Money burning Direct

The following short passage comes courtesy of an anonymous contributor to Doctors.net.uk, a doctor who was involved in the set up of NHS Direct and who clearly experienced the grim reality of New Labour's top down tinkering with the health service:

"I was involved in the set up of NHSD on the national clinical steering group - our job was essentially to try to limit the potential damage caused by the torrent of ill informed directives coming from the No.10 policy unit.

It was a fascinating introduction to the interface between politics and health care. I was eventually "invited not to re-apply" for repeatedly posing the question - What advice are we giving the callers and is it any good?

It was made very clear to me that NHSD was a great success and therefore such questions could not be asked. It cost about £230M to set up and must have cost at least as much as that again since.

So far as I know there is has been little serious study of its safety or effectiveness nor any serious attempt to measure value for money.

No one really knows the answer to your questions and my personal view is that is is pretty harmless and pretty useless, it certainly has not lived up to any of the grand claims made for it at the outset. As you well find out most people working in other parts of the NHS hate it with a vengeance, believing it to be inept, inefficient, generating work for others and probably dangerous."

At best NHS Direct is a benign waste of money, at worst a dangerous waste of money, the truth is probably somewhere in between. What this does demonstrate rather nicely is the way in which short term political gains have been prioritised over the short and long term public interest by some greedy control freaks at No 10. Money wasting short term gimmicks are now the normal response from No 10, the dis empowerment of professionals continues as important decisions are made by career politicians with no knowledge in the areas in which they are so keen to make these big decisions.

It is no coincidence that Clostridium Difficile continues to run riot in England. Several factors that have been key in this rise have been as a direct result of political meddling in the NHS; these being bed occupancy rates, a lack of capacity to isolate patients, the excessive movement of patients due to politically driven targets, a shortage of nurses to do the basic nursing and dirty hospitals partly because of the short termist privatisation of NHS cleaning services. Of course the people making the decisions, the big cheeses in No 10, will never take any responsibility for their actions and the sage will continue. That's progress for you according to the Supreme Leader.

Expensive half baked quackery

The NHS really is the envy of the third world, as doctors in training see their pay slashed and free accommodation withdrawn, the under trained are being rewarded with huge salaries given their minimal levels of training.

Physician's assistants only have to train for a fraction of that of a doctor, while entry is far less competitive and rigorous. However after a couple of years training and a dumbed down diploma one of these PAs can be earning well over 40 grand. It beggars belief.

This is while patients on the wards are left short of basic nursing care because proper hands on nursing is undervalued in comparison to clip board wielding managing and playing with fisher price stethoscopes on dumbed down quacking courses.
Whatever happened to having different training for different roles? Why is there this ridiculous need to merge all health care workers into one pseudo fabric of competency based mincemeat?

It seems that many people without the necessary knowledge and training feel happy to have a crack at the role of a doctor these days. Bizarrely the most highly trained of the health care workers, the doctors, are not allowed to apply for these nurse practitioner or physician's assistant posts. Why is this bizarre and nonsensical one way street being constructed? The Witch doctor explains this situation nicely:

"There is A New Cult being generated by this government: A cult that attacks professionalism: A cult that undermines intellectual capacity: A cult that is attempting to sway this nation into worshiping competency rather than the excellence that professionalism continuously strives to grasp: A cult that is attempting to turn health care into a commodity in order to generate a market share. The government has complex reasons for promoting such a cult. The Witch Doctor believes what this government is doing is very short-sighted and in the long term will be very damaging for the future health, knowledge base, and ultimately the freedom of this nation."

Indeed there is, and this new cult is a massive danger to the progress of our society. Short termist power grabbing and economics are the motives for policy that is spitting on the professions. Dr Grumble highlights some salient John Tooke quotes that make for some rather interesting reading:

"The results of role substitution experiments are not particularly well publicised, but when they have been conducted they’ve tended to reveal that the role substitutor for the doctor is no more cost effective and indeed in some cases less cost effective than the doctor doing that role. And the real reason for that is that a role substitutor may be able to follow a protocol, but unfortunately human beings and human disease don’t conform very neatly to protocols and that gets forgotten."

There are pressures from Europe to change our training in a way that meets dumbed down European standards as regards consultant level standards, this is dangerous as our health system is very different to other in Europe and by trying to conform a lot of damage will be done. This top down megalomania has gone far enough, it is time that we, the professionals, rallied against this catastrophic erosion of high professional standards.

The public need to be educated to these evils before it is too late, health is not a simple commodity like coal; doctors require large amounts of knowledge and a lengthy training for very good reason, their job is complicated and if it continues to be farmed out to the ever growing army of quacks, then the service will continue to be dumbed down and reduced in quality. What is the good in producing more and more coal, if the coal is of lower and lower quality? Not much I reckon, but this is the end result of a top down system motivated by pure greed.

The sinking ship

One big problem that no one in the medical establishment has even dared to think about addressing is the European Working Time Directive (EWTD). The phrase 'head in the sand' comes to mind when describing the attitude of the government, Royal Colleges, PMETB, BMA and other institutions to the EWTD.

By August 2009 all doctors in training will have to be compliant with 48 hour a week rotas. The Surgeon has published a piece detailing what a failure the pilot introduction of these new EWTD compliant rotas has been. Not only did the new 48 hour rotas result in poorer quality training for the doctors but it also resulted in a large majority of doctors feeling that patient's care had been compromised by a lack of continuity.

The naive proponents of MMC believe that their revolutionary new methods of training, consisting of lots of paperwork and lots of hot educationalist waffle, will increase the quality of training so much that a reduction in hours will have no effect on training. Any trainee on the ground will tell you how dumb this approach is, as the reduced hours has resulted full shift rotas replacing older more training friendly rotas, while there is far more cross cover than ever before, meaning that more time is spent doing mundane admin as opposed to the juicy training bits of the job. I won't comment on the paperwork burden, other than to say that chopping down trees only trains lumberjacks.

