The ghost of Christmas Past

The year before I moved to Ambridge to take up my present lofty post, I was working in the Second City General Hospital on the wards as a jobbing paediatric SHO. As such I was on call for Casualty for any potential paediatric emergencies. This was the tail end of the eighties, when you could tell the paediatric docs by the brightness and eccentricity of their knitwear, white coats being strictly off limits on the kids wards.

For domestic reasons I liked working Christmas back then, so that Christmas Eve found me resplendent in the jazziest of woolly jumpers prowling the ward and tending the on call bleep. It’s not such a bad time to be working in hospital. The wards were awash with choc’s and biccies donated by grateful parents, and nearly empty of patients- nobody wanting to trust that Santa could seek them out down the overlarge Victorian chimneys of SCGH that looked distinctly uninviting. Especially since this was in the pre-Air-Ambulance era so there was no convenient helipad for the landing of reindeer powered sleighs and such.

We had out fair share of victims of Tinsellitis* in through casualty, but all had been treatable and fit for home, and everything was looking rosy. The only crimp in the arrangements for the festive season was an ambulance strike, which saw the Army out on the streets providing cover using their converted Landrover ambulances. As it happened this may well have turned out a boon since it had, for the first time in years, deigned to snow and then freeze hard all through Christmas week.

And so it came to pass that late that evening the pager went off and I trotted into A&E only slightly redder in the face than in the jersey. A woman had arrived in labour, and the Squaddies hadn't realized the SCGH delivery suite was a couple of miles up the road in an NHS run nursing home staffed by nuns (if you've seen the excellent “Call the Midwife” on the Beeb, you know the sort of place I mean). The poor woman had no transport and had already slipped on the ice earlier in the week breaking a wrist, so she had trudged from her flat in the advanced stages of labour and called the ambulance from a payphone, only to have the Field Ambulance of the 477^th turn up to collect her instead.

The delivery went without incident and without a whimper from mum, and barely any from her newborn infant, and all we were missing were a few animals, shepherds, wise men and guiding stars, but still somehow this particular birth felt special. But then so do they all.

* A seasonal upper respiratory illness occurring in the week leading up to Christmas which, as any parent will confidently assert, is uniquely sensitive to antibiotics.

Hercule, Hastings and “the little blue pills”.

A short time ago a commenter left a request to get in touch about a publication they were planning. It's to be entitled "In Rude Health" and was looking for tales of a slightly risque (yes I know but my HTML isn't up to accents) nature form the NHS. It's hoped it will be out for Christmas and I'd encourage you all to go look for it (though possibly with some caveats as to the content being intended for the adult audience). What follows was going to be a putative entry, but it took far too long to put together and so won't be. Still having made the effort, I thought why not go mad and double my output for the year anyhow. 

So gentle reader, with the same caveats, read on, or look away as befits your own personal circumstance.

Hercule was a dapper gentleman in his mid seventies. He had become accustomed to living alone after the passing of Mme H some years previously after a difficult final illness with disseminated cancer. It came time to “downsize” and so he chose to move in to a local retirement community of sheltered flats overseen by a warden. As is often the case in such communities, Hercule was in something of a minority, living surrounded by ladies of similar age and circumstance, but very few other men. Like some latter day Mr Darcy, this led to him receiving numerous invitations to call on his new neighbours for afternoon tea and canasta. Being well brought up he was happy to oblige and soon developed a wide circle of lady friends. One thing led inevitably to another and soon it was afternoons out to Thés Dansant.

After a few months of this new lifestyle Hercule came in for a check up, and after a routine review of medications he bashfully raised the subject of the little blue pills. He’d heard that such were available for gentlemen afflicted by “performance problems” and wondered if they might be suitable for him. A glance at his record showed no contraindications so we agreed he might give them a try, and he took away his first script for Viagra with the usual warnings about not taking them too often and not to exceed the written dose. It seems Hercule had, in modern parlance, a new partner.

Some weeks later he was back to report a happy outcome. The little blue pills were working a treat and he wondered if he might have some more. Well actually quite a few more. It transpired that Hercule had become something of a celebrity in his small group, and was in high demand with a number of his dance partners. It took some persuasion on my part to limit both the frequency and quantity of his prescriptions.

Captain Hastings was a bluff matter of fact ex Colonial type. He and Mrs Hastings had met in the Raj, and after a lifetime of service in the tropics had retired to live in our neck of the woods. The Captain’s blood pressure was not too good, and his arteries were none the better for a hearty diet of kedgeree and curries. This deadly combination had given him problems “in the bedchamber” much to the chagrin of the Memsahib. So we agreed a cautious trial of the wonder pills, all the more so because of his likely circulation problems, He understood he was taking a risk, but Mrs Hastings was his Queen-Empress and he was not about to disappoint her.

As it happened all went well and the Captain was back to request a regular, but entirely reasonable repeat prescription. Years passed and Mrs Hastings suffered a slight stroke and became confused and prone to agitation, but the one thing that calmed her was the easy intimacy she and the Captain still shared. Shortly after this he developed atrial fibrillation, and I had to tell him we really ought to revisit the suitability of the little blue pills.

The Captain would have none of it. Mrs H would be so disappointed if this one thing left her was taken away. He understood he might be taking a risk, but his son would be there to provide for her in the event that his ticker gave out and for the pair of them it was quality not quantity that mattered for the time they would have left. In the end he persuaded me to continue prescribing. Some time later Mrs H suffered a second and sadly fatal stroke, and from that point on the Captain allowed his prescription to lapse, living on for another few years, content that he had “done his bit” for Queen and Country.

Life and art.

So, it’s been a while. All sorts of reasons why, but none to trouble the dear readers with I’m thinking. Today though, life and art have juxtaposed and that serendipitous event demands to be shared, so here I am, back again.

Les isn’t feeling too grand. The gout he had in the spring looks like it’s left a longer term arthritis which is affecting his thumb, making it hard to do stuff like cook, clean and so forth. He’s also had a cough for ages and is fed up with it. It sounds entirely innocuous but deserves some treatment so we opt for an antibiotic to go with some painkillers.

Then he mentions a bit of trouble with the waterworks, and being a gentleman of a certain age, wonders if he needs to worry about his prostate. In fact he had a test just a few months ago, requested by that nice Dr Neighbour, that he had quite forgotten, and never sought the result for, an it was normal so no real worries, but since he’d also brought “a sample” we do a dip stick test, and the only thing that shows is a bit of glucose.

“ I knew that would be up doc,” he chips in, “only the wife’s just left me and I’m fending for myself now….”

