Forging ahead

The government continues to rapidly change the way in which health care is to be delivered, and yet another reform is being steam rollered through in front of our very eyes. Do we trust the 'Commercial Directorate' to do this job properly? Does rapid rushed reform result in the best long term results? I'll leave that for you to answer.

Dr Grumble reiterates the worrying lack of consultation that has taken place regarding the lowering of the burden of proof in doctors' fitness to practice cases. It turns out that this highly controversial change is included in the government's legislative programme, this can be read here:

"13. Health and Social Care Bill
The purpose of the bill is to:
• create a new integrated regulator for health and adult social care, Ofcare, bringing together existing health and social care regulators into one regulatory body;
• reform professional regulation to enhance public and professional confidence and strengthen clinical governance as part of the Government’s response to the Shipman Inquiry; and
• include provisions to make a one off payment to all expectant mothers from the 29th week of pregnancy.

The main benefits of the bill are:
• to assure patient safety and apply a consistent approach to regulation for all types of provider through a new registration regime, requiring providers of health services and adult social care to be registered;
• to implement the 2006 Budget commitment to bring together existing health and social care regulators into one body (‘Ofcare’). This will operate with a significantly lower budget than the existing bodies and be established in 2008; and
• to implement, following the inquiry into the case of Harold Shipman, the manifesto commitment to strengthen clinical governance; and to ensure professional activity is more accountable to the public.

The main elements of the bill are:

• To establish a new, integrated health and adult social care regulator Ofcare,from existing regulators; to define the functions of the new regulator in the areas of safety and quality assurance, information and performance assessment and safeguarding the rights of detained mental health patients; and to update the system of registration that applies to providers of health and adult social care services and extend this to include NHS providers.
• To introduce legislation to use the civil, rather than criminal, standard of proof for all healthcare professional regulatory bodies; to create an independent adjudicator to undertake independent and objective formal adjudication for the professional regulatory bodies; and to ensure that all healthcare organisations employing or contracting with doctors appoint a ‘responsible officer’ with personal responsibility to work with the GMC to identify and handle cases of poor professional performance by doctors."

This government is not one to do things by halves. This government seems to think that legislation and reorganisation will automatically result in improvement to services, we have seen time and time again how the exact opposite is true. Endless reorganisations in the civil service has led to numerous scandals that could have easily been avoided, such as the missing data on the 25 million for example. Reorganisation without thought and with far too much speed is not necessarily a good thing. The token useless gimmicky policy is present with the one off payment for pregnant mothers, something else to encourage single mums to procreate, but what a great soundbite for our politicos to use in their regular propaganda delivery sessions.

DK and Dr Rant have been covering the slightly underhand efforts of a certain PCT in trying to force work in the direction of an ISTC. Choice (TM) as Dr Rant calls it seems to be the very opposite of genuine choice. Dr Ray covers the complete failure of yet another botched DoH attempt to improve efficiency by involving the private sector.

I particularly enjoyed this piece by Dr Rant that neatly describes the reality of MTAS, it puts the words of Donaldson et al into context; Donaldson's pride in the DoH's salvage job is a bit like George W Bush being proud of the mess that Iraq has been left in.

The recent rank incompetence exhibited by HMG is neatly summarised by Barry Monk, it really is hard to understand how these idiots think ID cards are such a good idea, when they repeatedly fail to deliver with much smaller schemes. This old piece by SJ Howard amazingly tells the story of how the government chooses to reward failure and rank incompetence with juicy new contracts; the makers of MTAS, Methods Consulting, appear to be profiting from their lack of skill. While on the subject of incompetence, Dr Grumble talks of a scandal that shows how the government will privatise anything, seemingly oblivious to the dangerous long term consequences of this; nothing new there then, short term gain and more long term pain.

The Witch Doctor is obviously more than a little sceptical of HMG's deep clean, I have to say I agree with him and when one sees that there has been another Clostridium Difficile outbreak in Maidstone right after their 'deep clean'; it certainly adds evidence to our argument. Another piece of misinformation present in the media is the constant lies about doctors' salaries. Chez Sam's points out that junior doctor's are relatively rather feebly rewarded given their training and expenses. Some rather salient facts are listed that make the financial rewards of nursing look relatively generous in comparison.

The rather grim reality of nursing in the NHS is spelt out by militant medical nurse, I can see why frontline nurses such as herself are considering fleeing to lands afar. Nurses are frequently left with far too much on their plates, as our many frontline doctors; and when the shit hits the fan, it's never the manager who gets the blame, even though they had been warned about the dangerously low staffing levels. It will be the doctors and the nurses who take the hit. This topic was touched upon fairly recently by Advanced Practitioner here.

Something that is sure to be in the news a lot in future weeks, is the rather worrying shortage of acute beds in the NHS. It's amazing that after so many billions invested in reform and reconfiguration bed numbers are falling year on year. Couple this with increasing immigration and an increasingly elderly population, and you have a recipe for disaster. Anyone working in the NHS will tell you that many problems such as MRSA are propagated by this shortage of beds and the need to run at almost 100% bed occupancy levels all the year round, most places I've worked at are full to bursting at even the most quiet times of year.

DoH hides motives behind CMO report

"OUTCOME OF A REQUEST UNDER FREEDOM OF INFORMATION [FOI] ACT 2000 FOR INTERNAL REVIEW

Thank you for your email in which you asked for an internal review of the Department’s decision to withhold information requested by you under the Freedom of Information (FOI) Act. Your original request was in seven parts and information was given in response to six parts except for part 4 which was withheld under s36. Part 4 of your request stated:

“If the content of the CMO's report was discussed with any of the above people, I would like to see records of precisely what was discussed and who was present.”

