Street Doctor - negligent medicine at prime time

Luckily I have not had to endure many episodes of the BBC's woeful 'Street Doctor', unfortunately last week I was unlucky. Not only is the program negligent in the way that it portrays medicine as something that can be done on a street corner without a proper thorough history and examination, but it is also negligent in the way that the doctors get medical things very wrong indeed. In last weeks episode there were these glaring errors:

Plantar Fasciitis - a man with mild plantar fasciitis was treated immediately with a steroid injection. This was poor medicine as he should have been treated with simpler measures before a steroid injection was even considered, however the Street Doctor went straight for a treatment that is at best slightly controversial and at worst can result in serious complications. This was undoubtedly poor medicine.

Dupuytren's disease - the Street Doctor got this very wrong stating that it was a thickening of tendons and could be treated with a steroid injection. This is complete rubbish, Dupuytren's is a disease of the palmar fascia and not the tendons, and cannot be treated with steroid injections.

Sebaceous cyst - a poor old chap got terribly scared by the Street Doctor telling him that squeezing his infected cyst would result in the infection spreading to the bloodstream, what utter hogwash. In fact squeezing an infected cyst may well prevent the infection becoming more systemic, the complete opposite of the doctor's advice.

This program is an embarrassment and a danger. It encourages sloppy half arsed medical practice and spreads medical misinformation to the general public. It's therefore no surprise that the BBC should see it as a key part of its new cutting edge programming. A cynic would even go so far as to say that this pathetic attempt at taking care into the community is being used to add weight to Darzi's corrupt NHS reform program.

Fisher Price NHS

The dumbing down continues apace, with pharmacists being given the chance to diagnose and manage 'minor illness' in another hair brained and arguably cost ineffective government scheme. One wonders quite how the pharmacist will be able to tell if an illness is 'minor', given that their training includes nothing on the diagnosis of disease? Apparently the following are minor:

"acne (a dermatologist may well be needed if nasty), athlete's foot, back ache (cauda equina can present with minimal pain if atypical), cold sores, constipation (hopefully not bowel cancer), cough (hopefully not asthma or lung cancer), diarrhoea (again hopefully not inflammatory bowel disease or cancer), ear ache (possibly something an ENT bod may be needed for), eczema and allergies, haemorrhoids (piles) (something that a colorectal bod can treat easily in clinic) , hay fever, headache (hopefully not hydrocephalus, meningitis, raised intracranial pressure), head lice, indigestion (hopefully not cancer or barret's oesophagus), mouth ulcers , nasal congestion (nasopharyngeal cancer), pain (quite a few things could be missed here), period pain (ectopic for one), thrush, sore throat , threadworms, warts and verrucae (don't miss a melanoma)"

I have just added in brackets a few of the ways in which these pharmacists could very easily miss a diagnosis and harm, or even kill a patient. GPs get things wrong enough, and this is with a proper medical degree and years of supervised training in the art of history, examination and diagnosis. The potential for pharmacists to go wrong is enormous.

Also how on earth can a pharmacist make a diagnosis? Are they trained to use a stethoscope, an otoscope, a proctoscope or an opthalmoscope? I very much doubt it. It is a bit like Dr Crippen's analogy of letting the air hostess take over from the pilot in the cockpit!

More evidence is coming to light showing that various dumbing down reforms are not really cost effective or safe. GPs with a special interest (GPwSIs) are really a very poor alternative to proper specialists, and this is evidenced by their cost effectiveness. While the dangers of nurse prescribing have already been written about in many quarters, here is yet more ammunition in the locker demonstrating how an inadequate level of training may well impact on standards of care:

"We may expect a marked escalation of preventable prescription-related disease from independent nurse prescribing on the basis of these figures."

Whether it be in the form of pharmacists acting as family doctors, nurses acting as doctors or GPSIs acting as specialists; the trend is a dangerous one away from proper training and high standards of care, towards dumbed down training and lower standards of care. That's progress for you.

An experienced geriatrician speaks

The debate around empowering nurses to make DNAR decisions is certainly a hot one, I have obtained permission from an experienced consultant geriatrician to publish this short piece he wrote on the topic, the opinion of a geriatrician is particularly useful as they are in my opinion amongst the best at understanding the complex issues that surround DNAR decisions:

" "In general senior nurses are well qualified and well placed to make these decisions."

No they are not

As a geriatrician end of life decisions are my bread and butter. I work with mostly excellent nurses. But in my time as consultant I cannot think of a single senior nurse who would have been capable of making complex decisions like this in complex patients.

That is NOT a criticism of nurses. It is a compliment to doctors. On this issue my firm belief is this is something that almost no nurse could be reasonably asked or expected to do. And that's before we get to the issue of bearing responsibility for that decision.

Some things remain firmly in the domain of "a doctor's job". This is one of them. And before anyone cries "protectionism" all I would say is demanding the right to retain this responsibility as a doctor must surely be professionalism and nothing else."

The nail has been hammered home. It also seems that many nurses agree with this sentiment.

