Monday, 30 July 2007

The empowerment of the ignorant

Progress can be described in many different ways, and when it comes to medicine it is undoubtedly true that different people have remarkably different takes on what 'progress' actually consists of. Typically common sense would lead one to assume that progress should consist of improving education and training standards so that a better standard of service can be delivered. However the Department of Health does not buy into common sense; it buys into illogical nonsense that cannot be justified by rational argument, hence the DoH tends to hide away from public debate or engagement with anyone who dares to criticise their holy stance.

Those working in the NHS have seen an ever creeping erosion of professional standards and training over the last few years, an erosion that common sense would say 'flies in the face of progress'. Properly trained professionals have been dis empowered by clip-board wielding managers, who have very little medical knowledge at all, in a rather dangerous way that threatens the decent medical management of patients. These ignorant non-medically trained managers have been blocking GP's referrals to specialist services to try to save cash. One would think that the dangerous empowerment of managers so that they can overrule the decisions of experienced clinicians would be unjustifiable, nevertheless the DoH has a crack:

"A spokesman for the Department of Health said referral management centres should only be set up where they would benefit patients, by ensuring they saw the most appropriate health professional."

How on earth can someone with no medical training safely decide where patients should be sent against the direct wishes of someone who is specifically trained for years to be able to do this job? This is the kind unaccountable dangerous quackery that has become the government's trademark over recent years.

A rather brave surgeon has risked a DoH beating by telling it how it really is in the NHS, he describes quite brilliantly how the ridiculous payment set-up of the internal market actually incentivizes bad medical care. Money and paperwork are shuttled around by idiots and the important person, the patient, is forgotten; while the clinicians are left fuming as they are stopped from doing what they are specifically trained for, that is providing a high standard of medical care for their patients.

The multi-million pound wasting NHS direct is never out of the news, and it is not surprising given that so much money has been spent on providing a significant net harm to patients. NHS Direct has again empowered those who are simply not adequately trained to do the job they have been given, incidentally the job they have been given would actually not be safely done by an experienced medically trained clinician; no wonder there is carnage when protocol-led nurses are handed an impossibly hard job. It is also not hard to find examples of nurses being empowered beyond their means, simply have a browse though NHS jobs and one is sure to find a few remarkable examples of this malaise.

It seems that training and education are no longer important in our Brave New NHS. Clinical decision making can now be handed down to anyone who wants to have a crack, simply call that person a 'Health Care Practitioner' or 'Manager' and this approach is suddenly magically justified despite the overt dangers that are rather obvious to anyone who possesses a small portion of common sense. Less and less training and education are needed for jobs than ever before, there is also no need for these new forms of HCP to be assessed by traditional means such as the 'examination'; who needs exams when one has the wonder of competency based learning which allows anyone to be let loose on anything that their employer chooses! It truly is depressing that the blind are leading the blind in this destructive anti-scientific manner. It is strange that if a doctor wanted to do a nurse's job then they would be told that they have not been trained to do it, however when a certain breed of nurse wants to do the job of doctor the DoH has no problem with it; it couldn't be anything to do with the fact that it costs more money to provide a decent service led by professionals that it does to provide a shoddy service run by quacks?

Wednesday, 25 July 2007

Democracy in motion

As you would have gathered by now I am a big fan of the government's unique approach on consulting its citizens on various decisions. It is remarkable that things appear not to have changed one iota with big Gordon in charge, democracy is still held in contempt it seems.

The government's attempts to 'reconfigure', in other words 'to cut costs by shutting good local specialist services', are being railroaded through in typical bully boy fashion. The Worthing Herald reported that hundreds of members of the public were shut out of a meeting that was set up to discuss the future of their local hospitals. One local commented:

"I was 40 years in the health service, ending as a director of nursing services in south London. I know what democracy is and this isn't democracy."

It was certainly strange that the meeting venue was no way near big enough for all the members of the public to attend and have their say. It is certainly not the first time that similar pretences to consult the public have appeared to be nothing more than a sham.

So many dangerous policies have been forced through against the will of the vast majority of the electorate, most of these have been all in the name of privatisation. It appears to be more than coincidence that no charges are to be brought in the cash for peerages scandal, this decision by the CPS seems to have been influenced by various government stooges including Lord Goldsmith, aka 'Tony's poodle'. The Labour party continues to suppress public opinion and show a rather unhealthy amount of contempt for democracy, coincidentally large donations continue to roll into Labour HQ as the NHS is privatised; can anyone join the dots?

