Little Red Riding Hood

Little red riding rood once had to deliver a parcel of food to her poor sick grandmother. She had to negotiate her way through the woods in order to get to her grandmother's house, but there was a big bad wolf that wanted to digest her, however he was afraid of doing so in public, so he approached her to find out where she was going, she naively spilt the beans...

The wolf beat her to the house, tricked little red's grandmother into letting her into her house, ate her and dressed up in the grandmother's clothes, then lay in wait for little red riding hood. Little red arrived a little later and was swallowed whole.

Luckily for little red a hunter came to her rescue and cut the wolf open to free both little red and her grandmother, all ended happily with the wolf being killed off by some large stones.

Incidentally Darzi's review was released today proclaiming 'Change – locally-led, patient-centred and clinically driven', maybe it's just me, but the very same government that has been wasting billions on centrally controlled, politician centred and politically driven health care reform appears to be very much in control of this one, while the calls for more 'personalised' care driven forward in an 'accelerated' manner looks like a wolf hiding in a 'quality' sheepskin jacket to me.

I fail to see how any of the following will improve 'quality': undermining high standards in medical training, allowing more private sector cherry picking, allowing more money to be wasted by PCTs on healthy lifestyle guff, more quangos, more reorganisation with no accountability, more inaccurate measurement of care quality by the use of patient satisfaction surveys (remember the botched ISTC jobs) and more care delivered by workers with lower levels of education and training than ever before. I could go on but you get the picture of our hairy and rather toothy bedfellow.

The medical profession is in the woods. The big bad wolf is ready and waiting, our grandmother is long gone and probably in the terminal ileum by now. Do we naively believe all we are told or do we get ready to hunt our wolf, the choice is yours.

A blogging rut, happy 60th NHS

If I knew the secret to writing inspiring masterpieces week in week out I'd be a billionaire by now, and if I could just intermittently write the odd masterpiece I'd be content. Finding the drive to write is difficult in the ruts, sometimes one thinks its better to just write nothing when there's no creative spark, at other times one thinks it would be better to grind through regardless.

I can't find the inspiration at the moment and I have no idea why. Work has been fairly busy, but then work is always busy, so that's no decent excuse. The NHS is 60 years old this year, so I should be celebrating this great landmark, but for some reason I do not feel like celebrating.

It is not the NHS that should be celebrated in my opinion, the system and the structure leave a lot to be desired in my eyes. From my few years of practice it is the humanity of the staff and the patients that should be celebrated, and this is frequently in spite of the system.

No matter how the government grind us down there are some things that they cannot take away from us, no matter how hard they try. The satisfaction and sense of achievement that one experiences at a job well done makes the daily grind well worth it. The variety and complexity that a career in medicine brings to one's life cannot be converted into pounds and pence.

I'm sure the government will try to spin the 60th birthday into some propaganda peddling extravaganza, luckily the majority of us stopped listening a long long time ago. Despite all the negativity and gloom, working in the NHS gives me a faith in humanity that stops me falling off in the ruts. Even though the government want to turn us all against each other in order to further their own short sighted self interest, through my daily contacts I see that they will never break us down.

Child dies

A sad story has emerged in which paramedics elected not to bring a child into hospital following a head injury, the child died a few hours later after another ambulance had been called.

Whatever the facts of the case, it is clearly unfair to put paramedics in this decision making position given their minimal levels of training in medical diagnosis and treatment. In the NHS these days managers frequently pressurise paramedics to leave patients at home.

This is a high risk strategy to say the least, these kind of decisions are hard enough for fully trained and highly experienced doctors, so it is not safe or fair to put paramedics in this position.

This is a familiar tale in the NHS today. Those without sufficient knowledge and training are routinely empowered to make decisions outside of their so called 'spheres of competence', the system is set up to encourage this dangerous practice. It's very sad indeed and it just isn't good enough.

R-UK goes live

The one flower to have blossomed following the MTAS explosion has been that of Remedy UK. The only group that showed the courage and determination to represent the opinion of doctors was Remedy, and as others floundered Remedy was strong.