Given that catering isn’t his strong point, and he’s had a bad hand anyway I think I get the picture, but I say how sorry I am to hear it. He looks a bit teary so I ask him if he wants to talk about it. And then it happens. I’m not quite sure if I’m whisked away to a steamy bayou and the insistent strum of a blues guitar, or a gritty northern working men’s club, but life has definitely begun to swerve into lyric, or comedy as he replies,

“Oh no doc, I’m alright with it, just not used to living alone quite yet, but the thing that’s really upset me is that the dog died last week. I really miss that dog!”

Typography?

Greetings from Ambridge-sub-Aqua. Once again the Am has broken it’s banks and is lapping at the back door of the surgery whilst the Koi Carp are disporting with the Mallards on the car park, the bigger ones with a decidedly hungry look about them, making me worry if there are such things as “man eating cyprinidae”.

On a side note apparently Koi is Japanese for carp, so in back translation that makes them “Carp-Carp” which sounds a bit like a stammer. Apparently Koi is also a homophone for the Japanese word for love, which must make for some interesting conversations in Japanese fish mongers and the like.

But, as usual, if you can have a “usual” in a journal as infrequently updated as this, I digress, even within my digression.

Sorry.

I’ll try to get back on track.

Despite the recent downturn in the weather, nothing is keeping the faithful of Ambridge -s-A from our door, and those that can breach the sandbagged parapet and make it “over the top” continue to delight and challenge in equal measure. A week or two back saw two consecutive consultations with diabetic patients about their med's. Both are proper old-school Type 1 diabetics, the sort that go from well to desperately ill and needing insulin in a matter of a few days.

Sophie, the first of the two, is a veteran, having been diabetic for almost as long as she can remember. She has her med's all figured out, is supremely confident to adjust dosing according to her sugar levels, which she monitors by finger prick four or five times a day. By all accounts, and looking at the lab bloods for confirmation, her sugars are near perfect and she is completely well. She has even had her flu jab and made the point that, as with insulin, if you relax the muscle injected, it doesn’t hurt at all—a tip worth passing on the 750 or so punters that will be in this Thursday for the fourth round of our flu campaign this year. I’m thinking of getting some “Sophie Says Relax” T shirts made.

Nick came next. He’s rather less self assured than Sophie. He hates testing and injecting, but then he’s only been at it for a couple of months, having been rushed in to hospital acutely unwell at the onset. He knows what he’s taking and the dose is still changing. Understandably his sugars are all over the shop when he tests them and he’s finding it all a bit demoralizing. He needs his flu jab, so we sort it there and then, but he winces despite my admonition that he must relax. (Easy to say when you’re the one holding the needle eh?)

We are being encouraged to put new patients in touch with more experienced “expert” patients to improve their knowledge of their condition, its impact and treatment in the hope that this will yield better outcomes. Diabetes is at the forefront of this approach and Nick could certainly do with some of Sophie’s wisdom.

The only problem is, that despite being diabetic for almost half a lifetime, Sophie is only six years old, and Nick is in his early twenties. 

(Oh, and yes, Sophie did come in with her Dad, but she did all the talking and was plainly in total control of her condition and its treatment.)

Florence lives!

As you will know it is my lot to have dealings with the Ambridge and District General Hospital and its mother institution the Borchester Royal infirmary on a regular basis as part of my day job. In this repeated exposure it has been all too easy to become accustomed to their working practices and assume that these are "industry standard" throughout our fractured and beleaguered "National Health Service".

In short I've become used to an attitude of expedient management-- a "sort and shift" mentality if you will, that does as much (well, little) as is needed to "stabilize" a patient in the "Assessment Unit" or if absolutely unavoidable, the ward, then boot them home to be sorted out from home either through Out Patients, or, increasingly often, by the practice team, doing what would normally have been done by the admitting medical, surgical or other specialist team as appropriate.

In part it's been our fault for accepting that this is the status quo, but it's also a mark of a prevailing attitude in our cash strapped area the patients are the enemy, to be kept out of hospital at all costs (or more accurately on the flawed assumption that being kept out "saves" the cost of a bed). Of course these savings never truly accrue since an empty bed is just a bed available for somebody else to occupy, which they pretty much inevitably do.

Over the past year we have had occasion, as a family, to have dealings with the Dreaming Spires University Hospitals Trust on a couple of occasions. Sadly the latest had the unhappiest of outcomes, but the prevailing attitude of the hospitals we have had to deal with, the care lavished on us and the expectation that a patient remains the centre of attention, the recipient of genuine care and attention and not an inconvenience, has been startling.

It has been all too easy to accept that the traditional virtues of caring have been ground out of the system by relentless “make-work” target setting and an obsession with counting things, but looking, as I have had to, further afield, whilst those targets still apply elsewhere, the bunker mentality does not and patients are still that, namely “sufferers” deserving of support through adversity, and not either commercial transactions to be shifted in bulk to maximize income, or threats by their mere presence to the meeting of targets for maximum trolley waits or other nonsensical metrics.

It is probably no coincidence that the DSUHT is well funded where the A&DGH and BRI are financial basket cases, so I can't help wishing that, with the same expedience with which I relocated the "surgery" to Ambridge all those years ago when this blog was a mere babe in arms, I could wave a wand and relocate again to the Dreaming Spires. But until I can the poor Ambridge & District can expect me to be on their case on a weekly basis to remind them of what they used to be about and should be again.

It saddens me greatly to have to say this, but I fervently hope that in the event that I or those closest to me have the misfortune to be ill and in need of hospital care, we can contrive to do so in the land of the Dreaming Spires and not here in apparently idyllic Borchester.

Animal Magic

So, not quite sure where July went if I’m honest. Seems real life might have been just a bit too frenetic. Also not quite sure what the month ahead has in store excepting a week on a costa, soaking up rays and studiously not worrying about Ambridge. Or GCSEs. (Not for me you understand, at least not directly so… suffice it to say I’ll be keeping a number of digits crossed for a couple more weeks.)

That said last week was a rare joy—if not a once in a lifetime event. You see last week we became a tiny part of what would turn into a little bit of history. It can’t have escaped notice that Dear Old Blighty has been having a Sports Day thingy going on. You can tell it’s hugely important because our Beloved Leader has been popping up all over the shop, feting this potentate and pandering to that panjandrum and begging Vlad not to break his fingers in the small spat we’re having over Syria.