Monday, 23 July 2007

Will they ever learn?

Floods are currently devastating rather large parts of the country, not something that we expect to happen in the middle of our uniquely British summer. More and more MTAS errors are also being unearthed on a daily basis, in fact the job selection process has been so flawed that it's very hard for even the most obsessed to keep up with the true scale of the disaster.

There will be some juniors out there who are probably having their worst ever summer, with no job for August and a house full of muddy flood water. The individual cases of woe that I've heard of do beggar belief. Some juniors have had jobs offers retracted, others have been offered multiple jobs despite making it quite clear that they had accepted only one job; also it is rather scandalous that those with jobs mostly do not have their contracts of employment as yet. One must not forget the thousands of highly skilled junior who are still without a job for August, many of these will be supporting partners and small children. Thousands of juniors and their dependents are in the process of trying to relocate in a very short period of time, it's hardly the icing on the 2007 cake. I won't even mention the inevitable bedlam on the wards come August as all junior doctors swap hospitals on the very same day, just make sure you don't end up in hospital in August.

The DoH who have been the driving force being this vindictive carnage do not seem to care for the people involved in the slightest. The fact that a rather large number of junior doctors are showing signs of mental strain shouldn't be reported in the DoH's opinion. The politically correct lies never stop being trotted out by the Department of Health. It is almost sick that they are happy to continue peddling their propaganda behind the dishonest pretence of caring for patients and doctors. It must not be forgotten that it is their policy and reform that has resulted in this mess, their dishonest attempts to try and take the moral high ground here show that they can always be relied upon to plumb new abhorrent depths.

The government's big game is the destruction of the medical profession so that medical care can be privatised, unfortunately this game is against the interests of a good standard of care for patients across the board. MTAS is part of this process of dumbing down and lowering standards so that a cohort of minimally competent worker drones can be bullied into producing dross for the rest of their working lives. No wonder the majority of the medical profession cannot stand the government's line of attack, as the majority of them are only happy in a system in which they can pursue medical excellence; the government wants to destroy excellence as this is expensive, it is far cheaper to provide a mediocre service run by its Stalinist health care professionals. In this brave new NHS there will be little use for doctors, and clinical freedom will be a thing of the past; as uneducated managers and quangocrats will proliferate in their stifling and controlling roles, resulting in clinicians being nothing more than puppets of the ever burgeoning state bureaucracy.

The government's response to the failure of MTAS is to push on with it, regardless of the ghastly short and long term consequences. The government's answer to the floods appears to be equally misguided. If there is one thing that should be done to help minimise the chances of floods wreaking the havoc that they have this year, it should be to stop building on flood plains. This is hardly rocket science. However knowing our government they will push on regardless with their plans for new homes, again regardless of the potentially disastrous consequences. When will these fools learn their lesson? Just how many lives will have to be wrecked for them to stop this irresponsible rampage?

Thursday, 19 July 2007

Sir Liam and his kind

The never ending problems in the NHS are summed up very well by looking at Sir Liam Donaldson. This podgy ginger stooge is the epitomy of a self serving corrupt regime that is bringing the health service to its knees. Sir Liam finally spoke on the subject of MTAS this week, this coming many months too late from a man who appears to be up to his neck in his own steaming faeces. Channel 4 news have summarised the ghastly MTAS affair here, it really is upsetting how badly so many hard working staff have been treated and August promises to be an absolute nightmare for patients, with thousands of junior doctors moving jobs on the same day.

Sir Liam is exactly the kind of doctor who is completely unsuitable to be making the big decisions that he is left with, he is man who will always obey his master, a man who would sell out his own family for the right price. The majority opinion of the medical profession has been ignored time and time again by cronies like Sir Liam, resulting in more and more destructive government reform being forced upon the general public. The cronies in positions of power are frequently doctors who have left the real medical world because they do not enjoy medical work on the ground, because they are not good at real medicine and because they would rather seek personal glory by shafting their colleagues who actually do the real work. There are many more Sir Liam types who hold positions of significant power in organisations like the DoH, the BMA, quangos like PMETB, the Royal Colleges and PCTs. These despicable turncoats are men who have sold their souls for peerages, they are men who should have been kept out of powerful positions at all costs. The same seems to be the case in the nursing heirarchy with good clinical nursing going unrewarded, while compliant little Hitler-type managers are rewarded for their compliance by a nasty vindictive over controlling Department of Health.