Nurses to make end of life decisions

"Responsibility for decision-making

The overall clinical responsibility for decisions about CPR, including DNAR decisions, rests with the most senior clinician in charge of the patient’s care as defined by local policy. This could be a consultant, GP or suitably experienced nurse. He or she should always be prepared to discuss a CPR decision for any individual patient with other health professionals involved in the patient’s care. Teamwork and good communication are of paramount importance. Where care is shared, for example between hospital and general practice, or between general practice and a care home, the health professionals involved should discuss the issue with each other and with other members of the healthcare team. There should be shared responsibility for deciding about the likelihood of a successful outcome from CPR, and discussing the issue with the patient or with those close to patients who lack capacity where a balance of benefits and burdens is needed. Nevertheless, one individual needs to take charge of ensuring that the decision is made properly, is recorded and is conveyed to all those who need to know it, including locum staff. Local policies should specify who that should be."

The empowerment of nurses gathers pace and is amazingly aided by the BMA, a union that now appears so politically driven that I wonder why any doctor in their right mind remains a member. This document explains the rationale, or lack of it, for the changes to procedure relating resuscitation decisions.

Decisions that relate to resuscitation are frequently badly managed but allowing nurses to make these decisions will only add mud to the waters of confusion. The public are generally poorly informed about what resuscitation actually is and how likely it is to succeed, while in hospitals the decision not to resuscitate often gets abused as a license for staff to not actively treat very treatable conditions. Making the decision requires a lot of medical knowledge and training, something that nurses, no matter of their experience, do not possess.

The BMA are a disgrace, their document uses the word health professionals endlessly without mentioning the word doctor. While nurses are now called 'clinicians' and despite their overt lack of training and examined knowledge, are being promoted to the same level as doctor 'clinicians'. Nurses are not clinicians, they are nurses; the government may have empowered them to have a rather amateur crack at diagnosis and doctoring but this does not make them trained clinicians, they are only trained at nursing. Doctors are clinicians, they have been to medical school and have had their skills and knowledge examined to a proper level.

The document also has a dumbed down protocol for DNAR decisions, the classic hallmark of a dumbed down nurse led procedure that will guarantee that common sense is cast aside routinely. Recently the hypocritical NMC also had the gall to accuse others of abusing the title 'maternity nurse'; this is while the NMC backs the empowerment of nurses and deception of the general public with nurses being called 'nurse consultants'. A 'nurse consultant' is simply an experienced nurse, so the tag of 'consultant' is nothing but a dishonest lie.

These new guidelines are the classic example of the dumbing down of medicine in this country. The suggestions at first do not appear that unreasonable, however it is the general tone of the document that fills me with fear; proper training and knowledge are being undermined as all healthcare staff are referred to as generic 'health professionals'. One does not need proper training or in depth knowledge to become a 'consultant clinician' anymore, anyone with a few years of service can have a crack. I would imagine that sensible nurses will not want to have this extended responsibility, however the growing cohort of 'chip on shoulder' wannabee doctors will be delighted that the line between doctor and nurse continues to be eroded.

Whatever happened to doctors doctoring after doctor training and nurses nursing after nursing training? We now have nurses doctoring after nursing training and doctors fuming with very good reason. The line between doctor and nurse continues to disappear, remind me again why I went to medical school? Because in my naivety I wanted to do my job properly.

Tooke - a remedy?

There is undoubtedly much of sense in John Tooke's report. The talk is certainly attractive, however one must always remain sceptical when analysing matters of a political nature, and this is especially the case when the talk turns to unquestionable principles, I must admit that alarm bells do start ringing. Tooke is undeniably spot on when he criticises the powers that be for their negligent role in the implementation of MTAS and MMC, the Department of Health deserves this scorn. His recommendations for improvement in this area do not convince me, I have lost my faith completely in the government and the only thing that would convince me would be for the government to be stripped of its control of medical training.

I welcome several other ideas including pushing for an increasing emphasis of the importance of medical training in the NHS' burgeoning management structures. However practically on the ground we have seen how training is rarely respected by cash strapped trusts, as money is clawed back in rather unethical ways from doctors who are then forced to pay for their own training. The following idea is good, but 'should' is very different to the reality of the BMA:

"Recommendation 18
The medical profession should have an organisation / mechanism that enables coherent advice to be offered on matters affecting the entire profession, including postgraduate medical education and training."

The suggestion to assimilate the useless PMETB with the GMC could do no harm, at best PMETB would no longer be able to inflict its incompetence upon us. When talking of FY1 and FY2 I think he loses the plot, despite the fact that his proposals are an improvement, I would favour a return to a PRHO year of six months of both medicine and surgery that is strictly regulated so as to ensure first year doctors become solid at the bread and butter. There is also far too much talk of 'competency assessment', as if the validity of this new educationalist ideology cannot even be questioned and this fills me with fear. I am also slightly fearful at his talk of standardised national forms, specialty specific questions and standardised assessment scores.

I am most concerned about the lack of consequences for those individuals who played such key roles in negligent implementation MMC and MTAS, will the likes of Liam Donaldson be held accountable for their actions or lack of them? Most worryingly John Tooke's suggestions will have to be listened to and acted upon by the very same incompetents who got things so very badly wrong the first time around, of course this is not Sir John's fault but it does have implications for the end product of his review. At the very same time that the Tooke review was being delivered, these very incompetents were delivering yet more MTAS style disasters in the form of Foundation 'white spaced questions'. While the incompetent workforce planners NHS Employers were delivering yet another piece of malignant rubbish that treats medical training with utter contempt. Undoubtedly training has to change but there are certainly much better ways of doing it than those proposed by the short sighted and cynical NHS Employers. These two examples are by no means isolated.

