Show Me The Money!

QOF Losing Steam

In the matter of GP's, and indeed Doctor's, much has been said about their future role as the new Guardian's of Primary Care. Unfortunately, that seems to becoming a bit of a 'poisoned chalice', as it is clear that they will probably be damned if Lansley's 'experiment' doesn't work and probably if it does, because in achieving the goals of Government they will become both the provider and the arbiter of provision. It will no longer be the PCT or NICE who will be on the receiving end of patient wrath, it will be the GP's themselves.

It is also important to examine how this unique 36,000 or so Doctors structure their relationship, with the State, because it is singularly different from the rules and practises that rest of society lives by and with. Most GP's are in fact 'small businessman' or indeed not so small. They are 'contractors' paid fees for the provision of Primary Care services to their patients. Quite a few are Limited Liability Companies, and some are already 'Consortia' in a loose coalition of practises, working out of Health Centres provided by Local Government, for which they pay rental. So how come we (the taxpayer) contribute to and manage their pension fund within the NHS? No-one that I can think of,  has this sort of 'special' relationship with their client or customer. 'Bob the builder' would dearly love someone to pay a sizable chunk of his pension contributions and guarantee him a good percentage of his final income from 60, but it ain't gonna happen, because he's a 'subbie', just like you. Difference is he will be incapable of working after 60, because he's 'knackered'! You can retire at 60, alright if you don't commit suicide first, with a gold plated pension, we (the prole's) can only dream of!

This is all part of the relationship that doctors have with society. All take, no give, 'loads a money' for their business, especially payment by results for s**t protocols that do not produce any real reduction in the ultimate end point (that's death!), but bags of surrogate end points like slightly lower BP or worse; lower LDL, that prove absolutely f**k all! Oh and don't forget the virtual exemption from any likelihood of ordure if you cause a patient to die, (although if you s**g one, watch out!). Some, albeit it a few, are making in excess of £250k, for office hours! Most make £105K or more. Some single handed practises in remote areas make up to £300k.

Almost all of you GP's, either couldn't be arsed to turn up to the recent BMA special conference or bother even vote for action, against reforms and took the 'easy' route. But, you were all up in arms about the idea of working to 65 as us poor mortals are going to have to, and even prepared to strike, or retire from the battlefield, on the grounds of self interest! As Pulse revealed, lots of GP's are already on the boards of Private Health care providers and will have a vested interest in supporting  their own Commissioning ambitions. This highlights some of  those in the Profession's, constant desire to command and control the situation for their own pecuniary advantage, whilst trotting out the usual rubbish about 'putting patients first'. A significant minority of GP's it seems, are looking forward to Commissioning as a vehicle to advance their careers and their pay.

Well, since Nye Bevan "stuffed their mouths with gold" in 1948, Doctors have been  overly concerned with the money rather than the welfare of their patients. In 2004, when they were able to 'palm off' the out of hours responsibilities to the PCT's, they could hardly believe their luck in getting away with this for a mere 6% of fees. This led to almost all of the call outs being handled by the Private Sector providers, who got away with murder, by the recruitment of foreign or newly qualified doctors, in an attempt to maximise profit at the expense of good care provision. In addition, the deal brokered by Blair's cronies with the BMA, launched on a 'clueless' public the Quality Outcomes Framework, which boosted pay so much that an additional £1.7 billion more than estimates, was expended for the somewhat dubious outcomes I highlighted earlier.

So GP's are extremely good at managing their finances, but not quite so good at managing their clients health, unless of course it's ensuring that said patient is adhering to the QOF protocol they have been placed on, which is the management of their finance because of the 'payment by result' they receive for this duty. And what is the method of 'measuring' the outcome? It is called a surrogate end point; so if a GP 'statinates' a patient, achieving a lower LDL level, will elicit the payment. Quite a few Doctors are aware that this will not make a difference to;

• Any Woman
• Any Man who is not a high risk or has had no CVD/CHD.
• Any Man who is at risk but has had no CVD/CHD.