Happily he stayed away when we went to Greenwich to see something truly magical. It had been months coming and planned with nigh on military precision. Last Thursday famille Jest decamped to the Ibis hotel in London’s Docklands—right next to the Excel centre where a great deal of grunting and straining has been taking place. We hotelled amongst pretty much all the officials there to oversee the various martial disciplines taking place in the exhibition centre turned Olympic venue. Friday morning saw us up early and breakfasting in their lofty company, but we were not off to see Kick Boxers, Judo-ists or what have you, it was just the nearest affordable room we could get to Greenwich, where the horses were strutting their stuff.

After breakfast we trekked by DLR (a sort of over-ground tube), Tube proper, and then by hoof to the park. En route the atmosphere was extraordinary. London, and especially Docklands, has a reputation that suggests outsiders might not always be entirely welcome, but that couldn’t have been farther from the truth. Everywhere was bonhomie in full flow. The most exuberant exponents were, without doubt, the Games Makers, strange people in pink bibs with at least one giant foam hand apiece, but everywhere you looked there were smiles and cheery waves and we were left with the impression that nothing would have been too much trouble.

Greenwich Park was extraordinary, from the vertiginous grandstands bedecked with the flags of seemingly every nation (and a few that were obviously made up), to the arena itself with its highly ornamented “sheds” for the judges, its little topiary embellishments and its manually operated, gnome height, white picket fences, to the high tech wizzo zipwire camera high above the action beaming its signal to the giant screen that was just a few tens of yards from our seats in the gods.

And there it was that we all sat for the better part of a day, watching horses dance. No really. It’s called dressage apparently, and it has since turned out that at least three of my compatriots are pretty good at it. We were watching heats, but even there it was evident that they knew a thing or two about it, as did all the riders we saw, after all they are the best few dozen exponents of the art on the planet. Each was required to follow a set routine of manoeuvres from trots to carousels to zigzags… even the salutes at beginning and end were marked. There was no questioning the evident skill of all the riders, or the levels of excellence in training of their mounts, but there were a few special performances that stood out. 

Every pair—rider and horse, ran through the routine in the right sequence. Barely a horse miss-stepped—so much so that the twice in the whole day they did there were suppressed gasps from the crowd, who otherwise sat in pin-drop audible silence throughout each ride, reserving the hooting and hollering until well after the end of each effort. And though sections of the crowd hooted louder for their own national team the whole crowd responded to every contestant.

Within all of this there were a handful of horses that stood out. For the others the routine was plainly well practised and well executed, but somehow still looked mechanistic. For the few special ones it was evident there was more to it. I mean it when I say that we watched horses dance. Dance, and float and pirouette with balletic precision.

In our overly cynical, over hyped, over commercialized world, it’s nice now and again to be reminded that there is genuine magic to be had out there, and for the past couple of weeks our little island has had more that its fair share. The spirit of the crowd on the trek home was if anything even more effortlessly cheery. If we could keep one tenth of that spirit alive when the last visiting contingent of supermen/women and indeed horses depart for their respective countries, that would be a legacy beyond price.

I feel privileged to have been allowed to be a small part of it in person, and I look forward to the day I have  grand-kids to tell all about the day I saw the horses dancing.

Communication is the problem to the answer... *

The Blobshire General Hospital

London Road

Blobcester

Blobshire

Dear Dr Jest,

Your patient, Miss Archer attended our unit today.

Presenting complaint;                            Personal

Assessment;

Diagnosis;                                             29E: Gynaecological Conditions – other

Treatment:                                            511: Medication – oral

Outcome;

So ran the letter that wung (or is that winged, wang… er…) its way to my electronic in-tray yesterday. It seems all those hours spent on communication skills at the Big Hospital are not practised in the far flung frozen wastes of Blobshire, or at least not in their General Hospital.

You have to give them some credit I suppose. They’ve managed to compile a discharge note and forward it to the right GP at least, but sadly it’s of approximately no use. At least not as a clinical communication anyhow. What this is, in effect, is a glorified invoice. 

You see Blobshire is some distance from our own dearly beloved Ambridge, and our paymasters are unlikely to hold a contract with them for services of any kind, "personal" or otherwise. So if Miss A felt the need for medical attention whilst there on a visit, her treatment will have to be paid for, after the fact, by our own PCT sending a wad of fivers to the Blobshire Acute Trust. To do this our PCT will require evidence of treatment being carried out, which is where we came in.

Disappointingly even the codes are no help. Our 29E is “Pain- Sensation- other” and makes no mention of any gynae’ problem, all the codes before and after it having to do with various types of limp. And on our system 511 doesn’t even exist, so I’m really none the wiser. Sadly as it appears Miss A was not assessed at all, and had no outcome recorded, I can only imagine what happened to her a few nights back on the mean streets of Blobcester.

Still all is not lost, I missed off my absolute favourite bit of the letter. Without, so far as I can glean, the font being so devoid of expression as to make irony improbable, any hint of the same, the communiqué concludes thus:

“If you require any further details, please contact us on the above number.”

* You all know what's on offer by now. EVCHN to the first correct attribution.

Striking a pose.

In twenty days and for the first time in my career, it looks as though I may be called upon to take some kind of industrial action. Aunty says I’m going to be on strike, but that’s not quite right. If I’m doing anything “disobedient” I’ll be doing my level best to make sure it won’t inconvenience the good burghers of Ambridge, and a great many of my colleagues up and down the country will be doing likewise.

Also according to Aunty, this action is all about my pension. And on a technicality there they have it a little closer to the truth, but if they bothered to actually ask any pertinent questions, and then bothered to listen to the answers, they might appreciate there’s a whopping great iceberg of seething malcontent of which the pensions issue is the tiny bit you can see. Still why let the facts cloud a good argument eh? 

The whole pensions argument is a thorny one to be sure, and for anyone out there in the private sector sitting anywhere below top executive “Golden Parachute” grade must wear very thin indeed. Still at the risk of sounding like a seven year old in the playground, what Dave and his cronies are trying to pull is “just not fair”. They say that pension provision is unsustainable, and yet our pension contributions, you know the pay we have stopped to cover our future liability, pay into the treasury roughly £2bn MORE that the pensions take out every year. That’s money abstracted from the scheme by HMG for other purposes. Or put another way TAX (if you’re feeling charitable) or theft if you’re not. Robert Maxwell did something similar a while back but because he was a baddy it was bad. When it’s that nice Dave, and his pal George, somehow it’s o.k. (And yes Tone and Gordon were up to it to, this isn’t a party political point).

Anyhow, that’s the status quo ante, but now Dave and George want a bit more, and at the same time they want to hang on to all our contributions a bit longer too, since we’d only squander them on fripperies if we were allowed to retire too soon. This on its own rankles a tad. And yet, on its own, I very much doubt it would have prompted my colleagues to vote for industrial action in their thousands.

