Monkeys for management, the NHS rot

As we all know money is in short supply, the government has frittered away billions on brainless ideological schemes in many policy areas, this is especially relevant to health and the NHS. Who can forget the billions that have gone on management restructuring every two years (SHAs/PCTs), PFI schemes of appalling value, C&B/PBC (the market), Darzification and Darzi's privatisation of general practice et cetera.

The lack of understanding of medicine and health care in general is excellently shown by this chunk the article in the Telegraph:

"Sixty per cent of activity which now takes place in A&E departments should happen in community clinics within five years, the document says, along with 55 per cent of outpatient treatment. Thirty per cent of outpatient appointments will be stopped altogether. Managers say not all appointments are necessary, though many doctors argue it is impossible to know in advance which patients do not need to be seen. The number of diagnostic tests carried out will be cut by 15 per cent, while the amount of surgery will be reduced by seven per cent."

This statement exhibits a rank lack of intelligence and a rank lack of understanding of medicine. Shifting work out to lame little community clinics does not work, not only do the under trained staff at these units have no idea what they're doing but they often end up referring most stuff onto other services anyway, they do not have enough knowledge and skill to actually properly sort patients out.

Just because nothing is done at an out patient appointment it does not make this appointment unnecessary, a lot of appointments involve patients being reassured and adequately diagnosed by a specialist. Not all flood defenses are necessary, does this mean that those manage our flood defenses will go about deciding which ones to remove before the next floods hit us? Of course not, this is the logic of morons. With medicine becoming every more sub specialised it is inevitable that referrals will increase as it becomes harder and harder for generalists to adequately manage in subspecialities which are becoming ever more complex with new treatments becoming available of which they know very little. In modern medicine patients are also becoming more empowered and knowledgeable, this will also drive up referrals to specialist services.

The idea of reducing diagnostic tests and surgery in this context is also completely nonsensical. In the modern day drives to cut diagnostic tests will probably lead to more litigation and hence increase costs, while as medicine becomes more complex and subspecialised, it is inevitable that diagnostic tests and surgery will need to increase. As imaging develops we are constantly finding new indications for surgery which are proven to be effective, you simply cannot aim to reduce diagnostic tests and surgery in this context, it is utter lunacy.

The layers of bureaucracy are now proliferating. Various uneducated ignorami at the DoH, SHAs and PCTs are wasting a massive amount of money in trying to increase efficiency with stupid policies that try to directly reduce referrals in a top down manner. This is done by creating more administration to regulate clinicians in an Orwellian manner, telling clinicians not to refer is plain stupid, clinicians do not refer for fun, they refer when they think the patient will benefit from a referral, so top down interventions to reduce referrals are actually in conflict with good medical practice, it encourages bad and arguably dangerous medicine.

So millions and billions are now being wasted on various crack pot schemes that aim to save money by effectively stop proper medicine being done. In this way money is wasted enforcing bad practice and bullying clinicians. This is a blatantly Stalinist system at work, it is a disgrace. Many of us have now seen first hand examples of this kind of logic at work in the workplace, PCTs are now refusing to pay for certain hospital services that patients need, the demand doesn't just go away if you refuse to pay for something, fiddling the hospital out of money doesn't make certain ailments disappear.

The current system sees various bureaucracies fighting each other, there is no cooperation which would result in efficiency savings, PCTs are fighting hospitals for money, the DH is clawing back money from PCTs, and then finally the government will cut the money off at the source. In the meantime patients will not magically get better, their illness will not just go away. Fiddling the books helps no one in the long term.

The government and our administrators would do better to look reality in the face, in an NHS in which administration costs have almost tripled in a few years thanks to their endless tinkering they would do better to stop the rot, stop the top down artificial market, get rid of the PFI deals, stop wasting money on management consultants that tell them to sack clinicians and hire more management consultants, stop the reforms that are increasing the waste and inefficiency. Start thinking about the needs of patients, start trying to meet their needs as best you can and stop hiring more administrators to increase the efficiency of the system, this is akin to pouring petrol onto a fire in order to put it out.

ISTCs and the disgraceful wasteful marketplace of doom

As with many recent government health reforms that have revolved around ideological nonsense and the enrichment of various groups with close political links, there has been no effort from the start to monitor the safety or performance of ISTCs from the very start. It is only thanks to some excellent local units that we are starting to discover just how much damage has been caused by these devastating reforms. This is without doubt only a small iceberg tip.

It is worth reading the full article and observing just how poor the record of these ISTCs is. The ISTCs have shown to be doing joint replacements that are failed at a rate of around 20% at three years, this is about twenty times the national NHS average rate, this is blatantly negligent and it doesn't need a statistician to tell one this. It is worth noting that this bodged surgery is costing the NHS a fortune to put right, add this to the fact that the ISTCs are often getting paid way more than the NHS for the same work. They are dangerous and bad value for money, the market is a clear failure in this context. The DoH is as always in complete denial as it is just pushing through ideological rubbish at the expense of patient care:

"Patient safety is top priority with all contracts with the independent sector. The Department of Health requires all Independent Sector Treatment Centres to have robust policies and procedures in place. All ISTCs operate under standards monitored by the Care Quality Commission, the independent health watchdog. The CQC... have not raised concerns with the Department about the safety of ISTCs."

What a lie and what a cop out. Like many new government reforms such as Walk in Centres and the contracting out of OOH (out of hours) work to private firms the effects in terms of patient care have not been monitored at all, it is a national disgrace. For example at ISTCs they are employing ' consultant' colleagues from other EEA states and many of these consultants have never worked in the UK before. They will, therefore, be working outside their comfort zone. They are often appointed with nothing like the formalities of an NHS Advisory Appointments Committee and sometimes appointments have even been agreed over the 'phone without any interview or meeting. This is dangerous practice and should be a risk management ' red flag '. Many of these consultants are not members of the respective UK academic college and are working in isolation from UK colleagues.

