The Jobbing Doctor

Battle on the airwaves.

2012-02-03T07:38:00.000Z

Today the Royal College of General Practitioners comes out strongly against the new Health Bill. If you have ever been to a meeting with doctors, you will know that trying to get them to agree on anything is really difficult: especially on a dry subject like legislation.

This time, we have a vote where over 90% want the Bill withdrawn. Not changed, but withdrawn.

Clare Gerada (RCGP Chair of Council) makes a cogent case for withdrawal of the Bill. A Government minister, Mr Simon Burns MP, says that is "not what he is hearing" when he goes round the country (need to start listening, Simon), and the Family Doctor Association (who are they?) support it.

If there is not a withdrawal of the Bill, then the GPs can say that they tried as an unholy mess unravels, the private profiteers cherry pick the easy bits to do, and we will be left with an uncoordinated, shambolic, expensive, and worse service (like the mail service and the Trains).

Find me a Jobbing GP who disagrees with Clare.

Frankly, we all agree with her.

Vindictiveness

2012-01-31T18:39:00.000Z

OBE

Over the last few days we have had the rather unsavoury experience of looking at the Government in its most spiteful and vindictive mode.

Firstly they make a man head of a failing bank, and ask him to turn it around.

They then fix a pay and bonus deal that is at the lower end of what many corporate bankers get. When the guy is entitled to this pay and bonus deal, rather than exercising executive action, they resort to pleading with him to do the "moral" thing and waive his bonus; they get their media support unit (BBC/ITV/Tabloids/Daily Mail) to engage in a hue and cry about it.

Poor guy eventually waives the negotiated bonus deal, under extreme pressure.

Next thing they do is rescind Fred 'the Shred' Goodwin's knighthood - as announced today, for bringing banking into disrepute. This is another populist and shabby action. Fred did what all bankers were doing over that period of time. He just did it better and bigger than others. He was engaged in naked capitalism. His bank folded catastrophically, but I don't think we should be rescinding his knighthood. Knighthood and Peerages have been given to all sorts of people in the last who don't deserve it. Robert Mugabe, for one. Lord Jeffrey Archer for another. The list of Lords, Dames and Knights is stuffed full of the venal, selfish and amoral types. The whole honours system remains very corrupt.

I have an MBE on my mantleshelf. It was given to my Dad for a lifetime of charitable work, selflessly and facelessly given.

He deserved the thanks of the country. Many don't, and it has debased his honour. He is not alive to see this now.

So the sight of the establishment at its moralising best is ghastly.

I love my job

2012-01-31T08:46:00.000Z

There are some great bits to my job.

One of the nicest things is when you have got to know a couple who are trying for a baby, and you have the roller-coaster of all the hopes and disappointments.

Often they are unable to conceive naturally and seek funding for assisted conception.

We still have funding for limited access to NHS assisted conception in Dullsville, and some are approved for that.

It is even better when women get pregnant the Natural way.

You will never see someone with a broader smile than that!

Decision time approaches

2012-01-31T08:08:00.000Z

The New NHS Bill

Against:

90-95% of GPs
19 out of 20 Royal Medical Colleges
Royal College of Nursing
Royal College of Midwives
Vast Majority of Working Doctors in NHS
Unite
Unison
Most Ancillary Workers
Most of the population (if they knew)
Health Service Managers
Academics
Medical, Management and Nursing Journals
Labour Party

For:

<5% of GPs
Department of Health
The "Future Forum"
Conservative MPs
Liberal Democrat MPs
Private Healthcare industry
NHS Alliance

Sitting on fence:

Royal College of Surgeons.

So, the BBC refer to the future forum as "Independent" (they are not) and interview a GP from the NHS Alliance (who is a strong supporter of wibble - and the Bill).

Who should the average person believe? The "Fors' or the 'Againsts'?

Understanding?

2012-01-29T19:00:00.000Z

I see an interesting post from Richard Blogger in NHS vault, commenting on the Chief Executive of the NHS, Sir David Nicholson, who said:

"If you've got a long-term condition, you might want to think in future about different GPs and whether they're providing a full range of service for that condition."

This comments on one of the roles that we have in General Practice, which is dealing with long-term conditions - like Diabetes or Stable Angina or Bipolar illness. This is part of my role, to be sure, but his analysis is rather facile in that it tries to break things down into compartments - the Diabetic usually has arthritis and may have depression as well. One of the skills we have is to be able to manage things holistically, dealing with a lot of different things.

We have many other things to deal with, and if we cannot deal with a specific problem, there is usually someone in the practice who can do other things.

A lot of medicine is about having to deal with incurable problems - persistent low back pain, or dementia, or learning difficulties - and just being there for patients: supporting people as they get iller.

General Practice is about lots of other things, such as co-ordinating specialised services, or explaining what is going on to people. The art and science of diagnosis is vital. The idea that people will "shop around" for different practices who offer different services is, I'm afraid, marginal.

One of the things I've experienced in my long career is how loyal patients are, and what a fantastic relationship we have with many of our patients. I have known people to ask for my practice area when they are moving house, so that they can tell the estate agent that they do not wish to buy a house outside of that area.

Once again the Bureaucrat's understanding of the relationship is based on competition and comparison.

Life is not like that.

An apology

2012-01-29T06:17:00.000Z

I wish to extend an apology to the international readers of my blog. Over the last few weeks, domestic politics has impinged mightily on the blog, resulting in most posts being about politics rather than medicine. I hope to return to more usual stuff soon, but not much at the moment.

In summary, the NHS (National Health Service) was set up in 1948 to be a state funded comprehensive health service, paid for out of general taxation, and available to all citizens of the country, regardless of income and circumstance. It has survived many changes, but has stayed largely intact. This may change in the next few months, if the current Right-wing coalition Government gets its way.

The argument for this Bill is based on a number of lies.

Lie 1. There will be "no top-down change in the NHS". This was Mr Cameron making fake promises before the elction. This change is so big and so top-dowm that, according to the CEO of the service, "It can be seen from the moon".

Lie 2. Change is essential. No organisation like the NHS avoids change. But not enforced, ideologically driven change. Chang should be gradual and consensual.

Lie 3. There is widespread support for these changes from those working in the NHS. This is so laughable to be contemptuous.

Lie 4. There is too much money spent on bureaucracy. The NHS is the most efficient service in Western Society, spending 5% on administration.

Lie 5. Our outcomes are inferior to other health systems. There are some outcomes that are better, and some that are worse. Everyone can pick areas of variation.

Lie 6. The private sector delivers more efficient care. The private sector delivers queue-jumping, shag pile and pot plants. It selects low-risk patients, and abandons the others.

There are other ongoing lies peddled by those with a vested interest in seeing the NHS broken up. I can be more neutral as I will earn a professional income whether I work in the Private sector or the Public sector.

The NHS is at risk, and we must act to protect it from the privatisers and the asset-strippers. If you want to see what this process results in, look at the railways.

Signs of panic

2012-01-28T21:23:00.000Z

Pile of Rubbish

Well, well, well.

Things are beginning to happen. There seems to be developing panic in the Department of Health. Mr Lansley's wretched Bill is likely to face some further amendment to placate Liberal Democrat peers in the House of Lords.

I see this report in the Observer, and it an indication of huge concern. But not for the Nurses, Midwives and many doctors. We are all pleased to see that the Bill is in trouble.

The Bill is one of the biggest crocks of shite in living memory. Amendment is not enough, it needs to be scrapped.

Who the Hell are they?

2012-01-28T12:57:00.001Z

They represent themselves......

I wake up to find that the BBC are splashing with the news that a group of GPs have written to the Daily Telegraph. They are from an organisation called the NHS Alliance, which is a self-selected group of people who are keen on commissioning. I cannot see the names of those who have put their names to the letter, but could have a good stab at who they are.

The headline includes suggesting the NHS is in "peril" if we do not proceed with the new Bill.

This is, of course, the exact reverse of the truth, and the NHS alliance represent nobody but themselves. I am sure they have been prodded into doing this by the Department of Health. Their lead GP is Dr Michael Dixon OBE. He has been at the barking-mad end of General Practice for along time, supports and promotes the nonsense of 'Integrated Health', has an OBE and wears a bow tie. He does not represent anything except himself and his rather ridiculous organisation. The RCGP (Royal College of General Practitioners) represents rather more, and in a recent poll 90% of GPs were against the Bill.

The BBC have been duped into giving this fringe organisation more credibility than they deserve. The peril will be listening to them.

A busy bee

2012-01-27T17:18:00.000Z

How I see Mr Lansley

Andrew Lansley has been busy this week. Not only has he been insulting the Nurses and the Doctors, but he has also been bullying the Royal Colleges to change opposition to the Bill (shamefully, this worked).

Now he is setting up a company to help flog off the NHS land.

Do any of the doubters have any doubts now?

The Tories are Privatising the NHS, and the project is close to completion.

It was our NHS.

Not for long.

Offensive?

2012-01-27T11:47:00.000Z

Mr Andrew Lansley, the Secretary of State for Health, is not having a good time. His supporters are now largely in the rank of the Conservative party, and he has signally failed to make the case for his new Health and Social Care Bill, which the media still say will put 'GPs in charge of using NHS money, to organise services.

I'm a GP and I should be pleased to be in charge of trying to get the best service for my patients, and I am convinced that it will do no such thing.

Three reasons:

Impossible to meet increasing demand with decreasing budget
5 New extra layers of bureaucracy
60% of the Budget is decided before GPs even get to sit down at the table.

Mr Lansley has resorted to playground bully tactics of calling people names. He has been pretty offensive about the nurses, and how he is piling more of his bile onto the BMA. He doesn't like the BMA because it disagrees with him and his shrinking cabal of zealots, chancers and doctors on the make.

If it is a good Bill, persuade me as to its virtues, Mr Lansley - don't call me names.

Mr Cameron found one GP supporter and.......ooooops!

2012-01-26T12:18:00.000Z

David Cameron (our current Prime Minister) was playing politics yesterday. He had primed his answer to the leader of the opposition, by having a GP supporter who happened to be based in the constituency of the Leader of the opposition.

Take that, Ed!

Except that his sole supporter in Doncaster is, ermmmmm, not there any more. In fact he has left the Clinical Commissioning Group altogether and left the area.

Never mind, Mr Cameron, your make-believe supporter might have supported you in the past.

Now go and find another ordinary GP who agrees with you [those with MBE, OBE and CBE need not be mentioned]. You might need to go further afield than Doncaster.

Arm Twisting

2012-01-26T08:01:00.000Z

Shiny shiny things

The Medical Royal Colleges are in a situation where they can significantly affect the future of the passage of the Health and Social Care Bill. They will be releasing a consensus statement today in their guise as the Academy of Medical Royal Colleges.

Already we have the Surgeons getting cold feet, and also I receive reports of the Physicians and the Obstetricians/Gynaecologists considering their positions.

I understand that the colleges are reconsidering, following "heavy lobbying" from Andrew Lansley, the Secretary of State for Health. Lobbying consists of carrots and sticks - offers and threats - enticement and bullying.

A row of beans

The offer is concessions on aspects of the Bill. We know that this will largely be cosmetic, and the shiny shiny concessions will be taken up by the more pliant or venal in the Royal Colleges. "Oooh look! Shiny shiny concessions!" We all know that they will only amount to a row of beans.

What threats does a Secretary of State have for these organisations? Reduction in funding? Questioning their charity status? Threats of lack of preferment?

If the Surgeons, Physicians and Obs/Gynae people refuse to stand up to the evisceration of the NHS by the Government, can we at least know the reasons?

The proper reasons.

The Conservatives, the Liberals. the Private Health Industry, the "Future Forum" and ...... the Royal College of Surgeons

2012-01-25T15:06:00.000Z

Statue of John Hunter FRS

These are the people who love the new Health and Social Care Bill.

The rest of the people who work in the Health Service (all the other Royal Colleges, the Nurses, the Midwives, the Unions and around 95-98% of doctors) are solidly against it.

Why are the Surgeons in support of the Bill. Is it because they all want knighthoods? Is it because they see a big commercial opportunity for themselves? Is it on a point of high principle?

I think we can all do the maths.

Are there surgeons out there who disagree with their college's principled stand?

It's not just me.

2012-01-24T20:50:00.000Z

Received an e-mail today from a doctor not too far away in a Deanery not too far away.

It reads like this

There is still a real chance that the withdrawal of the Health and Social Care Bill can be achieved, through the concerted opposition of the medical profession. In this, the position adopted by the Royal Colleges within the next few days will be crucial. This misguided and damaging Bill, for which there is no electoral mandate, is now opposed by the BMA, the NHS Consultants' Association, the Royal College of Nursing, the Royal College of Midwives, Unison and Unite. The Royal College of GPs has surveyed its members and found them to be overwhelmingly opposed. If they are joined by the other Colleges, surely it will become almost impossible for the government to continue to ignore the opposition of healthcare professionals.

What is at stake is nothing less than the survival of the NHS as a comprehensive and universal public service.

If you share my concerns about the Health Bill, I would urge you to write urgently to the President of your own College. A website has been set up to help you do this, and can be accessed via the following link: http://callonyourcollege.blogspot.com/

Apologies to those of you who have already been forwarded this link from other sources, and to GPs who may feel that their College has already sought and represented their views.

Thank you,

Jonathan Folb

Consultant Microbiologist, Liverpool

I do agree with him.

Good Diagnosis

2012-01-24T18:26:00.000Z

African Sun

Some of my patients travel abroad, and one chap has recently been away to West Africa. Being a sensible fellow, he took preventative treatment for Malaria.

Nothing terribly exciting or novel about that.

Except that when he started his tablets, his skin rash on his face got better. He had not been to see anyone about the rash.

He came to see me to discuss it, and whether it was a coincidence, or whether it was the African Sun that had improved his skin.

Pills

Tablets or African Sun?

The answer was that it was the tablets. He had been taking Doxycycline for Malaria prophylaxis, and the skin problem was a condition called Rosacea.

Doxycycline is used for both.

A good, DIY diagnosis!

Please E-Mail - send Bill to the dustbin of history.

2012-01-22T06:23:00.000Z

Where the Bill deserves to go.

I have seen this in the Ferret Fancier blog, and have done what he suggests: I have e-mailed the academy of Medical Colleges and my own Royal College to express my strong opposition to the recent Health Bill.

I have written my own e-mail with my real name and qualifications to do this. May I suggest you do the same?

Here is Ferret's suggestion:

Lansley's disastrous Bill appears to drifting towards the rocks, the BMA, RCN, RCM, Unison and Unite already oppose the Bill. The Colleges are not covering themselves in glory with their failure to oppose the Bill.

Now is the time for them to stand up, be counted and represent their members and the people of this country by openly stating their opposition to this destructive and incoherent Bill of idiocy.