Remedy have launched a new online Magazine and it's a site that's well worth popping past. Anyone can read the magazine, while everyone is also free to register and join the online Remedy community.

I would therefore urge everyone to be part of Remedy's solution, this is no time for apathy, admittedly many of us are feeling the strain after many months of unrelenting grinding against the system, however if we do not stand up now and try to make ourselves heard then we never will.

Darzi, Johnson et al are currently pushing through their antidemocratic reforms which promise to reduce the standard of care while privatising what is left of our National Health Service. We need to unite against this common evil, we need to believe that we can make a difference as individuals combining to destroy this malignant growth.

The power of public opinion is potentially huge and enough to stop any tyrant in their tracks, so it is up to us to find more ways in which to educate and engage the public, so that they can unite with us against this common enemy. We have the truth on our side, so despite our relative lack of finances and propaganda merchants, we can hit the bastards for six if we believe in ourselves a little bit more.

Rate your doctor

I have recently been ranting about the dangers of a one way doctor patient relationship, and since then I have been alerted to the rather interesting website RateMDs.com which allows patients to rate their doctors online.

It could almost seem like a good idea if one had left one's brain in the car park, however there are many reasons why this kind of website are a complete waste of time. For one it is completely insecure, meaning that anyone can submit a doctor and anyone can rate the doctor. There is absolutely no check at all of anyone's identity, it really does beggar belief.

In fact there a few famous UK doctors have already been rated, Sir Darzi, Sir Liam Donaldson and Dame Carol Black amongst the elite few. If you fancy rating them or anyone else, then go for it, the site is completely insecure!

I am sure this kind of hair brained scheme will be coming to the NHS very soon, despite the fact that using 'patient satisfaction' as a surrogate marker of care quality is about as reliable as a Roulette wheel, our political masters just want sticks to beat and bully us with.

The people running these schemes are invariably the politically climbing of the medical profession, people who have sold their souls in order to chase money and honours. Organisations like the GMC are now run by selfish politicos who are keen to sell out their colleagues in producing yet more layers of needless and useless regulatory bureaucracy. It is also strange that nurses and other HCPs are not subject to the same mechanisms of command and control.

Dr Crippen has also recently written on how Primary Care is being wrecked by these traitors. Ironically as the quangos and these new gimmicky schemes proliferate, the patients will be the ones to suffer as good local services will be destroyed and doctors will find their job of caring for patients increasingly obstructed by the hair brained new ideas.

The world has gone mad

When I was a youngster at medical school I remember being taught the importance of the doctor patient relationship, it was interesting stuff at the time, and even then it was emphasised how the relationship could be varied to get the best outcome out of it for the patient. Many factors affect this complex relationship, the personalities of the doctor and the patient, the issues being dealt with, the time available et cetera. Sometimes the patient wants a more paternalistic approach, and sometimes the patient wants to be involved more in the decisions making process.

Frequently what the patient wants is not best for the patient though. Whether it be the overweight smoker who does not want to listen to a doctor politely explaining the implications of their lifestyle, or the women with breast cancer who wants to be told that herbal medicine can be used to treat her cancer instead of the effective modern approach. These patients would be happy to be badly managed by their doctors, demonstrating the serious problems with assessing doctors by relying solely on patient satisfaction surveys. Ironically Harold Shipman was very popular amongst his patients, likewise I have seen countless examples of patients who have been negligently managed who have also been very happy with their care.

Teachers are being plagued by the same politically correct nonsense, I'm sure many of us can recognise that our best teachers were frequently not our favourite teachers at the time. I wonder how long it will be before all parents are forced to respond to all the unjustified complaints from their offspring, it may well result in TV all day with ice cream for breakfast, lunch and tea. Some of the new breed of Health Care Practitioner such as the nurse specialist love this new method of assessment, as they simply defer tricky problems that might make them unpopular to the doctors, while they have so few patients to see in so much time that they can afford to indulge the patient with plenty of ego massaging attention and a few cups of tea.