Millions of pounds of cash are still being dished out to ISTCs and there are simply not the systems in place to monitor just what they are doing in terms of harming patients. This is unacceptable, when those at the top of the political tree keep going on about standards and governance, why are these expensive unregulated disasters still being rolled out? Any changes to care delivery should be rigorously piloted and monitored to ensure that standards are not being compromised, this simply has not happened for the plethora of awful reforms we have seen in the NHS in recent years.

Whether it be your paramedic refusing genuinely sick people trips to hospital having been empowered by a short dumbed down course in being a doctor, your EEA GP with a limited command of English being flown in to do GP OOH work for a cost cutting private firm, your walk in centre quack pretending to be a GP and mobilising their Fisher Price (TM) stethoscope after a two week course in medical diagnosis or your EEA Orthopaedic specialist having a go at joint replacements in an ISTC with techniques which they have never done before, there is no excuse for this erosion of standards. The damage done is very hard to quantify as there has been no attempt to monitor the impact of any of these changes to practice, some things like Orthopaedic outcomes can be more easily eye balled retrospectively as has happened with the Cardiff ISTC but the vast majority of outcomes are almost impossible to measure without well though out prospective analysis, something it appears the government has avoided at all costs because it knows that this marketisation is doing harm to patients. The dumbing down continues.

Supermarket medicine

I apologise for my recent lack of activity, unfortunately life has dealt me a busy hand of late and far too much time has been spent working and in my car. Currently a porcine sore throat means I am feeling rather pathetic and tired, my energy levels are flagging.

It's hard to keep up with the news, there is just so much utter rubbish spouted from various media orifices that it is very hard to know where to start one's dismantling from. Certainly Andy Burnham's recent disingenuous ideas are as good a place as any to start, Dr Crippen has hit the nail on the head yet again:

"The demand is insatiable, and the only way the government can cater for it is by dumbing-down the service and moving towards a 24/7 "medical supermarket"."

The sheer nonsensical nature of the continued NHS reform beggars belief, the same failed ideas continue to be tried out again and again and again. It is no surprise that they continue to fail miserably. With the recession rolling on and debt levels high, cuts will inevitably be made in the places in which they will be felt the most. The real motives are hinted at here by Dr G.

The weak reporting of the the poorly explained entitity of 'misdiagnosis' really got my goat this week. The 'BBC investigation' was dramatic and breathtaking in the BBC's minds, in reality they showed nothing new but were rehashing and sensationalising the work of others. Strange that the beeb didn't mention how anyone can have a crack at diagnosis these days, just a few weeks with a toy stethoscope can give you the power these days.

I bet the useless NHS empire of bureaucracy that is made up by the DoH/SHAs/PCTs will not be trimmed, the front line services will be the ones to suffer as the aforementioned lame duck organisations waste money hiring management consultants and employing more idiots in trying to increase efficiency. Idiots will always try to improve efficiency by hiring efficiency officers to oversee efficiency reforms, a better management strategy would be to cut the ineffective rot out of the system. The problem is that the inefficient rot is running the show and as a result the NHS is doomed.

No waiting lists? Oh dear Burnham as swine flu misdiagnosis kills

Andy Burnham may be a nice bloke in his private life, he may enjoy football, but at the end of the day he is still an incompetent fool who has been caught with his pants down time and time again. Not only has Mr Burnham been caught telling untruths in Parliament on medical issues, he is now peddling utter bullshit as fact in many areas of health policy.

To be fair to Burnham he may not be being deliberately dishonest here, he appears more like a stupid schoolboy who is way out of his depth. The problems with Tamiflu are blatant, it's benefits are mild at best, while its negatives may well outweigh them. The whole Swine flu business smells very much of a useless government pretending to be doing something when it would be better off doing nothing and reassuring people.

The useless and completely dangerous swine flu hotline is not something new for this government, empowering the uneducated is a real hallmark of this government. As many of us predicted deaths are resulting from lethal septic episodes that have been assumed to be swine flu by the undertrained diagnosticians that have been empowered by our cretinous politicians.

The truth is that swine flu is a pretty benign disease, we would be much better off without any stupid NHS call centres manned by numpties, everyone should just go about things as normal unless they become unwell. The unwell then need to be assessed by those with appropriate training, ie medical degrees and experience in medicine. This lame duck of a government had a massive stockpile of useless tablets and wanted to become popular by being seen to be doing something, unfortunately it is doing more harm than good in its misguided attempts to interfere when no interference would be the less harmful option.

Burnham also seems to think waiting lists are a thing of the past. I would like to remind him that this is a complete lie. Waiting lists are alive and well, in fact the 18 weeks target for surgery is resulting in clinical need being thrown out of the window. Because of the blanket targets the most minor and non urgent of surgery is given a disproportionate amount of influence, this results in the more urgent clinical need of others being ignored in favour of elective surgery. This government doesn't seem to realise that rearranging the deckchairs doesn't magically create more deckchairs. So frankly Mr Burnham I don't care if you're a nice bloke when stoking the barbie on your sundays off, your work as health minister stinks and you are blatantly out of your depth.

Morons, swines, cretins and fools

These are the people that run the NHS and that waste ridiculous amounts of money on various useless harebrained schemes that are usually aimed at pretending to do something rather than actually doing anything of any use. The swine flu drama has encapsulated just how utterly pathetic the people are who run and managed the health service from the very top.