Various organisations have responded to Sir John's review, including the Royal Colleges and the BMA. There is strangely no mention of the role of the post-CCT doctor and how they fit into this grand scheme. It must be remembered that the BMA and the Royal Colleges have betrayed us more than once with these training reforms, so I would urge caution when listening to their enthusiasm for Sir John's review. That is not to say that I do not agree with much that is contained within the report, however I would suggest that we all remember that there is a long way to go in this battle for the future of medical training. Complacency could be very dangerous, as the good words in Sir John's report will mean nothing if certain malignant reforms are slid in via the back door when our backs are turned.

This is no time to get carried away. Thousands of excellent trainees will not find training jobs again this August, while there are many serious problems facing those trainees that are lucky enough to find a job, competency based fundamentalism and its dominance over experiential learning is just one issue that needs to be dealt with. But surely the most important thing will be that trainees remain militant and become more political than ever before, so that we can force the powers that be to stand up and take notice of what we demand for ourselves and for our patients in the future. After all if we simply roll over, there is little doubt that the government will treat medical training with contempt again; thus ensuring that hopes of excellence will be but a distant memory, and that dumbed down substandard dross will be their order of the day.

Another reorganisation of regulation

It seems that the government never learns from its mistakes. They have created yet another regulator, the Health Quality Commission, to enforce its centrally driven targets. So what will this new regulator actually do?

"The Care Quality Commission will have the power to close wards and order more frequent checks. The watchdog will focus on safety and quality across health and adult social care services, inboth the NHS and the independent sector. In particular it will be able toclose services that are unsafe, or where there is some other serious breach which is putting patients at risk. "

That all sounds well and good, but in reality it means very little indeed. As the government has cut bed numbers and with hospitals running at near 100% occupancy, I fail to see how shutting wards in over strecthed hospitals will do anything to address the root causes of these problems. The talk of fining trusts for not complying with centralised dictats is ludicrous, as the trusts in trouble are invariably the ones with the most financial debts, hence fining them is likely to potentiate the problem. This quote demonstrates the completely deluded thinking of whoever has come up with this bright idea of yet another reorganisation:

"Many of the powers are already available to the existing regulators, but
ministers hope tougher action will be taken by merging the responsibilities into
one body."

They should be asking questions now as to why the regulatory bodies are not doing their jobs properly, another reorganisation is unlikely to solve this problem as if by magic.

"The Care Quality Commission will also have an
important role in supporting patient choice, through assessing and providing
information on the performance of providers of adult social care and health
care, and in ensuring value for taxpayers' money."

This is the real truth of it. This regulatory body will be yet another vehicle by which the government can railroad through its anti-democratic privatisation of the health service. The disingenuous 'patient choice' really means 'government choice', as most people simply want good local NHS services and do not want to see their hard earnt cash donated to private firms that are friendly with the government. If the Care Quality Commission really cared for the quality of health care and for ensuring value for taxpayers' money, then they would tell the government to scrap the internal market and return to the days when hospitals were not run from Whitehall, thus ensuring that local people could have a say about their local NHS. As things are going though this reorganisation promises to waste yet more tax payers' money doing exactly what the taxpayer doesn't want.

The ferret's guide to Tooke: Part 6

"Recommendation 30
PMETB should be assimilated in a regulatory structure within GMC that oversees the continuum of undergraduate and postgraduate medical education and training, continuing professional development, quality assurance and enhancement. The greater resources of the GMC would ensure that the improvements that are needed in postgraduate medical education will be achieved more swiftly and efficiently. To this end the assimilation should occur as quickly as possible."

I don't think that this proposal would be very unpopular within the medical profession, it would be far better to have one organisation in charge and therefore accountable for their actions. This is the best recommendation of the lot for me.

"Recommendation 31
Under the Medical Act, Universities already have responsibility with regard to FY1. By breaking the linkage with FY2, it will be possible to guarantee an FY1 position in the new graduate’s local Foundation School subject to prevailing local selection processes. The linkage between FY1 and FY2 should cease for 2009 graduates."

Another sensible idea, back to a more house officer style of system.

"Recommendation 32
FY1 should be reviewed to ensure that i) harmonisation with year 5 is optimised; ii) the curriculum more clearly embraces the principles of chronic disease management as well as acute care; iii) competency assessments are standardised and robust. In future, doctors in this role should be called Pre-Registration Doctors."

I am not convinced by this, I believe the first year of pre-registration work should be the simple bread and butter. It should consist of six months of medicine and six months of surgery, and nothing else. It must be a good broad grounding in acute care that is a platform from which to spring.

"Recommendation 33
Foundation Year 2 should be abolished as it stands but incorporated as the first year of Core Specialty Training. The current commitment to FY2 GP placements should continue as part of Core Specialty Training and developed further as resources permit. Doctors in Core Specialty Training should be called Registered Doctors.

