Head in sand doesn't make everything all right

Modernising Medical Careers (MMC) was allegedly the reform of medical training for the better, as many of us have since learnt the government lied about the real motives that lay behind this Trojan Horse of festering garbage. When everything when so spectacularly tits up back in 2007, the government had to pretend to act because things had got so bad that the media had started to take notice. In actual fact MMC had been doing damage to training for several years before 2007, the creation of the lame 'competency based model' of Foundation training and the useless application process for these jobs had already been about for several years by 2007.

After some excellent Freedom of Information ferreting I have managed to get hold of documents which detail correspondence between the Secretary of State for Health and the deputy CMO Martin Marshall on the topic of the MMC inquiry. I have highlighted some interested snippets for you to have a look at, taken from Martin Marshall's letter to the SofS:

"PROPOSALS FOR AN INDEPENDENT REVIEW OF MMC DEVELOPMENT PROCESS

....Whilst there have been successes as well as problems...

I understand the NAO are coming increasing pressure to undertake a review, either of the immediate issues with MTAS, or of the wider MMC program. I would hope that the announcement of an independent review would influence this decision, or at least its timing.

The purpose of the independent review would be to examine the framework and processes underlying the design and delivery of the whole MMC process and to make recommendations to ensure improvements for 2008 and beyond. This is likely to involve revisiting some significant issues but not to review the principles underlying MMC. These principles, to develop a competency based training program for doctors based on defined national standards, have widespread support amongst professional leaders.

The leading candidate is John Tooke... He is a committed educationalist, extremely well respected by the profession and more widely, and informal soundings suggest that he might be willing to accept the role if asked."

The above snippets are quite revealing. Not only do they show that the Department of Health has a remarkable habit of being completely unable to realise when it has made a mistake, but they only act when they are forced to by outside forces. The DoH appears to live in a permanent state of denial, completely unable to see just how incompetent their own actions are at times; they only ordered an Inquiry into MMC as they were afraid the NAO were about to nail them with a much more damaging review at a later date.

It is very revealing that the 'principles underlying MMC' were not to be called into question by this review, these were untouchable and allegedly already widely supported by our professional leaders, this all smells of fish to me. Interesting that the 'principles of MMC' seem to change every few days, according to the MMC website they are:

"One of the intended benefits of Modernising Medical Careers (MMC) was to ensure a transparent and efficient career path for doctors."

So much for that efficient transparency, MMC has reminded me far more of corrupt cock ups than anything else. The real motive of MMC was this:

"MMC aims to provide consistent national standards for training through better-structured and managed programmes with competency-based curricula approved by the independent Postgraduate and Medical Education and Training Board (PMETB)."

In reality MMC has resulted in a less flexible top down system which has done nothing but paper over the catastrophic effects of EWTD on medical training. Tons of extra paperwork and curricula will not help train specialists in less years with less hours per year, training cannot be purely competency based tick box numpetry, training must be common sense based and time based to a degree.

This government has dishonestly tried to force through the subconsultant grade with MMC, they lied to us and pretended that MMC was about better training and better patient care when it was about nothing of the sort. MMC was much worse than simply doing nothing as if nothing had been done we would have had to address the evils of the EWTD, as things stand the DoH and the government have stuck their empty heads in the sand and pretended that MMC would fix all our training problems including the EWTD. At the same time many new problems have been created by MMC including a lot of competency based damage to training and rain forests, an erratic and under performing Foundation training system, as well as numerous problems with various job application systems including an invariably useless Foundation scheme application system.

I've rambled on, mainly because it makes me very angry when people stick their heads in the sand and pretend everything is OK when it obviously is not. A lot needs to happen to fix this mess, the failings of competency based training and Foundation training need to be addressed fast before it is too late, maybe an NAO review of MMC would be a good thing to push for as well, while the EWTD monster needs to be taken on at some point. I don't have all the answers by any means, but the first step is to own up to the massive problems that exist, not living in arrogant denial like some choose to do on a rather regular basis.

Shambolic and unclear: Kafka's NHS

It's not hard to find diagrams like the ones above, the Internet is littered with examples of just how overly complicated the NHS' management structure and bureaucracy has become. It shouldn't take several textbooks and a few years of intense study to understand the way in which a health care system works (or does not as the case may be), the fact that the NHS is so hard to understand implies that it is a disorganised shambles with no clear chain of command. It should be so much easier to comprehend, but the government keep reforming, making things more complicated and shambolic.

The market argument is a complicated one, even a bottom up market would probably be more inefficient and bureaucratic than a well run state run system. However one can guarantee that a top down state run market system will be ridiculously inefficient and cumbersome. The diagrams above the the government 'newspeak' sum up the stupidity of the current process. Even people at the top are starting to see the light, and about bloody time too, it's just a shame that our moronic leaders like Tony Blair cared more for their own wallets than the nation's health. The lack of a clear chain of command means that the system is also incredibly dangerous as no one ever takes any responsibility when things go wrong.

The sad thing is that there appears little that we can do as cogs in our great 'democracy' to affect change in this regard. Labour copied all the flawed ideas of the Conservatives and then put them into practice from 1997 to this day, the Conservative would carry a lot of them on if reelected, while the Lib Dems never seem to oppose anything much with any vigour. The current economic situation and the future NHS spending cuts mean that we can expect to see front line services hit hard, while I am sure that the spending on bureaucracy, managers, PCT numpties, new incomprehensible reform strategies, management consultants, quangos et aliter would not be affected much.

It makes my blood boil. So much corrupt and cynical politics dressed up in nothing more than glossy bullshit. In the current financial climate it is a disgrace that money should be wasted in such a wanton manner. If I want to buy a load of bread the most efficient way to buy it is not to pass the money to the shopkeeper via four organisations and decide upon which loaf to buy by employing a cohort of idiots who then hire a group of management consultants to make the expensive decision for them, I haven't even started talking about how this NHS-style system would go about getting my loaf home; if I need a loaf of bread I'd go to the shop and buy it myself.

Power without responsibility

It's a deadly combination, power without responsibility, as we've seen with MPs' expenses if people are allowed to do what they want with little fear for the consequences then they will behave quite appallingly and unethically. One of the best ways of ensuring high standards in any system is to ensure that those people who are making important decisions are made accountable for them, after all if something goes wrong and no one is at all accountable, then the same errors will continue to made time and time again. What relevance has this for the NHS, quite a lot I would argue.

I had the misfortune of encountering a rather arrogant and obnoxious radiographer the other day. Radiographers are the technicians who take XRAYs, CT scans et cetera. I have to say that most of the standard radiographers I come into contact with are very pleasant people. The problem is that as with all things in the NHS, radiology has started to be dumbed down, some radiographers have now been empowered to actually report XRAYs as 'reporting radiographers'.

Don't get me wrong, radiographers see a hell of a lot of XRAYs and are very good at spotting fractures, better than a lot of doctors in fact. Unfortunately they are not medically trained, they are not radiologists, meaning that they do not have the broad base of knowledge and training that enables them to think outside the box and think of rare pathologies. For this reason 'reporting radiographers' are only allowed to report a very small percentage of the XRAYs that are done. There is still a problem as what happens when a 'reporting radiographer' misses that rare abnormality that a radiologist would most likely have picked up, I get the distinct feeling that they would not be held to account as a radiologist would be.