I apologise for the delay in responding to your internal review request which has been subject to extensive discussions within the Department.

The review is now complete. The Department is satisfied that section 36 of the FOI Act was correctly applied to that part of your original request and that the public interest in withholding the information did and continues to outweigh the public interest in disclosing the information you requested.

Our public interest arguments were fully explained in our original response. I can also confirm that the opinion of a “qualified person”, in this case a Minister of the Crown, was sought as to the use of the section 36 exemption.

By way of further explanation of the decisions taken, the principle issue in this case concerned the fact that Ministers and Government officials need to be able to engage in free and frank discussion of all the policy options, to expose their merits and demerits and their possible implications as appropriate. Their candour in doing so could be affected by their assessment of whether the content of such discussion would be disclosed in the future. Additionally, papers need not be released if release would inhibit the provision of advice for the purposes of deliberation, or would otherwise prejudice the effective conduct of public affairs.

If you are not content with the outcome of the internal review, you have the right to apply directly to the Information Commissioner for a decision. The Information Commissioner can be contacted at:"

There we have it, democracy is dead, the fact that the CMO's report was discussed with ministers and civil servants is no surprise; however it is another thing that the motives and reasons behind this report can be hidden in this way.

How can the CMO's report be claimed to have been genuinely consulted, if the real reasons for it and the motives behind it are not revealed to those consulted? So much for consultation.

Remember the CMO's report includes the controversial downgrading to a civil standard of proof in fitness-to-practise cases, which has been included in the Government's Health and Social Care Bill. So much for this being properly consulted then.

I fail to see how the CMO's position remains tenable when it appears that so much of his work is so politically motivated. Above all this lack of transparency is not something one expects in a western democracy, I am amazed how our government is coming to resemble a banana republic. Metaphorically speaking, Sir Liam has certainly had his fair share of the bananas.

Blogging pick'n'mix

Frontpoint Systems has been in typically fine analytical form of late. The waste of public cash on procurement, the grave problems with ISTCs, talk of actually basing policies on evidence (not free market ideology) and dangerous plans to franchise primary care are just a few of the recent topics covered comprehensively.

Dr Rant has been ranting away furiously, with some good mocking of the government's needless drive for more 'access'; while a certain mole has thrown some light on a rather topical issue, casting doubt on the so called 'independence' of yet another of HMG's arms length bodies. While the idiocy of practice based commissioning is excellently described.

Dr Grumble tells a sad tale of someone whose career has been mangled by the MMC juggernaut; while I particularly enjoyed the provocative piece on targets and waiting times, something that anyone who works on health policy would do very well to read.

Anyone who wants to know what real story is as regards homeopathy need look to further than Ben Goldacre's damning piece, he really doesn't mince his words and why should he? The homeopathy brigade need to be attacked for their pathetic tactics which threaten to undermine proper scientific progress:

"But when they’re suing people instead of arguing with them, telling people not to take their medical treatments, killing patients, running conferences on HIV fantasies, undermining the public’s understanding of evidence and, crucially, showing absolutely no sign of ever being able to engage in a sensible conversation about the perfectly simple ethical and cultural problems that their practice faces, I think: these people are just morons. I can’t help that: I’m human. The facts are sacred, but my view on them changes from day to day."

Dr Ray has reproduced a brilliant, albeit lengthy, assassination of the Darzi NHS review. Darzi's sham review is deconstructed to reveal the cynical plot that lies beneath the superficial facade.

The courageous Barry Monk, consultant dermatologist, tells a shocking tale of just what tactics those in control of the NHS use to intimidate those who oppose their destructive reform. Any organisation that treats its most valuable and experienced assets like this needs its head testing, it gives an insight into the kind of attitude that is shown towards those who want to fight for the interests of their patients and the general public.

A lot of people are wondering where exactly Dr Crippen has gone? Has the Witch doctor's black cat caught up with him stateside? Watch this space for updates.

I would like to finish by highlighting the disgraceful performance of several DoH employees last week when they presented their 'evidence' (propaganda) to the Commons Health Committee. Sir Liam Donaldson led the way, closely followed by his profligate stooge Martin Marshall in trying to deny any responsibility for the mess of MTAS and MMC. Their explanations defied belief, as they arrogantly referred to the majority of medical opinion as 'noise', while the Douglas review group was portrayed as a voice of pure objective reason. However even they didn't try to argue with Sir John Tooke's review, but Liam Donaldson might need to read it again, as Sir John didn't paint the policy behind MMC is a particularly favourable light. In my humble opinion the incompetent buffoons who designed MMC and MTAS must be held to account for their actions, and they must resign. There is simply no argument that can save their low quality bacon, especially Donaldson's fatty rasher.

What do health correspondents know?

I thought that it would be rather interesting to survey the health correspondents, who work for the major media outlets in this country, to examine just how well educated they are in the field of science. The reasoning behind this was that in my opinion it is rather hard to do a decent job as a health correspondent without a reasonably scientific education, given how so many health related issues are so very scientific in nature. Unsurprisingly only a minority of those surveyed responded.

Credit must go to those who did respond. Nigel Hawkes of the Times who writes some excellent pieces, unsurprisingly has a very scientific background with a scientific degree and A Levels in Maths and the sciences. Jeremy Laurance of the Independent has A Levels in Maths and science with a philosophy degree. While Sarah Boseley of the Guardian has no science beyond GCSE level with an arts degree, she also felt the need to comment as below, she obviously knew the line which I was probing:

"I would add that I think the job of reporting is not necessarily to bring any previously-acquired knowledge to a story but to find out and understand it well enough to interpret for a reader who usually knows even less than we do. Some scientists have difficulty with that."