Recommendation 34
At the end of FY1 doctors will be selected into one of a small number of broad based specialty stems: e.g. medical disciplines, surgical disciplines, family medicine, etc. During transition, ‘run-through’ training could be made available after the first year of Core, for certain specialties and/or geographies that are less popular than others. Core Specialty Training will typically take three years and will evolve with time to encompass six sixmonth positions. Care will be taken during transition to ensure the curricula already agreed with PMETB are delivered and the appropriate knowledge, skills, attitudes and behaviours are acquired in an appropriately supervised environment.

Recommendation 35
For those doctors who do not know to which Core Specialty to commit at the end of FY1 there will be the capacity to take up to 2 years in hybrid rotations allowing experience in four main Core areas. Experience in the subsequently selected Core area will count towards the completion of Core Specialty training subject to successful competency assessment."

The wheel is being reinvented here, the outcome of the above would appear to resemble the old pre-MMC system.

"Recommendation 36
Colleges should work together with the Regulator and service to devise modularised curricula for Specialist Training to aid flexibility/transferability. They should also devise common short-listing and selection processes that have been standardised across the country to allow sharing of assessments between Deaneries. This work should be completed within two years."

There is good and bad in this, it is good for the Deaneries to pool ideas and knowledge, however why should things have to be standardised across the board? Diversity is the spice of life and without it I feel the pursuit of excellence will be hindered. The time limit may not be a good move either, we have seen how badly rushed reform can go.

"Recommendation 37
Satisfactory completion of assessments of knowledge, skills, attitudes and behaviours will allow eligibility for
i selection into Trust Registrar positions* in the relevant area or
ii selection into Higher Specialist Training.
Doctors in Higher Specialist Training will be known as Specialist Registrars,
those selected into General Practice specialty training will be known as GP
Registrars (equivalent to ST3 and beyond)."

This just states that registrars will continue to be registrars.

"RecommendatIon 38
The newly named Trust Registrar position* (formerly termed Staff Grade) must be destigmatised and contract negotiations rapidly concluded. The advantages of the grade (accrual of experience in chosen area of practice, consistent team environment) need to be made clear. Trust Registrars should have access to training and CPD opportunities. They should be eligible for a reasonable limited number of applications to Higher Specialist Training positions according to the normal mechanisms and also to acquisition of CESR through the Article 14 route."

I wouldn't argue with this.

"Recommendation 39
Doctors should be allowed to interrupt their training for up to one year (or by agreement longer) to seek alternative experience. The regulator in conjunction with the Royal Colleges will determine whether experiences should contribute to completion of training subject to appropriate competency assessment."

It wis essential that doctors are encouraged to gain a wide variety of experience.

"Recommendation 40
Selection into Higher Specialist Training to the role of Specialist Registrar
will be informed by the Royal Colleges working in partnership with the
Postgraduate training – Inquiry recommendations

The Panel proposes that in due course this will involve assessment of relevant knowledge, skills and aptitudes administered several times a year via National Assessment Centres introduced on a trial basis for highly competitive specialties in the first instance. A limited number of opportunities to repeat the National Assessment Centre tests following further experience will be determined. Candidates will apply via Postgraduate Deaneries or Graduate Schools.
Application will take place three times a year on agreed dates. Save in the most exceptional of circumstances, candidates will be restricted in the number of local programmes to which they may apply (and to the number of occasions on which they may apply).They will use a common national form with specialty specific questions and will provide their standardised
assessment score/ranking along with a structured CV. This will avoid the once a year appointment system with its inherent risks to service delivery. Graduate Schools linked to the 30 UK Medical Schools would reduce the size of Units of Application and address the family-unfriendly situations that arose therefrom. Shortlisted candidates will be subject to a structured interview for final selection."

I am scared by the mention of common national forms with specialty specific questions and standardised assessment scores, does this not ring alarm bells a la MTAS 2007? Why not allow there to be a bit of healthy regional variation to encourage diversity?

"Recommendation 41
The current Academic Clinical Fellowships in England allowing c25% of programme time for research methodology training and development of research proposals should be integrated with Core Specialty Training. There will be a need to ensure that those entering an academic training path in the devolved nations are not disadvantaged when moving between research
and clinical activities. Opportunities equivalent to ACFs should be competitively available for those wishing to develop educational, management, and public and global health skills, subject to available resource, through modular Masters programmes."

I am not sure what this means, Academic Medicine is a bit of mystery to me.

"Recommendation 42
Clinical lecturer posts in England will normally be coincident with higher specialist training (ST3 and beyond).

Recommendation 43
Successful completion of Higher Specialty Training as confirmed by assessments of knowledge, skills and behaviours will lead to a CCT. Higher specialist exams, where appropriate, administered by the Royal Colleges, may be used to test experience and broader knowledge of the specialty and allow for credentialing of subspecialty expertise gained post CCT and aid
selection to consultant positions."

Fair enough.

"Recommendation 44
To be eligible for a Consultant Senior Lecturer appointment, the applicant should possess a CCT in the relevant specialty area. Higher specialist College exams could be tailored to limited subspecialty expertise, recognising the narrower scope of practice that some clinical academics
may need to embrace.

