Short staffed and enslaved

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

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

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

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

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

PCTs 'incapable and useless'

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

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

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

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

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

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

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

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

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

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

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

BMJ praises Hospital at Night

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

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

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

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

They have conducted a comprehensive analysis of this project."

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

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

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

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

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

Dementia spinning

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

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

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

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

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

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

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

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

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

and

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

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

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