EWTD in its current form will further worsen patient care in an already fragmented service that lacks any continuity of care, and it will arguably worsen the quality of training even further in a system which is not giving enough exposure or experience to trainees as it is. Firstly training doctors need to realise that if we are to remain highly skilled professionals then we must remain apprentices in our trade and we cannot allow our hours to drop yet further. Secondly we must force those who represent us to listen to our views, and those who represent us must then force those in government to listen. If we do not, then the effects of EWTD could be quite catastrophic.

Wake up and smell the Coffey

The privatisation and destruction of the NHS continues apace, the government has one intention, to open the market up to big profiteering multinational corporations, and it is patients that will be bent over and shafted in the process.

The stupid and cynical one size fits all reform threatens to result in the closure of numerous excellent local GP practices up and down the land. These new plans will result in the needless waste of millions in paying for shiny new polyclinics, when the money could be far better spent supporting the primary care services that are already in place.

In fact the medical evidence is overwhelming that the loss of continuity for patients will be quite harmful to their health. While the increased centralisation will result in longer trips and yet more inconvenience for the elderly and disabled, stretching an already overloaded transport system even further.

One GP seems strangely keen on these reforms, and has backed all New Labour's destructive reforms over the years, he speaks today in the Independent and mentions no conflict of interest. His name is Tom Coffey and he has very strong links with the Labour party, strange he didn't mention that in the Independent, some would call this unethical, cynical even, I can think of other adjectives.

It seems that this is not the first time that the delightful Dr Coffey has backed his party's noble reforms that he claims will help the poor, I am sure they'll be just as helpful just as cutting the 10% tax bracket has been. Labour seem to be rather keen to shaft the poor these days, they are now a rather corrupt party that is funded by big business, whose interests they represent ahead of the poor and deprived.

This dangerous agenda backed up by the sham Darzi consultation is a disgrace, it is only about the overly equitable access to the health care market by private corporations, it is nothing to do with improving access for patients. In December 2007 the Department of Health ordered PCTs around the country to start making plans for these new private clinics, their minds were made up long before the consultation process ever started as Freedom of Information requests have revealed.

In typical fashion the consultation process is stage managed and none of the important details are ever revealed until it is far too late. Is it time to withdraw from the consultation process, as otherwise the government will use our lack of withdrawal to represent our consent to this malignant program of wanton destruction a la MMC?

My heart bleeds Mr Bully-imic

The lovely politician John Prescott has long been known to be a fat bastard, he has now revealed that his is also a bulimic, and strangely this amazing revelation comes as he releases his inspiring autobiography 'Pulling No Punches', what a coincidence.

It is rather ridiculous in my opinion that the most corrupt and malignant politicians expect us to show them sympathy when they come out as suffering from mental illness, in a way they are trying to hide behind the politically correct shield of 'mental illness'. It reminds me of Alastair Campbell coming out as a depressive, when he expected massive sympathy for his woes.

It is the likes of David Kelly that deserve our sympathy, not Campbell and Prescott. Do vindictive, dishonest, cruel, corrupt and selfish individuals merit sympathy from the public when they choose to come out as the sufferers of mental illness, even if we assume that their claims are entirely honest and well motivated? I think not.

I have about as much sympathy for the likes of Prescott and Campbell as I would for Adolf Hitler if I found out that he was suffering from manic depression during his last days. As humans we are defined by our actions, not our hollow words, and in some cases corrupt and dishonest actions can have knock on effects on one's mental health. If these people had considered other people in their lives a bit more and if they had acted more morally throughout their careers then I would have sympathy for them, as it is I struggle to have any sympathy at all for their ilk. My heart will not bleed a drop for the fat bulimic New Labour bully.

No common sense in the market

Why do we sometimes reach a point where everything around us seems rather foolish, and it's almost as if the walls are caving in but one doesn't quite know how to go about stopping the impending collapse? That's how I feel about the NHS and medical training at the moment.

The government have cunningly attacked the medical profession and our professionalism on so many fronts that they have split us up into numerous ineffective little camps. We have not had the power or organisation to unite as one in order to prevent the government's plans for piecemeal privatisation.

My everyday experience of hospital work helps convince me that the ridiculous payment networks and bureaucracy that have been assembled over recent years are so awfully thought out that they cannot possibly be good for anyone involved. The staff on the ground really want to the best for their patients, but over time they get ground down by the stupid protocols and the highly complicated internal markets that have been forced upon them from above.

I wonder why can't a hospital just get some money from the government and be left to spend this money as it sees fit? Would this really be worse than the intricate network of payments that currently take place that mean money is shuffled back and forth while the needs of patients are forgotten, and most importantly doing proper work is frequently disincentivised by the artificial gradients. The whole internal market has simply not been thought through, and it appears to me that the damage can increase exponentially as more hair brained managers come up with new market based solutions to problems that have been caused by the market based approach.

I could waffle on about the catastrophic idiocy of Darzi and his polyclinics, Brown and his penchant for PFIs but the theme remains the same, this government believes only in improvement that is driven by the excessive use of power from the top. There is a massive irony here, as when Alan Johnson states that choice is a means to an end, how on earth can improvement come about when choice is nothing but a sham and an illusion? The only choices being made are being made by the government, they choose the path that we must choose, there simply is no other option. I am still standing in the same place and the walls are still collapsing, which way to turn?

Lame ethics

Medicine is dumbing down, the apprenticeship is being replaced by less shift work, as old fashioned learning methods are replaced by politically correct self directed methods. Everyone must be complimentary to everyone else, pointing out that something is just not good enough is no longer allowed. Students and juniors are cotton wool wrapped like never before, as it becomes harder and harder for those who really want to learn to get the valuable experience that they so badly want and need.

This story perfectly demonstrates the dumbing down and the abdication of responsibility that is happening far more often than it used to. A Foundation 1 doctor, this is the grade formerly known as house officer (PRHO), was asked by a nurse to pop a venflon in (to site an IV). This doctor then called her registrar because they could not do this task. The registrar went along and asked this F1 doctor if they had tried to do this simple task, the F1 replied that she had not. When asked why she had not, she tried to defend her lack of effort by saying that it would be ethically indefensible for her to put a patient through any pain when the registrar was more likely to be able to succeed with the task. The registrar replied by politely stating that ethically she should think of all the patients that she is going to treat in the rest of her career, they will be relying on her skills that she must develop during her training. She then grudgingly had a go, failed and burst into tears.