Recommendation 45
The length of training in General Practice should be extended to five years, bringing it in line with specialty training and the other developed European countries."

The ferret fancier will shortly be releasing a concluding piece on the Tooke review, simply watch this space, I cannot promise that it will be coherent, however it will be under 100 pages in length.

The ferret's guide to Tooke: Part 5

"Recommendation 21
A suitably qualified Director level lead for medical education within DH should be identified and act as the reference point for interactions with the medical profession including postgraduate Deans. The relationship and accountability of this lead to the following should be explicit: CMO, DH Head of Workforce, NHS Medical Director, and medical educational leads within devolved administrations."

This is unadulterated simplicity, will this arrangement make much of a difference?

"Recommendation 22
Recognising i) the importance of linking workforce supply and demand, ii) the very recent devolution of workforce commissioning function to SHAs in England, we recommend that this situation prevails for the moment for initial Postgraduate Medical Training subject to the forging of closer links at all levels with the Higher Education sector. A formal review of the compliance with Service Level Agreements between DH and the SHAs relating to commissioning training and the functionality of the arrangements should be undertaken in 2008/9. Any deficiencies should prompt urgent consideration of a National Institute for Health Education (as outlined in
Recommendation 12) assuming the commissioning function.

Recommendation 23
Funding flows for postgraduate medical education and training should accurately reflect training requirements and the contributions of service and academia. The current MPET Review should lead to a clearer contractual basis reflecting both agreed volumes and standards of activity and should recognise the service contribution of trainees and the resources required for training."

I have to admit that this doesn't make much sense to me, I am lost in jargon.

"Recommendation 24
The Medical Postgraduate Deanery function in England should be formally reviewed to address whether i) the relationships and accountabilities are currently optimal ii) the present arrangements meet redefined policy objectives of optimal flexibility in postgraduate training and aspiration to excellence, and the NHS imperative of equity of access. Any new arrangements should conform to redefined principles, referred to in Recommendation 1, co-developed to govern postgraduate training.

Recommendation 25
Postgraduate Medical Deans should have strong accountability links to medical schools as well as SHAs in line with Follett appraisal guidelines for clinicians with major academic responsibilities. Such arrangements will improve links with medical pedagogical expertise and will facilitate the
educational continuum from student to continuing professional development.

Recommendation 26
Reflecting the fact that Postgraduate Medical Education and Training involves service, academic and workforce dimensions, it is proposed that the Foundation School concept be developed further as Graduate Schools, on a trial basis initially, where supported locally. The characteristics of such Schools, the precise nature of which would depend upon local circumstances and relationships, need to reflect the crucial interface function played by the medical Postgraduate Deanery between the service, the profession, academia and workforce planning/commissioning. Graduate Schools would involve Postgraduate Deans, Medical Schools, Clinical Tutors, Royal College and Specialist Society representatives and would have strong links to employers/service and SHAs. The Graduate Schools could also oversee the integrated career development of the trainee clinical academic/manager (see Recommendation 41), as well as NIHR faculty."

These recommendations appear to be sensible, in that they address the structure of post-graduate medical training for the good, I must admit that I feel a little out of my depth in this particular area, it is a tiny bit small print.

"Recommendation 27
To incentivise Trusts to give education and training sufficient priority they should be integrated into the Healthcare Commission’s performance reporting regime.

Recommendation 28
Responsibility for the local delivery of postgraduate medical education and training should form part of the explicit remit of Medical Directors of Trusts. Part of that responsibility should include regular reporting to Trust Boards on the issue.

Recommendation 29
Training implications relating to revisions in postgraduate medical education and training need to be reflected in appropriate staff development as well as job plans and related resources. Compliance with these requirements should form part of the Core Standards."

The logic behind these ideas is also sound, training should be a much higher priority for Trusts than it currently is; at the moment training is the first to suffer when money is scarce, short termism from Trust management like this must be prevented in the future. I can't help but think that it will take a lot more than Tooke's well intentioned recommendations in this area to have the effect that Tooke wants. The medical unions and doctors as individuals must remain militant in order to force these sensible ideas and principles into practice. As if people become complacent, then these recommendations will be looked back on as yet another load of hot air that achieved very little in practice, like 'Clinical Governance'; who could argue with the ideas, but in practice it is just a pretence at functionality. It takes actions to improve a system, not just words.

Opinion seller?

The sham of Labour's consultation exercises as regards the recent NHS review have been much talked about of late, and Dr Ray has been keeping a pretty keen eye on events. The ferret has been in touch with the lovely DoH about how exactly this consultation has been engineered with some interesting results:

Ferret: How have lay members of the public been chosen for events? DoH: Each deliberative event was attended by a regionally representative sample of members of the public (demographic data was taken from census data), with specific quotas set on health status (including use of certain services in the past two years). This ensured that there was a broad mix of members of the public, many of whom had used services and were in a position to give views based on their own experience of healthcare provision.

So the group of hand picked citizens are representative, but the question is neatly ignored, how are they selected though?

Ferret: Who has received invitations to these events?

DoH: Participants were recruited locally, to ensure a wide representation of the public. Members of NHS staff were nominated to attend by their Strategic Health Authorities.

