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@hladik
Were you one of those people who applauded Willie Walsh the other day when he suggested the entire staff of BA go without their salaries for a month? Fine for him, losing £60,000 of £743,000. Less fine for baggage cart driver who loses £1,000 of £12,000. If you think we don't have a working poor in this country, there is little point in continuing any kind of debate about anything really. Because pretty much all injustice in society can be put down to the gulf that exists between rich and poor.
But I will continue anyway:
On this point: nothing. It is unacceptable. It is also a direct result of inequality in society. Do some research on Practice Based Commissioning and Quality and Outcomes Framework. These two systems are central to the financing of General Practice. A **very **simplified summary of both:
*Practice Based Commissioning allows GPs to take control of their prescribing and referral budgets. *Imagine that we have a budget of 200,000pa to 'cover' the NHS treatment of patients we refer to NHS hospitals. If we refer less patients to hospital, and spend only 190,000 of that budget, we get to keep the 10,000 balance to spend on bettering our primary care service provision.
This seems like an incentive to stymie treatment for patients. It is not. It is an incentive to improve the way primary care is provided - opening longer hours, providing more appointments, providing better palliative care and active treatment of long standing conditions at the Primary Care level, and generally trying to be better as a GP surgery, which in turn reduces the *need *for so many referrals in the first place.
But if a patient walks in demanding a referral to some paediatric specialist at Great Ormond Street, because the patient knows, KNOWS, that their son has definitely got Autism because of that bloody MMR the GP made him have, then the GP might think twice, or rather, ask to see the son a couple of times, before making that referral.
It works to some degree. With the money my practice saved with PBC last year, we've been able to introduce a digital dictation system, which has greatly expedited the referral process at our end (we had sometimes a 2 week transcription backlog with tapes... now two days max). It has made all this 'paperwork' you dislike far easier and cheaper to manage - the only time we print anything is when the letter is totally complete, digitally reviewed by the doctors, signed with an 'digital' signature and ready to be posted. It also makes letters and referrals much easier to track and audit at our end, so when a patient calls up asking why they've yet to hear from the hospital, we can tell them exactly when and where we sent it. We will soon start to send our NHS referrals via email rather than snail mail - this will be yet another HUGE improvement.
We have also been able to introduce an Text Message based Appointment Reminder System, which has already started to cut missed appointments (thus saving us more money, and allowing us to reallocate cancelled appointments to patients who need them).
Unfortunately, and this is where your point is answered BlueQuinn, the disparity in practice income is directly related to the affluence of the area in which the GP is located. The practice at which I work reaps great benefits from PBC because it has a hugely affluent patient base. We can refer patients to private hospitals instead of NHS ones - they willingly go, so as not to endure the 'filth' of the NHS - and thus not sap any of our PBC referral budget and so on.
Not the case for Tower Hamlets GP it would seem. No (well, very few) private referrals there. No patients who use the NHS but have insurance to cover expensive drugs when they need them. This means more people have to draw more money from the Referral and Prescribing PBC budgets. Which in turn means no money to bring in digital dictation, or text reminders, or televisions in waiting rooms, or shift towards an entirely digital workflow like my practice has.
Very similar process with QoF. You get money based on meeting treatment and condition management criteria. When you need to ensure that 94% of your age 25+ female patient base has had a smear test in the last year to get maximum 'Points' (and 'Points' = Money) it helps when you can get all the 30 something mothers in for Smear tests whenver you like because they don't work and can, if needs be, leave the kids with the au pair, who came in for her smear test the week before. Many people just can't take time out of work for such things - particularly if they happen to be working full time for £12,000 in an un-unionised job. That is why we have a national problem, for example, with coronary heart disease. Try getting a full time working man aged 40+ in for a two minute blood pressure check with a nurse on a Thursday. It rarely, rarely happens, despite our practice opening at 7.30am three days a week and staying open until 8.00pm every single day.
I'll interject a personal opinion here: Both PBC and QoF are flawed, because they echo the bonus reward culture of the finacial services sector too much for my liking. They work well in areas of less social deprivation, where there are generally less chronic health problems and less demand on the NHS. The single biggest reform that could be made here is to introduce a redistributive element to any money saved via PBC - so my practice keeps £5,000 of the £10,00 saved, and £5,000 is redistributed to a practice that has maxed out its budgets and then some. That would balance things out a lot more. But the blame for the underlying inequality in society, which causes these inequalities in service provision - (and they are slight... we are talking 2-4% difference in PCT budgets from one area of London to another, if that) - cannot be laid at the door of the NHS.
