The ferret's guide to Tooke: Part 5

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

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

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

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

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

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

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

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

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

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

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

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

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

Opinion seller?

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

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

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

Ferret: Who has received invitations to these events?

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

Ferret: Where have the consultation events been advertised?

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

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

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

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

DoH: There are no records of these discussions.

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

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

The ferret's guide to Tooke: Part 4

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

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

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

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

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

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

Big Brother says so

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

"New data shows NHS working smarter"

It then makes the bold statement:

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

The claimed savings are huge:

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

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

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

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

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

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

The ferret's guide to Tooke: Part 3

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The principles of communism

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

1. Communism.

Principles of Communism (as described by Frederich Engels)

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

2. Modernising Medical Careers.

Principles of MMC (as described by Liam Donaldson)

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

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

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

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

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

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

Darzi's advisory board

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

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

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

Dr Michael Dixon (GP from Devon)

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

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

Sir John Oldham (GP from Glossop)

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

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

- a loyal PCT manager no doubt

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

-another loyal PCT worker

Paul Farmer (Chief Executive of MIND)

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

Anne Williams (President of ADASS)

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

Alwen Williams (CE, Tower Hamlets PCT)

-another loyal PCT worker

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

- a former Labour party candidate

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

The ferret's guide to Tooke : Part 2

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

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

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

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

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

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

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

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

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

Again, a good idea, but will it happen?

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

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

MTAS lessons not learnt

Just after the Tooke review has been released, hopes were high that the powers that be would be forced to change their incompetent ways; a reality check is often only just around the corner and it has come rather quicker than many expected.

The new Foundation Programme application form is available for all to see online and it contains the same white space questions that caused such uproar in MTAS 2007. These white space questions have been used to select for Foundation Programmes for several years and I have yet to find a trainee who thinks that they are not an utterly useless load of rubbish. Here they are:

"Question 1

Maximum points available: 5 points Limit: 250 words

* List your educational achievements.

Question 2

Maximum points available: 8 points Limit: 150 words

* Give one example of a non-academic achievement explaining both the significance to you and the relevance to foundation training.

Question 3

Maximum points available: 8 points Limit: 150 words

* Describe one example (not necessarily clinical) relevant to your medical training where you have felt personally under pressure and/or challenged. What did you do to manage this and what did you learn from this experience that will be relevant to your foundation training?

Question 4

Maximum points available: 8 points Limit: 150 words

* Describe one example from your undergraduate medical training of your ability to prioritise tasks and information from any clinical or education area. What was the outcome, what have you learned and how will you apply this to foundation training?

Question 5

Maximum points available: 8 points Limit: 150 words

* Describe one example from your own clinical experience that has increased your understanding of the importance of team working. What was your role and contribution to the team? What have you learned and how will you apply this to foundation training?

Question 6

Maximum points available: 8 points Limit: 150 words

* Describe one example of a recent clinical situation where you demonstrated appropriate professional behaviour. What did you do and what have you learned? How will you apply this to foundation training?

Question 7

Maximum points available: 10 points Limit: 250 words

* Compare and contrast the care pathways you have observed or two diferent patients with similar clinical problems. To what extent did each pathway take the individual needs of the patient into account? What have you learned from these patients that will be relevant to your foundation training?"

I am lost for words. This is no way to select doctors. It shows just how hard it is going to be for the Tooke review to have the effect it should, as we still have the same selection of incompetent organisations running things with the same idiots in charge. Surely for the Tooke recommendations to be implemented we need a mass clear out of the staff who have been shown to be incompetent and negligent with their actions in recent months?

If nothing is done to remove the large array of incompetents at the DoH, PMETB, GMC, Royal Colleges and BMA; then how will progress be made? It would be a shame if the Tooke review is just another talking shop that results in no real change in the useless institutions that are running things. The pressure must be kept up, otherwise this will not be the last time white space waffle is inflicted upon us.

The ferret's guide to Tooke: Part 1

The Tooke review is a lengthy document and a little hard to get stuck into, therefore I have decided to break it up into bite sized chunks and bore you to death by giving my opinion on it. Every day shall see a new edition of exciting Tooke review analysis, I shall start with a clarification of policy objectives:

"Recommendation 1
The principles underpinning postgraduate medical education and training should be redefined and reasserted, building on those originally articulated in ‘Unfinished Business’ but in particular emphasising flexibility and an aspiration to excellence. In devising policy objectives the interdependency of educational, workforce and service policies must be recognised.