Ferret: Where have the consultation events been advertised?

DoH: The events on 18 September were not advertised.
This is very suspicious, the NHS staff members were nominated by the SHA and the event was not advertised.

Ferret: Did the DOH/ministers/others discuss how to select people who would attend such events?

DoH: Officials at the Department of Health held discussions with the external contractor to ensure that a wide spectrum of people would be represented.

Ferret: If so, I would like to see records of these discussions.

DoH: There are no records of these discussions.

This is also suspicious, the DoH has no records of these important discussions which would reveal exactly how the external contractor was briefed to select the members of the citizens' juries.

There are several worrying issues here. The future of the NHS is being decided by this consultation process, a process which is not open for anyone to attend and which is not advertised. More worrying the government is paying a private firm to run this consultation and then not keeping records of how this firm was briefed to go about its job of selecting members of the public. Their is a funny smell here, and it is not one of democracy.

The ferret's guide to Tooke: Part 4

"Recommendation 18
The medical profession should have an organisation / mechanism that enables coherent advice to be offered on matters affecting the entire profession, including postgraduate medical education and training."

The BMA have certainly not been up to the task, it begs the question 'who is up to this mighty task?'.

"Recommendation 19
There should be enhanced opportunities for training in medical management during postgraduate training years to fuel an increase in clinically qualified managers and an awareness of the interdependency of clinicians and managers in the pursuit of optimal healthcare."

This is a good idea, there should be many more managers who actually understand clinical work and who have experienced life at the coalface. It is one great use of doctors who are not up to the task of clinical practice, they are likely to make much better managers than non-medically trained managers.

"Recommendation 20
Doctors in training should be better represented in the management structures of Trusts to ensure that they better understand service pressures and priorities and Trusts better appreciate their service role and training needs."

Another solid idea, doctors in training should be involved, this would promote an environment of cooperation. The management ideas are good, however there is a rather glaring omission, the issue of completely incompetent NHS managers is not addressed; maybe this is not within John Tooke's remit, even so, the general incompetence of NHS management and the way in which clinicians are ignored is something that needs to be addressed by somebody.

Big Brother says so

George Orwell would not know whether to laugh or cry if he were alive to read the latest propaganda released by the Ministry of Untruth, aka the Department of Health. It is titled:

"New data shows NHS working smarter"

It then makes the bold statement:

"The latest Better Care, Better Value indicators show that in the past year, the NHS has released £363 million by working more efficiently."

The claimed savings are huge:

"Length of stay        £152m
Day case rate           £2m
Pre-op bed days         £4m
Surgical variation      £9m
Emergency admissions   £79m
Outpatients            £40m
Statins                £77m"

Unsurprisingly there is a rather significant catch to this miraculous bulletin of good news:

"The productivity opportunity for each indicator is calculated by assuming that organisations improve their performance to that of the top 25% of organisations for that particular indicator."

This is rather a large assumption to make, the DoH is admitting that its figures rely on an assumption that all organisations will improve their performance to that of the top 25% of organisations for that particular indicator! Obviously in an ideal world all organisations would be prefect and one could assume this; however it is plainly ludicrous to assume that all organisations, including the worst 25%, will perform out of their skins in this way. The details to the DoH's brainless logic can be seen here.

Basically the Department of Health is predicting massive savings based on the assumptions of a two year old. I too could predict billions of pounds saved if I assumed that people would stop getting ill and therefore would not need any health care at all. In fact this is how the government is saving money all around the country, for example in my PCT certain essential operations and investigations are no longer funded at all. This is such a great money saving scheme. In fact why don't PCTs stop funding cancer treatments, emergency care and so on; it would save a lot of money?

I shouldn't joke, with so many centralised organisations wasting so much money such as the NHS Confederation, NHS Employers, NHS Choices, Our NHS, NHS Direct, NHS University, Healthcare Commission, NICE, PMETB and on and on,; it's quite amazing that there's any money left over to treat patients!

The ferret's guide to Tooke: Part 3

"Recommendation 11 DH should have a coherent model of medical workforce supply within which apparently conflicting policies on self-sufficiency and open-borders overproduction should be publicly disclosed and reconciled. The position of overseas students graduating from UK medical schools needs to be clarified with regard to their eligibility for postgraduate training."

Recommendation 12 DH Workforce should urgently review its medical workforce advisory machinery to ensure that it receives integrated and independent advice on medical workforce issues to inform/complement SHA and local deliberations. Both national and devolved workstreams must be adequately resourced. The medical workforce advisory machinery should also take account of national policies impacting on the workforce such as the shift of more care to the community. Revisions to the current arrangements need to reflect the following principles:

• Medical workforce planning needs to embrace the consensus view of the role of the doctor referred to in Recommendation 5
• Plans should be based on robust information on available and projected medical specialist skills, requiring relevant databases.
• Whilst recognising that doctors are just one part of the workforce, sufficient attention and resource need to be devoted to medical workforce planning reflecting doctors’ crucial roles and the expense involved in their development.
• A national perspective needs to be integrated with regional requirements, particularly with regard to the maintenance of sufficient subspecialty expertise to meet the needs of the nation, and the overall health of clinical academia. Consideration should be given to the creation of an arm’s length body, a National Institute for Health Education, NIHE, mirroring NIHR to undertake commissioning of higher specialist training that is not required in every locality. The criteria for the award of such training positions should reflect the Trust’s performance in relation to training, innovation and clinical outcomes.
• Professional advice to the medical workforce advisory machinery needs to include that from doctors at the cutting edge of their discipline with the foresight to project potential developments in healthcare.
• Regional workforce plans should be subject to a national oversight and scrutiny advisory committee with service, professional and employer representation. Such oversight should encourage local responsiveness and acknowledge issues facing the devolved administrations whilst ensuring national consistency on roles and standards.
• Modelling capacity should be enhanced by drawing on the expertise in the University sector, e.g. health economists, epidemiologists, modellers etc. The assumptions underlying projections should be subject to professional scrutiny and regular review."

The DoH should sort out its incoherent workforce planning, no argument with these recommendations.

"Recommendation 13 The Panel recommends that DH should work with the GMC to create robust databases that hold information on the registered/certificated status of all doctors practising in the UK. This will provide an inventory of the contemporary skill base and number of trained specialists/subspecialists in the workforce as well as those in training for such positions to inform workforce planning."

This is something that should have been done a long time ago, the GMC should be made to do something useful for the massive amounts of money it receives.

"Recommendation 14 The content of higher specialty training and the numbers of positions will be informed by dialogue between the Colleges, employers, and medical workforce advisory machinery to allow finer tuning of the nature of the specialist workforce to reflect rapidly evolving technical advances and the locus of care."

Strangely there is no mention of the medical unions here, I am of the opinion that the unions must be involved in this key area.

"Recommendation 15 Explicit policies should be urgently developed and implemented to manage the transitional ‘bulge’, caused by the integration of eligible doctors into the new scheme, with appropriate credit for prior competency assessed experience."

This is far easier said than done, for example PMETB are unable to manage their current workload; this complex task would certainly not be managed adequately by them.

"Recommendation 16 DH should recognise the burgeoning supply of medical graduates it has commissioned and make explicit its plans for the optimal use of their skills for the benefit of patients. It is recommended that sufficient numbers of Core Specialty training posts (see Recommendation 33) should be made available to accommodate doctors successfully completing FY1 and the use of commissioning funds for this purpose should be monitored."

The DoH must be held to this, graduates from the UK must have training opportunities available to them.

"Recommendation 17 Career aspirations and choices should be informed by accurate data on likely employment prospects in all branches of the profession and the likely competition ratios based on historical data, supplemented by professionally agreed foresight projections. Such information should be updated annually by the redesigned medical workforce advisory machinery and made publicly available so as to inform would be medical students, students and trainees. Medical schools should play a greater role in careers advice including i) information in prospectuses concerning career destinations and likely competition ratios, ii) offering selective components of the programme to allow experience in discrete specialties, iii) formal personalised advice/ mentoring."

Not much to quibble about here, the workforce machinery should start doing it's job properly. Overall this seems to be the them from this section, the DoH should start damn well doing its job properly.

The principles of communism

The government has a cunning, some would say not so cunning, knack of tricking people into their way of thinking with games of logic that we really should have learnt to side step by now. I would like to demonstrate how this occurs; to understand simply read through the three case studies below and all will become clear:

1. Communism.

Principles of Communism (as described by Frederich Engels)

• establish a classless, stateless social organisation
• based on the principles of social and economic equality
• common ownership of the means of production

2. Modernising Medical Careers.

Principles of MMC (as described by Liam Donaldson)

• be programme-based;
• be broadly-based to begin with for all trainees;
• provide individually-tailored programmes to meet specific needs;
• be time-capped;
• support movement of doctors into and out of training and between training programmes.

3. The Dilbert principle (as desribed by Scott Adams)

• management used to work on the Peter principle, ie capable workers were promoted until they reached their level of incompetence, they were then moved into management
• management is now based on the Dilbert principle, ie the most ineffective incompetents are now moved straight into management before ever finding that thing called competence

The three above examples are very different, two of them share rather a lot in common, while one is a rather astute observation that has some marked relevance to the NHS management. Communism and MMC are two ideas that superficially appear well intentioned and noble in principle, however first appearances can be deceptive. Who knows if the stated principles were genuinely well intentioned, in both cases it did later became apparent that those in power would not stay true to their noble ideologies but would primarily seek to service their own interests, while the ideas in practice were very different to their initial appearance on paper.

If I offered to babysit for your family, and set out a list of noble principles on powerpoint that included 'child safety', 'house security' and 'owner satisfaction', then I am sure you would expect me to live up to my principles and do a good job. If I proceeded to lose the children at the off license, get blind drunk on super strength cider and burn down the house while trying to make a bacon sarnie, then would my noble principle save me? And would I be rehired after an enquiry into events, as long as the noble principles of good babysitting were reiterated?

I think not. So why do we keep falling for this principles malarkey? Tooke wants to reassert the principles of Modernising Medical Careers, this sounds good and well intentioned; however if the same incompetents are still in charge of all the same incompetent institutions that have control of medical training, then practically will anything actually change? Answers in the white space below please.