I think Sarah Boseley's argument shows exactly why a scientific education is needed to report to a high standard on scientific issues. I think scientists have difficulty with this argument because of the flagrant lack of logic it demonstrates. A good scientific education is invaluable in analysing scientific evidence and scientific stories; it is essential for weeding out the good science from the dross, for spotting the dishonest lies that some people peddle as indisputable science. It seems to be no coincidence that the mainstream media gives so much time to medical treatments with no evidence behind them such as homeopathy and natural remedies, while so called experts in nutrition and psychology are trusted just because they have paid a few hundred dollars for a cheap masters degree in their field of expertise. I would argue that a proper scientific education is essential so that our health journalists can weed out the likes of Gillian McKeith, rather than naively believing anyone who can talk the talk.

I am still waiting for replies from several journalists, including the BBC's health correspondent. I am sure that journalists will have very wide ranging views on this topic, but surely this debate should be heard; as there is a real concern that if the dumbing down of science continues in the media as it is, then more and more con artists will continue to rip off the general public in a variety if ways with their dishonest pseudoscience. Sometimes it may only mean that someone wastes a few quid on a potion that doesn't work, but on other occasions it may mean that someone dies because they seek the attention of quacks instead of the real doctors who may be able to cure their health problem. I have seen early stage and eminently treatable breast cancer kill needlessly, because a patient was convinced that 'natural remedies' would cure her without the need for surgery. If any journalists wish to join the debate then please feel free to add your name and the details of your education below. Science is the foundation upon which so much modern progress has been built, so if we let these foundations wash away the consequences could be rather disastrous.

Donaldson and his cronies dissappoint

MMC and MTAS is being investigated by the Commons Health Committee today, all the written evidence can be seen here. It can be viewed via this link if you did not have time to see it live. Remedy Uk is holding a virtual vigil as we speak.

For me watching a few minutes in my lunch break between clinics, I am infuriated by the complete dishonestly and spin shown by Sir Liam Donaldson and his pack of cronies at the Department of Health.

Sir Liam tried to spin the disaster as evidence of how well his team has responded to a crisis, failing to mention that the crisis was largely his fault in the first place. The deputy CMO also tried to spin MTAS as something that a large number of people were happy to see continue without any change, as if it was a noisy minority that wanted things to be stopped.

The amount of times that the DoH cronies had to say "I don't know, I'll have to check that" began to beggar belief, what precisely do these idiots actually do all day at work? Sir Liam agrees with the Tooke report apparently, I hope he agrees with the bits that point out the complete incompetence and lack of leadership shown at the DoH throughout all this.

If I had had time to watch for much longer I would have been tempted to aim my fist at Sir Liam's rotund patronising cheeks staring at me via my computer screen. Heads must roll.

Darzi's democratic bypass

The government's sham consultation process for Darzi's NHS reform was first exposed by Dr Ray, other bloggers quickly followed his fine example to highlight this worrying issue. The Department of Health have been forced to admit that there is a rather worrying lack of transparency as regards this 'consultation' process, I quote the DoH commenting in response to a FOI request:

"In the weeks leading up to the events, people were approached on the street by Opinion Leader Research (OLR- the company that carried out the deliberative events on the Department’s behalf) and asked whether they would be willing to participate."

"OLR oversaw this process to representative specifications agreed with the Department of Health."

So the government gave this important job to a private firm, so one would therefore hope that this process was transparent given that it relates to matters of a very strong public interest:

"There are no records of the meetings held between Department and the contractor."

There we have it. The Department of Health is privatising the democratic process. They have outsourced an important public consultation to a company that prides itself on spinning and manipulating public opinion. The Department of Health strangely then has no records at all of meetings it has held between itself and Opinion Leader. This is even stranger when one considers that Opinion Leader were chosen ahead of other firms even though their tender was over ten times the cost. Opinion Leader are also involved in the government's nuclear power consultation, another open and honest process if ever there was one.

Meanwhile the DoH claims that no 'social influencers' were used by Opinion Leader at their NHS events:

"I can confirm that no social influencers have been used at any NHS Review event."

This seems to directly contradict the use of Opinion Leader staff as described by people who attended the event. I smell a bit fat porkie. It is yet more astonishing evidence that shows the lengths to which this government will go to manipulate the democratic process; it is also very scary indeed that this kind of important public work can be outsourced and then conducted in secrecy behind closed doors. New Labour is again spitting upon the grave of democracy.

Bankrupt Wanless is the Skills Escalator man

Christmas has come early if you previously thought that you had to go to medical school to become a consultant, because thanks to the NHS Skills Escalator anyone can have a crack without any proper qualifications. Their bizarre nonsensical plan has to be seen to be believed. Also have a look at how you can climb the NHS jobs ladder in the easiest possible way without gaining the proper training or qualifications, apparently the fact that a medical degree may be important for the career of physician or surgeon is seemingly brushed under the carpet by these idiots.

'Competence' can be simply self assessed and there appears to be very little restriction on what those with no decent training can have a stab at. Pharmacists and nurses are the most recent staff who have been given jobs well beyond their means, I wonder how long it will be before porters and receptionists are let loose to diagnose and treat minor illness. Where I work the unaccountable management are sometimes keen to give patients wound care advice. Who are the idiots responsible for this handing of power to the ignorant:

"With redesigned roles and competences and greater participation from other non-medical members of the team we will be better equipped to meet the demands of the future." "Skills for Health (SfH) works with employers and other stakeholder to ensure that those working in the health sector are equipped with the right skills to support the development and delivery of healthcare services. SfH are leading on the development of frameworks and standards to define and develop competence and a programme to support workforce and career development. As part of the modernising agenda and New Ways of Working a 9 level Career Framework was developed, describing England’s healthcare workforce by skills and competencies rather than traditional professional boundaries."