Of course I have a little sympathy for the aforementioned F1, however venflons should be bread and butter after a few months of house jobs, and even if the patient is particularly tricky then a junior should virtually always have a go before calling for senior help. Maybe I'm just biased, but I get a feeling that junior doctors are getting less and less experience than ever before. MMC was meant to remedy this, however it appears to do the very opposite, the combination of MMC and EWTD have led to most junior doctors working full shift rotas these days. This means that the continuity of care is affected which impacts upon training and patient care, while juniors are often busier with menial administrative tasks which means that they have less time to experience the useful bits of their job than in days gone by.

I have more experience of the surgical specialties and the current environment is most definitely shafting surgical training. I have to also say that I do come across many more trainees who are incredibly committed and motivated to learn, as opposed to the work shy clock-on-and-off shift workers. The new system does unfortunately encourage the latter's approach, and I must add that GP trainees are somewhat more likely to be part of the latter group as they have no interest in proving themselves to hospital consultants as they their path to GP-land is assured.

What's the solution to all this woe? Well a 48 hour week is certainly not the way to go. I like the idea behind Remedy's Barbados plan, as trainees must take the initiative if we are not to become a cohort of deskilled shift workers. MMC and the competency based lunacy that goes with does nothing to deal with these grave problems with training. Two things can be modified, either the service can be lowered in quality or the way the service is delivered must be changed. The empowerment of a whole raft of health care practitioners (HCPs) is changing service delivery but also reducing the quality of the service, while also having grave implications for the sustainability of the service, as if the consultants of the future are massively deskilled then this could have dire implications in the long term. I do reckon though that trainees must push to work longer hours otherwise not only will patients suffer the effects in both the short and long term, but we will not become as good a doctors as we once hoped we would.

The wonders never cease

It's getting better, it's our best year ever, but is it really? If these things were true then why would the majority of staff be so disillusioned with life and so frustrated at the poor standard of care that they see delivered left, right and centre.

As Dr Crippen points out, why would 25% of student nurses be quitting before the end of their training? After all nurses are not paid that badly, there must be something else at play here. Maybe it's to do with traditional nursing not being valued, and that there is now much more reward in becoming a bullying clip board wielding nurse manager.

74% of staff think they are not valued by their employers

25% think NHS trusts do not see patient care as their main priority - 29% are undecided

78% think the communication between staff and managers is poor

The Healthcare Commission has found out a few interesting facts, three of which I have reproduced above. The facts all fit with one explanation of events. Typically the managers like to pretend that the communication problem is the fault of clinicians, anyone who has worked on the ground will tell you that the problem stems from managers refusing to listen to staff because they have no power to do anything other than enforce what has been ordered to them from 'above'.

'Above' is typically the Department of Health that is lead by Gordon Brown and his cronies. Hence what hope have local managers got when they either enforce the DoH's orders or they listen to local opinion, thus ignoring the DoH's top down command and making it hugely likely that they'll be out of a job pretty damn soon. 'Stalinist' is an over used adjective but it describes the NHS very well indeed, Barry Monk describes three clinical cases very neatly that perfectly encapsulate how our government's top down control freakery has produced an incredibly useless Stalinist end product. This is progress, somehow I think not.

The modernising NHS

Through the eyes of a junior doctor,
progress can sometimes seem a very funny thing.

We are more competent,
but we are less experienced and less skilled.

We are more valued,
but we are less well paid and more expendable.

We work less hours,
but the inane paperwork makes up for the lack of practical experience as if by magic.

Training is better than ever,
but even students are not spared the dumbing down and over-emphasis on soft educationalism.

The government is taking responsility for training,
by telling trainees to train themselves and pay for it too.

We are optimistic for the future,
but in reality we have no job security and morale is at an all time low.

Patients are safer than ever before,
but the under trained are empowered and the medically trained harder to find.

Training standards are pushed to higher and higher,
but the proper training and qualifications are no longer needed for jobs of great responsibility.

The NHS is better than ever before,
but its harder to see an appropriately trained doctor than it used to be.

Sir John Tooke's review is provisionally great,
but the government are going to ignore it all and brush it under their bulging carpet.

Selling off the public services will be great for the economy and the service provided,
just as it has been with the Royal Mail and the railways.

Gordon and Sir Ara have our best interests at heart,
corporatising and dumbing down health care so that it can be privatised will be good for us all.

Gordon's spendthrift nation

The short termist policy that has been employed so negligently by Gordon Brown from his early days in office right until the present day are like a ticking time bomb, it is only a matter of time before the monumental explosion occurs.

There are very few areas in the public services in which assets have not been mortgaged up to the hilt in a tragically stupid and short sighted manner. NHS Trusts up and down the country are being financially crippled by having to service ridiculously expensive PFI deals. Valuable buildings and land have been sold off at cut price rates, as public services have moved to cheaper areas for short term gains. Our pension funds have been negligently raided by the irresponsible supreme leader Gordon Brown.

We have already seen the impact of the global credit crunch caused by irresponsible work in the sub prime mortgage market. Gordon Brown is recklessly ignoring repeated warnings about the state of the UK economy as this spendthrift policy continues; when the time bomb explodes Gordon will not be able to deny that he was warned, he has been warned time and time again.

Politicians like Gordon Brown need to face up to reality. It would indeed be very nice if we could have everything we wanted all the time, but life isn't like that, and by trying to provide more than we can practically afford Gordon is sacrificing our future security for this short termist slash and burn. Gordon is pawning the TV to buy another bag of smack. Gordon is one selfish power hungry gawping fatty who is happy to risk all of our futures for his own short termist political success. I wouldn't look so happy if I were you Gordon, your time is almost up.

