Tuesday, 27 February 2007

MTAS and its corruptible nature

The Medical Training Application Service (MTAS) was brought in with MMC to make the selection process fairer and more meritocratic. The centralised scheme was designed to make applying for a job easy and straightforward. If only things were that way.

I will be careful with my words. Firstly the application system is fundamentally flawed by allocating such a high percentage of marks to the short answer questions. I would argue that it is impossible to effectively discriminate between candidates using this skewed approach.

Each of these short answer questions was marked out of four marks and many problems have stemmed from the rigid marking scheme, as well as the weighting of marks in a way that virtually ignores examinations and other achievements. The MTAS process has not been audited or validated properly either.

" MMC profiteers. Get hold of a copy of Hospital doctor this week as RemedyUK help expose the burgeoning industry of people making a fast buck out of desperate doctors looking to buff up their application form. Of note is one MALVENA STUART TAYLOR, ASSOCIATE DEAN of Wessex Deanery, charging £129 to each of the 100 doctors desperate enough to show up for basic advice on filling out the application form. Helpfully included in her lowbrow 3 ½ hour lecture on the principles and background of MMC/MTAS etc (made possible by industry leaders www.123doc.com) was a seminar aimed at selling financial advice, particularly well received by attendees given their current situation."

I quote from RemedyUK above. They also found that around 1 in 5 SHOs had received formalised advice on filling in their forms.

The muck does not stop flying. Many candidates were helped in filling in their forms by consultants who had insider knowledge as they were involved in the marking and short listing process. Word on the street indicates that confidential marking schemes found their way to some candidates giving them an unfair advantage. Word on the street also tells me that there have been cases of printed confidential marking schemes being handed out to juniors by consultants. The rigid marking schemes meant that the system was inherently biased against doctors who had not been through this bizarre application process before. There are even rumours of even worse.

There have been several examples of companies profiteering thanks to insider knowledge.


This course, run by associate deans, claimed that it would help you 'take advantage' of the MMC process. I cannot see much difference between this and 'cheating'. This is by no means an isolated example. MTAS have also admitted that there is no system to ensure that short listing has been completed by all applicants; this is completely unacceptable.

MTAS and MMC were railroaded through under the promise of a fairer application process for all. I fail to see any evidence of this, it seems that the converse is true. The old system was by no means perfect, but no system is perfect; however by using CVs and local applications the process was much more meritocratic that today's. Doctors with greater experience, more motivation and more achievements had a fair advantage in the old system. The CV is a tried and tested selection tool that is still used to this day by all major companies. It is eminently less corruptible.

This tried and tested method has been replaced with an untried and untested farce. Doctors who lie, who cheat and who are assisted by those with insider knowledge are given a massively unfair advantage. While many of the best doctors with the most achievements are left out in the cold, because they did not fill in a few politically correct questions very well and because they did not lie or cheat. This is what MMC and MTAS has produced, a selection process that is not even as good as a roulette wheel; the roulette wheel is not as corruptible.

It is hard to sum up the human cost as a result of this selection sham. There are juniors who have worked their fingers to the bone for several years with the aim of a job in their chosen specialty. They have passed all the neccessary tests and examinations, they have attended all the relevant courses, they have worked hard to get material published and they have done this all while holding down a rather demanding full time job. Some of these juniors are supporting just themselves, but many are supporting partners and small children while they do all this. They are juniors who have a burning desire for their particular specialty and will be forced to emigrate thanks to recent events. How this new system is going to be good for medicine in the UK is quite beyond me.

Some of us have been lucky, this is true, but can we really sleep at night knowing that some of the best candidates out there have not got a single interview. Some of these juniors are family members, some are friends, but the vast majority are people we will never meet. Doesn't it feel a tiny bit hollow getting an interview when you know that the selection process is such a joke? Imagine how it will feel to get a job in your chosen specialty; it won't feel as satisfying as when the selection process was fair, there will be a nasty nagging emptiness inside of you that will eat away at you because so many juniors have been treated so very unfairly.

There are signs that the MTAS beast may be wounded, the media are starting to take an interest in what can only be described as a massive scandal:



Dr Crippen is spot on as ever: http://nhsblogdoc.blogspot.com/

This momentum needs to be kept up, the apologists for MTAS must be made to eat their hollow words, this battle must be won.

Watch this space.

Crony state of affairs

Last night on Channel 4 'Dispatches', government health policy was comprehensively analysed and blown to smithereens. Liam Halligan did an absolutely fantastic job in presenting such a well researched piece of journalism. He put the BBC to shame given their pathetic attempts at commenting on health policy in recent years, where ministers are given notoriously easy rides and tricky areas are just glossed over. Patricia Hewitt was made to squirm like the absolute ignoramus she is, something the BBC has singularly failed to achieve in several attempts.




I am sorry but the time for sensible dialogue with the likes of Blair and Hewitt is useless. They have no respect for the NHS and no respect for the public. This is shown by their repeated lies and overt contempt for the democratic process. The NHS reforms are not working, they are the root cause of the problems and things will only improve when these reforms are firmly stopped in their tracks. The politicians so far have not engaged in any fair debate, they merely repeat soundbites and drone on with some manipulated statistics to back up their flimsy arguments.

A rather biased BBC program looking at the David Kelly death was on the other night. Unfortunately all the 'proof' of suicide was kept for the end of the program, in a way that set out to convince people it was actually a suicide. A lovely bit of BBC spin.


Were viewers meant to forget the facts that had been presented earlier in the program? These were facts that showed the Hutton enquiry to have less power than a coroner's inquest, that showed the cause of death to be very unclear and unproven, and that showed the Hutton inquiry was deeply flawed and lacking in investigative rigour.


As these medical expert say, due process has not been followed in investigating the death of David Kelly. Serious and legitimate questions remain unanswered. Whether it was suicide or not; the David Kelly debate will rage on and on until it is investigated properly. My hat goes off to Norman Baker who seems to be one of a rather rare subspecies of politician; he actually cares and believes in certain principles.

