Independent Sector Treatment Centres (ISTC)

Dr Phibes is pretty much an apolitical animal, and there aren't too many things that really annoy me. However, the way in which ISTCs have appeared, promoted as providing CHOICE (that word again), really makes my blood boil.

What are ISTCs? They are privately run centres which have been contracted to do work for the NHS, such as hip and cataract operations.

The government say that they can cut down waiting lists by having all this extra capacity to do work in the ISTCs. They feel that my consultant colleagues deliberately run waiting lists long to encourage patients to go private, and that reducing waiting lists will stop this practice.

The first problem is that there is no new money. So whatever my PCT (Primary Care Trust) had to spend last year on certain operations, it has the same this year, i.e the same overall number of operations. Some of that has to go to the ISTCs. This means my local hospital has less money this year than last, and therefore can do less of these operations.

The local ophthalmology (eye) department is superb. Their waiting lists are very short, and very few people locally choose to go private. But still their budget has been cut, with a slice going to the ISTC.

The second problem is distance. The nearest ISTC to me is about 35 miles, while I have 2 DGHs within 5 miles. Time and time again patients will tell me that they don't want to travel for their care.

Thirdly is quality of work. The ISTC have very strict guidelines as to who they will operate on; in other words they cherry pick all the easy cases. Even so there have been problems. And who picks up the pieces when things go wrong- the local hospitals.

There is not a level playing field. ISTCs are paid more per case than the NHS despite the fact that they do the easy ones. They are also guaranteed payment whether they do the contracted number of cases or not. Many ISTCs are not working to full capacity.

My PCT are now telling me they are running out of money, so could I please send more people to the ISTC as it's already been paid for. Dr Phibes doesn't feel like helping to get the government out of a large hole of it's own making. This isn't CHOICE where I have to send patients 35 miles when they really want to be seen locally. Is it Dr Phibes' fault that ISTCs weren't thought through properly and aren't working to capacity?

But you can bet if I did send patients there, the government would be boasting how successful their scheme is.

Retirement timebomb

The way GP pensions are calculated is somewhat complicated.

What has happened recently with the new GP contract has left a situation where a large number of GPs are likely to retire in the near future.

I'll try to explain.

A GPs pension is based on an accumulated pot of superannuation contributions during their career. Say you pay in £1,000 in contributions (a number plucked from the air) each year for 10 years. The amount you've actually paid in is £10,000.

But then you have to factor in something called the dynamising factor. This is a figure calculated each year, which looks at how much on average GP's pay has risen. If the average GP has a pay rise of 5%, then the dynamising factor is 5%.

This dynamising factor is applied to the pot.

So, after year 1, contributions are £1,000, but with the dynamising factor, the pot increases by 5% i.e. to £1050.

Year 2, you pay in another £1,000 in contributions, so your pot is now £1050 + £1000 = £2050. If the dynamising factor this year is also 5%, then the pot after year 2 is £2050 x 1.05 = £2152.50.

So after 2 years you have an additional £152.50 on what you paid in.

And so on. Your final pension is based on a formula including the final sum accumulated in your pot. So the more in your pot, the bigger your pension.

In years where GP income increases by little, the dynamising factor is small, so the pot increases little other than with actual contributions.

On the other hand, where GP income increases sharply, the dynamising factor will be large, boosting pensions.

And this is where the new GP contract comes in. Over the first 3 years of the new GP contract, the dynamising factor is estimated to increase pensions by 40%, in other words without any contributions to your pot, it would still increase by 40%.

After these 3 years pay looks set to level off. The dynamising factor will be more or less 0.

From a financial point of view, anybody approaching retirement at this time would be better off retiring. Once you retire your pension is inflation linked; better than holding on with a 0% uplift to your pot.

Here are a few links: 1 2 3

More problems for Connecting for Health (CfH).

I recently mentioned problems with the government's new National IT scheme.

Incidentally, I mistakenly called the scheme NPfIT in my previous post. Of course, it is now called Connecting for Health, as this obviously has a more distinguished ring to it. No doubt it will get another name change in the not too distant future.