It will not take long to email the Acadamy of the Medical Royal Colleges and your specific Royal College President to pressure them into opposing the Bill, so get emailing and do it now:

Everyone:(AOMRC) academy@aomrc.org.uk

Medics: enquiries@rcplondon.ac.uk

Surgeons: president@rcseng.ac.uk

GPs: president@rcgp.org.uk

Anaesthetists: president@rcoa.ac.uk

Psychiatrists: cchurchill@rcpsych.ac.uk

Here is a brief letter template:

"Dear President

I am writing this email to complain about your abject failure to oppose Andrew Lansley's Health and Social Care Bill.

If you fail to publicly oppose this Bill then I feel you are failing your members, your patients and yourself.

Yours."

Storm Clouds

2012-01-21T21:57:00.000Z

The storm clouds are now gathering. My God, it has taken them long enough.

A committee of MPs, led by a Conservative, have started to savage the Health and Social Care Bill. This wretched piece of half-arsed legislation, cooked up in secret by a zealot, his office partly funded by a private health, and dumped on unsuspecting public is now needing life support.

The Royal Colleges are due to meet soon to decide their attitude to the Bill (really slow and really late).

The storm clouds are gathering.

Information for politicians

2012-01-19T21:38:00.000Z

I came across this the other day, and I think it has since been updated.

It is a graphic illustration of the support for the Government's Health and Social Care Bill (HSCB).

It really is quite simple.

2,000 up!

2012-01-19T21:03:00.001Z

Well, I'm rather amazed.

I've finally hit a personal milestone. 2000th Blogpost!

It didn't seem possible when I started the blog that I would still be posting.

But here we are!

This Blog started in March 2008, so that is more than one post a day, on average.

I am a bit of windbag, clearly!

Rather a nasty man.......

2012-01-19T12:49:00.000Z

Offending the nurses....?

Further to previous posts, we have the rather embattled Secretary of State for Health, Mr Andrew Lansley MP, indicating that the reason for the change in the stance of the Royal College of Nursing to the NHS Bill is because they:

"want to have a go at the Government because of issues like pay and pensions."

This is really a rather offensive comment. The RCN is notoriously supine when it comes to any form of action, industrial or not, and to suggest this is their motivation is really rather an unpleasant assertion.

Mr Lansley needs to question the whole nature of his bill, which is very little to do with giving front line workers a say in how the money is spent, but everything about privatisation by the back door.

Offending the nurses is a really bad move.

If Lansley and his Bill survives I would really be surprised.

Proud Parents

2012-01-19T05:45:00.000Z

The story goes like this:

Two parents at the final parade of their son who is finishing as an army officer at Sandhurst.

Mum: "Oooh look, Bill, they're marching by"

Dad: "Yes, they're all out of step except our Johnnie"

It is becoming clearer, by the day, that the opposition to the latest Health Bill is growing. The official backers of the Government's position are disappearing.

98% of General Practitioners in a recent Poll are against the Bill.

The Royal College of GPs is.

The Royal College of Nursing is.

The Royal College of Midwives is.

The British Medical Association is.

The Consultants' Committee is.

The Health Unions are.

That is a degree of unanimity that is hard to get over any subject. I find it difficult to understand why this opposition to a fundamental piece of legislation isn't all over the media. We are seeing the slow dismantling of an essential part of the fabric of our way of life.

It is as if Messrs Cameron and Lansley are at the parade ground, and saying that everyone is out of step except them.

Don't

2012-01-18T12:07:00.000Z

Hello, is it me you're looking for?

There may be new examples of the genre, but I will illustrate my point from songs from my youth.

Never have a song in the charts that asks a question.

Do ya think I'm sexy?

Hello, is it me you're looking for? Asks Lionel Richie?

NO.

Do ya think I'm sexy? Asks Rod Stewart?

NO WAY.

Are there other more recent examples?

Where are all the bloggers gone?

2012-01-17T06:26:00.000Z

Where have they gone?

Most bloggers run out of steam, and quietly subside, and get on with their lives.

Others, I'm afraid, are serial offenders. I am shortly to post my 2,000th blogpost, and during that time I will have offended many, cheered a few, and droned on a bit.

When I started, the Daddy of them all was John Crippen and his Blog NHS Blog Doctor. He retired to North Wales to mess about in boats. Militant Nurse Ann was a fabulous blog that had inspired and sustained rants which were eye-poppingly tragic. She went away to work in a private hospital. Mousethinks was also an excellent blog, but she was 'outed' and shut down after pressure from her employing trust. Many run out of steam, and things to say? I miss Dr Rant.

Where are their successors?

Where are the new blogs, the ones charting the daily life in the NHS, the ones moaning about politicians and their stooges high up in the professions?

What will happen when I close my blog down?

Can anyone point me in the direction of new and exciting blogs?

Home calls

2012-01-16T19:49:00.000Z

Today I have spent quite a lot of my time (around 2 hours) doing my rounds, and visiting people at home. At each visit I was known and welcomed.

I was offered plenty of cups of tea, which I politely declined. I don't tend to drink tea in patients' houses as they tend to make it with PG Tips or Typhoo tea strong enough to melt the average teaspoon, with sterilised milk and 2 sugars. I'm an Earl Grey tea man, which has to be quite weak (my mother would call it "Weasel's", as it resembled the urine of a large rodent).

When I teach young doctors and students about visiting people in their homes, I suggest that they look at the pictures/photographs on the wall or the mantlepiece. It tells you lots about people.

One I visited this evening was of a couple who were pictured when they were 'courting' (for modern readers that is when they were going out together, but were not engaged or married), and this was during the war (in 1942). They made a mightily handsome couple. The vibrancy, the youth and the love in their eyes was there to behold.

Now they are old and ill (that's why they needed the doctor), but the love was still there.

It is very precious.

This is the future.....

2012-01-16T10:32:00.000Z

Medical services are changing in the UK.

The Private Sector are apparently using surgeons who are not sufficiently qualified and experienced to work in the public sector.

So let me get this straight. They use inferior products (see posts passim about breast implants); they employ surgeons who are not sufficiently good; and they expect the NHS to clear up the mess afterwards.

This, ladies and gentlemen, is the future.

Unless you do something about it.

Reading material for the "Future Forum"

2012-01-14T08:26:00.000Z

The NHS Future Forum is rapidly becoming seen as a group of self-serving and unaccountable time-servers, establishment stooges and dilettantes.

It serves no purpose except to rubber stamp already formulated policy, and gives an entirely spurious and false credibility to a process of NHS privatisation that they either support or don't understand.

I'm sorry to be so scathing about some people who have done much good work in the past, but they are rapidly turning into what Lenin apparently described as "Useful Idiots" - people whose earnestness and naivete result in outcomes that they did not intend.

We are in the process of seeing the National Health Service disbanded before our eyes. If the breast implant scenario teaches us anything, it is that the private sector generally plucks the low-hanging fruit, and even then can make a mess of it.

Members of the Future Forum need to take a long hard look in the mirror, and ask themselves what they are doing, and why so many people are deeply worried about the current plans. Why can they not think about what they are achieving?

I would urge them to read this article by Aseem Malhotra, a Junior Hospital Doctor, and reflect on the morality of what they are doing. I hope Dr Malhotra does not mind my cutting and pasting his short and eloquent piece. It is worth it.

A few weeks ago I attended a meeting in the House of Commons organised by the shadow health secretary, Andy Burnham. The purpose of the gathering, attended by around 40 leaders and representatives of all the major health organisations, was to determine views and gather support for a proposed "plan B" for the health service and to oppose the health and social care bill. Towards the end, a GP asked the learned ensemble: "Please raise your hands if any one of you does not have serious and grave concerns about the health and social care bill." Not a single hand went up.

I have been a qualfied doctor for more than 10 years. I am extremely proud to occupy a position of being able to treat my patients according to clinical need, not ability to pay. That is the underlying ethos of the overwhelming majority of doctors in this country. It is why I spent years slogging in medical school, inspired by being able to practise in a health system representing social justice.

This is the foundation behind the NHS. An NHS that still holds an 80% satisfaction rate among all who have been treated by it.

It is the characteristics of honesty, reliability, beneficence, personal responsibility, integrity and independence that make up the moral character of health practitioners. But also what makes doctors competent has to be supplemented by what makes them caring: it is not just a matter of providing items of service against a contract, a costed menu. This is also why doctors still command the highest trust rating of any profession among the British public: 92%.

But these attributes that have laid the foundations for a health service will be irreversibly threatened if we allow Andrew Lansley's health and social care bill to go through. This monstrous bill is designed to privatise the NHS at every level: primary and secondary care, in community health services, and in commissioning - all of it deceptively concealed by the trusted NHS logo. The reforms will increase the stake of private companies in the NHS, so that instead of GP-led primary care and consultant-delivered hospital services we will witness "any willing providers" picking up the most lucrative operations, with the NHS left to provide complex, costly care. There should be absolutely no illusion that we are being led towards an Americanised system of healthcare.

The reforms will also produce a different breed of doctor, with many going in to medicine with a different mindset. We are in danger of producing doctors who go into the profession not out of a sense of public service duty and vocation; they will go in because it will be seen as another career option. The doctor-patient relationship, built on trust, will be eroded from the social contract and the rights of the patient to the "sales contract" and the rights of the "consumer".

So this is where Lansley and the Conservatives are trying to lead us despite the overwhelming majority of doctors, nurses and the public being against this bill. What they are doing to the health service is totally undemocratic. Any spin they publicise to the contrary is at best misleading and at worst downright deception.

But there is still time to save the NHS. Lansley has tried to pacify opponents of the bill by making some concessions after liaising with the individual heads of the various medical faculties, but they fall far short of what is needed.

In my opinion there is only one solution. All doctors leaders must unite with one voice calling for the bill to be dropped, and there is hope. The next few weeks will potentially prove to be the most historic moments in the history of the NHS. Andy Burnham is holding a second meeting with health leaders to galvanise support to ask the government for the bill to be dropped. A goverment e-petition to "drop the bill" set up by GP Dr Kailash Chand, has already gained more than 27,000 signatures, while the 38 Degrees "Save the NHS" petition has been signed by nearly half a million people. David Cameron made a pre-election promise that there "would be no top down reorganisation of the NHS".

It is time to expose what is really behind this bill. Let us therefore expose the catastrophic consequences these reforms will have on the health of our nation.

Doctors' leaders have one last chance to do what they know is best for their patients.
Let us not look back in years from now and have the realisation that we could and should have done more.

Dr Aseem Malhotra is a cardiology specialist registrar

I hope that Professor Field and his friends will find time to read it.

Read our lips

2012-01-12T14:21:00.000Z

Over the last year, the Government has continued to advance the view that most GPs are in support of the new Health and Social Care Bill. This has, from my experience, been completely at variance with my knowledge of my colleagues' views.

There are some who are in favour of the new Bill, but they are not part of the mainstream [Clue: if they have letters after their names like OBE, MBE, CBE or DBE they will generally support the Government]

A poll from the Royal College of GPs is a damning indictment of the fact that Mr Lansley and Mr Cameron have no professional support from Jobbing Doctors.

According to a "source close to Mr Lansley", the findings lack credibility. I agree. Mr Lansley does not find them credible, because he has his own fixed delusion that we support him. He picks his advisers to confirm his own world view. He listens to no-one else.

We think this Bill stinks, and it will wreck the NHS.

If that is what the people want, then so be it. Don't complain in 5 years time if the privatised NHS behaves more and more like the current private sector.

You have been warned.

Breast implants: a post-script

2012-01-11T18:42:00.001Z

I had cause to enquire, on a patient's behalf, whether one of my local hospitals used the PIP breast implants that were filled with industrial-grade silicone by a bankrupt French firm (see posts passim).

I have had the following answer back.

This hospital has never used implants made by PIP.

So there you have it.

NHS = quality, patients first, integrity, good judgement.

Some parts of the private sector = .... well, you do the maths.

I'm Spartacus

2012-01-11T07:01:00.000Z

"I'm Spartacus"

I am an occasional Twitterer.

I use Twitter to keep up with people whose views I rate. I could not help noticing that there is a report called the Spartacus report, this is about the way in which the diabled are being treated by the current Government. I have also had it raised by one of the readers of my blog (Thanks CP)

I strongly support this action against the way that central Government, through their appointed private agents Atos, whose actions I see every day in my clinical practice.

This is what CP sent me.

"Hi

I'm a disabled reader of your blog. (I have bipolar disorder and arthritis.)

Have you heard about the spartacus report? I gather it's all over twitter (I don't tweet) so you may have seen it. I gather #spartacusreport trended at number one yesterday.

It's a report produced by a group of disabled people about the government's plans to get rid of DLA and replace it by PIP, cutting 20% off the budget in the process. It includes evidence gathered from FOI requests.

If you haven't read it, you may like to read what some doctors have said about it - http://thebrokenofbritain.blogspot.com/2012/01/whos-backing-spartacusreport-issues.html

...
Best wishes
CP"

Thank you CP, I am very happy to raise this. It fits in with the current pattern of apparent oppression of the poor and needy by the rich and healthy.

Quite a lot of my time is spent supporting the appeals of the sick and unhealthy or disabled and disadvantaged against arbitrary decisions about benefit, and I see the worry and fears in their faces as they face yet another change in the benefit system that will disadvantage them.

I'm Spartacus, and so is my wife.

O, FFS, FF, FO

2012-01-11T06:37:00.000Z

Edward Heath PM 1970-4

Edward Heath did it to Margaret Thatcher.

Alan Hansen and Mark Lawrenson do it to Fergie and AVB on 'Match of the Day'.

Retired people telling those doing the job how to do it.

Margaret Thatcher PM 1979-1990

We have a proliferation of this in the new stormtroopers for the Government, the so-called 'Future Forum'. This is a group of around 50 people who are billed as being 'Independent' of the Government, chaired by a former GP who does occasional surgeries. They are now being used as instruments of Government Policy. Like the wretched Lord Darzi before them, they are tasked with trailling Government's ideas, cloaked as 'Independent' advice.

They are not 'Independent', they are hand-picked by politicians, as they are deeply embedded in the establishment, very few workers in their midst, and mostly those with views that are only a gnat's whisker away from Government Policy.

Several of them were given Honours in the New Years Honours List, so don't be fooled. They either support Government policy, or they are poodles. That's how you get onto these committees. I will gloss over the nonsense spouted about the "public health message" that Doctors, Nurses, Physios and Pharmacists are supposed to give to people.

Let me talk about the advice to nurses. In the Daily Telegraph (Tory Paper) the headline is....

"Nurses are losing their sense of compassion"

Message warmly endorsed by Messrs Cameron and Lansley.

Let me quote from another source....

Cameron... once again you prove how out of touch you are with the NHS.

The scapegoats that are nurses once again come under the cosh.