Radiologists are notoriously cautious because they know how tricky interpreting XRAYs and other tests is, most of the time one can see the obvious answer straight away, however if one just jumps straight in without thinking one would never diagnose the subtle, rare and potentially career-ending-if-missed pathologies. Radiology is like a minefield littered with the occassional career ending mine, most of the time one will be OK skipping through nonchalantly, however if one skips for long enough one is sure to get blown to smithereens.

I have digressed. The point I was trying to make was that the rather obnoxious 'reporting radiologist' was so overly confident because they lacked the knowledge and insight to be aware of their own limitations, they were skipping through the minefield assuming that their luck would hold. The particular one I met chose to take a quick glance at the XRAY, then claim that it was completely normal and should never have been done. I kept quiet and didn't mention that a rather esteemed Consultant surgeon had a very good clinical grounds for performing the XRAY. This is power without responsibility in the NHS, it generates this rank arrogance in the ignorant, it creates a potentially lethal over confidence in those who do not have enough knowledge to realise their own limitations. I could move onto the tale of the osteopath who reports XRAYs and misses bone tumours the size of footballs, but I would want to get sued for insulting a quack would I?

John Black is a living legend

The President of the Royal College of Surgeons has had his say on the EWTD and its disastrous effect on training today, and he certainly doesn't mince his words:

"The Junior Doctors Committee of the British Medical Association met for its annual conference on May 9th. A motion which was passed by a large majority included the statements “The current provision of service and training in the 9 surgical specialties mentioned above will not allow optimal training to be achieved in a 48 hour week” and “The changes required to optimise training will not be implemented at Trust level by the August 2009 deadline”. Good news one might think for those opposed to the introduction of the 48-hour week for surgeons. At last the BMA juniors have woken up to the fact that the EWTD is a disaster for training. However in the latest BMA News Review their spokesman ignores the motion passed by his own JDC and confirms that official BMA policy remains that the 48-hour week should be introduced in August. Their own JDC admit it is impossible to train surgeons in a 48-hour week but still want to see it brought it. This can only mean they do not want surgeons to be trained under the current system, an interesting and challenging position, which I hope to see clarified.

On 20th May Alan Johnson the Secretary of State for Health wrote to the Chairman of Medical Education England (MEE) saying “I would like the MEE to commission the Postgraduate Medical Education and Training Board (PMETB) to conduct a review of the quality of postgraduate medical training within a EWTD compliant working environment”. He also states that “There is no evidence that training is any less effective since the gradual reduction in junior doctors’ hours over the past ten years, or that greater numbers of trainees are failing their annual assessments where 48 hour working has been introduced”. Surgeons will be astonished by the Secretary of State’s complacent belief that training is no less effective than before at a time when surgical trainee logbooks are the thinnest in living memory. However aside from the minister giving orders to the independent MEE and to the independent regulator PMETB, this initiative is very welcome. The Board of MEE had already decided to look at the effects of EWTD on training at its next meeting on June 8th, and it is to be hoped that PMETB will not distance itself from the current training crisis, an approach it adopted during the MMC/MTAS crisis of two years ago. Mr Johnson also joins the BMA in his self-contradictory approach. Everything’s fine with training, but I want you to conduct a review. Why? Because we all know it isn’t! Again we await clarification.

As August 1st approaches the Department of Health is collecting data from Strategic Health Authorities (SHA) on progress towards EWTD compliance. The College has looked at the data for the surgical specialties, and I am grateful to the Regional Specialty Advisers and others who helped in this task. On May 21st I attended a meeting of the Department of Health EWTD team and the Academy of Royal Colleges to discuss this emerging data. It was a truly frightening occasion, as specialty after specialty described the reality of mythical rotas with gaps which cannot be filled, dangerously thin levels of cover, multiple handovers and unplanned and untested service re-configurations. The number of unfilled junior posts, both service and training, now approaches 3,000. The April SHA data do not show further movement towards compliance compared with March. Overall national compliance fell from 78 to 72% as paper rotas are revealed as mythical. As the situation is examined more critically, I just wonder what the true figure will be, 60%, 50%, or even less?

I attended the recent Association of Surgeons meeting in Glasgow and was heartened by the massive support for the College position. However a speaker from the floor made the point that it is quite likely that the 48-hour week will be forced in whatever we do or say and that consultants will as ever shoulder the burden for the sake of their patients. He has a point but you must not despair. The fact is that the NHS will not be 48-hour compliant in August. The emerging SHA data prove this. The EWTD is unworkable, dangerous for patients and disastrous for training. This battle is for the soul of surgery, and must and will be won. Patients will ultimately suffer and some may even die if it is not. I do not know when, but sooner or later this government or its successor will have to exempt surgery, and I suspect many other specialties too.

John Black
President"

Absolutely awesome. The BMA have had their head in the sand, the DoH and the politicians are in denial, the effects on training are disastrous, while the consequences for patients could be catastrophic. John Black is spot on, the man is a legend, however he may well have kissed goodbye to his peerage.

EWTD and the great deckchair rearrangement

The following description of the shocking state of affairs concerning the European Working Time Directive (EWTD) and the NHS has been largely stolen from a great piece on Doctors.net.uk, given the enormity of the problem I just felt this needed airing to as wide an audience as possible.

After a huge amount of pressure, and only 12 weeks before the full weight of the Working Time Directive hits the NHS Alan Johnson has ordered an enquiry into the effect of EWTD on the training of doctors in the UK.

In announcing it Alan Johnson has tasked MEE (Medical Education for England) to commission PMETB to consult 'stakeholders' as to solution to the imminent changes. This ultra-arms-length approach hints at lack of foresight and planning - arguably not boding well for a quick-fire solution in the 12 weeks that remain.

The writing has been on the wall for some time, and those pushing the WTD agenda cannot fail to have heard the message. In a recent joint statement the Royal Colleges of Anaesthetists and Surgeons wrote "Both colleges believe that the implementation of the WTD is in serious danger of having a deleterious effect on medical training, patient safety and service delivery."
A pilot study from Galway last year found that "all [the SHOs'] reported a deterioration in training and 81% felt that patient care suffered".

A Royal College of Physicians study found that "...the new 48-h working week has resulted in significant reductions of not only the quality of patient care, but also of general medical and medical specialty training. In particular, continuity of patient care has been affected adversely." Two former Royal College Presidents wrote to The Times this week and argued that "It is evident from many sources that quality of care of patients and proper teaching and experience for doctors in training cannot be provided for adequately in many specialties within a 48-hour week. This is particularly true of acute medicine and surgery".

Yet the Chairman of MEE, Sir Christopher Edwards, claimed today that the Secretary of Health was being 'proactive' in ordering this enquiry. Bearing in mind the timescale behind the implementation we think this is a new meaning of the word 'proactive'.

Last week the Department of Health admitted up to 28% of rotas were not going to be able to comply with the WTD by August. Some of those which were ostensibly had plans were completely unrealistic and were dependant on recruiting large numbers of doctors over the next few weeks. In a presentation made last week by Wendy Reid, the National Clinical Advisor to the EWTD, she acknowledged "Its not wise to go for a ‘big bang’ approach on August 1st". She also highlighted that despite throwing over £150million at the problem there were still many unanswered questions.

Implementation of the WTD requires more than just a reshuffling of rotas. It requires a major rethink in the way clinical care is delivered in hospitals, with changes to staffing levels and work patterns. Such a 'whole systems' approach requires far-sighted planning, central coordination and clear leadership. The government have had years to look at this. Why have they only noticed the impact on training now? The words from the new chair of MEE also make this man appear either completely out of touch with reality or so far up the government's derriere that his job is pointless.