Lazy all round

I stumbled upon this piece by Dr Crippen that drew my attention to a certain fat lazy male nurse, who has been having a pop at me on his blog:

"The usual nurse bashers have had a dig, Dr Crippen, Ferret Fancier, and the usual bollocks is spouted about quacktitioners. It amazes me that both of them seem to think that this a good excuse to have a pop at nurses again."

If fat lazy male nurse had ever bothered to read my articles in full then he would realise that I do not have pops at nurses. What I do feel obliged to do is point out the dangerous dumbing down of standards that is currently occurring in the NHS. In my article to which fat lazy male nurse was referring I explicitly stated:

"The worker drones are not the ones to be blamed in cases like Dr Gray's, it is those who empower them beyond their means that need to be held accountable."

Thus when he says I am having a pop at nurses, he is well wide of the mark, in fact I am having a pop at those such as Dr Gray who should know better than to empower people beyond their limited means. Dr Crippen's response does outline the flaws in this empowerment rather well, as without proper the proper education and training these staff do not have sufficient insight to see the dangers of their ways.

In fact if fat lazy male nurse has some time on his hands, I suggest that he read this piece I wrote recently on the dumbing down process. If he bothered to read this properly then he would not accuse me of nurse bashing, as I made it very clear that I am not criticising the staff who are being empowered beyond their means. The dumbing down process is all part of the government's ideological reform agenda, it's about cutting corners to cut costs, as professional standards are eroded in order to privatise the NHS.

The fault lies with the government for forcing through this shabby agenda, and with the senior medical staff who have engaged in the process for personal gain in the form of honours and career advancement. I do not blame those on the ground, whether they be the HCA who is left to do the job of a fully trained nurse, the nurse practitioner who is left to do the job of a GP unsupervised at a Walk in Centre, or a GPwSI who is left to do the job of a fully trained specialist consultant. It is simply not fair to criticise people for pointing out that this dumbing down is going on, and this dumbing down is certainly not fair on the unsuspecting patients.

The BBC and fundamentalist NHS reform

This BBC piece of 'journalism' starts off with a glaring error and then proceeds to serve as an advertisement for the government's deeply flawed ideological reform of health care (note original has since been amended).

"Patients with acute conditions like multiple sclerosis and diabetes could get control of their own NHS budgets to buy treatment, the government has said."

Firstly diabetes and MS are chronic conditions which may present acutely, so the BBC has got this completely wrong in the first paragraph. The pursuit of choice in the health care system is beginning to appear rather religious in its nature:

"Choice is a means to an end, the end being better quality and more personalisation of healthcare. Choice, combined with payment by results, is an important driver of quality."

The government took us to war in Iraq because of a flawed belief that violent regime change would be the means to an end, the end being the Utopian style of government that is western democratic capitalism. Their naive ideological pursuit is failing dismally there.

There are parallels between Iraq and the NHS. In both situations the government is trying to apply a one size fits all ideology to a situation that is eminently more complicated and intricate than they realise. In both cases they have a misguided and almost 'religious' belief in an ideology that is a means to an end, the end in both cases is seen by them as an achievable utopia. They are stupid and deeply misguided.

As is excellently point out here, anyone who sees that there is an end point in the provision of the perfect health care system is most likely an imbecile, a politician or both. All systems have their flaws and there unfortunately is no utopia. The government's ideological pursuit of a market in health care, when finite resources are available to manage an exponential demand, is deeply flawed. This reform is leading to more and more money being wasted on creating the market, managing the market, rigging the market and fiddling with the market.

The end result is an NHS in which more and more money is diverted away from patient care and towards a burgeoning bureaucracy. Just like Marxism, fundimentalist free market capitalism exhibits all the hallmarks of deluded religious thinking; their ideology is a means to a perfect end, the end justifies any means and they cannot be wrong. To hell with reason.

Stalin's dress code

Working in the NHS gulag has its pleasures and one if them is to be subjected to ridiculously verbose and authoritarian documents created by nurse managers in order to make themselves feel mighty and powerful, and make the rest of us feel rather angry and frustrated. A certain NHS trust has issued its uniform and dress policy for clinical staff, and I thought that I'd share some of its gems of wisdom with you all.

Apparently it's not only important to be clean and smart for infection control reasons, but because the public use appearance as a 'proxy measure of competence'. So anything that makes the patients happy, right? Also if one has strange religious beliefs then you can probably blag some kind of exemption from this authoritarian code by liaising with the 'Equality Steering Group', probably another group of dried up nurse managers who spend most of their time snacking on ethnic goodies.

This new code will also be enforced by the managers, as long as they have time to stray away from the cookie jars, as they will be carrying out 'Spot checks of dress and uniform compliance' and 'Questioning samples of staff regarding their knowledge of the policy'. They are very particular about footwear

'Footwear must be navy or black. They must be closed-toe and low heeled/flat, with non-slip, low noise soles. Sling-backed shoes are not acceptable.'

I despair, why on earth must the colour of my shoes be dictated to me by these mincers? Also it seems that those of us who develop stubble rapidly may have to shave midway through a long shift:

'Men must be clean-shaven or have their beard and/or moustache clean and tidy.'

While they are keen to point out the precise nature of any make-up, what constitutes an offensive tattoo and the need for no strong smells; it certainly will be hard to find that balance between body odour and deodorant use, if i stray too far in one direction will the strong odour police come sniffing?

'Make-up must be discrete (light, natural and well applied). Tattoos must remain covered if extensive or deemed offensive. Strong fragrances, body odour or the smell of tobacco must not be evident.'

No 'necklaces, chains, bracelets and ankle chains, rings with stones or ridges' are allowed. They are also rather particular about :'The wearing of earrings is limited to one pair of stud sized earrings no larger than half a centimetre in diameter' , I am sure this will make a difference to that proxy measure of competence. Apparently shoes should also be of 'low noise', I must remember to leave my talking Bob the Builder shoes at home.

What a load of gushing rot. These clipboard wielding megalomaniacs must be having so much fun drafting these lengthy diktats, in between Quality Streets of course. Hand washing is important, I have no problem with this, but dictating every little minute detail, even down to the volume and colour of one's shoes is taking things a bit too far. I wonder if the managers will be living up to this detailed dress code, and would Stalin's moustache be acceptable in today's NHS? I wonder.