In fact there is very weak evidence to support the use of statin's with patients, even at high risk, but with a previous CVD/CHD event, but the reduction is almost not significant and a large body of scientists actually believe that statin's are working in a different way from their mechanism design. Many Doctors know all about the risks and the lack of evidence for statin use, but cynically do not do anything about it. Dr Phil Whitaker, who is also an author, recently said " My GP colleagues and I have become press ganged into the role of pill-pushers, the tyranny of QOF subjecting patients to bewildering and sometimes injurious choices of drug, irrespective of circumstances". Doctors can 'exception code' patients, and some do. But do this with more than few and the PCT 'Stasi' will be onto you.

If you really want to upset Lansley's dream of an NHS peopled by 'right thinking' private consortia, guided by the Kings Fund, Kaiser et al, then commit some acts of disobedience like exception coding all your patients and tell the 'thought police' to take a hike, or refuse to cooperate with the ConDem's grand plan. Just do something that isn't related to your personal wealth. Just for once!

We're All Idiots!

So we're all so stupid and self destructive to the point where we have to be protected from ourselves, or so it would seem. Now we have the spectre of cigarettes no longer being allowed to be in sight of customers in shops, or indeed for the packets to have any colour other than white, so as to ensure we will not be seduced by the pretty colours, to take up this evil habit. This is despite the fact that this same Government sees fit to rest some £11 billion a year from smokers wallets, who then go on to cost society a mere £3.6 billion in health care. Seems pretty much a bargain to me!

No, I do not encourage smoking, it is dangerous and destructive of health. It has been established that smoking can and does cause lung cancer, that I accept. It also causes Chronic Obstructive Pulmonary Disease, probably more often than Cancer, but that is not the point. Banning the display of anything, has no foundation in the evidence of prevention, be it Tobacco, Alcohol or indeed anything, and has been counter productive or even dangerous. One only has to look at the Prohibition of Alcohol in the US to form that opinion. Placing things 'under the counter' has usually created a vicarious desire to obtain said things whatever they may be. Not gifting people with the brains with which they were born is worse. But more, personal freedom is curtailed. We no longer have any liberals in Government only a few Liberals.

Politicians, especially the draconian regimes we have enjoyed since 1979, have not been able to resist the pleasure of forbidding things, they feel to be injurious to health, despite the fact that they often continued in those same pleasures (sins), behind the closed doors of Government themselves. Maggie herself liked a few whiskies and without doubt John Major, enjoyed pleasuring Edwina, despite his public condemnation of others who enjoyed extra marital 'hobbies'. There is of course considerable evidence, that drinking moderately is in fact healthful (and sex is both good for the mind and body) but politicians seem to feel it essential to regiment the behaviour of the 'proles' just because they have it in their gift to do so. Most of the time their efforts not only have been in vain, but wrong.

They have preached that 'fat' is bad and makes you fat and gives you heart disease, unless of course it is a fat sanctioned by the 'health police' at the Food Standards Agency (now DH), which will be a vegetable oil then. That helps get rid of the enormous surplus of this Government subsidised crop extract, that is only fit for biodiesel, not human consumption. In fact, look only to the arable farming lobby to see that we are entreated to eat. Grains, or extracts of grains, with some more, err... grains.

Red Meat, well that's bad too, but it isn't of course. It just isn't part of the Farming Lobby (anymore) because that has been 'hijacked' by the arable crop magnates, who can run several thousands acres of heavily subsidised grain producing land with two men and a vast array of machinery. Look to where the money is, and where it isn't, you will find that which is 'bad' for you. So the livestock producers, of lamb, beef, pork et al, are all struggling to make ends meet.

As for milk, well the same goes. Producers of high quality grass fed (the cows that is) milk, especially high fat Jersey, Guernsey and Buffalo milk are dwindling, because the Dairy magnates just want cheap, bulk milk with low nutritional value, to process into that 'white water' that is stacked on the supermarket shelves, all because we are told not consume dairy fat.

There is always an agenda, always motivation beneath the surface, even if it seems benign or co-incidental. We no longer have any liberal minded politicians, just the Neo-Thatcherites, the inheritors of the Blairite agenda. There is little 'real' opposition, just arguments about the position of the deckchairs on 'Titanic' UK, between a bunch of bickering 'toffs' and academics, who cannot resist the temptation to micromanage the lives of their people. Trouble is, they're s**t at it.