The same cannot be said for Tony Blair and his cronies. Their behaviour in the David Kelly affair was absolutely scandalous, they hung Mr Kelly out to dry in a way that was totally indefensible. There is a complete lack of rigour that seems to apply to politicians when they make decisions that have massive implications. They can take us to war and then when is abundantly clear that due process has not been followed, and nothing happens. If something inconvenient happens to the government and it is investigated; the PM will appoint one of a band of friendly cronies to investigate, thus ensuring the PM will hear what he wants to hear. Even when it is proven that a politician has acted corruptly, it still requires the PM to act for some kind of punishment to occur and we know how often things are simply brushed under the carpet. The PM also has his resident 'poodle', the Attorney General, who he can always pressure for legal backing to any decision if he needs it. This complete lack of accountability seen in politics is in stark contrast to the recent clampdown on medical regulation; doctors will have their reputations wrecked under a civil 'balance of probabilities' rather than the old criminal 'reasonable doubt' and doctors will be constantly living in fear thanks to several other draconian measures imposed upon them by their political masters.

No wonder the NHS is in a mess. The democratic process that we rely on to drive us forwards is failing. This crony government seems to be answerable only to itself, as it goes about wrecking our country's chances of long term prosperity in the pursuit corrupt and idiotic short term gains. The one hope is that they will be made accountable at the next election, but how do we know that the next lot will not do exactly the same?

Monday, 26 February 2007

The shambolic disgrace of MTAS

This year has been the first year that all junior doctors have been blessed with the opportunity to apply for their specialist training posts via MTAS (Medical Training Application Service). I use the word 'blessed' to intimate how those in power see things working.

Junior doctors do not see things like this. The application process has been a disorganised shambles. From the very start there were hundreds of problems with; the application forms, the website crashing, the vague questions asked, the help desk not answering valid questions, the submission of applications not working, chunks of applications going missing, job descriptions changing after applications had been submitted, job numbers changing after applications had been submitted, not forgetting the poor souls who missed the application deadline, as well as countless other problems. The most glaring problem was the fact that the server crashed day in day out, thus losing people's applications, and then when the closing date came: the server ran at the speed of a dead tortoise while crashing every few minutes.

The problems didn't stop there. Hundreds of consultants have had to shortlist applicants for interviews based on their answers to vague politically correct waffle. Over 75% of the 'marks' are given for these vague questions, while achievements like exams and work experience are pretty much ignored. This has infuriated consultants who have the impossible job of choosing the best candidates when they effectively have their hands tied behind their backs. Add the appalling lack of meritocracy to the fact that there simply has not been enough time to mark all these applications and complete the shortlisting before the allotted deadline.

This has meant that the deadline has been pushed back to 9am today on the 26th of February. Today it should have been possible for all juniors who had applied to check their applications, see if they had an interview, book the interview and organise the time off work.

Inevitably the theory that MTAS is run by a small band of management consultant monkeys has been substantially strengthened after the events of today. Over half the deaneries have not had time to complete their shortlisting and there are yet again numerous problems with the MTAS website. This practically means that junior doctors are being stressed out beyond belief as they don't know if they have interviews and they don't know if they have to book time off work for an interview (in some cases the interviews are in two days time!) . Dr Rant has a rather good piece on MMC/MTAS et al.


MTAS is symptomatic of this government's gross incompetence, which is revealed by repeated attempts to centralise everything in the naive belief that grand centralised schemes are always better than the systems they are replacing. Junior doctors have not only been shafted by this government's reforms of medical training and the destruction of a healthcare system that can support training in a sustainable manner; they are now been royally rogered by an application system that is nowhere near being fit for purpose. No wonder juniors are emigrating in droves; the true cost of this government's policies will not become fully apparent for years but when they do become apparent, the faeces will emphatically hit the fan.

I'm off to buy my sledge hammer.

Sunday, 25 February 2007

NHS getting better! more marvels of the internal market

I just had to come out and say what a revolution to patient care the old 'internal market' is. There's more evidence of the successes of payment by results here in the paper:


The logic is truly poetic. Operations are being postponed around the country because there is no enough money to pay for them! One would assume that there is not enough money to pay for the surgeons, nurses, equipment etc, but this is not a problem at all. The PCTs do not have enough money to pay the hospital to do the work, because of the ludicrous 'internal market' system.

Thus we have highly skilled surgeons sitting around twiddling their thumbs, while theatres sit empty and nurses think of ways to pass the time! These staff and facilities are all paid for and able to do the work, but there is not enough 'money' to pay for it!

Am I an idiot to think that the 'internal market' makes about as much sense as an epileptic monkey on a type-writer? Patricia Hewitt think so, but then she is arguably less articulate that the aforementioned monkey.

Why not just fund the hospitals to pay for the work that needs doing? No, that would be far too simple, more efficient and less bureaucratic! That was the old NHS, this is the brave new NHS.

Looks like the brave new NHS' monkey in charge, Patricia Hewitt, may start feeling the heat in the form of some Channel 4 crafted gusts up her skirt:



Get ready for Channel 4 to stick the knife in, it is about bloody time that the 'internal market' and the government's useless mismanagement were exposed for the scandals they are.

(post scriptum- another great piece in the telegraph explaining how the governments policies are destroying things: here:http://www.telegraph.co.uk/health/main.jhtml?xml=/health/2007/02/26/hnhs26.xml)

Saturday, 24 February 2007

Dubious flawed and corrupt.............D'oh

Another night shift passes by, my eyes hurt and my breath smells of general unpleasantness. A topic of great controversy in medicine today is that of extending the roles of other non-medical so-called healthcare practitioners.

Trends seem to pass over the Atlantic almost seamlessly at times, and there appears to be little correlation between policy migration and policy quality. For one the UK has miraculously managed to export gang culture from the US of late. There are those who would utter words including privatisation, deregulation, flexible labour market and imperial capitalism. I won't go there for the moment, my fingers are too tired to embark on that journey.

In the UK the role of nurse has been extended in many ways in recent years. There are undoubtedly some new nursing roles that provide a great service very safely. However I would argue that some boundaries have been pushed back way too far, in such a way that we have pseudo-practitioners dangerously practising medicine in areas in which they have not been adequately trained. One example of this is handing the right to fully prescribe to nurses and pharmacists. Another is handing diagnostic work (which includes history taking, physical examination, ordering/interpreting investigations, initiating safe management plans and organising aftercare) to those who have not been sufficiently trained in this area.