The thing is, as has been droned on about at some length, both here and other-where, our paymasters and rulers have rather lost the good will of the profession. Tone and Gordon playing fast and loose with the contract started the process, true.  Lansley’s back of a fag packet re-organization after we were PROMISED no top down re-structuring, and the appalling mess they’re making of its implementation (a mess so scary they’ve had to veto releasing the “risk register” for fear of frightening the horses) are way more important and way more worrying to those of us who wish to see a true National Health Service for our kids and theirs and so forth even unto the seventh generation and beyond.

The tiny problem with that is that you can’t hold a ballot for industrial action on an abstract concept, so we are left like disenfranchised barons attempting to force bad old King John to Runnymede on the issue of the unfair abstraction of our lands and chattels.

If you care about your surgeries, your hospitals, your lovely district nurses and midwives wobbling about on their sit-up-and-beg bikes and all the other paraphernalia of the only vaguely successful stab at socialized medicine in the known universe (excuse the hyperbole) I urge you to see past the whole “fat cat pensions” thing and think about why the B.M.A. for the first time in a generation has seen fit to hold a ballot at all. And if you’d then like to lend your weight to the campaign, why not email Dave*, George, Andrew , and your own MP to tell them so. 

If you’d like to do it weekly, even daily till they get the message then so much the better. And on 21^st June I shall make a point of being on hand to see urgent cases whether they come bearing hob nobs or not. I’m just saying… ;-)

*seems you might have to write to Dave. 

Try

House of Commons, London, SW1A 0AA
Tel: 020 7219 3475
And remember to sign off “LOL”
I'm told he likes it.

Testing times?

A couple of weeks ago I had the pleasure of Brian’s company. He’d been at the golf club the night before at one of their legendary social functions. These functions used to be a simple excuse for a night of bacchanalian excess, but in these times of scrutiny and accountability even the hallowed portals of the Ambridge and District are not sacred and every function must serve an higher purpose. To that end the committee had invited in someone to do a bit of “health promotion” and offer “screening” before they sat down to their fifteen course banquet with attendant wine list, port and cigars to follow and brandies after the Loyal Toast.  

If you are detecting a hint of irony here I fear it was utterly lost on Brian.

In any event the screening on offer posed us a bit of a problem. It seems that Brian was informed his test (a P.S.A. allegedly) was “high”.

And that was all.

No advice about symptoms, no suggestion of what to do next, indeed no quantifiable information on what “high” might mean in “pounds shillings and ounces” *. Apparently the same was true for a few other stalwarts of the A&D, but fortunately they will be off bemusing their own medical attendants as none of them saving Brian are registered with us.

So what to do now? Well P.S.A. is a notoriously fuzzy test at the best of times. It’s undoubtedly captured the zeitgeist of those men, like Brian, of a certain age, and many attend seeking the “reassurance” of a quick test, on the assumption that a “low” result will ward off the spectre of prostate cancer. And here we run into a few difficulties.

The test measures a chemical put into the blood by an “unhappy” prostate. The problem is the source of prostatic disquiet could be anything on a spectrum from infection through inflammation to cancer. There had been hopes a few years back that it might prove useful as a test for the latter, but the test is just too imprecise to be useful and indeed the prevailing wisdom is that the potential harm of the number of unnecessary biopsies and other procedures that would arise from using it as a screen far outweigh any benefits it might provide in identifying new cases of prostate malignancy.

Needless to say, just because the medical establishment, hampered as it is by a need to evidence practice, doesn’t view the test as a good thing, doesn’t mean, now the Djinn is out of the bottle and the movers and shakers of groups like the A&D up and down the country won’t engage the services of the 21^st century equivalent of the Snake Oil salesmen of old. So it is that they end up buying in unproven services from unscrupulous predators, keen to turn a fast buck at the expense of the anxious and ill informed, all from the best of motives. But this leaves Brian with a bit of a problem. Now he’s had a “screen” and it is “high”, but he has no symptoms of prostate disease.

I’ve offered him an examination (not described here for the sake of the squeamish—fans of Billy Connoly will know what I’m talking about though) but for now he has declined. Do we repeat the test, and if so when, and what do we do if it comes back raised again.

He’s agreed to go away and think about it for a while, and knows to come back at any point if he starts developing symptoms that suggest his prostate is unhappy, but I’m not sure he won’t be back asking for a lab test at some point in any event.

*EVCHN for attribution as usual.

Brand X

Enter Jamie, from his Nike trainers to his fashionably oversized baseball cap (I’m guessing it has some other appellation, but am too unhip and disinterested to go looking—but you all know the sort) festooned with its own logo (which again I “should” know, but again can’t really be bothered enough to go looking) he is every inch (or centimetre for the younger reader) an Ad Man’s dream.

Now I know I’m old, and grumpy, and horribly uncool, but I can’t be doing with all this branding. In the good old days, when life was austere—and I mean properly austere, not the austerity-lite Dave and George are enacting, we were glad to have shoes of any sort—let alone trainers, and trousers that came to within four or five inches of the floor without having to have extra bits let in. Labels were things you cut out of the back of your jumper to stop them itching, not “accessories” to blazon every spare surface.

Well o.k. there was the year every red blooded male child hankered after a pair of hiking shoes with a compass in the heel and a “bear paw” tread, but that was essential survival gear for when you found yourself trapped behind enemy lines, a fate more common for the average eight year old back then, when the average eight year old was allowed, nay expected, to play out in all winds and weathers and states of enemy occupation… but I digress.

On this occasion Jamie (who’s closer to sixteen than eight by the way) was accompanied by a worried looking Cathy (his mum) and after a cheery Jesterly “What ho!” she prompted him to roll up a letter strewn sleeve to reveal the forearm underneath. It transpires Jamie’s forearm has a hole in it. Well more a crater than a hole—it has a base. A mainly greeny-grey rather septic looking base, with angry looking red edges all around. It’s around 2-3 millimetres deep, and self inflicted. A few nights before, Jamie and some mates had been out braving the Biblical floods getting out of their heads on scrumpy and howling at the moon (traditional country pursuits in these parts). For some reason they then decided to do a spot of branding of their own, and one by one heated a lighter to a glowing white heat before jabbing it, now unlit at least, onto their own forearm!