YES, every nurse in the country would indeed love to actually spend time with their patients... but how can nurses spend time with up to 16 patients on each shift ( I once had 26) when you have to carry out regular clinical observations, administer drugs, administer PEG and NG drugs/ feeds. IV drugs, complete falls risk assessments, waterlow scores, MUST scores, VTE scores, GCS scores, look after drains, catheters, fluid balance charts, food charts, complete assessments and referrals for nursing homes, continuing care, intermediate care, social workers, dietitician, podiatrists, physios, OT, Ensure post op patients are pain free via their PCA. Look after palliative patients with kindness and respect, also ensuring that they remain pain free via their syringe driver. Not forgetting diabetic patients that require regular ( hourly sometimes) blood sugar monitoring and titration of sliding scale. Not forgetting patients that require daily dressings of surgical wounds, leg ulcers etc. This is before any outbreak of C- diff or norovirus or flu. This is the tip of the iceberg to what most nurses do on a daily shift, this is without any cardiac arrests, falls, confused, abusive or just plain drunk patients. This is before we consider the amount of phone calls and inquiries from relatives, liaison with other services, discharge planning, TTOs.

Did you know that nurses are more likely to suffer assault at work than police officers? And all for £10 per hour after 3 years and a BSc at University.

Cameron... come and join me on a shift... I would bloody LOVE IT!!!

This source is a reliable one.

I don't expect anything different from politicians, who bring duplicity to new levels of dissemblance. But the so-called 'future forum' is stuffed full of fellow-travellers, lackeys, dilettantes and time servers, and are merely the storm-troppers for the Government and the big business that helps fund it.

Independent?

My A***.

A poem

2012-01-07T22:50:00.000Z

"My name is Ozymandias, King of Kings.
Look on my works, O ye mighty, and despair.
Naught else remains....."

These lines are part of the wonderful sonnet by Shelley. It is one of my favourite poems. It reflects the overweening arrogance of power and money, and is a metaphor for the times. I was musing about this poem today when I was reading a report in the newspapers. A report about private medicine.

I would like to feel that the breast implant imbroglio is shining a light of the darker side of privately arranged medicine, and I do not like what I see.

I understand that there are a number of clinics who have profited enormously by inserting cheap breast implants into women who thought they were paying for quality medicine. What these women have got is a second rate implant insertion that they have paid first rate prices for, because costs were cut (apparently) by using inferior products.

Yesterday, I had my first patient making enquiries about the implants that she had had inserted 5 years ago. This operation was (fortunately) done by a reputable surgeon on the NHS, and I am confident that the implants were proper ones, and the surgery was done well [I am checking, next week, just to make sure].

At least 2 clinics (who have reportedly done 47,000 operations between them) are refusing to remove them without charge as they say that it would "bankrupt" them. I would have thought that the clinics would be liable as they have sold a shoddy product, and existing legislation would cover this. To be honest, if clinics like "Transform" and the "Harley Medical Group" went out of business, then I would not be concerned. They are, however, seeking to blame the regulators.

This, people, is the brave new world that the Government wants doctors to embrace, with the expansion of private medicine into the mainstream.

A right mess, to be sure.

Lansley gets it right

2012-01-07T08:42:00.000Z

Occasionally gets it right

Mr Andrew Lansley, MP, is shaping up to be the most catastrophic, deluded and incompetent Secretary of State we have ever had. That is quite an accolade as there is a pretty inglorious list of knaves and fools who have preceded him.

Just occasionally he gets it right, and I believe that he has handled the breast implant situation pretty well. What he has done is be dynamic, he has taken advice from senior and appropriate professionals (and not just the usual toadying lickspittles in the Department of Health).

The approach, as I understand it, is to agree to the NHS dealing with the patients who had implants done in the NHS on the basis of clinically determined decision. He is also urging private firms to do the same for the faulty implants that they inserted (95% of all those done in the UK). I believe that Spire, Ramsey, BMI and Nuffield have agreed to do this.

We cannot expect the NHS to underwrite the costs of removal of faulty implants done privately. If necessary the NHS should do it and sue the clinics and providers who refuse to deal with this situation on the basis of clinical need.

So congratulations to Andrew Lansley. This is what happens when you listen to professionals who can give you best advice.

Now had you done that with the NHS, then you wouldn't be in such a pickle......

More nonsense

2012-01-06T19:51:00.000Z

Our Prime Minister

Our Prime Minister is a lightweight. High on presentation and hubris, and low on policy and value. He always looks to the general soundbite, as you would expect from a man whose previous job was in public relations.

Today he has spouted more nonsense about nursing in the NHS. Apparently he wants nurses to do hourly ward rounds. I suppose he thinks they sit around talking to each other and eating 'Quality Street' chocolates.

My daughter is a brilliant hardworking nurse at her hospital. She is not happy about Mr Cameron: I quote

Ok, apparently our pm - think his name is arsehole - thinks nurses should spend more time with their patients to tackle the real problem with nurses in our hospitals. We should be treating them with the respect and dignity they deserve. I'm glad he's told me this - I thought nursing was just about sitting and drinking tea. Thanks arsehole!

The problems include these:

Vast amounts of time are spent filling in paperwork, doing audits, answering queries, ticking boxes, speaking to relatives. They are run ragged, to be honest (you should have read Militant Medical Nurse before she gave up and worked in a private hospital).

You need more qualified nurses in the wards. What is the Chief Nurse doing to tell the PM that he is talking nonsense?

Probably nothing.

Right-wing zealot

2012-01-04T14:35:00.000Z

Rick Santorum

Rick Santorum is a social conservative who is running on the Republican Ticket against Barack Obama in the primaries for the 2012 American Presidential election.

Here he espouses a loyalty to Margaret Thatcher that is as sweet as it is misguided, and says that the NHS has had a devastating effect on Britain.

Words fail me.

Breast implants

2012-01-02T08:34:00.001Z

The facts are beginning to emerge about the faulty nature of the silicone breast implants that have been used in providing women with breast enlargement.

I have, down the years, been asked by various patients about non-cancer-related breast surgery. Generally, the requests for breast reduction surgery outnumber the requests for enhancement. Each case needs to be assessed on individual merit (physical and psychological effects are considered), and this is where the GP Gatekeeper role is evident.

I am one of the minders of the public purse, and will take a view on whether a case has medical merit or not, especially as decisions on referral involve the spending of taxpayers' money: in today's consumer-orientated society, this approach seems rather paternalistic, but as the ramifications of the new health bill roll out, you will find that even that element of individual decision-making disappears. No breast enhancement surgery will be available from the public purse.

On an individual level, I can understand the misery that this will cause to some patients: on a corporate level, my hands are tied.

The only patients in my experience who have had breast enlargement surgery have done them privately. Even then, I have a role to advise people who I think would be best to do this. I have a list of around 6 surgeons in my region that I give to patients. These are people who have demonstrated the highest levels of ability, and the outcomes are known to me. I don't know anyone who has had one of these inferior PIP-silicone implants that have been made on the cheap by a private firm.

If any of my patients has had an implant inserted on the NHS, then I feel I can justify them being referred back for removal/replacement on the NHS. If it was done privately, then it should be removed privately.

Market forces do not always benefit people's health decisions.

Right and wrong

2011-12-31T08:16:00.001Z

Gongs.....

I mused the other day on what would be in the New Years Honours Lists. I got some things right, and some wrong.

Certainly some in the healthcare sector have been honoured in the New Year's Honour list.

Not many GPs in the list, but I guess that we aren't the flavour of the month. Those that do have all been supporters of Government policy.

Dr Has Joshi has been a stalwart in the Royal College of GPs, and was a practising GP in South Wales, as well as an educator: his honour is well deserved, although he is flaky on revalidation. He has been made an MBE - deserves more.

Professor Ruth Chambers is an academic and part-time GP. She is keen on developing skills in commissioning.

Dr Paul Zollinger-Read is a typical man for honours. Started as a GP in Cambridgeshire, and moved into management, he is a key person both in the development of commissioning and in the King's Fund 'charity' which has largely been taken over by right-wing privatisers. His award was pretty predictable.

Dr James Kingsland is an archetypal GP on the make. He has been involved with the Government's agenda, and as a part-time GP in Wallasey he has taken part at every stage of the privatisation and commissioning projects. He is heavily involved with the private sector, and is a Government insider.

4 GPs, all very part-time. All support Government policy.

Elsewhere, those in the NHS future forum have been richly rewarded: Julie Moore and Moira Gibb have both been made DBE (so there is a place next to David Nicholson's knighthood on the mantelpiece for Julie). Hilary Chapman becomes a CBE. Jimmy Steele a CBE. All on the NHS Future Forum that helped de-toxify the NHS bill, but did not change it.

I see in the list includes Dr William Cunningham of Corbridge, Northumberland, who gets an MBE (he is retired and was involved in commissioning). As goes Dr Gabriel Ivbajaro in London, another who is heavily involved in commissioning.

Not a single average GP who is full-time and not involved in commissioning.

I can think of 20 who really deserve accolades, however.

Right then....

2011-12-30T10:29:00.000Z

Jobbing Doctor on a bad day...

I am getting increasingly fed up with the knobheads who seem to be in charge of various aspects of the NHS.

Chief idiot is the dangerous zealot, Andrew Lansley MP, who is imposing a Bill on the country that no-one voted for, as is a blatant plan to privatise the NHS.

Also in the group of dangerously misguided ones is the rather unsavoury trio of Lord Howe, Simon Burns MP and Paul Burstow MP, all ministers in the increasingly useless Department of Health, and who are wheeled out to justify the party line.

We have a Chief Medical Officer who is not listening to the Profession's views, and is clearly a professional conduit for what comes from Government. There are others, including Dr Michael Dixon (arrant supporter of the Bill) and other frankly misguided GPs and Consultants who seem to see no evil, speak no evil and hear no evil.

The GMC is headed up by a former journalist and is a Quango that has no support from doctors at all.

Then you have the former NHS manager who leads up the NHS confederation, a Mr Mike Farrar, who says that a quarter of hospital patients should be treated at home. The man is an idiot, and I would recommend reading Dr Zorro's views on what he says, as they are widely felt within the professional people (nurses, technicians, ambulance staff, doctors) who actually run the service.

I have been impressed by the common sense views of Roy Lilley, who used to be a NHS manager, whose views are always worth reading. He says that we need to fix what is wrong first before ambarking on this latest barmy adventure. I agree with him. In his last post he includes an e-mail from a manager/patients point of view. It is clearly pointing out where the system is unsatisfactory.

It makes me want to weep.

A real zealot

2011-12-29T18:26:00.000Z

When I was a young doctor I was fascinated by the theory behind homoeopathy. I went to a few meetings, and certainly suggested that bruised patients might use arnica. I wasn't sure if it worked, but as time progressed, I realised that the science was not there, there was no evidence base, and so I stopped using it around 30 years ago.

I just wanted to know about it.

Over the years there has been a distinct lack of evidence for any of the preparations.

Recently, I have watched the way in which alternative practitioners have been trying to defend their positions.

The action by the British Chiropractic Association in suing Simon Singh, and Matthias Rath suing the Guardian and Ben Goldacre were interesting cases that brought the issues to the fore.

More recently we have the evidence-lite recommendations of a fancy clinic in Texas, and the vast amounts of money they are getting from the desperately ill on unproven and/or unlicensed remedies.

Cetainly there are some seriously rich and angry people practicsing Alternative Medicine.

Like this guy, John Bennet, who has a 6 minute rant about those who question his faith in homoeopathy, and finishes with an advert for his own clinic and services.

It's that time again

2011-12-29T06:45:00.000Z

This weekend sees one of the more quaint events in the Calendar: the New Year's Honours list.

This is the opportunity for the country to celebrate the life and work of many who have contributed to our society. Many are worthy people who have devoted a lifetime to charity or to their locality, and no-one could begrudge their moment of pleasure. Indeed I have a picture of my late father receiving an MBE for charity work over a lifetime to those with learning difficulties.

Over the years the politicians and the ruling classes have used honours as a tool to advance their own agendas: in the early part of the 20th Century, David Lloyd George sold peerages for vast sums of money. There has been some attempt to democratise the process since Margaret Thatcher used to give knighthoods to backbench MPs to keep them keen as supporters. My own MP was given a Knighthood for services to the Conservative Party. Tony Blair improved the process a little, by removing some of the more blatant excesses, but still ennobled supporters who would follow the party line. In my profession, Lord Robert Winston and Lord Ara Darzi were made peers of the realm by Labour - there were many others (mostly those who were increasingly distanced from clinical work, and are regarded by many as taking the King's Shilling).

I note that those who have been favoured by the Government include:

Lord Liam Donaldson
Dame Sally Davies
Dame Carol Black
Sir Bruce Keogh
and so on.......

They all have or had leading roles in Government policy in Health policy over the last few years, and have lost their credibility and support in the process.

The next crop is due to be honoured, and we will have some who deserve it, and others who will have entered the Faustian pact that is generally part of this process.

Who will be in the list?

Someone high up in the educational deaneries, possibly in London, perhaps?
Several members of the Future Forum, the gang of patsies who have sanitised peripheral parts of the latest bill, perhaps?
A GP or two (preferably ones who support the new NHS structure)?
A couple of senior and respected doctors who are at the peak of their professional powers, maybe?

I don't think I'll be too wrong on this.

That's a surprise

2011-12-28T09:17:00.000Z

Back at work today (ho hum) and things seem pretty much the same as before the festive holiday.

I read a report in the paper that says that 80% of doctors think that the cuts are affecting patients. This is a poll of consultants (doctors working in hospitals in a specialised area).

I'm a bit surprised, really. I'm not sure that I believe the numbers they are quoting, as they don't feel believable to me. Of what I can see the methodology is sound.

My own view is the figure should be nearer 100% of doctors think that the cuts are affecting patients.

Facelifts before femur fractures

2011-12-27T13:59:00.000Z

The Christmas holiday period is a good time to release news. The lack of scrutiny with mainstream media and others being occupied with other issues means that things can be slipped out into the public forum.

Mr Lansley has got his House of Lords spokesman, Earl Howe, to announce that NHS Hospitals can now take up to 49% of private patients. This is, of course, the plan to gradually shift everything from public provision to private provision. No longer will people's needs be the reason for admission, but now half of the (already inadequate) provision will be taken up by people who can pay.

Profitable surgery rather than essential surgery.

Facelifts before femur fractures.

That's the way it will start to look.

It's all part of the plan.

I want to be like you

2011-12-27T06:53:00.000Z

It is quite extraordinary that recent UK Governments are doing their best to transform the UK National Health Service into a mirror of the US system. The USA system costs huge amounts of extra money, and delivers a style of consumerist medicine that relies on over investigating and treating the well-off and ignoring the poor. This system helps significant parts of the US population, at the same time as crippling their economy with debts. It also seems perverse in this strongly Christian country.

Like the bankers, the people running private hospitals seem completely immune from the quotidian suffering of the average citizen, paying themselves millions of dollars, even when the hospitals they are running are closing or losing money. A good example of some of the excesses is here.

Here is Roy Poses' summary.