The world is going mad. Junior doctors already have things hard, they are easy targets for bullying from other staff due to the short nature of their placements;they are now an easy target for other HCPs thanks to the wonders of the 360 degree assessment which allows the assessors to criticise in a completely unaccountable fashion. What next, all doctors being forced to enlist themselves with websites that allow patients to rate their care in a similarly unaccountable one way fashion?

The doctor patient relationship should be a two way street, not the one way street that our nonsensical politically correct culture is trying to force upon us. While it is important that patients have sufficient power to comment and complain, it is equally important that doctors are not subject to unfair abuse and bullied by manipulative aggressive patients. I wonder what the reason for the deteriorating discipline in patients, pupils and children is these days? It couldn't be anything to do with out politically correct culture empowering them way beyond the limits of common sense?

Doctors do not have an easy job, they frequently have to choose the lesser of two evils and it is not uncommon for some people to be offended in the process, even when the best option is chosen in the most polite way humanly possible. Opening yet another avenue in which patients can unaccountably vent their spleens promises to benefit no one, except the politicians who want to enslave our profession. I wonder, will this new set of chains enable us to feedback on the management prowess of Sir Darzi, Sir Liam and Dame Carol? I very much doubt it.

Pharmacy and the 'clinical practitioner'

It seems to have been smuggled in by the back door, but now even pharmacists are allowed to have a crack at history taking, examination, differential diagnosis and the management of medical disease. Pharmacists, albeit being quite handy at pharmacology, have bugger all training in anything else but for some reason the government thinks it's safe to let them loose as yet another prong in the ever expanding army of pseudo doctors as 'clinical practitioners'.

One wonders what the government's precise motives are, just why would they be dangerously empowering those who tend to work for large pharmaceutical corporations while trying to undermine self employed doctors? Labour is struggling for funding these days, and Boots et al have been known to be rather cuddly with el Gordo and his greasy pals.

Pharmacists up and down the country are opening up their small cupboards and acting doctor in these pseudo doctor's rooms, some of them are quite happy to get their stethoscopes out and start playing doctor. Whether it be managing the complex medical complications of Diabetes or the brittle Asthmatic, the new 'clinical practitioners' will feel quite at home playing around in waters well out of their depth.

This dangerous empowerment won't even save money as GPs are already paid to do the same job for less, so the government is wasting money and dumbing down standards at the same time, how very priceless. When this is combined with legislation that acts in the interests of big pharmaceutical firms and not patients by restricting GP dispensing, here we have a government that is frittering away our cash in order to keep big business happy. It seems this government will do anything to get their dirty mitts on more cash, it's just lucky for us that money can't buy them trust anymore.

World class idiocy

Type the words 'world class commissioning' into google and you'll unearth a goldmine of utter tosh, starting from the DoH's page on the subject. Apparently there are four key parts to this large hunk of management turd:

"a vision for world class commissioning, a set of world class commissioning competencies, an assurance system and a support and development framework."

Have a read and if you can honestly make any sense of the undecipherable management speak then please get in touch, because I can't. The document is littered with meaningless guff like 'adding life to years and years to life', it is utterly cringe worthy. Essentially all they're saying is that they intend to make health care better with world class commissioning, in the most long winded and nonsensical manner humanly possible.

The meat of this reform is hidden in the FESC section, that's Framework for procuring External Support for Commissioners in long. This is essentially privatisation by the back door again. PCTs will be enabled to directly commission work from independent providers, private providers in other words.

FESC is designed to privatise the NHS further, the PCTs will undermine the local NHS services by starving them of funds by commissioning their work to private firms instead. PCTs are turning into the biggest joke in the NHS, their bureaucracies never stop expanding and instead of actually paying those who know what their doing to do their jobs, ie the hospitals and local NHS services, they would rather burn our money in commissioning their own hair brained schemes.

It would be far too simple to fund our hospitals and local services properly, our PCTs want to starve these services of cash while lining the private sector's pockets. In this manner PCTs spend lots of money trying to avoid paying GPs and hospitals for the work that they actually do, increasing the bureaucratic inefficiency of the system.

The way in which DoH stooges try to dress up this agenda of privatisation as some kind of revolutionary breakthrough in the science of commissioning has to be seen to be believed, have a read of the incomprehensible Helen Bevan's explanation:

"The biggest risk is that the transformational aspirations of tomorrow get hijacked by the thinking of today."