Recommendation 2
Policy development should be evidence led where such evidence exists and evidence must be sought where it does not.

Recommendation 3
DH should formally consult with the medical profession and the NHS on all significant shifts in government policy which affect postgraduate medical education and training, workforce considerations, and service delivery and ensure that concerns are properly considered by those responsible for policy and its implementation.

Recommendation 4
Changes to the structure of postgraduate medical education and training should be consistent with the policy objectives and conform to agreed guiding principles."

The principles of this sound well and good, there is nothing one would initially argue with at first glance. However if the same dysfunctional bodies and people are still in charge of medical education and training, how can Tooke ensure that this talk of adhering to principles actually comes to fruition, and isn't just ignored by the incompetents at the DoH? The talk of evidence is all well and good, however people must be careful not to become evidence based fundamentalists, by this I mean there are many things that are just plain common sense which have no hard evidence behind them; this doesn't mean that the old tried and tested common sense should be replaced by new techniques that do have evidence behind them. The key will be in ensuring that the power that be use their common sense and interpret evidence sensibly with common sense. The talk of consultation is also good talk, however how many times have we heard of government consultations that have been a complete and utter sham, I wonder what is the mechanism for ensuring that the government will genuinely consult us on more training reform? I just hope it doesn't involve government stooges and citizens' juries.

There is always a lot of talk of asserting 'principles' and adhering to them, but what does this mean? I struggle to understand sometimes. What is abundantly clear is that when Liam Donaldson set about reforming medical training with 'unfinished business', the real motives behind the reforms were not revealed, this has been proven with several Freedom of Information requests. Thus if the same hidden, arguably cynical, motives still exist; then what is the point of reasserting a set of principles? I am therefore slightly sceptical of how much good it will do to reassert principles, principles that may well have been a smokescreen for some rather cynical power grabbing government reform.

Tooke review out

The eagerly await Tooke review has proverbially hit the shelves, it can be read in full here. There is plenty upon which to cogitate and at first glance it appears that John Tooke has done a pretty damn good job. There are some very damning words which should make the government and some of the other chief architects behind MMC and MTAS think very hard about the wrong they have done.

Importantly it is emphasised that training should aspire to excellence, a thinly veiled jab at the destructive force of competency based training if ever there was one. I will go into the details more at a later date, but I would like to reproduce this short extract in full:

"Service needs cannot be met now or in the future unless there is a clear understanding of what part each healthcare professional plays. This is particularly true for doctors and needs to be articulated for each career phase, including doctors in training and certificated specialists.

Without such definitions it is impracticable to pursue outcome focused medical education or attempt to plan the workforce. The Inquiry has revealed evidence of non-resolution of these fundamental definitions, and a lack of acknowledgement of the professional attributes the doctor brings to the healthcare team.

The doctor’s role as diagnostician and the handler of clinical uncertainty and ambiguity requires a profound educational base in science and evidence based practice as well as research awareness. The doctor’s frequent role as head of the healthcare team and commander of considerable clinical resource requires that greater attention is paid to management and leadership skills regardless of specialism. An acknowledgement of the leadership role of medicine is increasingly evident nationally with the appointment of an NHS Medical Director and a medically qualified Health Minister.

Role acknowledgement and aspiration to enhanced roles be they in subspecialty practice, management and leadership, education or research are likely to facilitate greater clinical engagement. Encouraging enhanced roles will ensure maximum return for the benefit society will derive from the investment in medical education.

Greater acknowledgement of the service contribution of trainees will help
reverse the emerging trend wherein some young doctors in training seem to
see themselves as trainees first and doctors second."

The emphasis here is key, doctors are not just another member of the leaderless impotent multidisciplinary team, they are the most highly skilled and highly trained leaders of the team; and it is about time that the government started treated medical training with the respect that it deserves, not with utter contempt like a political football that can be cynically abused at will.

The interim report

The interim report Our NHS Our Future by Prof Darzi can be read at the DoH website here, as always many pages are taken to say very little of any concrete meaning. In fact Prof Darzi thinks it is groundbreaking to say that the NHS should be 'fair, personalised, effective, and safe'.

His summary is amazingly meaningless, would anyone imagine that Prof Darzi would say that the NHS should be 'unfair, ineffective, and dangerous'? Of course not, despite the fact that the government reforms are creating a dangerous, ineffective, wasteful and totalitarian service. The motives behind Darzi's report are obvious as he strongly hints at reconfiguration and more privatisation via the disingenuous patient choice propaganda. It seems that he is avoiding the reconfiguration of acute care for now as that would be a killer for Gordon Brown with the election only just around the corner.