MMC, sub-consultants and the Trojan Horse

"Remedy have obtained documents through a Freedom of Information (FOI) disclosure revealing previously undisclosed motives behind the MMC reforms of 2007. In short it appears that MMC was something of a foil by the powers that be to usher in the Subconsultant grade and change irrevocably the career prospects of all UK trainees......"

Excellent ferreting Remedy. I would strongly advise anyone interested in medical politics to read through the documents that the DoH have finally been forced to release.

In my opinion the rank dishonesty shown by the DoH throughout this whole sorry affair reveals why the health service will never flourish with these bullies at the helm. If only those in the positions of power were willing to cooperate and work with people in order to improve the systems that are in place, if only. The current regime would prefer to cynically spin the facts, deliberately hide their real motives and smuggle their corrupt reform agenda in via the back door. Shame on them.

GMC in denial

The story of the German GP who negligently killed an English patient whilst working as an out of hours GP locum has been in the news a lot recently, and quite rightly so. It appears that this was not an isolated incident either, this GP was clearly way out of his depth and other patients died that day.

I do not wish to dwell on this case because it is the theme that is important, the theme being the fact that non-UK trained doctors from the EU can easily register with the GMC after only the most minimal of checks, they are then free to compete with our own doctors for jobs, despite the fact that their education and training may not be nearly comprehensive enough to prepare them for the work they will be doing in the NHS. We now know that these EU trained doctors can then kill patients negligently, return home, receive the lightest of punishments and then return to practice as if nothing has happened. This is a disgrace.

If there is going to be a free market of labour in the EU in terms of health care work, then there must be a rigorous system of regulation in place that holds people to account if they make negligent errors whilst working away from their homeland. The blame lies squarely at the door of the government who have signed us up for this free market of labour without thinking of the serious consequences of a dangerously patchy system of regulation. Any doctor working in the NHS will tell you how they have encountered several non-UK trained doctors from the EU who have shockingly bad language skills and who lack even the most basic of medical knowledge, yet strangely they had no trouble getting their full registration from the GMC. This is not good enough.

There are many medical schools in certain EU countries that do not train doctors to the level of competence that our own UK graduates achieve, however the GMC cares not for the standard of your medical degree, any EU degree is good enough for them, while their language test is so easy that even a martian could secure top marks. Bizarrely excellent Australian and New Zealand graduates are now faced with a mountain of stupid paperwork before they can practice in the UK, while some of their dangerous counterparts from the backwaters of the EU can get in without any trouble at all. Well done the government and well done the GMC. Although the free labour market helps you push people around, it is killing patients at the same time, well done.

Watch this space: MMC

"Modernising Medical Careers (MMC) is a programme of radical change that aims to drive up the quality of care for patients through reform and improvement in postgraduate medical education and training. "

The government's stated aims of MMC are directly quoted above. The government also claimed that all it was doing was fair and transparent:

"One of the intended benefits of Modernising Medical Careers (MMC) was to ensure a transparent and efficient career path for doctors."

There was also meant to be better training for doctors and 'evidence' behind this improved training system:

"For patients, it was intended to mean that a higher proportion of care would be delivered by an appropriately skilled workforce. For trainees, the new programmes’ structures meant an assured high quality of training, better formal supervision and continuous development of acquired competencies, backed up by good evidence."

It is strange that despite such noble motives, the reality is virtually the polar opposite of the government's hollow chatter. The training quality is not better, the competency based ladder is simply a way of dumbing down health care so that less training and skills are needed for its delivery, this is beautifully demonstrated by Dr C's Pharmacist's tale. The quality of care is consequently not better, it is worse, as less experience and skill are needed to treat patients these days. The 'fair' MMC process is excellently demonstrated by this sad tale from a junior doctor who has actually experienced the reality of this grossly unfair and shoddy system.

So training is worse, there are less hours for training and a much smaller window of opportunity for learning one's trade, and at the same time training is being shortened. Something does not add up, these promises of better care seem a blatant lie. So what are the real motives for MMC, I would advise you to watch this space for some rather important breaking news.

Burning our money, the fire goes on

I warn you not to read any further if you have a slightly dicky ticker, the following figures may shock you so much that it may result in a burning rage so severe as to drive you to the very edge. It's that subject again, the NHS and its amazingly wasteful and inefficient bureaucracy.

The Conservative party have worked out that the NHS' bureaucracy now costs around 12 billion to run each year, a rise of around 100% in just five years, that's almost a rise of 20% in administrative spending per year, utterly amazing. Incredibly this massive figure does not even include the money spent on PCT administration and waste which is probably another monumentally huge figure given their Kafka-esque setup. The 12 billion figure only includes the DoH, Quangos and the regional health authorities (SHAs).

The number of managers is increasing at a rate far outweighing their need, the number of useless arms length agencies also continues to rise and rise, here are some of the little gems the DoH has recently excreted:

"Cosmetic Surgery Steering Group, Advisory Board on Registration of Homeopathic Medicines, Alcohol Education and Research Council, Herbal Medicines Advisory Committee, Independent Advisory Group on Sexual Health and HIV, and the Leadership and Race Equality Action Plan Independent Panel"

It's just so wasteful that it's hard to come up with words, I'm almost beyond rage, I am also now beyond laughing and crying, I just try to get on with my daily job. Every year there are more and more layers of useless bureaucracy which end up using up the extra money that should be going to the productive front line services, there are more and more uneducated idiots with no knowledge of health care and medicine being empowered so that they can decide how to throw money onto this wanton bonfire of our money. PCTs are now paying people to lose weight, what next paying people for exercising and not injecting drugs?

Ironically as a front line NHS worker 'Clinical Governance' is allegedly the system that means that health care in the NHS should always go from strength to strength, it's about creating the right 'open' environment in which training prospers, mistakes are learnt from and evidence is always studied before any money is frittered away. Sadly Clinical Governance appears like someone's sick joke as virtually all of it is ignored, while the opposite seems to be the case in the reality of the NHS. The 'open' culture is so open that whistle blowers get burnt at the stake, the training is so important that the untrained are empowered, while the evidence is routinely ignored by policy makers as they only care for propaganda, gimmickry and ideology. Brave old NHS indeed.

Tales from the gulag

The following tale is taken with kind permission from the author from Doctors.net.uk. I particularly like this tale because it gets across several of the ways in which the NHS is falling apart, simply read it and see what you think, the tale is told from the perspective of a Specialist Registrar in Urology (a surgical specialty):

"She wanted to know what to do with a 42 y.o. woman with hypertension, heavy proteinuria, microscopic haematuria and an albumin-creatinine ratio of 32.

So she decided to call the urology consultant on call. I intercepted the message (well, the boss' secretary asked me to deal with it) and phoned her back:

Me: I understand you had a query about a patient?

Nurse: Yes. [relates details above]. I don't know who to refer her to. Urology or renal?

Me: Are you in a GPs practice?

Nurse: Yes.

Me: Did you think of asking the patient's GP?

Nurse: I did, but he didn't know who to refer to either and suggested I phone you.

Me: Really? He really couldn't tell if a 42 year old woman's heavy proteinuria and hypertension was a nephrological or urological problem?

Nurse: No.

