Vulnerable?

"The best test of a civilised society is the way in which it treats its most vulnerable and weakest members."

Mahatma Gandhi

With David Cameron saying he is going to revitalise the concept of the One Nation Tory (I really hope he succeeds), he's going to need some tools for the job. One good place to start is to focus on the most vulnerable. This is all very well but by their nature the vulnerable are often so because they can be hard to spot. Those exploiting or creating vulnerability are hardly going to advertise the fact and the vulnerable themselves generally struggle to stand out or even recognise their condition.

A civilised society is one therefore that takes a more pro-active role. Given that primary care seems to be held up as the solution to most of society's ills we're not going to be able to escape this responsibility. So what to do?

Much has been made of the need for the NHS to keep up with new technology. However the focus too often is on the gadgets and remote monitoring of tele-health where the benefits so far have not proven that exciting; largely, it seems to me, because when you are ill the last thing you want to do is faff around with more gadgets. I'm sure this will change but in the meantime the NHS has to hand something pretty special in Western medicine - an abundant source of rich, comprehensive, well-structured data. Our USP, which, in any more NHS re-organisations, must be preserved, lies mainly in the fact that the data describes geographically oriented, list-based primary care. Theoretically, we know a lot about local populations, unlike health systems without this local focus. It is this we need to exploit to prove how civilised we are.

Working in a practice serving a deprived population at Saffron Group we are only too aware that the context of someone's illness is key to recovery and vulnerability. We like to think of ourselves as family doctors but too often we aren't fully aware of this context, even in patients we think we know well. The irony is that often this data is available in other household members' records; we usually don't have time to hunt for it so its presence just passes us by. This is a lost opportunity for our patients.

But what if we moved our unit of analysis away from the individual patient? What if we moved our unit of analysis to the household?

We decided to use our IT skills to bring primary care data together at the household level. The tool we have developed consolidates a huge range of data from our clinical system and presents it by household. The tool contains a search engine to analyse it and a viewer of the output. This means you can search for a huge range of possible combinations of diagnosis and vulnerability. You can view the whole household in one go with vulnerabilities such as domestic violence, dementia, being a carer etc highlighted, which we are hoping will bring new insights to our practise, with vulnerable people as the beneficiaries. This is our first attempt and we are making it available for others to use free of charge at www.ukaguzi.com/VH.htm. Read more here.

The Household search tool and Household explorer

With the increased collaboration between health and social care this could become a powerful force for good. We have only just begun to explore its possibilities such as using it to view the whole household in our child safeguarding meetings. We hope this can develop into a wider open NHS collaboration. Please acknowledge us if you do any work based on this and if someone else decides to make money out of the idea or the system suppliers adopt it, remember where you saw it first. Sadly, as it is entirely voluntary we cannot provide support for the use of the tool. We hope you find it useful.

Rational regulation - where I get touchy about no-touch taps

Let me start with a quotation from easily the most useful medical textbook I have ever read - one that has actually helped me save lives,

(Speaking of operating in a developing country) 'In an emergency you may even have to operate by the light of a hurricane lantern. The light will attract insects, and these will fall into the wound, but even so they are unlikely to influence the patients' recovery'

The point being made here depends upon the concept of marginal risk reduction. Using surgery as the example there are a number of ways you progressively reduce the risk to the patient.

Firstly, choose your cases carefully.

Not opening an abdomen that doesn't need opening is always going to be safer. Of all the potential cases for laparotomy, 40% may not need surgery.

Pre-op: have a check-list - 15% risk further reduction

Good anaesthetic technique - 15% more, say

When you operate use sterile equipment - that's another 15% risk reduction

Use good surgical techniques - handle tissues gently and you have another 10%

Sterile gloves 2%, experienced assistant 2% and so on.

Each addition gives a marginal risk reduction which is subject to the law of diminishing returns.

So what if a moth falls in the wound (desirable if it doesn't of course and believe me fly screens are much more useful in Africa than here) but it only has a minor impact on outcome when all the rest is in place.

Using single use instruments will reduce risk further, but by nothing like as much as sterility. Similarly different scrub techniques of longer duration and newer antiseptics and laminar air flow and hotter water and plastic floors and de-cluttering and no touch taps all will help but, in ordinary primary care minor procedures, not detectably so when the rest is in place.