These schemes originated in the US and have since migrated to the UK. The motives for handing more responsibility to less skilled staff are arguably linked to the pressures that drive the american healthcare system. The largely privately run US healthcare industry could be said to be trying to squeeze profit at the expense of service. It may be cheaper to replace highly trained and highly skilled workers with undertrained minions, but what of the service provided? It is certainly not unheard of for the private sector to squeeze service for the sake of profit, the term 'fat trimming' is often used to look upon this practice favourably.

Anyways I digress, back to the point, and that was meant to be extending full prescribing rights to non-doctors. In 2006 a vote was passed by a committee that handed out this power to nurses and pharmacists. Dubiously this committee was made up of a majority of non-medically trained individuals and all those who were medical voted 'NO'. The consultation process revealed that an overwhelming majority of medical bodies were opposed to the scheme. Despite this dodgy vote and flawed consultation process, surprise surprise, the government has carried on and it is now law. Someone has therefore tried to obtain a bit more juice on this from the DOH:

"Dear DOH,

I write as regards the decision to extend prescribing in non-medical practitioners in 2006.

Pulse obtained documents in 2006 that showed that not one of 16 medical bodies supported this move for pharmacists.

Also only one of fourteen medical bodies supported the move for nurses.

The moves were unsurprisingly supported by nursing and phamacists' bodies or NHS bodies, all clearly very baised sources to base any decision on.

The questions I want answered are:

1. How can this consultation process have been deemed fair and adequate when it ignored the massive majority of expert medical opinion in making a medical decision?

2. If you still claim the consultation process was adequate then did you have any scientific peer-reviewed research that suggest nurse or pharmacist prescribing is safe?

3. I do not quite understand how nurses and pharmacists can be allowed to prescribe when they have not been adequately trained to take a history, examine and diagnose; this means they cannot be safe to prescribe as these diagnostic skills are key in safe prescribing.

4. I quote Pulse: "A Department of Health spokesperson insisted the recommendations took all consultation responses into account, 'including those from doctors'."; a consultation process does not merely involve pretending to listen to the information achieved via consultation, it involves scrapping schemes where there is an abundance of expert opinion that states the scheme is not appropriate or unsafe. Why did the DOH press ahead despite the wealth of medical expert opinion against the scheme?

5. Specifically I want to who ( if the prime minister, any politicians, advisers or other senior DOH officials) had an input into making this decision to go ahead with these scheme of non-medical prescribing despite a wealth of medical expert opinion against it? I want to see any documents of discussion between officials/minister/advisers about this consultation process and decision.

6. Also there was a vote on this non-medical prescribing. I want to know how the committee that discussed and voted on the issue was decided upon. Were senior minister, politicians, government advisers, senior DOH officials involved in the decision as regards who was on this committee? I want to see documents of any discussion as to who should sit on this committee?

7. Also as regards the vote on non-medical prescribing; I would like to know the details of everyone who was on the committee and which way they voted, and if they had any conflicts of interest ( ie who they worked for and any financial interests of relevance )?

8. Finally where did this idea of giving full prescribing rights to nurses and pharmacists come from? I want to know if there were any high level discussions between the PM, politicians, advisers, senior DOH officials that reveal where this idea came from and the motives behind this idea? Were any private healthcare companies involved in lobbying politicians about this issue?

9. Specifically have any employees or representatives of any of the following companies ever discussed the issue of non-medical prescribing with any politicians, ministers, advisers, DOH officials, civil servants? The companies I am interested in are Boots, United healthcare, Capio healthcare, BMI Healthcare, MercuryHealth, Alliance Medical, Aspen Healthcare, Netcare, BUPA, InterHealth Jarvis, Patients Choice Partners.

10. I would also like to know if any of the following companies' employees or representatives ( Boots, United healthcare, Capio healthcare, BMI Healthcare, MercuryHealth, Alliance Medical, Aspen Healthcare, Netcare, BUPA, InterHealth Jarvis, Patients Choice Partners.) have lobbied or discussed any of the following subjects with politicians, civil servants, advisers, DOH officials? The subjects I am interested are the extension of nurses roles, the new role of the physicians assistant, Modernising medical careers (MMC), ISTCs and PFI schemes? If they have then I want to see evidence of any discussions/negotiations,

many thanks for the excellent service you provide,

yours, "

Friday, 23 February 2007

Comical 'Blair', private equity and patient 'safety'....

Could Tony Blair be copying the tactics of the mighty comical Ali?


An excellent piece on those lovely fellows who work in the world of private equity, selflessly making the economy a better place for us all in the long term.


A highly respected diplomat tells us what he really thinks of Blair and Iraq.


"Sir Ian Kennedy, chairman of the Healthcare Commission, said health ministers had imposed a welter of targets on the NHS since 1997 to change behaviour in hospitals and GP surgeries. But they did not give patient safety the attention it deserved. Apart from a target to reduce deaths from MRSA, there were no other signals from the centre that patient safety was the NHS's most important issue, he told a safety seminar in London.
"Even when targets ruled the day, there were none relating to the [overall] safety of patients. Yet targets were the way the government indicated its priorities. I am not advocating a wholesale return to targets. But I am saying patient safety should be everyone's business and everyone's responsibility," he said."


Indeed, there seems to be no one in the management hierarchy, including Sir Liam and the DOH, who is actually looking after this much repeated phenomenon 'patient safety'.

Could it be something to do with the complete lack of a holistic understanding of the health service in general? Could the deliberate manipulation of systems to fiddle targets, in order to produce ammunition for government spin, be anything to do with the problem?

Thursday, 22 February 2007

CFISSA - media blackout

CFISSA- This stands for centrally funded government health initiatives and is a very hush-hush topic in the press. It shouldn't be.

This is because last year 2005-6, CFISSA was over 6 Billion pounds over budget out of a total budget of less than fifteen billion pounds.

Given that operations and investigations are being cancelled thanks to an NHS deficit of less than 1 billion pounds, it makes one scratch one's head and think why is this not reported in the mainstream press?

The NHS deficit has accumulated over many years and is tiny relative to the total NHS budget. While the CFISSA deficit is over six times the total NHS deficit, it has gathered in a relatively much shorter space of time.