Me: Wow. Well, it's pretty clear to me. If that patient was in front of me, I'd request a renal ultrasound and ask for the report to be copied to the nephrologist she [i]should[/i] be seeing.

Nurse: So I should refer to nephrology?

Me: Probably not. Probably the GP should decide, then he should refer to whomever he thinks is appropriate. I'd bet that'd be nephrology, though.

Nurse: Oh, ok. It's just not clear from the NICE guidelines... (she actually said that) Should that be an urgent referral or routine?

Me: It's not clear from the NICE guidelines??? Look. I am not a nephrologist or a GP. I don't treat nephrological problems. I suggest again you speak to the patient's GP."

Sometimes the empowerment of the undertrained is a story that is unfairly told, as only the danger of this policy is highlighted, not the scandal that is the supervision of these undertrained people by people who should know much better. What I mean by this is that too many GPs and consultants have looked after their own interests ahead of the interests of patients and other doctors by supervising this empowerment of the ignorant. Too many GPs and consultants have only looked after the short term interests of their own bank balances rather than concentrating on the quality and sustainability of the service. The NHS' new generation of the empowered ignorant have been trained by doctors.

This story sums all that up. It also touches upon how medicine can be practiced incredibly badly if people are empowered to act beyond their station by relying on protocols and guidelines. This is something the government has been pushing towards with the empowerment of nurses and protocol-led medicine. Falling standards of medical education also make this a big problem because if young doctors are not given a good solid grounding in the basic sciences then they will not be able to practise gracefully using their common sense. Yet again it is rather apparent that the quality of service will not be improved if people continue to profit from this dumbing down. Short termist cost cutting in terms of training and protocols do not a high quality service make.

Remedy survey reveals the truth about MMC

A recent Remedy survey has shown the devastating impact that Modernising Medical Careers (MMC) has had upon patients, doctors and their families. The results are not surprising but are still very important as none of the powers that be have ever looked for any feedback or comment from doctors on MMC.

It is strange that in an NHS with so much bureaucracy and pretend feedback that organisations such as the Department of Health, PMETB, the Deaneries and the BMA have never asked any meaningful questions about MMC. If you do not look for something then you will not find it, also if you hide from something then you are also a damn sight less likely to encounter it.

Amazingly despite the stated aims of MMC being to improve patient care and postgraduate medical training, 78% of all respondents say that patient care and postgraduate training is worse than previously. Very few (just 1%) could comment on MMC positively.

Sadly MMC is but the tip of the iceberg of failing and destructive healthcare reform, it is also true that this failing government healthcare policy is also only the tip of another even bigger iceberg, the one that represents this government's general failure in all it touches. Whether it be the riding roughshod over our civil liberties or the never ending empowerment of various Kafka-esque state agencies, this government treats most people with no respect, and if you treat people with no respect and showpeople no trust then you know what you can expect in return.

Cancer mortality unchanged and more targets

It is obvious that the government's grandiose inefficient top down schemes don't work very well, another example of this has been the government's 'Cancer plan', yet another superficially catchy plan backed up with more targets that appears not to have worked. Blanket targets that force patients to be seen within a certain time frame irrelevant of their actual clinical need are ways of robbing Peter to pay Paul.

The only way to improve our cancer mortality figures is to scrap the targets and continue to sink money into capacity on every level. This doesn't only mean quicker surgery by more operative capacity, it means more radiotherapy capacity, more capacity of adjuvant therapies like chemotherapy, easier access for GPs to diagnostic services and more capacity in the specialist clinics and in radiology departments. It would take a hell of a lot of money to drag us back into line with the rest of Europe on this one after so many years of relatively underspending.

Simon Caulkin's quite magificent article in the Guardian brilliantly exposes just how foolish the government's approach is to these complex problems:

"Target-driven organisations are institutionally witless because they face the wrong way: towards ministers and target-setters, not customers or citizens. Accusing them of neglecting customers to focus on targets, as a report on Network Rail did just two weeks ago, is like berating cats for eating small birds. That's what they do. Just as inevitable is the spawning of ballooning bureaucracies to track performance and report it to inspectorates that administer what feels to teachers, doctors and social workers increasingly like a reign of fear."

You can read the rest of this excellent critique here, it really is a fantastic piece of journalism:

"They even propose a health warning: "Goals may cause systematic problems in organisations due to narrowed focus, increased risk-taking, unethical behaviour, inhibited learning, decreased co-operation, and decreased intrinsic motivation." As a glance at Stafford hospital would tell them, that's not the half of it."

'Individual management failures'

The headlines surrounding Staffordshire General Hospital have been hitting the news in the last few days and it is hard to see how anyone could not be outraged at the appalling standards of care 'provided' there. Gordon Brown was answering questions on the subject at lunchtime today and he kept repeating the words 'individual management failures' while ignoring repeated criticisms of the NHS' dire central management which imposes the market from Whitehall and the top down target based system that is arguably to blame for problems like Staffordshire General's.

Others have covered this story already. Dr C points out that anyone pointing out these kind of glaring failures in care is likely to be labelled mentally ill by the GMC, such is a whistleblower's fate in the NHS. Dr Grumble points out how the idiotic target based system encourages the prioritisation of political imperatives over clinical ones leading to junior doctors being bullied by managers into ignoring the clinical priorities of patients. Dr Rant points out where the blame should lie. The Witch Doctor cleverly points out that the 'leaders' which this government is so keen to marginalise are probably the only people who could dig the NHS out of the deep pit which the politicians have been digging for so many years.

Alan Johnson and Gordon Brown are living in cloud cuckoo land. While some hospitals do manage to provide high standards of care, it is despite the government's central megalomania, not because of it. The problems in Staffordshire General stem from No 10, the DoH and the top. The government's top down control freakery and brutal imposition of various brainless reforms is the cause of problems like this. The management structure of the NHS is centrally driven and top down, there is no room for feedback, no room for local decisions, it is do as the government says or die, quite literally in some cases.

It is no coincidence that patients were killed in both Maidstone and Staffordshire as a result of Trusts prioritising their finances over patient care. Both hospitals were trying to gain Foundation hospital status, hence they wanted to save money and meet targets, whatever the cost in terms of patients being slaughtered. The government has killed these patients with its systemic mismanagement of the NHS. The market has been their top priority and imposing this from the top has come with the obvious costs attached. There is no doubt that the governent has created this environment in which finances are prioritised ahead of patients' lives.

Gordon Brown and Alan Johnson have the blood on their filthy hands. These are not individual management failings, these are systemic failings as a result of a Stalinist system that forces managers to prioritise the government's wishes ahead of patients' clinical needs. The government's explanations for these deaths do not cut the mustard, it is simply not good enough to try to pin the blame on individual managers. The blame lies with a cynical and corrupt system that is set up to meet the short term propaganda gathering needs of politicians, local managers are frequently in a no win situation as they are forced to meet political targets rather than improving the process of clinical care with their hospital.

Gordon Brown's stupid words in defence of his targets sum it all up beautifully, he claimed that no reasonable person would deny that cancer patients should be seen within two weeks and that AE patients should be seen within four hours. Actually Gordon I am reasonable and there are many situations when it is very reasonable for minor injuries to wait many hours for treatment, as if there are moribund patients needing resuscitation in the same AE department they must be the number 1 priority and the sore big toe or the itchy buttock can damn well wait.