It is at these margins when already high levels of safety are in operation that I start to question the regulatory regimes. For new builds or major renovation, no problem; but when the margin of potential further benefit is small the risk of generating harm by perturbing an existing system becomes significant. If the process of implementing a regulation carries a greater risk than the potential marginal risk reduction it could bring, it is stupid to implement the regulation. 

Let me relate the story of my tap.

At 5am on 28/4/2014 I was called to the surgery by our cleaners as one of 4 new automated taps, only changed to meet CQC regulations and done 3 days earlier, had flooded my consulting room, the corridor and part of a neighbouring room with over 30l of water, rendering it smelly and unusable for over a week. We had to employ a specialist cleaning company to make my room habitable again. Prior to this my single lever mono basin mixer tap had functioned for over 20 years (actually 7,390 days) without flooding, Legionnaires Disease or any attributable infection in well over 1000 minor procedures carried out in my office. The introduction of a new tap would appear to be at least 615 times (7,390 / [3x4]) more likely to cause an incident that damages patient care than the old tap in usual operation! As one of our lovely-wiser-than-CQC cleaners put it, 'If it ain't broke...'

In order to be sure of overall patient benefit from changing a system, the ongoing risk to patients from the old system must be greater than the risk to patients from the new system plus the risk to patients from the process of change-over. However, from our experience, it would seem that the maximum absolute risk reduction achievable by changing taps (which equals the absolute risk to patient care from the old taps) is likely well over 600 times smaller than the risk attributable to the process of changing the taps.

Should CQC have required that we only change taps at the end of their operational lives (ie when we have to incur the risk of change)? I wondered if CQC risk-assessed the implementation of their regulations by balancing achievable marginal risk reduction against the risk of system change. I asked Prof Steve Field at the RCGP Conference 2014 but I don't think he really 'got' the question and possibly I didn't ask it very clearly, so I still don't know. I didn't find anything on the CQC website on this.

Now maybe we were just exceptionally unlucky in having the only incident in the installation of at least 2,400 (4 x 600) taps or maybe my old tap was actually far more dangerous than direct observation suggests but it seems very unlikely.

This may seem a trivial example, but if it is generalisable there is a real chance that systematic damage is being done up and down the country in CQC's name. Tick box regulation: 'Have you got this new super tap Y/N?' is simple but at best simplistically naive and if it has not accounted for marginal risk properly, at worst it is negligent.

However, the risks are not confined to direct service delivery; there are opportunity costs and unquantifiable risks (but increasingly real as the GP recruitment crisis unfolds) such as the negative effect over-regulation might have on morale. We had to spend practice resource on these changes and as the marginal risk reduction is tiny then the benefit/cost ratio is also and may have been a lot smaller than say spending the money on increased staff. To spend on improperly assessed regulatory requirements is to waste NHS resource.

I would be grateful if CQC could reassure us that it routinely assesses the risk to patient care resulting from the process of implementation of its regulatory requirements and only insists on implementation where the overall risk is shown to be lower. 

Taking exception

Over recent years there has been a growing trend to use the UK General Practitioner (GP) Quality and Outcomes Framework* (QoF) exception reporting rates as a quality measure or standard. For example, in Leicester, one entry requirement for the Primary Care Diabetes (Enhanced) Service (a scheme to reward more specialised community diabetes care) is:-

The specification requires the provider(s) to (show):

• Evidence of QoF low exception reporting ( less than 10% )

In the annual quality review of our practice the overall exception reporting rate is routinely reported as a quality measure, comparing it with the Clinical Commissioning Group (CCG) average, but with no explanation of what this actually is supposed to indicate.

This marks an unwelcome development as I believe it betrays a misunderstanding of the topic. This blog is about why.

For the uninitiated some explanation of the system is necessary. QoF payment is based on points scored in a range of disease areas for achieving certain quality standards. The number of points available for each area such as for how well blood pressure (BP) is controlled is fixed. The actual point score for a practice is calculated from the proportion where the audit criterion was achieved at the year end of a defined percentage range of eligible patients within which points are counted. So if the points available are 10 for this disease area and the point scoring range is 50-90%, if 70% of eligible patients meet the audit criterion, say of good BP control, 5 points (10 x (70-50)/(90-50) are scored.

