Words of a not so junior doctor

Sadly despite our common goal of improving NHS care, talks between our union, the BMA, and government broke down many months ago due for reasons which have yet to become fully clear.  Recently the overtly hostile and aggressive mode of the government’s ongoing threat of unilateral contract imposition upon junior doctors has been particularly morale sapping and depressing to endure.  After all, I am rightly expected to be totally honest with my patients, so how can it be fair or right that the government and Jeremy Hunt treat me and my colleagues with such a total lack of dignity and respect?  The details of the contract are complex but the key flaws within the government’s argument can be summarised fairly succinctly.

Jeremy Hunt and the government claim contract reform is essential to create a ‘truly 7 day NHS’.  There are two critical problems with this as what is meant by a ‘truly 7 day NHS’ has yet to be defined, while many NHS services have already been reformed to become high quality fully 7 day services and this has been done within current contracts and well before Mr Hunt’s reign began.  Notably this has only been managed because ground breaking reforms in areas such as cardiology and trauma were clinically driven and the views of those who would have to deliver these very reforms on the frontline were honestly sought.  Therefore the government’s argument is a weak straw man; existing contracts are perfectly compatible with improving services, while pretending to reinvent the wheel of ‘7 day services’ does not magically create a new wheel.

If Jeremy Hunt and government wanted to incentivise better care at weekends, then surely the new contract to achieve this aim would have to increase the reward for antisocial working?  One would think so, which makes it particularly strange that the new contract imposition rewards antisocial hours less than the current deal.  This is particularly problematic in terms of the recruitment and retention of doctors, which are already in pretty dire straits in several areas including General Practice, A&E, Paediatrics and Psychiatry.  Jeremy Hunt’s ‘11% pay rise’ is a disingenuous sleight of hand, the deckchairs have simply been rearranged, the overall pay package is unchanged, money has simply been moved away from rewarding antisocial hours and into the basic pay pot.  Given that recruitment and retention is particularly dire in many of the specialties with a lot of antisocial hours, this makes the contract particularly regressive and potentially unsafe in terms of creating more dangerous gaps in rotas. 

Jeremy Hunt has claimed that junior doctors will work fewer hours under the new contract but has actually removed the only robust contractual safeguard against excessive hours from the contract, the financial penalties for employers who breached hour limits.  At the same time he has introduced nothing credible with teeth which could possibly ensure that his vision could become a reality.  Many of us already work many extra overtime hours which are currently unpaid by the current system, despite Hunt’s ignorantly offensive claims that doctors lack ‘professionalism and a sense of vocation’, the system is still very reliant on this professional goodwill.  Again Hunt’s claims do not fit with the objective reality of the new contract, there will be no more doctors, and with the removal of our only robust hours safeguard, it is highly likely that junior doctors will be left unprotected from dangerous excessive hours.  This inevitably means that patients will be needlessly put at risk of harm; as there is a plethora of solid evidence showing that tired doctors make considerably more mistakes. 

There are many more significant flaws in Hunt’s contract including the negative effect on both research and gender equality, but the recurring themes remain the same: there is a gaping chasm between the government’s rhetoric and the likely reality of the contract they aggressively threaten to impose.  It is no coincidence that both representatives of the Department of Health and Jeremy Hunt routinely refuse to appear in public or in front of the media to take open questions on this mismanaged dog’s dinner, while junior doctors are more than happy to be questioned live and to speak to members of the public on the street to inform them of the reality of this toxic contract imposition.  If the government had such a great progressive contract on the table, why do they hide from public discussion and why have 98% of highly educated professionals voted in favour of industrial action?  The stressful dilemma facing us now is that none of us want to strike, what we want is a safe contract which is compatible with a sustainable 7 day NHS.  However the government has not given us a good option, we have the option of industrial action or a regressive dangerous contract which will destroy any hope of a safe sustainable 7 day NHS in the longer term.  With heavy hearts we have opted for the least bad option of industrial action, knowing not where it will lead, but at least knowing we are doing the right thing for what we hope will be our many future patients in the NHS.  We want negotiation but we welcome the recent move from Jeremy Hunt to engage in conciliatory talks with the BMA via ACAS, however while the government refuses to withdraw its threat of contract imposition meaningful negotiation cannot happen and a strike remains inevitable.

I am honestly not sure what I am meant to feel anymore, the emotional rollercoaster has still to run its course.  Since I graduated from medical school over ten years ago life has certainly had its up and downs, the biggest ups were getting married and having a wonderful daughter, the downs have included failing several exams along the way and the incessant shifting of the goal posts in medical training.  On the whole medicine has been a wonderful career, being a doctor is a great privilege in ways I had not imagined before embarking upon this journey; simply being in a position to meet and learn from so many fascinating diverse characters is a great privilege.  It says a lot given how rewarding I find the day to day job, that I doubt that I would encourage my daughter into medicine these days.  It is a pretty sad indictment on the mismanagement of this situation by the government and Jeremy Hunt that they are bullying through the creation of an environment in which I would not want to see my own child work, consequently they are sculpting an NHS in which I would not want to be a patient, and that is the most damning indictment of them all.  The continued creation of a high quality 7 day NHS can only be done with collaborative and cooperative working, bullying misguided flawed policy from on high will only create more problems, not solve them.

Dear Mail Group.......

Dear Mail Group

I am writing for several reasons, all under the same general umbrella of admiration for your mighty journalistic tradition which invariably serves the public interest above all else.  It is most excellent that you are now taking such an interest in the junior doctor contract story, particularly the way in which you are now focusing on the characters involved, it is most educational and intellectually invigorating.    Obviously the fact that doctors are in uproar about the lack of robust safeguards to protect their patients from doctors working dangerous excessive hours is not really important.  Also the fact that antisocial hours are going to be less rewarded during a global recruitment and retention crisis is also immaterial, the inevitable workforce crisis that will result will not matter.  It is far more noteworthy to Mail readers that some junior doctors are also young photographic entrepreneurs and have healthy interests outside of medicine, does this make them capable of membership of David Cameron’s ‘party of the workers’?  Or is membership of this neat little club contingent on only particular types of work such as running a hedge fund or banking?