Summary

In a health care system with ever rising costs, declining access, and stagnant quality, we no longer can tolerate the perverse incentives generated by unaccoutanably high compensation to top executives. As long as top executives continue their sense of "self-entitlement," and can continue their current management practices reinforced by ever rising pay checks, expect poor leadership to undermine any attempts to improve health care. Tired repititions of the usual rationales, that the CEOs are brilliant and hard-working, and that their compensation is mandated by the market do not make these rationales true.

We need health care leadership that has compassion for the increasing hardships that their patients have to endure, and that puts doing the right thing for patients' and the public's health ahead of self-interest.

We used to have an NHS system that we could be proud of. The doctors and nurses worked really long hours, were devoted to the profession, were paid a lot less than in private medicine, and the patients got good care. This was the NHS that I joined in 1974. It stayed like that until we had the right-wing Governments of Thatcher, Major, Blair, Brown and Cameron. They have, between them, aided and abetted changes that, in 5 years time, will have similar excesses in the UK system.

The final push will start with the latest NHS Bill, which is going through the Houses of Parliament at the moment to be rubber stamped by the craven legislature, and that will start the end-game.

Fortunately, Jobbing Doctor will be leaving the NHS before the full stupidity of the current changes becomes apparent to the General Public. But I will still be a citizen and a patient, living in the same area that I have worked for most of my professional life.

I may well carry on blogging about these matters, even when I have retired: maybe the strapline will be "I told you so".

Another one

2011-12-26T22:10:00.000Z

Malignant stricture

I was reading today about the death of columnist Sue Carroll, who wrote for the Daily Mirror for many years. She lost her battle with Cancer of the Pancreas on Christmas Day at the age of 58.

They say that this is no age, and they are right. 58 is no age to die. Of course, no-one is too young to die, and you feel the cold breath of inevitability the older you get. Who is the next one to go from this terrible illness? It has claimed Philip Gould, Christopher Hitchens and now Sue Carroll in quick succession. I have friends and patients who are dying from cancer, but the one I am seeing at a younger and younger age is upper GI cancer, mostly oesophagus. It claimed my best friend last year, and now is afflicting one of my patients who is only 24. Another mate has a months-only prognosis.

Maybe I notice it because I am older, but I don't think so - I genuinely believe we are in the middle of a small epidemic.

The problem with many of these cancers is that they can be present for a long time before presenting any symptoms of note.

So in this season of happiness (JD became a great uncle again on Xmas Day!), it is not happy for everyone.

Hard cases

2011-12-24T07:01:00.000Z

Hard cases make bad law.

Thus said the great judge Oliver Wendell Holmes, Jr. It probably was not original to him, but he was the first to write it down that I know of. It is a widely understood maxim, and has its current equivalent in the framing of current legislation. Examples of this include reform of the GMC and introduction of revalidation following the murderous exploits of Harold Shipman; and the Dangerous Dogs act. Both are examples of poor legislation that are/will be unfit for purpose.

So I was alarmed by the assertion by Paul Corrigan that the Mid-Staffordshire enquiry, chaired by Robert Francis QC, will become the basis of the next NHS bill. I rather hope that the good Professor had imbibed too much gluhwein before penning his blogpost, and this had impaired his judgement. Experience suggests, however, that as Prof Corrigan has been at the centre of policy making for so long that he knows exactly the way things are done.

It could be that the mid-Staffordshire enquiry will actually give us a very honest answer, and will ensure that the report actually addresses the current ills of the NHS. If this happens, then I am a monkey's uncle.

What went on in Stafford was a microcosm of what is now occurring in the NHS all over England. There was poor care because the overwhelming drive of the management of the Trust was to become a foundation Trust (as promoted by the Government of which Prof Corrigan was a central part). The financial imperative meant that not enough suitably qualified staff were available to meet the health needs of the population. The clinicians were either ignored or silenced, the overseeing of the whole process was either impossibly lax or absent, and people died.

People died because the focus was on developing the building blocks of the internal market.

The wise report would point fingers at the Chief Executive of the Board, the Medical and Nursing Members of the Board, the responsible people in the Strategic Health Authority, and the effect of the introduction of an internal market into a monopoly system. Blame would be allocated where it should be, and we would use this as a good example of the ills of the current system being forced on us through Mr Lansley's new Bill.

Since the BMA and the RCGP have clearly stated that the New Bill has virtually no support from the Medical Professional classes, maybe the politicians and lawmakers will reflect, as they enter their winter recess, that we have the chance to prevent the ills of Stafford being extrapolated to the system as a whole.

The mid-Staffordshire report is, however, going to be interpreted by people to suit their own agenda. There will be no blame placed on the then CEO of the West Midlands Strategic Health Authority, and the CEO of the trust has long since moved on. There will be much criticism of people lower down in the hospital, and much praise for remedial actions that have occurred since.

This will ensure further chaotic legislation.

I just hope that Professor Corrigan is wrong.

The usual.......

2011-12-23T15:36:00.000Z

Mmmmmm.....

The last working day before Christmas is always a slightly strange one.

There are the usual people who have run out of their medication, and cannot wait till after the holiday. I've even had a patient who requests a supply of the "little blue" tablets, as he might need them over the holiday [Clue: they are made by Pfizer, and are locally known as the "Pfizer riser"]. I know his wife, and I'm not sure his luck will be in.

We get some children who have been unwell for a few hours and they need to be seen in case they get problems over the holiday [Crystal ball needed for these consultations].

By and large, however, people are too busy to go to the doctors when there is the eatingfest that is Christmas around the corner. My practice is by a big supermarket, and the car park was full at 8 o'clock this morning. Full - must be 300 parking spaces! At 8 o'clock!

Today has been quiet, and it reminded me of what General Practice was like 30 years ago when I was a young GP.

*sigh*

Christmas celebrations

2011-12-22T09:47:00.000Z

Not quite ready for the Christmas festivities as yet, but the Jobbing Doctor household likes to do things in a very traditional manner.

Turkey with all the trimmings.

Christmas Pudding. Christmas cake.

And Bejgli. Bejgli?

Bejgli is a traditional Austro-Hungarian cake (either with poppy seeds or walnuts or both). Home made.

Yum yum.

The barbarians are at the gate.

2011-12-20T06:31:00.000Z

British people are sometimes accused of dwelling too much on the Second World War, and of living in the past. The world is said to be a fast moving place, and we should "move on". Conceptually I have no problem with this. The idea that Britain should engage in war with Germany is now laughable.

We recently had a lovely German houseguest, who was staying with us so we could both perform in a fund-raising performance of 'Messiah' (him tympani, me Baritone). We were watching a comedy show on the TV, and talking about British and German concepts of humour. This episode of the satirical TV programme 'Have I got news for you' had a lot of Hitler jokes in it. I realised then what we still have an obsession with the war.

What happened during and after the war was really significant in Britain. We had a unified consensus of how we wanted our country to be run. Three giants of the post war period were hugely influential in this legacy.

Beveridge, Butler and Bevan.

Liberal, Conservative and Labour.

Middle, Right and Left.

Lord Beveridge set the ground for the implementation of the welfare state. This is now becoming dismantled by the current Government. Yesterday I saw a patient who can only travel greater than 50 metres with the use of a wheelchair. He is in constant pain that I struggle to keep under control (believe me, I've tried). He claims incapacity benefit, but the rules have been changed and reinterpreted, so he has been told he will lose his benefit, and will have to get a job. He wants to work, but he can't. There are no jobs for him with his disability. Beveridge's safety net is being removed from him.

RAB Butler brought in the concept of universal education, provided for by the country through locally accountable and fully-democratic systems. This whole process is being turned upside down by the introduction of unaccountable Academies, run by private 'Sponsors', where schools are taken out of local control, headteachers are sacked, Governing bodies are removed, staff are "parked" (the new word for losing their jobs). There is a good description of this process here.

Nye Bevan helped set up the NHS. We know now that the privateers are closer than ever to picking the bones of the old system, and we will be left with a worse and less fair provision of health care. There are many posts on this and other blogs detailing the process of gradualist privatisation.

The post-war greats have been replaced by three infamous alternatives: political pigmies all.

Duncan Smith, Gove and Lansley.

These are the men tasked with the job of finally destroying the post-war consensus. In the name of liberty. Freedom for the rich to exploit the poor. Freedom for the tax evaders to oppress the poorest.

In a Christian country.

The Barbarians are at the gate.

Getting philosophical

2011-12-18T12:39:00.000Z

Ho, ho, ho

December is not a good month for the Jobbing Doctor. Two bad anniversaries.

Then I have to do the Christmas Cards for the household, and I update my address book. I can cope with the people who have got divorced (none this year) but to remove two people off the list because they have died (both in their 50s, both from upper GI cancer) makes me very sad.

Despite the general sense of merriment, I do not find this a very pleasant time of the year.

Sorry to be gloomy.

We're actually bloody good

2011-12-16T13:50:00.000Z

I do not know what we can do to impress on people how good their Primary Care is in the UK. If it were left to the National Media outlets, you would think that General Practice was unremittingly awful.

This is not the view of me, or my cosy little bubble (to quote one of my frequent anonymous commenters) or the Royal College of GPs.

No, this is actually the view of the Government, in a document they have quietly released, without any fanfare or the usual press releases.

There is room for improvement, but where else, for example, can you get a 93% satisfaction from any service anywhere? This is that 93% confidence and trust in the last GP they saw.

93% is pretty awesome in the light of what we are trying to do, and the difficult circumstances that we are trying to do it.

If you don't believe it, ask the Government.

There is always room to improve, and some GPs are pretty average or even poor. But I am quietly pleased with this figure.

Rhys Morgan: Star for the future

2011-12-15T10:44:00.000Z

Rhys Morgan

Sometimes I am enormously impressed with people. When you get to the age of the Jobbing Doctor, then you have seen most aspects of human life and behaviour, from the great to the despicable; I am no longer easily impressed.

The story of Rhys Morgan, a 17 year old student from Cardiff, is an inspiring one, and is detailed in this article in the Guardian.

This is a tale of corporate bullying, non-evidence based 'cures', desperate parents, kind hearted celebrities and the ability of some to become wealthy from the suffering of others.

In the case that was highlighted by the Quackometer, a young child has a brain tumour, and her desperate parents will do anything they can to seek a cure. They have had money raised by people like Peter Kay, and send their daughter to a clinic in Texas where unlicensed treatment is given at an enormous price.

The American Clinic

Rhys Morgan did some research, and found no properly published evidence that the treatment worked. So the clinic decided to threaten him with legal action. He stood his ground, and the clinic have backed off.

For this to be done by a 17-year-old student is, frankly, amazing: I am delighted that he wishes to become a doctor, and wish him all the best. I hope to welcome him to my profession.

Much respect.

Passionate about Diabetes

2011-12-14T08:58:00.000Z

I have always had an abiding interest in Diabetes Mellitus. This was inspired by a gifted consultant I worked with in Birmingham called Ray Blachford (many years deceased now), and he was responsible for me embarking on a career to become a Diabetes Consultant. Events conspired to change my career path, and I have no regrets about this.

When I went into General Practice, within a year I had set up a Diabetes Clinic in my surgery, working with the support of a dynamic and sensible consultant. We used to have 1 Diabetic clinic a month. Now we run 3 a week. We have three doctors who have taken on the responsibility of supervising this with a nurse practitioner who has had special training. I still help, but from the sidelines. We offer an excellent service to our patients.

We do all the screening, and do insulin and exanatide starts.

So I was somewhat disappointed to hear that the Health Minister, Mr Paul Burstow MP, had ordered an audit of Diabetes to "expose how bad Diabetes Care was". Not to see how care was in the country, but to start with a fixed idea, and try and get the facts to demonstrate that, somehow, this is my fault as a GP.

Or am I being too paranoid?

The audit shows that, using predictive models, 24,000 deaths could be prevented from better Diabetes care. In my experience, there are a group of people some of whom do not care much about Diabetes - the patients. If they stuck to a better diet, took their medication regularly, exercised and attended clinic and followed our advice about weight and smoking, then they would have better outcomes.

But its always easier to blame the GPs, isn't it?

Particularly when you are a politician.

Is this a pointless exercise?

2011-12-13T11:44:00.000Z

One of the more interesting communications that GPs get is notification of when the local hospitals are full. We are exhorted to not admit patients unless it is absolutely necessary.

Firstly, the huge majority of admissions to hospital are either as a result of self-referral, or have been sent in out-of-hours, and so I would only refer a patient to Accidet and Emergency (ED) or directly to a ward around one every month or so.

I don't sit there and think:

"This patient could be managed at home, but I can't be bothered so I'll admit them to hospital"

So I would suggest that we are not the people to whom these letters should be sent.

Can anyone indicate if this is a useful exercise?

Guidelines or Guidance?

2011-12-12T12:00:00.000Z

There is an interesting debate going on at the moment, that is talking about Guidelines. Certainly, when I went into practice, there were very few examples of this genre, and you tended to develop your own clinical practice on the basis of knowledge and experience. Generally that worked.

Guidelines are, in many cases, a rather pernicious thing. I remember, at the start of the Evidence-Based Medicine movement, reading David Sackett's book (Clinical Epidemiology) and realising that the mushrooming of guidelines could be a two-edged sword, on one hand ensuring a knowledge of best practice as considered by others, and also a means to attempt to unify treatment when treatment unification is not always a good thing.

We now have an industry of guideline writers, and they do ten to regard their work as being like Tablets of Stone, brought down from Mount Sinai. But this is often not the case, as anyone who has tried this process in Primary Care (and understands how Primary Care works), would understand. There are 22 guidelines that have been developed for managing substance abuse. Guidelines change as Medical trends change, as anyone who treats Heart Failure (beta-blockers bad, then beta-blockers good) and Back Pain (rest good, then rest bad) will know.

In the same way as diagnostic algorithms are pretty useless in General Practice (I tried out the 'Map of Medicine' and it was of very limited value), treatment algorithms have a limited place in clinical practice, and finally referral guidelines should be treated with some scepticism.

In some quarters doctors are criticised because they "haven't followed the Guidelines", and there is a view that adherence to guidelines should be a performance management issue. I would suggest that this point of view is simplistic and simply does not understand the nuances of modern medical practice. This suggestion should be resisted.

Guidelines are only really as good as those who write them, and many people involved in writing Guidelines are no longer doing any significant amount of clinical practice. This is the phenomenon of GOBSAT:

Good
Old
Blokes
Sitting
Around a
Table.

I shall return to this subject again in the future.

Smokescreen

2011-12-07T06:07:00.000Z

Smokescreen

We have, as secretary of State for Health, a man with a mission. Andrew Lansley arrived at the Department of Health as the top man in 2010 as the politician who had shadowed his brief for longer than any other. He knows what he is doing, and he is definitely a man with a mission.

Today he is announcing changes in the NHS, including "60 step-plan to restore faith in the NHS". As is the norm in these days of media management, the announcements are trailed in newspapers.