So for the above QoF area a practice scores nothing if it does less than half the work and nothing more if it meets the QoF criterion in over 90% of those potentially eligible.

So where does exception reporting come in? The key is in the phrase 'eligible patient'. Individual patients who might be suitable for assessment of care in each QoF disease area can be deemed ineligible and exception reported. There are various valid reasons for this. Eg a person with a poorly controlled BP not meeting the target value required may also be suffering from a terminal cancer, in which case worrying about their degree of BP control is hardly relevant. Such a person could be exception reported as 'unsuitable'. Someone else may just refuse to be followed up making it impossible to meet the care standard which can be exception reported as 'informed dissent'. These patients are then not counted when it comes to assessing points.

The rationale for this is to level the playing field between practices, as the number of patients in these groups is going to vary year on year and by population served and to avoid inappropriate treatment.

So why the fuss about exception reports above?

Suppose you have two practices with 100 patients each who are potentially eligible for a particular QOF indicator. Just before the year end one has met the criterion in 83 patients and another in 89. Both are a little short of the maximum 90% target. In the first practice there are 8 patients who could be legitimately excepted, an 8% exception reporting rate. The practice excepts them, achieving 83/92 or 90.2% and thus gets the maximum number of points available for that area.

In the second they except two, a 2% exception reporting rate, achieving 89/98 or 90.8%. The rub is this, both get the same maximum QoF points but the second practice has treated 6 more patients to target. So you can see why having a low exception report rate might be seen as a 'good thing' but does a low rate actually indicate a better quality of care?

Supposing in the two practices the maximum number of patients that could reasonably be excepted was 8 and 2 respectively. In this case the first practice failed to treat 9 (=92-83) to target of the patients it could have treated, as did the second (=98-89). So despite a fourfold variation in exception reporting rates they under-treat the same number of people. (The first has treated 6 more people to target but only because it was easier to do so; exception reported patients are frequently more complex or less compliant and so it is perfectly reasonable that they both get maximum QoF points in this area, despite the variation in exception reporting rate.)

But supposing both practices could have excluded 8 patients, then the second practice is performing better, it just didn't need to report as many to get maximum points, because once you have achieved maximum points there is no point in taking exception reporting further. The problem is you cannot know this just by looking at exception reporting rates; you need to know the number who could have been exception reported, and this latter figure is never assessed in QoF.

The point is both practices have at least met their contractual obligations to the same degree but that one might be over-performing, if its exception reporting rate could have been higher. So on their own exception reporting rates tell you nothing about quality of care.

One might argue that despite this, downward pressure on exception reporting will help keep coverage rates up. However, it cannot be assumed that this is necessarily a good thing as it may result in over-treatment which itself carries hazards we are increasingly aware of.

A better strategy to keep treatment rates high would be to increase the top of the QoF target range and this is what has happened as QoF had gone on. But even this may not be wise given the dis-benefits are bound to increase and as the above figures show the potential improvements are marginal.

In our example suppose you had to hit 95% to get maximum points. Our first practice would indeed have to boost performance from 83 to 88 patients as it could except no more; our second, if it could except more, could except 7 to achieve the 95% target. It's exception reporting rate will have jumped over threefold to 7% in response to the 90 to 95% change in top target range but its quality of care is no different; it's just making real its over-performance under the old 90% target. On its own exception reporting cannot be used to meaningfully compare practices or to assess a single practice over time when the target range or audit criteria have changed.

So the message is exception reporting is not a meaningful quality measure unless you also know the maximum potential exception reporting rate for each indicator in each practice. So please Area Teams and CCGs stop using it as such!

Maybe the worry is that some practices over-exception report merely to hit QoF targets and that patients for whom a care standard is appropriate are being denied it by being wrongly exception reported. If this is happening then this is a probity issue, not a quality of care one. CCGs, by all means query outliers in exception reporting rates and do some post payment verification. All practices should be recording reasons on the exception codes to justify them. But please drop the uninterpretable exception reporting rates from your quality dashboards and service specifications.