Swine flu is a a disease which differs little from severity from several winter viruses, but the English NHS is behaving as if we are in the middle of an Ebloa epidemic. Call centre operatives are making diagnoses on the basis of no training at all, indeed one can even dispense with the call centre and simply diagnose oneself on-line - they are then dispensing a drug of uncertain benefit, but with known side effects and with a documented ability to produce resistance, 'prescribed' by either a computer or a call centre operative with no discernible medical training or skill.

As I have read elsewhere it is rather obvious that many people will have died and will die due to various untrained and uneducated people assuming that every febrile illness is swine flu, thus people who are unfortunate enough to get a severe case of meningitis, urosepsis, cholangitis, endocarditis, and on and on will just be left at home to die because it's 'probably swine flu'. Stories of various patients being refused hospital admission by those without medical degrees with febrile illnesses which were clearly not swine flu are already coming to light. Various numpties have been empowered to diagnose swine flu, who needs doctors? Well, no one does if you would rather die.

This little story also captured my imagination, the DOH is commissioning management consultants KPMG to report on a vision for a digital strategy for the NHS. Well, whoopeedoo, why not waste more money on reviewing just how many completely useless schemes you can come up with to compliment NHS Direct and NHS Choices while diverting more money away from the frontline services that actually make a difference to patients.

I will review NHS Direct and NHS Choices for free, the former is a dangerous waste of money while the latter is more of a plain waste of money. The sad thing is that both the Tories and Labour want to continue to develop this market of madness which simply involves around paying off various big companies to generate more useless NHS bureaucracy that does sod all of any good for patients. What hope is there for the NHS, there is no choice for voters, we are doomed either way.

Remedy 1 GMC 0

RemedyUK has won the first stage of its legal challenge against the GMC’s refusal to investigate the managerial deficiencies leading to the MTAS recruitment fiasco. Mr Justice Hickinbottom found in favour of Remedy in their Permission hearing.

The case can now go on to a substantive hearing which is likely to take place before the end of the year. The case concerns the jurisdiction of the GMC over complaints against senior doctors who were responsible for MTAS.

MTAS was the new process for the selection and recruitment of junior doctors and was an integral part of the "Modernising Medical Careers" initiative. It proved to be a disaster. Remedy argued that the doctors responsible should be referred to the Fitness to Practice committee of the GMC for deficient professional performance and/or serious professional misconduct, and over 1600 supporters joined them in this. The GMC declined to hold an enquiry.

"We’re heading into the biggest public health crisis in recent memory and it’s particularly important that the conduct of doctors in senior managerial positions is not impervious to scrutiny" said Matt Jameson Evans, Chair of RemedyUK. "Accountability lies at the heart of modern professional medical practice, and there should be no double standards for those sitting at senior levels."

The judge acknowledged that MTAS has been a disaster which had brought the profession into disrepute. He recognised the precedent of the case of Roylance, which established the jurisdiction of the GMC over doctors in management, and he recognised that there was a link with the present case. He therefore granted permission for the substantive hearing, on two grounds, and he also awarded a Protective Costs Order in Remedy's favour. He declined the GMCs request for a reciprocal cost-capping.

"This isn’t solely about the events of 2007" said Richard Marks, Head of Policy "but it is also about the jurisdiction of the GMC over doctors in management roles." This is a great day for Remedy. We survive only on our paid supporters - if you value what we do then please join us today.

ps Remedy Uk and others have also had some rather sensible things to say on the topic of the European Working Time Directive reducing junior doctor hours to 48 per week this August at the very same time that the country may be in the midst of a flu pandemic, great work as always from the government and Department of Health, maybe it's time for another deckchair rearrangement Mr Burnham?

Head in sand doesn't make everything all right

Modernising Medical Careers (MMC) was allegedly the reform of medical training for the better, as many of us have since learnt the government lied about the real motives that lay behind this Trojan Horse of festering garbage. When everything when so spectacularly tits up back in 2007, the government had to pretend to act because things had got so bad that the media had started to take notice. In actual fact MMC had been doing damage to training for several years before 2007, the creation of the lame 'competency based model' of Foundation training and the useless application process for these jobs had already been about for several years by 2007.

After some excellent Freedom of Information ferreting I have managed to get hold of documents which detail correspondence between the Secretary of State for Health and the deputy CMO Martin Marshall on the topic of the MMC inquiry. I have highlighted some interested snippets for you to have a look at, taken from Martin Marshall's letter to the SofS:

"PROPOSALS FOR AN INDEPENDENT REVIEW OF MMC DEVELOPMENT PROCESS

....Whilst there have been successes as well as problems...

I understand the NAO are coming increasing pressure to undertake a review, either of the immediate issues with MTAS, or of the wider MMC program. I would hope that the announcement of an independent review would influence this decision, or at least its timing.

The purpose of the independent review would be to examine the framework and processes underlying the design and delivery of the whole MMC process and to make recommendations to ensure improvements for 2008 and beyond. This is likely to involve revisiting some significant issues but not to review the principles underlying MMC. These principles, to develop a competency based training program for doctors based on defined national standards, have widespread support amongst professional leaders.

The leading candidate is John Tooke... He is a committed educationalist, extremely well respected by the profession and more widely, and informal soundings suggest that he might be willing to accept the role if asked."

The above snippets are quite revealing. Not only do they show that the Department of Health has a remarkable habit of being completely unable to realise when it has made a mistake, but they only act when they are forced to by outside forces. The DoH appears to live in a permanent state of denial, completely unable to see just how incompetent their own actions are at times; they only ordered an Inquiry into MMC as they were afraid the NAO were about to nail them with a much more damaging review at a later date.

It is very revealing that the 'principles underlying MMC' were not to be called into question by this review, these were untouchable and allegedly already widely supported by our professional leaders, this all smells of fish to me. Interesting that the 'principles of MMC' seem to change every few days, according to the MMC website they are:

"One of the intended benefits of Modernising Medical Careers (MMC) was to ensure a transparent and efficient career path for doctors."