Again, you misunderstand the process somewhat here. If you are treated as an outpatient (i.e. you are not actually admitted to hospital but attend for a day procedure) I don't understand how or why you expect to be ferried around St. George's as though things like schedules and other patients don't exist. All those other people who are inpatients, lying in those wards you only walk past are sicker than you. They get treatment before you because the medical professionals with their many, many years of training believe they need it more. You can't be squeezed in for a test, because the testing facilities are booked solid with the** sicker inpatients**. You can't reschedule your op for next week if a complication arises, becase the operating theatres are reserved for the sicker inpatients. If the clinicians thought the complication severe enough, or life threatening, you'd be seen in days. It is by and large their call, and they, with their medical knowledge, more often than not call it correctly. The majority of the super efficiency and proficiency of the NHS is reserved for the seriously ill, because they simply need it more.
Example: Cancer. If a GP suspects you have any form of cancer, you get an appointment at with the specialist most qualified and experienced with the suspected type of cancer within two weeks. Generally much quicker, but it is known as the Two Week Rule. You will turn up at hospital and you will get the works, because everyone knows that cancer kills.
Witness my father. Spent his entire childhood and adolescence running around shirtless in the South African sun. Is thus part of a know High Risk group for Melanoma. Upon being convinced by my mother to go see the GP about a mole on his back, he was sent an appointment four days later with the UK's leading skin cancer specialist who happens to work at St. George's. He got a biopsy done upon arriving, at about 10.00am, saw the specialist afterwards for a clinical examination, got the biopsy results back a few hours later, had the first batch of skin cancer cut out of his shoulder by 5.00pm. Went back two days later for a review and had a second (and, thankfully, the last) lot of cancer cells cut out. Now goes back for annual review with same world leading specialist. Lives.
That happened, because the GP, at the primary care level, knew something was seriously wrong, knew that skin cancer, if not caught early enough quite literally and without exception = death, and knew that he needed treatment immediately.
When you turn up at the GP with a jammy knee that you put out playing football at the weekend in the company of some friends, some decent beer, and no warm-up, to expect the same level of service is absurd.
Your girlfriend's problems sound less than pleasant, and it seems as though you have been exceptionally unfortunate at various stages along the way. Yes, the NHS is not nearly as efficient as it can be (I was halfway through a post specifically on what needs to be changed in my view before I fell asleep last night... i'll redo it later in this one), but equally, it doesn't sound like you made it particularly easy for yourselves.
It sounds as though she maybe grew up in Shropshire, seeing this specialist, then moved to London some years later, which has hospitals, Primary Care Trusts and GPs that are entirely disconnected from Shropshire Country PCT. Presumably she changed GPs, had her notes moved down, and forth? Or did she decide she wanted to see the Shropshire based specialist as a result of research etc, and that was when difficulties began?
See I don't really understand this part.
A) either way, do you not perhaps think that *moving from a Tower Hamlets GP to a Shropshire GP in order to get the treatment you believe you need, whilst presumably continuing to been seen at Tower Hamlets GP as a temporary patient whenever you are in London, despite your notes being located in Shropshire, or is it Tower Hamlets, with some letters being sent to Shropshire address and some to Tower Hamlets address and no one really knowing what the hell is going on, yourselves included, *might create some additional bureaucracy along the way?
I don't mean that as a personal attack in any way... I am just pointing out the complexity involved in the action your girlfriend decided to take. Shifting from GP to GP is just not as simple as it outwardly appears.
also,
B) 'dole scroungers' have nothing to do with provision of primary care. Assuming we all have an equal right to treatment that is. Unless you believe those who don't pay tax shouldn't get access to healthcare? Which sounds a lot like private healthcare to me....
You also said earlier:
You can do exactly this, within reason. It is called 'Choose and Book'. As evidenced by teddy's post earlier:
Exact same story for my girlfriend and some rather acute issues she has had.
Choose and Book empowers patients no end. It just requires us all to do a bit of the leg work. The NHS provides all kinds of waiting time lists and statistics, and, as people contribute more and more to NHS Choices, we, the prospective patients should be able to read considerable numbers of consumer reviews of consultants, departments and hospitals around the country, enabling us to make more informed decisions about where and to whom we would like our GPs to refer us.
Wrong again. Unfortunately, everything is about money.