He is putting up a lot of suggestions that sound really patient-centred and caring.

Among those that have been deliberately leaked to the press are:

He is going to save 20,000 lives by ensuring

Access to NHS Dentistry is improved
More patients with Asthma and Diabetes are going to be treated in the community
Data about patients' experiences at their GPs' surgeries will be published
Recovery times will be published
Surveying bereaved and children
and other measures not yet leaked to the press

Mr Lansley has been a long-term critic of centrally imposed targets, so it is good that he has decided to, errrrm, impose centrally imposed targets.

He says that:

"The long-term row over NHS reform must end and the Health Service must concentrate on improving patient care".

Stripping out all the bullshit in this announcement (and there is plenty), it seems to me that the message is:

'we want you to stop campaigning against the privatisation of the NHS, so we are going to introduce a new raft of measures and targets to tie everyone up in knots, and allow the project to carry on without scrutiny.'

I have two comments to make to Mr Lansley

We know what your ultimate aim is (privatisation)

and

How dare you say that people have lost faith in the NHS.

Poison Pens

2011-12-04T18:01:00.001Z

I have commented in the past about the risks and dangers of the uncritical value placed on websites with give reviews of peoples' experiences.

A simple example of the problems of this kind of feedback came when one author (Professor Orlando Figes) wrote a critical review of a rival's book (Robert Service) and the Amazon review was subsequenty traced back to Figes. I was disappointed that Figes did this, as I have several of his books in my home library, and he is an excellent writer (Natasha's Dance and The Whisperers are both very good indeed in chronicling the 20th Century history of Russia). Service is also a distinguished writer.

In the health field we had the laughable nonsense that was called iwantgreatcare.com, which is now dead in the water, having carried scurrilous reviews of doctors who were entirely blameless, or vindictive diatribes, or even reviews about doctors who were dead. The database they used was quite hopeless and out of date.

More pernicious, of course, was the website NHS Choices, a wretched waste of taxpayer's money, which gave an official imprimatur to anyone who wanted to whinge, or with an axe to grind. I have made my views known about this wretched nonsense in a post for Pulse Magazine, and it is interesting that there are now others who are mirroring my concern.

I see there is an article in the Observer today that is echoing some of my stated concerns.

One comment from a Practice Manager, (about an anonymous complaint) which I actually thought was reasonable read like this:

"The concept of this forum is entirely flawed, as anybody can write anything with absolute impunity. I take all comments seriously, even though some of them are contemptible. Since you choose to hide behind the title of 'anonymous', I have little alternative than to dismiss your comments as unhelpful and unsubstantiated."

I would reckon that there are thousands of doctors and practices who would agree wholeheartedly with that sentiment (if not the language).

Needless to say the Department of Health thinks it is a wonderful idea and thinks it is an "incredibly useful" tool.

It isn't useful to anyone, and all it does for me is make me feel angry.

What is going on?

2011-12-01T20:32:00.000Z

The Golden Era

Over the last few years we have seen a sustained effort by the politicians, who represent the people (they say) to try and micromanage the NHS.

They have introduced targets, cost control, the skills escalator, new training programmes, increased management, and a gradual deprofessionalisation of clinicians. Now we have increasing management combined with cuts in budgets, and the hope is that this can be accommodated by the clinicians who will be able to deliver a better service.

The problem is, that it isn't.

Even in the prestigious hospitals we are seeing the effects of Government interference. The senior people are beginning to despair. St Bartholomew's Hospital is an iconic hospital that has been a leading teaching centre for hundreds of years.

Yet we have one of their surgeons, President of the Royal College of Surgeons, who describes:

"Appalling deterioration in services"

What on earth is going on with our great hospitals? What are we to make of this?

Bells should be ringing in the Department of Health. The Chief Medical Officer should be meeting with these surgeons. The senior doctors should be listened to, not hectored at.

I despair.

Day of action

2011-11-30T06:49:00.001Z

Today there is a national strike by Public Sector workers, called legitimately by the Trades Unions. This is largely in response to proposals by the Government to change peoples' pensions.

In short, the Government wants workers to pay more into pensions, have lower pensions, and work for longer before they can get their pensions. Work harder, pay more, get less. That is not an easy message to get across.

Rather surprisingly to many, GPs are not public servants. They are private contractors who contract their services to the public authorities. We are self-employed. So we are not covered by this industrial action, and so GPs have not been balloted, and will be at work today.

However, I support the action fully.

This is why. We have already had a raid on our pension arrangements in 2008. I think Dr Philyerboots explains it very well. We have a proposal to raid the pension pot further, despite the fact that our pension is financially viable and affordable.

There would be more sympathy for the Government's situation from the workers if they had not massively mismanaged the economy over the last few years. On political programmes the Tories/Libs blame Labour for getting us in this mess, and Labour saying it is the fault of the Tories. They both blame the Europeans.

The politicians are behaving like ferrets in a sack. This crisis is the fault of the political classes' policies over at least 30 years, as they have embraced Casino economics and abandoned Keynesian principles of prudence and management.

There is no support from the professionals for helping to clear up this mess, as they have been bullied, denigrated and harassed for far too long by the political classes, with their weasly henchmen in the popular press.

We are now in the sixth year of pay cuts, and face more controls and interference at every level. Many younger doctors are moving abroad. People like me will be retiring soon. Services are being closed or limited, there is no money or demand in the economy, taxes are going up, unemployment is going up, workloads are going up, pay and pensions are going down.

People are getting fed up, and today's day of action will be repeated unless the ruling classes start listening to the people.

We are all in this mess together (except the bankers, the tax avoiders and the politicians).

So as I plough through another long day (I will finish surgery work at around 10 pm this evening as I have a practice meeting, in my own time), my sympathies are with all the public servants.

Words, words

2011-11-29T21:22:00.000Z

I love the terms that people use to describe their children's, ahem, genitalia.

I was called upon today to check the penis of a one-year old, to see if it was normal.

"Will you have a look at little johnnie's winkle, please, Jobbing Doctor?"

Winkle? We've also had tuppence, john thomas, dick and other euphemisms.

Is this a local thing? Are winkles national, regional or local?

Quack, quack....

2011-11-27T07:57:00.001Z

I worry about the fact that I am a blogger.

I blame my former appraiser who encouraged me to use a "weblog" to act as a reflective diary. Since that time I have posted nearly 2000 posts on the internet, and hundreds in the medical magazine, Pulse.

Here is a classic example of the risks of blogging; where a vulnerable child with an incurable condition is having hundreds of thousands of pounds of money raised, so that he can has quack treatment made out of urine at a 'clinic' in Texas. The blogger, his blog is called the Quackometer, has received threatening letters from a representative of the 'clinic' which are extremely nasty. An excellent commentary is on David Colquhoun's site here, with the original details here.

We do seem to be in a situation where people can be exploited in an extreme form, and it is up to the authorities to ensure these places are not allowed to thrive on the back of the vulnerable.

So, in the spirit of

"I'm Spartacus"

I am going to say that I strongly disapprove of doctors and others using quack remedies to extract money out of sick people, their friends and their families. If the treatments work, then share that good news with everyone and subject them to proper trials.

I hope the Burzynski Clinic of Texas will do that. They have as a strapline "First do no harm", which is from the writings of Hippocrates, which I think is a shameful thing to use in these particular circumstances.

But I worry that I will get a similar letter.

Today, Matthew, I'm going to be a Jobbing Baritone

2011-11-26T09:14:00.000Z

My local church

In my local town, that I have lived in for a third of a century now (33+ years), we have seen enormous changes.

We have seen the disappearance of a historical industry of crystal glassmaking, and much other industry besides, and the independent shops disappearing to be replaced by charity shops, betting outlets, pawnbrokers, and indentikit chain-stores. This is probably a story that is reflected up and down this great country.

There is not a huge amount to differentiate my local high street from any other in the country: this happens, and is not a moan, but an observation - in a sense, we (the public) are to blame.

However, the churches remain distinct. I am a jobbing atheist, and therefore do not attend church, although I love visiting churches here (and abroad) and feel they encompass the culture and history of their locations. I cannot forget the Church of the Splattered Blood in St Petersburg, or the Rock Church in Budapest or the Duomo of Siena.

Our local Anglican church is 250 years old, and needs repair. The roof is decidedly dodgy. So a mate is getting together a performance of the Messiah by G F Handel next week and is roping in all who can sing (including my sister), and it is going to be a great event. We hope to raise lots of money.

Today I am not a Jobbing Doctor but a Jobbing Bass-Baritone.

Halleluia!

Leaflets

2011-11-25T12:02:00.000Z

Inside every prescription box there seems to be a leaflet. Patients read these leaflets, and we get many extra consultations directly related to the information put in these leaflets.

Some leaflets are quite responsibly put together, but many are just a list of any side effect that has been reported, anywhere in the world. In seems to me that the leaflet has been compiled by a lawyer rather than a doctor.

Today was a case in point where there was a leaflet listing the side effects of a naturally occurring substance, thyroxine. My patient has stopped the treatment because of this and became ill as a consequence.

I am not suggesting that we return to the old era when 'doctor knows best'. I do remember a long deceased senior GP being reported responding to a patient when she asked what her treatment was:

"They are for you to take, and me to worry about, my dear."

But the verbiage in these leaflets can be counterproductive.

He who pays the piper.....

2011-11-24T09:12:00.000Z

Over the last few years, there has been a particular organisation that I have observed in action. It used to have, as its President, the late Clare Rayner, whom I invited to give a lecture to my local postgraduate centre.

She was excellent, forthright, opinionated, and all you would expect from her: she was also understanding, sympathetic and respected.

Over the last few years, since her death, the organisation that she headed has remained active. It is called the Patients' Association. I used to think this was the authentic view of grassroots patients, and have struggled over the last 5 years to attempt to understand their view of the NHS.

Some of their stuff has been superficial, populist or downright rude, generally extrapolating from the selected specific to the general. Their current spokespeople are seen by the Jobbing Doctor as a rent-a-quote brigade, who can be guaranteed to give good copy to the Daily Mail, and other rather seedy low-brow newspapers.

I was reading the Lancet the other day, and in an editorial (2011; 378: 1757) I discover that it is funded by pharmaceutical, insurance and private medical companies. This certainly explains to me their general attitude over the last few years.

He who pays the piper calls the tune.

Consumerism versus professionalism

2011-11-23T12:13:00.000Z

I see that that rather overweening and generally average organisation NICE has been commenting on stuff that they would be better not doing.

They want to give to every woman the option to have a Caesarean Section by choice. In this they have been advised by the Royal College of Midwives.

So anyone who wants to can opt to have a major operation, either under regional anaesthesia or general anaesthetic, just because they want to.

"I want to have a Caesarian Section, doctor" they will say. "NICE says that it is my right"

Nice said in their 2004 Guidance:

"Maternal request is not on its own an indication for CS and specific reasons for the request should be explored, discussed and recorded. When a woman requests a CS in the absence of an identifiable reason, the overall benefits and risks of CS compared with vaginal birth should be discussed and recorded."

I wonder why this advice has been changed?

There will be ore operations, more complications of anaesthesia, more cost, more morbidity.

This at a time when we are trying to cut the costs of the NHS. The triumph of consumerism over professionalism.

I sometimes think that NICE is becoming populated by idiots.

Freedom of Speech

2011-11-20T21:18:00.000Z

Edmund Burke

There has been quite a lot of comment on a colleague's blog today, in a follow-up to the disappearance of Dr Rant from the medical blogosphere.

Whatever, or however the reasons for his/their decision to discontinue blogging, it is clear that he/they have been leant on.

Anybody who has blogged about contentious issues has felt this pressure from time to time. Even if you feel completely justified, nobody wants the GMC breathing down their neck. There are a lot of bullies and establishment toadies in our profession.

I would point you in the direction of Dr Rita Pal's comments on Dr Zorro's blog and remind you that

"All that is necessary for the triumph of evil is that good men do nothing." (Edmund Burke)

It is essential that free speech is not compromised for the convenience of those in authority, and I would like to support the freedom of Dr Rant and others to express opinions that may or may not be distasteful to many.

Conspiracy or coincidence?

2011-11-19T07:51:00.000Z

Blogger silenced?

When do random events become linked?

When does haphazard become correlation, and correlation becomes causation?

I ask these questions because three events have recently happened, and they may be linked.

Firstly, the irreverent and scatalogical Dr Rant has disappeared (the website is silent, and the facebook page is empty.

Secondly, the estimable Dr Phil Peverley, a prolific and excellent columnist, seems to have gone silent.

Finally, Dr Grumble has closed his blog to all, except invited readers.

Is this all coincidence, or are they connected? They have all happened in the last few days.

Hang on a minute; [sound of receding footsteps]........[rustle of papers]........[return of footsteps]; just checking I don't have a letter from the GMC on my doormat.

How long is it before the Jobbing Doctor feels the wrath of the establishment?

The Daily Mash

2011-11-19T05:22:00.000Z

I loved this.

Problem is that it is a lot truer than you think!

Classical Presentation

2011-11-18T16:27:00.000Z

When JD was younger as a doctor, we used to rely on clinical signs to help diagnosis.

Who could forget Virchow's node, for example? The answer is, of course, most of us.

The advanced signs of illness were more important when we didn't have such sophisticated investigation tools (Ultrasound, CT, MRI, PET etc) or that illnesses went on for longer before they were diagnosed.

The older clinicians like me can still remember stuff. One of the hallmarks of late liver disease is the 'Caput Medusae'. For the classical scholars amongst you, that means the head of the Medusa, which was festooned with snakes, and would kill you at a glance. This gorgon was slain by Perseus.

The appearance of veins around the umbilicus in advanced liver disease looks like a Gorgon's head, and so it is called Caput Medusae.

I had a new case where the veins just "popped out": knew what it was straight away.

Politics again....

2011-11-17T18:09:00.000Z

I slept, I dreamt.....

I see that our friend, Professor Steve Field, has written to the Secretary of State for Health (Mr Andrew Lansley MP), outlining recommendations to the SoS to adjust his new legislation.

The letter is here, and it makes for turgid reading. Make of it what you will, but there is a gap in recommendations for Education and Training - I wonder why?

The Future Forum is not what they would like to think. It is not a collection of distinguished and independent experts who have the NHS at heart. It is a handpicked group of supporters of the new legislation, most of whom represent particular interest groups, organisations, charities etc and serve the interests of aformentioned groups, organisations, charities and, of course, themselves. As I commented at the time, there is not one single opponent of the New NHS Bill in their midst.

I commend them for travelling the length and breadth of the land listening to peoples' concerns. They might even have strayed into non-orchestrated meetings where there is the odd opponent of the Government's strategy (like 95% of the workforce).

Apart from suggesting flexible Tariffs, I wonder what else is in Prof Field's letter?

May I suggest a pithy alternative version.

'Dear Secretary of State.

This Bill is a disaster that will fragment and destroy the NHS.

