Doris could however choose to go 10 miles further to a charity-run orthopaedic treatment centre, where she will be operated on by a Consultant, where there is no MRSA, where they use the most modern techniques and where they have a great service ethic. The existence of this provider, contracting with the NHS, does apply pressure to the surrounding 3 NHS hospitals to up their game…

In contrast, in some medical specialities, where there is no local realistic alternative, there is complacency, repeated appointment cancellations etc etc

Trouble is – unless the LBSs are competing with other LBSs or providers – you will get some who are brilliant and well-stocked and helpful out of the goodness of their hearts and because they want to be excellent – but lots will be serving that poo sandwich, because they can get away with it.

G I’m guessing they did it by having a cooperative management team on the Trust side – based on the way our trust has sandbagged negotiations – and continues to do so in other services. And this is because we are next to the sea it means we have less competition around, no other acute trusts for 20 miles, so they can get away with it. Which is why we have to bring in other providers to get an alternative. If there was Wiggle and no other bike shop would the prices be as cheap and the service as fast?

TJ That’s about your first decent point, but made better previously by someone else. I see you are still not acknowledging the way Labour had totally got into bed with the private health sector. This is where your political stance seems to blind you. 😉

Nice for you. Down on the sarf coast we seem a bit behind the times…

OK Grantway. I worked with the local physio department on designing their forms, providing web based info on their services and referral criteria, and the same for the new additional service from a private provider. I know that they refuse self referrals.

Used to live in E14 (before the Yuppies arrived) and then E3 myself.

I live 6 miles from the Sea. I am sure you must do too. Have you checked? 😉

I prefer not-for-profit or charitable providers, for the reasons you mention. But the current system allows inefficient and bad departments to continue to function with unjustified subsidies from better ones.

This is in the Bourough of Newham East London
But cannot see this only being offered here, think you may need to check.

Grantway – trust me I know it isn’t. It could have saved me making regular formal complaints on behalf of patients.

Far from it. Trusts have to pay people. They actually do need money. Every outpatient appointment, every day in hospital and every A&E attendance generates a bill. Some do make “profits” which usually get nicked by the failing trust next door. So you really don’t want to underspend too much 😉

Errr… What?

No physio self referral on the NHS on our patch…. Shame. If you have it that’s great but it is not universal.

We do now have a decent alternative NHS Funded route, via a private provider. Took 4 years of battles though.

Project 😳

Ok… If you have only one LBS, don’t expect cheap prices. If this staff don’t get any incentive to work well, don’t expect good service.

TJ Tony Blair was being advised on Health Service reform by a nice bloke called Simon Stevens many many years ago. Google him and who he is now if you think things are really any different now. Or look at the Labour imposition of Capital Charges to “level the playing field” so the private sector to compete. Or the Labour impostion of DTCs? The trouble is you make it a simple political issue, foist on the UK by a political party which has no legitimacy in Scotland. Actually it is a continuation of what has been happening for years. And Labour (of whichI I was once a member) are just as bad. And some sort of competition and willingness to let some NHS organisations fail is necessary to get any change.

Project re the physio cost issue – You’d think so – especially when another hospital they ran was a “National Exemplar Site” for physio access targets. But because GPs were not allowed to refer anywhere else, or to private providers, they had no incentive to change and develop an efficient system, and because sections of the budget were not hypothecated to the departments which had generated the income the physio dept had no money to do it…

In very many ways the way the NHS is organised rewards failure, not efficiency. The lack of clear hypothecation and budget streams means money rarely gets thrown at efficient departments, it gets thrown at the inefficient problem departments. And often that is as much to do with pig-headed Drs as it is down to managers.

The big costs in running a hospital are staff. Not premises. Using them efficiently would be a start. And private providers have fixed costs too.

I don’t think the Giant one is over here yet, except in reviews. I have one on oder and am being quoted another 3 weeks or so to wait.

TJ see this is why I know you don’t know what you are talking about… GPs form/are formed into consortia, and the 95% have the commissioning done, with external governance and oversight arrangements, on their behalf by a board which includes the 5% who do have the skills. And similar organisational arrangements to a greater or lesser extent have obtained for the last 10-12 years, from PCGs to PCTs and PBC. So it is not 95% going direct to private management companies.

I think I’ll have to join that list of people who leave a thread when you join it. There really is no point when you seem unaware of the boundaries of your ignorance.

Project The issue is more why the NHS is sometimes so expensive that a physio appointment with a junior level physio locally was costing about £70 on average with a 6 to 8 month routine wait. The world of NHS budgets is totally Alice-in-Wonderland.

Project – well – shifting physio activity outside to private providers for instance – patient experience and outcomes would improve. And some investigations can be shifted very easily, and protocol guided. All this has been done all over the place with good outcomes and high customer satisfaction.

My local NHS hospital breaches waiting list targets, the charity-run private provider up the road gets the same NHS tariff and sees people within a week or two, keeps its MRI waiting list down etc etc etc and has no MRSA…

There are some very weird costings in the NHS, and some very perverse incentives.

Anyway – no point in continuing this – I’ll never convince those who assume external involvement is always bad.