Darzi is a disgrace to the medical profession as he pretends that his 'review' has been widely consulted with the medical profession in his terms of reference:

"Working with NHS staff to ensure that clinical decision-making is at the heart of the future of the NHS and the pattern of service delivery"

The review document is full of the same old New Labour propaganda too, ignoring some shocking health outcomes in the UK such as cancer mortality and maternal mortality, and then whitewashing over how good the New Labour reforms have been for us all. He blows the trumpet of the private sector:

"Independent sector providers have also helped extend choice, add capacity and spur innovation. They have increasingly become a fixture of NHS provision, with three-quarters of a million NHS patient care episodes performed by the independent sector to date."

In fact this is a massive stretch of reality. The independent sector has helped waste a lot of money doing very little work indeed, it has undermined good local services that patients want to choose, however the 'patient choice' agenda has forced patients to choose things that they simply don't want.

Darzi ridiculously talks about patients feeling like numbers and not people, and fails to link this with our Stalinist government policy in the form of Choose and Book. Patients want to be treated at a good local hospital and not treated like a stupid piece of meat by a patronising over controlling government that forces numerous top down policies on them like Choose and Book.

Darzi next turns his attention to health inequalities, and demonstrated well that is rather foolish to let a bum surgeon loose on something so far away from his area of expertise. Public health doctors must be livid with the drivel that he produces in this chapter, even I can appreciate that there is a lot more to reducing health inequalities than NHS policy, this massive area encompasses the whole of government policy and must be tackled in an over arching manner. I fail to see how privatising primary care will reduce health inequalities.

"have asked the Government’s Chief Medical Officer, Professor Sir Liam Donaldson, to develop a standard quality framework and proposals for systematic measurement against this framework. I have asked Professor Sir Bruce Keogh, the NHS Medical Director, to advise on how best to implement it within the NHS."

How worrying is this, yet more targets and frameworks produced by political stooges, will they ever learn? So much money is being pumped into more quangos, more regulation and more reform. When will the reformed realise that they are part of the problem?

His next topic of ignorance is Hospital Acquired Infection, amazingly he does not even mention the problem of falling bed numbers and a lack of rooms to isolate MRSA positive patients. He simply mentions the standard gimmicks that the government has already talked of, and throws in the idea of punishing hospitals that do badly. The understanding of this issue is utterly pathetic and when the government is already driving some hospital trusts into the red as it is, how will it help to fine the struggling ones when they cannot afford to deal with these serious health issues?

Darzi also throws his hat into the MTAS and MMC ring:

"Despite the highly publicised problems with the Medical Training Application Service (MTAS) recruitment system, I believe that the principles of the Modernising Medical Careers (MMC) programme developed with the professional bodies and regulators are sound. It is the implementation that has fallen so far short."

My God, words fail me; maybe Prof Darzi thinks that the principles of communism are sound, it is just the implementation of communism that is the problem. A valid parallel to draw I feel. The disturbing talk of an 'NHS constitution' was more than a little scary:

"In my terms of reference, the Prime Minister and the Secretary of State said that, at the end of the Review, a decision will be taken on whether there is a case for an NHS Constitution, as part of a new and enduring settlement for the NHS as it approaches its 60th birthday. The objective would be to enshrine the values of the NHS and increase local accountability to patients and public."

What on earth is the point of yet another group of committee types getting together to produce yet more glossy paperwork that will be used to back up government reform. The NHS was actually founded on the principles of 'free care, care available to all and uniform quality'. It seems that Darzi is adding nothing to this, but trying to modify them so that more reform and privatisation can be illogically justified. He finished of his limp document with more talk of how easy it is to get involved, strange how it has proved the very opposite so far.

So the summary of Prof Darzi's glossy document? It is clear that we have a man who is not suitably qualified to be reviewing the whole NHS, even if he did it with proper consultation and over a decent amount of time. Unfortunately his review is only consulting small number of people that have been hand manipulated by the government, experts on health care and health policy are ignored, while government friendly compliants are used as evidence of how popular primary care privatisation, polyclinics and reconfiguration will be. His top down reform is calling for more regulation, more Quangos, more punishment for the cash strapped failing trusts and more glossy paperwork to be produced to overwhelm the growing army who are discontent with this agenda of systematic NHS destruction.

