Marmalade

It's February, so for a few weeks the Seville oranges are available to make marmalade. I've always enjoyed making marmalade. I don't save money doing it, it doesn't really save any time. For me it is therapy!

The fruit

This year's first batch is four fruit marmalade - oranges, lemons, limes and grapefruit, and here is a picture of the fruit ready to be cut, squeezed, peeled, de-pithed and generally prepared. It is hard work, but it is rather pleasant to have your hands smelling of citrus!

Here is the boiling pan, with a muslin bag containing all the pith and pips. The finely shredded skin is on the surface.

Boiling the fruit.

Hours and hours later, and boiling the mixture frenetically gives you your marmalade, which needs to be poured into jars and sealed (and labelled - I'll get around to that later!)

14 jars of heaven!

However, what it is all about is the flavour, and the freshness, and the enjoyment of making something that is properly home-made. The marmalade is a little runny (despite using the pectin from the fruit, jam sugar, and a sachet of extra pectin), so any suggestions in letting me know how to get my marmalade more solid would be gratefully received.

Mmmmmmm..........

The end of stupid....

Some ideas are just plain stupid.

It doesn't stop some idiot promoting them for all they're worth. The idea of 'Dementia Screening' fails at every level of sensible medicine.

A passing understanding of the Wilson/Jungner criteria of screening (this is not new, developed in 1968 by the World Health Organisation) would ensure that policy makers would understand that this would be a pointless and wasteful exercise.

Here are a couple of basics:

Screening picks up a condition in its pre-symptomatic form. Dementia 'screening' does not.

There has to be an acceptable treatment for the condition that works. Not so in Dementia (which is a variety of conditions, anyway).

There needs to be a clear understanding of the pathophysiology of the condition. We don't in Dementia.

News has come that the programme is to be abandoned: not before time. It has achieved nothing of value.

Surely there ought to have been someone at the Department of Health who could have said to the idiot politicians pushing it that it was a waste of time, money and effort. Politicians were told by many people at the time. They chose to ignore opinions outside of their narrow and shallow understanding. This is why the Department of Health is, by some distance, the worst department in Whitehall.

Pants on fire....

The central theme of the Government's latest argument, this time with the junior doctors, is that the lack of staff working at the weekend causes higher mortality.

This is despite many people, including Margaret McCartney, the original authors of the piece in the BMJ, the editor of the BMJ and many others saying that Jeremy Hunt's interpretation of the data was deeply flawed, and he can't make any assumptions based on this information.

Now it would seem that even the Department of Health [a.k.a the worst Department in Whitehall] have even managed to make a correct judgement.

The wheels are falling off his argument now, and what he needs to do is stop being so arrogant and naïve, and start taking advice. And stop saying things that aren't true.

Is that too much to expect?

Another day, another report

Today we have a report on problems in mental health services in the UK.

They are not good enough for a country of our size and wealth.

If you spoke to anyone who has any experience of working in mental health services, or anyone who has used them, they usually say that this is not news and has been like this for many many years. Certainly, I was keenly aware of all the problems when I was a Jobbing Doctor, so much so that we tried to treat as much in house as we could, as the opinions and back-up for our mental health patients were patchy, mostly bad.

It is being spun today as being an attitudinal problems, and there is some validity in the view that mental health is regarded as less worthwhile by many in the country. The real problem is lack of facilities, lack of resources and lack of people on the front line with the requisite skills. Reorganisation upon reorganisation, and squeeze upon squeeze (all with the support of the Department of Health) has left psychiatric services in their knees.

As an example, I used to use a treatment called Lithium to help with patients with severe bipolar disease: these I started and monitored in primary care, as I felt I had the experience and knowledge to do so. I would have preferred to have these done in secondary care, but the resources were not there to give a good service to my patients.

Who is responsible for the poor quality of mental health services? Is it the public (with their blinkered attitude to mental health)? Is it the front line workers (who are not good enough or plentiful enough)? Or is it the politicians (with their squeeze on funding, and pointless reorganisations)?

I know who I blame: but no-one will take any responsibility for this.

So I give this piece of advice: fund the front line properly, treat the professionals as professionals, and allow them to do the job they want to do.

Is that so hard?

A friend of a friend told me....

The NHS seems to be going to hell in a handcart. We have had a 13-year freeze of resources in primary care, so that General Practice is now on its knees with the lack of funding and demoralisation.

I hear (from a friend) that in a large and well-respected local practice that it is common for patients to be queuing out into the car park to get an appointment, doctors are leaving and retiring, the patients vent their anger and anxiety on the receptionists (not their fault), and what have the authorities done?

Bugger all.

The NHS is not just about doctors, but it is the doctors who are in the cross-hairs.

First they came for the Junior Doctors, but I did nothing, as I was not a junior doctor. Sound familiar?

