Torture

The last few days have been extremely traumatic for everyone going through the MTAS process this year. Jobs have finally started to be offered to candidates, however the never ending torture is continuing for the majority.

The offering of jobs by deaneries has been a bit of a disorganised muddle to say the least. Candidates have had no idea on which day their email should arrive if they are successful, and there have been virtually no emails sent out which convey a negative result. Hence thousands of people have been left in a state of agonising limbo not knowing if they have a job or not, and not knowing whether they will be one of the lucky few to benefit from other people turning down one of their multiple offers.

I find the fact that most unsuccessful candidates have to find out their fate via third parties and the Internet to be completely unacceptable. Surely common decency obliges the deaneries to inform candidates that they have not been initially selected? It is inhumane to keep people in this never ending state of limbo, people have been subjected to enough stress already this year. It is typically good practice for an employer to inform job applicants whether they have been successful or not, so why have so few candidates had an email saying 'no' to put them out of their misery?

It is hard enough finding out whether you have a job or not, but when it is done in such a drawn out tortuous fashion it does make it a lot harder. I shouldn't be surprised that the disorganisation continues, but it saddens me that so many people have to suffer so much thanks to the government's rank incompetence. It is after all primarily the fault of the government for pushing through their useless policy at far too fast a pace.

Labour lack logic

Tony Blair attempts to justify Labour's latest anti-terrorism legislation, quoted from the Telegraph:

"We have chosen as a society to put the civil liberties of the suspect, even if a foreign national, first. I happen to believe this is misguided and wrong."

Note the sudden change from 'we' to 'I'; pretty typical of Mr Blair isn't it, only he knows what's best for us.

"Do you know why only 40 per cent of secondary schools use setting and streaming even though they have been encouraged to do so by official policy for years? Because a huge proportion of the teaching profession still resists even the minimal selection process. Mixed-ability teaching remains an article of immovable faith among a huge swath of the state sector."

This quote from a columnist in the Telegraph demonstrates how flawed Labour's bizarre use of competition is. It's fine to allow competition between schools so that the worst, instead of being helped and improved, are simply run into the ground. However competition in schools is seen as some kind of abhorrent evil by Labour, does anyone else remember the school sports day where the teacher was not allowed to measure your long jump because that would be seen as too 'competitive', it was just 'well done, good jump'.

How anyone can believe that not streaming children based on their ability can possibly be a good thing is beyond me. Children can be taught better and can learn faster in groups that are sorted by ability, it's simple common sense. This Labour mindset that encourages the persecution of anyone with talent and the enforcement of mediocrity is precisely the reason we have the likes of Prescott, Reid and Johnson flourishing with their groundbreaking dimwittedness.

This is almost unbelievable as it is so ridiculous. This example is symptomatic of a culture that wants no one to be better than anyone else. There is already a massive problem with certain children at school getting extra time in exams for various 'learning disabilities'. Nowadays even the most able child can be taken to a educational psychologist and diagnosed with a mild disorder that then enables them to gain an unfair advantage over their fellow pupils. I know of cases where the best pupil in the year group has been the only one to get extra time, as a direct result of these ill thought out measures.

The motives behind these measures are indeed noble, however in practice they do not work. In trying to make the race fair, more mechanisms for unfairness have been unearthed. More worryingly a philosophy that despises achievement is being used to engineer a race where everyone will come equal first. Not only will everyone come first, but they will all come last, as a depressing world of bland mediocrity replaces a dynamic competitive environment. This philosophy leads to children becoming unmotivated and apathetic, as their destiny cannot be altered by their own actions in this rigged Big Brother game.

The protocol paradox

I felt an urge to follow up on the excellent Dr Grumble's musings on medical protocols, as throughout my practice as a doctor I have encountered numerous problems with these brain dead devices.

These days there are so many protocols available that one has to be very knowledgeable in order to decide which protocol to use, however if you are that clever that it is likely that one wouldn't need the protocols in the first place. Hence protocols are useless, QED. This my paradox of the protocol, and it means that if someone relies on protocols to manage patients; then are they really expert enough to be independently managing patients?

It can also be argued that if a protocol leaves room for manoeuvre then an individuals clinical acumen is the important factor in the decision making process, hence is the protocol of any use? However if the protocol is very rigid and allows no room for flexibility, then the protocol is likely to be doomed to failure as it lacks any common sense.

These generalisations are probably a little harsh on protocols as they do have their limited uses. However there is no denying that a over reliance on protocols can be a very dangerous way to practice. There is no substitute for good thorough medical training and a broad experience, and 'medicine by numbers' will never come close to replacing this.

NICE have produced their fair share of dodgy protocols and their head injury guidelines are but one example. According to their guidelines anyone who has a GCS of 14 or below at 2 hours after their head injury merits an urgent CT scan. If one obeys the protocol to the letter then anyone who is confused at two hours after their head injury needs an urgent scan. Obviously under certain circumstances this will be sensible, however should this apply to the demented elderly patient or the disoerientated drunk? Of course not. The NICE alogorith also reckons that anyone who is 65 years old or above who sustains any 'loss of consciousness' post head injury merits a CT scan, this is another ludicrously stupid rule.