Targets do not improve patient care, only extra investment and a consequent increase in capacity can do this, the targets are a bit like robbing Peter to pay Paul, improving care for one condition invariably results in someone with another condition suffering. All the managers in Staffordshire General were doing was responding to the pressures of a system that had been put in place by central government, if they had some local autonomy then it would be fair to blame them, unfortunately they did not. The government has created this dangerous clinical environment, it is they who should be up in court charged with murder.

Alan Johnson: liar or just plain ignorant?

Anyone who works in the NHS these days, well pretty much anyone, can tell you that Alan Johnson is extremely innacurate with the following statement that is documented on the record in Hansard:

"There is no question but that it has been challenging to work towards full compliance. The NHS has over 46,000 doctors in training at any one time. Incidentally, there is no vacancy problem, as the hon. Member for South Cambridgeshire (Mr. Lansley) suggested. On the last set of figures, we had a 95 per cent. fill rate; there is absolutely no vacancy problem anywhere in the country that I know of. This is a service that by its very nature has to operate for 24 hours a day, seven days a week. Trainee doctors need to train and work in as many medical disciplines as possible to become good doctors. Hospitals have had to make dramatic changes to how staff work. So, yes, it has been difficult, but it is simply not true to say that the NHS is ill prepared to achieve full compliance by August this year. We have provided substantial financial support to the NHS to help it to meet the requirements of the directive—£110 million in the current financial year, rising to £310 million for the year to come."

Either Mr Johnson is incredibly ignorant of what is going on in his own department or he is telling big fat porkies. For many reasons there is a staffing crisis at many junioir doctor levels in the NHS, numerous rotas are being run short of multiple staff members, meaning that doctors are missing out on training and patient care is suffering.

A recent survey of surgeons in training showed that over 50% of surgical rotas were significantly short of staff, and this is not an isolated problem for surgery, it is occurring across the board and it is not good for anyone. Doctors are getting overly tired covering the gaps while patients will be getting less continuity of care, as well as less time dedicated to their various problems.

The blame for this lies with the government thanks to their stupid reform that has led to non-EU doctors being kicked out, all doctors changing on the same day every year and hundreds quitting the NHS due to their great disillusionment. This is all compounded by reducing working hours thanks to EWTD and the fact that the BMA are doing nothing about this serious problem. NHS Trusts cannot find locum cover to fill these gaps, while even if they can it is very expensive and wasting a lot of money needlessly. Well done Mr Johnson et al, you have shafted a generation of doctors and now the patients are suffering too.

You get what you pay for, less training more mistakes

With kind permission from the author I have reproduced the following tale to show how quite simply less training leads to more mistakes and a lower quality of care:

"Not so long ago, in a land not far from here, a young boy awoke one morning with a painful tummy.

"Daddy!" he cried. "My tummy's hurting."

The father looked down at his dear son and said, "Don't worry, O son, for I know a Wise Woman who will be able to cure your pain. Let us go and visit her."

And so, the family made haste their travel to the local Walk-In Centre, where the friendly nurse greeted them with a warm smile. "Come in, and tell me all about it," she said. And the young boy proceeded to tell the Wise Woman of his painful tummy."This is nothing to worry about!" she declared in a very wise and motherly way. "Be gone, for your pain is due to a virus."

The Wise Woman did not need to examine the young boy, for she had been on a "couple of courses."

The family thanked the Wise Woman for her great wisdom and made good their journey home.2 days later, the post-mortem report concluded that the boy had died from a perforated appendix.

The morals of this story are that:

1: When you assess a patient, you often have to examine them.

2: If you do not know how to examine a patient, you should not be assessing them.

3: Sometimes it takes a few disasters before mistakes in policies are addressed.

4: Nurses, as with doctors, have a duty of care to their patients. If that duty is breached and harm results, then they are NEGLIGENT.

5: After a few civil cases, nurses in WICs will realise that they are on their own, in a failed policy.

6: The public should be fully informed when consenting to treatment: "You get what you pay for."

Wise words. I am not pretending doctors are perfect, far from it, however less training results in worse care, it's very very simple.

Short staffed and enslaved

The government's recent attempts at medical workforce planning are embarrassing. The reduction in doctor working hours as a result of EWTD has combined with government training reform (MMC) and draconian anti-IMG (international medical graduate) to produce a disastrous short and long term situation. A recent survey of surgeons in training found that over half (53%) were experiencing problems with rotas that were short staffed, this is not just a surgical problem, it is a systemic malaise present in most hospital specialties. If you visit a hospital this year, chances are that the doctors looking after you are working extra shifts and seeing their training reduced thanks to this very serious problem.

Not only has EWTD resulted in more doctors being needed to fill hospital rotas, it has also reduced the training gained in jobs as full shift rotas are brought in across the board. Meanwhile MMC has resulted in the disappearance of the service providing 'lost tribe' bulge, as thousands of doctors who missed out on the golden 'run through' ticket have either left the profession or fled abroad. The Department of Health has also forced thousands of IMGs away with their ridiculously unfair and stupid changes to the way in which IMGs are treated by our health system.

The end result is a disaster for both patients and training, in both the short and the long term. Not only is patient care being compromised as rotas are left at dangerously low levels of staffing, but the training of doctors is also being significantly compromised as doctors are spread too thin and the training element of jobs is spread even thinner. Patients are getting less thorough care and less continuity, while the doctors who are left to pick up the government's pieces are finding the quality of their training is going quickly down the pan.

This problem is not going away and it does not appear to be being solved, meaning that more trouble is only just around the corner. The government thought it could expand medical school places and force British grads into service level posts, however that was never going to work, the service level jobs are not attractive for our own grads, they will remain empty until something is done, while EWTD's further enforcement will only make things worse.

NHS Employers has recently announced a rather blatant u-turn in their policy making by trying to make it easier for non-EU doctors to work in the UK, a tacit admission that their previous attempts were gross bungles. Unfortunately this will not help the doctors who are currently doing lots of extra hours and shifts to cover the huge gaps that have arisen as a result of this calamitous government thinking. They are slaves to their NHS trusts, despite being treated like dirt they work on for their patients, it's just a great shame that the government has treated them so very shabbily.

PCTs 'incapable and useless'

As the latest news tells us of the full magnificent of Lord Darzi's latest reforms, I am not surprised that some 'GP-led centres' will have no doctor on site at all, amazingly really:

"Some GP-led health centres could be run without a GP on site at all times, GP newspaper can reveal. "

So much of this government's reforms involve paying monkeys peanuts to do a job that was previously done by a more skilled monkey for pretty much the same peanuts, no wonder the quality of the service is falling all the time.

Another interesting aspect of the NHS is the fact that monkeys are frequently being hired by monkeys, who are being hired by monkeys ad infinitum. With more and more layers of bureaucracy year by year, the layer of useless monkeys proliferates, while those who actually do work on the front line find their funds cut as the monkeys want it all for themselves. If this continues we shall be left with just bureaucrats. The biggest monkeys of them all are the PCTs:

"PCTs lack analytical and planning skills and the quality of their management is very variable, the inquiry found. The report states: "We consider this to be striking and depressing."

"However, we remain very concerned that PCTs are not yet up to the task of putting these reforms into practice....We heard a lot of evidence about weaknesses in PCT commissioning "

The HSJ has taken this from the Health Select Committee report which can be found here, in fact the original document is even more damning as regards the complete inability of PCTs to do the job asked of them:

"Indeed, PCTs have attracted a good deal of criticism over a long period, often focusing on their inability to evaluate data and identify cost-effective interventions based on evidence."