The fact that we already have excellent 7 day services in many areas with the current doctor contracts is also irrelevant, we should simply trust Jeremy Hunt when he says contract reform is necessary for improving the quality of care, he is a man with an impeccable record, a man without conflicts of interest, a virtuous beacon of noble text messaging just at the right Murdoch moment.  This honourable Health Secretary would never attend non minuted meetings during taxpayer funded working time with newspaper editors such as Geordie Grieg of the Mail on Sunday in June 2014 and  then refuse to release any details of what was discussed, would he?  That pesky Freedom of Information does need scrapping while we’re on that topic, allowing the public to understand the real motives lurking behind the big decisions would not really help propagate the benevolent interests of the Daily Mail owners would it?   Meanwhile it is quite right that the Mail ignores the ‘Hunt effect’ which demonstrates that the Health Secretary’s scaremongering may be costing patients their lives; it is also quite irrelevant that Hunt has been instrumental in burying the most important lesson from the Midstaffs disaster, that being the vital  safe staffing work by NICE.

 Anyway I digress, I am just so grateful to you for your powerful investigative journalism, it really is a battle against all the odds, David against Goliath: months of painstaking fieldwork lurking on ‘secret’ forums populated by thousands of people which effectively makes them open, covertly watching and waiting, and then striking out, in brazen tones, and motivated above all else by what you think is right, right for you, for your Editor, for your owner, and right for the short term needs of your newspaper.  While we’re on that topic, it’s worth remembering the benevolent history of the Mail itself, Lord Rothmere was a friend to so many, not matter their race, religion or creed, Hitler and Mussolini were certainly not left out of his fold, what a terrible shame that the rest of the British press did not give fascism the support it so deserved.  It is also notable that the working class ownership of the Mail continues with the controlling shareholder of the Mail Group the 4^th Viscount Rothmere is worth around a billion pounds and is a keen supporter of David Cameron.  It is also notable that the noble Viscount, when not fighting for the poor, has non-domicile tax status and pays very little tax on his income, investments or wealth. 

Back to the topic in hand, the Mail really is spot on with its excellently researched article so appropriately entitled “Junior medics’ attempt to plunge the NHS into crisis”.  It really is about time that these lazy workshy junior doctors took their fair share of the blame for the crisis that the NHS finds itself in today.  If only these arrogant spoilt medics, who dare own homes and spend weekends doing things other than working, had implemented the Conservative party’s magnificent Health and Social Care Act better, then we would be not be in the mess we’re in today.  Surely funding shouldn’t matter and the real terms reduction in funding that frontline services have experienced should really be no excuse, these lazy wasters should be working for free and donating their personal possessions to the cause to make up for the government’s rank incompetence.  By fighting against Jeremy Hunt’s magnificently progressive new contract, which promises to make everything better because he says it will, they are the ones to blame for any resulting crisis.  They should just accept this great new deal, after all who needs safeguards from dangerous excessive hours, who needs to retain and recruit staff when there are numerous huge gaping chasms in rotas already, who needs to value staff and reward them fairly for working more antisocial hours? 

The fact that the workable details of the contract have yet to be revealed despite Hunt threatening to impose it in well under a year is a trivial minor snag, these whingeing junior medics should get on with it, sell their kidneys and just damn well do what is in the greater good of the Conservative party.  7 day working according to Hunt will be magnificent, staff recruitment in Australasia is going well, social care is in crisis, spreading everything thinner over 7 days will have obvious gains, the inevitable staffing crisis will be used as a convenient excuse to centralise emergency services, shut lots of smaller hospitals that only the public want, and then it will be child’s play to sell off a lot of profitable elective services to the private sector vultures who are already lurking in the shadows.  This is democracy; this is progress, for the small minority of super wealthy people like our esteemed Viscount it is.

Finally one last thank you, I am so very grateful for your finely engineered prose who so succinctly details the real problems with the junior doctor contract situation.  If only the country was governed by the Daily Mail, what a place it would be, we could get rid of these workshy lazy maggot-like junior medics, we could dump them on Australasia as the convicts of old, and if we are to believe the honourable Mr Hunt, they could simply be replaced with various health ‘Apps’, after all technology is the way forward, long live the Viscount and the party of the 'workers'!

With love

A junior doctor

Letter for Jeremy Hunt via HEE

Dear Health Education England

I am writing in response to the message sent by Jeremy Hunt, the Secretary of State for Health, which was sent out to all junior doctors by you on the 4/11/2015.  It is most excellent that there is now a direct channel of communication between junior doctors and Mr Hunt.  As you now appear to be acting as his intermediary, I would be very grateful if this could be forwarded straight back to Mr Hunt,

Thanks

Ben Dean

Dear Mr Hunt

It is most kind of you to have spent the time to write a letter to junior doctors and send it to us via Health Education England (HEE).  I know you are a very busy man and that it must be hard to find time to keep up to date on what junior doctors do and our contract situation, especially given you have so many non minuted meetings during taxpayer funded time with editors from newspapers such as the Sun, Mail, Times and Telegraph.  I also know you are very busy keeping up to date with the latest research from NHS England.  It was also much appreciated that your message reached us via the media well before the email from HEE, I presume this was just to make sure the message got through, it was so very thoughtful indeed.  Anyway onto a few simple points I would like to make regarding the junior contract situation, I presume they were all innocent errors, after all you do have so much on your plate.

Firstly on safety, I would love to know a little bit more about the details of how junior doctors will be protected from excessive dangerous hours by CQC inspections.  The removal of the current system of hours monitoring which is a robust independently overseen process with real teeth and its replacement with a system which appears utterly toothless appears nothing other than dangerous.  The assumption that the CQC will manage to enforce safe hours with a 40% cut in funding, without the necessary expertise and without proper independence from government, appears nothing other than cloud cuckoo delusion which will catalyse the acceptance of dangerous working practices.

Secondly on the ‘pay rise’, the way in which this has been released and propagated in the media is nothing other than a disingenuous insult.  It is worth remarking that junior doctors are not paid for overtime, our routine rota’ed hours are covered by basic pay and banding supplements.  Certainly this is an unusual system but it works pretty well, but it does mean that effectively our basic pay for routine hours worked consists of both our basic pay and our banding payments combined.  In reality our pay is at best being frozen, and in three years’ time when the sticky plaster pay protection ends, many of us will experience significant pay cuts.  Therefore please stop misleading the public by pretending that a rise in ‘basic pay’ represents a pay rise, it clearly does not.

Thirdly on your 7 day reforms, it should be noted that many services are already high quality and 7 day, and this has been achieved effectively using current contracts for both junior doctors and consultants.  The way in which you pretend contract reform is necessary for improving the quality of patient care is both deceptive and dishonest.  Given the recruitment and retention crises we are experienced in many areas of medicine today, forcing more antisocial hours of no extra reward is likely to worsen this already brittle situation, thus posing a serious threat to patient safety.  This ignorant ‘Gatling gun’ approach to service reform is unsupported by a credible evidence base and likely to be highly counter-productive, both in terms of financial sustainability and in terms of patient safety.