If you want less paperwork, we need an entirely uniform, exclusively nationalised digital administration system that provides digital interchange of referral letters, clinical examination reports, test result data, NHS hospital consultant notes, Private hospital consultant notes, gp consultant notes, homeopath consultant notes, private botox consultant notes, private cognative behavioural therapist notes, pharmacist notes, past prescriptions, current medications, current active problems, past significant problems, at every stage embedded with Electronic Patient Record meta data and heavy encryption to protect confidentiality, that can be accessed and contributed to by all healthcare practitioners.
Right now, there are god knows how many private companies that develop software for use in the NHS, with little to no compatibility between them, because that would undermine market share and competition.
Our practice alone uses one company, and server, for our Patient Administration System (PAS) (where your electronic medical records are kept), another for our digital workflow managment, another for the digital dictation, in combination with the standard windows/microsoft office package. We have a separate telephone exchange server thing (not my area??) maintained, it seems, both by BT and some other company contracted by the PCT to provide communications assistance.
We employ a 50 something year old woman whose sole job is to come in 4 hours a day, sit at a computer and scan in the 100 or so letters we get from hospitals each day, selecting a hospital and department from which the letters originate and the date of the clinic to which the letter is referring, assigning it to a patient's record, then sending it to a doctor to review, digitally.
When we recieve correspondence from any hospital, anywhere in the country, Private or NHS, there are almost always huge differences in data presentation that need to be made uniform to increase efficienty. Lister Hospital might write the date as [dd/mm/yyyy], whilst Guy's is [day of week-dd-month name-yy]. Private hospitals have an entirely different system of data presentation that doesn't adhere to any NHS guidelines anyway, and makes all our lives more difficult. Some hospitals have 'Geriatric Medicine' departments, others have shifted to 'Elderly Medicine'. Our digital document managment system thus needs to accomodate both. But sometimes it can't, because the only way to put these two categories in is by changing various fields in the PAS, and sometimes one piece of software just will not communicate with the other properly.
Now that seems like a massive paragraph of criticism, but it is not. We are so close to hitting a much higher level of efficiency - we just need more uniformity across the country. We could cut out the 4-hour-a-day woman if all the documents were sent digitally in the first place (although what she'd then do for a job, lord knows).
We need a public, ideally open source and extensive software programme to replace all these disparate private products.
We need a centralised database that all healthcare practitioners can access, to which they they can all contribute, that is run using this single piece (or suite) of clinical software.
We need people to enter data correctly when people swap GPs, and code diseases in the correct way, so that when you run a SQL search of your practice population, you can flag up every patient who is due a diabetic review in the next month, cross check that again people who have opted in to the Text Reminder system, and send the balance a text message reminder asking them to book an appointment for this review.
When a GP refers someone to hospital, they should be able to select various data fields on the EPR - relevant consulatation notes, medications, problems, intial diagnoses and contact details - and mail merge them into a 'letter' that is concurrently sent to the relevent department at the hospital to which you are referring the patient and automatically logged in the patient's EPR.
This might seem like an unachieveable fantasy, but it is not. It just requires us to get rid of the hundreds of different private companies on which the NHS currently relies, whose massively varying practices cause more harm (and paperwork and The Dreaded Bureaucracy) then good.
It also requires much better computers than most GPs and Hospitals have, as well as a younger, far more computer literate workforce who have the time to learn, and the flexibility to accomodate dramatic change in The Way Things Work.
They need to be prepared to work for less money than in the private sector and to deal with a far more diverse range of people ethnically and financially, who are young, old, have mental problems, or cancer, or need physio so SO badly, or have cut their hands, their heads or been stabbed in the liver by some evil young man outside a bar on Kingsland Road.
And it all requires more money. But no one is really prepared to pay. Because some of their money might go to a 'dole scrounger' in Tower Hamlets instead of their brother, or a grandma with emphysema in Manchester instead of their grandma who needs a GP check up after her private hip replacement. Might sound trite but it is basically true. For the NHS to work as efficiently and effectively as possible, language such as 'dole scrounger' needs to be removed from the collective national vocabulary.
You blame the NHS, and political interference, I blame market capitalism, social deprivation and a lack of understanding.
I have one more point to make, regarding frivilous and unecessary GP and A&E visits touched upon by various people - a huge and costly issue for the NHS, but I'll do it later, because I still have not had breakfast.
Sorry for the lengthy post and any typos.