MTAS is only the obvious tip of the government reform iceberg, unfortunately beneath the water lurk many other disastrous schemes hatched by the same bunch of disgraceful cronies. ISTCs have been a massively wasteful use of tax payer's cash, it turns out that the government doesn't even bother to check up on the value and quality of some rather expensively privately contracted work; the cynic would argue that this was a deliberate ploy, after all it is easier to get away with squandering cash on corrupt reform if no one keeps an eye on where the money has gone. The scandal of ISCTs is one of many examples of inefficient reform catalysed by the government's control of several crony-led institutions and the deliberate riding roughshod over the majority of public opinion. A man named Sir Ara Darzi has been pulled off the same production line that negligently spat out the monstrous Sir Liam, yet another government crony who will tell the government exactly what they want to hear.

The NHS has become the exact opposite of what was originally intended. The nasty bullying tactics employed by the DoH have crept down the chain of command, and now the actual doers are persecuted by a bunch of cretinous cronies who haven't done a proper day's work in years. Dishonesty and nastyness are rewarded, while hard work and excellence are no longer actively encouraged. The dumbed down service that the government has in store for the future does not have the interests of patients at heart, it is all about serving the interests of an elite minority of scumbags.

The catastrophy of Sir Liam's MTAS and his complete inability to take responsibility for his own mess sums up where things are going so badly wrong. The majority of good hard working doctors are being shafted by a minority of lazy good-for-nothing cronies. These bastards have blood on their hands but they still refuse to acknowledge this rather obvious fact. I really do not know how their kind sleep at night.

Sunday, 15 July 2007

Spot the wage

The mainstream media are never short of stories that tell us how overpaid doctors are and how underpaid all other NHS workers are. The following game is designed to demonstrate that this opinion is a little wide of the mark.

Guess which job gets each of the seven hourly rates:

House officer (first year doctor), Senior House Officer (second/third/fourth year doctor), Specialist Registrar (level above SHO) , staff nurse, senior staff nurse, sister........... and a strathclyde bus driver:


(The increment is at realistic level (3yrs as an SHO before SpR, 8y as SN before SSN, 5y as SSN before sister) and for an average 37.5 hrs worked per week only. Nurse's rate includes antisocial supplement. Dr's rate from BMA website.

I haven't included overtime (>37.5h). For that, nurses get time and a half, or double time on bank hols. Doctors get time and a quarter on 2B or 1A banding (average banding) or none on a normal working day.)

See if you can put the hourly rates of pay in the correct order, starting with the lowest and working up to the highest. You may be surprised by the results.

Thursday, 12 July 2007

The Ministry of Untruth

The Department of Health have hardly covered themselves in glory this year, indeed some might go so far as to say that they have emphatically proven themselves to be a bunch of utter incompetents. The latest evidence of their ineptitude is revealed by this press release, demonstrating their idiocy and state of complete denial. The DoH tries to put a positive spin on events:

"Majority of NHS junior doctor posts filled in England"

I translate this spin to mean: "A worryingly large number of posts are still unfilled and it is only a matter of days until the August change over." Apparently this is all rather good news for patients and the NHS.

There is strangely no mention of the thousands of excellent juniors who have no training job, there is no talk of those who have fled for greener pastures abroad and there is no word of this catastrophic waste of talent and money. This is a scandal.

Not only is there a huge problem for the service in August as there are hundreds of training posts unfilled, not forgetting the huge number of non training posts that are also unfilled. This will have inevitable clinical consequences for patients come August as there will be simply too few hands at the pump.

The manner in which the Department of Health, "the ministry of untruth", have tried to cover up this embarrassing balls-up is not only dishonest but it is also insulting to thousands of juniors who have been treated so inhumanely this year.

The Department of Health are beneath contempt, they have revealed their true incompetent colours this year. They have woefully mismanaged everything that they have touched as far as MTAS and MMC are concerned. Nothing has gone right, and this is because they have ignored all the fears and concerns raised along the way, they have simply pushed on regardless in order to satisfy their political masters. They have made so many mistakes that people have stopped counting, in fact many juniors are now so apathetic as a result of this systematic torture that they are struggling to motivate themselves to carry on.