So much for that efficient transparency, MMC has reminded me far more of corrupt cock ups than anything else. The real motive of MMC was this:

"MMC aims to provide consistent national standards for training through better-structured and managed programmes with competency-based curricula approved by the independent Postgraduate and Medical Education and Training Board (PMETB)."

In reality MMC has resulted in a less flexible top down system which has done nothing but paper over the catastrophic effects of EWTD on medical training. Tons of extra paperwork and curricula will not help train specialists in less years with less hours per year, training cannot be purely competency based tick box numpetry, training must be common sense based and time based to a degree.

This government has dishonestly tried to force through the subconsultant grade with MMC, they lied to us and pretended that MMC was about better training and better patient care when it was about nothing of the sort. MMC was much worse than simply doing nothing as if nothing had been done we would have had to address the evils of the EWTD, as things stand the DoH and the government have stuck their empty heads in the sand and pretended that MMC would fix all our training problems including the EWTD. At the same time many new problems have been created by MMC including a lot of competency based damage to training and rain forests, an erratic and under performing Foundation training system, as well as numerous problems with various job application systems including an invariably useless Foundation scheme application system.

I've rambled on, mainly because it makes me very angry when people stick their heads in the sand and pretend everything is OK when it obviously is not. A lot needs to happen to fix this mess, the failings of competency based training and Foundation training need to be addressed fast before it is too late, maybe an NAO review of MMC would be a good thing to push for as well, while the EWTD monster needs to be taken on at some point. I don't have all the answers by any means, but the first step is to own up to the massive problems that exist, not living in arrogant denial like some choose to do on a rather regular basis.

Shambolic and unclear: Kafka's NHS

It's not hard to find diagrams like the ones above, the Internet is littered with examples of just how overly complicated the NHS' management structure and bureaucracy has become. It shouldn't take several textbooks and a few years of intense study to understand the way in which a health care system works (or does not as the case may be), the fact that the NHS is so hard to understand implies that it is a disorganised shambles with no clear chain of command. It should be so much easier to comprehend, but the government keep reforming, making things more complicated and shambolic.

The market argument is a complicated one, even a bottom up market would probably be more inefficient and bureaucratic than a well run state run system. However one can guarantee that a top down state run market system will be ridiculously inefficient and cumbersome. The diagrams above the the government 'newspeak' sum up the stupidity of the current process. Even people at the top are starting to see the light, and about bloody time too, it's just a shame that our moronic leaders like Tony Blair cared more for their own wallets than the nation's health. The lack of a clear chain of command means that the system is also incredibly dangerous as no one ever takes any responsibility when things go wrong.

The sad thing is that there appears little that we can do as cogs in our great 'democracy' to affect change in this regard. Labour copied all the flawed ideas of the Conservatives and then put them into practice from 1997 to this day, the Conservative would carry a lot of them on if reelected, while the Lib Dems never seem to oppose anything much with any vigour. The current economic situation and the future NHS spending cuts mean that we can expect to see front line services hit hard, while I am sure that the spending on bureaucracy, managers, PCT numpties, new incomprehensible reform strategies, management consultants, quangos et aliter would not be affected much.

It makes my blood boil. So much corrupt and cynical politics dressed up in nothing more than glossy bullshit. In the current financial climate it is a disgrace that money should be wasted in such a wanton manner. If I want to buy a load of bread the most efficient way to buy it is not to pass the money to the shopkeeper via four organisations and decide upon which loaf to buy by employing a cohort of idiots who then hire a group of management consultants to make the expensive decision for them, I haven't even started talking about how this NHS-style system would go about getting my loaf home; if I need a loaf of bread I'd go to the shop and buy it myself.

Power without responsibility

It's a deadly combination, power without responsibility, as we've seen with MPs' expenses if people are allowed to do what they want with little fear for the consequences then they will behave quite appallingly and unethically. One of the best ways of ensuring high standards in any system is to ensure that those people who are making important decisions are made accountable for them, after all if something goes wrong and no one is at all accountable, then the same errors will continue to made time and time again. What relevance has this for the NHS, quite a lot I would argue.

I had the misfortune of encountering a rather arrogant and obnoxious radiographer the other day. Radiographers are the technicians who take XRAYs, CT scans et cetera. I have to say that most of the standard radiographers I come into contact with are very pleasant people. The problem is that as with all things in the NHS, radiology has started to be dumbed down, some radiographers have now been empowered to actually report XRAYs as 'reporting radiographers'.

Don't get me wrong, radiographers see a hell of a lot of XRAYs and are very good at spotting fractures, better than a lot of doctors in fact. Unfortunately they are not medically trained, they are not radiologists, meaning that they do not have the broad base of knowledge and training that enables them to think outside the box and think of rare pathologies. For this reason 'reporting radiographers' are only allowed to report a very small percentage of the XRAYs that are done. There is still a problem as what happens when a 'reporting radiographer' misses that rare abnormality that a radiologist would most likely have picked up, I get the distinct feeling that they would not be held to account as a radiologist would be.

Radiologists are notoriously cautious because they know how tricky interpreting XRAYs and other tests is, most of the time one can see the obvious answer straight away, however if one just jumps straight in without thinking one would never diagnose the subtle, rare and potentially career-ending-if-missed pathologies. Radiology is like a minefield littered with the occassional career ending mine, most of the time one will be OK skipping through nonchalantly, however if one skips for long enough one is sure to get blown to smithereens.