We have come to the conclusion that either you must tell the electorate this and let them decide, or withdraw it and start again.

Yours,

Future Forum (with Cojones)'

And then I woke up........

When I grow up I want to be a nurse......

2011-11-15T06:23:00.000Z

Times were that you used to know the difference between a doctor and a nurse.

Doctors were male and Nurses were female.
Doctors wore white coats, and nurses wore dresses with aprons and hats.
Doctors married nurses, and lived happily ever after.
Doctors did doctoring, and nurses did nursing.
Doctors had to get very high academic results, and nurses came into the profession via a vocational route.

That was the way it was.

*sigh*

Things have changed.

There are more female doctors than male ones: especially in the under 35 age group. In hospital most people seem to wear scrubs or ordinary clothes. Nurses live with policemen and firemen: doctors live with policemen and firemen.

These are changes that are interesting, but not that important.

The important ones are now that doctors do doctoring, and nurses do doctoring as well: much of the ordinary nursing is done by health care assistants. Nurses have to get some academic qualifications and have to go to universities (the academic qualifications are generally more modest, and the Universities are usually the new Blairite Universities).

The distinction is being blurred. That's the way it is going. Some call it the skills escalator, others call it dumbing down.

Now the distinction is blurred further in income terms. On balance (and here I am talking about what I know - General Practice), GPs these days earn a modest income, considering their qualifications and training (3 'As' at A-level, 5-6 years at medical school, another 5 years training and examinations after, before you can even start). Do not believe the newspaper reports of mega-salaries: that isn't true for the huge majority of Jobbing Doctors (including me).

Now I see an advert for an advanced Nurse practitioner who can earn £70,000 a year for a 37.5 hour week, seven weeks holiday a year.

This is a good deal more than many GPs at the moment. All they have to do is a clinical workload. Be paid more than a lot of doctors, have fewer qualifications, less experience and don't have to be as academically qualified.

At the moment, I'd be tempted to apply.

Wake up and smell the coffee, everyone!

2011-11-13T13:08:00.000Z

There are some truths that ought to be blindingly obvious. If an organisation is failing in the public sector, then selling it off to the private sector, and adding the component of the need to make a profit, will make the whole process more difficult.

This is happening at a School near you.

Mrs JD's school is being turned into an academy. The statistics were skewed to make it look like it was failing, the head teacher and the Governing Body have been sacked, the teachers are being made to reapply for their jobs (some of which will disappear), fewer will be kept on, and there's nothing that the local people or the school staff can do about it.

Stories are now becoming clearer that jobs are being done by those who are less qualified, and they are being paid less. That will result in poorer service - less good teaching quality, schools spiralling downwards, and lack of any accountability. It is sinking into a slough of despond.

The politicians are spinning it as a move towards "John-Lewis" style co-operatives, but this is a mask for taking people out of the public sector, removing services from the Public Sector Borrowing Requirement (PSBR). It is happening in schools, has happened in Health (ISTCs) and in the prisons.

The public sector is being asset-stripped as we speak, and nothing seems able to stop it.

Wake up and smell the coffee, everyone!

The whole country is being shafted by the monied classes.

Shine a light

2011-11-12T07:00:00.000Z

Let's get this straight. Most of our MPs, a Majority in the House of Lords, Professor Steve Field and the NHS Future Forum, The King's Fund and much of the Media say that the new Health and Social Care Bill will 'liberate' the NHS and empower the frontline workers to develop services.

They all say that it is a good thing.

Then it must be so.

Who also agrees with them? Private Health Care firms.

The majority of the Great and the Good.

Let us, for a moment, accept that this is a large body of expert opinion that is convinced of the rightness of their policy. They will undoubtedly have a cogent case to argue their case and a wealth of evidence to back up their plans.

The Government have done a risk analysis of the effects of the new Bill. They refuse to release it, as it would interfere with "policymaking". I do wonder what they have to hide - might this be that this strategy is enormously risky, and is likely to fragment and destroy the NHS?

They have been told by the Information Commissioner to release the documentation by early December. I can already feel the shredders and black 'redacting pens' working overtime.

In truth, this Bill is being steamrollered through by the Tories (and their slavering coalition "partners" the Liberal Democrats) because it puts money into the pockets of their supporters. And wrecking a public service in the process.

Why was Andrew Lansley's office given £21,000 whilst he was in opposition by a Private Health Care firm (Care UK)?

I think we get the picture.

Same old Tories.

Yesterday......

2011-11-11T15:55:00.000Z

Ann Abraham - Ombudsman

Yesterday I blogged about the way a GP up in the Midlands had been told to pay £500 by the NHS Ombudsman because he would not tolerate rudeness and swearing from a patient's relative.

The details are here.

I have been contacted by another doctor who has been similarly dealt with by this particular functionary in her little office in London. Once may be regarded as a rather stupid judgement, the second looks like vindictiveness on a grander scale.

Let me quote from the case he was involved in......

"Your post about the Ombudsman and bad behaviour has really struck a chord with me.

We removed a couple from our list for bad behaviour. The PCT backed us but the Ombudsman did not. We got a £1000 fine and she threatened to report me to the GMC. It took her 3 months to decide she had no reason to report me to the GMC. I complained that she took so long and was told she had simply "been busy". Her technique seems to be to apply a fine in the report, you then get a letter a few days later saying she is considering referral to the GMC. In other words pay up accept the report or its off to the GMC. Guess what the MDU & MPS say, pay up and avoid the GMC! She is entirely unaccountable. You cannot complain about her, I have had support from my MP, a cabinet minister, but even he admits she is out of control. The reply she wrote to him was offensive.

12 months later the Daily Mail featured this same couple, on the back of a press release from the Ombudsman last month. Large photo of the two of them beaming with pride from the pages of the newspaper, £1000 richer and well rewarded for their behaviour with the offical sanction of a public body. Telling the world how dreadful their GPs were.

I really despair but what is the answer?"

What is the point of this Ombudsman and her hectoring and bullying judgements?

We could save a good deal of money by getting rid of her - there is good news, however. She is stepping down at the end of the year.

Let's hope her successor shows better judgement.

Well, it's begun

2011-11-10T19:04:00.000Z

The Government have started to take the first step in the privatisation of the NHS. This is the plan to allow Hinchinbrooke Hospital in Cambridgeshire to be run by a private sector firm Circle.

I don't know much about Hinchinbrooke Hospital, as it is not in my patch, but we can all watch to see what happens here. The Privatisers say that Private companies managing an NHS hospital will deliver services cheaper and better than the existing plan.

Circle is described as a 'John Lewis-type' partnership firm. It isn't, as 50.1% of the voting shares remain with the main shareholders, with a base in a tax haven.

If you want to see what chaos will ensue, just see what happens to Schools that are becoming Academies.

Is this Hospital a basket-case? Or will it be the first of hundreds going down this avenue.

I shall be cautious about this: Prepare for the worst, but hope for the best.

Experience tells me that the floodgates will open.

Liked this

2011-11-10T12:36:00.000Z

Poor decision

2011-11-10T08:24:00.000Z

A story is breaking over at GP Online, concerning a doctor whose case has been passed through to the Ombudsman. I must admit that it has troubled me, as it seems to be another organisation that seems to be making bad judgements and exercising undue power.

The case is a puzzling one, as I have been only able to glean fragments of details about it. A doctor in a practice in Dudley, near Birmingham, has been fined £500 by the Ombudsman. This relates to a letter that was sent to a patient asking her to apologise for her bad behaviour at the practice, being abusive to the receptionists, kicking at a door and describing the practice as 'Shit'.

The clinical details are confusing as it relates to a patient who "has an undiagnosed medical condition that causes her to collapse". That is a very strange description. The complainant bought this woman (her adult daughter) to the practice after surgery was finished, but before the closing time of the building, and when told that an appointment was not available, started behaving badly.

This seems a really disproportionate response from the Ombudsman, which includes reporting the case to the General Medical Council, and making the details public. That appears to be a centrally decided strong-arm response by an official body that has not obvious credibility for me.

We face low level complaining all the time in General Practice. It is about us trying to match increasing demands to vanishing resources. We get absolutely no help from the authorities and the media. Now we have a woman in an Ivory Tower actually fining a doctor for asking a patient not to be rude to his staff.

I stand 100% behind the wronged doctor. He should not pay the fine. This is an outrageous response from a meaningless apparatchik. It is described as compensation. Compensating the complainant for what, exactly - bad behaviour?

As for reporting the case to the wretched GMC and making the details public, words do fail me. Maybe they'll fine me £50,000 for blogging about it. They can pay the compensation to the GMC, after all they've had enough of my money in the past.

Grrrrrr.....

The 'Daily Mail' of TV

2011-11-09T05:35:00.000Z

News reaches me that there will be a report on Channel 4 News tonight about a story generated by them. This concerns the use of drugs that are broadly defined as 'anti-psychotics' being prescribed for under 18s.

In a classic piece of Daily Mail-type journalism, their report uses the usual journalistic, gutter-press techniques. It is dripping with innuendo and shows lack of any balance, peppered with quotes from 'so-called' experts.

The report is here.

The language use is typical: Paragraph 1 - "Soaring numbers" "Chemical coshed" "as young as 5".
Paragraph 2 - "Staggering Numbers" "Double the number"
Paragraph 4 - The ubiquitous "Experts believe" "Chemical cosh"
Paragraph 5 - "Left on drugs for years" "Not properly monitored"
Paragraph 6 - ^Worryingly" "No-one knows long term effects" "Pharmaceutical companies have blocked requests"
Paragraph 7 - "Experts are concerned"
Paragraph 8 - "Child psychiatrist must be involved"
Paragraph 9 - "Mental health experts believe" "needlessly given out"
Paragraph 10 - "Professor Tim Kendall......figures are 'extremely concerning' "

and so it goes on.

Professor Tim Kendall has form here. He has been wheeled out in the past from his little Ivory Tower in order to give alarmist quotes to journalists.

Firstly, I wish they would stop using the term "Chemical Cosh". It is deeply offensive to me.
Secondly, anti-psychotics are never given out without strong and ongoing recommendations from a child psychiatrist.
Thirdly, prescribing habits alter over the years and so there is an element of these newer and cleaner drugs being used instead of older ones.

I am getting very fed up of the Daily Mail. It is a hate-filled 'newspaper' that is despicable. Channel 4 news used to be worth watching. Not any more.

This report will be the usual hate-filled tosh.

When Doctors go bad.......

2011-11-08T15:30:00.001Z

When I agreed to abide by the Hippocratic Oath, I presumed that I was joining a respected profession with high ideals, and a wish to improve the lot of humankind. The profession of Jenner and John Snow and Semmelweiss, all of whom left indelible marks on our civilisation. Jenner has been described as the man who has saved more human lives than any other.

Dr Radovan Karadzic

Dr Hastings Banda

In general I have been proud to call myself a doctor, and tried to live my life to these high ideals.

Most of the people I have worked with I am proud to be associated with, for all the good things they have done. But there are exceptions, and those exceptions make me ashamed of my calling, and I would not wish to be considered in the same breath as them.

Dr Bashir Al-Assad

In my Parents' generation, the activities of Dr Joseph Mengele were those to be ashamed of. In my generation, most of the evil docotrs have been evil on an enormous scale (such as Dr Harold Shipman), and there have been others in recent living memory: I would suggest Dr Radovan Karadzic, Dr Hastings Banda and Dr Bashar Al-Assad. All led countries (Republika Srpska, Malawi and Syria) and are notorious for the brutal or oppressive nature of their regimes. Dr Banda's legacy is mixed (some still hail him as a patriot), Dr Karadzic's exploits in Bosnia as leader of the 'Republika Srpska' are now the subject of deliberations by the international court in The Hague. Dr Al-Assad leads the Syrian Government, which is engaged in repressing its own people, with many thousands of victims.

Dr Ayman al-Zawahiri

Another doctor who is regarded as an international pariah, and generally held to be a bad man is Ayman Al-Zawahiri, an Egyptian Doctor who is the force behind the organisation al-Qaeda, and second only to Osama bin Laden in that organisation.

These are bad men, with the title "Doctor" bringing shame on us all. How can they have sworn the Hippocratic Oath?

I don't know.

A slow journey to Totalitarianism

2011-11-05T07:48:00.000Z

A rather silly man

I struggle to keep my views on certain people in authority to myself. Certainly, over the years, I have seen the behaviour of the ruling classes descend into quasi-totalitarian behaviour that really eats away at the fabric of a balanced society.

I suppose I am decrying the continuing decline of the concept of professionalism.

Professionals are people who have high standards of entry into the profession, a code of conduct where professionals are expected to perform and behave at specified norms, they police their own profession, exclude those whose behaviour and performance drop below mutually-accepted minima, and are able to practice free of unacceptable interference.

As a definition, I don't think this is a bad one.

All professionals have, over the last generation, been subject to increasing interference with their performance, micromanaged by the wilful, ignorant or partisan, have been systematically abused by the professional and media classes in a vain attempt to pull them into the gutter where politicians and journalists increasingly inhabit.

A simple example should suffice to illustrate what I say: there are a group of drugs whose use has been linked to harms (the anti-psychotic drugs are thought to be a factor in increasing the risk of strokes in patients with dementia). The science is suggestive as a correlation rather than compelling as causation. The general view amongst clinicians like myself is that these drugs are best avoided in elderly demented patients in residential accomodation. I have looked at my own clinical practice, identified the risk population, check what they are taking, and have discovered that <1% of patients are on these drugs - actually one patient - and this was prescribed following specialist advice and input. We keep this situation under review. That is how it is done in a professional way.

The Government way is different. You get a minister with limited knowledge, who visits a pressure group, and in order to gain cheap and evanescent support and respect, talks in apocalyptic language about sending doctors to jail if they don't do what his Department says.

Here is the report.

This kind of behaviour makes me despair.

He is clearly a rather foolish man.

New section of the Department of Health

2011-11-01T05:59:00.000Z

There is a new section in the Department of Health. The announcement has yet to be made, but I expect it to be merely a question of time.

If you look at the headlines, you will se that GPs (that is, people like me) are being encouraged to tell people to return to work. This is in a document from an organisation called the General Medical Council, which used to be an organisation that regulated doctors and protected patients: no longer.

This wretched bunch of control freaks (the GMC) recently have been consulting about what their role is. Recently they were suggesting that the should police what doctors are doing in their spare time. Now they are suggesting that we are unpaid agents of the Department of Work and Pensions, telling people to get back to work, or find work.

I would suggest that the GMC tries to do its core function properly, and not turn itself into an executive arm of the Department of Health.

They struggle with the difference between regulating and controlling, and recently they have lost their focus, and any respect they might have expected, by simply doing Government's bidding. They might as well just be incorporated into the Department of Health, and end the charade.

Declaration of Interest: My only contact with the GMC is an annual letter asking for money, so they can carry on their "work". That amount has increased over the years and is now 1400% more than when I started as a doctor. I resent paying them to behave like they do, and I shall have great pleasure in rescinding my registration in 18 months time. They won't get another penny off me then.