Debbie Mellor, Rob Webster and Becca Spavin are the clueless stooges behind this negligent dumbing down agenda. This is the same Debbie Mellor that was largely responsible for the MTAS disaster. And as the Witch Doctor points out, Derek Wanless is the Skills Escalator man:
"The Government –commissioned report into health sector workforce led by Wanless contends that the only way we can plug potential gaps in the system in future will be to work from the bottom up, starting with the patient, then working through Healthcare Assistants through nursing therapists to medical professionals."

Derek Wanless, Debbie Mellor, Rob Webster and Becca Spavin have no understanding of working on the ground in the NHS, their hard brained schemes to empower the untrained are demonstrative of their complete ignorance of what it takes to provide a good standard of clinical care to patients.

This is the same Derek Wanless who has presided over the recent catastrophe as regards Northern Rock, and in the opinion of many experts was significantly to blame for the problems that arose, problems that were eminently foreseeable and preventable if the likes of Derek Wanless did their jobs properly. He is allegedly an expert on finance, so if he can be shown to be so useless in his field of expertise, I really fear for his idiotic plans as regards the NHS Skills Escalator.

It may well be true that someone with no education could do as good a job reviewing the NHS as Sir Derek, however he should not lump us all together in his boat of rank incompetence. Professional boundaries were there for a reason, they were not just there for fun; they were crucial in maintaining high standards of clinical care and in protecting patient safety. The erosion of proper professional boundaries as catalysed by the idiotic Skills Escalator works against the very essence of professionalism, they represent an incoherent amateur approach that threatens to endanger the safety of patients everywhere, as proper education and training are cast aside because they are just too expensive and too much hassle. Wanless and his incoherent plan must be opposed at all costs, otherwise the lunatics will have truly taken over the asylum.

Enforced equality destroys excellence

Consultants are level 9
"Senior SpRs" are level 8
"Junior SpRs" are level 7
SHOs are level 6
FY1s are not mentioned

"Consultant" practitioners are level 8
Nurse practitioners are level 7
Ward sisters are level 6
Newly qualified nurses are level 5

This utterly ridiculous ladder shows an utter contempt for the rather obvious fact that doctors are not nurses and that nurses are not doctors. It attempts to weave together everyone under the 'practitioner' umbrella.

This simple ladder shows how the government is dumbing down our health care system. Training, education, examinations and experience are not important in preparing workers for their jobs. Everyone can be crudely lumped together under the same simplistic umbrella.

Nurse are trained for nursing and do not have a sufficient foundation of knowledge to be let loose as doctors, unless they are willing to train to as rigorous a level as medically qualified doctors and obtain a proper medical degree. Experience as a nurse is virtually useless in training to perform doctoring roles, the two jobs are completely different, this doesn't appear to have stopped the government trying to bizarrely merge the two roles.

Just compare the level 7 workers as an example. The NP has a nursing degree followed by nursing experience and a very short course to become an NP which does not include any proper examinations, they are then deemed level 7 competent, whatever that means. A junior registrar has managed to get into medical school, pass all their exams to obtain a medical degree, worked several years gaining doctoring experience and obtained the appropriate rigorous Royal College exams. Yet these two very different groups are both lumped in the same box which claims they are level 7 competent:

"Experienced clinical professionals who have developed their skills and theoretical
knowledge to a very high standard. They are empowered to make high-level clinical
decisions and will often have their own caseload. Non-clinical staff at Level 7 will
typically be managing a number of service areas."

One of these groups is highly trained and capable of practicing medicine independently to a high level, and the other is not. It is also clear that the DoH is trying to merge managers into this crude ladder that appears to be based upon very little logic.

By trying to lump a vast array of very different roles into the same simplistic boxes, the leaders of reform are insulting a vast array of highly skilled staff. Nurses are not trained to doctor, doctors are not trained to nurse, management roles are not practitioner roles; these different varied roles have evolved for a reason. The government is dragging us back to square one, and in the process advances in proper education and training are being purged.

By trying to make every NHS worker a branch of this universal health care practitioner, the government is dragging us back to the dark ages when anyone could have a crack at treating medical ailments. There was a reason that the different sub-specialised roles developed, it resulted in patients getting a much better service as proper regulation enabled dangerous quacks to be marginalised. The reverse is now true, the government's short sighted cost cutting agenda is already resulting in the minimally trained being dangerously let loose on the unsuspecting.

It is time that our roles were rigorously redefined. The BMA and Remedy must take a stand on this issue. Isn't it strange that the regulation of the medical profession is seen as such a problem, when the nursing profession can empower nurses to take on jobs beyond their means and at the same time allow these individual nurses to define their own areas of competency? There would be outcry if junior doctors were let loose in this manner to determine their own areas of ,within which they were free to independently practice; and junior doctors have been through much more rigorous training that includes a rather important thing called a medical degree. It's very sad that a medical degree and a proper education count for so little these days in this NHS of enforced equality.

New Labour

Nurse prescribing

Given that there is zero evidence that shows nurse prescribing to be safe, it is extremely worrying when an esteemed Professor of prescribing science writes of his concerns:

• There were more than 20,000 independent nurse prescriptions for the full range of antibiotics and antivirals.

• Amiodarone and cimetidine are being prescribed – both very risky drugs with dozens of potentially fatal interactions.