I have digressed. The point I was trying to make was that the rather obnoxious 'reporting radiologist' was so overly confident because they lacked the knowledge and insight to be aware of their own limitations, they were skipping through the minefield assuming that their luck would hold. The particular one I met chose to take a quick glance at the XRAY, then claim that it was completely normal and should never have been done. I kept quiet and didn't mention that a rather esteemed Consultant surgeon had a very good clinical grounds for performing the XRAY. This is power without responsibility in the NHS, it generates this rank arrogance in the ignorant, it creates a potentially lethal over confidence in those who do not have enough knowledge to realise their own limitations. I could move onto the tale of the osteopath who reports XRAYs and misses bone tumours the size of footballs, but I would want to get sued for insulting a quack would I?

John Black is a living legend

The President of the Royal College of Surgeons has had his say on the EWTD and its disastrous effect on training today, and he certainly doesn't mince his words:

"The Junior Doctors Committee of the British Medical Association met for its annual conference on May 9th. A motion which was passed by a large majority included the statements “The current provision of service and training in the 9 surgical specialties mentioned above will not allow optimal training to be achieved in a 48 hour week” and “The changes required to optimise training will not be implemented at Trust level by the August 2009 deadline”. Good news one might think for those opposed to the introduction of the 48-hour week for surgeons. At last the BMA juniors have woken up to the fact that the EWTD is a disaster for training. However in the latest BMA News Review their spokesman ignores the motion passed by his own JDC and confirms that official BMA policy remains that the 48-hour week should be introduced in August. Their own JDC admit it is impossible to train surgeons in a 48-hour week but still want to see it brought it. This can only mean they do not want surgeons to be trained under the current system, an interesting and challenging position, which I hope to see clarified.

On 20th May Alan Johnson the Secretary of State for Health wrote to the Chairman of Medical Education England (MEE) saying “I would like the MEE to commission the Postgraduate Medical Education and Training Board (PMETB) to conduct a review of the quality of postgraduate medical training within a EWTD compliant working environment”. He also states that “There is no evidence that training is any less effective since the gradual reduction in junior doctors’ hours over the past ten years, or that greater numbers of trainees are failing their annual assessments where 48 hour working has been introduced”. Surgeons will be astonished by the Secretary of State’s complacent belief that training is no less effective than before at a time when surgical trainee logbooks are the thinnest in living memory. However aside from the minister giving orders to the independent MEE and to the independent regulator PMETB, this initiative is very welcome. The Board of MEE had already decided to look at the effects of EWTD on training at its next meeting on June 8th, and it is to be hoped that PMETB will not distance itself from the current training crisis, an approach it adopted during the MMC/MTAS crisis of two years ago. Mr Johnson also joins the BMA in his self-contradictory approach. Everything’s fine with training, but I want you to conduct a review. Why? Because we all know it isn’t! Again we await clarification.

As August 1st approaches the Department of Health is collecting data from Strategic Health Authorities (SHA) on progress towards EWTD compliance. The College has looked at the data for the surgical specialties, and I am grateful to the Regional Specialty Advisers and others who helped in this task. On May 21st I attended a meeting of the Department of Health EWTD team and the Academy of Royal Colleges to discuss this emerging data. It was a truly frightening occasion, as specialty after specialty described the reality of mythical rotas with gaps which cannot be filled, dangerously thin levels of cover, multiple handovers and unplanned and untested service re-configurations. The number of unfilled junior posts, both service and training, now approaches 3,000. The April SHA data do not show further movement towards compliance compared with March. Overall national compliance fell from 78 to 72% as paper rotas are revealed as mythical. As the situation is examined more critically, I just wonder what the true figure will be, 60%, 50%, or even less?

I attended the recent Association of Surgeons meeting in Glasgow and was heartened by the massive support for the College position. However a speaker from the floor made the point that it is quite likely that the 48-hour week will be forced in whatever we do or say and that consultants will as ever shoulder the burden for the sake of their patients. He has a point but you must not despair. The fact is that the NHS will not be 48-hour compliant in August. The emerging SHA data prove this. The EWTD is unworkable, dangerous for patients and disastrous for training. This battle is for the soul of surgery, and must and will be won. Patients will ultimately suffer and some may even die if it is not. I do not know when, but sooner or later this government or its successor will have to exempt surgery, and I suspect many other specialties too.

John Black
President"

Absolutely awesome. The BMA have had their head in the sand, the DoH and the politicians are in denial, the effects on training are disastrous, while the consequences for patients could be catastrophic. John Black is spot on, the man is a legend, however he may well have kissed goodbye to his peerage.

EWTD and the great deckchair rearrangement

The following description of the shocking state of affairs concerning the European Working Time Directive (EWTD) and the NHS has been largely stolen from a great piece on Doctors.net.uk, given the enormity of the problem I just felt this needed airing to as wide an audience as possible.

After a huge amount of pressure, and only 12 weeks before the full weight of the Working Time Directive hits the NHS Alan Johnson has ordered an enquiry into the effect of EWTD on the training of doctors in the UK.

In announcing it Alan Johnson has tasked MEE (Medical Education for England) to commission PMETB to consult 'stakeholders' as to solution to the imminent changes. This ultra-arms-length approach hints at lack of foresight and planning - arguably not boding well for a quick-fire solution in the 12 weeks that remain.

The writing has been on the wall for some time, and those pushing the WTD agenda cannot fail to have heard the message. In a recent joint statement the Royal Colleges of Anaesthetists and Surgeons wrote "Both colleges believe that the implementation of the WTD is in serious danger of having a deleterious effect on medical training, patient safety and service delivery."
A pilot study from Galway last year found that "all [the SHOs'] reported a deterioration in training and 81% felt that patient care suffered".

A Royal College of Physicians study found that "...the new 48-h working week has resulted in significant reductions of not only the quality of patient care, but also of general medical and medical specialty training. In particular, continuity of patient care has been affected adversely." Two former Royal College Presidents wrote to The Times this week and argued that "It is evident from many sources that quality of care of patients and proper teaching and experience for doctors in training cannot be provided for adequately in many specialties within a 48-hour week. This is particularly true of acute medicine and surgery".