The majority of us just want good local services, that are not driven into the ground by the inefficient internal market. We are happy with our good local GP service and do not want tacky impersonal privatised polyclinics. Unfortunately for the majority of us who want a good local un-privatised services, we will not be consulted or listened to by Darzi et al, they want to continue dishonestly privatising the NHS and this sham interim report is yet more proof of their corrupt motives.

The NHS Review

It seems that the government have shot themselves in the foot in an attempt to gage public opinion. Their latest website http://www.nhsreview.com/ has been set up to provide further backing to the consultation process regarding the NHS review that is being undertaken by the Brown administration, led by none other than Professor Darzi.

A recent poll of public opinion has shockingly found that not one single member of the public trusts Prof Darzi or Gordon Brown to lead the NHS review, astonishingly as things stand over 20% of people have more faith in small marine animals that may not even be alive. The current opinion poll leaders are Dr Rant, Dr Crippen and Alyson Pollock.

It As Dr Grumble saysmust be admitted that it is a brave and admirable move from the government to set up this open dialogue with the public. It appears in sharp contrast to the rather dubious consultation methods employed by the Darzi/Brown partnership, this video shows how biased and leading this consultation process has been so far.

There are some things that it would be sensible to ask the public and there are some things that it is not sensible to ask. The public are simply not adequately informed enough to know when they are being fed big fat porkies, the public also do not know enough about health care provision to be able to make complicated decisions about its future nature. As Dr Grumble says, if on a random day you were to ask people if they wanted it to be Christmas day then they would probably say 'yes'; this doesn't mean it would be sensible to make it Christmas day every day. Ask a child if they wanted chocolate for every meal and they would probably think it a great idea, not the best parenting in the world though; governing the country well is a bit like good parenting, there are simply some things best left to those in the 'know'. Unfortunately the government wants us to eat chocolate supplied by big business 24 hours a day. Their leading questions and manipulated consultations do not appear to be in the best interests of public health.

The people who do know enough are the clinicians and NHS staff on the ground, yet these are the people that the government is excluding from the consultation process. It is fairly clear that with the skillful abuse of selective opinion polls, one could come up with solid backing to do just about anything. It is clear that the government wants backing with which it can then cut costs, privatise, shut excellent local hospitals and replace them with tacky polyclinics.

I, for one, am glad that the excellent NHS Review site gives us all the opportunity to let the government know exactly how we feel about their abuse of their power.

MTAS- frankly DoH your suggestions stink

Several organisations have fed back their views on the MMC board's proposals for the medical application process for 2008. It seems that there is a recurring theme in all the following responses from the BMA, Remedy Uk and Fidelio: it appears that the suggestions for MTAS 2008 offered by the government were to put it plainly, rubbish.



It appears that the vast majority of people want to revert to the old tried and tested process that was used before 2007, and that they want local applications and short listing with smaller units of application. I think that quite a few of us have been saying this for a very long time.



It was embarrassing that the MMC board's suggestions were so leading and stilted that it gave no opportunity for the process to be completely discarded, a complete scrapping of the MTAS process would seem sensible and could not be seen as 'throwing the baby out with the bath water', as there is nothing other than dirty water in the bath.

This letter does the GPs' talking

The following letter from an esteemed GP to his MP reveals the truth behind the government's dishonest and cynical propaganda campaign against General Practitioners, the letter really does all the talking:

"Patrick,

For your information and feel free to forward this to Andrew Lansley some facts about the GP pay deal and its "overperformance". (Okay I accept that I may be biased! But here are some facts, from one who actually knows the deal because I helped negotiate it!

I was one of the 8 doctors who negotiated the whole of that deal. Not only was I present in the room but asked the killer question of what happens if there was to be overperformance. Answer from Mike Farrar, the NHS team lead "The NHS Bank will bank roll it". We spent a WHOLE day telling them it would overperform. They checked back with ministers including The Treasury and the rest is history there are just 2 doctors left of that team of 8, myself plus Dr Laurence Buckman the GPC Chairman. There are NONE of the core NHSE team and NONE of the DoH core team still around and active on this work who negotiated the whole deal start to finish, so what the quality of advice to ministers is I don't know but from other interactions there is huge misunderstanding and misconception about the GPs first ever written contract!