Here are the latest problems.

This morning's surgery.

2 patients stand out this morning.

Mary is 77. I see her regularly to check her blood pressure. It is always raised, and despite numerous alterations to her medication ranging from wholesale changes to subtle tweaks, I have had little success. 2 weeks ago I started her on a medication called diltiazem. I had been resisting this as she also takes a beta blocker. Both drugs can slow the heart, so this can be dangerous.

Today her blood pressure was excellent, the best I've ever seen it. I hope it's not a one-off!

Emma is a young Type 1 Diabetic. I was routinely reviewing her diabetes, which is generally excellently controlled with insulin injections. Emma has mastered managing her own diabetes. She adjusts the amount of insulin she takes depending on what she is doing day to day. There seemed very little I needed to do. Then I asked Emma whether her diabetes ever got her down. She became very tearful, and confessed that she often wondered if she was depressed, but had never felt brave enough to initiate this topic with a doctor, as they might think she was being silly.

We had a long chat, during which time I'm confident I was able to convince Emma that she could discuss depression with me on any occasion without fear of ridicule. This is one of the more satisfying aspects of being a GP, when you can draw out a patient's real worries which they otherwise would not have mentioned.

Practice based commissioning (PBC)

In addition to the usual mayhem post bank holiday, I've a meeting to go to at lunchtime to do with Practice Based Commissioning.

There's been no shortage of press coverage concerning the perilous state of NHS finances.

So the next great scheme to save money is PBC, with GPs shouldering the responsibility of whether it succeeds or fails.

Each GP practice has their own "indicative budget". Everything that I refer to secondary care (outpatient referrals, emergency admissions etc) has a tariff, and all the medications I prescribe have a cost. Add up the total cost of all of these, and this is what I spend out of the NHS pot. This is my indicative budget.

Now I don't get actually get a cheque for this amount, it's all a notional idea. The Primary Care Trust (PCT) writes the cheques to the local hospitals.

With PBC it is now down to me to make savings on my indicative budget. In other words I need to spend less. So how do I do this? 2 ways; I buy things more cheaply, or I buy less.

So how do I buy things more cheaply? Take the example of a patient with a heart problem. I decide to refer them. It doesn't matter which hospital in the country I refer them to because there is a national tariff, so it will cost exactly the same. However the tariffs only apply to hospital care. So if a similar service is working in the community, charging less, then I can refer here and save money. The government are pushing for this.

The current trend is to set up a service in the community with a GPWSI (see this post for what a GPWSI is). Factoring in everything, this may not actually work out cheaper at all.

As an aside, I am supposed to offer up to 5 choices to my patients as to where they would like to be referred to. If offered a choice between a consultant or GPWSI, I know who I would choose. But if I want to save the NHS some money, I must try to steer the patient towards the GPWSI option. I see this as a conflict in interest.

Coming back to my 2 options for saving money, the second is to buy less. In other words don't refer so many patients, admit so many patients, or prescribe so many medications.

And so my meeting today is to look at strategies to avoid admitting so many patients to hospital. Sounds daft? Well it is and it isn't.

There are a large number of patients (mainly elderly) who become unwell and are unable to look after themselves temporarily. They are not life-threateningly unwell, but stop coping. Ideally they need 24 hour supervision rather than acute medical care. With adequate social support, numerous admissions could be avoided. But social services have their own cash-strapped budget, and the reality is that they are rarely able to help when someone becomes ill and stops coping. The only option is to admit to hospital.

But many patients are admitted out of hours, or directly via A+E, over which I have no control.

So what's in it for me? The government has said that practices can keep up to 70% of savings to invest in its own practice. This isn't income, and there are strict guidelines as to how any savings money could be spent.

But as there are unlikely to be any savings, then the answer to "What's in it for me?" is nothing, apart from blame when it doesn't work.

The World Cup Is Coming!!

I saw this which tickled my fancy.