Joining the dots

"Rather than looking at harm and deaths that occur to patients as one off events, we should look at connections and similarities, the common causes, and use them as a source for learning and action just as the airline industry has done"

These words of wisdom came from the CMO, Sir Liam Donaldson, a man who loves to compare the airline industry to the NHS. There are certainly many similarities such as the low quality food, the cancellations, the dirty toilets, the long queues, the lack of local services et al.

However I wonder what Sir Liam will try to learn from the pandemonium at Heathrow terminal 5. Is a new initiative of putting the possessions of patients onto conveyor belts and watching them drift into oblivion about to come into place?

The only thing that one can learn from the airline industry is that monopolies, whether run by the state or private corporations, can become rather inefficient and useless at providing the service that they are meant to. We all need a kick up the backside from time to time, and that's why it's so important that the government has the balls to do this to both state-run services and those run by private firms. It's a great shame the government has no balls, as they seem to be firmly in the grip of the CBI and big business.

The utopian nightmare of MTAS 2008

I must apologise for taking my eye off the ball of late, the disaster that is going to be MTAS 2008 deserves to be highlighted more vigorously that I have done so far. Part of the problem this year has been a general apathy that has developed following the government's persistent abuse of the medical profession, the current consequent silence is not helping the medical trainees who face the grim prospect of career termination.

Sam is right, this silence needs to be broken; Remedy are doing their best but the money is drying up, and it is becoming harder and harder to motivate an increasingly apathetic cohort of doctors. Doctors need to unite, those who have done well from the MTAS and MMC debacles need to get behind those who have been shafted, we all need to work together for the long term good of the profession. Anyone who thinks that they need not act because they themselves are doing OK should be ashamed of their deeply selfish attitude, it is precisely this kind of attitude that has got us in this mess in the first place. Bruno Ribiero has been one man that has spoken out as regards the devastating impact of MMC's implementation, he should not be an exception to the rule.

If you believe the DoH then its the best year ever for patients as they will benefit from the intense competition for jobs. What utter rot. The long term impact of driving thousands of highly motivated and talented doctors from the NHS will be devastating for patients. Ironically this is happening while the government continues to empower the ignorant and under trained to do the jobs that should only be done by proper doctors.

The battle must be fought on several fronts. Firstly we need more training posts to prevent an unprecedented loss of talent from the NHS. Secondly we need to fight to maintain high standards of medical training, we must take on the competency based fundamentalism that is threatening to destroy training, and we must fight to preserve the royal college exams. Thirdly we must come up with a practical solution to the loss in training hours that is being forced upon us by the EWTD, the Barbados plan by Remedy is a preliminary step in the right direction. Fourthly we must oppose the sub consultant grade and fight for enough decent jobs for doctors who have completed their specialist training. There is no time for apathy or inaction, it is time to unite against the common enemy, as if we don't then we will all be in trouble in a few years time, even if we are not already.

What a money making idea!

The brilliance of the NHS is there for all to be seen. Behold the fact that PCTs are hoarding cash up and down the country, for example in the north west a surplus of 230 million pounds is being stashed while some hospitals are being forced to borrow money to pay wages, this is the genius of the multiple layers of bureaucracy that the NHS possesses.

Similar things are happening elsewhere, as PCTs build up surpluses of unspent cash while the frontline service providers are starved of their fuel. This means that an overall NHS surplus is developing while more and more standard treatments are withheld by PCTs. The inguinal hernia repair is just one example of an effective treatment that is being rationed in my PCT. The end result is that patients suffer while PCTs wallow in their bath tubs full of smug notes.

How about the NHS stopped treating any patients at all, this would then mean that it could make a 75 billion pound surplus, or profit, every year; that's what I call a great idea. It couldn't be that the best type of NHS would spend all of its money effectively providing patients with a valuable service, rather than wasting lots of money on various complicated layers of Kafkaesque bureaucracy that would rather hoard money than treat patients? No, that would be far too sensible and efficient.

Saving money and confused logic

If one choose to believe the DoH's propaganda releases, then the NHS IT scheme is simply a brilliantly organised wonder that is saving us millions, however if one takes a few seconds to look into the details of the claims then they begin to look rather absurd. For example Health Minister Ben Bradshaw said:

"Our use of computer technology in the NHS is becoming the envy of the world. It is saving lives, saving time and saving money. If you talk to health and IT experts anywhere in the world they point to Britain as example of computer technology being used successfully to improve health services to the public."

While Chief Executive of the NHS David Nicholson said:

"This report shows that we've made really solid progress against delivering an integrated IT system for the NHS, which is not only making us more efficient, but is helping our clinicians and staff deliver better, safer services for patients."

Scratching beneath the surface, it becomes rather obvious that the NPfIT has cost a hell of a lot of money, and that this multi-billion pound figure will only continue to rise above the current 12 billion estimate:

"The overall cost of the National Programme for IT in the NHS is estimated to be £12.4 billion by 2012, of which £2.4 billion had been spent by 31 March 2007, including £1,290 million payments to suppliers. Contracts entered into with these suppliers have provided unprecedented value to the taxpayer by ensuring that the cost of any delays in delivery by suppliers is carried by them. Similarly, payment only happens when the systems are in place and working."

The DoH reckons that this scheme that will cost over 12 billion may save us just over a billion pounds by 2014:

"The new IT systems in the NHS are on course to deliver better care and an estimated £1.14 billion in savings by 2014, according to the first annual Benefits Statement published by the Government."

How on earth can this be seen to be good value for money? Twelve minus one is eleven, meaning that the NPfIT will have cost the tax payer eleven billion pounds by 2014, it will not have saved the tax payer a penny. Computer Weekly have already revealed that Tony Blair recklessly rushed the NHS IT scheme against the interests of the general public, simply so that he could profit politically in the short term from this grandiose delusional scheme.