Fourthly on the argument that transparency can drive better systems for patients, one you have used rather selectively in various speeches in recent months.  I am a strong proponent for openness and transparency; however one has to be consistent in applying this logic.  You have frequently exploited the Midstaffs scandal for your own political gain, but sadly the most important lesson from this mess looks like being ignored.  The NICE safe staffing work has been buried under your watch as a result of political expediency; this is a travesty for those who have suffered poor care in the NHS.  This is not the only example of your cherry picking when it comes to transparency, your refusal to release details of what you discuss with editors from newspapers such as the Sun, Mail, Times and Telegraph is another classic one.

I would so much appreciate if you had time to respond to the specific of these concerns raised, whether you choose to answer these via HEE, the media or directly to myself, I would appreciate some honest answers whatever the mode of delivery.  Certainly given how frequently you meet with the media behind closed doors, it may be easiest to get your response out as a Sun or Times editorial, I’m sure I would be able to notice it was you responding, even if you were not named directly.  I do realise you are a very busy man, I know you have a copy of Trisha Greenhalgh’s excellent book on evidence based medicine to read, as well as a letter from the BMJ editor Fiona Godlee to respond to, you also have meetings with the Colleges to attend to, as well as liaising with NHS England about their research agenda.  Thanks so much for your time, I do hope you don’t have to resort to hiding behind vegetation this time around,

Yours

Ben Dean

DH miss the point and fail to apologise for breach of confidentiality

This is the full response I have received from the DH:

"Our ref: DE00000948527 

 

Dear Mr Dean,
 
Thank you for your recent correspondence to the Department of Health about the image used in a tweet posted on 17 July.  I have been asked to reply.

The Department has looked carefully at this matter and what took place was an entirely unintentional mistake.  The Secretary of State for Health’s sole intention was to celebrate some excellent clinical work he was grateful to have been able to see first-hand at University College London Hospital.

As soon as the Department was alerted to the mistake, the image was removed and replaced.
 
I hope this reply is helpful.

Yours sincerely,
 
Paul Larkin
Ministerial Correspondence and Public Enquiries
Department of Health"

 

The DH totally fail to see the point of the complaint.  It is utterly irrelevant that the clear error was 'unintentional'.  Jeremy Hunt clearly breached patient confidentiality with his tweet and there has been zero consequence to this action.  We have not even seen the whiff of an apology.  Given Hunt's talk of candour and the way in which frontline staff are regularly punished for such clear breaches, it is utterly limp of the DH to write off such a breach in this manner.  It really says a lot about their incompetence and their failure to live by the rules which they are happy to destroy others with.

Jeremy Hunt tweets photo with in-patient names clearly visible

 

Jeremy Hunt is not having a great day and my heart bleeds.  Having attacked and denigrated NHS staff as he continues his campaign of destroying the NHS as a publicly delivered service, poor Jeremy made the error of tweeting a photo of himself posing within a hospital ward with hospital staff.

Unfortunately for Jeremy he tweeted this photo and contained within was a board listing all the patients on that particular ward.  The patient names were clearly visible.  If a doctor did such a thing, they could expect definite consequences.  As things stand the tweet stayed up for a good few hours, then was replaced by a new tweet with the patient board fuzzed through.  There has been no apology or admission of this confidentiality breach as yet.

I would urge everyone to write to the Department of Health via their online complaints form below.  At the very least Jeremy Hunt should apologise for his tweet and apologise to all those whose names were clearly visible in the original photo.  He is a senior public official and should know far better, after all isn't candour something he feels strongly about?

 

http://www.info.doh.gov.uk/contactus.nsf/memo?openform

 

"Dear DH

 

I would like to make a formal complaint about Jeremy Hunt's tweet on the 17/07/2015 (see attached screen grab).

 

The photo shows patient identifiable information clearly on a board in the top left of the photo.

This tweet constitutes a clear breach of the Data Protection Act.

 

I expect this matter to be thoroughly investigated and at an absolute minimum Jeremy Hunt should issue a full and frank apology to the patients whose confidentiality he has clearly breached,

 

regards"

GMC consultations - please respond!

Here is my response to the GMC consultations on 'credentialing' and 'generic professional capabilites':

 

"Dear GMC

As regards the two consultations:

Firstly as regards credentialing, the whole premise behind your goals is flawed.  There is no proven benefit to introducing credentialing.  It simply cannot be assumed that introducing credentialing will enhance regulation and protect patients.  Rather the opposite is more likely, credentialing is likely to result in more expensive box ticking paperwork which will distract clinicians from protecting patients and will provide no tangible gains to patients.  The benefits to credentialing should be proven before an expensive and possibly harmful bureaucracy is forced upon doctors against their will.

Secondly as regards the 'generic professional capabilities', the whole premise behind this plan is deeply flawed.  Doctors in training are already overwhelmed by a burdensome bureaucratic system that consists of largely unreliable and poorly validated assessments.  The harm done by such a flawed competency based framework are clear and well documented in the medical literature.  While the framework domains adds nothing to what is assessed by the extensive array of assessments that doctors in training are already subjected to today.  The GMC has simply not provided a clear rationale as to why such a framework is necessary.  Without a proven need the framework promises to introduce yet more burdensome bureaucracy on doctors in training at a time when service pressures are becoming increasingly unsustainable.  While the talk of assessments will simply lead to more box ticking of more poorly validated assessments which will do nothing to help standards or patients, rather the opposite.

I would therefore like to register my general lack of faith in both these consultations as the need for these proposals has not been adequately demonstrated,

First the GMC should do no harm,

regards"

 

 

I would urge all doctors to email your thoughts to educationconsultation@gmc-uk.org - do not feel obliged to use the GMC's highly constrained white space forms, simply express your opinion to them without being pidgeon holed.

GMC spend on media relations

"The GMC Media Team

 

The Media Team work with colleagues across the organisation to promote the work of the GMC; and they have direct relationships with a variety of journalists, from both national organisations and specialist publications.

 

There are 4 different roles within this team and the staff resources have been allocated as follows:

 

·         Head of Media Relations (London Level 2) – £60,444 – £92,530
·         Media Relations Manager (London Level 3) – £39,766 - £58,338
·         Media Relations Officer (2 officers in Manchester Level 4) - £23,413 - £34,090
·         Media Relations Officer (2 full time, 1 part time officers in London Level 4) – £29,078 - £42,546
·         Communications Executive (London Level 5) – £25,582 - £37,337"

This appears to me to be quite a lot of money and funded by doctors.  Certainly this is a discussion that should be had in the public arena.