Both sides adopted the principles of a "wise agreement" through principled negotiation backed by facts. All of my team and many of the NHS/DoH core team were all trained by the same negotiator training consultancy. There was almost no positional bargaining and little horse trading.

There has been a concerted government and probably No. 10 inspired campaign for several months about access to GPs, extended hours opening, and out of hours services. They are 3 different things but the government is trying to coalesce them. Part of the campaign has been to smear GPs by constant reference to their performance related pay earnings which are referred to a net earnings. Such net earnings are NOT take home pay but Net of practice expenses BEFORE tax, national insurance, sick pay insurance and surgery mortgage capital repayments.

At no stage during the current media onslaught against GPs has the government in the shape of No.10, The DoH or ministers contacted the General Practitioners Committee of the BMA - the body with whom the deal was done- about extended hours of service. We have received not one phone call, no letter, no email no communication about extended hours. This could be the subject of difficult PQ if Mr Lansley wishes? None of the negotiating team, nor my chairman has even had any informal approaches concerning extended hours from senior civil servants nor ministers in our day to day business including when paths have crossed. All that we have had is megaphone defamation from a government which governs by assent from the baying crowd whipped up by spinmeisters feeding the chatterati via the media.

Out of hours services( Services outside M-F 0800-1830)

Out of Hours are the responsibility of PCTs and have been since 2004. The NHSE, Treasury and DoH underestimated the cost and complexity of a service which GPs had provided at an uneconomic cost and a massive personal price since the inception of the NHS in 1948. For years the DoH officials had been denying the GPs assertions about the burden and the costs. Quite how my practice went from 7 out of hours call per week average with 2 out of bed calls when I joined in 1985 to 60+ calls per week and out of bed 1-2 times per night (despite dropping obstetrics) in 2004 beats me. It was in fact the rise of consumerism coupled with a belief that there was 24 hour general practice. There never was 24 hour general practice and still isn't...just an out of hours service for emergencies and urgencies. What is more Saturday morning surgeries were never for routine matters as we did not have full services or staff available. Even now privately and also in a letter from DoH to one of my "constituents" the DoH concedes that GPs and their staff are entitled to proper work life balance.

The out of hours services horror stories occur because the PCTs wont commission sufficient cover and are using Eastern European doctors whose command of idiomatic English and knowledge of the system makes them slow. (I know what this means to patients, my own mother in law died because of the new arrangements when NYED failed). GPs in Derbyshire myself included work for the service (which is a good one) and actually there are fewer sessions than we are prepared to work as some of the work is being skill mixed to variable effect.

GPs have NOT stopped doing out of hours; they have ceased to be the body responsible for making that provision. GPs still work in significant numbers on the service and there are fewer doctor shifts than takers

Extended hours is about the provision of NORMAL General Practice into the evenings and weekends.

As you are fully aware modern General Practice requires receptionists,phlebotomists, Health Care assistants, practice nurses, district nurses, pathology and X-ray facilities (and the ability to discuss findings with a consultant), access to social services etc. Rough calculations indicate that to keep open my practice at HALF staffing for 2 evening per week to 9pm and for 3 hours on Saturday morning would cost in the order of £100K per annum and there would be no district nursing district nurses, pathology and X-ray facilities (and the ability to discuss findings with a consultant), or access to social services at that figure. With the new contract we took on 52.5 hours of opening based on 37.5 hours of staffing and funded the difference from our "overperformance". PCTs have always been free to commission extended hours and some GPs (my practice included) are prepared to provide it IF COMMISSIONED at a commercially acceptable price. We are NOT prepared to simply be a "GP with a prescription pad" working alone with patients having to return to complete the consultation just so that the government can have a soundbite

I have asked my staff if they would (for pay obviously) be prepared to work extended hours and to a man/woman said not at any price. In any event in order not to breach the EWTD we would have to take on and train yet more staff something which would take considerable time and resource. As they pointed out the evening bus service is dire, they would have difficulty getting home and patients would have transport difficulties in getting to the surgery. (Buses, for example, after 1800 hours to Cromford are at 1900 and 2100 only and their are none to the outlying villages)

Access.
This is about the ease with which patients can make and obtain an appointment. A survey has been done and there is a satisfaction rate of 84% (The London Evening Standard [deliberately?] got it the wrong way around on Thursday. (Analysis of this survey results in politically difficult messages Most of the 16% are practices of a particular type, in a particular geographical locations, serving a particular type of population,with services delivered by a doctor qualified from particular parts of the world). I know of many leading edge practices where they refuse to try to meet the 48 hour target (and forgo the resources) where the urgent and emergent are dealt with today but a routine appointment is 15-17 working days away.