* a quality incentive scheme still responsible for a significant but shrinking proportion of GP remuneration where payments are made depending on the points scored

The Anatomy Of A Drug Error

I made a serious drug error last year. There, I said it - confession is good for the soul. Fortunately, no one was harmed but this was the first time in 23 years as a GP that I got it that badly wrong. The story is worth telling in detail as it contains important lessons for me, my practice and the wider NHS.

In a nutshell I prescribed an antibiotic (No, that wasn't the sin – there was a genuine indication!) to a frail patient in a care home whose records unambiguously contained a correctly coded allergy to that drug. The drug was prescribed, dispensed and the full course given before the error came to light. Had the patient had a significant reaction, in his/her frail state, it could easily have caused death or hospital admission.

All doctors have a mental script they rehearse when prescribing to stop this from occurring. My checkpoints for a home visit are as follows:

1) Check the patient print-out I carry where allergies are recorded on the front page

2) Ask myself, ‘Are there any other reasons, drug interactions or co-morbidities, which would contraindicate this drug?’

3) Ask the patient, ‘Are you allergic to anything?’

4) Ask the carer or relative, ‘Are they allergic to anything?’

5) On writing the visit up back at the practice, prescribe the drug on the clinical system, without printing the already handwritten prescription, as this will alert me automatically to drug errors as part of the process

6) Trust the dispensing chemist, who often has drug reactions recorded on their system, to alert me if they are aware of a problem

7) Trust the care home administering the drug will check the drug against their records and alert me if there is a problem

This has served me well for 23 years and only once before have I got to stage 5 and had to back-peddle to prevent a drug being given wrongly.

So, to the anatomy...

In August 2013, as a result of growing pressure from an increasing list in too small a building, we made an application to close our list to new registrations. In making the application one of the reasons I gave to NHSE was 

‘Increased stress on doctors raising the risk of adverse patient events’

And I concluded the application with 

‘We believe that, without a change, continuing to increase the pressure on our building by increasing our list size and continuing to the increase the pressure on individual staff because of our recruitment difficulties will necessarily result in patient harm at some future point. We are obliged to avoid this and raise the issue with the LAT and CCG. We believe our proposal is reasonable and timely.’

I quoted the relevant GMC guidance, for good measure.

It took NHSE four months (much longer than the contracted time for response) to reject our request concluding that,

‘there was adequate GP to patient ratio provision available at the practice to manage the current demand’

helpfully adding, despite our pointing out how over-stretched we were, that

‘The practice could also consider exploring seven day working as a way of managing the current demand’

We were obliged to struggle on. On 8/3/14, after a particularly bad day on call, I emailed my partners, describing my day, flagging it as a significant event for my appraisal discussion in July and suggesting that we apply for a list closure again, concluding:-

‘I don't think I did any harm y'day but the safety margins are becoming uncomfortably narrow which might be tolerable for old hands but carries a bigger risk for GPRs and less experience salarieds’

There was a general reluctance to re-apply because it was felt there would be little point, given such a negative response first time around. Nevertheless we started re-drafting an application.

In August 2014 I experienced one of the busiest days I have known in general practice. I worked from 7:45am, foot continuously on the accelerator, until after 6:30pm with no break for coffee or lunch or tea. I probably managed to pass urine once. For the first time in 22 years I was unable to complete the work I needed to do that day before being late for our Partnership meeting that evening. It was a 13.5 hour day and I cycled home exhausted. I slept fitfully and woke early, my mind racing with the events of the previous day and thoughts for the coming one, as I was to lead a meeting that afternoon to discuss federation plans with several local practices.

The fateful visit occurred later the same day, at the end of another full-on morning with no break and no lunch, with only a few minutes to get back to the surgery to lead the meeting. The patient, who I knew well, was acutely ill and needed a prescription. In my rush at checkpoint 1), I missed the drug allergy on my patient printout. I can’t remember whether I checked and just missed it or whether I just didn't check. I thought I knew the patient so skipped through checkpoint 2). The patient has dementia so no point in checkpoint 3).  I wasn’t the only person having a busy day, the carer got called away to someone else mid-consultation and so checkpoint 4) was omitted too. For some reason checkpoints 6) and 7) also failed to kick in.