The Department of Health would have done much better to admit their errors and try to change their dishonest manipulative ways. They have not done this, and they are sinking lower and lower by the day.

Wednesday, 11 July 2007

Ten years too late

Apparently these are Gordon Brown's main aims with the NHS:


· Power back in hands of patients and staff

· All patients best health care"

So why have you been behind the devastating reform agenda of the last ten years that has wasted billions of pounds centralising and privatising the service while taking power away from patients and staff? Why have you been behind the woeful reform that has handed more and more power to managers and politicians so that they can fiddle statistics to provide propaganda for the party?

Gordon Brown's actions for the last ten years have meant that patients have suffered directly as a result of many ill thought out top down NHS schemes. The wasteful PFI is Gordon's lovechild after all, it hardly helps provide the best care for patients does it Gordon? I find it's pretty hard to provide good basic care when your local trust has run out of money because it is obliged to pay for an expensive PFI white elephant, thus cutting basic services to feed the white elephant.

I will believe it when I see it Gordon, and please stop leaving your mouth hanging open, it really is a rather unpleasant sight.

A sad day

One of the most dedicated and fantastically hard working people to have supported the cause of junior doctors up and down the country has been Lindsay Cooke, the voice of Mums4Medics. The following letter from Lindsay sums it all up really, it gets across the empty feeling many of us have been left with and the tremendous human cost that the government's reform agenda has had this year in particular:

"Hi everyone

This is a hard thing for me to say, but I think the time has come to accept that the fight is over. Even as I'm writing these words, I still can't quite take in the enormity of what's happened. We are witnessing the destruction of a system of medical education that was the envy of the world. We are witnessing the elevation of competence over excellence. We are witnessing the concept of the doctor as 'healer' replaced by the concept of doctor as medical technician. God helps us all in our old age - and God help the NHS.

There is no concensus among you about further action - nor, indeed, is there among junior doctors. The Remedy forum - as those of you who are regular visitors will know - is eerily quiet. There is no talk of further resistance; just appeals for information and the sharing of yet another injustice. Today, I learnt that some have been told that their jobs now won't begin until October 1st, leaving them unemployed for two months. Today, I read of someone being deemed ineligible for a post because he'd worked in a specialty for 48 months rather than 'under 48 months'. What can you say? It's utterly shameful.

Here are 'our' statistics for you - thank you to those 36 people who sent me details of 'their' doctors' status.

1. The 36 comprise eight F2s and 28 SHOs.
2. Of those, 50% have jobs - 16 have ST posts and three FTSTAs.
3. Of the 50% who don't have jobs, one is an F2 and 18 are SHOs.
4. Of the 19 without jobs, one is leaving medicine, five are going abroad,
one is applying to the Forces and one is thinking about going abroad - a total
of eight doctors lost or potentially lost to UK medicine, around 45% of
'our' total.

This sample is too small to be statistically viable, but it provides a frightening snapshot of the scale of this disaster.

Frankly, I don't know where we go from here. The brutal truth is that this campaign started at least two years too late - and probably three or four. The profession has sleepwalked into this through inertia; a disinterest in 'politics'; a complacent disregard for those courageous few who attempted to advise and warn; and the compliance of its institutions. We have fought the good
fight in support of our own and their colleagues and will always know that we fought for what was right - but it's hard to see how we can take it forward. I'd be interested in any positive suggestions.

I'm so sorry, but I just cannot continue to devote most of my time to Mums4Medics in the way I have done since the beginning of March. I'm promised that, tomorrow, there will be a Mums4Medics area on the Remedy forum - which means that you will have a platform to talk to each other, something that hasn't been possible up to now except through our local contacts - who I recommend to you. You will find their names and email addresses on our web site,
_www.mums4medics.org_ ( . I will continue to liaise/work
with Remedy and to provide a weekly update on a Friday and suggestions for action in support of junior doctors for as long as that seems useful and to answer your emails - but I cannot help with individual issues any more. I need to take some time away from this, not least to come to terms with the fact that I'm losing my own daughter to the other side of the world. I'm truly sorry, but I'm exhausted and heartsick right now and honestly don't feel I have much to offer in the way of positive proposals. I hope that will change.