The more clinical experience I have gained, the more I have learnt to take the dubious generalisations offered by protocols with a very large pinch of salt. These protocols are often hatched in secret by small committees who make no effort to engage with the majority of clinical opinion. Beware of health care professionals who rely on protocols.

Where does the spaghetti grow?

It seems that a debate has been brewing in blogosphere, Dr Crippen has been commenting on a certain blogger who has been expressing her worries about immunisations and giving space to some other standard scaremongering stories. This blogger says:

"It’s arrogant for us to believe that we know everything about our physiology, our environment, the chemicals we pump into the air, our bodies and into the ground and how all of these things may interact."

"Maybe all vaccines are safe, or maybe they harm people. I don’t know. Researchers don’t know, Doctors don’t know. NO ONE knows for sure. Oh….well apparently the Good Doctor does."

and she expresses her balanced view of the medical profession here:

"The medical profession has had an interesting history, at one time we believed that giving lobotomies to depressed people was a “cure” too. We believed that “blood letting” got rid of all that “bad blood” making you sick. Freud believed cocaine was a miracle drug, I guess for some it is. We thought that Red Dye #5 was safe, that smoking was healthy and most recently that our plastic baby bottles were safe to feed our babies out of. I've personally gotten to the point where nothing surprises me anymore, and am waiting for the shit to hit the fan about frankenfoods next."

It is indeed true that many medical treatments over the years have done far more harm than good. I shall not comment upon the harm that various misguided psychological theories have done over the years. The debate at the bottom of the page makes very interesting reading indeed, as Dr C explains that vaccinations are generally a very good thing indeed.

I don't want to get into a detailed scientific debate about vaccinations, as there are many more able people out there like Dr Crippen who can easily deconstruct those who base their ideas on paranoia and not the science. I also do not wish to get embroiled in an argument about antibiotics, it is fairly obvious that antibiotics are an essential part of our armoury to improve people's health and health care in general; obviously there are problems with antibiotics such as inappropriate prescribing and multi drug resistance, however these problems do not mean it would have been better to have never discovered antibiotics.

There are complications and side effects to all medical and surgical treatments. Does this mean we should never graft people's coronaries because they may die in the operating theatre? Does this mean that we shoud never operate on abdominal aortic aneurysms because of the high risk of on the table death? Of course not. Medical science continues to improve people's lives because treatment can be tailored to provide a net benefit to patients, based on the scientific evidence at hand. Things are not perfect by any means and there are still some very contentious treatments out there; while it is undeniable that drug companies have been caught fiddling results which may in turn harm patients. However these are issues that are discussed openly in the scientific press and community on a daily basis.

I found the logic used in her argument to be particularly weak. It is indeed arrogant to believe that science knows everything about our physiology, chemistry and so on. However just becuase we accept that science does not know everything, it does not therefore consequently mean that science knows nothing at all. As by following this kind of bizarre relativistic logic on, it means that we cannot assume to know anything at all, as even the most certain thing is very slightly uncertain.

This kind of extreme relativism flies in the face of progress and results in the net loss of a lot of children's lives to very preventable diseases.

The Black death

There are some very interesting turns of phrase in this letter which is in the Times today. Prof Morris Brown et al do not mince their words as blame is laid firmly at the door of PMETB, while there are some veiled comments regarding a certain infamous letter that was recently in the Times 'repudiating the democratic opposition':

'Doctors were then stunned by two letters, not apparently from the silent CMO, but a defence of him signed by the colleges and the BMA. These threatened disciplinary action against rebels and (letter, May 17 ) repudiated the democratic opposition to the disaster with an order for doctors to unite behind the CMO’s creation.'

There are some thinly veiled comments about a certain female puppet of the state:

'By contrast, the independent doctors on a review body were outnumbered by the CMO and his staff from the DoH; and it is regarded as acceptable that someone close to the Department of Health can act as spokesperson for the royal colleges and sit on the independent body monitoring medical appointments and training.'

The complete dependence of the 'independent' review panel is remarked upon, while the finger is pointed firmly at one particular government stooge. It is completely unacceptable that such a government crony can be given such a powerful role, the conflict of interest is rather glaring.

As Prof Morris Brown says, there must be an immediate separation of powers.

Eye despair

This paper in Eye has looked at patients' preferences of surgeon for cataract surgery, it appears that if you ask a stupid set of questions then you get a stupid set of answers.

The found that only 70% of patients accepted that surgical trainees should operate as part of their training, meaning that 30% of people thought that surgical trainees should not be operating. One wonders how it would be possible to train a consultant surgeon if trainees were not allowed to operate? It seems that this 30% of patients are rather short sighted and arguably more than a little dim.

Only 57% of these patients were happy to be operated on by a surgical trainee supervised by the consultant. That leaves 43% of patients who were unwilling. The abstract finishes:

'If 'patient choice' extends to the choice of operating surgeon, then there are clear implications for the training of future UK ophthalmologists.'

Indeed, if 'patient choice' actually meant 'patient choice' then this would indeed be true. However as we well know, the government's idea of patient choice involves creating an inefficient internal market and rigging it so that they can push lots of patients away from named consultants' care towards unknown operators in ISTC portacabins. It is a mechanism for enforcing the privatising the NHS. This statement shows the absolute absurdity of real 'patient choice', as trainee surgeons have to learn and if trainee surgeons were not allowed to operate then we would fast run out of consultant surgeons.