I rushed back to people waiting for me and the meeting went well. Then with my mind buzzing I set about catching up with all the tasks and letters and path results that had come in that morning and afternoon and the work I had been unable to complete the previous day. I wrote up the visit and went through checkpoint 5). The computer warned me about the drug interaction but I flicked through ignoring it along with all the other non-clinically relevant warnings that come up.

A week later I was reviewing the patient’s notes for some reason and to my horror realised what had happened. I printed out the visit slip – yes the allergy was there. I tried re-issuing the drug – yes the computer did warn me. The really scary thing is that despite being a conscientious GP for 22 years, despite predicting that something like this would happen (though not to me!) and despite teaching safe prescribing habits to GP registrars for 15 years, I did not realise what was happening at the time. I was just overloaded and hitting me so I'm more careful in future isn't necessarily going to help.

We reviewed the event as a practice and we have made the visit printout even clearer and have heightened awareness but if I have another 48 hours like that I don’t think I can guarantee it won’t happen again. The only way I can avoid it is by being able to control my workload to within what I know after 22 years’ experience is safe. I had already asked for that and was refused, against my better judgement.

This all occurred a week after we had again applied for a list closure at the end of July 2014, with a pretty much identical document. We did not hold out much hope as if NHSE were consistent they would have to respond in the same way as the first time.

This time they granted our request!

I was itching to see how they would explain this volte face in the formal response. The application was identical, their response the opposite. In the event whether to hide their total inconsistency or because organisational dementia prevented its recognition, the letter merely detailed the rules and our duties concerning list closure, without any explanation of the decision.

I have no confidence in our area team. They failed to listen to my concerns first time round which was at least partly responsible for me nearly killing someone and then behaved wholly inconsistently without explanation.

Since the list closure things have been a bit better and I have no further incidents to report. But in four weeks we have to open the list again and nothing fundamental has changed. We've looked at hot-desking and made significant changes to the appointment system and phone system which will help.

Much is made of learning from the airline industry in making the NHS safer. However, NHSE, DoH and the government are not credible in this matter. The current contractual arrangements mean that there is no point beyond which a GP cannot be pushed and NHSE is quite intent to keep on pushing. This is in stark contrast to flight crew safety rules which 

‘recognize the universality of factors that lead to fatigue in most individuals and regulates these factors to ensure that flight crew members in passenger operations do not accumulate dangerous amounts of fatigue.  Fatigue threatens aviation safety because it increases the risk of pilot error...’

If only the GMS/PMS contract was as sensible.

So what is the solution to the current situation where resignation from one’s livelihood is the only reliable way to escape an intolerable safety risk? Well one thing that would help is giving GPs absolute discretion about list closure. We could have avoided the above near miss, which convinced me that Area Teams are not competent to make such decisions as they are susceptible to political pressure. It is absurd that GPs are trusted to decide on the patient with chest pain in front of them and on commissioning for populations but are denied the ability to decide on a safe workload in their own practices. The requirement to go cap in hand to Area Teams to get a list closure has contributed to the serial de-funding of primary care by allowing them to pretend there is adequate GP coverage. Politically, of course, it would cause major embarrassment as practices closed lists up and down the country but this is a crucial safety governor and would oblige proper resourcing and commissioning of primary care to save political face, which is the right way round.

And if no solution is forthcoming, General Practice will have crossed, by NHSE’s action, from ‘if’ serious patient harm occurs to ‘when’ but it will be the GP who is hung out to dry. I find myself asking a question I never dreamt I’d ask, ‘Is it ethical to be a GP?’ Should I continue to work within this system, knowing there is a real chance of inadvertently harming a patient, when it deliberately and incompetently denies me the means to minimise that risk?

So how long do I continue to push my luck? If I do err again and someone is harmed whether I appear before a coroner’s or civil or a criminal court, or the GMC or the Health Ombudsman or the CCG Performance Committee or CQC or the latest ‘Safety’ Agency, I’ll produce this blog as evidence for the defence, M’lud.