• A wide range of cardiac drugs is being used by nurses, including digoxin, ACE inhibitors, angiotensin receptor blockers and calcium channel blockers. Many of the digoxin prescriptions were for the higher dose tablet, and there were 98 prescriptions for the calcium channel blocker verapamil – a drug that should only be instigated by a cardiologist and prescribed by a GP.

• There were hundreds of prescriptions for diuretic-hypotensive combinations, including co-amilozide and co-amilofruse, both of which carry a serious risk of plasma electrolyte problems and are major causes of drug-related emergency admissions.

• Nurses were prescribing the full range of anti-diabetes drugs, despite diabetes being the most brittle and treacherous of syndromes, even in specialist hands.

• There were many prescriptions for antidepressants – after antibiotics, the most over-prescribed drugs.

• There were thousands of prescriptions for NSAIDs – the most dangerous drugs of all, accounting for more than 30% of all reported serious adverse drug reactions.

• Nurses had given out about 200 scripts for atypical antipsychotics, whose incorrect use may lead to permanent sequelae.

• There were a host of other drugs prescribed by nurses that are potentially seriously risky. These included more than 1,000 prescriptions for a-blockers, more than 100 of methotrexate and almost 500 prescriptions for erection enhancers.

Most of these drugs are suitable for a nurse to prescribe in a medication plan agreed with a doctor. Given nurses’ entirely inadequate training in diagnosis and therapeutics (which of course is not the nurses’ fault), hardly any of these drugs should be prescribed independently.

Currently, about 5% of emergency hospital admissions are the result of faulty GP prescribing (in the elderly the figure rises to 12%), despite the prolonged training that GPs get and the long period of supervision.

We may expect a marked escalation of preventable prescription-related disease from independent nurse prescribing on the basis of these figures.

However those who back nurse prescribing will cast this aside as it is simple common sense, and they have ways of living in denial and ignoring good old common sense.

Street Doctor - negligent medicine at prime time

Luckily I have not had to endure many episodes of the BBC's woeful 'Street Doctor', unfortunately last week I was unlucky. Not only is the program negligent in the way that it portrays medicine as something that can be done on a street corner without a proper thorough history and examination, but it is also negligent in the way that the doctors get medical things very wrong indeed. In last weeks episode there were these glaring errors:

Plantar Fasciitis - a man with mild plantar fasciitis was treated immediately with a steroid injection. This was poor medicine as he should have been treated with simpler measures before a steroid injection was even considered, however the Street Doctor went straight for a treatment that is at best slightly controversial and at worst can result in serious complications. This was undoubtedly poor medicine.

Dupuytren's disease - the Street Doctor got this very wrong stating that it was a thickening of tendons and could be treated with a steroid injection. This is complete rubbish, Dupuytren's is a disease of the palmar fascia and not the tendons, and cannot be treated with steroid injections.

Sebaceous cyst - a poor old chap got terribly scared by the Street Doctor telling him that squeezing his infected cyst would result in the infection spreading to the bloodstream, what utter hogwash. In fact squeezing an infected cyst may well prevent the infection becoming more systemic, the complete opposite of the doctor's advice.

This program is an embarrassment and a danger. It encourages sloppy half arsed medical practice and spreads medical misinformation to the general public. It's therefore no surprise that the BBC should see it as a key part of its new cutting edge programming. A cynic would even go so far as to say that this pathetic attempt at taking care into the community is being used to add weight to Darzi's corrupt NHS reform program.

Fisher Price NHS

The dumbing down continues apace, with pharmacists being given the chance to diagnose and manage 'minor illness' in another hair brained and arguably cost ineffective government scheme. One wonders quite how the pharmacist will be able to tell if an illness is 'minor', given that their training includes nothing on the diagnosis of disease? Apparently the following are minor:

"acne (a dermatologist may well be needed if nasty), athlete's foot, back ache (cauda equina can present with minimal pain if atypical), cold sores, constipation (hopefully not bowel cancer), cough (hopefully not asthma or lung cancer), diarrhoea (again hopefully not inflammatory bowel disease or cancer), ear ache (possibly something an ENT bod may be needed for), eczema and allergies, haemorrhoids (piles) (something that a colorectal bod can treat easily in clinic) , hay fever, headache (hopefully not hydrocephalus, meningitis, raised intracranial pressure), head lice, indigestion (hopefully not cancer or barret's oesophagus), mouth ulcers , nasal congestion (nasopharyngeal cancer), pain (quite a few things could be missed here), period pain (ectopic for one), thrush, sore throat , threadworms, warts and verrucae (don't miss a melanoma)"

I have just added in brackets a few of the ways in which these pharmacists could very easily miss a diagnosis and harm, or even kill a patient. GPs get things wrong enough, and this is with a proper medical degree and years of supervised training in the art of history, examination and diagnosis. The potential for pharmacists to go wrong is enormous.

Also how on earth can a pharmacist make a diagnosis? Are they trained to use a stethoscope, an otoscope, a proctoscope or an opthalmoscope? I very much doubt it. It is a bit like Dr Crippen's analogy of letting the air hostess take over from the pilot in the cockpit!

More evidence is coming to light showing that various dumbing down reforms are not really cost effective or safe. GPs with a special interest (GPwSIs) are really a very poor alternative to proper specialists, and this is evidenced by their cost effectiveness. While the dangers of nurse prescribing have already been written about in many quarters, here is yet more ammunition in the locker demonstrating how an inadequate level of training may well impact on standards of care:

"We may expect a marked escalation of preventable prescription-related disease from independent nurse prescribing on the basis of these figures."

Whether it be in the form of pharmacists acting as family doctors, nurses acting as doctors or GPSIs acting as specialists; the trend is a dangerous one away from proper training and high standards of care, towards dumbed down training and lower standards of care. That's progress for you.