As someone who has first hand experience of surgery in the NHS, I would much rather be operated on by a surgical trainee who was being supervised by a reputable consultant than by a unnamed foreign surgeon in an ISTC. The consultants of today actually deserve their title because they have been trained to a certain level. Unfortunately the government seems intent on destroying this and eroding the meaning of the word 'consultant'. Government reform gives patient no real choice to have care under a competent named consultant; it will force them to be treated by any of a large band of less competent generic sub consultants. This is the real 'patient choice' agenda, it is dumbed down lower quality care for anyone who can't afford to pay for a named consultant privately. What progress.

Prof Morris Brown - nugget of wisdom

"The last week has seen people power in action. No people has had a stronger or more noble set of champions than RemedyUK. There must be, and will be, no turning of the clock back to a time when powerful organisations ride roughshod over those whom they should be protecting; when leaders of such organisations believe power absolves them from consulting those who have put them in charge. Remedy has not been vanquished. Only those who have failed to speak out against the system castigated by the Judge. He has not said that Remedy’s solution is wrong, only that the law does not permit him to impose it. This is the end of the beginning. We must remain inspired by Remedy to show the public and our patients who has the real interests of National Health in our hearts."

Many thanks to Prof Morris Brown for allowing me to reproduce his words from DNUK here.

Terror tales

The wonderful Hospital at Night team have brought us yet more cost cutting dumbing down in the form of 'Safer Care Safer Training' and the 'developing of the role of nurse coordinator'. It really must be seen to be believed. There is an extensive 56 page document that outlines the so called 'competency framework' of these nurse coordinators. 'Competency' is really such a great way of introducing this marvellously termed 'safer care safer training' agenda, I wonder if the lambs skipping through the green pastures come as a free bonus item?

"Implementation of the European Working Time Directive (EWTD) and the associated reduction in the working hours of junior doctors has provided impetus for new ways of working, service reconfiguration and role redesign."

translation: EWTD means we are replacing doctors with nurses

"By using these competences, Trusts can be assured of a highly effective patient focused resource, maintaining continuity and supporting the challenge of the EWTD."

translation: by listing endless competencies we shall pretend that it is safe to use nurses in a role for which they do not have adequate skills and have no had adequate training.

"There is evidence to suggest that with improved clinical co-ordination at night, this innovative model of care delivery results in better patient care"

reality: No, there is no evidence that HaN results in better patient care. In fact there is an ominous lack of any data and a rather large amount of anecdotal evidence that points to the opposite; even the well funded pilot schemes showed no improvements in outcomes, there was actually a rise in clinical incidents.

In fact only just over a half of the participants actually took up the competency framework, this leaves almost half who don't have any care for competency. This is what these nurses are let loose to do clinically:

"• Review presenting conditions and determine the appropriate intervention for an individual

• Assess an individual’s health needs and status
• Prioritise individuals for treatment and care following assessment
• Co-ordinate further assessment or investigations prior to initiation of an intervention
• Develop and agree treatment plans for individuals
• Provide therapeutic care interventions within sphere of competence"

and

"Take a presenting history from an individual to inform assessment

Perform a comprehensive physical examination and demonstrate the ability to recognise normal, deviation from normal and abnormal findings in relation to the following systems:
• Cardiovascular, Respiratory, Abdominal, Neurological

• Interpret routinely performed diagnostic tests


• Prioritise and refer individuals for further assessment and care


• Demonstrate an evidence-based approach to patient care


• Discharge an individual into the care of another service"

So how will these nurses be trained to carry out these doctor's jobs? The answer is that they will certainly not be trained to the high level of doctors, they will only receive a dumbed down and shortened training before being let loose on the public. Will these nurses have to pass rigorous examination that test their clinical knowledge and skills thoroughly? Hell no, that would be far too hard, they can simply assemble a portfolio of random evidence that proves their undoubted 'competence' to be doctors. In this way a bit of reflective practice can replace proper tests which they might fail.

In this lethal manner proper medical training is being undermined by this dumbed down 'competency' based empowerment of non-medically trained staff. The claim of 'safer care, safer training' is a cover for the reality of 'shoddy care, dumbed down fisher price training'. It simply beggars belief that staff without adequate training are being let loose to diagnose, interpret investigations and manage patients in this manner.

It goes hand in hand with modernisation program that has brought us Hospital at Night, a scheme that has no decent evidence that it is even safe, which has seen hospitals run with dangerously few doctors around to save a few quid. The pressure on trusts throughout the country, thanks to large centrally imposed deficits, is the driving force behind this program of 'competency' based cost cutting.

Lives are being lost as a direct result of schemes like this, but the government just keeps on 'modernising'.

from whose cake hole?

This interesting speech has come to my attention:

"Mr Simon Eccles
Tuesday 29 June 2004

Good afternoon, or perhaps I should say Good Evening. And I’m reluctant to talk for too long for fear of restricting our debate.

And as I stand here halfway through our 101st ARM, can I give full credit to George Rae for introducing more open debate and more opportunities for exploring our views to this year’s ARM?

But there is a limit to what the Chairman of RB can do. We must all be brave and venture out of the nineteenth century and into the twenty-first.