"Witnesses were critical of the Department's initial attempts at Practice Based Commissioning (PBC) and doubted whether the situation would improve."

"Previous criticisms of PCT commissioning have centred on their inability to evaluate data and identify cost effective interventions based on evidence. Neither the Department nor Mr Farrar elaborated on the criteria which should be used to evaluate PCT commissioning. Neither did they tell us how they would identify the actions that would be taken to address poor performance. "

I suspect that even if PCTs were staffed with intelligent capable staff (which they most evidently are not) then they would struggle to turn Darzi's and the government's reforms into winners, as the reforms are fundamentally flawed down to their very ideological foundations. PCTs are currently in the process of wrecking all the good services left in the NHS, as they are deliberately starving hospitals and front line services of cash, while they throw money at daft scheme after daft scheme. The PCT layer of bureaucracy has always struck me as a waste of space at best, now they are not only wasting space, but they are doing immense harm to any good that remains. It is time that PCTs were blown away.

BMJ praises Hospital at Night

The BMJ is a pretty ropey journal and if we're honest it wouldn't really be read by many people unless it was dished out free with membership of the BMA. Then if we're honest the BMA wouldn't be very popular if doctors had a decent union (that instead of trying to gain itself knighthoods and peerages for itself) that bothered to try to represent the interests of front line doctors.

The BMJ has recently come up with a load of awards in categories from 'Best Research Paper' to 'Excellence in Learning and Education', the full list of nominations can be viewed here. There are some very worthy nominations there, for example Ben Goldacre in the snazzily named category 'Health Communicator of the year'. However there are unsurprisingly some rather pathetic nominations that seem to have been done in a rather typical 'politically pleasing' manner. The nomination for the Hospital at Night team beggars belief and is factually incorrect for starters:

"Hospital at Night team: Skills for Health - Workforce Projects Team
The Hospital at Night (HaN) programme is a clinically driven and patient focused change programme which uses both a multiprofessional and multi-speciality approach to delivering care at night and out of hours. The programme enhances patient safety and outcomes and supports medical training and service delivery. The benefits of utilising HaN to training are:

• Exposure to the key management skills for early detection, management and support for acutely ill patients out of hours in a multiprofessional approach
• Enhanced utilisation of team competences
• Escalation of clinical issues with supervision and support from senior clinical staff
• Develops the capacity to deliver the junior doctor foundation programme curriculum.

They have conducted a comprehensive analysis of this project."

Interestingly the problems associated with the low staffing levels at night times in hospitals are not the fault of Hospital at Night (HaN), they are the fault of shift working and the EWTD which have resulted in hospitals being left dangerously short staffed with a real lack of continuity of care for patients. HaN is the government spin being used to paper over these gaping cracks.

HaN claimed it improved patients outcomes when it was first introduced, despite having no evidence that it did, it even wrote in big letters on its website 'better care'. Even recently the evidence on outcomes that it has is scanty at best and this evidence appears to have been misrepresented rather cynically by the HaN team.

The only report that has measured patient outcomes following HaN introduction is methodologically flawed and shows no results to back up the HaN teams claims, there were no statistically proven improvements following HaN's introduction. In fact there was an increase in 'the actual number of deaths' following HaN, however this is written off as being because of increased patient numbers, there are other explanations that they have not considered however.

The spin from the BMJ and the HaN makes it appear that all is wonderful thanks to the HaN scheme, despite the lack of any decent evidence to back these claims up, at best HaN has made no difference to outcomes or safety. Anecdotally if you speak to any doctors on the ground you will hear horror stories of nurses being empowered beyond their means, staffing levels that are dangerously low, doctors working outside their areas of expertise due to this short staffing and patients dying as a result of all this.

It's great that the BMJ are recognising these achievements of the HaN team, it speaks volumes for the way in which statistically insignificant evidence published on a government website can be spun in such a dishonest and irresponsible manner. Well done HaN team, I hope you're proud.

Dementia spinning

The Dementia story has been flashed all over the news today, if one believed the government then their gimmicky plans for earlier diagnosis will have a dramatic impact. Dr Grumble cleverly interprets the story here. The lobbyists claim:

"Research has shown that a brief four or five-hour programme of support and counselling at diagnosis can reduce institutional care by an astonishing 28 per cent or an average of 557 days compared with those not receiving such interventions. This is particularly crucial considering that much of the cost associated with dementia results from expensive care home provision."

In actual fact the abstract of the research that the lobbyist is spinning is:

Mittleman, M.S., Haley, W. E., Clay, O.J., & Roth, D. L. (2006). Improving
Caregiver well-being delays nursing home placement of patients with Alzheimer’s disease. American Academy of Neurology 67, 1592-1599.
The purpose of this study was to determine the effectiveness of counseling and support intervention for spouse caregivers in delaying time to nursing home placement of persons with Alzheimer’s disease and to identify the mechanisms through which the intervention accomplished this goal. A randomized controlled trail of counseling (6 sessions of individual and family) and support (support group, ad hoc telephone counseling available) was compared to treatment as usual for 406 spouse caregivers of community-dwelling patients with AD over a 9.5 year study period. Patients who spouses received the intervention experienced a 28.3 % reduction in the rate of nursing home placement compared with treatment as usual. Median time to placement was 557 days. Improvement in caregivers’ satisfaction with social support, response to patient behavior problems, and symptoms of depression collectively accounted for 61.2 % of the intervention’s beneficial impact on placement. The authors concluded greater access to effective programs of counseling and support could yield considerable benefits for caregivers, patients with AD and society.

Even from quickly skimming the abstract one can see that this is not a study about just early diagnosis and a brief support programme, it is a long study over almost ten years in which carers were given a lot more counselling and support than they would otherwise have been given.

This quick case study is the perfect example of the way in which the modern media and lobby industry operates. Scientific evidence is spun by non-scientists and manipulated into saying things for which there is simply no evidence. It makes headlines for the government to launch its gimmicky new early diagnosis centres for a relatively small amount of money but they are the equivalent of pissing in the wind; as if there is not a substantial investment in carers, care homes, support systems for carers and other facilities then the point will have been completely missed and the urine will continue to fly into the carers' faces.

The PCT list: New Labour's NHS legacy part 2

Following on from the original list, courtesy of a kind GP I have been updated that the initial list was not nearly comprehensive enough. Here goes, it's a bit of a mammoth beast, be warned, here are the lists of the job titles of those working in a few other subsections of the very same PCT (I have had to shrink the font due to the great length of this list):