I didn't go to the Remedy meeting last night but am promised the minutes in due course and have also asked for an update on their future plans, which I'll put in Friday's update. I've also written to Prof Morris Brown to see what Fidelio's plans are.

With every good wish to you and your families

Lindsay Cooke"

Thankyou Lindsay for all your hard work, it's hard to know what else to say really.

Wednesday, 4 July 2007

Darzi and dusted

What do lying treacherous politicians do when they realise they have been caught out with their corrupt stinking pants hanging down by their ankles? Call for a review, that's what.

This is what Alan Johnson has done. He must be hoping that Sir Ara Darzi can fool the medical profession and the general public that he is competent to do the review and that he is not a New Labour stooge. He may struggle to fool us on both counts.

I have already written about Sir Ara's convenient report findings that have consistently told those in power exactly what they want to hear. It is also rather noticeable that one of his reports was so low in quality that an independent review, written shortly after Darzi's report, directly inferred that Darzi's ideas were unsafe and unworkable as a result.

So what do New Labour do with a man that struggles to satisfactorily review emergency services in one small area? Yes, that's right, they give him the job of reviewing the whole of the NHS.

Unfortunately this is no joke, this is New Labour at their mesmerising best. It is also unfortunately no joke that we have a dimwitted fool called Alan Johnson running the NHS, a man who thought that Labour's education record was great because more pupils were getting A grades than ever before.

We now have a postman running the NHS, this truly is New Labour at their stunning best.

Monday, 2 July 2007

New Leader, same old New Labour

The public are fed up with spin and lies, so it is no wonder that Gordon Brown's recent words promising 'change' and a new 'listening' style of government have gone down well. It is just a great shame that so many people have been sucked in by this dishonest charade. Gordon Brown has played a key role in Labour's antidemocratic reform over the last ten years, and judging from his actions he promises to push yet more reform through in this rather antidemocratic manner for as long as he posssibly can.

If you thought Gordon Brown as leader meant an end to unelected unaccountable cronies running the country, then think again because Gordon is assembling an array of 'yes' men who would not dare stand in the way of his grandiose plans and ironically he calls these men 'the ministers of all the talents'; it really does take some talent to unquestioningly follow orders and please the boss with a 'yes sir, three bags full sir' response every time.

Sir Ara Darzi appears to be one of these compliant 'yes' men, a man who poses as an objective voice but in reality he has been supplying the government with what it wants to hear for several years now. Sir Ara was handed his first role in 2002 and was asked to conduct an emergency review of services in Darlington and Durham county by the health authority. Unsuprisingly Darzi's report told the health authority exactly what they wanted to hear, even though the vast majority of local medical opinion felt his suggestions were flawed and unsafe. Darzi's plan silenced the criticism of clinicians and managers by forcing a merger of the two Durham Trusts. The North Durham trust chairman, a local Labour councillor called Kevin Earley, was sacked after speaking out, while the able CEO of the Northern Durham trust was also moved out. The sacking of Earley did attract a bit of attention in Parliament though.

A rather similar situation repeated itself a few years later involving Sir Ara Darzi, this time it involved the 'reconfiguration' of acute hospital services in Hartlepool and North Tees. Again Sir Ara's report came up with a report in which the medical community had absolutely no faith:

but to the medical profession I am afraid that it was an outright disaster.'

Again it was a case of Sir Ara providing what was wanted to be heard, even though this appeared to be a clinical disaster area. The Darzi report conveniently came just before a Labour election victory, only for a maternity unit to close just after this election victory. The conservatives see Darzi as a man who serves up exactly what his masters order:

Mr. Lansley: "It does not clear it up at all. The hon. Gentleman implied that I somehow misrepresented the situation. It is very straightforward. The Prime Minister went to Hartlepool. He said that there was no question of the general hospital in Hartlepool closing or being run down. The truth of the matter is that the North Tees review had proposed that it should be run down and eventually closed and that a new hospital should be built. The Department of Health put in Sir Ara Darzi, who seems to be its spokesman of choice for this purpose, in order to try to keep the hospital going. He said that it could be kept going. The matter then went to the IRP and the IRP went back to the North Tees review. According to the IRP, the hospital will be run down and then closed."

In fact Sir Ara's words have been used as a crutch in the Commons by none other than the ex-Secretary of State for Health, Patricia Hewitt:

Hewitt: "Professor Sir Ara Darzi, one of our country’s leading surgeons, who is conducting a review of health care across London, has summed up the changes that are taking place very simply:“health services as close to people’s homes as hospital where necessary”."