The DoH is dishonestly abusing the english language in covering up its own crass incompetence, and this incompetence extends upwards all the way to our corrupt dictators in Labour HQ. It is more than a little worrying that these idiots who are running our country cannot own up to their mistakes when they make them, as they would prefer to pretend that their mistakes represent brilliance; this means that lessons are not learnt and that the incompetence is allowed to proliferate. The billions will continue to smoulder.

A whiff of accountability?

The interesting case of a GP who is alleged to have empowered a nurse practitioner beyond their means is to be heard by the GMC shortly. Obviously the full facts are not known, however the concept is certainly a very salient one.

This case could have rather grave implications for the likes of Simon Fradd, and the government, as they seem very keen to empower the ever growing army of health care practitioners well beyond their means.

The standard response to nurses being empowered beyond their means from some nurses continues to be that the NMC will step in and make nurses accountable for their actions when they step outside their 'sphere of competence'.

This does not happen. The NMC have been complicit in empowering the nursing profession beyond their means, hence they are all too keen to overlook these incidents, incidents that are becoming ever more frequent in my opinion.

The point is that this stupid attitude to medicine and competency is exactly where things are going wrong. If one has not been educated and trained to a sufficient level, then one will never know when one is acting dangerously outside of ones 'sphere of competency'; this is the position that many health care workers find themselves in these days, whether it be as WIC nurse practitioner, or as a physician's assistant.

The worker drones are not the ones to be blamed in cases like Dr Gray's, it is those who empower them beyond their means that need to be held accountable. As happened when the Royal College of Veterinary Surgeons dished out punishment to an experienced vet, those who knowingly empower the ignorant should take the rap.

The main players in this dangerous empowerment have been the government, the Department of Health, the Royal Colleges and a group of senior politically climbing medics. These are the people that need to be punished, otherwise the dumbing down will continue and standards of care will continue to slip.

Reinventing the turd

It appears that policy moves in rather illogical and long winded circles, and we often return to from where we initially started, yet this occurs after numerous 'brilliant' government reforms, begging the rather obvious question: if these reforms are so great, then why do we always end up back at square one having spent a rather significant amount of time and money chasing our own tails?

Either we are not back at square one, or these so called 'reforms' are politically motivated garbage of little meaningful content. I would go for the latter as you might guess.

Calman's report of 1993 lead to the reform of the old Senior Registrar grade (SR grade), and there was certainly plenty of debate at the time about how training should be reformed, the BMA were also not happy with the delays in implementing the Calman report (almost as Tooke is currently being delayed by HMG).

To cut a long story short, the SR grade did the majority of the NHS service work while the consultants slunk off to do their lucrative private work; these consultants were obviously keen to restrict the number of future consultants as this would impact upon their private income. Overall far too many doctors spent far too many years being abused as SRs, while the consultants ate the cake. There was also the problem that training doctors were frequently inadequately supervised and left to crack on.

The Calman report led to the specialist register being established, along with the introduction of the certificate of completion of specialist training (CCST), it promised that the days of sub-consultants would be long gone and that a massive consultant expansion would lead to the end of all our problems.

Alas, Modernising Medical Careers came along not long after Calman, so before things could settle down, training had to be rehashed again. The European Working Time Directive (EWTD) had also reared it's ugly head, starting to have a massive impact upon the hours worked by doctors in training from the late nineties. This meant that the new consultants produced by Calman's system with their shiny CCSTs would never be the equivalent of their consultants of old, they simply wouldn't have the experience that was obtained in days of old.

The gimmicky and cynical MMC was a dishonest con from the start, based on Sir Liam Donaldson's 'Unfinished Business', it set out to solve problems that were not present, while creating many more problems that have still not yet be addressed. Tooke's analysis of MMC was spot on, pointing out the vague meaningless principles and poor implementation that have plagued this politically motivated fudge from the start.

We have now come full circle. The current post-CCST fellows are the exact equivalent of the old SR grade, they have finished their formal training but there is no organised and fair route by which they can continue their training to become an independently practising autonomous consultant. The post-CCT fellow and the old SR grade are the exploited underclass of the future and the past respectively. The new system sees doctors struggling to get adequate amounts of experience throughout their training, and then potentially stuck at a miserable sub consultant grade, in which the forced terms and conditions of service may be rather poor, and the chances of career progression may be extremely limited.

Unhappy demoralised doctors who are treated shabbily by their employer, while having their hope for the future crushed, do not make productive and enthusiastic employees. It is good common sense to treat your employees well and fairly to keep them happy, and consequently get the best out of them. This government is treating doctors like shit and this is not a good thing for patients, but then the government cares not for patients, it cares only for its own self preservation and this is a great shame for the vast majority of us.

Darzi's brave new medicine

It seems that as well as gifting millions to private health care corporations, polyclinics will also be used to dive down standards by creating yet another cohort of inadequately trained staff grade doctors. This new impersonal service that is being enforced by central government diktat is being revealed as a second rate service to our current setup.

Polyclinics will have only one properly trained General Practitioner, and the remainder of the doctors will be made up of 'career grades' who have not had the proper training in general practice to be let loose to work unsupervised. Undoubtedly these will be the doctors who are unfortunate enough not to have got proper GP training jobs or hospital training jobs, who have been forced into this unenviable position of working without being properly prepared by a government that is obsessed by bullying staff, rather than working with people in cooperation.

As Dr C points out, this is something that should not be brushed under the carpet, we should not be forced to keep quiet about the clear fact that many staff are being dangerously empowered way beyond their limited means. The great irony of all this is that Darzi's polyclinics are just another prong of the government's dumbing down fork, and this is while the DoH is claiming that they will revolutionise primary care. Darzi's dumbed down polyclinics will also be manipulated by various large corporations so that patients can be sold a load of useless alternative pap in the form of herbal medicines, homeopathic treatments et other bull. Even the right leaning Economist has come out strongly against Darzi's agenda for change, while the Witch doctor has noticed an excellent piece that decontructs the real motives behind these government reforms. So all in all, the DoH see progress as less access to properly trained staff and more access to useless alternative medicine, fantastic isn't it?