The Junior Doctors have started this process already. Our conference this year, under the Chairmanship of Jason Long, broke new ground. In a one and a half day conference we spent less than two hours debating motions. And yet the conference gave my committee the strongest policy direction we could have been given.

We, the BMA, must be pro-active and not just reactive.

So what have the Junior Doctors Committee being doing this year?

We have been calling for a reform to post-graduate medical education in this country for many years. We have demanded a better start to training and to an end to the abuse of the PRHO grade. We have been asking for an end to the bottleneck from SHO to SpR training. We need assessments to accurately reflect our abilities to do the job not our willingness to fund college port collections. We need to revitalise Academic Medicine whilst ending the need to do research to obtain a training number.

Modernising Medical Careers is potentially offering us all this. This IS good news. We should make the most of this opportunity and to that end; I, Simon Calvert and the Education and Training team have been working with MMC. We must continue to do so.

Sadly the implementation of these reforms has not been so positive. Even as I speak: 4th year medical students are applying to their August 2005 Foundation Programmes, via early matching schemes.

These programmes are compulsory and yet they don’t know - which specialties will be included, - whether or not the jobs will be recognised for subsequent training in these specialties; - what salary they’ll be paid - or where, geographically they’ll be based.- 5 out of the 7 precious pillars of MMC are not yet fully defined.

So what are we doing about it?

Joint guidance from MSC and JDC went out to students at the start of this month. The MMC team has agreed to set up four ‘think-tanks’ to explore these issues and produce solutions in a very short timescale, for all parties to comment on.

We achieve most when we work together. The early implementation may have been quite dreadful and astonishingly poorly coordinated but this process offers us everything this association has been demanding for years.We should not waste the opportunity.

Moving to the other significant area of our work this year - the EWTD

JDC has managed to lead the way on possible solutions to this overly-restrictive directive.
- From the Hospital at Night project which has achieved compliance, enhanced training and improved patient care;
- through handover for safe transfer of information,
- and good monitoring practice to know what’s really happening;
- to the DH compendium of guidance, which we rewrote.

The JDC has set the agenda to ensure training is of the highest standard and patients get the best care we can offer whilst complying with the law.

I’d like to finish by returning to the Post-graduate training reforms. The BMA has been ‘reassured’ that there is no attempt to dumb-down the standards of consultants.

Let us be clear about our reasons for saying no to a different end-point of training. This is not just JDC saying no to any change. We support the reform of training as I said before. This country and our patients need their consultants to be able to offer the full range of cover in the event of their becoming unwell. We do not have enough doctors in this country to have multiple tiers of specialists on-call in any given field.

At 3 am the consultant covering Trauma does not have the ‘phone-a-friend’ option open to them. When the numbers have increased, when the networks are more in place, then perhaps it will be different.

Not now. We have the very highest standards of medical training in this country to produce the very highest standards of consultants to offer the very best service to our patients.

We must not ruin this on the altar of political expediency."

It is a shame Dr Eccles has not kept true to his last sentence, it's amazingly ironic that this comes from a man who seems to spend more time on this altar than perhaps any other practising medic. The speech talks of the brilliance of MMC and the opportunity of working together to improve medical training. It's just a shame that in Dr Eccles eyes 'working together' may be interpreted as building his own CV at the expense of junior doctors throughout the country. The virtues of the dangerous cost-cutting Hospital at Night scheme are trumpeted, it's a great pity that there is no evidence to back these statements of 'fact' up.

How sycophantic does Dr Eccles look now, in retrospect? It's been no surprise that Patricia Hewitt has been caught quoting him to back up her argument that the medical profession is largely behind her destructive reform agenda, he's one of only a small handful of apologists who are always willing to back the government up. The BMA seem to have churned out quite a few of this politically expedient sort in recent years, and is seems to be pretty symptomatic of their deeply unrepresentative nature.

I wonder what Dr Eccles' junior staff think of him, would he command their respect with his unique devotion to government reform? I would be amazed if he managed to sleep at night, but then again he has never demonstrated possessing a conscience with his actions in his numerous medicopolitical roles; maybe some people just care purely for themselves.

Cutting comments

The President of the Royal College of Surgeons, Bernard Ribiero, has withdrawn from ongoing discussions about the selection of junior doctors. His actions may be a little late for some people, but it is indeed better late than never. He was pretty damning in his comments:

“Almost two years after first raising my concerns, there is still no recognition whatsoever by the DoH of the scale of this problem or its profound implications, far less the prospect of an acceptable solution in terms of a temporary expansion of national training numbers.

I am also concerned about the arrangements for selection of junior doctors into run-through surgical training programs. Surgery has unique requirements in terms of recruitment – the criteria for selection include diagnostic skills, clinical judgment and manual dexterity. It is neither practical, nor indeed safe, to select junior doctors with a view to a career in surgery without the opportunity for assessing whether they have the full mix of professional skills required.

It is with the greatest reluctance that I am dissociating myself and my College from any further involvement in the Review Group that you are chairing.”

There are some very good points made here, the full letter can also be read. These points apply not only to surgery, but to all the other medical specialties; MMC is inflexible and flawed as it selects far too early, before juniors know what they want to do and before they can prove that they are suited to a particular specialty.

If the DoH is railroading and not listening, then the only option remains unilateral withdrawal from proceedings. It's a shame that this wasn't realised sooner.