TJ Projects outside Dementia and MH services?

I cannot see who else can give a perspective which is has both a clinical element and a broad scope. Consultants and Nurses as they progress up the hierarchy get to know more and more about a narrower and narrower range of issues.

The Consultants feel threatened and excluded by processes going on at the moment, but try and get them to work and talk together, or do a Friday afternoon operating list…

And once again you are viewing GPs as a whole group. The GPs who will be involved with this and who have driven a lot of the change over the last 20 years are a small group of 5% tops, who can and want to do this. I could do it, but no longer want to. Time for someone else.

TJ

I must take you to task about the role of GPs – yes they have a good perspective on some parts of the NHS – however they simply do not have the expertise or desire to undertake the role the government envisage.

1) Which bit of this did I misunderstand?
2) What is your expertise in Health Service change outside Dementia services in the last 10 years?

This subject is too important to be simplified into privatisation vs NHS. I’ve put together business cases where shifting activity into the private sector (of which I am not a great fan) could save 50% costs, double activity and get rid of waiting lists… and what happened? – the Chief exec of the local acute trust banned any of her team from talking to me without her present… Many Managers within the NHS tend to think of their organisations agenda and profile first, their next job next, the patients after that, and their employees last.

TJ

Not for the first time I wonder what an earth you base some of your misinformed ex cathedra statements on. I have searched to find out the basis of your professed broad expertise in matters of health. Cannot find very much. I am new around here – do feel free to educate me…

If you read my post you would see I said that not all GPs have the expertise. Actually very few. As someone who has been involved in this sort of thing (not now) for some years and been on the courses with Don Berwick’s mob, sat on the committees, got the T shirt, set up the collaborative schemes in various clinical areas, lobbied for and got new services across a population of 450,000, worked on process mapping and service redesign in various areas, and education/promulgation blah blah blah, run an internet resource promoting local services/education/EBM for 10 years etc etc, I do know a bit of what I am talking about. Where does your experience in the management capacities of GPs come from?

We need decent managers (we ain’t got many), decent clinical leadership (usually not from Consultants who tend to fight turf-wars) and decent financial and activity analysis. Management support will be needed – but it has been needed for many years. And this will need to come from outside, because most of the decent managers fled there over the last 10 years. But no one else (Public Health espescially poor in the UK) actually gets to see the issues that happen throughout the system.

The issue is more in the way the current government is setting the whole thing up to fail. The number of changes that there have been already are mind-boggling. 4-5 years ago the system was about right and could have developed by evolution. But we are screwed.

A couple of us were discussing you at the weekend. We felt that where we found we agreed with what you were saying it tended to make us reconsider our point of view… 😉

Fair point. Wonder how much mud absorbs sunlight.

CaptainFlashheart & Binners

Don’t worry your pretty little heads about it. The grown-ups are talking 😉

Not sure why you bother to post say you aren’t interested, and why you seem so proud of your disinterest. It is the chat forum, and this is a fairly important subject, and people discussing such issues should be the foundation of a democratic process. But I’m not a big-hitter so I wouldn’t really know…

And yes – I had an awesome couple of days riding (badly) in the Quantocks since you asked.

Err – actually a pretty rigorous recent report did show that the NHS is the second most cost-effective Health Care system of those in developed countries. But I could find plenty of people whose jobs are pretty useless, whilst the ones we needed have been “reorganised” away.

There are problems and interesting oddities.

1) The sector which is the most efficient, has the best information systems, and acts as “gatekeepers” to the expensive bits is Primary Care… and lots of other countries are trying to recreate this. And as someone mentioned above – GPs are mainly self-employed sub-contractors to the NHS who can therefore avoid a lot of the BS and slow management-decision pathways. So are they Private?
2) Governments (both this one and the last) find the NHS too much of a big trainset to avoid playing with it. The rules change every few years, another bunch of managers come along, spend a year learning the ropes, a year doing something useful and then a year looking for another job when the next reorganisation comes along. They all have a hard-on for the Kaiser Permanente system in the US but ignore studies which show how different and costly it can be. They all want to import other US models, even though the admin costs are huge and the efficiency is doubtful.
3) Contrary to TJs opening post – about the only people who have a broad enough perspective on what is going on, and some idea on what needs to change, are GPs – not all of them – just some who have been doing this and service redesign work for over 20 years. But we are all getting peed off by the flip-flopping from the DoH and the way local health managers seek to preserve their power over achieving cooperation and clinical change.
4) Targets – which the Tories are against – work.

Net result is a whole generation of us who have invested time and emotion into trying to change things are giving up, checking our pensions forecasts. 🙁

I am sure this will be dilligently investigated and reported by the team at Singletrack Towers and a timely and accurate statement of what has happened and acceptance of blame will appear here from CRC, who will put a warning on the home page of their website to protect their customers whose security they value so highly…

And that a team of flying pigs are about to go past.

But he’s getting them from Merlin 😉

Bur he’s getting them from merlin

Saw it when it came out… 😳

Great visuals. Poetic and elegiac.

What application?

I haven’t found a LED which touches halogen ones yet. But the megaman CFLs are pretty good but bulky for anything other than down lighters.