Health consumerism.

2011-10-30T12:29:00.001Z

The new norm?

News reaches us that there is going to be a 'right' for every woman to get a Caesarean Section, and this will not be merely be based on medical needs. The report will come out from 'NICE' next month.

This news is disturbing at a number of levels.

Firstly, the risk of anaesthetics (Regional and General anaesthesia).

Secondly the risk of having a scar on your uterus.

The risk of subsequent subfertility.

There are also risks in destabilising the local health economy (the costs for Caesarean Section are at least £800 more for the commissioners). When I have to ration procedures for my other patients, taking a hit on costs because of this will mean that other people will be deprived of what they might be entitled to.

I know that there will be some who will point to the potential risks of Birth Trauma, but this is a very small (albeit important) number.

It feels to me like the advance of health consumerism, and the prevalence of the "too posh to push" tendency.

I can be accused of being sceptical of this because I am (a) older (b) paternalistic and (c) a bloke. These are true to a degree (actually a. and c. are completely true), but I don't feel that this is the right thing.

Can anyone persuade me differently?

Seen on the internet......

2011-10-29T10:05:00.000+01:00

"What did you do, Daddy, when they sold the NHS, closed all the libraries and privatised all the schools?"

"I voted on the X-factor and complained that my Blackberry network went down"

from Ryan Alexander via Twitter

Breast screening

2011-10-26T07:08:00.000+01:00

A family member is shortly to undergo breast screening.

This is a programme of X-Ray (Roentgenographic) screening of the breasts in women in the UK who are over 50 years old. There has been an ongoing debate over the risks and benefits of this process down the years that has had, frankly, more emotion than science in it. Certainly the material sent to women is wholly in favour of screening.

For many people, the mere fact of screening is sufficient for it to be a "good thing". There is precious little analysis of the data in the mainstream media that is any different to this.

I quite like the simple Mathematics that are associated with the measure NNS (Numbers needed to screen). You have two groups, the screened and the unscreened, you apply the screening and observe the outcome in both groups over a period of time. By simple maths the numbers needed to screen (or harm) can be calculated (1/CER-EER).

Sackett has the NNS for X-Ray mammography of 1096 in 9 years. That means you need to screen 1096 women over a 9 year period to prevent one death from breast cancer. The Nordic Cochrane centre has the figure of 1/2000 over 10 years - screen 2000 women over 10 years to save one death. The NNH (numbers needed to harm) in this process is around 1/200. The programme costs the NHS a figure getting on a for £100 million pa.

In America, I knew of one programme (insurance based) that insisted women have X-Ray mammographic screening every 2 years from the age of 40. This would continue till age 65. The cumulative dose of radiation is a lot (could almost make your breasts glow in the dark!).

I don't think the programme will be abandoned, despite the relatively poor outcomes. There is too much emotion and publicity for this to happen. But at least a rational and objective discussion should take place. I hope this review achieves that.

More twists and turns....

2011-10-25T18:02:00.000+01:00

HSCB

The new Health and Social Care Bill (HSCB) has demonstrated a degree of ministerial and civil service incompetence that I have not seen for a considerable period of time.

For those readers who are not living in England, I apologise for going on about this, but it might herald the start of the end of a co-ordianted and collaborative and inexpensive universal health care system.

One of the major planks of the bill is the clause that relieves the Secretary of State for Health of the duty to provide a comprehensive Health Care system, and pass this on to unelected quangos, all as part of wish to retain power (setting the budget) and dumping the responsibility (rationing care). Many people (ranging from Baroness Williams through to Allyson Pollock) have pointed out that this is a pivotal part of the new Bill.

Jobbing Doctor has been listening to the mood music coming out of the Department of Health, and now the entertaining and estimable Roy Lilley, has pointed out that Mr Lansley has finally agreed to change the wording of this (Clause 1).

I understand that he has agreed that

"the Secretary of State retains ultimate responsibility to Parliament for the provision of the health service in England"

I hope that there is is no way that this wording can be interpreted any differently (my innate suspicion of politicians/lawyers/civil servants warns me to be careful), but this would seem to hole the Bill below the waterline.

This Bill is a complete Dog's Dinner. It has no mandate, and is rapidly losing its way, so that the neoliberal rightwingers like Oliver Letwin will not achieve what they want.

I wonder what Paul Corrigan will make of it? Is a bad Bill better than no Bill?

I'm alright, Jack......

2011-10-24T09:42:00.000+01:00

Some colleagues cannot understand why I'm getting so cross with the Health and Social Care Bill (HSCB), as (a) I shall be retired by the time it gets implemented and (b) I shall never be out of a job. They have a point, as the HSCB will not impact on my professional life.

Most of my GP colleagues are either sceptical or pragmatic. We have seen so many Government-inspired changes to Health Care over the last 20 years, we just keep our heads down, and wait for the next Bill to try and correct the cock-ups of the previous Bill. The majority will say that it is a disaster beginning to happen, and the remainder say 'let's try and make the best of this nonsense'.

I do have an interest, however. When I retire, I shall be a patient. I do not know what kind of service will be available, especially when the Secretary of State is getting rid of his responsibility to provide a comprehensive National Health Service.

It would be easy for me to say "I'm alright Jack, pull up the ladder"

But I'm not going to

A leader emerges

2011-10-20T17:24:00.000+01:00

Today I have seen the speech delivered by the Chair of Council of the Royal College of General Practitioners, Dr Clare Gerada. It is an inspiring speech, it is humane; it speaks to me personally at a time of feeling very low professionally.

Clare, I salute you and what you stand for. If I wasn't teaching today, I would want to go to Liverpool and give you a big hug.

In an era where the barbarians are at the gates, I'd like to thank you.

A Jobbing Doctor.

PS Thank you, Johnathan for posting it on your blog.

Patient information leaflets

2011-10-19T11:51:00.000+01:00

One of the more irritating features of 21st Century medicine is the proliferation in length and detail of patient information leaflets that are given when patients are prescribed anything.

Every single side-effect that has ever been reported seems to be on these leaflets, and although some give an idea of frequency of side-effects, some just list them.

I'm not against these in principle, as I acknowledge the problems of iatrogenic illness [illness caused by medication/treatment/doctors], but I get the feeling that many of these are produced by the firm's legal department with the express notion of preventing them from being sued.

Is that so?

Do I do it?

2011-10-18T08:08:00.001+01:00

My staff have to put up with an amount of verbal abuse.

Regularly, my receptionists are told they are useless, or have to put up with intermittent low level shouting, simply because people cannot have what they want. This happens on almost a daily basis.

I get around £68 per adult per year to look after my patients. That includes the expenses of employing staff and running a surgery. That is less, per annum, that it costs for health insurance of a hamster.

Many people get frustrated when they cannot see the doctor of their choice at the time of their choice on the day of their choice. I understand that. But it is not possible to have the capacity to fulfil that role with the resources that we have.

You get what you pay for.

Today it is all over the papers about how some people have been removed from their doctor's list for reasons of verbal abuse and other reasons. The ombudsman has investigated 500 of these cases, and some of the time has found that there is little justification for this. However, in some cases the investigations did not include the situation from the doctor's point of view.

There are nearly 40,000 GPs in the country and 800,000 consultations per day. So this will happen. But it is extremely rare.

The last time I removed a patient from my list was when my patient was racially abusive about one of my colleagues. Should I put up with that because I am a public servant? I don't think so. That was 8 years ago. Since that time I will have had approximately 55,000 consultations.

So lets get this all into perspective.

PS. People being removed from doctors' lists will happen even more in Lansley's new privatised NHS. There is no incentive for doctors to take on expensive patients who will drive a coach and horses through their budgets. So they will find ways to remove them.

A good speech

2011-10-15T08:36:00.001+01:00

I haven't had the time this week to blog effectively on the legislation going through the British Parliament to privatise the National Health Service.

I am a Jobbing Doctor working 8 Clinical Sessions a week and 2 Educational Sessions.

That is full time.

I do know that I sit and seethe at the sheer folly of politicians and their fellow travellers who are in the end stage of a project to destroy one of the cherished aspects of British life.

I have been looking at Hansard to see if the House of Lords in any way reflected what my perception is of the new legislation. I found this excellent speech by the lawyer Helena Kennedy.

Baroness Kennedy of The Shaws: My Lords, I make a declaration that I am a fellow of three royal colleges, too, like the noble Baroness, Lady Cumberlege. I should also say that I am married to a surgeon who has spent his life in the National Health Service. He is from a dynasty of doctors. His grandfather was a doctor, his mother a doctor, his aunt a doctor and now our daughter is entering medical school. They all entered medicine not because they are interested in making money but because they want to care for people. It is the idea of being at the service of others that draws most health carers into medicine. They do not want to run businesses; they do not see their patients as consumers or themselves as providers. They do not see their relationship as commercial and they do not want to be part of anything other than a publicly funded and provided National Health Service.

Health professionals also feel proud, as all of my husband's colleagues do, that Britain is the only country in the industrialised world where wealth does not in some measure determine access to healthcare. They are saddened that the National Health Service is now facing the prospect of becoming a competitive market of private providers funded by the taxpayer. When we hear talk of accountability, they point out that nothing in the Bill requires the boards of NHS-funded bodies to meet in public, so there will be a lack of transparency. That will be complicated by the fact that private providers are not subject to the Freedom of Information Act, so they can cite commercial sensitivity to cover their activities.

Others have spoken of the removal of the duty on the Secretary of State to provide healthcare services and pointed out that that duty is now to be with unelected commissioning consortia accountable to a quango, the national Commissioning Board. The Bill does not state that comprehensive services must be provided, so there may well be large gaps in service provision in parts of the country, with no Secretary of State answerable. Providers will be able to close local services without reference of the decision to the Secretary of State. Although the Government say that the treatment will be free at the point of delivery-we hear the calm reassurances-the power to charge is to be given to consortia. That paves the way for top-up charging and could lead eventually to an insurance-based model.

Monitor, the regulator, is to have the duty to sniff out and eliminate anti-competitive behaviour-and, of course, to promote competition. According to the Explanatory Notes to the original Bill, Monitor is modelled on

How is that for reassurance to the general public? If anything should be a warning that this spells catastrophe, it should be that this is another step in the disastrous selling-off of the family silver to the private sector, with the public eventually being held to ransom and quality becoming second to profitability.

The regulator, Monitor, will have the power to fine hospital trusts 10 per cent of their income for anti-competitive behaviour. Any decent doctor will tell you that for seamless, efficient care for patients, integration is key to improving quality of life and patient experience. The question is whether competition and integration can co-exist. Evidence from the Netherlands is that they cannot. There, market-style health reforms designed to promote competitive behaviour have meant that healthcare providers have been prevented from entering into agreements that restrict competition, so networks involving GPs, geriatricians, nursing homes and social care providers have been ruled anti-competitive. There is a fear that care pathways, integrated services and equitable access to care in this country will be lost when placed second to market interests.

Under the delusion of greater patient choice, people are to be given a personal health budget. I am interested to hear what happens if it runs out halfway through the year. Private hospitals will enter the fray as treatment providers and, as in other arenas, they will undoubtedly, as others have said, cherry-pick and offer treatment for cases where they can treat a high number of low-risk patients and make a profit-for example, hip and knee replacement, cataracts, ENT and gynae procedures.

It is essential in an acute teaching hospital to retain the case mix, though, so it will be the teaching hospitals that will also provide the loss-making services such as accident and emergency and intensive care and deal with chronic illness and the diseases of the poor, such as obesity-we can name them all. These are essential services but they are also very costly. An ordinary hospital cannot provide them if it does not have the quick throughput cases as well to maintain a financial balance. If relatively easy procedures go to private providers, the loss of revenue to the trusts will eventually lead to them being unable to provide the costly essential services. It will mean that doctors trained in these places are not exposed to all aspects of patient care. Private companies cherry-picking services undermines and destabilises the ability of the NHS to deliver essential services like, as I have mentioned, intensive care units, accident and emergency, teaching, training and research.

Clause 294 allows for the transferring of NHS assets, including land, to third parties, and the selling off of assets. Clause 160 allows for the raising of loans by trusts, so hospitals taken over by the private sector could be asset-stripped and then sold on, as happened with Southern Cross homes.

The removal of practice boundaries and primary care trust boundaries will mean that commissioning groups will not be coterminous with social services in local authorities, so vulnerable people are more likely to fall through the gaps between GP practices. GPs will also be able to cherry-pick by excluding patients who cost more money and can lead to overspend.

Then there is the issue of the cost of market-based healthcare. Advertising, billing, legal disputes-I say this as a lawyer-multimillion-pound executive salaries, dividends and fraud could end up consuming a huge amount of the pot that can be spent on front-line services. We will end up, as in America, with that extra stuff taking up 20 per cent of the health budget. The downward spiral of ethics, the increase in dishonesty and the conflicts of interest become huge, and you see the destruction of the public service ethos.

I want to scream to the public, "Don't let them do it"-and in fact the public are responding by saying in turn, "Don't let them do it". Market competition in healthcare does not improve outcomes. The US has the highest spending in the world and the outcomes are mediocre. The US overdiagnoses, overtreats and overtests. Why? Because that increases revenue. You change the nature of the relationship between doctors and their patients. You get more lawsuits and doctors therefore practise defensive medicine. You ruin your system.

I say this particularly to colleagues on the Liberal Democrat Benches. They may be being encouraged to think that voting against the Bill may bring down the coalition, but all I can say is that the electorate is watching. If people feel failed by the party on this, I am afraid that it will pay a terrible price.

This has been a 25-year project, done by stealth. It started with the internal market and is now moving to the external market. It was not thought up by mere politicians but by the money men, the private healthcare companies and the consultancies like McKinsey-the people, in fact, who in many ways brought us the banking crisis. They have funded pro-market think tanks and achieved deep penetration into the Department of Health, into many of our health organisations and right into some of the senior levels of my party as well as those on the other Benches.

The NHS is totemic. It is about a pool of altruism and it speaks to who we are as a nation. It is the mortar that binds us in the way that the American constitution does the American people. For us, it is about this system. It really is the place where we are "all in it together"-one of the few places, it would seem at the moment. Doctors get 88 per cent trust ratings with the public, while politicians get 14 per cent. The vast majority of doctors are saying to us, "Withdraw this Bill". We should be listening.

However, her speech was sandwiched by other speeches from loyalists, flunkies, fellow-travellers and assorted other craven supporters.

The public is beginning to get wise to what the Tories and Lib-Dems are doing.

We shall not forgive them at the next election.

Nemesis awaits.

None of their business

2011-10-14T09:35:00.000+01:00

I have blogged in the past about my thoughts on the Doctors' regulatory authority, the General Medical Council (GMC).

To be fair to them, they have decided to consult on the question that they wish to ask.

The question is:

Do you think that the GMC should regulate doctors' life outside of medicine?