You would never guess that his latest offering seems to be proposing yet more of the same, this time in London. Again a report is produced based on the most scanty of evidence bases, and conincidentally it says exactly what is wanted to be heard by those on high. The 'bonkers' nature of proceedings are explained below by Mike Grapes MP:

Mike Gapes MP: "There is something bizarre about the process. On11 December, the chief executive of the NHS London region, Ruth Carnell, sent a letter to all London Members of Parliament in which she said that the NHS London region is commissioning a major document from Professor Sir Ara Darzi setting out a framework for “radical thinking about how to deliver services” across London. That is to be published in spring 2007 and a final health strategy for London will be published in the summer. That seems bizarre and absurd: one starts the process to carry out cuts in services in one part of London and then one decides the strategy for the whole of London. It is bonkers."

There is another far more cynical explanation of events that does not need to be spelt out by myself in absolute terms. It does seem more than coincidence that clinicians and the public are being ignored in every single consultation, while clinically dangerous cost cutting reconfigurations seem to go hand in hand with the government's centrally enforced NHS deficits; meanwhile the 'ministers of all the talents' provide the objective justification for this cruel charade. It seems that under Gordon nothing will have really changed:

Stephen O'Brien MP: "We have seen Ministers and Cabinet Ministers running around seeking to defy their own Government policy. That may be collective hypocrisy, rather than collective responsibility, but I hope that at last they will now listen in order to make reconfiguration respond to the demands of patients, rather than simply to act as an emergency outlet for their financial mismanagement."

Sunday, 1 July 2007

Re-inventing the wheel

Sir Ara Darzi has been made Health Minister by Gordon Brown, it's all part of Gordon's new drive to recruit party-neutral experts in this revolutionary new style of Gordon centred, sorry public centred, government. I will believe it when I see it Gordon.

The report produced earlier in the year by Sir Darzi, the noble warrior for patients, throws a lot of doubt on his neutrality; it appears that he is another agent of HMG reconfiguration and reform disguised in friendly clothes. His words hardly fill me with confidence:

"I will be working closely with Alan Johnson to map out the next steps of the reform agenda that has achieved so much in the last 10 years. But we can do better."

His 'groundbreaking' report can be viewed here at the health care for London website. If you are able to endure the full portion of the nauseating propaganda then you will be able to follow the thread of my argument. The report can be viewed in full here.

The report uses DoH white papers for its evidence at times and falls back on the same selective use of public opinion to justify its program of reform. In fact some of the dubious evidence that backs up the expensive shifting of work from hospital to community has already been shown to be seriously flawed. Apparently Sir Darzi is also one of the leading forces behind the surgical nurse practitioner grade, a threat to surgical standards and training if ever there was one.

Darzi's report does not offer anything more ground breaking than the reinvention of the wheel. There are obviously some problems with attracting GPs to work in the poorest and most deprived areas, while the government has helped worsen community care by shutting a rather large number of community hospitals in the first place. Also the kind of community hospital used as an example in Darzi's report seems to resemble an inferior version of a District General Hospital.

London can probably get away with this type of sub-DGH as London is a freak, I say this because London's huge population in a small area is very much not the normal for the UK; this means that when things go belly up it is only a very short blue light trip to the specialist centre down the road. This doesn't mean that having certain types of elective surgery without the intensivist backup on site won't have some rather negative consequences, it will, however the proximity of the specialist centres will minimise the damage; this will not be the case if the same logic is applied elsewhere in the UK, in Sussex for example.

This centralised approach backed by Darzi's report is already being forced upon the rest of the UK, even though the evidence upon which it is based is less than wafer thin. The contempt that this arrogant mindset shows for the excellent specialist care provided by DGHs around the country is a disgrace. The most worrying potential aspect of this reform is that excellent DGHs that can adequately manage the vast majority of obstetric emergencies, paediatric emergencies and medical/surgical emergencies will be replaced by dumbed down units that will have to send these emergencies a significant distance for appropriate treatment. At the end of the day this cost cutting will cost some patients their lives, however I'm sure the noble Sir Darzi will be happy with his achievements, and he might have been promoted above Sir by then.

The UK is not London, and cutting costs costs lives, something Sir Darzi would do well to realise.