Yet the Chairman of MEE, Sir Christopher Edwards, claimed today that the Secretary of Health was being 'proactive' in ordering this enquiry. Bearing in mind the timescale behind the implementation we think this is a new meaning of the word 'proactive'.

Last week the Department of Health admitted up to 28% of rotas were not going to be able to comply with the WTD by August. Some of those which were ostensibly had plans were completely unrealistic and were dependant on recruiting large numbers of doctors over the next few weeks. In a presentation made last week by Wendy Reid, the National Clinical Advisor to the EWTD, she acknowledged "Its not wise to go for a ‘big bang’ approach on August 1st". She also highlighted that despite throwing over £150million at the problem there were still many unanswered questions.

Implementation of the WTD requires more than just a reshuffling of rotas. It requires a major rethink in the way clinical care is delivered in hospitals, with changes to staffing levels and work patterns. Such a 'whole systems' approach requires far-sighted planning, central coordination and clear leadership. The government have had years to look at this. Why have they only noticed the impact on training now? The words from the new chair of MEE also make this man appear either completely out of touch with reality or so far up the government's derriere that his job is pointless.

MMC, sub-consultants and the Trojan Horse

"Remedy have obtained documents through a Freedom of Information (FOI) disclosure revealing previously undisclosed motives behind the MMC reforms of 2007. In short it appears that MMC was something of a foil by the powers that be to usher in the Subconsultant grade and change irrevocably the career prospects of all UK trainees......"

Excellent ferreting Remedy. I would strongly advise anyone interested in medical politics to read through the documents that the DoH have finally been forced to release.

In my opinion the rank dishonesty shown by the DoH throughout this whole sorry affair reveals why the health service will never flourish with these bullies at the helm. If only those in the positions of power were willing to cooperate and work with people in order to improve the systems that are in place, if only. The current regime would prefer to cynically spin the facts, deliberately hide their real motives and smuggle their corrupt reform agenda in via the back door. Shame on them.

GMC in denial

The story of the German GP who negligently killed an English patient whilst working as an out of hours GP locum has been in the news a lot recently, and quite rightly so. It appears that this was not an isolated incident either, this GP was clearly way out of his depth and other patients died that day.

I do not wish to dwell on this case because it is the theme that is important, the theme being the fact that non-UK trained doctors from the EU can easily register with the GMC after only the most minimal of checks, they are then free to compete with our own doctors for jobs, despite the fact that their education and training may not be nearly comprehensive enough to prepare them for the work they will be doing in the NHS. We now know that these EU trained doctors can then kill patients negligently, return home, receive the lightest of punishments and then return to practice as if nothing has happened. This is a disgrace.

If there is going to be a free market of labour in the EU in terms of health care work, then there must be a rigorous system of regulation in place that holds people to account if they make negligent errors whilst working away from their homeland. The blame lies squarely at the door of the government who have signed us up for this free market of labour without thinking of the serious consequences of a dangerously patchy system of regulation. Any doctor working in the NHS will tell you how they have encountered several non-UK trained doctors from the EU who have shockingly bad language skills and who lack even the most basic of medical knowledge, yet strangely they had no trouble getting their full registration from the GMC. This is not good enough.

There are many medical schools in certain EU countries that do not train doctors to the level of competence that our own UK graduates achieve, however the GMC cares not for the standard of your medical degree, any EU degree is good enough for them, while their language test is so easy that even a martian could secure top marks. Bizarrely excellent Australian and New Zealand graduates are now faced with a mountain of stupid paperwork before they can practice in the UK, while some of their dangerous counterparts from the backwaters of the EU can get in without any trouble at all. Well done the government and well done the GMC. Although the free labour market helps you push people around, it is killing patients at the same time, well done.

Watch this space: MMC

"Modernising Medical Careers (MMC) is a programme of radical change that aims to drive up the quality of care for patients through reform and improvement in postgraduate medical education and training. "

The government's stated aims of MMC are directly quoted above. The government also claimed that all it was doing was fair and transparent:

"One of the intended benefits of Modernising Medical Careers (MMC) was to ensure a transparent and efficient career path for doctors."

There was also meant to be better training for doctors and 'evidence' behind this improved training system:

"For patients, it was intended to mean that a higher proportion of care would be delivered by an appropriately skilled workforce. For trainees, the new programmes’ structures meant an assured high quality of training, better formal supervision and continuous development of acquired competencies, backed up by good evidence."

It is strange that despite such noble motives, the reality is virtually the polar opposite of the government's hollow chatter. The training quality is not better, the competency based ladder is simply a way of dumbing down health care so that less training and skills are needed for its delivery, this is beautifully demonstrated by Dr C's Pharmacist's tale. The quality of care is consequently not better, it is worse, as less experience and skill are needed to treat patients these days. The 'fair' MMC process is excellently demonstrated by this sad tale from a junior doctor who has actually experienced the reality of this grossly unfair and shoddy system.

So training is worse, there are less hours for training and a much smaller window of opportunity for learning one's trade, and at the same time training is being shortened. Something does not add up, these promises of better care seem a blatant lie. So what are the real motives for MMC, I would advise you to watch this space for some rather important breaking news.

Burning our money, the fire goes on

I warn you not to read any further if you have a slightly dicky ticker, the following figures may shock you so much that it may result in a burning rage so severe as to drive you to the very edge. It's that subject again, the NHS and its amazingly wasteful and inefficient bureaucracy.