My optician [as opposed to the local spectacle supermarket] is booking 5 weeks ahead, my dentist 14 weeks, my solicitor 5 weeks, and my accountant 4 weeks. The Derbyshire Building Society wanted me to make an appointment to deposit a significant sum last week and yesterday PC World couldn't touch my computer for 3 weeks.

As you know from your formal visit to the practice in December 2005 (?) Doctors have always struggled with their appointments systems we are now on the 8th version since i joined the practice and much of the problem concerns workforce resources and increasingly surgery space! The de facto moratorium on practice premises funding (unless you are in a Labour area LIFT scheme) means that we cannot increase our staffing as we are hot desking already! We have always seen anyone with a clinical priority the same day and a clinical emergency on an immediate basis. Mr Blair's interference over the 48 hour access target (which we by and large meet) has meant that we cannot forward book significant chunks of the appointment book. I DO recognise the problems which working people especially those who commute have in gaining access, but they are the very same people who do not want taxes to rise! Of course I could operate (and actually would take pride in) an 0700-2200 ROUTINE service 6 days per week (provided nobody was required to work compulsorily more than a 40 hour working week) but that is neither affordable nor cost effective and even if we have the resource the staffing is impossible on current workforce.

GPs are tired of the "banks and supermarkets opening argument". The longer banks and supermarkets open the greater their profits. What is more it takes at least 5 years to train any of my professional staff to work independently and a year for my non professional staff. Shelf stackers, and checkout operatives take a matter of weeks to train and the operation of the store does not require the continuous shop floor presence of the board of directors. The only people banks employ are sales people and money counters and again take little real training. Indeed medicine, dentistry and veterinary medicine are the only professions where nothing can happen without the actual presence of the most highly skilled and trained part of the team individual working on the shop floor or immediately available to do so.

The ultimate insult has been the appointment of Ara Darzi to review General Practice. What does a TERTIARY world class surgeon know about general practice or primary care?

The crude attempt to blacken GPs for the political prize of 16 hours per day general practice even if does mean a return to paid slavery for GPs personally is despicable. To blame the GPs for the NHS deficit is deceit. Irrespective of the financial facts the government have conveniently forgotten the long term health gains already accruing from tha performance related practice resource deal - the Quality and Outcomes framework. Doing this by means of public envy and disapproval our earnings is beneath contempt and is hypocritical. ministers conveniently omit the facts in addition that GPS still have to provide a service for a 40% longer working week than the norm. GPs still exceed the EWTD. GPs only have to adjust their individual referral patterns by 1 referral per day to double waiting lists. 40% of GP income is Performance related pay. GPs are stunning value for money. It is fascinating to note that the new accession states in the Baltic have adopted the British primary care system becasue of its cost effectiveness.

The new GP contract was negotiated and agreed with the knowledge,influence and intervention of No.10, HM Treasury as well as all 4 Departments of Health. It was further endorsed by the independent Doctors and Dentists Pay Review Body whose recommendation was not amended by the Prime Minister or the Chancellor at the time and they did not see fit to interfere with its findings! Gordon Brown and Tony Blair therefore had at least two opportunities to veto this deal if they felt that it had been too generous. The GP pay rise was deliberately substantial in return for substantial extra work and to correct the massive workforce crisis in General Practice. It was designed to correct 15 years of pay drift from repeated interference with DDRB reports Remember that GPs were only required by Ken Clarke's contract to do 26 hours over 42 weeks per annum, you now get 52.5 of responsibility with an actual average of 44. The fact that out of hours was priced by the independent DDRB as late as 1997 at only a few thousand pounds meant that the loss of it could only cost us a few thousand pounds.

Patrick, you need to know that the massive relentless adverse and unfair media onslaught of the past few months against GPs has demoralised them hugely. Cheesing off GP will damage the NHS because of the corrosive effect it has on morale. We have a massive GP retirement bulge looming in the next few years and the UK needs as many GPs as it can find. The government assertions border on lies, they are distorting the truth in a manner which if I indulged in my practice I would be struck off.

I hope that this information helps to inform debate and I am happy to elaborate"

This letter explains pretty much everything there is to know about the GP out of hours debate and it does not make the government look very trustworthy or competent, in fact in makes the government look like a rather disorganised and dishonest bunch of bullies.