Press Release from Department of Transport

Due to the nature of the quality of driving in England the Department of Transport has now devised a new scheme in order to identify poor drivers and give good drivers the opportunity to
recognise them whilst driving. For this reason as from the middle of May 2006 those drivers who are found to be driving badly which includes:

- overtaking in dangerous places;
- hovering within one inch of the car in front;
- stopping sharply;
- speeding in residential areas;
- pulling out without indication;
- performing U turns inappropriately in busy high streets;
- under taking on motorways and
- taking up more than one lane in multi lane roads,

These drivers will be issued with flags, white with a red cross, signifying their inability to drive properly. These flags must be clipped to a door of the car and be visible to all other drivers and pedestrians. Those drivers who have shown particularly poor driving skills will have to display a flag on each side of the car
to indicate their greater lack of skill and general lower intelligence mindset to the general public. Please circulate this to as many other motorists as you can so that drivers and
pedestrians will be aware of the meaning of these flags.


Department of Transport.

More QOF

I've already spoken about QOF, but would like to mention a bit more (and I'm sure it won't be the last time).

The rules have changed for this year's QOF. Let me give an example. You score points for doing certain things which are deemed good clinical practice, one of these is for checking cholesterol levels in patients who are diabetic. The QOF looks at the percentage of patients who have had this done. There is a maximum of 3 points available. Previously you started scoring points once 25% of patients had been checked, and it increased in a linear fashion until you got to 90%, whereby you got maximum points.

This year the minimum threshold has been set at 40%; in other words you have to do more work before you can start scoring points at all.

In addition new targets have been included this year. One huge problem is knowing if you're collecting the right data at present for the new targets to get the points.

Medical data is coded using "Read codes". Sounds simple enough; but unfortunately any given medical diagnosis can have several different read codes, some of which are acceptable for QOF, some of which are not. This is an example of the information available to determine what codes are needed to be used for the new chronic kidney disease section of QOF.

You need a bit of IT savvy to make sense of this.

Many GPs are going to have to wait until the Autumn for some software which will make sense of the above, and allow them to know if they're collecting the correct data. Until then it's fingers crossed.

A Day Off

It's sports day today at my children's school, so I've taken the day off work.

But the overnight rain has put paid to that. Never mind, at least I get some time to relax at home and watch the cricket.

Choose and Book

Have you notice lots of shiny new computers and IT equipment in your GP surgery of late?

For this you can thank your government's wonderful scheme- Choose And Book.

At the last count the cost of the overall National Programme for IT (NPfIT) scheme has been estimated at 30 billion.

Its aims are laudible. Eventually, wherever you are as a patient, your complete medical record should be instantly available. You go on holiday, travelling hundreds of miles from home, only to become ill. Wouldn't it be great to know that the first Dr to see already knows exactly what medications you're taking, and what illnesses you've had in the past.

This is some way off yet.

At present we have Choose And Book, or Booze and Chuck as it's better known.

With C&B I can refer a patient for a hospital outpatient appointment while they sit with me in the consultation room.

And this is where the shiny new computers fit in. I'm supposed to log onto the C&B website with the patient's details. I'm supposed to offer the patient up to 5 different choices of where to go. I discuss the options, and either book the appointment there and then, or give the patient a telephone number to ring and referral number to quote.

This, apparently, is all supposed to only take 30 seconds.

Our clunky old computers would never have been fast enough to cope, so the whole lot have been upgraded. All the broadband connections have been upgraded too; we now have an N3 connection (whatever that means). Now do this across the whole country, and it's already getting expensive.

But do the new computers do it in 30 seconds? Of course not.

Get A Note From Your Doctor (GANFYD)

Ask GPs to name one thing that really irritates them, and many will answer the Get A Note From Your Doctor (GANFYD) culture.

At first it might appear reasonable to ask your GP to just write a quick letter saying it is alright to do this, or alright to do that. But there are two big reasons why it is not.