He'll be coming round the corner

The latest insightful and frankly bang-on assessment of the dumbing down of medicine and the empowerment of the pseudo-doctor has prompted me to offer my two pence worth. It is simply infuriating that the same old tired arguments come out in defence of the under trained practitioner.

Firstly one must distinguish between the nurse specialist and the 'noctor'. There are numerous extended nursing roles which get the best out of some excellent experienced nurses, for example the wound care nurse specialist or the home IV nurse specialist. These roles work because the experienced nurses work in a clearly defined narrow role, and that role is mainly in nursing related duties. It is not rocket science, but nurses are generally better at doing what their training trains them to do: nursing!

Secondly all health care professionals (HCPs-what a politically correct term) make mistakes. However this does not justify handed more and more medical work to less trained workers. This strain of logic would justify the hospital cleaner being allowed to operate, as 'we all make mistakes'. This is utter nonsense.

The problem comes when certain under trained HCPs are handed roles which they are simply not safe to practice in. It takes a doctor about nine years absolute minimum before they can practice independently, often this is too little even given the great depth to their training. Doctors are trained thoroughly in the art of history, examination and diagnosis. They are also educated to very high levels in anatomy, biochemistry, physiology, pharmacology, neuroscience et al. A key part of a doctor's training is learning to think independently and to make sensible decisions. It is drummed into doctors from day one that it is important for them to ask for help whenever they are not sure of what precisely they are doing.

This is in stark contrast to the levels of training that some HCPs are given before they are let loose on the public. Some experienced intelligent nurses can just about get away with it most of the time, however even they struggle with some of the dangerous new extended roles that the DoH has introduced to cut costs and dumb down the NHS. It is certainly nothing to do with their 'nurse practitioner' training that some experienced nurses can cope with their jobs. Hence when more junior inexperienced nurses are handed extended 'nurse practitioner' roles after a few months of mickey mouse medical training, the faeces inevitably hits the fan.

There are so many problems with these extended roles that I have no hope of summing them all up in this short piece. There is a huge danger to patients as under trained HCPs are let loose to practice completely independently in WICs and GP practices up and down the country. There are also huge dangers in hospitals as various new roles have left under trained workers free to make really big decisions that they are not trained adequately to make; the nursing triage system in Hospital at Night is one pertinent example of this. There is also a massive impact on the training of the consultants of the future, the NHS will not be able to provide a decent service in the future if the juniors of today do not get a proper exposure to clinical problems.

This dumbing down also applies to doctors, as there is arguably too little emphasis in medical curricula on hard knowledge in key areas such as anatomy. While MMC threatens to reduce the high level to which juniors are trained by reducing their levels of experience dramatically, as training is dumbed down to cut costs and create an inferior sub consultant led service.

The motive of this dangerous dumbing down is simple, it's all about saving money at the expense of the quality of the service delivered. It is also remarkably shorttermist and stupid, as many of these new roles are not cost-effective and the dumbing down of medical training could be incredibly damaging to the service in the long term.

This dumbing down cannot be excused by the same old tired arguments. I have got nothing against nurses, in fact a massive majority of the best senior nurses I have spoken to agree with me, while those who disagree cannot put a strong argument for their case forward. Medicine is an art form and cannot be practised effectively by the use of rigorous protocols and proformas. One needs to understand the art form before one can decide which protocol one should use in the first place, otherwise they are more of a hindrance that a help. Most dangerously it is not good enough to claim that anyone is safe working in any role as they will instinctively know when they are outside their 'sphere of competence'; they will not know when they are practising dangerously, this is precisely why medical training is so hard and so long, it does not come instinctively without the experience or the training. Interestingly look who delivered Gordon Brown's babies and who dealt with Tony Blair's dodgy ticker? And think who would you want replacing your knee joint or delivering you the happy gas?

It's just more New Danger from New Labour, and funnily they have never given the public a choice in this dangerous policy; would the public rather be seen by an independently practising doctor or nurse with their tricky diagnostic problem? Interestingly most nurses are far too sensible to be led into these dangerous new roles as independent diagnosticians, unfortunately it is often the least sensible nurses who are the ones to grab these new roles firmly with both hands; unfortunately for the patients that is.

Hewitt twists her vindictive blade

Despite a clear request from the judge to the opposite, Patrica Hewitt has been directly and personally involved in the decision to claim costs against Remedy UK. Just when you think she can sink no lower, she continues her downward plummet towards the fires of moral bankruptcy. The Judge had no choice to award the costs in the end but as Lindsay Cooke cleverly points out by quoting the immortal words of Francis Urquart, "You might call such an act vindictive, but I couldn't possibly comment."

The BBC has been reporting events in their typical HMG manner, they use the headline 'Hewitt retains MP's confidence'; a lovely bit if spin. Hewitt only won the vote by a slim majority of 63, hardly showing that MPs had great confidence in her work! The BBC are however correct in that it is really Blair that should be carrying the can for a lot of the failed health policy, after all he has been the driving force behind the NHS reform agenda.

Hewitt's deeply unpleasant and vindictive streak has been commented upon by other bloggers here and here. It seems that the woman is running out of support, with only her close friends willing to limply defend her unique brand of arrogant incompetence. As Dr Crippen points out it is quite remarkable that the BMA opposed Remedy in the high court; the BMA's JDC had recently passed several motions that directly contradicted their stance in the high court, and the BMA has not once consulted its members on MTAS. The BMA is fundamentally antidemocratic.