This got the unsurprising answer of 5% Yes, 94% No. [I am astonished that 5% said yes!]

This is a very odd question to ask. When I am not a work, I like to dress down. I don't wear a tie, and sometimes wear Jeans. I go to the cinema from time to time, and I might go to the pub and have a few beers. I occasionally watch sporting fixtures where I may question the parentage of the referee.

What business is it of the GMC what I get up to in my private life? If I am not breaking civil and/or criminal law it is NONE OF THEIR BUSINESS.

I wish the GMC would understand what their role is.

And do it properly.

Significant Day

2011-10-12T14:52:00.000+01:00

Today is a significant day in the history of Government in the United Kingdom (well in England, mostly). In the same way that Tony Blair took us into an immoral and illegal war in 2003 against the wishes of the people, we have David Cameron setting in train the dismantling of a fair equal and effective Health Service that has been with us since 1948.

It was a forlorn hope expecting a bunch of ennobled flunkies to show any backbone, nor did they. Now we have the continuance of an act of National vandalism that we - the ordinary Doctors and Nurses - have opposed throughout.

I neither have the time nor the energy to write any more.

My blog over the next few months will, I'm sure, start to chronicle the death of the NHS.

It was a Chronicle of a Death foretold.

Last chance saloon

2011-10-10T07:12:00.001+01:00

Over the next few days, we will see if the House of Lords is able to stall the Health and Social Care Bill; Lord Owen (himself a former Junior Hospital Doctor and Foreign Secretary) seems to imply that the Lords cannot constitutionally derail any bill; they can delay it but they are a revising chamber, and this is not the 'way things are done'.

So let me get this straight:

There was no electoral mandate for the Bill.
It is being implemented at a time of cost cutting.
It involves top-down reorganisation that is bigger than any other.
Most Nurses are against it
Most Doctors are against it
Most managers are against it.
The Scots are against it.
The Welsh are against it.
The Northern Irish are against it.
Its implementation will cost a lot of money and will fragment the NHS.
It will not benefit patients.
It will benefit private Healthcare providers.

This Bill is an act of political wrecking on a service that will affect generations of people in England. This is why Lord Owen and his colleagues must not flinch from stalling the Bill. The reasons above are why convention needs to be put on one side.

This week, we are in last chance saloon for the NHS. If this Bill goes through, then the few supporters and fellow-travellers will get their rewards, but earn the derision of the public who have been lied to and cheated out of something that is rightfully theirs.

The rich and the healthy will be all right.

The rest of us will have had something quite precious stolen from us.

The slow march of private medicine

2011-10-08T07:54:00.000+01:00

There has been much brou-ha-ha about the North Yorkshire practice who have been offering minor surgery procedures privately to patients, because they are no longer available in their area from the Public funded service.

General frothing at the mouth from commentators, to be sure.

This is, however, a logical progression from where the Government are taking us. We are expected to make £20 billion of cuts, and therefore non-urgent stuff is bound to be rationed or unavailable. There is bound to be a conflict of interest from clinicians who are going to provide services and will also commission them. Policy-makers should understand that.

I don't criticise my colleagues in Yorkshire for what they do (although it is the antithesis of the morals of the service I joined in 1975). They have a practice to run, which is a business, and they (like us) have seen a freeze in income for the practice for the last 7 years. They are also responding to patients' wants and/or needs.

This is the way the NHS is being pointed, as a result of Government policies started in 1990, and continued slowly and relentlessly to this day.

No, you can't have your varicose veins done (until they are so severe that you have got ulcers)
No, you can't have IVF
No, you can't have that non-malignant mole removed
etc etc etc

There will be tough times ahead for all of us. We have to pay the consequences of many years of Governmental laisser-faire, meddling and incompetence.

We still have the reorganisation of the NHS to fund (£2 billion), the useless IT project (£6.7 billion squandered so far, and another £6 earmarked), Darzi centres not fit for purpose (cost uncertain to protect 'commercial confidentiality'), Independent Sector Treatment Sectors (cost £hundreds of millions and running nowhere near capacity). Frankly, if this lot were scrapped, then you would be close to £20 billion at a stroke, with virtually no effect on patients.

So, over the next few years I am going to have to tell my patients that either they go private or they don't get an increasing number of interventions.

This does not feel like a civilised and moral country to me.

The last of the lot

2011-10-07T15:49:00.000+01:00

Jobbing Doctor has been putting oestradiol implants into patients in Dullsville for the last 30 years. Many patients prefer to come for a minor procedure every 6 months, and then forget about their HRT. We must have about 40-50 per year that we sort out.

Not any more.

This afternoon I am putting the last implant in.

Why is this? Are they dangerous? No. Are they misused? No.

The implants are no longer made. The firm responsible for supplying the implants has decided to stop making them: I presume because they can't make enough profit from the process. Now a sensible Department of Health would negotiate an appropriate deal with the firm to continue making the implants, acknowledging the value to many patients.

But we are talking about the UK Department of Health. They're probably too busy with their plans to ~~privatise~~ re-organise the NHS to worry about these details.

My patients are pretty cross, and I am cross.

But what do we matter, except at election time?

Cough, splutter....

2011-10-07T09:20:00.000+01:00

In work today, but I have a stinking cold. This is one that makes you feel viral and changes you from Baritone to Basso Profundo!

In a large organisation, people would take time off for this, but if I lay in bed and go "Oh-oh-oh-poor-me" and not turn up, my colleague will have to see double the amount of patients, and I would feel guilty as hell.

I suppose I may well be spreading it to others, but since I probably caught it off a patient, then what goes-round-comes-round, as they say.

I'm sure some of my patients will be less ill than me......!

This is important

2011-10-06T19:59:00.000+01:00

Today, I have read an open letter addressed to the House of Lords. I have permission from Kailash Chand to reproduce it.

"As doctors in England, we are writing to you to express our conviction that the Health and Social Care Bill will irreparably undermine the most important and admirable principles of the National Health Service, and to appeal for its rejection by the House of Lords.

Because it is universal and comprehensive, and publicly accountable, and because clinical decisions are made without regard for financial gain, the NHS is rightly regarded all over the world as the benchmark for fairness and equity in healthcare provision.

The transfer of services to private, profit-making companies will result in loss of public accountability and a damaging focus instead on low-risk areas that are financially profitable. A confused patchwork of competing providers will deliver a fragmented and inequitable service and any reliance on personal health budgets or insurance policies will further increase inequality. Because there will be a financial incentive for providing treatment patients will be over-treated, the potential costs of which are limitless. And the possibility of the commissioning role being outsourced to the private sector is also deeply concerning.

In forcing through this ill-conceived Bill, without an electoral mandate and against the strident objections of healthcare professionals, the Government is also ignoring overwhelming evidence that healthcare markets are inefficient and expensive to administer.

The public has been misled throughout, first by claims that no major reorganisation of the NHS would be undertaken, later by repeated denials that what is happening represents privatisation, and furthermore by suggestions that the Bill enjoys the support of the medical profession. We do not accept the argument that "things have already gone too far" - the enactment of some of the Bill's proposals has been premature and illegal, however some of its most damaging aspects may still be mitigated.

We believe that on moral, clinical and economic grounds, the Health and Social Care Bill must be rejected."

Thanks to him,

Jobbing Doctor

Not been a good 24 hours.

2011-10-06T08:46:00.000+01:00

They say things come in threes.

Three deaths in the last 24 hours.

Steve Jobs changed the face of computing. I got into Mac computers when (a) my PC broke down for the nth time and (b) my Sony MP3 player started playing up. I was told by a friend that I should replace my PC with a iBook computer, and I was able to make up the difference in cost. Then I saw how easy iTunes was, so I replaced the MP3 player with an iPod. Now we are all Macs at home, and I am reminded about the ease of using Apple computers every day at work, where we use PCs. I am still using the iBook, and the iPod to this day. Steve Jobs died from cancer aged 56.

Graham Dilley was a fast bowler for Kent, England and Worcestershire. He was instrumental in setting up the famous Headingley test win against the Australians in 1981. You ask any cricket lover to list the best ever test matches, and this one must be in the top 3. Whilst he was never quite in the league of John Snow or Bob Willis, he was there and made it happen. Graham Dilley was 52, and died from cancer.

Bert Jansch was a Glaswegian guitarist, who helped set up the Pentangle, a folk-rock group of the 1970s. Mrs JD and I regularly listen to the Pentangle, and really enjoyed their best album 'A basket of Light'. His abilities as a guitarist were on a par with Clapton and Harrison. Bert Jansch died from cancer, aged 67.

So there you have it - computers, cricket, music: all enlightened by these good people.

All three died from cancer, and were not old.

All impacted on me in different ways.

May they rest in peace.

GMC Propaganda

2011-10-05T08:23:00.002+01:00

The General Medical Council used to regulate doctors by consent. The Profession would self-regulate by electing to this body esteemed members of the profession who had demonstrated great work over many years and were respected by colleagues.

It had a role to examine the behaviours of errant and incompetent doctors, and their proceeding were beloved by the downmarket media who revelled in the shenanigans that took place. Doctors used to be in trouble for what were described as the 3 'A's: Addiction, Adultery and Advertising. That was the GMC I registered with in the mid 1970s.

Fast forward 30-odd years, and what do we have? An organisation that is appointed by Government and is a quango. An increasing interference in the way many professionals work, a meddlesome, slow, tedious and unrespected arm of Government which appears to attempt to control doctors so that they are unable to express independent views without fear of being hounded.

Their catalogue of incompetence has mushroomed over the last few years, and their latest pronouncements show absolutely no sign of understanding the contempt that this organisation is held by your average working doctor. They are supposed to introduce a system of checks on doctors that is cumbersome, unwieldy, unfit for purpose and expensive: this revalidation process was due to be introduced in 2002, and we still await its implementation.

There are many examples of the poor performance of the GMC, and these include their shocking treatment of Roy Meadow and David Southall; their outrageous co-opting of Penny Mellor on to an advisory committee; their eccentric decision making and the enormous stresses placed upon individual doctors whom they investigate. I have been told of doctors who committed suicide due to the stress of facing the GMC.

We have some poor doctors, some incompetent ones, some naughty ones and some criminal ones. Doctors reflect the society we live in where we have incompetent MPs, incompetent journalists, incompetent lawyers etc. It happens.

The GMC has lost its way. It is now suggesting that it is the duty of a doctor to ensure people return to work. I have read my Hippocratic oath, and it doesn't mention that at all. This is it being the stooge of the executive (again).

If the people want doctors to be regulated by the Government, then that is fine. I don't see why I should pay a sizeable amount of money to support it (a 1,400% increase in fees).

On monday there was a Programme on Channel 4's Dispatches series which was a pretty shoddy bit of populist nonsense, implying that all GPs were rubbish, and then they selected several Doctors who had already been reported to the GMC to do secret recordings of, aided and abetted by a Professor of General Practice who sat in his little ivory tower facilitating it.

It turns out that Professor Aneez Ismail of Manchester University was a key adviser to Dame Janet Smith's report on the Shipman enquiry.

I hope Aneez is pleased with what turned out to be an hour of GP-bashing and GMC propaganda in the media.

He has lost my respect, I'm afraid.

It is interesting that Dr Clare Gerada of the Royal College of General Practitioners was interviewed for this programme: I suspect to add a level of realism and balance. How much of her input into the programme did we see?

Errrrm.......nothing.

La-la-la-la

2011-10-04T06:35:00.000+01:00

"La-la-la-la-la"

There's none so deaf as those who don't want to hear.

Over the last few months the Conservative-Liberal Democrat Government have been pushing through a bill on changing the National Health Service (NHS) that have been based on principles of commercialism and fragmentation of the service. Many of us feel that this is back door privatisation based on market principles and see it as the end of a comprehensive service.

The changes have some support, from high-profile zealots such as Dr Michael Dixon, but are rejected by most doctors. Even the (largely cosmetic) changes introduced by the 'Future Forum' process chaired by Steve Field are not enough to address the basic fault of the bill.

Needless to say, the politicians have lied and bullied their way through most of this process. The lies include a manifesto pledge not to introduce 'top-down' changes in the NHS (this is an obvious lie) and the ludicrous claim that most doctors and health workers support the changes (they do not). The bullying and arm twisting is apparent in the political process to get this bill enacted (for which there is no mandate from the people).

We now have strong opposition from public health to add to the rejection by the Royal Colleges, the Unions, the Nurses, the rank and file of workers of all types in the NHS.

Government reaction?

Slavering apologists like Paul Corrigan mutter elegantly about vested interests (his backers are vested interests too) and David Cameron tells doctors to work to implement the bill.

He is standing in the corner with his fingers in his ears going "la-la-la" so he can't hear what the advice is. The House of Lords is the last place where this bill can be killed: either the bill fails or the NHS will.

Here we go again

2011-10-02T07:11:00.000+01:00

I get a bit fed up of this, and frankly when the better end of the media in England indulges in this kind of second-rate nonsense, well.........

Apparently the NHS is 'failing' mothers with depression because they are being offered antidepressants, and not talking therapies.

It very much goes along the pattern of:

Special Interest group does survey (angled towards their special interest)
They rely on so-called "expert guidelines" (including nonsense from 'NICE')
They find some celebrities whose cases may or may not be relevant (doesn't really matter - just gives a good picture and a personal angle)
They make assumptions based upon (a) personal prejudices and (b) fallacious advice
They look around to see who to blame
They blame family doctors

The assumption that 'baby blues' and postnatal depression are the same is rubbish. The journalist is confused, fed biased information and has made a decision before their facile and uncritical assessment of fairly useless data.

How available are talking therapies? I'm lucky if I can get adequate service for my patients at all.

This article is unadulterated rubbish.

He rolled over in bed, and said 'I love you'.....

2011-10-01T11:10:00.000+01:00

'Local Bloke' by Tolouse-Lautrec

It is usually fairly straightforward to diagnose a heart attack (Coronary Thrombosis, Myocardial Infarction). The classical presentation is a 'crushing' chest pain, going into the neck or left arm, severe, and associated with nausea, sweating and shortness of breath.

The ECG (EKG in the States) shows typical changes (S-T wave elevation), and there is a blood test called Troponin that should be elevated above a specific figure.

Actually, many heart attacks do not present classically. Some occur without any symptoms at all (the so-called 'silent' Myocardial Infarction).

In the area I work, some of the patients are very stoic, and will put up with a lot. I remember one chap I saw on a monday morning in my surgery. He said that he got some chest pain at 3 o'clock in the morning on the saturday (around 36 hours before coming to see me). He said the pain was not too bad, but then said

'Actually, doc, the pain was so bad that I rolled over in bed and told the wife I loved her"

This is most uncharacteristic for Mr Local Bloke, and that was a clincher. I was sure he'd had a heart attack. Tests afterwards confirmed that. He's never said it since...

So this is the Jobbing Doctor's sign...... The "I love you" sign.