No Helen, the biggest danger is that people will see through your camouflage of management mumbo jumbo and see world class commissioning for what it really is, yet another dishonest attempt to privatise the NHS that will have a devastating effect on local NHS services and standards of care. Mark Britnell's limp words sum up the Kafkaesque nature of this government campaign.

It may have passed the the moronic DoH apparatchiks who read the Health Service Journal by, but their ilk have been wrecking the NHS for the last eleven years, therefore why on earth should anyone believe the faeculent management speak that is spewed forth from their treacherous behinds. These apparatchiks are very good at producing meaningless waffle that claims they will make things better, but if these hollow words are not backed up by meaningful action then surely these failures should be shown the door? Unfortunately for us this government rewards lying and failure with promotion, so we have an NHS run by a proliferating network of dishonest cretins who have only just mastered shoe lace tying.

So as 'world class commissioning' grows, expect to see your local GP and local hospital starved of cash resulting in essential services closing, then watch and weep as the private sector is paid large sums to do the same work less well. This is world class idiocy.

Utterfraud in the Times

I don't believe I am on my own in stating that Thomas Stuttaford doesn't half love to pretend to be a master of everything. His latest offering concerns Deep Vein Thromboses (DVTs) and their sometimes fatal complication, the clot in the lungs called the Pulmonary Embolus (PE).

Dr Thomas comes out with some rather dubious statistics that the Department of Health has recently plucked from it's arse:

"DVTs and pulmonary embolisms are estimated, according to a recently published Department of Health report, to account for 25,000 deaths a year in British hospitals."

I would love to know how the DoH 'estimated' this figure, it may have involved the arse plucking that I suggested earlier. Dr Thomas doesn't stop there though:

"The figure of 25,000 fatalities may well be an underestimate because many patients thought to have died from a post-operative chest infection may in reality have initially suffered from small pulmonary emboli."

It may well be a massive overestimate too, as this figure is a complete guesstimate, this doesn't appear to have occurred to Dr Thomas though. His final paragraph then claims that many of these deaths are preventable and that a new drug called 'Pradaxa' will help in this regard:

"If adequate precautions were taken before someone undergoes surgery associated with a high risk of DVT, many of these deaths could be prevented."

Actually Dr Thomas you are completely wrong in this regard, there is absolutely no evidence to back up this statement that you make. DVT prevention (aka prophylaxis) in the form of various drugs has been shown to have no effect at all on mortality and symptomatic DVT rates.

Large cohorts of high risk patients who have received no prophylactic treatment have been shown to be at no increased risk of death compared with their counterparts who have been treated with expensive blood thinning drugs. Dr Thomas doesn't mention this, he seems very keen to blow the trumpet of expensive new drugs, is there a conflict of interest here that he is not revealing?

Hot air from Darzi

"Education, training leadership and the NHS review" was the topic for debate held at the Royal College of Physicians on workforce, education and training led by Lord Ara Darzi with Professor John Tooke, Professor David Sowden of MMC and Clare Chapman, Director General of the NHS Workforce.

Darzi talked of improvements needing to be made and a framework of accountability, but never touched upon how this would actually be done, while he also ignored calls for ring fencing training budgets. There was also a lot of banter about 'learning agreements' that were seen as some kind of magical fix by some, however how on earth they would force Trusts to take training seriously was not explained adequately.

Sir John Tooke saliently pointed out that there was no one in charge of training, that there was no one to blame if things went wrong. An excellent question was posed by Richard Marks of Remedy UK as regards the workforce planning as regards junior doctor numbers. Do we appoint trainees in a number proportional to the consultant posts that will be available in the future or related to the service needs? Clearly the government wants to flood the market with 'training posts' in order to force down wages by creating a sub-consultant non-training grade, this must be opposed.