If Remedy have to pay these costs then I, for one, will be keen to do my bit to help raise some cash. I would also urge anyone supportive of Remedy to donate to their war chest, they may well need all the money they can get their hands on.

While we're on the topic of Patrica Hewitt, an unpleasant topic I know; did she lie to parliament when she claimed that MTAS has been abandoned because of 'concerns' for junior doctors? This is taken from the judge's final judgement:

"The effective abandonment of MTAS would seem to have little to do with the concerns of junior doctors, but be a consequence of significant fresh problems with the system. As I understand it, the algorithm needed to govern the allocation process under MTAS did not work. Fresh software was needed to enable offers to be made. Such software could give rise to security problems."

Pants on fire Patricia.

Let battle commence

Unfortunately Remedy have lost their case in the high court today, however the judgement demonstrates that their case was not fought in vain, far from it, it has released some purulent debris from the corridors of power occupied by our medical dictatorship:

'There was no pilot for MTAS.'

'It is not surprising that many junior doctors feel upset, anger and a real sense of grievance.'

'The BMA's calls for delays to MTAS were ignored.'

Jo Hillborne describes the current situation as 'the least bad solution in the circumstances'

'Dr Hillborne states that there is no certainty that a proper or rigorous process would follow'

'Dr Hillborne says that there would not have been time to revert to the old system'

'Making RTT jobs short term would lead to uncertainty and be unfair and lead to uncertainty'

'Dr Fielden agreed with the above comments'

'A meeting between Remedy and Clare Chapman did not take place as agreed, this meeting was suggested by Clare Chapman'

'Professor Douglas did not allow questions to be put to him about a possible solution'

'Such meetings as there were fell well short of consultation'

Then this piece is key:

'Mr Cavanagh QC on behalf of the BMA submits that Mr de la Mare's submissions on consultation are wholly misconcieved. The BMA is the only recognised trade union. The fact that all doctors are not members is not to the point. It is democratic. It knows and can take into account its members' views. The fact that some junior doctors disagree with its views does not mean the process of consultation was flawed. Moreover, as is clear from the evidence the BMA did invite Remedy UK to make a presentation to it. It arranged the meeting of 15th March 2007. It was sufficient for the defendant to consult the BMA.'

'MTAS was a flawed system in the waysI indicated. This judgement does not mean I agree with the decision of the review group; merely that it was one the review group was entitled to. Neither does it mean that individual doctors would not have good grounds to appeal regarding their allocation or that they would not have good cases before an employment tribunal. Quite the contrary could well be the case.''

My impression from reading through the judgement is that the judge did not get to grips with the reality of MTAS and its 'consultation'. He made the mistake of assuming that the BMA was even vaguely 'democratic' which it has recently been proven not to be. I do not understand how a union can just be assumed to be representing its members when the BMA have not consulted its members on MTAS and MMC once. Prof Morris Brown et al's recent survey proved that the review group's decision, which the BMA have stuck to in the high court, was against the wishes of a majority of their members.

The MTAS process is grossly unfair and flawed, and this was all entirely preventable. The powers that be, including the DoH and BMA, did not address the problems adequately and have left junior doctors with a fudged shambles. Remedy is the only body or group that has represented the majority of junior doctors throughout this sorry affair. The negative verdict is yet another example of the architects of the this disaster conspiring against the grass roots of the medical profession. The BMA and the DoH have blood on their hands.

It cannot be denied that thanks to these corrupt cronies the medical profession will see hundreds of long term jobs handed out to some of the weaker candidates, while stronger candidates may well be left out in the cold. The process is still unfair and gives a massive advantage to candidates who benefited from the useless short listing process. The BMA and the DoH have conspired to prevent this unfairness from being minimised against the will of the majority of doctors.

Despite this, well done to Remedy UK, you have flourished during many a junior's time of need. Without you many of us would have been left without a voice. I thank you for that and only hope that the battle can be continued on pastures anew. This defeat can only make us stronger.

Use this rag as bog roll

The same old rag that brought us Polly Toynbee, has now rolled another clone off their production line and she is called Jo Revill. I found it hard to spot the difference between Toynbee's praise of Blair's NHS legacy in the BMJ and Revill's similar piece in the Observer.

The same luvvie style of prose flows and the same dishonest techniques are used; one is the technique of catching the reader with one 'hook' truth initially, then slipping in numerous unsubstantiated untruths posing as fact in an effort to 'reel' the gullible reader in.

Both of these luvvies used the initial 'hook' of saying the NHS was better than it was, this is undeniably true. However both then built on this by saying that the NHS was 'more efficient' than ever before, and that any improvements were as a direct result of the government's reforms agenda. The ever decreasing productivity of the NHS under Labour seems to contradict Revill's claims about efficiency. The truth is then spun as their agenda dictates.

How amazingly similar is Revill's line of 'This skewing of perceptions means that the current political debate over the NHS is completely unreal.' to Toynbee's argument that all unrest is simply down to the scaremongering in the right wing press. Surely there is another rather more obvious explanation here, and I think it is rather more likely that the perceptions of Toynbee and Revill are completely detached from reality; or are these luvvies right? But this would then make a majority of the public and the NHS staff deluded fools, no?