Niall Dickson's response.....:)

"The independent Shape of Training review was established by the four governments of the UK and was supported by a number of organisations including Health Education England, The Medical Schools Council, NHS Education Scotland and The Academy of Medical Royal Colleges.

It was the GMC’s role as the secretariat to arrange meetings with a whole range of organisations to enable them to discuss the proposals. However, it is ridiculous to suggest that there were any so called ‘secret meetings’ held with politicians or anyone else. Of course there were routine meetings to help Professor Greenaway gather views from those with an interest in this area. There was also a public consultation, discussions and country-wide events throughout the process and the details are available for all to see on the Shape of Training review website.

As is perfectly normal the only notes taken were by GMC staff, the purpose of which was to support our secretariat role and as an aide-memoire for the sole use of Professor Greenaway who led the review. It is standard practice for these types of notes not to have been publicly available.

There are differing views among stakeholders as to what changes are required but there is a consensus that more needs to be done to meet the changing needs of patients and to provide high quality care in the future.

The review has made recommendations that could require changes to postgraduate training and everyone accepts that more work needs to be done to understand the benefits and impact of this. However, any proposal for change will involve seeking the views of doctors in training, those who train doctors, and those who fund education, training, and the health services across the UK."

I have reproduced Niall Dickson's response above, just in case it is retracted.  I have to say I found it rather revealing for several reasons.

Firstly Niall Dickson claims it is 'ridiculous' to claim there were any secret meetings, however there is no justification to support this statement.  The meetings which were called 'secret' took place behind closed doors, were not formally minuted, were not referenced in the review's paper trail and were not reflected in the review's evidence section.  To anyone outside the review, the meetings can accurately described as 'secret' in my opinion.

Niall Dickson is also rather economical with the story on the GMC's use of the meeting notes as the GRC judgement made clear.    The talk of 'consensus' is ironic given that the key review recommendation to shorten consultant training went against the majority of the consultation respondents' opinion.

Finally the response from Niall Dickson totally ignores the four questions posed to the GMC about various issues that were unearthed and supported by various pieces of evidence, I wonder why Niall?

Due process, or lack of it, and the Shape of Training

This week the BMJ published my opinion piece on the 'Shape of Training' review:

"The GMC spent more than £4000 on legal fees in resisting my freedom of information request. The court also commented on information obtained from the GMC’s internal correspondence that did not relate to the Shape of Training review: “The evidence was that at one meeting an individual sought an assurance that the minutes would not be published and his willingness to discuss matters freely was contingent upon getting this assurance.” This shows the general way that the GMC effectively allows lobbying on policy off the record, despite supposedly being an independent organisation."

As I have previously described on several occasions, there are numerous problems with the review.  The case and evidence for the major structural change proposed have never been adequately made, the logic underlying the review's recommendations is lacking, the potentially harmful consequences are huge and the methodology is far from transparent and robust.  There is also the broader issue of transparency and the public interest:

"Without transparency there can be no accountability. A reliance on secret discussions may, therefore, erode accountability, potentially leading to policy that better serves the interests of government than those of anyone else. Why key matters relating to patient safety cannot be “fully considered and debated” in a transparent manner before decisions are made is incomprehensible to me."

Anyway what's the point?  Well the review is currently in the process of being implemented, so every little thing that we can all do now can make a difference to the outcome for our training and our patients.  The simple things you can do include writing to your MP, sign my petition on 38 degrees, write to your Royal College or trainee organisation, and spread the petition/BMJ article on the social media or via email.  Please make the effort, every little bit of momentum really does help.....

More on Shape and well done Tom Dolphin

 

Anyone who reads this blog will be aware of the Shape of Training review, irrelevant of this I would strongly advise you have a glance at this excellent piece in the BMJ exposing several critical flaws of the review.  It is worth reiterating that Shape's critical flaws include its methodology, its lack of transparency, its flimsy evidence base and its dangerous recommendations.

It is easy to criticise, but nonetheless criticism is an important thing as it provides homeostatic feedback and one can only improve if one opens one's ears to it, perhaps this is why reviews that don't listen always end up doing more harm than good.  Undoubtedly the BMA made mistakes on MMC and Tom Dolphin would be the first to admit that, the key thing is that the BMA and Tom Dolphin have realises this and learnt the lesson, those in government would do well to take note of this, it takes courage and insight to do this.

I won't hide the truth from you, I have spoken to Tom on the phone in recent months relating to the review, I must reveal this fact and not pretend that I have not got to know him better.  The point I am laboriously trying to make is that Tom has shown a lot of courage in standing up to those backing the review, he was in a tricky position and it would have been easy for him just to keep his head down and go along with things, he did not, he stood up for what he and many of us think is right for our patients.

Recent developments included a rather vague non-specific statement from the Shape Steering Group, almost as if they want all this fuss to die down so that can force things through after the election.  The BMA have responded cautiously, while trainee groups such as ASiT have called the vague non-specific rambling of the Steering Group out for what it is.  For me we now need specifics on key issues like training time, we need a concrete statement saying that hospital consultant training time will not be shortened as things stand, anything less than this is meaningless waffle.  It is simply not acceptable to continue the implementation of such a flawed review.  Please add you name to this petition and stick it up on Twitter/Facebook, over 5,000 and growing:

https://you.38degrees.org.uk/petitions/stop-the-shape-of-training

The straw men of the 'Shape of Training'

 

So many straw man have been put forward in an attempt to justify the potentially disastrous 'Shape of Training' (ShOT) review's recommendations, that it is slightly tricky to know where to start.  It is also important to acknowledge from the start that it is impossible to discuss these issues logically with some people, much in the same way that it is impossible to debate religion with someone who has a fundamentalist belief that they are right.  Anyway here we go:

Straw man 1: Training is not perfect, hence Shape is justified

Firstly everyone acknowledges that there are problems with training today, however Shape does nothing credible to address these and improve training quality, actually it promises to do rather the reverse by diluting down the quality of the consultant grade of trainers.  ShOT also threatens to worsen other problems with training today including an over reliance on box ticking competency based methods, a lack of employers valuing training and trainer time over short term service needs and the inadequate regulation of training exposure. For example >10% of FY1s get zero emergency exposure throughout their whole first year of work, a really worrying statistic ignored by the powers that be and ShOT.  Opposing SHoT is not the same as saying nothing can or should be done about training.