An experienced geriatrician speaks

The debate around empowering nurses to make DNAR decisions is certainly a hot one, I have obtained permission from an experienced consultant geriatrician to publish this short piece he wrote on the topic, the opinion of a geriatrician is particularly useful as they are in my opinion amongst the best at understanding the complex issues that surround DNAR decisions:

" "In general senior nurses are well qualified and well placed to make these decisions."

No they are not

As a geriatrician end of life decisions are my bread and butter. I work with mostly excellent nurses. But in my time as consultant I cannot think of a single senior nurse who would have been capable of making complex decisions like this in complex patients.

That is NOT a criticism of nurses. It is a compliment to doctors. On this issue my firm belief is this is something that almost no nurse could be reasonably asked or expected to do. And that's before we get to the issue of bearing responsibility for that decision.

Some things remain firmly in the domain of "a doctor's job". This is one of them. And before anyone cries "protectionism" all I would say is demanding the right to retain this responsibility as a doctor must surely be professionalism and nothing else."

The nail has been hammered home. It also seems that many nurses agree with this sentiment.

Nurses to make end of life decisions

"Responsibility for decision-making

The overall clinical responsibility for decisions about CPR, including DNAR decisions, rests with the most senior clinician in charge of the patient’s care as defined by local policy. This could be a consultant, GP or suitably experienced nurse. He or she should always be prepared to discuss a CPR decision for any individual patient with other health professionals involved in the patient’s care. Teamwork and good communication are of paramount importance. Where care is shared, for example between hospital and general practice, or between general practice and a care home, the health professionals involved should discuss the issue with each other and with other members of the healthcare team. There should be shared responsibility for deciding about the likelihood of a successful outcome from CPR, and discussing the issue with the patient or with those close to patients who lack capacity where a balance of benefits and burdens is needed. Nevertheless, one individual needs to take charge of ensuring that the decision is made properly, is recorded and is conveyed to all those who need to know it, including locum staff. Local policies should specify who that should be."

The empowerment of nurses gathers pace and is amazingly aided by the BMA, a union that now appears so politically driven that I wonder why any doctor in their right mind remains a member. This document explains the rationale, or lack of it, for the changes to procedure relating resuscitation decisions.

Decisions that relate to resuscitation are frequently badly managed but allowing nurses to make these decisions will only add mud to the waters of confusion. The public are generally poorly informed about what resuscitation actually is and how likely it is to succeed, while in hospitals the decision not to resuscitate often gets abused as a license for staff to not actively treat very treatable conditions. Making the decision requires a lot of medical knowledge and training, something that nurses, no matter of their experience, do not possess.

The BMA are a disgrace, their document uses the word health professionals endlessly without mentioning the word doctor. While nurses are now called 'clinicians' and despite their overt lack of training and examined knowledge, are being promoted to the same level as doctor 'clinicians'. Nurses are not clinicians, they are nurses; the government may have empowered them to have a rather amateur crack at diagnosis and doctoring but this does not make them trained clinicians, they are only trained at nursing. Doctors are clinicians, they have been to medical school and have had their skills and knowledge examined to a proper level.

The document also has a dumbed down protocol for DNAR decisions, the classic hallmark of a dumbed down nurse led procedure that will guarantee that common sense is cast aside routinely. Recently the hypocritical NMC also had the gall to accuse others of abusing the title 'maternity nurse'; this is while the NMC backs the empowerment of nurses and deception of the general public with nurses being called 'nurse consultants'. A 'nurse consultant' is simply an experienced nurse, so the tag of 'consultant' is nothing but a dishonest lie.

These new guidelines are the classic example of the dumbing down of medicine in this country. The suggestions at first do not appear that unreasonable, however it is the general tone of the document that fills me with fear; proper training and knowledge are being undermined as all healthcare staff are referred to as generic 'health professionals'. One does not need proper training or in depth knowledge to become a 'consultant clinician' anymore, anyone with a few years of service can have a crack. I would imagine that sensible nurses will not want to have this extended responsibility, however the growing cohort of 'chip on shoulder' wannabee doctors will be delighted that the line between doctor and nurse continues to be eroded.

Whatever happened to doctors doctoring after doctor training and nurses nursing after nursing training? We now have nurses doctoring after nursing training and doctors fuming with very good reason. The line between doctor and nurse continues to disappear, remind me again why I went to medical school? Because in my naivety I wanted to do my job properly.

Tooke - a remedy?

There is undoubtedly much of sense in John Tooke's report. The talk is certainly attractive, however one must always remain sceptical when analysing matters of a political nature, and this is especially the case when the talk turns to unquestionable principles, I must admit that alarm bells do start ringing. Tooke is undeniably spot on when he criticises the powers that be for their negligent role in the implementation of MTAS and MMC, the Department of Health deserves this scorn. His recommendations for improvement in this area do not convince me, I have lost my faith completely in the government and the only thing that would convince me would be for the government to be stripped of its control of medical training.

I welcome several other ideas including pushing for an increasing emphasis of the importance of medical training in the NHS' burgeoning management structures. However practically on the ground we have seen how training is rarely respected by cash strapped trusts, as money is clawed back in rather unethical ways from doctors who are then forced to pay for their own training. The following idea is good, but 'should' is very different to the reality of the BMA:

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

The suggestion to assimilate the useless PMETB with the GMC could do no harm, at best PMETB would no longer be able to inflict its incompetence upon us. When talking of FY1 and FY2 I think he loses the plot, despite the fact that his proposals are an improvement, I would favour a return to a PRHO year of six months of both medicine and surgery that is strictly regulated so as to ensure first year doctors become solid at the bread and butter. There is also far too much talk of 'competency assessment', as if the validity of this new educationalist ideology cannot even be questioned and this fills me with fear. I am also slightly fearful at his talk of standardised national forms, specialty specific questions and standardised assessment scores.