The Conservative party have worked out that the NHS' bureaucracy now costs around 12 billion to run each year, a rise of around 100% in just five years, that's almost a rise of 20% in administrative spending per year, utterly amazing. Incredibly this massive figure does not even include the money spent on PCT administration and waste which is probably another monumentally huge figure given their Kafka-esque setup. The 12 billion figure only includes the DoH, Quangos and the regional health authorities (SHAs).

The number of managers is increasing at a rate far outweighing their need, the number of useless arms length agencies also continues to rise and rise, here are some of the little gems the DoH has recently excreted:

"Cosmetic Surgery Steering Group, Advisory Board on Registration of Homeopathic Medicines, Alcohol Education and Research Council, Herbal Medicines Advisory Committee, Independent Advisory Group on Sexual Health and HIV, and the Leadership and Race Equality Action Plan Independent Panel"

It's just so wasteful that it's hard to come up with words, I'm almost beyond rage, I am also now beyond laughing and crying, I just try to get on with my daily job. Every year there are more and more layers of useless bureaucracy which end up using up the extra money that should be going to the productive front line services, there are more and more uneducated idiots with no knowledge of health care and medicine being empowered so that they can decide how to throw money onto this wanton bonfire of our money. PCTs are now paying people to lose weight, what next paying people for exercising and not injecting drugs?

Ironically as a front line NHS worker 'Clinical Governance' is allegedly the system that means that health care in the NHS should always go from strength to strength, it's about creating the right 'open' environment in which training prospers, mistakes are learnt from and evidence is always studied before any money is frittered away. Sadly Clinical Governance appears like someone's sick joke as virtually all of it is ignored, while the opposite seems to be the case in the reality of the NHS. The 'open' culture is so open that whistle blowers get burnt at the stake, the training is so important that the untrained are empowered, while the evidence is routinely ignored by policy makers as they only care for propaganda, gimmickry and ideology. Brave old NHS indeed.

Remedy survey reveals the truth about MMC

A recent Remedy survey has shown the devastating impact that Modernising Medical Careers (MMC) has had upon patients, doctors and their families. The results are not surprising but are still very important as none of the powers that be have ever looked for any feedback or comment from doctors on MMC.

It is strange that in an NHS with so much bureaucracy and pretend feedback that organisations such as the Department of Health, PMETB, the Deaneries and the BMA have never asked any meaningful questions about MMC. If you do not look for something then you will not find it, also if you hide from something then you are also a damn sight less likely to encounter it.

Amazingly despite the stated aims of MMC being to improve patient care and postgraduate medical training, 78% of all respondents say that patient care and postgraduate training is worse than previously. Very few (just 1%) could comment on MMC positively.

Sadly MMC is but the tip of the iceberg of failing and destructive healthcare reform, it is also true that this failing government healthcare policy is also only the tip of another even bigger iceberg, the one that represents this government's general failure in all it touches. Whether it be the riding roughshod over our civil liberties or the never ending empowerment of various Kafka-esque state agencies, this government treats most people with no respect, and if you treat people with no respect and showpeople no trust then you know what you can expect in return.

Cancer mortality unchanged and more targets

It is obvious that the government's grandiose inefficient top down schemes don't work very well, another example of this has been the government's 'Cancer plan', yet another superficially catchy plan backed up with more targets that appears not to have worked. Blanket targets that force patients to be seen within a certain time frame irrelevant of their actual clinical need are ways of robbing Peter to pay Paul.

The only way to improve our cancer mortality figures is to scrap the targets and continue to sink money into capacity on every level. This doesn't only mean quicker surgery by more operative capacity, it means more radiotherapy capacity, more capacity of adjuvant therapies like chemotherapy, easier access for GPs to diagnostic services and more capacity in the specialist clinics and in radiology departments. It would take a hell of a lot of money to drag us back into line with the rest of Europe on this one after so many years of relatively underspending.

Simon Caulkin's quite magificent article in the Guardian brilliantly exposes just how foolish the government's approach is to these complex problems:

"Target-driven organisations are institutionally witless because they face the wrong way: towards ministers and target-setters, not customers or citizens. Accusing them of neglecting customers to focus on targets, as a report on Network Rail did just two weeks ago, is like berating cats for eating small birds. That's what they do. Just as inevitable is the spawning of ballooning bureaucracies to track performance and report it to inspectorates that administer what feels to teachers, doctors and social workers increasingly like a reign of fear."

You can read the rest of this excellent critique here, it really is a fantastic piece of journalism:

"They even propose a health warning: "Goals may cause systematic problems in organisations due to narrowed focus, increased risk-taking, unethical behaviour, inhibited learning, decreased co-operation, and decreased intrinsic motivation." As a glance at Stafford hospital would tell them, that's not the half of it."

'Individual management failures'

The headlines surrounding Staffordshire General Hospital have been hitting the news in the last few days and it is hard to see how anyone could not be outraged at the appalling standards of care 'provided' there. Gordon Brown was answering questions on the subject at lunchtime today and he kept repeating the words 'individual management failures' while ignoring repeated criticisms of the NHS' dire central management which imposes the market from Whitehall and the top down target based system that is arguably to blame for problems like Staffordshire General's.

Others have covered this story already. Dr C points out that anyone pointing out these kind of glaring failures in care is likely to be labelled mentally ill by the GMC, such is a whistleblower's fate in the NHS. Dr Grumble points out how the idiotic target based system encourages the prioritisation of political imperatives over clinical ones leading to junior doctors being bullied by managers into ignoring the clinical priorities of patients. Dr Rant points out where the blame should lie. The Witch Doctor cleverly points out that the 'leaders' which this government is so keen to marginalise are probably the only people who could dig the NHS out of the deep pit which the politicians have been digging for so many years.