Significant Underspends (2004-2006):
Cancer -77 million
CHD -37 million
Mental health -34 million
Reducing health inequalities -169 million
Workforce -667 million

Significant Overspends (2004-2006):
Older People +165 million (interesting this: an overspend of +374 million, followed by a dramatic underspend of -209 million)
Improving patient experience +68 million
IM&T +696 million
Specialist health services +1065 million (audiology, dentistry, ophthalmic <-- already privatised) Modernisation agency +63 million Primary care +4153 million Residual budgets (eg to SHAs) +3938 million
PCT allocations +5574 million

Those bottom two are very significant as virtually the entire overspend is from these. A couple of ferrets have been sent undercover on a special mission and it is likely there is more to be said on this topic.

Where did all the money go?

Wednesday, 21 February 2007

Point by point - then off on a tangent

I wish to address points one by one and I will directly quote from "Learning from tragedy, keeping patients safe" the government's recent report. (http://www.dh.gov.uk/assetRoot/04/14/32/49/04143249.pdf)

1. Why are doctors being singled out in this when there are ample examples of nurses murdering patients? There has also been the extension of full prescribing rights to nurse practitioners and pharmacists, and this must have implications for the regulation of these professions; however I see no white papers singling them out?

Remarkably nursing personnel made up 86% of the healthcare providers prosecuted here, and doctors only 12%! Even if nurses make up eight times the number of doctors then both are equally likely to serially murder, meaning that the question still begs an answer. http://www.ingentaconnect.com/content/bsc/jfo/2006/00000051/00000006/art00017;jsessionid=2mn3l8cfms0uj.alice

2. "the statutory protection for whistleblowers should be strengthened." I will be looking our with interest to see if this is just hot air. See Dr Rant for a good piece on this: http://www.drrant.net/2006/08/dr-otto-chan.html

3. "the adoption of the civil standard of proof (“on the balance of probabilities”) rather than the
criminal standard (“beyond reasonable doubt”) in fitness to practise cases;"

Lovely! I'm glad to see the media have not picked up on this rather significant point. The government's argument is that our healthcare system must be centred around the patient. The government will now be able to manipulate the process to their own ends more easily; as they get to appoint some members of the panel and the burden of proof is significantly less. Is it fair that one could be struck off and have one's life wrecked at less than a criminal standard of proof?

No, this is not fair. This part made me fume.

Especially when you consider that the politicians who rule us get to regulate themselves and their record makes the GMC look like a utopian organisation. Anyone waiting for Blair to launch an inquiry into the Iraq war? precisely (Shipman eat your heart out). And we all know that politicians appoint their own cronies to investigate any areas of controversy....Hutton. Then think for one minute what politicians have to gain from their lack of proper regulation ($). The medical profession does not stand to gain in anything like the same way by self-regulating, yet this power is being stripped from us by these corrupt morons.

4. "-to assess the quality of the care they provide, using a combination of clinical outcomes and
measures of patients’ experience;
-to reflect on this experience, including both successes and failures; and
-to apply the lessons learnt in order to improve the quality of services."

These three principles of clinical governance seem to contradict all government health policy. There is no evidence behind any of their policies (PFIs/ISTCs/CATs and on). They do not monitor the impact or performance of their privatised schemes. They carry on reforming despite massive amounts of hard evidence proving that the reforms are failing.

5. "At the level of the individual clinician or clinical team this process includes participation in
clinical audit. But healthcare organisations as a whole – and PCTs in relation to the primary care
services which they commission on behalf of their populations – need to carry out a similar process
of assessment in order to identify poor-quality services and to encourage and reward the good.
Identifying poor performance, and taking whatever steps are needed to protect patients from its
results, is therefore an integral part of clinical governance."

Again, convenient banter than runs against the grain of government health policy. The same comments relevant to 4 apply.

6. "supporting people who want to make complaints or raise concerns, so that they know where to go and can be assured that their story will be listened to and acted on;"

It's all very well to claim that we should listen to complaints and concerns. However they are many instances when patients' complaints are completely unfounded. Something the government consistently ignores is that it is important to weed out well-founded complaints from baseless accusations. The current complaints procedure encourages baseless accusations to be taken higher and higher, and if they carry on pandering to patient power we will soon have a situation where doctors cannot even give patients lifestyle advice without fear of a complaint.

The doctor-patient relationship is a key part of a functional NHS. However at the moment we have patients who swear at staff, who are threatening physically to staff and who physically attack staff. In my last week at work I have been sworn at my drunk patients and the nurses I work with have been called the c-word on several occasions. I can tell you this is becoming more and more routine. There is also a distinct lack of respect shown towards medical staff at times; for example patients chatting on mobile phones during consultations and then getting upset when they are asked to switch their phone off. I must emphasise that the majority of patients are very respectful and well behaved. The government's measures will undoubtedly give more power to patients who make baseless accusations and more doctors will be disciplined for things that they did not do.

I'm off on a ranting tangent now, but what's wrong with going with the flow on occasion? I've damn well had enough of radio phone-ins hosted by morons where patients are are encouraged to slag off the medical profession. The media is allowed to openly call doctors 'arrogant' and 'overpaid'. This is not a debate about medical regulation, it is gutter journalism of the lowest kind. Most patients trust their doctors more than any other profession and most patients are very happy with the service they receive. I think the journalists should stop pointing out the small grain of dust in the eye of the medical profession, when there is a rather large rowing boat in their own; public trust in journalists is not exactly impressive.

There is a serious point here. Thousands of doctors are in the process of emigrating or switching careers. There is already a significant problem with suicide, mental health and drug abuse in the medical profession. Will a more punitive culture run by political stooges be good for the health of doctors and good for the care of patients? Quite clearly the answer to both is no.

Finally look at what is really happening here. Power is being taken from a trusted and respected profession and this power is now subject to a greater political influence. Will this power shift make it easier for the government to crank up the speed at which the NHS is dismantled and privatised?


For a second ponder how many politicians and managers have been made accountable for decisions that have had disastrous impacts on patient care? By this I mean how many have been sacked or struck off their professional register for these errors? None, they are simply moved sideways and they have no professional register as they are not regulated. As Dr Rant points out above their is a growing trend of management trying to influence clinical decisions. Who carries the can when this goes wrong? The doctor carries the can. The white paper will make it easier for doctors to be blamed and castigated for the errors of their controllers.

The lowering of the burden of proof the the politicisation of medical regulation must be debated in this context. When the government is so keen to chat of clinical governance, is it not a tad hypocritical to pick on the medical profession in this way, while the politicians and managers are completely unaccountable for decisions that can sometimes result in the death of hundreds of patients?