Clots, clots and more clots

The Times has jumped upon a bandwagon being driven by the portly ginger CMO, Liam Donaldson, apparently too many people are dying from those deadly 'clots'. They are interestingly not referring to the clots who formulate government health policy or the clots who report health care in the media, they are talking of clots of the red stuff, good old blood. Liam Donaldson reckons the number of deaths secondary to thromboembolic events is largely because there is no systematic approach:

“there is no systemic approach to identifying and treating those patients at risk from blood clots in hospitals. There is significant room for improvement.”

These words are ignorant at best and dishonest at worst. In simple non-scientific terms there is no decent evidence behind giving various drugs prophylactically to try to prevent clots in the legs and lungs. Operations on the lower limbs and pelvis put one at high risk of clots, but no treatment has been shown to reduce the incidence of fatal clots or symptomatic clots.

Drug companies are keen to flog their overpriced injections of LMWH (heparin of a sort) but they do not prevent deaths or symptomatic clots, but they do have a negative effect on wound healing and bleeding from various orifices, as well as costing a hell of a lot of cash. It is also likely that the dangerous side effects of prophylactic heparin are much more common in pratcice than in the trials, as very different patient groups are involved. Aspirin does reduce peri-operative mortality due to its cardioprotective effects, but won't do anything to the clots. In certain patients warfarin has a role, but only in the very high risk, as if used in lower risk patients its side effects would outweigh its positive effects.

Thus overall the evidence for the use of heparin injections is sketchy when viewed with the eye of faith, and utterly crap when viewed objectively. Sir Liam is therefore talking out of his spotty ginger arse when he says that this problem should be dealt with systematically, how can one deal with something systematically when nothing has been shown to be of systematic benefit? Maybe he knows something we don't, or maybe he's an utter twat. I certainly feel that there are some rather malignant clots residing alongside Sir Liam in the Department of Health headquarters that should be dealt with before he turns his attention to this highly controversial area.

Ignorantly hacking away

I knew there was trouble ahead when I read these opening paragraphs in the Telegraph Health section:

"I have known Rosanna for a while. So when I bumped into her recently and moaned that my children were always suffering from one virus or another, she didn't hesitate.

"Sounds like they need their immune systems boosting," she said. "Bring them to me. I'll show you what you need to do." Reflexology, the practice of massaging specific zones on the feet to relieve tension, ailments or "imbalances" in other parts of the body, has a bit of a flaky reputation, but in the right hands, it can be a powerful tool."

It has a flaky reputation for a reason, it is a load of complete and utter hogwash. It is yet another alternative remedy that abuses the word remedy, as the word implies that the treatment should do what it claims on the tun, and reflexology has absolutely zero evidence behind it for treating the problems that the author describes and that the reflexologists claim it can. I'd bet her daughter is probably rather fatigued from having to put up with a mother who panders to her every need, and who tries to rub organic horse manure in her eyes in order to stay at one with nature.

The author goes on to describe how giving her children massages helped them become closer and it also gave her children pleasure, hardly the revelation of the century is it? I just cannot stand the way in which that this kind of shoddy journalism dresses up having a massage as being something on the cutting edge of science. Humans like to feel good and have social contact with others, thus anything that encourages these things is likely to improve our health, it's hardly bloody rocket science.

However dressing up a massage as a pseudo medicine in the form of 'reflexology' is just a clever way that a few bullshitters have come up with to make stupid people part with excessive amounts of their hard earned cash. The author also advises vitamins and fruit juices for staving off viral infections at the end her lame piece, yet another piece of advice that has no evidence behind it and that will also see numerous idiots wasting more money on overpriced pap.

You won't improve the function of your bodily organs by having the sole of your foot prodded by hippy con artists wearing flower power t-shirts. If you want to feel good and stay healthy, then sleep plenty, eat a balanced diet and exercise regularly, also stay off the crack cocaine and don't smoke toxic chemicals. It's hardly rocket science, it's simple bloody common sense and you can get it here for free, I won't try to peddle you overpriced gimmicky merchandise and dress up my simple advice as pseudo intellectual drivel in an attempt to charge you lots of money for something that is simple common sense advice. Next time your walking down the street, just be careful that you don't tread on your colonic area, it could have devastating consequences.

Bad bad science

This 'study' is meant to show how cost effective diabetic nurse specialists are, however even by just glancing at the details of the 'research' one can see several rather gaping holes in the logic used:

"The DSNs managed to identify and review 111 people with diabetes, of which 47 (42%) were discharged within 24 hours.

The average hospital stay for a person with diabetes is normally 11 days, according to the study, which is being presented at the Diabetes UK Annual Professional Conference in Glasgow.

With an average daily bed stay at the trust costing £215 in 2007, 47 fewer admissions equates to a saving of £111,155 for the hospital a year.

Translated across the NHS, this could be up to £100 million a year, researchers said."

How many dubious assumptions do they want to make? They assume that all the discharges were as a direct result of the nurse specialist's input, I wonder if they have any evidence for this assumption at all. They also assume, extremely naively in my opinion, that these patients that were discharged within 24 hours would have stayed another ten to eleven days if it were not for the nurse specialist! The so called research has now fallen apart right in front of our eyes.

At best even if we assume that the diabetic nurse specialists prevent 47 admissions a year in this hospital, and that these patients stay a day less in hospital, then they are only saving the hospital ten grand a year. I bet you the cost of employing a specialist nurse for this amount of time would cost well over ten thousand pounds, plus it's not as if they use no equipment and incur no other extra costs to the hospital. At worst the diabetes nurse specialists prevent no admissions and wast money, one cannot just assume that because 42% were discharged quickly within 24hrs that this would not have happened anyway. This research is a turd burger that relies on stupid assumptions. I am just amazed at how uncritically it is being analysed in the media.

Spinning the lists

From a personal point of view I am sick to the back teeth of stupid politically driven targets. In surgery for instance care is now driven towards targets that are not clinically driven, meaning that there is simply no clinical common sense in place. Patients with urgent problems go into the same 18 week statistics pot that patients with very non urgent problems go into, the word 'treatment' is now redefined to mean any contact with anyone who resides vaguely near a hospital and patient pathways are fiddled about in order to improve statistics, rather than simply improving care via clinical drivers. While the enforced market via 'Choose' and Book has meant that patients get an impersonal service with no continuity of care, so much for Alan Johnson's personal NHS, it's only personal for the damn Labour party.