* Acting Purchasing Team Leader
* Acting Supplies Manager
* Acting Supplies Support Team Leader/Trainee Buyer
* Action On Smoking Coordinator
* Active Lifestyles Development Officer
* Admin Assistant
* Admin Support Officer (Commissioning)
* Administration Officer – Supplies
* Administrator – Health Promotion
* Administrator, PA To Associate Director of Clinical Standards
* Administrator/PA Dental Services
* Assistant Business Accountant – Business Development
* Assistant Director – Communications
* Assistant Director - Corporate Development
* Assistant Director – Equality & Diversity
* Assistant Director Clinical Quality, Commissioning/ Deputy Director
* Assistant Director of Commissioning & Contracting
* Assistant Director of Finance (Commissioning)
* Assistant Director of Finance (Financial Management)
* Assistant Director of Finance (Financial Planning & Performance)
* Assistant Director of Public Health Training & Development
* Assistant Director Patient Safety & Clinical Governance
* Assistant Financial Accountant
* Assistant Management Accountant – Business Development
* Assistant Management Accountant (x3)
* Associate Director
* Associate Director of Public Health
* Breath Test Coordinator / Receptionist
* Business Development Manager
* Business Manager – Public Health
* Buyer – Purchasing Team
* Cancer Screening Coordinator
* Cardiac Network, Services Development Manager
* Chair (x2)
* Chief Executive
* Choose & Book Lead & Development Facilitator
* Citizens Advice
* Claims And Litigation Manager
* Clinical Governance Manager
* Clinical Quality Administrator
* Clinical Quality Coordinator (x2)
* Clinical Quality Manager (Care Homes)
* Clinical Receptionist
* Commissioning
* Commissioning Choose & Book Officer/ Commissioning Officer
* Commissioning Improvement Manager
* Commissioning Information Performance Manager
* Commissioning Lead For Younger Adults Physically Disabled
* Commissioning Manager
* Commissioning Manager CHD/Diabetes
* Commissioning Support (Temp)
* Communications Administrator
* Communications Assistant (FOI, Media & Campaigns)
* Communications Officer (Media & Campaigns)
* Compliance Support Officer
* Consultant – Public Health (Clinical Effectiveness)
* Consultant In Dental Public Health
* Continuing Care Case Manager
* Continuing Care Manager/Clinical Lead
* Continuing Care Network Lead
* Continuing Care Nurse/Care Manager
* Continuing Care Secondment
* Corporate & Legal Services Support Officer
* Corporate Services Manager (x2)
* Counselling Administrator
* Director of Clinical Quality & Nursing
* Director of Commissioning & Informatics
* Director of Corporate Strategy
* Director of Dental Services
* Director of Finance And Performance
* Director of Health Promotion
* Director of Human Resources And Organisational Development
* Director of Public Health
* Directorate Secretary - Public Health
* Domestics Supervisor
* Driver & Admin
* Employer Adviser
* End of Life Programme Facilitator
* Exercise Recommendation Coordinator
* Finance (x2)
* Finance Assistant – Financial Management
* Finance Assistant – Financial Services
* Finance Assistant – Treasury Management (x2)
* Finance Assistant (Temp) (x2)
* Finance Assistant (x5)
* Finance Manager
* Finance Manager - Patients Monies & Charitable Funds
* Finance Officer (x2)
* Finance Officer, Treasury Management
* Finance Officer–Financial Management–Treasury
* Finance Team Leader
* Finance Team Leader – Treasury Management
* Finance Trainee
* Financial Accountant – Financial Management
* Financial Team Manager – Treasury Function
* Free Nursing Coordinator
* Funded Nurse Care – Lead Nurse
* General Office Administrator (x2)
* General Office Administrator/ Physical Activity & Obesity Adviser
* Head of Cancer Commissioning
* Head of Clinical Quality (Commissioning)
* Head of Clinical Quality, Primary Care Independent Contractors
* Head of Commissioning Improvement Team
* Head of Corporate Governance
* Head of Disability Services, Children, Young People & Disabilities
* Head of Financial Management
* Head of Financial Planning & Performance
* Head of Information, Commissioning
* Head of Long Term Condition Programme
* Head of Practice Based Commissioning Finance
* Head of Primary Care Finance
* Head of Professional Development (Children's Services)
* Head of Professional Development (Community Hospitals)
* Head of Rehabilitation & Intermediate Care
* Head of Speech And Language Therapy
* Head of Strategy & Planning
* Health Improvement Officer
* Health Improvement Specialist
* Health Promoting Schools Adviser (x2)
* Health Promotion
* Health Promotion Admin Assistant
* Health Promotion Driver/Admin Assistant
* Health Promotion Service Administrator
* Health Trainer Programme Coordinator
* Healthy Business Adviser
* Healthy Schools Adviser (x3)
* Healthy Workforce Nurse
* Highly Specialised Podiatrist
* Hotel Services - Catering
* Infection Control Champion Programme Facilitator
* Infection Prevention & Control Educator (Nursing Homes)
* Infection Prevention & Control Nurse Specialist
* Infection Prevention & Control Team Leader
* Infection Prevention & Patient Safety Clinical Specialist
* Learning Coordinator – Health Trainers
* Long Term Conditions Administrative Officer (Commissioning)
* Long Term Conditions Commissioning Administrator
* Long Term Conditions Commissioning Manager
* Long Term Conditions Manager
* Management Accountant – Rehab & Intermediate Care Services
* Management Accountant (x4)
* Medical Director/PEC Chair
* Medical Secretary
* Medicines Management Technician (x2)
* Men’s Health Programme Manager
* Non-Executive Director (x7)
* Nurse Practitioner – Rapid Response Nursing Team
* Office Manager (Public Health)
* Operational HR Business Partner
* Orthopaedic Screening Secretary (x2)
* PA (Temp)
* PA (x2)
* PA Older People Advisor
* PA Public Health
* PA To Assistant Public Health Director
* PA To Associate Director of Clinical Quality (Commissioning)/Deputy Director
* PA To Associate Director of Communications & Associate Director of Corporate Development
* PA To Chair And Chief Executive
* PA To Director of Commissioning & Informatics
* PA To Director of Finance And Performance
* PA To Director of HR & Organisational Development
* PA To Director of Public Health
* PA To Directorate of Corporate Strategy & Trust Board Support Officer
* PA To Health Improvement Specialist
* PA To Medical Director/PEC Chair
* PA To PH Specialist Pharmaceutical Manager/Research Manager
* PA/Admin Support - Corporate Strategy
* PA/Secretary – Public Health
* PALS & Dental Temp
* PALS & PPI Manager
* PALS Information/Admin Officer
* Physical Activity & Obesity Advisor (x6)
* Physical Activity & Obesity Programme Manager
* Physical Activity Diet And Obesity Coordinator
* Physical Activity Programme Manager
* Physical Activity, Diet & Obesity Programme Manager (Men's Health)
* Podiatric Consultant
* Podiatric Specialist Registrar
* Podiatrist
* Podiatry
* Podiatry Reception
* Porter (x2)
* PPI/PALS Officer (x2)
* Primary Care Administrator
* Primary Care Lead Pharmacist (x2)
* Primary Care Locality Manager
* Primary Care Support & Development Manager (x2)
* Professional Development & Patient Safety Officer
* Professional Development Lead
* Professional Development Lead (Community Hospitals)
* Project Lead Community Nursing Services Development
* Project Worker – Action On Smoking
* Public Health
* Public Health Analyst
* Public Health Partnership Manager
* Public Health Secretary
* Public Health Training Network Administrator
* Public Health Workforce Manager
* Receptionist (am)
* Receptionist (pm)
* Receptionist/Telephonist (am)
* Receptionist/Telephonist (pm)
* Research Assistant
* Research Manager
* Research Officer
* Resource Library Manager
* Schools & Young People Team Coordinator
* Screening Manager For Long Term Conditions
* Secondary SRE Adviser
* Senior Buyer – Contracts Team (x3)
* Senior Buyer – Purchasing Team (x2)
* Senior Commissioning Officer
* Senior Dental Nurse
* Senior Financial Accountant
* Senior Management Accountant (x6)
* Smoking Cessation Adviser
* Specialist Community Public Health Nurse/Stop Smoking Advisor
* Specialist Pharmaceutical Adviser For Public Health
* Specialist Registrar In Dental Public Health
* Specialist Stop Smoking Advisor (x8)
* Specialist Trainee In Public Health (x2)
* Staff Podiatrist
* Stop Smoking Adviser (x7)
* Stop Smoking Facilitator
* Supplies Manager
* Supplies Support Officer (x3)
* Support Manager For Continuing Care
* Support Officer, Prescribing & Meds Management
* Support Pharmacist
* Support Services Manager/PA To Director of Health Promotion
* Systems Assistant (x2)
* Systems Manager
* Team Leader Stop Smoking Service
* Telephonist (am)
* Telephonist (pm)
* Temp Continuing Care
* Temporary Secretary
* Tobacco Control Project Worker
* Tobacco Control Worker
* Tobacco Control Worker/Outreach Worker
* Trainee Buyer
* Training
* Workplace Health Coordinator
* Workplace Health Project Worker