Straw man 2: Time is a useless measure of genuine clinical expertise, therefore shortening training time is of no consequence to training standards and patient safety

If one withdraws all context, no measure is useful.  In context of the hours worked, the training exposure of a job and the trainer quality, time is a very useful measure of clinical expertise.  For example in surgical training, reducing training time and not improving quality as Shape does, will reduce operative exposure which will have inevitable implications for the quality of the consultant grade.  Time is imperfect as a measure, but in context it is a very useful aspect of appreciating expertise levels and far more valid than many modern tick box assessments.  It is also ironic that Shape talks of valuing the apprenticeship model but seeks to ignore time served as an important factor.

Straw man 3: There needs to be more consultant involvement in our of hours care, this justifies Shape's plans

There are several aspects of this flawed argument in relation to Shape.  Firstly reducing the quality of the CCST/consultant grade has the inevitable safety implications, if consultant delivered care involves effectively re branding registrars as 'consultants' who need to continue training it is not entirely honest with patients and any gains of 'consultant delivered' care may well disappear.  For example one cannot re brand earth as chocolate and expect it to taste as good.  The implications of creating an less autonomous consultant grade who may be stuck at this level indefinitely could be extremely negative for recruitment and retention, meaning that rota problems could well be made worse in the long term by this short sighted strategy.  Also many young consultants are already extremely hands on in clinical terms, why do we need to restructure the whole training system to increase consultant involvement?  Simple, we don't.

Straw man 4: Other countries train consultants in a shorter period, therefore Shape's shortening of consultant training is justified

There are many differences between different countries' training system reflecting differences in factors such as service delivery, hours worked, training quality, training regulation and funding.  It is not apparent that any country currently trains most doctors in some sort of generic ‘generalism’ before then permitting a few to ‘top-up’ their training and become specialists. In much of Europe and North America doctors go straight into specialist training, which is shorter than that in “Commonwealth” countries, but usually has a narrower focus and does not involve much if any generic training, plus in many countries such as the US many more hours/week are worked. This is not the model which is proposed by SHoT, and indeed is not a solution which would work in the NHS as it is currently constituted or funded. The “Commonwealth countries”, excluding Canada but including Ireland i.e. “Commonwealth” is a bit of a misnomer, generally have a model of broad based training, leading to specialist training – but not truncating the majority of careers at the end of this broad based training.   The UK doesn't have a monopoly on excellence in medical training, although it is arguable that those who exit the UK CCST program have a broader and deeper experience than their equivalents at the point of certification from some other countries - in time this levels out, and indeed it may be that if one looks at case numbers and years spent practising it all comes out in the wash.

Straw man 5: Patient needs are changing, hence Shape is justified

The way in which the evidence was analysed to identify and assess the future needs of patients in ShOT was highly flawed and grossly inadequate.  High quality evidence was not provided, the review appeared to simply rely on non peer reviewed opinion which generally resembled dogmatic hot air (this piece is excellent on a tangent to this theme in that it exposes the problem basing policy on evidence free dogma).  The review stated “No papers looked specifically at whether current postgraduate medical education prepares doctors for working with patients and the public in such a way as current trends dictate.”  but never defined what was meant by 'current trends'; the huge flaws in this kind of approach are obvious.  In order to adequately address the future needs of patients one needs to adequately analyse the evidence in this area, this was never done.

Straw man 6: Training needs to be more flexible, thus Shape is justified

Flexibility can easily be improved within current training structures.  There is some degree of sense in 'transferable' competencies, however the use and applicability of this has probably been massively over hyped by those intent on distracting from the potentially harmful aspects of ShOT.

Straw man 7: Patients need more 'integrated' care, hence Shape is justified

The review's evidence section stated “an acknowledgement of integration as the direction of travel for UK health and social care is vital to the decisions made in the Review” however the evidence gathered totally failed to justify making this dogmatic acknowledgement, it was also notable that 'integration' was never properly defined at any point in the evidence section.  Ironically the greatest 'disintegrator' of care has been Lansley's HSCA, using the major structural reform of training as a lever to increase the 'integration' of care appears misguided at best.

Straw man 8: We need more 'generalists' and less 'specialists', hence Shape is justified

This is a largely a false dichotomy.  As explained in straw man 4 the UK training system is already fairly generalist in many ways and particularly in many specialities such as geriatrics and orthopaedics.  Many consultants are trained as generalist specialists at current CCST level as things stand, certainly there is no way one can train competent autonomous 'generalist' consultant in a shorter time than it currently takes to train a specialist.  Shape's solution of re branding generically trained middle grades as 'generalist' consultants is not honest and it will not provide an equivalent quality of care to that provided today by today's properly trained generalist consultants.  Notably the review ignored the majority of consultation respondents in this regard "...most individuals and organisations argued that generalists would require a longer training period or reconstruction of training to capture the breadth of experiences needed to provide competent general care”.  In areas like acute medicine it would be perfectly feasible to encourage more trainees to dual-accredit, a simple way of increasing the number of proper generalists without engaging in yet more destructive major structural change.  This brilliant analysis exposes the huge problems if one applies Shape's ideas to Gastro training.

Straw man 9: Shape means patients will see the most 'appropriate' doctor

Patients want a high quality service and they often want to be treated by a properly trained consultant.  Who decides what this 'appropriate' means and how?  I doubt many patients would be keen on the government decided that it was 'appropriate' for them to be seen by a lower quality 'consultant' who cannot practise autonomously and who is still in training via the 'credentialing' route. 

Straw man 10: Genuine clinical competency is reliably measured by competency based assessment methods, thus training time is unimportant

There is an abundance of evidence in the educational literature which demonstrates that an over reliance on competency based training methods is harmful to standards and that many competency based assessment methods are far from valid.  The official line from the likes of HEE and the GMC is that competency based assessments reflect training 'outcomes', sadly the vast majority of these assessment tools are poorly validated and do not reflect any meaningful outcomes for anyone.  There is also a paucity of evidence to justify ticking off targets on an extensive curricula bit by bit as a way of developing genuine clinical expertise.  'Medicine by numbers' is a good way of making the regulator appear effective to the uneducated bystander, but a very poor way of training high quality clinicians and maintaining motivation in trainees.

Straw man 11: The crises in acute rotas justify creating a cohort of sub-consultants to provide this service

There are crises in acute and emergency medicine, and Shape's plan appears to be addressing this by making everyone a middle grade in acute care, issuing a CST and then stopping most career development at that point. Only in the UK can the solution to an unattractive career be to force everyone to do it, rather than trying to work out why it is unattractive and resolve those issues.  Ultimately if one doesn't address the root causes by making these acute jobs attractive to work in, then strategies such as Shape are doomed to fail and in the process worsen the existing recruitment/retention problems.