On the plus side, in the modern era of antibiotics the resulting sepsis can be easily treated, and the circle is no bigger than the blunt end of a pencil. On the minus side it looks deep enough that it can’t but heal with a substantial and rather ugly looking scar. Unlike the brands he’s wearing now, but will be too cool for himself in a year or two, this one will be for keeps. He says he’s not unhappy, he wasn’t “self harming” in that sense, and that it was just a “lark”, and for now I think I believe him, but I hope this isn’t the start of some new and scary trend. Somehow it feels far nastier that the present dual fetishes for piercings and ink.

Nice Weather....

April has been an odd month in Ambridge. For odd, read wet. Indeed were I of a superstitious nature I’d be laying in biblical quantities of wood right now, and assembling a binary menagerie. You see the Am has burst it’s banks and roams abroad the flood plains of Borsetshire like an invading army and the denizens of the quaint Am-side villages are stockpiling tinned goods and filling sand bags “just in case”.

In consequence the roads of the customary drive to work have become waterways, especially those approaching the foot of the Ambridge Escarpment. Last week I sloshed up behind a Clio that was crawling along at a sedate pace in the middle of the canal… er, road, seemingly oblivious to the tailback that was forming in short order behind me.

It transpired as they approached the rise to the aforementioned escarpment, that there was a tailback of their own in front. Or at least a tail attached to the back of a young lady mallard who had, not unreasonably, taken this particular part of the Queen’s Highway for a new tributary to our mighty river, through which she was paddling and plashing along, oblivious to the chain of four wheeled watercraft arrayed in line astern. I can’t help wondering what went through her mind as she encountered the uphill gradient of this particular watercourse though.

There have been benefits to the “wettest-April-on-record”. The lawns at Jest Acres now, at last, have a greenish hue and no longer resemble blasted and windblown tundra. Admittedly most of this greening is of mossy origin, but as you all know I’m never one to complain. And the wizened and stunted trees of the soon to be legendary Jest Orchard have finally seen fit to sprout a few green shoots and varicoloured pink and white blossoms which cling desperately to their branches for a few moments before being lashed away by the battering rains.

Just now it looks for all the world as though May is destined to continue the aquatic trend, though we are told it would need to keep up like this for months ahead if we are not to regard present conditions as a drought still. (It seems the spirit of Michael Fish is alive and well at the Met Office). Be that as it may, imagine my delight when, on approaching the escarpment this morning I espied a hastily hand painted sign reading simply, “Caution! Ducks!”

Roll on the 23rd Century

What follows is perhaps not for the squeamish, or for reading too close to mealtimes...

It is an inconvenient truth, but there are some things we are called on to do that are just plain awkward and embarrassing to have done. Until Dr McCoy’s hand held “Wibbly” scanner is invented we have to make do with more archaic and difficult methods, and en route to that same Star Trek tech we are developing methods that though better than the traditional, are still plain odd at first blush. (Blush being very much the operative word here).

There, how very English of me. I’ve spent an entire paragraph skirting around a difficult topic without saying anything meaningful or illuminating. And I’m risking spending another doing just the same, so time to bite the metaphorical bullet and get on with it. There’s an old surgical aphorism that’s as true today as it’s always been, and it simply states “If you don’t put your finger in, you put your foot in it!”

Men of a certain age, and ladies of pretty much any age will now be cringing and looking away squeamishly. The awkward reality is that there are some bits of us that can go spectacularly wrong, that we can’t actually see, and so, to gain a better understanding of certain symptoms of alarm we have to rely on other methods. These begin with the simple (?) “digital exam”. No, not some clever electro replacement for “analog exam” just the humble expedient of placing a gloved finger into an orifice and “rummaging” (it’s actually a bit more technical than that at the operators end, but I fear further explanation would put us all off our cornflakes). This method remains the gold standard for initial assessment for enlargement of the prostate and early examination of some suspected ovarian problems and can help differentiate the likely causes of some abdominal pains or “funny bleeding”.

Moving along we have an array of other bodily intrusions on offer from the now antique barium studies through scopes for use from either end (though separate scopes for each you’ll be glad to hear), there are also scopes that go up the hooter (or schnozz for American clinicians). The latest innovation in our neck of the woods is an ultrasound probe designed to bypass the bones of the pelvis to generate ultrasound images of the uterus and ovaries internally. All of these would fit nicely into the folklore attending those lurid tales of alien abduction so beloved of Midwestern agrarian types and hairy, wild eyed, science geek conspiracy theorists.

So why am I mentioning all this now, I hear you ask. You did ask didn’t you? You’ve not just read a couple of lines at random and run away screaming?

Good.

So why indeed.

On a handful of occasions down the years patients, including one of mine right now, resist the suggestion that we intrude on their “personal space” to such an extreme degree. Despite careful explanation they find the concept of an invasive examination too personally challenging. Mostly, with some gentle persuasion they can be won round, or alternative methods can be found to garner the necessary information, but every doctor carries with them a few cases where this has not been possible, and for the want of a timely smear, or prostate exam, or colonoscopy or other such “space invader” examination, an aggressive disease has taken hold where it need not have.

For these patients, as Dr Neighbour so elegantly put it a few weeks ago, it’s as though they are “dying of embarrassment.”

It's all Greek...

Two weeks ago, in mid-afternoon surgery, there was a soft “plink” noise. Only a quiet noise, but such a noise as comes laden with evil portent. Accompanying the “plink” was a flash of the screen, followed by an evanescent appearance of the fabled BSOD* then nothing. Like a heavyweight boxer smacked on the chin by Ali in his pomp, my computer folded at the knees, collapsed to the canvas and tiny cartoon bluebirds started flitting around its brow to the accompaniment of a tweety whistle.

The gremlins had struck with perfect timing, late on the Wednesday before the Easter weekend. So Maundy Thursday morning we called IT. They promised and engineer on next working day (i.e. Tuesday). No big problem as one of our learners was off on hols and her broom cupboard --- er *room* (ahem) was free to consult in. **

After a tranquil and relaxing Easter (yeah right… but that’s another whole set of stories involving fire and sacrifice and tedious little distractions of a similar sort, not for here and now) your humble interlocutor was out of surgery on Tuesday morning touring the Nursing Homes of the district—part of a new initiative to enhance our care of the elderly-- and so fully expected to be back after lunch to find a shiny new terminal humming away right as nine-pence.

No such luck!

Happily we were a nurse down so had a treatment room spare, with a computer in, so 3 days 3 rooms and on with the motley. Except none of the punters could get used to the idea of me consulting in the nurses room and all and sundry developed a compelling need to rummage in the treatment room cupboards for this dressing or that blood tube as I was trying to work. Still we got through. But by close of play still no sign of IT.