The first is the sheer number we get asked to do. If it was just the one every now and again, it wouldn't be a problem. But Dr Phibes is asked to do several every day, and my partners similar numbers. This has real implications on workload, and therefore comes low on a list of priorities. In addition these notes are not part of our work for the NHS, so we charge to do them.

The second is how inappropriate and unnecessary many requests are. One of the more common requests comes from probation officers who ask for a note to verify that their client missed a day in court because they were unwell. It doesn't seem to matter to them that we haven't seen the patient during the course of this illness. The most common "illness" is sickness and diarrhoea on the day in question. Of course I have no way to verify or disprove the claim. So what possible use does a letter from me serve?

This is another example that happened to me only yesterday. I'd received a letter from a physiotherapist asking for me to sign a letter saying it was ok for her to do acupuncture on one of my patients. I phoned her up. The conversation went something like this:

Dr Phibes- You've asked me to sign a letter saying it's ok for you to give acupuncture to my patient.

Physio- That's right.

Dr Phibes- I'm afraid I don't know anything about acupuncture. Under what circumstances would it not be safe?

Physio- Well something like unstable angina.

Dr Phibes- So there are specific medical situations where it is unsafe?

Physio- Yes

Dr Phibes- Well as you know what these are but I don't wouldn't it just be simpler if I sent you a summary of her medical history for you to look at for problems?

Physio- You already sent these details when you referred her to the medical clinic originally.

Dr Phibes- So if you already have enough information to know whether it's safe or not, why do you need a letter from me?

Physio- Because it's what we've been asked to do.


These types of notes are known as buck-passing. I get similar requests from gyms saying that they checked Mr Smith's blood pressure, and it was up, so they now need a note saying that it is ok to use their facilities. I've never visited these gyms, so I don't know how vigorously Mr Smith will be exercising, and whether this would be risky or not. What the gyms are thinking is that should Mr Smith drop down dead while there and I've written a note, they'll be able to say "But Dr Phibes said it was ok".

Another issue is how much Drs charge to do such notes. A comment often heard is "You've charged me £20, but it only took you a few minutes to do." What must be born in mind is that generally the Dr is being asked to accept responsibility for whatever they are signing for. So they are charging for their time and any legal liability.

Sick Notes

Billy has just been to see me.

He is 32 and fell off a ladder, breaking his ankle. He is now in a plaster cast, and using crutches. He was reviewed in the fracture clinic, who advised him he would need time off work. He was then advised to come and see his GP to get a sick note.

The question is why? There is no reason why the Dr seeing him in the fracture clinic couldn't do one for him. Having assessed the severity of things he is in a much better place to know how much time Billy will need off.

Instead Billy has had to waste his time by making a further appointment with me. I could have refused to do it, and sent him back to the hospital to get one, but the only person who would have lost out would have been Billy.

I wish this was a one off. But it's an all too regular occurrence, and a sad reflection of one of the many inefficiencies of the NHS.

Pityriasis Rosea

Mandy came to see me this morning.

She had a rash. It was pityriasis rosea.

Mandy had been to see one of my partners last week, who told her then she had pityriasis rosea, and had clearly documented there was little to be done. So why did she come back to see me today?

It could be that she didn't trust my partner's diagnosis (my partner is better at dermatology than I'll ever be), or didn't take in what my partner had told her.

In this situation I find printing out a leaflet giving definitive advice helpful. Patients seem more trusting when it's written down in black and white.

Big Brother

Yes, I'm referring to the Channel 4 show.

At this time of year, it's all that seems to be talked about in the practice.

Staff regularly ask me "Anton, did you see Big Brother last night?"

I must confess to enjoying BB in a toe-curling cringeworthy way. This year is no exception so far.

I'm sure there's a personality disorder or two waiting to be diagnosed there.

I Want This Now

I've just seen Roger with his wife.

Roger was admitted to hospital fitting a few days ago. Last night he discharged himself from hospital against medical advice.

While in hospital he had an MRI (scan) of his brain, and an EEG (this checks for brainwave activity and susceptibility to fitting). Because he self discharged he has no paperwork, no follow up planned, and no knowledge of what is wrong or what needs to be done.