But… If you want something funky… Got some of the remote controlled colour changing LED GU10s in a sprogs bedroom. Cool.

Ok. Idiot asking questions.

I’ve got a place on this. Entered before I realised my usual riding buddies would be involved organising our Insomnia overnight race on the Saturday at Bedgebury (and I’ll need to be there from 1800 to marshal this year).

But I’d still like to go along on friday night and saturday am/afternoon.

The race is listed as starting at 1100ish. I cannot see how long it lasts. Did the muc-off 8 at the same place last year, sounds a shorter race. Is it worth going along if I have to remain sober 😉

Very little beats this… Not for the squeamish

http://www.youtube.com/watch?v=u1un1YuIhC0

dratted double post

stumpy01 – fair points – and I wear a helmet for everything. But anecdote isn’t proof. There may be – in a road context – negative safety things about helmet wearing or drivers attitudes to helmet wearers which may balance the obvious advantages. I could give you tons of examples in medicine where the obviously intuitively safer/correct option was actually wrong…

jimification – I was wearing a helmet which I broke, was knocked unconscious and was carted off to hospital and scanned after a fall at Swinley a few months back. Do I blame the helmet, say it saved me, or say it did not help? I prefer to think it saved me – but I don’t know. As I said above – we know that skiing helmets mitigate severity of head injury – we also know motorcycle helmets reduce death rate. We don’t actually know this properly for cycle helmets, I personally suspect it does for MTBing in woods. But the “self-evident” is often wrong

And that statistic someone else happened to trot out is part of the current state of knowledge.

The argument is difficult because until someone does a study where people undertaking different types of cycling are randomly allocated helmet or no-helmet whatever their own wishes/intentions are, we will not have cohorts of people with matched demographics and matched attitudes that we can compare. And we are not going to get those studies. The studies of individual helmet usage will be flawed in having choice and attitude as confounding variables. The studies of whole populations and effects of legislation lump too many different contexts together.

Until then some of the leaps that some people sometimes take – generalising death rates from data mainly about road cycling where death may often be by mechanisms (eg squished by a Lorry – or very high speed impact) that no cycle helmet will ever mitigate – to other contexts (MTBing) is illogical.

Equally illogical is the frequent quoting of a study which says cars go closer to people with helmets, when that study was basically the observations of behaviour towards one single cyclist, sometimes wearing a womans wig… sometimes not… sometimes wearing a helmet… sometimes not…

In skiing – my other sport – we have the same issues. But where we are is:
1) Fatal head injury is so rare, that it is unlikely that any study will ever have the statistical power to show a death rate difference in Helmet wearers.
2) But we do now know that significant head injury is reduced in helmet wearers, that there is no increase in neck injury, and no evidence of “adaptive behaviour” (eg taking more risks because of the lids).

I suspect that for much MTBing – with rocks and trees in proximity and relatively moderate speeds, a properly conducted randomised trial would show a significant reduction in head injury severity, as has now been shown in skiers and boarders.

For pootling along a canal path (low risk) or cycling on the road where lots of things you hit will squish you like a bug, there may indeed be no point.

It does remain a personal choice though. And my personal choice is not to ride in the woods with anyone with no lid.

The domestic cat would not be in my top 10,000.

No real place in the ecosystem, precious little food value, crap everywhere and kill small birds, selfish fickle fur balls whose only useful purpose is to give advance warning to blokes that their single female owners are single for a reason…

*awaits incoming*

http://www.rockyroadsnetwork.com/category/mountain-bike-en/freeride-mountain-bike-en/

Their coverage – infrequent updates – and use of the same photo for 2 different events is not exactly inspiring…

Due diligence done?

Absolutely within their rights. We’ve had to reply to dodgier requests than this… and I have made a few myself 😉

Study data is neutral and should be openly available in an anonymised form.

Their subsequent interpretation and usage of the data may well be flawed, but that allows an opportunity to challenge them publically.

Hiding scientific data – as widely practiced by Pharmaceutical companies for trials with negative results – is never a good thing.

and FWIW I hate tobacco companies and they way they act – but they are still within their rights.

MSP – I’d disagree – but we musn’t pull the thread too much OT.

The death rate per year of one bunch of 20 year olds, compared with another.

Not saying they are realistic alternative choices, but whilst the death rate in the modern army understandably is a concern to any parent – and a real shame – we are not talking about the fatality rate in lots of previous conflicts.

My point is that people may have an artificially high perception of the death rate in the services.

Let him go. Good on him.

Interesting “More or Less” programme on radio 4 a few weeks ago where they said that the chances of death per year of a UK Soldier on active service was lower than the chances of death per year of a musician who achieved chart success…

The land they bought may have been “green belt” but wasn’t it actually a bit of a scrapyard before?

I suspect there are good arguments on both sides, although I’d love to see the travellers tax returns and vehicle insurance…

You just cannot completely declare yourself free of all the rules and restrictions of society.

But yes – the deciding issue for me was Vanessa Redgrave… 👿

Open – when you are ready.

If you chuck them you will kick yourself later

How old?

Nobody?

Ah well.