Wednesday and Dr Neighbour was out all morning—day 4 room 4 and by now it wasn’t just the punters that didn’t know where they were going. All my diagnostic kit was liberally distributed through the other three rooms, all of which were now in occupation, so whenever I needed to check an ear, dip a urine or test a BP I was off wandering the corridors like a lost soul looking for my kit. Oh and Wednesday we had a student in for tuition with yours truly. The poor thing didn’t know what on earth was going on, but gamely took to entertaining the punters whilst I roamed chuntering through the building questing for this or that.

IT phoned late on Wednesday and announced they would definitely be in on Thursday. Probably.

Thursday we had a problem. Everybody was back in and consulting, so I had a room (my own) with no computer, and there was a computer in the office space behind reception with no privacy. Solution, print out contact sheets for the whole surgery (recent history, significant problem lists, current meds and any up to date bloods) and consult without the “one eyed monster” writing scripts by hand and updating the computer record afterwards. Simples!***

So sure enough two patients in, IT guy arrives to install a new box and take the old one away to be sealed in carbonite and buried in a vault on the Death Star. Brilliant news, except that he needed an hour and a half to twiddle knobs and adjust dials to get the thing working properly. And it’s a one time now or never offer ‘cos he’s got to be elsewhere working for a godlike NHS manager by 13.00 and he’s off to a stag do in Amsterdam after that (you’re thinking TMI right? So was I). So send all the punters home or try to consult in the car park? As I ask the question of our chief receptionist we both look to the vacant practice manager’s office for inspiration. P.M. off for the week getting drowned in the balmy post Easter rains so no help forthcoming from that quarter.

Now I know you’re all already ahead of me here. Office, vacant, and with computer linked to clinical system. There followed what the younger generation would call a face-palm moment.

Day 5 room 5 and by lunch surgery sorted and back, at last to normality. I’m back in my Tardis and all’s right with the multiverse. Excepting the trivial matter of a loss of data slowly gleaned over ten or so years of consulting and only partially and fitfully backed up. And the abiding impression of a few dozen punters and a final year student of my Alma Mater that I’m a bumbling fool who suffers with terminal “olecrano-gluteal dysgnosia”****.

*Blue Screen Of Death

** Yes the Ambridge surgery treats its learners rather like Hogwarts does. Only without the pointy hats and wands and such.

*** In joke in Blighty about a talking meerkat. In all honesty if you need to ask you're better off not knowing, trust me. (Though You Tube will probably oblige, but you’ll really wish you hadn’t bothered. Honest.)

**** EVCHN for first correct translation. (There's a tiny clue in the title)

A good walk

Ray’s been back in a couple of times recently. When he arrives the front of house team find him and his dopey black lab a quiet seat out on the maelstrom that is our waiting room, and instead of the usual summoning by bells I actually get up and prowl the corridors to fetch them. Only the time before last there he was on his own.

The last time that happened it was because “Rockstar-dog” his first and dare I say prettier guide dog had succumbed to a coronary at the relatively spry age of ten. Since then he’s had “Dopey-dog”, who has been a faithful, if far more docile companion. So, with grim inevitability, I plant a size nine boot firmly in mouth by enquiring “What, no Rockstar-dog today?” Ray is of course far too much the gentleman to pull me up on my alarming faux pas, but gently says “No, Dopey-dog is out with my neighbour for a run...”

Our consultation runs its course, he’s actually looking better now than last summer when he was experiencing problems with his meds, and as we finish and I’m walking him back to the pharmacy, we return to the subject of the absent Dopey. Apparently the neighbour purloins him now and again to prowl the perimeter of the local golf course, seeking out strays. Stray golf balls that is. It turns out the neighbour is a devotee of the “good walk spoiled”.

Happily the quote stays firmly in my head, as Ray inquires if I play myself. I have to sheepishly admit I do not. I know it’s something of a cardinal sin for a chap of my tender years and noble profession not to play, but I never really saw the point. At my admission Rays face lights up in recollection—“You really should you know, it’s a great game. I used to love it, back before the arthritis got me.”

Now Ray is almost to the day ten years my senior, and the arthritis well and truly got him a good three and a tad decades ago. Anything that sparks such an evidently joyful reaction on reminiscence can’t be all bad, can it? So now I’m beginning to wonder if I’m missing out on something. Not that I’m sure I’ve got the time for a new pursuit just now, but that’s another story.

And yes, Dopey-dog was back next visit, and still in need of guiding, by me, to my room, the room he’s been coming to four or five times a year for most of his adult life while he’s been “guiding” Ray. But it seems the both of them know their way around a golf course better than I’m ever likely to.

Something something Dark Side....

I can’t quite believe I’ve done this, but after a small discussion piece courtesy of Aunty this morning (Radio 4 Today programme to be exact—where else?) I’ve just toddled over to the dark side for a peek at “Conservative Home”. It’s a scary place for a dyed in the wool pinko liberal like myself, but Tim (the proprietor of same—apparently that’s how his punters like to name him) has woken up far too late in the game, to the unpopularity of the Health and Social Care Bill. Well done Timbo. Trouble is you’re a couple of years late and a tad more than a dollar short (roughly £20 Billion in modern nomenclature).

The reality is, whether Dave ditches Nutter Lansley (the Fred Dibnah of NHS restructuring) or no, the damage is already done. The changes our esteemed Health Secretary wanted made have been enacted by fiat, un-trialled and unchallenged and there’s no turning the clock back now, Bill or no Bill the NHS must restructure because he’s already blown to tiny pieces the bodies that were running the fractured health economies that made up the hopelessly balkanized soi-disant “National” Health Service. With PCTs de facto abolished and Commissioning Groups champing at the bit to take over (but still in our locale hopelessly ill equipped and un-resourced), Dave and the soaraway success that is our coalition can fiddle all they like. Rome is well and truly ablaze and we can only await the Phoenix that will arise from her ashes.

Tim’s article and the opinions of his various commenters just go to show how utterly our political class fails to grasp “health” as an issue. They can’t resist tinkering and faffing. As I’ve argued before it would be impossible for them. It’s not their fault, and it’s not particularly different under this administration if I’m honest, except in outcome. Lansley has been more radical that some, less than others in his stated intent, but worryingly, he has been let loose to run amok BEFORE fully framing the legislation and establishing the structures that would allow his reforms to take shape. The last time this happened, in 1997, it took us a while to sort, but thanks to the dedication and professionalism of countless much derided NHS managers, and the care and devotion of all the NHS professions, it got sorted.