Straw man 12: Formal accreditation such as 'credentialing' provides inevitable benefits and does no harm

A recurrent theme in health policy is the negative 'unintended consequences' which rapidly become apparent after yet another hare brained policy is railroaded through.  Perhaps 'credentialing' has some roles in some niche areas but to ignore its potential negative effects is foolish.  Informal accreditation is cheaper, less bureaucratic and will do less harm in terms of time spent on the accreditation process.  The routine use of 'credentialing' for post CST consultants is potentially dangerous as employers will have excessive power of who becomes properly trained and who does not, there are problems for workforce planning in this area too.  Note the problems in the erratic employer controlled training of HCAs remarked upon by the Francis report.  Not only that but the costs of training will be passed onto the 'trainee' consultants.  Also there is a real paucity of evidence to demonstrate any benefits of formal accreditation over informal means in terms of patients outcomes.

These are just a select number of straw man I have seen thrown around by the minority of individuals who support Shape in its current form.   The bottom line remains that ShOT has not been justified by credible evidence or coherent rationale, it is largely confused in logical terms and potentially very harmful.  It is interesting that virtually all those who support Shape have some rather interesting links to those forcing the review's recommendations through against the will of the majority of front line trainees and trainers, can't imagine why this would be?  If you feel that Shape is bad for training and bad for patients then please sign the petition to protest against these major changes:

https://you.38degrees.org.uk/petitions/stop-the-shape-of-training

Please sign on and support high quality medical training!

 

The Shape of Training was an 'independent' review of medical training chaired by an economist, Professor Greenaway, which reported at the end of 2013 is currently in the process of being implemented by government.

The review was less than fully transparent in revealing the potential influence of government during the review process.  There are a number of other problems with the review including the fact that it ignored the majority of consultation respondents in recommending the training time for hospital consultants be shortened across the board. The RCP is one of several expert bodies that continues to express its concerns about the likely harms of the review.

This fact is compounded by the fact that the review does nothing to address the major problem areas with training quality today and that diluting down the exit standard of consultants is likely to further reduce training standards. The knock on effects on recruitment/retention are also likely to be largely negative.

This petition is not to say I or anyone has all the answers, it is simply to state the Shape does not have the answers and is likely to be harmful in many ways. My personal opinion is that we do not need major structural change to address the future needs of patients and that change within the current structures would be far more sensible that Shape's drastic reconfiguration.

"Training needs reform, therefore any change should be signed up to" This straw man argument is weak and frequently used by those backing Shape because they appear to have little else to offer to the discussion. The generalist versus specialist dichotomy is false, shallowly training 'generalist' registrars and calling them 'consultants' is not an honest or safe solution to anyone's problems.

The petition does not say that training in this country doesn't need to be improved it does, there are many simple ways of doing this to meet the needs of trainees and patients without major structural change. We need better regulation with teeth, we need less reliance on the competency based processes which ignore the important of time on the job/clinical experience, we need more of an opportunity for trainees to feedback problems to genuinely independent bodies, we need better mechanisms to ensure that employers value training and feel the stick when they give no value to it.

Overall the point is that this debate needs to be open, honest and transparent - and it appears that thus far this has not been the case with the Shape of Training.

Therefore if you feel the implementation of Shape should be halted, please sign the petition, every little helps, if you can also stick it up on Facebook/Twitter/email it to some friends, this would also be massively appreciated.

Thanks to your support we have almost 10 times as many signatures on the petition as the Shape of Training got in response to its consultation in total, a truly fantastic effort:

http://you.38degrees.org.uk/petitions/stop-the-shape-of-training

Credentialing: shifting more costs onto the trainee

Shape of Training has many disastrous regressive elements, not least the introduction of 'credentialing'.  Note first of all that the GMC defines a credential as a 'formal accreditation of attainment of competences'.  Therefore the direction of travel pushed by the government via the GMC and Shape is yet more competency based methods in training.  As if we haven't seen the harms of an over reliance on this deeply flawed reductionist approach in terms of encouraging minimum standards and demotivating trainees....

Look at the extract in the Figure above, it demonstrates concisely just where the cost of credentialing is going to be dumped, it will be the Royal Colleges initially and then, yep you've guessed it, the College will then pass this extra cost onto the trainee.  As if medical training wasn't expensive enough already with student debts, GMC fees, College exams and fees, Training body fees (JRCPTB/ISCP etc), now the government is dumping yet another cost onto the trainee.  It's just as well we don't have multiple recruitment crises at the moment, oh wait a minute....

This excellent piece in the NEJM summarises the lack of benefit of this kind of training bureaucracy and the huge costs involved in maintaining it.  This article relates to 'meeting maintenance of certification (MOC) ' in the US but there are stark parallels with both revalidation and credentialing. 

Much like the Shape of Training's recommendations, there is zero credible high quality evidence to justify the introduction of 'credentialing'.  Arguably revalidation and credentialing are of little, if not zero, benefit to both doctors and patients, while they introduce extremely costly self serving bureaucracies which can also do a lot of harm in a number of ways.  There are many more potential harms to credentialing, including fact that it introduces more employer control over access to training and the quality of training.  The lack of any proven benefit combined with the fact that it appears designed to dump yet more costs onto the trainee make it something that should be firmly rejected by the profession and any reasonable doctor.

Doctors - email your trainee group NOW!

The BMA have produced an excellent statement on the 'Shape of Training' review and a large number of trainee groups have rightly signed up to reject the review in its current dangerous form.  The groups which have signed up are:

Association of British Neurologists Trainees
Association of Clinical Pathologists trainees group
Association of Otolaryngologists in Training
Association of Palliative Medicine trainees group
Association of Surgeons in Training
National Dermatology Trainee Committee
British Junior Cardiologists Association
British Medical Association Junior Doctors Committee
British Orthopaedic Trainees Association
British Society of Gastroenterology Trainees' Committee
Oncology Registrar Forum
Royal College of Obstetricians and Gynaecologists Trainee Committee
Royal College of Ophthalmologists Ophthalmic Trainees Group
Royal College of Radiologists Junior Radiologists Forum
Young Diabetologists' and Endocrinologists' Forum


There are a number of notable groups who have not signed up despite a total lack of interest in consulting their members on this potentially destructive review.  I have collated a list of email addresses for those of you who belong to the following groups, please email them and ask them why on earth they have no supported the BMA's statement:

Medics (Royal College Physicians) Trainees.Committee@rcplondon.ac.uk
RCSEd traineescommittee@rcsed.ac.uk
Emergency medicine EMTA@collemergencymed.ac.uk
Pharmacuetical medicine TraineeSubcommittee@fpm.org.uk
Anaesthetics trainee@rcoa.ac.uk
GPs aitcommittee@rcgp.org.uk
Paediatrics and Child Health training.enquiries@rcph.ac.uk
Psychiatrists ptc@rcpsych.ac.uk

Massive questions remain unanswered on the real motives of Shape......