It's more central credit and local blame from those in power. It's rather ironic that medical regulation is passing from the GMC, once labelled a 'totalitarian' organisation, to the Department of Health! Once could never accuse the Department of Health of resembling a totalitarian organisation, they'd have you struck off.

Trust me I'm a politician

Today is indeed a dark day for the medical profession. The current administration continues its attempts to grab as much power as possible, while apologists in the media look on in a rather accepting manner. I am not pretending the old system was perfect, but change for the sake of political power grabbing is not in the interests of patients or doctors, it is in the interests of politicians and their puppet masters.

Doctors will have their abilities and skills tested against a set of unvalidated and meaningless criteria in the name of political expediency. Doctors will now be judged by people who have been appointed by politicians. There will also be a sliding scale for the level of proof against which doctors are tried.

The government wants our trust and claims we should go along with this for 'patient safety'.

I do not trust their record on patient safety so far, do you? Here are some examples where patient safety has been jeopardised by:

- PFIs - bankrupting trusts meaning they have no money to provide basic investigations and treatments

-ISTCs - unregulated and poorly audited surgical centres where foreign surgeons, with less training and unknown/unassessed competency, are allowed to operate away. These centres are also paid significantly more than the NHS for the same work.

- Nurse and pharmacist prescribing - extending prescribing to staff who have not had sufficient training to be able to safely diagnose and prescribe. The medical profession's opinion was ignored during the consultation.

- Extending roles of Nurses and other non-medically trained practitioners like Physicians Assistants. There is a virtually non-existent regulation process for these workers and their introduction has not been adequately assessed from a safety or financial point of view.

- Walk in Centres - another wasteful cost-ineffective scheme where unless you present with something simple like a blocked nose, you will be referred on to a GP or A&E department

-Hospital at Night - a scheme introduced around the whole country without any monitoring of its impact on patient outcomes/safety. This is despite a large amount of anecdotal evidence which suggests it is very dangerous for patients.

-National IT scheme - we've seen that the early pilots of choose and book and certain computerised systems have failed miserably, resulting in patients missing appointments and operations

-Cutting bed numbers and more power to unregulated managers - as hospitals are made more shiny, beds mysteriously go missing; this results in a desperate bed shortage and consequently managers unfairly put pressure on medical staff not to admit patients whose clinical state neccessitates admission. Surprisingly these managers are never held to account for their reckless and dangerous actions.

I could go on. Not a great record is it though? Add this to other policies where there is an increasing trend towards centralised power building and the never-ending erosion of civil liberties, and you have a rather worrying picture. This is a situation where politicians are trying to win our trust but all the objective evidence proves they do not deserve our trust; a situation where politicians claim we need to protect our democracy by bringing in draconian new laws to combat terrorism; a situation where politicians want to create increasingly centralised surveillance systems and bureaucracies.

Has anyone heard of this happening before?

This white paper must be vigorously opposed. The BMA must stand up and be counted. Actions will speak louder than more empty rhetoric. If Greenpeace can beat the government on nuclear power, then the medical profession must do the same.

Tuesday, 20 February 2007

PAs:good value or expensive waste?

Have a peek at these questions that may have been sent to the Department of Health. It was in response to some replies that they supplied on the topic of 'Physicians Assistants'.

Given that we will have a surplus of several thousand unemployed highly skilled and highly trained junior doctors come this August (thanks to the shambolic work force planning of this administration) Is it really sensible to be training thousands more physicians assistants and nurse practitioners? Each doctor has cost several hundred thousand pounds to train; so just from an economic tax paying perspective it seems like lunacy to waste their talents in this way. Add to this that there is no evidence that these non-doctoring grades are more cost-effective! It is not as simple as just cost-effectiveness either. There are numerous ways in which modifying the health system by introducing new non-doctoring grades is expensive.

Just think: these new professionals must be regulated (not cheap), existing healthcare structures need to be modified to accommodate these new professionals (more reorganisation-not cheap), their performance must be monitored rigorously as they are an unknown entity(not cheap), what of the effects on the long term sustainability of the service and training? and how will the consultants of tomorrow be trained? (this has not been adequately considered, the same is true for the privatisation of the NHS and the impact this will have on medical training and the sustainability of the service). It seems that the DOH has no evidence at all to prove what it is doing will improve the service provided or save money. If anything it will waste a lot of money in the ways mentioned and have a potentially disastrous impact on the sustainability of the NHS.

I wonder where that CFISSA money went? There was certainly far too much money missing for it to be explained by Tony's mortgages alone. Anyway the DOH has been sent some further questions:

"Dear DOH,
I am writing again in reply the response I received as regards physicians assistants.
I am not keen and do not have time to shadow a physician's assistant unfortunately. It would not have any affect either my requests or line of argument.
I have a further few questions under FOI act:
"The Department of Health documents on New Ways of Working are written in collaboration with the NHS, and tested with key stakeholders (Royal Colleges, regulatory bodies and soon). The information is easily accessible on the Department of Health website (http://www.dh.gov.uk/) and is open to public scrutiny."
1. I am aware of this information but my question was "Are the DOH publications peer reviewed or subjected to the same level of scientific rigour as a proper medical journal? ". Thus I assume the answer is no, unless you respond otherwise.
Quoting again from your answer "Experience has shown that the continuity of the role within the medical team does free up time for the more skilled and experienced staff to concentrate on more complex patient care requirements. "
2. Specifically what evidence do you have that time is freed up? And is there any other evidence other than this 1 study of PAs working in cardiology.
3. ' http://www.hsmc.bham.ac.uk/publications/pdf-reports/Physician%20Assistant%20final%20report.pdf ' I am not convinced by this rather long winded piece of writing. It has not published in a journal and has not been peer-reviewed. Do you not have any evidence other than this? and by evidence I mean something that has been published in a reputable peer-reviewed journal.
4. "Employers will have the opportunity to, and the choice in, defining the skill mix they require to meet patient needs. If, as you suggest, PAs and Nurse Practitioners are more expensive, this would be something that the employer would consider during their decision-making process." I think this statement reveals a slight problem. Tax payers money goes towards training all these professionals (PAs, NPs, doctors, nurses). How can it be sensible to train too many, thus creating a surplus of unemployed skilled staff? This is surely a waste of tax payers cash and an inefficient way of providing a service. Can you convince me otherwise?
5. http://www.aagbi.org/pressoffice/statements/anaethesia_practitionersfeb06.htm It seems that not all the medical bodies are in agreement with the RCS and RCP. I wonder if you have any evidence that the RCGP, RCP or RCS consulted their members adequately about the introduction of physicians assistants? (as if it is merely the senior members making these decisions the consultation process would not seem adequate)
6. Has the medical profession in general been consulted in the introduction of Physicians Assistants? ( via the BMA or otherwise)
7. Will doctors be able to apply for the Physicians assistant posts? (surely they are adequately trained) and if not, why not?
8. Who will regulate the Physicians Assistants? ("Local clinical governance arrangements and national regulatory requirements take account of the practice of healthcare practitioners." I do not think this statement is sufficient.)
9. It seems all reform in the NHS today. I wonder if you have any evidence that nurse practitioners or physicians assistants are more cost effective that doctors? (as surely what is the point in changing the system if they are the same cost- the measures to put changes in place will make the overall process more expensive)
10. Given that there are over 30,000 junior doctors applying for under 10,00 run through training posts, has the Department of Health estimated how much money has been wasted training these doctors?
11. Will these unemployed junior doctors be able to apply for nurse practitioner posts as well? (surely they are adequately trained for these jobs) and if not, why not?
12. "The Department would refute the suggestion that the product from these PA programmes will not be trained sufficiently. However, as with all new education programmes, they will be subject to internal and external review, and amendments to the programmes will be considered to ensure that practitioners are fit for practice and purpose. " What is the DOH planning to monitor the performance of these Physicians Assistants? I assume there will be some concrete clinical measures in place?
13. "The information is easily accessible on the Department of Health website (http://www.dh.gov.uk/) and is open to public scrutiny." How is the information open to public scrutiny other than by being accessible via the website? Why not introduce some kind of on lone voting process whereby members of the public can agree or disagree with policies?
14. On another topic. What evidence does the DOH have that the medical profession and public were consulted adequately on the roles of nurse practitioner and surgical nurse practitioner?
I am very grateful for the excellent responses I have had so far to my questions,
yours, "

Monday, 19 February 2007

The CMO's report

Last year Sir Liam Donaldson produced his review of medical regulation (http://www.dh.gov.uk/assetRoot/04/13/72/78/04137278.pdf). To say that there are several flaws in his report would be an understatement and there there has been a significant backlash of opinion from many experts, since the report was released.

An article was written in the BMJ which had several rapid responses published here: http://www.bmj.com/cgi/eletters/333/7560/161 and http://www.bmj.com/cgi/content/full/333/7575/0-f. In particular Dr Pringle's response merits a careful read due to its eloquence and popularity among the medical profession.

The report is based on the fundamentally flawed assumption that it is possible to measure exactly what makes 'a good doctor'. Even though the CMO admits this flaw, he then goes on to suggest a range of reforms that aim to measure the unmeasurable! The resultant cost and bureaucracy do not bear thinking about, let alone the numerous inevitable impracticalities that would soon become apparent upon trying to implement such reforms.

It short the CMO's report set about politicising medical regulation, giving responsibility to a body (PMETB) that couldn't organise a piss up in a brewery, reducing the burden of proof that doctors are tried against and pushing for the grossly impracticable revalidation of the medical profession. The Walton of Detchant's comments are very fair in my view (http://www.bmj.com/cgi/eletters/333/7560/161).

Not wishing to go into too much detail, I will bore you terribly otherwise; the problems appears to be that these reforms are being driven through in a manner a la nuclear. By this I mean that the consultation process appears to have been a typical New Labour exercise of charade. In my humble opinion these reforms should not be put into practice until a proper consultation process has been seen. I am sure the reason for this is that, with a proper consultation process, the CMO's report would be planted firmly in the dustbin. The decision is coming up on February 21st.

For an example of the expert opinion disagreeing with Sir Liam, take the scottish CMO and the BMA (http://www.bma.org.uk/ap.nsf/Content/CMOresponse1106).

Then again nothing surprises me with this administration. My favourite man, our Tony chuck, has come up with a great idea! http://news.bbc.co.uk/1/hi/health/6374093.stm

Nevermind that this suggestion is an old one that was abandoned several years ago due to a massive problem with increased surgical complications. Not forgetting the fact that there are few other 'slight' hitches with this idea: who does the operating? surgeons already work hard with long hours, the back up services are not around at night, who pays for this surgery? (remember elective surgery for routine stuff like hernias, varicose veins etc has been postponed indefinitely in numerous parts of the country!) and what of emergency cases at night- how do they fit in with this?

Even an NHS manager, who had had their brain substituted by half a peanut, would have realised that this idea is the stuff of Dime bar adverts.

Another way of solving the waiting list problem would be much simpler. It would involve taking the market based approach out of the NHS, paying for and doing the work that is medically indicated, scrapping all expensive schemes like PFIs/ISTCs/CATs and letting the NHS provide a service again.

That seems very much like a pipe dream, as opposed to the nightmare Tony has imposed upon us.

An email may inadvertently have been sent to the Department of Health on the topic. You shall be kept posted.

"Dear DOH,
I am writing as regards a FOI request about the CMO's report from July 2006. I have some specific questions.
1. Before the report was published, with who did the CMO discuss the possible content or suggestionsto be included in the report?
2. Did the CMO receive any advice advice before embarking upon his work on his report? If so who was the advice from and what records do you have of this advice?
3. Was the possible content of the report discussed by the CMO with the prime minister, any ministers or politicians, government advisers, senior DOH officials, or corporate representatives?
4. If the content of the CMO's report was discussed with any of the above people, I would like to see records of precisely what was discussed and who was present.
5. What evidence do you have that the consultation process for the CMO's suggested reforms has been adequate?
6. Do you have any records or documentation of any possible discussions of this consultation process between the CMO, DOH officials, ministers and advisers?
7. If you think the consultation has been adequate then how would you reassure members of the public and medical profession who are concerned with certain areas of the CMO's report,
many thanks for your service,
yours, "

Sunday, 18 February 2007

Faustus has lost his soul

After a rather frantic night shift, I returned home to relax, thought I may catch Match of the Day; unfortunately on BBC 1 I have the great misfortune to see a certain Prime Minister, yes, that man, Tony Blair.