I am most concerned about the lack of consequences for those individuals who played such key roles in negligent implementation MMC and MTAS, will the likes of Liam Donaldson be held accountable for their actions or lack of them? Most worryingly John Tooke's suggestions will have to be listened to and acted upon by the very same incompetents who got things so very badly wrong the first time around, of course this is not Sir John's fault but it does have implications for the end product of his review. At the very same time that the Tooke review was being delivered, these very incompetents were delivering yet more MTAS style disasters in the form of Foundation 'white spaced questions'. While the incompetent workforce planners NHS Employers were delivering yet another piece of malignant rubbish that treats medical training with utter contempt. Undoubtedly training has to change but there are certainly much better ways of doing it than those proposed by the short sighted and cynical NHS Employers. These two examples are by no means isolated.

Various organisations have responded to Sir John's review, including the Royal Colleges and the BMA. There is strangely no mention of the role of the post-CCT doctor and how they fit into this grand scheme. It must be remembered that the BMA and the Royal Colleges have betrayed us more than once with these training reforms, so I would urge caution when listening to their enthusiasm for Sir John's review. That is not to say that I do not agree with much that is contained within the report, however I would suggest that we all remember that there is a long way to go in this battle for the future of medical training. Complacency could be very dangerous, as the good words in Sir John's report will mean nothing if certain malignant reforms are slid in via the back door when our backs are turned.

This is no time to get carried away. Thousands of excellent trainees will not find training jobs again this August, while there are many serious problems facing those trainees that are lucky enough to find a job, competency based fundamentalism and its dominance over experiential learning is just one issue that needs to be dealt with. But surely the most important thing will be that trainees remain militant and become more political than ever before, so that we can force the powers that be to stand up and take notice of what we demand for ourselves and for our patients in the future. After all if we simply roll over, there is little doubt that the government will treat medical training with contempt again; thus ensuring that hopes of excellence will be but a distant memory, and that dumbed down substandard dross will be their order of the day.

Another reorganisation of regulation

It seems that the government never learns from its mistakes. They have created yet another regulator, the Health Quality Commission, to enforce its centrally driven targets. So what will this new regulator actually do?

"The Care Quality Commission will have the power to close wards and order more frequent checks. The watchdog will focus on safety and quality across health and adult social care services, inboth the NHS and the independent sector. In particular it will be able toclose services that are unsafe, or where there is some other serious breach which is putting patients at risk. "

That all sounds well and good, but in reality it means very little indeed. As the government has cut bed numbers and with hospitals running at near 100% occupancy, I fail to see how shutting wards in over strecthed hospitals will do anything to address the root causes of these problems. The talk of fining trusts for not complying with centralised dictats is ludicrous, as the trusts in trouble are invariably the ones with the most financial debts, hence fining them is likely to potentiate the problem. This quote demonstrates the completely deluded thinking of whoever has come up with this bright idea of yet another reorganisation:

"Many of the powers are already available to the existing regulators, but
ministers hope tougher action will be taken by merging the responsibilities into
one body."

They should be asking questions now as to why the regulatory bodies are not doing their jobs properly, another reorganisation is unlikely to solve this problem as if by magic.

"The Care Quality Commission will also have an
important role in supporting patient choice, through assessing and providing
information on the performance of providers of adult social care and health
care, and in ensuring value for taxpayers' money."

This is the real truth of it. This regulatory body will be yet another vehicle by which the government can railroad through its anti-democratic privatisation of the health service. The disingenuous 'patient choice' really means 'government choice', as most people simply want good local NHS services and do not want to see their hard earnt cash donated to private firms that are friendly with the government. If the Care Quality Commission really cared for the quality of health care and for ensuring value for taxpayers' money, then they would tell the government to scrap the internal market and return to the days when hospitals were not run from Whitehall, thus ensuring that local people could have a say about their local NHS. As things are going though this reorganisation promises to waste yet more tax payers' money doing exactly what the taxpayer doesn't want.

The ferret's guide to Tooke: Part 6

"Recommendation 30
PMETB should be assimilated in a regulatory structure within GMC that oversees the continuum of undergraduate and postgraduate medical education and training, continuing professional development, quality assurance and enhancement. The greater resources of the GMC would ensure that the improvements that are needed in postgraduate medical education will be achieved more swiftly and efficiently. To this end the assimilation should occur as quickly as possible."

I don't think that this proposal would be very unpopular within the medical profession, it would be far better to have one organisation in charge and therefore accountable for their actions. This is the best recommendation of the lot for me.

"Recommendation 31
Under the Medical Act, Universities already have responsibility with regard to FY1. By breaking the linkage with FY2, it will be possible to guarantee an FY1 position in the new graduate’s local Foundation School subject to prevailing local selection processes. The linkage between FY1 and FY2 should cease for 2009 graduates."

Another sensible idea, back to a more house officer style of system.

"Recommendation 32
FY1 should be reviewed to ensure that i) harmonisation with year 5 is optimised; ii) the curriculum more clearly embraces the principles of chronic disease management as well as acute care; iii) competency assessments are standardised and robust. In future, doctors in this role should be called Pre-Registration Doctors."

I am not convinced by this, I believe the first year of pre-registration work should be the simple bread and butter. It should consist of six months of medicine and six months of surgery, and nothing else. It must be a good broad grounding in acute care that is a platform from which to spring.

