everyone knows about those. I’m talking about what goes on behind the scenes. Nurses needing to retrain when they move hospitals because one hospitals certificate aren’t valid in another hospital. New doctors not having the faintest idea how to fill in requests for tests as every hospital does it differently. TTO forms that vary from place to place with varying information filled in. Getting everyone to agree on all this would be a nightmare. But then that’s where politicians come in, so we can blame them if it all goes wrong.
I read that it’s the ambition of Labour and Conservative that every hospital becomes a Foundation trust (worked well for Mid Staffordshire?). With this of course it would mean a rebranding of each hospital. New signs, new letterheads, new everything. That will not be cheap, and surely some of that money could be better spent ensuring the smooth running of the hospitals and the staff that work there. You might even improve patient care, but that’s not my main concern, I just want an easy life.

Shit Life Syndrome

I think I have discovered a new syndrome, well I say new but really its been around for as long as politicians have lied. I had a patient see me the other day who was feeling down in the dumps. Being a kind & caring GP I patiently sat and listened to her tell me her life story of how she has no money, no job, an abusive boyfriend, a young baby to feed and how its all making her feel a bit, well, shit. Believe it or not but I don’t have a magic pill that can fix this, I asked her why she came to the GPs but she wasn’t sure, she didn’t know what else to do. She has a syndrome that I am seeing more and more nowadays. It consists of low mood caused by adverse life circumstances. Otherwise known as “Shit-life Syndrome”.
Depending on where you work you’ll probably see a few of these cases. They are easy to recognise. About 5minutes into their history you mind will start to wander, perhaps thinking about what you are going to have for lunch or how that bid for an ivory back scratcher is going on ebay. Several minutes later your mind will wander back the patient who will still be telling you about all the terrible things that are going on in their life. There isn’t really much you can do, you ponder that if your life was going as shit as theirs you’d feel pretty depressed too. What about counselling? “Nah, tried that before doc and it was rubbish” (Waiting list is vast anyway). Ok then, what about antidepressants? Won’t change a thing but will make the drug companies happy.
I know! Exercise, going for nice walks, going out with your friends? Gyms too expensive, have you seen where I live doctor, and I’ve not got money to go out are the 3 rapid replies. This patient has “shit life syndrome”, nothing you can do for them other than listen. Maybe sign the odd ‘fit-note’ so they can get a bit of extra cash to help pay for the 50 inch flat screen telly every feels they have to own.

What’s the solution? Perhaps society needs to concentrate less on accumulating wealth and more on accumulating happiness? But we live in a consumer-drive society with an economy in nosedive so this isn’t going to happen anytime soon. Oh well, lets just cut benefits, raise taxes and penalise anyone else who happens to have shit-life syndrome (aka the Daily Mail solution)

NHS cuts or efficiency savings..?

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.

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?

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?

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.