The problems with the Shape of Training review of postgraduate medical training become more and more obvious by the day.  Today the BMA has released a joint statement on Shape calling for the powers that be to reject the review in its current form:

"We therefore reject the current direction of travel for Shape of Training"

The bottom line remains that the public have never been adequately informed or engaged in the review, and they should have been.  The most important thing is maintaining high quality patient care, for a number of reasons Shape threatens to undermine quality in the name of creating a compliant and flexible workforce.  This appears fundamentally driven by the interests of employers and not the public.

The evidence review was flawed, the review's recommendations are regressive and potentially extremely dangerous from a patient safety perspective, trainees have not been involved, in fact the profession has not been adequately consulted or involved.  The GMC refused my Freedom of Information request pertaining to the documentation of secret meetings involving Ministers and the review's Chair, as did the Information Commissioner.  I have been fortunate enough to recently be vindicated in court and the GMC were therefore ordered to release the withheld documents to me. 

The sad thing in all this is that who is looking out for transparency and the public interests?  Just who is everyone serving in all this?  My personal battle is simply to ensure that all the information reaches doctors and the public, they both deserve to be fully informed of the direction of travel that is being proposed and those running the review should listen to their opinion, not steam roller these potentially dangerous recommendations through against the public interest.

Solidarity - Charlie Hebdo

May those who were murdered in cold blood today in Paris rest in peace.

I hope some good can result from today's appalling crimes, in that decent rational people can unite against the misguided nonsense that motivates the misguided fools who commit acts such as this in the name of their make believe 'Gods'.

The 'Dean review' of medical training

I have commissioned myself to review UK postgraduate medical training.  The pre-review steps are complete, I am indeed a fit and proper person, I have 5 GCSEs, I have no conflicts of interest that I am aware of, plus I am genuinely independent of government.  Frankly who could compete with that?  The terms of reference have been decided by myself, these being to 'review medical training in any way that I see fit', excellent, now let us begin.

The first step of the review is complete, this being the evidence review.  I conducted a systematic review using the latest 2015 PRISMA guidelines.  The search terms were 'UK medical training'.  I excluded all studies that did not exactly predict how future patients would need to be treated, hence this search yielded zero studies.  I have therefore concluded that there is an inadequate evidence base upon which to determine any exact strategies for medical training reform.  This means that I shall be 'first, doing significant harm' by ensuring that my plans will be major structural reforms that will tear up everything we have in place and start from a lovely blank slate.

Now for the second step, the consultation process.  This is now complete, I have tweeted for input and there were zero responses.  I have asked the cat, who did not respond with words, I have also asked my wife who is currently watching Eastenders and not interested.  Therefore my own personal opinion shall drive the review's direction, excellent work.

Now for the final 'Dean report', this is now complete.  I have deliberately kept things simple, firstly the principle of the review is 'to create a world class training system which catalyses commissioning based patient safety augmentation collaborative excellence brilliant wonderfulness'.  There is no way anyone could disagree with that principle, but perhaps I need to mention pathways and flows?  There's no time for consideration or reflection, let's stick with that simple principle.

Finally the recommendations, these have yet to be decided and really are they that important?  Surely like in MMC and the Shape of Training it is accepting the principles that is key?  If one can accept the noble principles then surely any recommendations following will be good news for everyone, by everyone I mean myself that is.  Anyway I think that's sensible, let's leave out the recommendations, I'll simply decide those behind closed doors once you have accepted the principles.   You can trust me on this, look at the review's methodology thus far, it's rigorous beyond the Cochrane collaborative.  I may or may not have had secret meetings with those secret important people who commissioned the 'Dean review' in the first place.

Great, now that's all sorted, training's going to be so much better, I am also particularly looking forward to my knighthood, Sir Dean, that really has a good ring to it.......

Inaccuracy and Obfuscation - the facts thus far

 

I do not have all the answers, as I do not have all the facts and I do not have the knowledge of a legal expert.  However this piece is simply designed to summarise some of the key facts relating to the Meirion Thomas saga, so that you can use this to make up your own minds, and realistically we will all need more information before we can do this with any degree of certainty.

Firstly I wrote some recent pieces criticising the coverage of events by the Daily Mail and the Spectator.  The chief reason for criticising their coverage was that they told only one side of the story and ignored some key aspects of it.  Both the Mail and the Spectator ignored that Mr Meirion Thomas’ arguments contained factual inaccuracies, were not solidly based on evidence and were widely dismantled by more reasoned objective work elsewhere by the likes of the RCS and Margaret McCartney.  It was also strange not to mention the legal element to this affair when they were overtly criticising the Royal Marsden’s actions.  Therefore my chief arguments were not about the rights and wrongs of Mr Meirion Thomas’s or the Marsden’s actions, it was with the biased and stilted coverage by the Mail and the Spectator.

Secondly to my limited understanding of the law in this area, it is worth remembering throughout that I am not giving an opinion about whether I think the law is morally right, or whether anyone’s actions are morally right or wrong, I am just describing the legal aspects of this case according to the limited facts we have available.  It is worth remembering that we do not know the exact terms of Mr Meirion Thomas’s contract, we do not know what has gone on behind closed doors in discussions between him and his employer, and we do not know what the exact outcome of these discussions have been.  Let us just note what the Royal Marsden have stated:

“Following two articles that appeared in the Daily Mail on Thursday 20 November and in the Sunday Mirror on Sunday 23 November by Professor Meirion Thomas, The Royal Marsden NHS Foundation Trust would like to make it clear that Professor Thomas’ views are entirely his own and in no way reflect the opinion of those working at The Royal Marsden.

“Professor Thomas has expressed his personal views about GPs and health tourism in the Daily Mail and Sunday Mirror respectively without consulting staff at The Royal Marsden. We do not share, condone or support the views he has expressed. It is important to state that all individuals are entitled to express a view. They are not however entitled to speak on behalf of an organisation without that organisation’s consent. Professor Thomas did not seek or receive this organisation’s consent to either article.