It is therefore rather ironic that average NHS waiting times have actually gone up under labour, a story that has hit the news this week. Most importantly clinical imperatives are now overridden by political ones. Urgent cases are now delayed because non urgent ones must be carried out, in order to meet the holy targets and it results in more patient suffering than strictly necessary. In health care one has to be very careful what one measures, as once something becomes measured it changes its nature entirely. In health care measures can also be rather meaningless and deceptive, for example as regards productivity; if productivity is simply seen as completed patient contacts then one could increase productivity by replacing all doctors with monkeys, however logically this is clearly a daft idea, it's a great shame that the likes of Simon Fradd and the government like the monkey thesis. Targets continue to appear a bad idea on many levels, and this situation will not be helped by the government introducing more targets to cover the previously un-targetted areas. I wonder, would this government fix a leak in the roof by taking the roof off? I sincerely suspect they would.

Ben 'bullsh*t' Bradshaw

Hospital parking fees have been introduced for staff and visitors alike over recent years, by a government that has no sense of what is reasonable or what is fair. I, for one, have to pay a not insignificant fee for the privilege of parking where I work, oh, what a joy it is to work for an employer that treats you like dirt. In Wales parking has been made free across the board.

Ben Bradshaw, the slimy Labour grease ball that he is, tried to defend the fact that staff and patients in the English NHS still have to pay fairly hefty fees to park at hospitals around the country. He claimed that if parking were free, then it would be subsidised at the expense of patient care. I think the thick Bradshaw might like to know that parking has been free for many many years before his sick government introduced this stealth tax as a way of subsidising patient care, people are in effect paying twice, as they pay for the NHS and they now have to pay to park at their local NHS hospital. Bradshaw's logic is the stuff of a decapitated limpet, so fairly standard for the Department of Health then.

It is Labour that forced NHS trusts into a corner, from which they were forced to start introducing parking fees, it was Labour's top down centralised control freakery that forced trusts to balance their books in this short termist and foolish manner. In Labour's mind a hospital that sold off all its assets and land but made a profit would be seen as a success story, even if it could treat no patients.

What next? Will Ben Bradshaw be defending NHS charges for the air we breath whilst on NHS premises? Surely they will then have to continue charging for the air we breath, otherwise patient services will be affected. Great logic Ben, you putrid Department of Health fistula to the outside world.

One year on

It is now a year since many a disenchanted doctor had to endure the disaster that was MTAS 2007. One year on I hardly think trainee doctors in the NHS feel much brighter and more positive, then again I hardly think that senior doctors are bursting with enthusiasm for the current state of affair.

Tooke has come along and suggested many sensible things, he deserves a lot of credit for showing some integrity when so many in positions of power have shown so little, mentioning no names, the BMA and the Department of Health.

The same incompetent and misguided fools are still in charge of the asylum, meaning that we are still coursing at full speed towards a very nasty precipice, again mentioning no names, Liam Donaldson, Sarah Thomas, Clare Chapman et al.

The government is doing what is has done to medical training across the board, ie railroading through top down idiocy in an antidemocratic, short sighted and frankly foolish manner. In this way health, education and society in general are being woefully mismanaged.

On the medical front, the government has done diddly squat to prevent a massive cohort of excellent experienced doctors leave medicine plus or minus the country that they would rather stay in, if it wasn't for this morally bankrupt regime.

Several of my close friends have emigrated, I am sure that this is the same for many of us, while I know that many of my colleagues and possibly myself may well join this cohort should we not be lucky enough to get the rub of the green. This is utterly stupid and totally preventable.

The UK is under doctored, while the consultant expansion that was promised has not fully materialised; the crazy thing is that the work is out there to be done, but this government would rather fiddle waiting lists and employ bean counters to manipulate statistics, than actually employ people who can actually do a bloody well useful and essential job. Money is now spent on avoiding work rather than actually doing the work that needs to be done, useless rationing quangos have proliferated and front line services continue to be starved of cash.

The government is afraid of those with intelligence and skill, so it prefers to treat us with disdain than with respect, it prefers to empower the undereducated and under skilled to do our jobs less well. How the mainstream media, on the whole, have failed to catch on to this catastrophic waste of talent and dumbing down of professional standards is beyond me, but then again the likes of the BBC don't really have the energy to report the news anymore, they just tend to lazily reproduce what they are fed by their masters.

Everything is now seen it terms of short term economic gains. People are earners of money, not human beings with feelings and emotions. Nothing is worth doing unless it produces an economic profit, so what is the point in being nice to people, why ever care, why ever show compassion?

Universities are the coalmines of the 21st century, there is no point learning things to achieve academic excellence, there is no need to seek absolute truths, after all if it has no economic value attached it is pointless. We should all be mining for coal.

The government is now applying this logic to health care, health care is now a commodity, just like coal. Patient in, patient out, money in, money out, service done, who cares for the quality of the service or the human cost, it's just a matter of counting up the coal at the end of the day.

Decisions are not now made by doctors on sensible clinical grounds, they are made by ignorami in offices with no medical knowledge on economic grounds. 'Patient safety' is reinvented as a concept by non medical suits, despite the fact that everything a doctor learns is in its pursuit, it is another pulsus paradoxicus of Labour's NHS, say one thing but the precise opposite happens, just like the disingenuous gimmick of 'patient choice' which would be more appropriately termed 'government diktat'.

Would it not be sensible to stop and think for a second, is health care really a commodity like any other, doesn't the way we treat out fellow man define who we really are? Doesn't it make us rather inhumane if we simply treat patients as items that are rolled out on a factory production line? Economics is important, this is true, but there are many other needs we have as intensely social beings that are completely ignored by this type of economic tunnel vision. Targets, beans, coal, depressing, control freakery, grim, gloom. This is not the way medicine should be going.