The argument of the public's twisted perception is continued, one wonders whether Revill was tempted to draw a great comparison to the Iraq war a la Toynbee? Maybe the failings in Iraq are all down to cynical scaremongering too? Iraq is really on the mend isn't it Polly, after all you insinuated that Blair's great legacy would include a 'bedded down' Iraq. One wonders what you had in mind, does 'bedded down' relate to the whole country resembling a pile of gunpowder and rubble?

All the improving statistics are trotted out, while the negative ones are buried. I didn't see Revill mention the rising maternal mortality rate in the Uk to almost the highest in the developed world? The use of the holy grail of scientific evidence that is patient satisfaction surveys is really scraping the barrel. One wonders why the scientific literature which points out how dangerous this government's target based strategy can be is never mentioned. The waste of billions of pounds on ideological reform is ignored, have Toynbee and Revill heard of PFI schemes and the NHS IT scheme? It is amusing that the topic of medical training is also markedly absent from our favourite ladies' musings, there are rather too many gaping holes in their analyses to name them all.

The decision of whose story has more truth to it is up to you. Do you believe our luvvies Toynbee and Revill who would have you believe that government reform is wonderful, the public and NHS staff are deluded idiots and it is only leftie journalists who write in ivory towers who have a grip on objective reality? Or is the truth nearer mine, I would have you believe that the NHS has indeed improved but this has been largely despite the government's wasteful reform agenda, if the government had spent the money more wisely then we would have a significantly better service. The choice is yours, I shall leave you with one of Revill's clever 'reeling' untruths that she used as her conclusion. It is strange how she has jumped from the NHS being a bit better to it being in 'rude health' over the course of her article:

'The truth is that despite all its faults, the NHS is in rude health. No intelligent debate on its future can take place without the transformation being acknowledged.'

I'm just very sorry that my debate is not intellgient enough for Ms Revill.

The abuse of statistics

I noticed this little piece that paints doctors as being dangerous because they are 'more lethal' than gun owners. This is argued because in Sweden one is 7500 times more likely to be killed by a doctor than by a gun owner. What marvellous logic.

It is also true statistically that one is more likely to be killed by a family member than by a serial killer. By the same logic this would mean that our family members are more dangerous than serial killers. Something does not quite add up here.

Obviously statistics are being abused here. It is very rare for someone to be gunned down in Sweden, and it is also rare to be blown up while rolling a large bomb down a hill;

"(2006, Vietnam) In a similar event, a Rolling Stone isn't all that gathers no moss. Three men scavenging for scrap metal found an unexploded 500-pound bomb perched on a hill, and decided to retrieve it with help from Sir Isaac Newton. As they rolled the bomb down the hillside according to the laws of gravity, the bomb detonated, leaving a four-meter crater and sending the three entrepreneurs to a face-to-face meeting with their Maker."

Obviously one's chances of being killed by a doctor are much higher than being exploded by rolling a large unexploded bomb down a hill, however this does not make rolling large bombs down hills safe and doctors dangerous.

I don't even have to explain this any further, it's pretty damn obvious that millions of people are seeing their doctors as we speak and statistically this means that some of these people will be being harmed by their doctors as we speak. However this does not make doctors dangerous, in fact the work of medics the world over will be doing a rather large amount of net good. Conversely the infrequency of people being killed by unexploded bombs does not make these bombs safe; it's just that people aren't often stupid enough to try rolling them down hills!

DoH - breaking the law

It seems that the DoH's behaviour goes from bad to worse, it has now emerged that they have 'broken the law' by refusing to reveal the short listing scores of junior doctors in MTAS. The DoH was trying to hide behind the excuse of pretending that the short listing process was an 'examination':

“In these circumstances it is our view that the DoH cannot use this exemption to delay responses to subject access requests. We have made our view known to DoH and informed them that they should now take steps to respond to all the subject access requests.”

Quite right. The DoH's cover is at last being breached, let's hope it continues.

Post scriptum: I also cannot resist insulting the pathetic BBC again. Dr C has pointed out that their 'Newsnight' program on NHS morale consisted of a panel that was made up of a Tory politician, a Guardian hack who writes a la faeculaent Toynbee and the government lackie ex-BMA chairman (BBC didn't mention that he had resigned because he was representing himself and not his members). Yet more objective reason from them then.

The remarkable successes of Foundation training

'The successes of foundation training are undeniable'- discuss; instead of repeating a statement of fact over and over and over in the vain hope that saying something enough will make it true, I shall try to argue my case in a different way to the flimsy approach used by our despotic leaders.

MMC and its side arm MTAS have been rushed through without adequate consultation despite HMG's claims to the contrary. A proper consultation involves seeking opinion, listening and modifying ones actions based upon the aforementioned processes. The government's railroading through of MMC/MTAS has involved creating a malignant quango called PMETB, using PMETB to take control of medical training, involving a minority of non-cronies whose remonstrations are ignored and whose non withdrawal is equated to consent, using a few token junior doctors on various panels whose opinions are ignored, not modifying the original policy thanks to the domination of various committees by government appointed cronies, ignoring any well grounded criticism of their policies, hiding those involved from exposure to the media and conducting all the crucial discussions about these tactics behind closed doors in an undemocratic manner.