My worry is that we’re not now the service we were then, and that the dedication and devotion has been severely eroded by over a decade of being on the sharp end of loony initiatives and make-work restructuring, plus struggling to hit unattainable targets, like performing seals honking air horns for fish. And this erosion is far from the fault this administration alone. Indeed though the seeds for our present difficulties were sown by dear Margaret Hilda and her barmy army, they were seized on wholeheartedly by Tone and Gordon and driven further and harder under them than I suspect any right of centre government would have dared.

So if this is all sounding rather like a counsel of despair, you’re probably right to see it as such. It is far from clear what our battered health services will look like when and if the dust settles. Locally our own health economists are looking at a “once in a lifetime opportunity” to reshape services for the future, but I fear even before their plans have been drafted we’ll be moving on to the next initiative— and scrapping the bill will make very little difference one way or the other. Sadly health in real life isn’t like health in the popular imagination—fuelled as that is by dramas that wrap up a complex case in sixty minutes (forty five on independent channels to allow space for adverts for things almost calculated to make you ill). And politicians, as again I think I’ve said before, are taught to think in terms of balance sheets and changes to be delivered in their entirety within eighteen months or at least ahead of the next reshuffle. So Tim, if you’re listening—and I can’t see any reason you would be-- say what you like about the bill and its prospects for Dave’s re-election chances, but please, please spare a thought for the poor bastards on the receiving end* of your masters' extravagant insanities, and try to persuade them to think in terms of generations and not reshuffles.

* Oh and by the way that’s all of us—assuming you’re ever unfortunate to suffer a long term ailment that the private sector won’t insure—like diabetes, arthritis, heart disease, chronic lung disease, any occupational ailment..... well pretty much anything except a boob job** if I’m honest. Oh and especially NHS managers—those we have left.

** Oh and probably boob jobs too-- at least if they were done on the cheap.

I wouldn't get too excited, but...

"Crikey, two posts in under a month-- what's he playing at? You wait months and months and nothing at all, then this..."

"Shh I think he's trying to say something!"

"Well I for one am not holding my breath so there!"

(And you're right not too. It's been a bit quiet round here of late I know, but here goes...)

As you can probably gather 2011 has hardly been a vintage year at Jest Acres. In fact we’ll none of us be too unhappy to see it go. There have been times this year when it’s been hard to string a coherent thought together, let alone get anything down on the page—virtual or literal. I miss writing hugely, but for large chunks of this year the words just wouldn’t come. There have been moments and punters worthy of anecdote, but it’s just not been possible, and for that I apologize to those of you who might have stopped by from time to time.

I’m hoping for better things in 2012, though if we’re to start looking after 25% of the inpatient population in addition to doing the day job (as one boffin seems to think we ought, to the rapturous reception of Mr Lansley among others) that might be a trifle ambitious. Whatever the case I’m determined to try harder to put virtual pen to paper as it were.

I hope ’11 was good to you all, and whether or not, I hope ’12 will be fantastic for us all. There’s a lot of doom and gloom about pretty much everywhere at the moment, but despite it all there is much to be grateful for (among many other blessings I’m especially looking forward to sampling some home made Mars Bar Vodka over the New Year holiday—if I survive I’ll report back).

So a slightly early Happy New Year one and all, and I’ll be back, soon I hope, to see you all next year.

East of Eden

Whether you take it as revealed truth or allegorical myth there’s something compelling about the argument that we live in a flawed and imperfect world. Perfection is there to be striven for, but it’s unrealistic to expect that we shall get there alone. We allow in our oral histories that transcendence *is* possible, but only to a very few very special individuals, and then generally with the help or agency of some higher power. For the rest of us East of Eden is where we are expected and expecting to remain—in this life at least.

Indeed, if anything just now it feels we’re heading further and further east, away from calm, plenty and fulfilment as each day passes. Perhaps it doesn’t help that it’s winter now for real in Ambridge, after an Autumn so mild half the bulbs at Jest Acres seem to think it’s Spring again, but the old Crystal Ball resembles more a Snow Globe than anything else looking to the next year or two.

In the midst of all this gloom and angst we get a bizarre assertion in the news today. 24,000 deaths a year could be avoided if diabetes were treated better. With a token apology for pedantry, avoided? Really? Now I know modern medicine is pretty hot stuff, but I’m not aware of any innovation potent enough to permit us to avoid death. It’s not clear from the reporting whether this is a verbatim quote of a grandiose claim or just sloppy journalese, but I fear I have to disappoint you all. The best we can attain for now is a deferral, which in the colloquial idiom “ ain’t nothin’" but I fear falls far short of the alleged outcome.

I’m also a little uncomfortable at the assertion that there’s some kind of blame to be attached in each of these 24,000 “un-avoided deaths”. It’s almost certainly true that a great many could be helped to look after their diabetes better and in so doing delay or avert death from this condition, but it is equally the case that a number of them would prefer to be let alone, not seeing a prolonged existence as desirable for any of a number of reasons, some well thought through and some, to external scrutiny apparently frivolous.

I worry that in seeking to target this group of patients for “better” care we risk trampling on their autonomy. This is an increasing trend in all areas of modern patient care, where we are pressed to treat to a target—evidence based for sure, but paying little or no regard to the individual on the receiving end.

This is in no way to suggest that trying to offer better holistic care would be a bad thing, and if by so doing patients can be engaged and encouraged to try a bit harder to reach the targets then this can only be a good thing, but where like Mme. Voizin in Chocolat there are patients who know their choices are unhealthy, but opt to continue to indulge, accepting a shortened rather than an impoverished span, who are we to deny them.

Where there's a Will...

Peggy was in today. She’s well into her eighth decade and in pretty good shape. She survived a cancer diagnosis – going through surgery then chemo and radiotherapy and follow-on operative procedures all over ten years past, and has never looked back. The surgeons have told her she’s cured and she hasn’t needed follow up in more than three years.

Today she’s in to talk about a minor injury, sustained a week or so ago, and healing nicely, so no need to worry. And yet... worried she is.

How do I know? She tells me so—though she did look far more apprehensive that the minor injury warranted so I had already guessed as much.

And why? Not through the injury, and not from her past health scares. No today she is worried because last week she and Jack visited their solicitor and made their Wills. As she put it “We’d never made a Will before, and now I have I’ve got to face up to the fact that I’m going to die.” It’s as though the simple act of making a testamentary disposition has opened wide the door to the Grim Reaper, The Fourth Horseman, The Pale Rider (no not Clint—the real one*). In short she has had to formally acknowledge her mortality.