Clare Chapman farcically talked of 'openness and honesty', I don't think she intended this as a joke but this is how it came across to me. Given that her malignant Department is behind the dumbing down of training and the deliberate creation of a surplus of demoralised doctors, I doubt her comments would pass a lie detector test. An excellent workforce point was made by Sir John and one Oncology trainee, who both pointed out that demands for particular specialists may change massively over short times; meaning that it would be sensible to ensure that all trainees receive several years of more generalised training before sub specialising, so that they are more prepared to adapt to future workforce needs.

Some superb comments were made about the naivety of educationalists who think that more training content can be easily achieved by fiddling with the bureaucratic elements of training. Darzi was then thoroughly unconvincing when he tried to explain the massive cynicism that the audience felt towards politicians, Darzi claimed that this cynicism was all part of 'democracy', he should have added in the word 'corrupt' before the democracy I feel.

The general dumbing down of undergraduate education was mentioned, as was the massive step backwards that competency based training assessment methods have been. Trainees have gone from being closely monitored by one senior clinician to being grossly unsupervised in their training. The excellent point was also made that doctors are being downgraded in the context of the MDT, doctors in training have to take a lot of the clinical responsibility but are treated with a lack of respect and sometimes disdain by other members of the MDT. If this kind of lack of respect and disdain was shown by doctors to other members of the team, then the doctors would be in great trouble; unfortunately with the current ethos of all Health Care Professionals being equal doctors are being downgraded and routinely bullied to satisfy the government's need to enslave the profession. Clare Chapman was quite pathetic in her comments on this topic.

Overall Darzi appeared all talk, there was a lot of hot air expressed as regards how genuine his role was and how things were so different at the top, with clinicians being engaged. This battle is only just starting, but it was clear from the overall opinion expressed that doctors are not happy with being treated undervalued and bullied by their employers; medical training needs to be completely depoliticised so that patients can be better cared for in the long term. Doctors genuinely want better training because they want to be good at what they do, hence they are fighting the government's desire to dumb down training in order to catalyse the privatisation of the NHS. I'd love to get Darzi on a lie detector.

PMETB - wrecking medicine

As entry standards for medicine at University are dumbed down in a rather politically correct fashion, PMETB continues to oversee the wanton destruction of decent medical training, with years of knowledge and expertise being thrown in the bin because the political stooges at PMETB would prefer to implement the unwieldy psychobabble that spews forth from the recta of educationalists.

Educationalists have a lot of waffle that they used to justify their half witted rubbish, they believe that they can pull the wool over our eyes by repeating words like 'reliability' and 'validity' until the cows come home. In fact A Levels and GCSEs have been dumbed down in the same manner as the Royal College membership exams, the MRCP and MRCS, by making everything so objective that is ceases to be a useful measure of anything at all.

Educationalists do not allow experienced clinicians to use years of their expertise and knowledge to judge candidates, they insist upon replacing tried and tested exams with tick box exercises that allow no room for subjective manoeuvre. In denying the value of subjectivity PMETB regulations have forced the Colleges to comply with their vacuous plans that enforce the dumbing down of training standards, in this way the surgical vivas and clinical exams that are assessed by top consultants are being replaced by OSCEs that can be manned by non-medically trained technicians. This is happening across the board.

PMETB has also dumbed down what 'training' actually means. The poorly worked Foundation program and MMC have resulted in thousands of posts that were previously non-training posts magically becoming 'training posts' overnight, despite the fact that these jobs still have no proper training content. This means that thousands of doctors in training are struggling to get the necessary experience because their job simply does not give them adequate exposure to the core of what they need to learn.

Competency based assessment is then used to pretend that the overtly woeful training is actually thorough and comprehensive. In the old days one had to do decent chunks of a wide variety of specialties to progress, meaning that one needed a broad base of skill and experience to progress to the next level. Now all one needs is a few bits of paper signed that prove one has done a few things once, and one is magically transformed into a super-competent doctor. The wonders of competency based training never cease.

In reality the great irony is that competency is not encouraged by competency based training. Competency is a very grey entity and one cannot prove one's competency by doing something once, and then getting a piece of paper signed. PMETB produces more turd burgers than the biggest dairy farms in the land, it is an organisation that has been found wanting in recent inquiries and investigations into it's complete failure throughout the implementation of MMC. So why on earth is PMETB still being listened to? Why are PMETB's educationalists still allowed to carry through the implementation of the dumbing down of medical training? Why are the competency based fundamentalists being allowed to triumph? PMETB should be wiped out of existence and we should only listen to the sound of it's explosion.