We have seen the recent uproar in reaction to the farcical MTAS, a brilliant demonstration of how this corrupt policy making protocol can be guaranteed to generate utter chaos as the majority of medical opinion is set firmly against it. It has shown that no matter how hard the government tries to force its sofa through the cat flap, it will not fit. We have seen lie after lie after lie from the government's agents of destruction, a recurring theme has been the ignoring of any concerns raised and just pushing on regardless.

The utter reliance on the flawed competency based model of training is a massive danger to standards on its own. Martin Talbot has written some outstanding articles on this topic; Dr Grumble has printed a good Talbot letter that summarises the dangers of the MMC style approach. He is not the only highly respected medic to point out these glaring flaws, the BMJ has published a critique of the competency based model:

' If applied inappropriately, it can also result in demotivation, focus on minimum acceptable standards, increased administrative burden, and a reduction in the educational content.'

There are many other examples of similar well researched criticism. The end result of ignoring this criticism may well be a catastrophic dumbing down of medical training.

Importantly what do the guinea pigs think of Foundation training? After all if this great new MMC system was providing such good training, then surely an overwhelming majority would come out in support of MMC? It is a great shame that the BMA has no asked its junior members for their opinion on MMC, as the results from Remedy surveys are damning. Alex Liakos, an ex-student adviser to MMC, organised this petition against the competency based selection of medical students for their first doctoring jobs. The ridiculous reliance on self-assessment and the devaluing of academic achievement were among the main criticisms of this politically correct competency based process. Over 1300 doctors have signed this petition listing some pretty revealing comments along the way:

"The MDAP system is NOT impartial as claimed: students who exaggerate their achievements and use the right buzzwords will score highly over those who are more realistic in their self-assessment. It is a cheater's charter."

"This MMC is a devious cost cutting measure which does not seem to care about the incipient deskilling of the medical profession it will inevitably cause."

"I don't understand why ignorant fools are being allowed to design and implement public/social policy. Especially where their decisions are likely to have dire consequences for the medical profession as well as this country's health service. WAKE UP!"

"MMC IS THE MOST POORLY THOUGHT OUT INITIATIVE IN THE HISTORY OF OUR PROFESSION."

"I have been a teaching hospital consultant neurologist for 10 years. The new system deprives hospital doctors from selective the brightest and best medical students and is another fine example of dumbing down and political correctness gone mad"

There are many more comments like these. The warnings were there for all to see, this petition was done in 2006! The criticisms are virtually carbon copies of the criticisms of MTAS 2007. If I remember correctly we have even had to listen to politicians claiming how well the MTAS selection process was working for medical students, it seems the students on the ground would disagree.

Foundation training is based on the same shaky foundations as MTAS, the same principles apply. The establishment's psycho babblers Patterson and Thomas have provided the scanty evidence base upon which this crumbling shack was built. Genuine competence has been replaced by a politically correct pseudo-competence that relies on ticking boxes, bullshitting and minimum standards. The assessment tools such as DOPS, mini-CEXs, CBDs are relied upon despite the fact that they have been minimally tested and when tested have been found wanting on many levels. Clinical experience, honesty and doing your job well are all but ignored in the pursuit of meaningless paperwork that is claimed to prove a doctor's definitive 'competency'. The word 'competency', notoriously almost impossible to define when it comes to doctoring, has been completely misrepresented and abused by the government's educationalist nincompoops.

Training is being dumbed down before our very eyes. Foundation programmes have converted numerous non training posts into training posts, while doing nothing to increase their training content. Many of these Foundation jobs therefore have zero acute experience; the impact of this on training cannot be underestimated. This August will see numerous staff grade jobs converted into FTSTAs, decent training is being diluted down. The logic of our competency based fundamentalists would assume that the process of filling in eighteen bits of paperwork a year and documenting what the ward clerk thinks will miraculously train competent doctors; their logic circuits must have shorted many years ago. This goes on as training budgets are slashed, royal college exams are dumbed down and study leave becomes much harder to obtain. The malignant PMETB oversees this disaster while the dis empowered royal colleges that once held training standards high, now know not what to do next in order to save the day?

The end result will be a poor training system that will produce a much lower calibre of doctor, and there will inevitably be consequences for the patient as a result of this. The grass roots of the medical profession are no fools, they can see that the new MMC system will not help them become the outstanding doctors that they so badly want to be. The introduction of the sub consultant grade will cuts costs, but it will also result in a shoddy service for anyone unfortunate enough to be treated by this lower tier of staff. The frustration and anger felt by juniors of today is tangible and it cannot be allowed to continue. A solution that drives training standards up will only be found if the grass roots are properly consulted, and the real issues that threaten medical training today will only be defeated with a strategy of genuine cooperation.

The thinking behind MMC/foundation training and MTAS has been shown to be significantly lacking. A finely evolved medical training system that used to be the envy of the world is being cast aside, in favour of a dimwitted psychologist's crackpot scheme that threatens to turn us into a humiliated laughing stock. The creation of a disempowered sub consultant grade is the genuine aim, and the government cares not if it ruins medical training in the process. It is time that the medical profession unilaterally withdrew and refused to cooperate any longer with this half witted burglary of our crown jewels.