I've always tried to remain calm, whatever the circumstances, whatever the provocation, but sometimes one has to let one's top blow and vent that steam! Tony Blair drives me to blowing my top everytime he opens his slimey lips. It's amusing that whenever its pointed out to him that something is deteriorating under his rule there are several standard catchphrases merge together with some hand movements to give the pretence of caring. If he comes up against hard facts that prove he's useless, he 'disputes' the facts. If his world view is challenged, it's 'hang on, listen to MY point of view'. If he's interrupted when chatting hot air, then 'come on, hang on' with more emphatic hand gestures. The man is a leach of a human being, sucking the lifeblood from the withering slag heap that is the remains of our society.

Before I get carried away and start insulting his wife, I'll take his points one by one.

1.The world according to Blair this morning has the NHS near a state of no waiting lists!

Now 'hang on' Tony, this is utter toad testacles. PCTs are cancelling elective surgery across the country as we speak and in many regions standard surgery is not offered for conditions such as varicose veins and inguinal hernias. Maybe that is one way of getting rid of waiting lists but it's hardly an achievement old chap?

2. Iraq is getting better, and the Iraqi police and security services are winning the battle against the 'extremists'.

Again, {emphatic hand gestures by myself, slightly serious and firm facial expression} Tony, you are chatting a la gonad. Iraq is an utter dog's dinner. The police and security services have been infiltrated by various militias and are a large part of the problem. Also it is not getting better, the violence is escalating and the refugees are fleeing, the human cost is truly appalling. Your view of the world where all the problems are caused by 'extremists who act without logic or reason is truly childlike and embarassing. It's no wonder that trying to defeat all these 'extremists' without understanding the issues is about as successful as Eddie the eagle Edwards.

3. Tony 'cares' and 'empathises' {note my sarcastic hand expressions of mock empathy and concern}.

Caring is not just about chat, it is about actions. Since coming to power you have done precisely nothing that proves you really care. You are good at pretending to care, that I can't deny, but your actions do not match your many words. If I had a penny for everytime you pretended to give a monkeys then I'd be almost able to pay off your sizeable mortgage. You've gone back on so many promises since you came to power that no one believe a word you say these days. I only listen so that I can criticise your hollow promises and dishonest arguments.


This recent episode sums up your rank contempt for the democratic process, which you have demonstrated emphatically here. There are many other examples I could pick, after all there is no shortage of your lies; remember Lobbygate, Iraq's Weapons, your corrupt connections with big business and the cash for peerages scandal for example.

Your government carried out a consultation process that was found to be illegal due to its corruptness. As Prime Minister you should take this on the chin and agree that an open mind must be used for any future decision. But no! Heaven forbid the Prime Minster respect the law and wait until after a proper consultation to bless us with his views, expert on energy that he is.

Look at this piece for a low-down on the Nuclear Industry and their links to the government, including a certain Mr Milliband, a man that reminds me of Mr Blair in the way that he is such a greasy pseudo-caring vermin-like creature.


I have had enough Mr Blair, in fact I had had enough of you a long long time ago. The worst thing about you is your pretence; if you didn't pretend to be such a nice caring man then I would not be so angered by you. It's bad enough that your leadership is buggering our country on several fronts, but the worst thing is that you do it knowingly while pretending to care for the people who's lives you are deliberately destroying for your own personal gain. I do hope you enjoy your retirement job working for the dirty digger and expanding your property portfolio. One thing that makes me happy though is the fact that you will have to live with the knowledge and guilt of what you have done, and I will not lose sleep thinking of you lying awake regretting those years during which you sold your soul- I'm sure you had one once upon a time.

Saturday, 17 February 2007

BBC spreading muck again


This presents a study where it was found that, shock horror, there are lots of bugs in the workplace. What a surprise, I thought the world was completely sterile and that there was no such things as evil little grimey scummy filthy murderous bugs. It's yet another in a long line of lame bits of journalism that points out there are indeed bacteria in our environment. It wouldn't be so bad if they pointed this out in a balanced way, problem is they don't, and they never explain that most bugs are entirely benign. For example the BBC's headline is sensationalist and they only briefly mention the benign nature of these bugs later on in the article, in a slightly devious way in my opinion.

Then at the end of the article:

"The study was commissioned by disinfectant maker Clorox."

Well monkeys, I think the fact that this little study was funded by a company that stands to gain from whipping up hysteria about bugs is pretty damn important! This shouldn't just be mentioned in passing at the end of the article.

Why on earth are the BBC doing this job for companies like Clorox? They are companies that cynically profit from whipping up a paranoid frenzy that convinces people they must kill, kill, kill all those filthy little bugs.

It brings me onto this:


For those of you that don't know MSSA is a standard bug that lives on every human's skin, thus calling it a superbug is an utter lie. Leslie Ash unfortunately developed a complication of an epidural, a standard complication that she had been consented and warned of I may add. She has proceeded to cynically manipulate her situation by rambling on about superbugs when she knows about as much about science as a 3 week old foetus. She has also helped develop this ridiculous handwash (http://www.matron.biz/) and stands to profit like Clorox by exploiting the fears of the uneducated and paranoid.

Check this bit at the bottom: "
Watchdog�s Nicky Campbell also confirmed that Matron ��smells quite nice and does not dry your hands out� A major USP of the product." My you've convinced me already, KILL, KILL, KILL!

Is the BBC about to bring out its own range of KILL MSSA handwash?

I wouldn't put it past them. They do keep surprising me by plumbing new depths from week to week.

Thursday, 15 February 2007

Looney tunes

In the crazy world otherwise known as the NHS, routine surgery is now being frozen to save money! This is not the first time this has happened either.


This is no isolated incident; this is common practice around the country and it gets worse. It has also become routine for surgeons who operate on patients too quickly, in order to keep the waiting list short, to be fined for their efficiency! Barmey! Here are just a couple of examples I've rooted out:


And yes it gets worse, now some hospitals are taking out their lightbulbs to save cash!


Everyone has their opinion as to why the NHS is going wrong from the government trying to pin blame locally to some who think anything run by the state is doomed to failure.

I believe neither of these two theories. The government's chronic mismanagement and abuse of the NHS are the reason for the state it is in today.