Darzi's advisory board

These are the members of Professor Darzi's advisory board as stated in his interim report:

Dr Sam Everington (GP from East London and Member of BMA Council)

-member of the Labour party and health adviser to the Labour party

Dr Michael Dixon (GP from Devon)

-OBE for 'for services to Primary Health Care' and of Chair of NHS Alliance, an organisation backing the government's strategy in reforming primary care

Prof Mayur Lakhani (GP from Leicestershire and Chair of Council of Royal College of GPs)

Sir John Oldham (GP from Glossop)

-former Head of the Improvement Foundation, that organisation that supports all government reforms

Ursula Gallagher (Community Nurse and Director of Quality, Ealing PCT)

- a loyal PCT manager no doubt

Andrew Burnell (Community Nurse and Director of Provider Services and Nursing, Hull PCT)

-another loyal PCT worker

Paul Farmer (Chief Executive of MIND)

- also a member of the Department of Health National Stakeholder Forum and the Department of Health National Choice Group

Anne Williams (President of ADASS)

- President of the organisation 'Association of Directors of Adult Social Services' that she was on the steering group to establish

Alwen Williams (CE, Tower Hamlets PCT)

-another loyal PCT worker

Dr David Colin-Thomé (National Clinical Director for Primary Care)

- a former Labour party candidate

No one could realistically argue that this is not a very conveniently compliant advisory board, it is strange that there are so many close links to the Labour Party and the PCTs. This is hardly a selection of expert opinion, there are no microbiology experts, there are no public health or health policy experts, this is nothing short of a disgrace. The only problem is that we have become so used to this kind of corruption of the democratic process, that it is now just standard fare, and that is a very sad indictment indeed. We are hardly short of examples of this sytematic corruption.

The ferret's guide to Tooke : Part 2

"Recommendation 5
There needs to be a common shared understanding of the roles of the doctor in the contemporary healthcare team. Such clarity must extend to the service contribution of the doctor in training, the certificated specialist the GP and the consultant. Such issues need to be urgently considered by key stakeholders and public consensus reached before the end of 2008. Education and training need to support the development of the redefined roles."

This seems a good suggestion, the role of a doctor has been eroded over recent years by the advancement of certain less thoroughly trained quacktitioners, it is therefore important that the role of the doctor is properly defined. However I am no fan of the artificial line that some see dividing service and training, so defining the service role of trainees with clarity may not be such a good thing. I think the roles that trainees have should support training and not the other way around, as Tooke phrases it. I see a little room for some cynical government manoeuvring here.

"Recommendation 6 DH should strengthen policy development, implementation, and governance for medical education, training, and workforce issues, embracing strong project management principles and addressing specifically a) clearer roles and responsibilities for a single Senior Responsible Officer, b) clear roles and accountability for senior DH members, c) better documentation of key decisions on policy objectives and key policy choices, d) faster escalation and resolution of ‘red risks’."

Again I cannot argue with this recommendation, the DoH's incompetence and unaccountability must be addressed; but given the DoH's record on staying with the rules, it is easy to say but probably much harder to put into practice. Surely those at the DoH who played a big role in the MTAS scandal should be held accountable now? This would set a precedent that would deter future DoH miscreants.

"Recommendation 7 The introduction of necessary changes stemming from this report should i) involve all relevant stakeholders especially professional representatives, ii) abide by best principles of project and change management include trialling where appropriate and feasible, iii) be subject to rigorous monitoring and evaluation."

Again good banter, but who does the monitoring and evaluation?

"Recommendation 8 Recognising the interdependency of education, clinical service and research DH should strengthen its links not only within the Department and with NHS providers but also with other Government Departments, particularly the Department for Innovation, Universities and Skills and the Department of Business, Enterprise and Regulatory Reform. Ministers should receive annual progress reports on the development and functioning of such links."

I am sceptical that this ever proliferating band of government departments could actually organise themselves to do anything useful as individual departments, let alone in combination with each other. Are there not too many departments such as these which spend a lot of money not really doing much of any use?

"Recommendation 9 At a local level Trusts, Universities and the SHA should forge functional links to optimise the health:education sector partnership. As key budget holders SHA Chief Executives should have the creation of collaborative links between local Health and Education providers as one of their key annual appraisal targets."

Again, a good idea, but will it happen?

"Recommendation 10 All four Departments of Health in the UK and the four Chief Medical Officers must be involved in any moves to change medical career structures. In many instances it seems likely that the Department of Health in England will continue to have a lead role but from time to time, collective agreement may determine that lead responsibility for specific issues passes to another Health Department and/or its Chief Medical Officer. Regardless of which Department leads, accountability should be explicit and every effort made to acknowledge the views of the four countries."

The problem here is that the Medical Officers do not appear to be guided by the majority opinion of the medical profession, so involving them may not help matters unless the way in which the Medical Officers are selected is changed. An improvement that would guard against cynical government reform, would be to involve the medical unions or the medical profession when selecting representatives such as the Medical Officers. I, for one, have no faith in Liam Donaldson's ability to represent our profession's interests; it appears that he is keener on personal advancement than doing a good honest job.