"Recommendation 33
Foundation Year 2 should be abolished as it stands but incorporated as the first year of Core Specialty Training. The current commitment to FY2 GP placements should continue as part of Core Specialty Training and developed further as resources permit. Doctors in Core Specialty Training should be called Registered Doctors.

Recommendation 34
At the end of FY1 doctors will be selected into one of a small number of broad based specialty stems: e.g. medical disciplines, surgical disciplines, family medicine, etc. During transition, ‘run-through’ training could be made available after the first year of Core, for certain specialties and/or geographies that are less popular than others. Core Specialty Training will typically take three years and will evolve with time to encompass six sixmonth positions. Care will be taken during transition to ensure the curricula already agreed with PMETB are delivered and the appropriate knowledge, skills, attitudes and behaviours are acquired in an appropriately supervised environment.

Recommendation 35
For those doctors who do not know to which Core Specialty to commit at the end of FY1 there will be the capacity to take up to 2 years in hybrid rotations allowing experience in four main Core areas. Experience in the subsequently selected Core area will count towards the completion of Core Specialty training subject to successful competency assessment."

The wheel is being reinvented here, the outcome of the above would appear to resemble the old pre-MMC system.

"Recommendation 36
Colleges should work together with the Regulator and service to devise modularised curricula for Specialist Training to aid flexibility/transferability. They should also devise common short-listing and selection processes that have been standardised across the country to allow sharing of assessments between Deaneries. This work should be completed within two years."

There is good and bad in this, it is good for the Deaneries to pool ideas and knowledge, however why should things have to be standardised across the board? Diversity is the spice of life and without it I feel the pursuit of excellence will be hindered. The time limit may not be a good move either, we have seen how badly rushed reform can go.

"Recommendation 37
Satisfactory completion of assessments of knowledge, skills, attitudes and behaviours will allow eligibility for
i selection into Trust Registrar positions* in the relevant area or
ii selection into Higher Specialist Training.
Doctors in Higher Specialist Training will be known as Specialist Registrars,
those selected into General Practice specialty training will be known as GP
Registrars (equivalent to ST3 and beyond)."

This just states that registrars will continue to be registrars.

"RecommendatIon 38
The newly named Trust Registrar position* (formerly termed Staff Grade) must be destigmatised and contract negotiations rapidly concluded. The advantages of the grade (accrual of experience in chosen area of practice, consistent team environment) need to be made clear. Trust Registrars should have access to training and CPD opportunities. They should be eligible for a reasonable limited number of applications to Higher Specialist Training positions according to the normal mechanisms and also to acquisition of CESR through the Article 14 route."

I wouldn't argue with this.

"Recommendation 39
Doctors should be allowed to interrupt their training for up to one year (or by agreement longer) to seek alternative experience. The regulator in conjunction with the Royal Colleges will determine whether experiences should contribute to completion of training subject to appropriate competency assessment."

It wis essential that doctors are encouraged to gain a wide variety of experience.

"Recommendation 40
Selection into Higher Specialist Training to the role of Specialist Registrar
will be informed by the Royal Colleges working in partnership with the
Postgraduate training – Inquiry recommendations

The Panel proposes that in due course this will involve assessment of relevant knowledge, skills and aptitudes administered several times a year via National Assessment Centres introduced on a trial basis for highly competitive specialties in the first instance. A limited number of opportunities to repeat the National Assessment Centre tests following further experience will be determined. Candidates will apply via Postgraduate Deaneries or Graduate Schools.
Application will take place three times a year on agreed dates. Save in the most exceptional of circumstances, candidates will be restricted in the number of local programmes to which they may apply (and to the number of occasions on which they may apply).They will use a common national form with specialty specific questions and will provide their standardised
assessment score/ranking along with a structured CV. This will avoid the once a year appointment system with its inherent risks to service delivery. Graduate Schools linked to the 30 UK Medical Schools would reduce the size of Units of Application and address the family-unfriendly situations that arose therefrom. Shortlisted candidates will be subject to a structured interview for final selection."

I am scared by the mention of common national forms with specialty specific questions and standardised assessment scores, does this not ring alarm bells a la MTAS 2007? Why not allow there to be a bit of healthy regional variation to encourage diversity?

"Recommendation 41
The current Academic Clinical Fellowships in England allowing c25% of programme time for research methodology training and development of research proposals should be integrated with Core Specialty Training. There will be a need to ensure that those entering an academic training path in the devolved nations are not disadvantaged when moving between research
and clinical activities. Opportunities equivalent to ACFs should be competitively available for those wishing to develop educational, management, and public and global health skills, subject to available resource, through modular Masters programmes."

I am not sure what this means, Academic Medicine is a bit of mystery to me.

"Recommendation 42
Clinical lecturer posts in England will normally be coincident with higher specialist training (ST3 and beyond).

Recommendation 43
Successful completion of Higher Specialty Training as confirmed by assessments of knowledge, skills and behaviours will lead to a CCT. Higher specialist exams, where appropriate, administered by the Royal Colleges, may be used to test experience and broader knowledge of the specialty and allow for credentialing of subspecialty expertise gained post CCT and aid
selection to consultant positions."

Fair enough.

"Recommendation 44
To be eligible for a Consultant Senior Lecturer appointment, the applicant should possess a CCT in the relevant specialty area. Higher specialist College exams could be tailored to limited subspecialty expertise, recognising the narrower scope of practice that some clinical academics
may need to embrace.

Recommendation 45
The length of training in General Practice should be extended to five years, bringing it in line with specialty training and the other developed European countries."

The ferret fancier will shortly be releasing a concluding piece on the Tooke review, simply watch this space, I cannot promise that it will be coherent, however it will be under 100 pages in length.