Be clear on cancer!

Be clear on cancer. Well my patient was: 'Three weeks of heartburn? See your doctor', so they did.
I wish I was that clear!
No risk factors, no drinking, no smoking.
No red flags, no vomiting; eating, swallowing and appetite fine.  Put on a bit of weight. Typical mild but annoying symptoms on lying and bending, eased by a simple antacid. And on examination no nodes, no lumps, no anaemia, looks as well as I've ever seen them. No sign of cancer at all.
And when you dig a bit: well yes I've always been a bit prone to it, so not just three weeks, but worse in last year since starting the aspirin for the silent ischaemic heart disease based on the abnormal ECG and since stopping the PPI (anti-stomach acid drug) you gave to cover the NSAID (gut-rotting anti-inflammatory drug) course for the arthritis flare.
But there you have it, the big C genie is out of bottle or is it ogre out of his lair: could it be cancer? Well it might be and really only your age is against you but weight gain, aspirin and medication changes are actually much more likely causes.
Be clear on cancer: your GP estimates your risk at less than 2% given the above but a) he might be wrong and the risk is actually higher and b) if he isn't you could still be in the 2% anyway (you might have asymptomatic cancer and your symptoms are coincidentally due to the weight, aspirin and medication changes and I'm about to blow your luck - he said with a smile on his face)!
You always cheer me up, doctor!
It's called explaining risk to the patient - you are 98% OK. OK?
Oh... so you're not 100% sure....
Be clear on cancer because your GP is not wholly non-anxious about his conclusion about the best course of action here and saying 'You're the Doc' is not much help when I ask 'What do you think?'
Am I mistakenly colluding with your desire to avoid endoscopy to your disadvantage, or are you just being nice to me in my uncertainty, giving me an excuse not to refer?
And if we refer you all something else will have to go - causing longer waiting times for the 2% who do turn out to have cancer whose prognosis will worsen as a result.
So we're clear on (symptoms that have <5% chance of) cancer, just unclear on what to do about it.
Decision! Stop aspirin (and increase your heart attack risk - he smiles again) and restart a PPI and I'll review you in two weeks.
It'll either be another totally unsung, well-judged piece of risk management that saves enough cash to allow the NHS to fight another day, avoids delaying the diagnosis of those we hope will be less fortunate than you and avoids your small endoscopy associated risk and your inevitable anxiety or I'll be thrown to the dogs as another cancer-missing-GP. Watch this space!

Well that was two weeks ago and on telephone review (What it is to be an early adopter of new technology!) my patient is absolutely fine. Will now stop PPI and see. Still no certainty of course - I've either slightly saved the NHS from financial self-harm from a miss-targeted ad campaign or I've missed a cancer and covered up the symptoms - useless GPs...
As a Reader in the good old C of E I could go on a funeral course and then I could legally bury my mistakes. Mmm better not mention that to my appraiser.

PMS Slash: A Postscript

We met with our local area team reps about the so called ‘Review’.

Seems the spreadsheet was not as misleading, as some of the compensatory money for our PMS slash comes from others’ loss of MPIG being re-injected into global sum; so as beneficiaries of others’ worse misfortune we apparently should be grateful. There was no answer to my charge that the rest of it was misleading. But there were more reasons to be grateful that the practice which I have spent 22 years of my life building was about to be destabilised. At least there was a locally agreed transition arrangement and we might be able to get the money back through (an as yet an unspecified means of) reinvestment: MPIG practices had no such luck. Which do you prefer; at least a chance of avoiding death or disability by annual cuts over 6 years or instant limb amputation?

And the pain management service we have provided since 2002, currently at double the number of patients we're contracted for? As I predicted they had no idea, none at all, at just what they were about to 'review' out of existence. And they saw my point re our growth element to address inequalities but... 

The last drops of goodwill and trust are thus squandered. But it's worse than that. I now know that there is no point in trying to create innovation within NHS structures because future iterations of these sociopathic, demented entities will capriciously squish it. Reality is: 'cynically take advantage where you can, realising it may be transient'. This is absolutely not the lesson needed at this critical juncture and is completely at odds with the stated aims of the review. The positive words about PMS in the announcement of the review are entirely contradicted by NHSE's behaviour, at least locally. A proper PMS review was never done and there was never the least intention of doing so. They had concluded that they could get away with giving practices a Hobson's choice and effectively bully them into GMS contracts.