Roger couldn't remember the name of the consultant looking after him, or the name of the ward he was on.

But Roger and his wife wanted to know the results of his tests now as they were worried about him having further fits.

I've said I'll see what I can do. Even once I've found out which ward he was on, there's a good chance the notes will have already gone. I explained this to Roger and his wife, and that if he hadn't self discharged he wouldn't be in this situation now. But they still wanted me to sort it as soon as possible.

They did say please.

Orthopaedic referrals

In my part of the country, I am now no longer allowed as a GP to refer directly to an orthopaedic consultant. Instead, I have to refer to an orthopaedic triage system.

And what does an orthopaedic triage system do? It looks at my referral, and decides who will see that patient. This could be a physiotherapist, a nurse practitioner, a fellow GP with a specialist interest in orthopaedics (known as GPWSI and called in the profession "Gypsies"), or, if I'm really lucky, a consultant.

So why is this happening? Management will tell you it's so that patients are seen by the most appropriate person.

But the real answer of course is money. It is cheaper for the NHS to have my patient seen by a physiotherapist than a consultant.

Jack is 75 and has gross osteoarthritis (wear and tear) of his knee. He needs a knee replacement, so I referred him with this in mind. He was seen initially by a nurse practitioner, who decided he would benefit from some physiotherapy. 3 months later he is no better. He returned to see the nurse practitioner again. The nurse practitioner asked the consultant to see him, who told him immediately that he needed a new knee.

Jack, quite understandably, can't understand why he didn't see a consultant to start with, and feels aggrieved that he has had to wait an extra 3 months before he can even go on the waiting list for an operation.

So has this saved money?

An Unexpected Death

The coroner's officer phoned me during surgery this morning to tell me that Harold, one of my patients, had hanged himself on Saturday.

He had asked his neighbour on Friday night to pop in on him the following morning.

Harold was 70 when he hung himself.

Harold didn't attend that regularly, and never regarding his mood. There was nothing in his record to suggest why he did what he did.

Quality and Outcomes Framework (QOF)

In June 2003 GPs voted in favour of a new contract- The New General Medical Services Contract.

A sizeable proportion of my pay now comes from part of the new contract called the quality and outcomes framework, known as QOF, and pronounced as quaff.

The QOF is designed to "reward good clinical practice". But ask many GPs and they'll tell you it is converting us to "tick-box medicine" practitioners.

Let me explain a bit more.

The QOF pays you points for doing certain things- for instance if you keep a list of patients with an underactive thyroid, you score 2 points. Do a blood test during the year in more than 90% of these people to check whether they are getting enough thyroxine and you score a further 6 points.

In the year 2004/05 the average full time GP was paid roughly £25 per point. In 2005/06 this went up to £40 per point. There were up to 1050 points available.

For a complete run down on what you could score points for look here.

There are points to be scored for checking smoking status. Have you found that suddenly your GP is very interested in whether you smoke or not? That's because there are a lot of points available for asking these questions of asthmatics, diabetics, and certain other patients. How does this improve patient care? It doesn't, but it's a box to tick.

The government thought we as GPs would only score 750 odd points in the first year, and only budgeted for this. However the majority of GPs scored more than 1000 points.

Were we praised for performing so well? Of course not. We have been portrayed by the government as money grabbing, and responsible for the NHS overspend.

So now the goalposts have changed for 2006/07. More targets, tougher targets, and now only 1000 points.

Welcome to my blog.

Hello. If you've stumbled onto here, then welcome.

Having worked within the NHS as a GP for some time, I thought it might be worth trying to get down in words how things appear from my point of view.

The clinical apsects of work are enjoyable. Lets face it, that's why most of us went into medicine in the first place.

But the paperwork and bureaucracy within the NHS are unbelievable, and at times beggar belief.

I hope to give a flavour of all of this over the course of time.

So, off we go. Hope it's informative as well as honest.

Dr Phibes