Who needs beds?

The imminent loss of 5,000 Oncology beds has been hitting the news this weekend. Apparently in order to improve our radiotherapy and chemotherapy services, these beds will need to be cut to fund the investment. It's all part of the great Darzi review that pledges to force reform upon the whole country in its uniquely undemocratic manner.

As has been pointed out to me by the ever aware A&E charge nurse "the UK population has grown by 17% since 1951 while the number of NHS beds has fallen by 40% since 1959 - we have one of the lowest bed per 1000 patients in Western Europe: 3.3 compared to 6 beds in Germany, to cite just one example."

Certainly keeping some people out of hospital is a good thing, however many of the DoH's reforms have wasted money in ineffectively trying to keep people out of hospital and in forcing patients out of hospital when it is clearly the most appropriate place for them to be. I also heard in the news that the budget for elderly care is to be trimmed by several billion over the forthcoming years, another example of the lack of joined up thinking in government, as with an ageing population and an increasing demand for care for the elderly, these short sighted cuts will only result in yet more inefficiency with old people blocking acute hospital beds as there is nowhere else for them to go.

The cut in Oncology beds is bizarre, as anecdotally I have heard of cases of there being such a shortage of beds locally that sick Oncology patients are having to be treated as in patients in waiting rooms and day rooms. Oncology patients get sick quick, radiotherapy and chemotherapy have some pretty serious side effects such as neutropenic sepsis, and these cannot be adequately managed in 'cottage hospitals' as the government seems to think. The Darzi philosophy seems to be all about cutting services and beds, while shifting sick patients into the community to save cash, I personally don't recognise this a progress.

The national bed shortage and near 100% bed occupancy rates have so many negative knock on effects in terms of patient care and efficiency that I could bore you with them all day . Around the country numerous operations are needlessly being cancelled because there are no beds in which to admit patients for their stay, meaning that surgeons, anaesthetists and theatre staff are often left to twiddle their thumbs in empty theatres because of this knock on inefficiency. Patients are frequently not cared for in an appropriate ward to suit their particular illness, as bed shortages mean that any bed sometimes has to do; this can sometimes be deeply inappropriate with adults being cared for on paediatric wards, and it can also result in significant morbidity and mortality as patients may be significant distances from their medical staff, while their specialist nursing staff may well not be familiar with the particulars of dealing with another specialities' patients, surgical nurses looking after oncology patients for example. The link between high bed occupancy rates and hospital acquired infection is for another day.

Overall the beds are cut and the inefficiency increases, economies of scale are ignored as the short sighted penny pinching results in the flushing of bank notes down the toilet on a rather regular basis. It makes me weep to see stooges like Darzi pretending that these reforms are in the best interests of patients up and down the country. If my mother was lumped on an orthopaedic ward with her neutropenic sepsis I would not see this as progress, I just wonder why Ara Darzi is so happy with this dismal state of affairs.

Health Committee bottle it - first thoughts

The Health Select Committee released their report on the mess that is also know as Modernising Medical Careers (MMC) today. A bunch of politicians with only a little understanding of medical training were never going to produce anything as insightful or intelligent as Sir John Tooke. Overall the report talks the talk, pointing out a lot of glaring errors that occurred along the way, but fails to walk the walk, as it does not call anyone to account or propose any sensible changes that would help prevent similar mistakes being made in the future.

The report states the obvious failings that occurred time and time again throughout the botched MMC process. The DoH rushed the reform through negligently without listening, where have we heard this before? The leaders of numerous quangos and the so called 'leaders' of the medical profession let us all down time and time again. PMETB and the GMC are muppets. The CMO won't even take responsibility for his own nappy.