What impresses me most is that after everything she went through ten years past it hadn’t even entered her consciousness that cancer was something she might not survive. Her faith in the undeniably excellent care and support she was given then, and for the years after, had allowed her not to have to do so. She’s a little surprised that she feels this way now, but I can reassure her it’s something I’ve seen many times before and so, far from cracking up, she’s displaying a normal if utterly irrational response to the feelings generated by this simple act of forethought.

I’ve tried to calm her fears by telling her that to the best of my knowledge there is no hotline from Hades to the offices of the legions of probate solicitors worldwide, and especially none here in Borsetshire. At least I hope not.

*That said, these days Clint is looking his venerable age, and might pass in a dim light for the Bony Fingered Wielder of the Scythe.

Re-Assura-nce ?

O.k. I know I’ve not been around much lately—or indeed at all, for months. I know there’s a lot to say right now, and not having a voice with which to say it has been a huge frustration, but sometimes words just elude me. So I’m grateful for an email from a friend that gave me a prod to try again.

I fear it’s polemic time, but since I imagine so many of you have drifted quietly away in the long silence perhaps I won’t end up boring too many people. I should also point out that the email came over two weeks ago, so I fear this is not the best place to come for an answer to any queries you may have. Certainly it’s unlikely to be the speediest :-(

So on to the email. My friend was talking with a consultant who revealed the following;

“Apparently the PCT are refusing to fund all 3 monthly hospital reviews, and have been for some time (ie before Coalition took over) The hospital are still arguing about this, to get the PCT to accept those patients they put on pathways exempted from the GP's…”

I have to say the same is true, in some form, in our own PCT and likely in almost every PCT in the country. The reasons for this are many and complicated and though driven by finance are not purely dictated by the bottom line. What we have to bear in mind is our fractured, battered, beloved but struggling NHS has been through six decades of continual change. This change has been technical and clinical every bit as much as financial.

So, how dare a PCT dictate to a consultant when and how a patient should be reviewed? Well the first motivation right now will undoubtedly be financial. Each encounter of a patient with any hospital or “hospital-supplied” service since at least the early 1990s has carried a price tag. So the initial encounter at outpatients generates a bill. There is then a tension between hospital and PCT, both of whom have a primary statutory duty to deliver a balanced budget which overrides any other duty they may have. So more hospital outpatient reviews means more money for the hospital, and a bigger drain on PCT resources.

In the time I’ve been in family practice the level of care and expertise available in the community has gone through a quiet revolution. Pretty much everyone, including our consultant colleagues still see general practice as a sleepy medical backwater of two surgeries a day and a round of golf in between. Anyone who has had any regular dealings with their GP surgery over the past decade or more will know that things aren’t like that anymore. At least they will if they take a quick look around. First, it’s likely that their surgery has a number of doctors rather than just the one or two that was the norm in the first few decades of the NHS. Next, as well as the normal surgery appointments there are likely to be dedicated clinics for a number of conditions including diabetes, heart disease, asthma and COPD as well as “lists” for minor operations ( a rarity in 1990 and near universal by 2000) wart treatment, travel clinics, counseling, physio, and in some of the more adventurous, even “alternative” therapies like acupuncture, chiropractic and a host of others. (True in remoter and more deprived areas not all of this will be so, but even there the GP is still likely to be offering a range of services that thirty years or more ago would have been the preserve of the hospital).

All of this activity is also funded by the PCT. So if the PCT can agree diabetes reviews as an exemplar, in practices, for a fixed price well below that of the hospital, and if the practice is geared up to provide a service at least as good as that of the hospital for the vast majority of punters, why would they opt to have these patients reviewed in hospital or hospital led outpatients? Particularly when the service commissioned from General Practice is a “block contract” paid per capita and not per encounter. But there’s great deal more to this than mere finance. Any regular user of hospital services will tell you that they seldom get to see the same doctor two clinics running, because of the way hospital careers and training are organized, and because the minimum realistic interval between appointments is many months. In practice a GP will generally take a lead role in a given clinical area and will be rather more available. When patients are stabilized and well managed yearly or six monthly reviews will generally be the norm and these could be delivered in either setting, but in Practices the team doing the reviewing will de facto be smaller and longer in post, and so likely more consistent, delivering better continuity and with a greater hollistic knowledge of the patient. And when things are more complex practices can generally respond if needed in a day or two and review in a week or two, where the only option available to the consultant would be admission or “urgent” outpatients which—in this locality at any rate, could be anywhere upwards of 4 to 6 weeks.

This is not to deny that there are some, rather iller and more complex patients who genuinely need more frequent hospital care, and for them the existing system is undoubtedly flawed, to the unending frustration of Consultants and GPs alike.

There was another point raised in the email, “(h)is other interesting information was that here the GP's refer to a private company called Assura as well as the NHS. He pointed out that many of the local GP's have significant shares in Assura and therefore a clear conflict of interest…”

Here’s where things start to get complicated and not a little murky. Before I start I must declare an interest in that our locality has services provided by Assura in which every practice in our consortium are partners.

Assura was started some years ago as a commercial supplier of outpatient style services to GPs run by GPs. They have grown down the years and to the best of my knowledge now continue this model and also help practices with premises development in a model similar to PFI. They tend to develop local services as stand alone ventures—franchises if you like, in joint ownership with GPs, and often engage some of those same GPs who have developed particular expertise, alongside Consultants and other practitioners as appropriate, to provide the service. Their services can range form Physio to Dermatology to Orthopaedics to name but a few. I believe they have also been involved in tendering to offer out of hours GP services as well but cannot be sure if they presently run any.

True they are a “private provider”. So are many others currently offering care and services under the NHS umbrella. And true they provide services in partnership with local GPs, and invite referrals from those same GPs. However, to be able to provide such services they are obliged to tender in an open market to the PCT who commission the service, in competition with other providers, NHS and Private Sector, and stringent attention is paid in that tendering process to cost benefits and to potential “conflicts of interest”. So much so that it can take anything upwards of 18 months to 3 years for tender to gain official sanction.

This is the shape of our modern NHS and current reforms look set to oblige commissioners to look not just to NHS-allied organizations like Assura, but also to the wider marketplace, opening the door for strictly commercial private sector providers who will not have either the tradition of engagement with the NHS nor the public service ethos that alliance with GPs who are grounded in the existing systems carry in their “DNA”. One of the consequences of these new arrangements in our locality has been an increase speed of access to specialist opinions for patients who would otherwise have had to pay personally to see a consultant privately. Under these arrangements the PCT is paying the franchise and the patient is seen as an NHS patient. I wonder if this has some bearing on my friends’ consultant’s concerns over conflict of interest?