“The Royal Marsden is very proud of its good working relationships with our GP colleagues, particularly through our GP engagement programme and referral process, and we value their experience, knowledge and the excellent contribution they make within the NHS.”

The difficulty in interpreting any of this is that we are not privy to the full information; hence some speculation is simply not sensible or wise.  It is worth remembering the facts about what was written in that the Mail article named the author as a ‘Royal Marsden consultant surgeon’ and it was never stated this articles were his personal view.  Some would argue that it should be assumed that the articles are his personal views, there is a great difficulty with this argument as he does mention his specific employer and job title, he talks about work relating to this specific employer (Lansley opinion) and he may have used a photograph on Trust premises, and he does this without stating that the articles are a personal view.  I will freely admit this is not black and white, but to suggest that it is clear these articles are his personal view is absurd and in denial of the facts.  The facts significantly close down the distance between Mr Meirion Thomas’ personal opinion and his employer, the Royal Marsden, and from the Marsden’s statement it appears that this is a significant factor in their actions thus far.  It is therefore likely that Mr Meirion Thomas' articles breached Trust media policy on more than one occasion and the terms of his contract with the Trust.

The legal arguments about reputational harm are likely relevant.  If employees have been judged to have caused significant harm to their employer’s reputation by their actions then this would be another avenue by which the Royal Marsden may choose to act.  There is certainly a reasonable case for arguing that Mr Meirion Thomas’ articles causes reputational harm given their disparaging nature.  Certainly Mr Meirion Thomas does not meet the legal definition of a whisteblower and would not have a credible case if he used a public interest defence to justify his articles.  However from what has been stated it appears likely that the Marsden felt Mr Meirion Thomas had breached his contract of employment by ‘speaking on behalf of an organisation without that organisation’s consent’.  It remains unknown which exact details in the articles led the Marsden to this opinion regarding speaking ‘on behalf’ of an organisation. We also do not know precisely what action has been taken by the Royal Marsden, the talk of confidentiality or ‘gagging’ clauses may or may not be true.

In purely legal terms given the available information it appears that the Royal Marsden have acted properly and to suggest otherwise would appear to be rather evidence free.  It is also worth noting that I have not yet given my opinion on whether I think the Marsden’s actions are morally right or the most effective course of action, this has not been my motive, I am simply trying to give my readers as much objective information as possible with which to make up their own minds.  Perhaps I shall do this at some point, but at the moment I do not want to confuse these simple arguments, I want more information before coming to any definitive moral judgements on this complex affair.  If people have an issue with the Marsden’s actions then they should either point to specific legal arguments or direct their arguments towards the legal system, and not the Royal Marsden.

Suspicious omissions from the Mail and Spectator

It is interesting that the Spectator and the Daily Mail have both sided in rather stilted fashion with Mr Meirion Thomas, the surgeon who wrote articles for both of these publications, strange no other publication has joined in the rose tinted defence, I cannot imagine why, I really can't.  Anyway sticking to the basic facts, the Spectator and Daily Mail both have experienced Editorial teams.  Yet despite this in the Mail Mr Meirion Thomas was described as 'of the Royal Marsden Hospital in  London' and in the Spectator 'a consultant surgeon with the NHS'.  Interestingly in one of the Mail pieces a photo of Mr Meirion Thomas was used and it looks suspiciously like he was on NHS property at the time.  The following chunk has been taken from one Mail article demonstrated that Mr Meirion Thomas also clearly wrote about matters relating to his NHS role:

"Because I am a senior consultant in an NHS hospital, Mr Lansley sent me an early outline of his plan for reorganisation and asked for my advice.

I told him: ‘GPs are the problem in the health service, not the solution.’

He did not ask my advice again, but instead pressed ahead with his misguided scheme."

What is the importance of these details you ask?  Well they are vital when it comes to employment law.  Here is a chunk of media policy from a standard NHS Trust:

"If you are approached to speak to the media in another capacity (i.e. for a professional body, trades union or charity) you may do so. However, if this occurs in a way that will link you to the Trust, e.g. using the Trust address, mentioning your role at the Trust, or filming in your department for a back-drop, we would ask that you contact the communications office so that the Trust is aware of the media interest."

Notably Mr Meirion Thomas was not writing on behalf of another body such as a union, he was writing as an individual, however this was never made clear by either the Mail or the Spectator, a fact I find rather strange given their editorial experience.  In fact the Spectator went as far as saying in their recent one sided defence 'he insisted on being described simply as an NHS surgeon', this is suggestive that the Spectator may well have advised him of the negative implications in naming the NHS, I also wonder what he was advised by the Mail.

There is a lot of case law relating to employee being disciplined for speaking out against their employers.  However there are certain situations when it can be justified.  For example it is fine if you are speaking for a professional body or union, Mr Meirion Thomas was not.  It is also wise to make it clear one is speaking as an individual and not name your employer, Mr Meirion Thomas did not do this.  It is also unwise to use a photograph taken on your employer's premises, Mr Meirion Thomas may have been unwise on this.  If one is a whistleblower one can justify speaking one, sadly Mr Meirion Thomas comes a country mile short of meeting any legal definition of a whistleblower.

When one effectively speaks under an employer's umbrella and risks harm to that employer's reputation by making ill informed and disparaging comments, then one has a recipe for being on extremely dubious legal ground.  In this situation one's employer has a very strong case in bring disciplinary action against the employee, just as appears the case with Mr Meirion Thomas. 

In summary the fact that the Mail and Spectator have totally ignored the key issue of employment law is highly suspicious, they are no idiots when it comes to legality, meaning the likely explanation involves Mr Meirion Thomas being a victim of media exploitation.  Note that a story carries far more weight as 'surgeon X from hospital X' or an 'NHS' surgeon than a 'surgeon writing as an individual without his employer's approval'.  The Mail and Spectator had much to gain, Mr Meirion Thomas had much to lose, I wonder.

Overall the talk of 'gagging' and 'free speech' by the likes of the Mail and Spectator is both disingenuous and highly obfuscatory.  It appears highly likely that the Royal Marsden have acted entirely properly and have simply acted to protect their reputation by disciplining an individual who threatened to undermine that reputation by disparaging his medical colleagues.  The talk of abuse, GMC referral and the rest is all a neat distraction tactic, there are idiots on both sides throwing around needless abusive insults.  The bottom line here is that employment law is the key and it dictates that employers have every right to act to protect their reputations in cases like this.