Tooke's report was infinitely superior to the Health Committee's inelegant and cumbersome blunderbuss of an effort. They seem to have been sucked in by certain porkies concerning the glorious success of Foundation training according to the DoH and Deaneries, what neutrals these people are in describing their own lovechilds. They were not sucked in as regards to completely useless process that was the infamous MTAS 2007. While the Committee's comments on the consultant grade appear ominous to say the least.

Overall though the Health Committee have just produced a lot of paper and hot air, there is not much at the end of all this that will prevent such disasters happening again in the near future. No one is being forced to account, meaning that many of chief MMC culprits are being left in control to 'fix' their own mess, the useless MMC programme board carries on regardless. NHS:MEE and Tooke have been neatly sidestepped, it is simply not good enough to say that the DoH must listen in the future, they have been told this time and time again, but they never listen because no one is ever responsible or accountable for their wreckless decisions and reforms. The problems of EWTD and the sub-consultant grade will not magically dissappear, likewise the evil of competency based fundamentalism is also ignored. What is the role of the doctor? One hopes that bending over to be regularly shafted by the government is not part of the job description.

One thing I have learned from this disatrous MMC and MTAS experience is that unless we all unite and force the hands of the so called 'leaders' then we will continue to be led down the garden path towards the dung heap. The DoH, the GMC, PMETB, Ara Darzi, the Colleges, our so called 'leaders' and the BMA will not suddenly grow testacles and brains in order to save medical training from the MMC blender, we will have to do that for ourselves somehow.

I don't know if I can do this anymore

This DNUK extract is well worth a read, the doctor who wrote the original piece has kindly given me permission to reproduce his words here. It sums up the way in which the front line doctors of the NHS are frustrated beyond belief at a system that continually obstructs the thing that they want to do to the best of their ability, namely care for their patients:

"I love medicine. I think I wanted to be a doctor from about the age of eight. Although I'm sure this sounds like a cliche, it's true; I wanted to be a doctor since I was a kid.

A hospital chaplain once said to me that one person only has so much patience, compassion and energy. I think he is right.

I have just finished a long set of nights in a moderately busy emergency department. It is a relatively good department, in a relatively good hospital.

A lovely gentleman presented with very severe chest pain and back pain. His family were even more lovely. I did a heart scan that showed his aorta, the largest blood vessel in the body was tearing. This is called aortic dissection and is to understate things, a surgical emergency.A CT scan of his chest and abdomen showed that the dissection extended from his heart all the way into his abdomen.

I contacted the local cardiothoracic surgical centre and spoke to the surgeon who would be able to fix this probably fatal condition. In a rather embarrassed tone he told me that there were no available beds on his unit.

Meanwhile the patient sits opposite me. I advised his wife that they should try to get all his available relatives to see him, as he might die suddenly. Each one arrives, and comes to thank me for "all that I am doing".

After two hours I had spoken to four other surgical units. None of them had any beds.

Another family member arrives, walks over to his relatives. They point at me, the relative walks over touches my arm and smiling thanks me for all I am doing.

What am I doing? Am I colluding with a system that is letting this man and so many others like him down. I am trying to tread water in a what sometimes seems a third world system. A system crippled by short sighted targets and budgets. A system where a waiting list is more important than an intensive care bed. A system where the four hour target means that patients are rushed through the hospital, not getting the correct diagnosis, waiting in corridors, in pain and critically ill.

I don't know if I can do this for another 20 years."

I think the nation's professionals all feel this incredible frustration, and the blame lies firmly at the door of an increasingly centralised and controlling state. The state has steadily made it harder for all professionals to do the jobs that they love to the best of their ability, professionals work better when they are treated with respect and trusted to do their jobs by their employers. The current top down micro managed state of affairs is not helping anyone, and certainly not our patients.

ME mincing

Logic has been cast aside as some geneticists have got more than a little carried away in trying to subdivide ME/CFS into genetic subtypes. Firstly I would like to state that I am not of the opinion that everyone with the ME/CFS label has nothing medically wrong with them.