In the end the meeting was not about 'reviewing' anything (well we knew that really), this was a done deal; they were there to tick the 'Met with practice' box. The localism that PMS was supposed to be is revealed as a lie; so what does that tell us of what the centre really thinks of that other manifestation of localism, CCGs? A quantitative easing in the NHS with the currency of contempt?

They had nothing to offer and displayed the body language to match; minimal eye contact, except as demanded by a measured politeness, and a kind of corporate weariness. (Please this is not a personal criticism; the cogs in a bulldozer are just that.) It became clear why.

In 6 weeks it's no longer their problem. That's when co-commissioning kicks in. If you, like me, thought the 'co' participle implied joint working, that was in no way the impression conveyed. But in line with the above experience, we can no longer assume that what's said relates to what will be. There was an unmistakable sense of signing off of responsibility which was to land squarely onto CCGs. So folks the commissioning of most secondary healthcare and now primary care rests with an organisation of which I am obliged to be a member and thus accept responsibility for, despite having no control at all over the amount of funding (unlike local councils) and with ineffective representation. If secondary care fails it's GP commissioning failure and soon the same is true of primary care. The sting is ready, the denouement awaits the election result.

At the same time as passing primary care commissioning to CCGs NHSE has acted in a way that curtails their freedom of action by ensuring most PMS return to GMS. The centre will continue to control the agenda as they.have for the last 10 years. This charade 'review' wasn't about saving money or cost effectiveness but about retaining central power over core GP contracts. CCGs are denied the option to fund GP contracts properly via PMS. They can only repeat the history of the IOS Red Book failure in the form of damaging short term LES proliferation/fragmentation. The bung to CCGs to accept this has been paid for by PMS practices. In my practice the losers will be people in pain and the disadvantaged, as well as increasingly demoralised partners.

I genuinely do try to adopt St Maureen's positive spirit and I'd love to report something good but it's so, so hard when I find my every cynical thought backed up by evidence that that very path has already been laid. It's like seeing a patient where you immediately think 'cancer' and where, to your growing horror, every red flag symptom you ask about turns out positive. I wonder if I'm paranoid but if I am, then, at the very least, there has been massive communication failure by NHSE to GPs. I didn't get the impression they cared a jot.

The challenge now is to carry on even though we know we can't trust anyone outside our organisation. To judge from comments at the end of Pulse articles many already have decided it's no longer a challenge for them. Not long until Good Friday.

Apocalypse in a bus shelter

And I saw a creature with whirring wings hovering in the sky. And with six wings it hung over the bus shelter and spied the shelter with a camera eye. And I was in the eye and on the roof there were big blue letters in the colour of the UN and the letters were ‘NHS’. And I rejoiced greatly that, so visible from the sky, it would be protected.

Then I saw a hilux pick-up driving to the shelter and, not black, as I feared, but a blue creature and its yellow cur came from the truck. And like reapers, but with sledgehammers for scythes, they raised them to the glass of the shelter.

And I cried out 'But you have no mandate for this! Where is your authority?' And the wise watchers exclaimed, 'This must not happen to the shelter of the people!' And the creatures pretended to pause and then swung into the shelter anyway. In slo-mo the single, crystal glass shattered into millions of sparkling shards. And I despaired at the shards but the vultures rejoiced.

Woe to the shelter of the people!

And as I watched ant workers came from the ground and tried to carry the shards and piece them together. And I wept and wept for the workers. Who will help repair the shards? And I thought I saw one like a son of man walking among the bus stands. Wail for the shelter, its damage seems too great.

And as I looked, podiums were established; there was a red and a yellow and a blue and one that looked like a fag-end soaked in stale beer. And there was a green and there wasn't a green one. And those who perched on the podiums and their minions fought with words and SoMe.

And I heard a voice, the voice of the people, with ire, like the roar of the sea, and the voice said, ‘Stop pissing around! This is a bus shelter not a pantomime; people are going to die!’