Alan Johnson and Gordon Brown are living in cloud cuckoo land. While some hospitals do manage to provide high standards of care, it is despite the government's central megalomania, not because of it. The problems in Staffordshire General stem from No 10, the DoH and the top. The government's top down control freakery and brutal imposition of various brainless reforms is the cause of problems like this. The management structure of the NHS is centrally driven and top down, there is no room for feedback, no room for local decisions, it is do as the government says or die, quite literally in some cases.

It is no coincidence that patients were killed in both Maidstone and Staffordshire as a result of Trusts prioritising their finances over patient care. Both hospitals were trying to gain Foundation hospital status, hence they wanted to save money and meet targets, whatever the cost in terms of patients being slaughtered. The government has killed these patients with its systemic mismanagement of the NHS. The market has been their top priority and imposing this from the top has come with the obvious costs attached. There is no doubt that the governent has created this environment in which finances are prioritised ahead of patients' lives.

Gordon Brown and Alan Johnson have the blood on their filthy hands. These are not individual management failings, these are systemic failings as a result of a Stalinist system that forces managers to prioritise the government's wishes ahead of patients' clinical needs. The government's explanations for these deaths do not cut the mustard, it is simply not good enough to try to pin the blame on individual managers. The blame lies with a cynical and corrupt system that is set up to meet the short term propaganda gathering needs of politicians, local managers are frequently in a no win situation as they are forced to meet political targets rather than improving the process of clinical care with their hospital.

Gordon Brown's stupid words in defence of his targets sum it all up beautifully, he claimed that no reasonable person would deny that cancer patients should be seen within two weeks and that AE patients should be seen within four hours. Actually Gordon I am reasonable and there are many situations when it is very reasonable for minor injuries to wait many hours for treatment, as if there are moribund patients needing resuscitation in the same AE department they must be the number 1 priority and the sore big toe or the itchy buttock can damn well wait.

Targets do not improve patient care, only extra investment and a consequent increase in capacity can do this, the targets are a bit like robbing Peter to pay Paul, improving care for one condition invariably results in someone with another condition suffering. All the managers in Staffordshire General were doing was responding to the pressures of a system that had been put in place by central government, if they had some local autonomy then it would be fair to blame them, unfortunately they did not. The government has created this dangerous clinical environment, it is they who should be up in court charged with murder.

Alan Johnson: liar or just plain ignorant?

Anyone who works in the NHS these days, well pretty much anyone, can tell you that Alan Johnson is extremely innacurate with the following statement that is documented on the record in Hansard:

"There is no question but that it has been challenging to work towards full compliance. The NHS has over 46,000 doctors in training at any one time. Incidentally, there is no vacancy problem, as the hon. Member for South Cambridgeshire (Mr. Lansley) suggested. On the last set of figures, we had a 95 per cent. fill rate; there is absolutely no vacancy problem anywhere in the country that I know of. This is a service that by its very nature has to operate for 24 hours a day, seven days a week. Trainee doctors need to train and work in as many medical disciplines as possible to become good doctors. Hospitals have had to make dramatic changes to how staff work. So, yes, it has been difficult, but it is simply not true to say that the NHS is ill prepared to achieve full compliance by August this year. We have provided substantial financial support to the NHS to help it to meet the requirements of the directive—£110 million in the current financial year, rising to £310 million for the year to come."

Either Mr Johnson is incredibly ignorant of what is going on in his own department or he is telling big fat porkies. For many reasons there is a staffing crisis at many junioir doctor levels in the NHS, numerous rotas are being run short of multiple staff members, meaning that doctors are missing out on training and patient care is suffering.

A recent survey of surgeons in training showed that over 50% of surgical rotas were significantly short of staff, and this is not an isolated problem for surgery, it is occurring across the board and it is not good for anyone. Doctors are getting overly tired covering the gaps while patients will be getting less continuity of care, as well as less time dedicated to their various problems.

The blame for this lies with the government thanks to their stupid reform that has led to non-EU doctors being kicked out, all doctors changing on the same day every year and hundreds quitting the NHS due to their great disillusionment. This is all compounded by reducing working hours thanks to EWTD and the fact that the BMA are doing nothing about this serious problem. NHS Trusts cannot find locum cover to fill these gaps, while even if they can it is very expensive and wasting a lot of money needlessly. Well done Mr Johnson et al, you have shafted a generation of doctors and now the patients are suffering too.

You get what you pay for, less training more mistakes

With kind permission from the author I have reproduced the following tale to show how quite simply less training leads to more mistakes and a lower quality of care:

"Not so long ago, in a land not far from here, a young boy awoke one morning with a painful tummy.

"Daddy!" he cried. "My tummy's hurting."

The father looked down at his dear son and said, "Don't worry, O son, for I know a Wise Woman who will be able to cure your pain. Let us go and visit her."

And so, the family made haste their travel to the local Walk-In Centre, where the friendly nurse greeted them with a warm smile. "Come in, and tell me all about it," she said. And the young boy proceeded to tell the Wise Woman of his painful tummy."This is nothing to worry about!" she declared in a very wise and motherly way. "Be gone, for your pain is due to a virus."

The Wise Woman did not need to examine the young boy, for she had been on a "couple of courses."

The family thanked the Wise Woman for her great wisdom and made good their journey home.2 days later, the post-mortem report concluded that the boy had died from a perforated appendix.

The morals of this story are that:

1: When you assess a patient, you often have to examine them.

2: If you do not know how to examine a patient, you should not be assessing them.

3: Sometimes it takes a few disasters before mistakes in policies are addressed.

4: Nurses, as with doctors, have a duty of care to their patients. If that duty is breached and harm results, then they are NEGLIGENT.

5: After a few civil cases, nurses in WICs will realise that they are on their own, in a failed policy.

6: The public should be fully informed when consenting to treatment: "You get what you pay for."

Wise words. I am not pretending doctors are perfect, far from it, however less training results in worse care, it's very very simple.