However I think it is completely stupid to claim that all people with a ME/CFS label have the same 'disease', as the 'disease' has no specific symptoms, no specific signs, and no decent diagnostic tests. I think the medicalisation of these kind of so called 'diseases' as discrete entities when one cannot even define what the 'disease' is creates far more problems than it solves. That is not to say that many of these people do not have very real pathologies, however to lump them all together under the ME umbrella is nothing but foolish and short sighted as we are no way near understanding this condition as yet.

There are other conditions that are very poorly defined and hence come into the same trouble as ME/CFS, many of them rather vague and sometimes bogus psychiatric diagnoses, and one can't help but feel that the diagnosis of Irritable Bowel Syndrome is another steaming pile of poorly understood conditions that have been lazily dumped together in an attempt to feign a pretence for understanding things that are simply not yet understood.

Back to the case in hand, how on earth can geneticists claim to be able to subdivide up a condition into genetic subtypes when they cannot even define or diagnose this condition in the first place? I would argue that they cannot. More importantly pretending to understand things that are not understood is dangerous, as it prevents people from openly and honestly trying to understand these conditions better, as anyone who questions the existence of ME/CFS as a discrete pathological entity is written off in a rather annoying politically correct fashion.

There are also many cases of people who have had clear diagnoses missed and then been inappropriately labelled with ME or IBS, meaning that their real diagnosis went untreated. Also the more we medicalise the poorly understood then the more normal people with no problems will become medically labelled, and then start acting up to their label; I don't think this is a good thing either. The worried well will be happy though, the ever growing band of fashion conscious Gluten avoiding bored housewives will have a new act to follow.

Brace yourselves

"The Health Committee will publish its Third Report of Session 2007-08 on Modernising Medical Careers (HC 25-I) on 8 May 2008 at 00.01 am. A Press Conference will be held at 10 am on Wednesday 7 May in Committee Room 5, Palace of Westminster. Please note: that all comments made at this press conference will be strictly embargoed until publication of the report at 00.01 am on Thursday 8 May 2008. Embargoed copies of the report will be available from Committee Room 5 on Wednesday 7 May at 9.30 am."

I wait with interest to see what the Health Committee will have to offer when it passes judgement on MMC. I expect this type of political committees to swallow a fair amount of the DoH's propaganda, however there are limits and surely they must be able to see what a dismal failure MMC has been thanks to some rather corrupt political agendas lurking beneath the surface that have been pushed through by some rather compliant 'leaders' of the medical profession.

Medical training should be sculpted with the interests of patients at its heart, unfortunately MMC has been crafted with the aim of deprofessionalisation the medical profession and privatising the health service, and this has worked directly against the short and long term interests of patients in this country.

The deprofessionalistion has gone hand in hand with a national initiative of devaluing proper education and training via the Skillification advocated by Labour crony Lord Leitch. In the NHS this has seen the dangerous empowerment of a wide variety of undertrained and undereducated workers, justified by the logic of people with no experience of medicine and health care provision.

The aim is the opening up of the market, as this is seen as the holy grail in the naive free market fundamentalists' warped master plan. In their pea sized brains there is no danger in empowering the ignorant to do things way beyond their means, as the market will magically prevent any harm being done. In reality harm does result, as consumers are not perfectly educated and perfectly informed to make sensible rational decisions. In reality a lot of useless and/or dangerous rubbish can be peddled successfully in the 'perfect' free market, as the brainwashing of consumers with manipulative advertising and the exploitation of the consumer's uneducated ignorance can combine to devastating effect.

One only has to take a small glimpse around to see the garbage that is peddled dishonestly in the name of improving one's health; back street surgery by untrained surgeons, multivitamins, Chinese medicine, homeopathy, osteopathy, reflexology et al. I wonder what the free marketeers would say to this, the consumer does not appear to behave at all rationally or cleverly with these stupid decisions.

Anyway I digress, but the point I'm trying to make is that MMC is part of a perverse and stupid vision for health care provision that has been plopped out of the back passages of idiots who have no concept of what it takes to provide a sustainable high quality service for patients. The Modernisation of MMC stands for dumbing down and crushing high standards of medical training and working towards a useless competency based system that will allow anyone to have a crack at anything, I just hope the Health Committee have the honesty to describe MMC for the steaming turd that it is.

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.