and

* 5-A-Day Coordinator
* Acting Team Manager – Specialist Team – Speech & Language
* Admin Support (Primary & Community Services)
* Admin Support Officer (Commissioning)
* Admin Support To XXX
* Administrator For Locality Mgr, Adults & Older People – Community
* Assistant Accountant (Sure Start/Commissioning)
* Assistant Clinical Director - Medical Directorate
* Assistant Complaints Manager
* Assistant Director - Integrated Governance
* Assistant Director – Strategy
* Assistant Director Commissioning & Contracting
* Assistant Director Medicines Management
* Assistant Director of Finance (Provider Services)
* Assistant Director of Information & Mental Health Commissioning
* Assistant Director of Planning
* Assistant Director of Planning & Programme Support
* Assistant Director of Public Health Clinical Effectiveness
* Assistant Financial Accountant
* Assistant Head of Adults & OP
* Back Care Advisor
* Chlamydia Screening Admin/Secretarial
* Chlamydia Screening Programme Coordinator
* Chronic Disease Management Nurse
* Clerical Officer
* Clerical Officer – Corporate Strategy
* Clinical Advisor
* Clinical Placement Facilitator
* Commissioning Lead Provider Services
* Communications Manager
* Communications Officer (Publications & Websites)
* Community Rehab Team
* Complaints Manager (x2)
* Complaints Support Officer
* Consultant In Public Health (x2)
* Continuing Care Nurse/Care Manager (x2)
* Continuing Care Secretary
* Database/Course Administrator
* DATIX Officer
* Day Unit Receptionist
* Environmental Manager
* Estates Project Manager
* External Communications Officer
* Finance
* Finance Assistant (Temporary)
* Finance Officer
* Fire Safety Advisor
* Fresh Start Advisor
* Fresh Start Advisor (Public Health)
* Fresh Start Pregnancy Advisor
* Fresh Start Specialist Advisor
* Funded Nursing Care – Assessment Nurse (x2)
* Governance Information Manager
* Governance Officer
* HCA (x2)
* Head of Adults & Older People
* Head of Complaints
* Head of Finance Provider Services
* Head of IM&T Strategy – Provider Development
* Head of Integration
* Head of Learning Disabilities Commissioning (Health)
* Head of Organisation Development And Core Education
* Head of Planned Care
* Head of PPI/PALS (x2)
* Head of Risk Management
* Head of Urgent Care
* Health & Safety
* Health & Safety Administrator
* Health & Safety Assistant
* Health & Safety Manager
* Health Promoting Schools Advisor
* Health Promotion Administrator
* Health Promotion Assistant (pm)
* Health Referral Administrator
* Health Referral Administrator – Public Health Department
* Healthy Schools Advisor (x3)
* Hotel Services
* Hotel Services Administrator
* Hotel Services Assistant Manager
* Hotel Services Manager
* Housing & Health Strategy Manager
* HPS Coordinator (Public Health)
* HR Advisor – Operation Business Partner
* HV Manager
* Infection Prevention & Control Nurse
* Information Officer (x2)
* Integrated Governance Administrator
* Integrated Governance Officer
* Interim Human Resources Manager (Temporary)
* Intermediate Care Coordinator
* Intermediate Care Pharmacist
* Intermediate Care Sister
* Intermediate Care Team Leader
* Knowledge Manager (x2)
* Knowledge Services Manager
* Learning & Development Manager
* Learning And Development Facilitator – Core Learning
* Library Technician – Knowledge Services
* Locality Lead Rehabilitation And Immediate Care
* Management Accountant – Specialist Rehab Services
* Medical Directorate Administrator
* Medical Secretary
* Medicine Management Programme Facilitator
* MTS Trainee
* NPfIT (x3)
* NPfIT Admin Assistant
* NPfIT Project Manager
* NPfIT Project Team Leader
* Office Administrator
* On Secondment to XXX
* Outpatient Physio, OT & MSK Services Lead
* PA to Assistant Director of Commissioning (x2)
* PA to Public Health Dept. Director And Public Health Consultant
* PA to Public Health Strategy Managers
* PA to XXX (x2)
* PA/Commissioning Officer
* Pharmacy Technician
* Physio
* Physiotherapist, Intermediate Care Team
* Podiatry (x2)
* Prescribing Advisor
* Prescribing Support Advisor
* Prescribing Support Technician
* Primary Care Commissioning Officer (x2)
* Project Manager – PCT Provider Services Commissioning
* Project Worker
* Provider Development – Locality Manager
* Provider Development – Urgent Care & Inpatients – Locality Manager
* Provider Services (x3)
* Public Health Project And Campaigns Officer
* Public Health Trainee (x2)
* Receptionist /Telephonist (x2)
* Secretary – Complaints Team
* Senior Financial Accountant – Financial Management
* Senior Management Accountant – Business Development & Reference Costs
* Senior Management Accountant – LTC & Community Nursing Services
* Senior Management Accountant – Specialist Services, Capital/LIFT
* Senior Public Health Strategy Manager
* Senior Public Health Strategy Manager (Tu/Th/F)
* Senior Rehab Support Worker
* Sexual Health Development Manager
* Site Services & Admin Manager
* Smoking Cessation Advisor (x2)
* Specialist Registrar In Public Health
* Specialist Services Manager
* Speech & Language Therapist (x6)
* Speech & Language Therapy Assistant (4)
* Speech & Language Therapy Manager (Adults)
* Speech & Language Therapy Support Worker (Admin)
* SRE Project Worker - Primary
* Team Leader Physiotherapist Out-Patients Physiotherapy
* Team Manager – Speech And Language Therapy
* Temp PA to XXX
* Unison
* Weight Management Coordinator

Be warned, this list is not anyway near the whole PCT staff. I would also emphasis that several of the jobs on the list are jobs which involve a fair bit of clinical work. However the vast majority of these jobs are managerial and involve either no or very little clinical component, what about the need for a 5-A-day coordinator!. This list is New Labour's NHS legacy, it is the incredibly top heavy management structure that is bringing the country to its knees, it is wasteful, it is inefficient, it is foolish, it is unproductive, it is so very New Labour.

When I talk of money not getting through to the front line, this is what I talk of, and remember the hospitals also have their own management staff, the GPs have their own managers locally, the SHAs and Department of Health are full of more managers too, this list is but the tip of the immense iceberg that is sinking ship NHS.