In my opinion Alyson Pollock is a woman who has hit the nail on the head concerning this subject. Her books are absolutely unparalleled in their objective destruction of government policy.

The creation of the internal market by Thatcher was the beginning of the end. Since then endless reorganisations and reforms have reduced a remarkably efficient locally controlled service into an inefficient top down dictatorship. Ideology and the pursuit of myths has led to more and more privatisation and a ridiculous situation where the NHS is becoming more a funder of private corporations than a healthcare provider!

PFIs/ISTCs/PBC/C&B/CATs/WICs are examples of hair-brained schemes that have been forced upon a public by the dictators in power via the Department of Health. There are many more of these schemes than I can be bothered to mention, but they have been imposed upon us with only one aim; that is the privatisation of the NHS.

The privatisation has also been aided by the quite deliberate bullying and victimisation of the medical profession via several means such as training reform (MMC), regulatory reform (the CMO) and the empowerment of other quango-practitioners. The government would not be able to push through its deliberate program of corrupt privatisation if the medical profession was strong and united; hence the reason for their multi-pronged attack on the medical profession.

So the NHS is left with a dysfunctional top down management structure where DOH orders must be obeyed or the fires of hell will be unleashed. The good will that kept the system running has been lost and healthcare professionals are losing their moral and will.

The politicians pin the blame locally even though the DOH has total authority and control and the media ignore many billions wasted on centrally funded initiatives and PFI, instead they concentrate on an NHS deficit of less than a billion that has built over many years.

It make one think why do the politicians want to wreck things and privatise the NHS? I'll leave that for a rainy day.

Wednesday, 14 February 2007

BBC 'didn't spin'..........my beard grows longer

The BBC replied to my complaint:

" Many thanks for your message, and interest in the site.

I am sorry that you were upset by this story.

The research was published in a respected peer-reviewed journal,
published by the British Medical Journal group, and as such I feel it is
valid to bring this to the public's attention.

I think the point about treating older patients differently for valid
reasons is covered by the following section:

"The doctors said their reasons for treating patients differently were
to do with the patients' wishes, potential complications and the frailty
of the individual concerned.

One doctor said: "I think generally you have to try and identify from an
individual what is in their best interests.

"I don't think bypass surgery in an 87-year-old is in their interests."

Also Vivienne Nathanson, from the BMA, is quoted in similar vein.

In addition, the researchers have suggested that even taking these
issues into account there is a problem.

For those reasons I do not accept that this story has been spun at all -
it is an accurate reflection of the paper.

Kind regards,"

I will keep this pretty factual. The research is:

Which doctors are influenced by a patient’s age? A multi-method study of angina treatment in general practice, cardiology and gerontology
C. Harries, D. Forrest, N. Harvey, A. McClelland, and A. Bowling
Qual Saf Health Care 16: 23-27

To quote this journal piece in its entire discussion and conclusion:

"Conclusions: Age, independent of comorbidity, presentation and patients’ wishes, directly influenced decision-making about angina investigation and treatment by half of the doctors in the primary and secondary care samples. Doctors explicitly reasoned about the direct influence of age and age-associated influences."


"These results replicate national and international case and survey research showing that elderly people receive different clinical management. They were less likely to be referred to a cardiologist, to be given angiograms, exercise tolerance tests, or revascularisation, than middle-aged patients. The study revealed that these differences reflect the independent influence of patient age on decision-making. Half the doctors in all three specialties treated the patients aged 65 and over with chest pain differently from those aged under 65, regardless of comorbidity or presentation. Each was influenced on one or two decisions. Those doctors who were influenced by patient age tended to be older than others. Those GPs and care of the elderly physicians who were less likely to refer elderly patients to a cardiologist were more likely to use alternative management strategies for them. Cardiologists who were less likely to provide a particular treatment for elderly patients were also less likely to provide other treatments for them. Examination of the reasoning behind decision-making suggests that age may be directly influential, indirectly influential, or may be used as a proxy for patients’ wishes and other age covariates.

International research, based on actual patients, shows that older people are less likely than younger people to receive indicated cardiological treatments. Our research shows that age is indeed a factor that drives these differences, but that reasoning about old age is rarely distinguished from reasoning about its clinically relevant covariates. Interventions are needed to address clinicians’ reasoning about patients of different ages at each step in patient management."

You can draw your own conclusions as to whether to agree with the BBC that they weren't sensationalist or using spin!

The BBC sums it up as "
Doctors 'deny elderly treatments'" and "Doctors deny older people treatments they would offer younger patients, according to a study." I quote from the horse's mouth here.

However there seems to be a large amount of grey and the actual scientific research openly states that it is hard to unravel the factors involved and that "
Examination of the reasoning
behind decision-making suggests that age may be directly influential, indirectly influential, or may be used as a proxy for patients’ wishes and other age covariates."; to me it seems that this is a very complicated topic indeed and the way the complicated issues were summed up by the BBC can only be described as 'sensationalist' and 'using spin'.

Indeed many of the doctors seemed to be taking the patient's wishes into account when making their decision- shock horror I know- couldn't the BBC sum it up us "Doctors care for patients- shock horrror!".

Overall a slightly dubious and very debatable piece of research with conclusions that were far from conclusive, has been summed up in a very sensationalist and deeply unfair manner.

Looking at the research out there, it is clear that elderly patients can benefit from intervention when appropriate. However the attitude of the BBC in denying that elderly patients have different wishes and attitudes, is somewhat unfair to the majority of doctors who try very hard to make the best of very tricky situations. Not that the BBC wanted to stop there, they wanted to introduce that politically correct term 'ageism' into the argument to stir up our emotions. Thanks to the Beeb, for their objective and balanced journalism.

post scriptum addition:

Given that the authors of the above journal article are so keen to claim that age should be ignored as an independent factor, and it should not be used to guide decisions. I would like to point out that this is a highly controversial area and that several studies have shown age is an independent risk factor:


( very relevant in cardiac surgery! )

( hip surgery )

(ageing as an independent risk factor in surgery)

(in cardiac surgery again)

(again in cardiac surgery)

(in coronary intervention)

(coronary intervention)

(coronary intervention again)


(PCI again!)

(coronary intervention)

(coronery intervention)

(coronary again)

I rest my case!