Then they came for the nurses.

Then they came for the support and reception staff.

Then they came for the consultants.

Then when I became ill there was no NHS left, and I was asked for my Mastercard Number.

And when that ran out...........

Infamy

It is quite difficult to explain to non-medics the significance of 11th February 2016 in the status of medical care in England.

You certainly won't get a balanced view from the mainstream media, who seem incapable of analytical understanding of the issues. Soundbites provided by press offices seem to be easy to regurgitate as fact whilst ignoring the complexities.

The bald facts are that the Secretary of State for Health decided to impose a new contract on Junior Doctors (anyone who is not a consultant or a GP), in the stated belief that he is working towards a seven-day NHS (whatever that means). He uses some cherry-picked statistics to back this up (despite the authors being unhappy about his hi-jacking of their data in a selective way), and attempts to take the moral high ground.

Imposition of a contract on people who are very intelligent, highly motivated and have transferable skills is a recipe for them to leave, retire, resign or emigrate: this will happen in record numbers over the next few years. You do not treat professionals like this: if you stop treating people as professionals, they will stop behaving like professionals - they will not be minded to cover difficult shifts, they will work to their contract and no more. This is the rule of unintended consequences.

Over the next few months I shall be chronicling the unintended consequences of this rash decision, and pointing out where things can be changed for the better.

11th February 2016 was the day where the English NHS started to die.

Weep for what we are about to lose.

Nemesis

It looks to me like the Government has decided to impose a new contract of work on the Junior Hospital Doctors. An announcement is expected today from the Secretary of State for Health, Mr Jeremy Hunt MP.

If this is the case, then we are approaching the break-up of the National Health Service, chaos in hospitals, and the resultant morbidity and mortality that will result will mean that people will die.

This is a political struggle with the Government trying to rebadge Saturday as a weekday, and cut costs and expect people to work these days as a matter of routine. This is something that MPs do not do.

This is a very dangerous time for the service I spent 38 years working for.

By 2020 the end stage of the Lansley reforms and the Hunt contracts will result in a fragmented, inferior, privatised service, and the jewel of our NHS will be a distant memory. In the same way that national Education has gone, Health will follow.

The roll call of shame is, indeed, a very long one: you expect the Tories to be liars, selfish, and arrogant. This is what Tories are. But there are many fellow travellers who should be ashamed of themselves.

These two are at the head of the roll call of shame:

I wonder how they can sleep at night realising what they have done?

The Magic GP tree

General Practice is in crisis, and I see this in contacts I have with all my ex-colleagues. The last time we approached a problem of this magnitude was around the time of the 2003 GP contract. That was the time when the then Government were keen to start privatising aspects of the NHS, and out-of-hours services were seen as an obvious choice. So GPs were bribed to stop out-of-hours, and NHS Direct, commercial GP out-of-hours services and NHS 111 were all introduced.

And we all know how successful that has been!

Last year the Prime Minister promised an extra 5000 GPs by 2020. I really don't know how the Government will achieve this, when there are record numbers of GPs retiring, emigrating or leaving medicine, and applications for training are down by 5% this year alone.

Where are they going to come from?

The magic GP tree at the bottom of the garden?

A Jobbing Patient

These things eventually have to come. Having spent 38 years as a doctor, being the one doing things to other people, or listening or deciding, there comes a time when you are a patient, and stuff is done to you, and you are no longer in charge.

Following a serious rugby injury 40 years ago (collapsed scrum, trapped at the bottom, dislocated knee and torn ACLs) I was offered conservative or radical treatment: I opted for conservative therapy, which meant a Robert Jones bandage, and analgesia. No rest, as I was a junior hospital doctor. That went pretty well for around 35 years, but having the build of a rugby playing man (loose-head prop) meant that the inevitable was merely postponed.

So, I have now had 2 total knee replacements as an NHS patient. The surgery and care was excellent, and I am recuperating, but it is quite difficult not being in charge. I suppose that, as the years progress, I will have to get used to the change in relationship with my doctors (my GP now was a GP Registrar in my practice many moons ago). It isn't easy being passive, and having to rely on others' decisions.

I suppose that makes me a Jobbing patient.

A new Nadir

I thought that I would retire gracefully, and leave it to others to comment on all things medical. I have maintained this self-induced purdah through thick and thin over the last year, and resisted any temptation to comment on matters medical.

One thing has changed my mind, and that is the wondrous incompetence of our current Secretary of State for Health, a certain Mr Jeremy Hunt MP.

Jeremy is a man who takes no advice from anyone medical, for he clearly knows best what to do. You won't need GPs in 20 years time, all you need is a computer and an algorithm to diagnose anything. His tame puppets, like the ghastly Sophie Borland of the Daily Mail (see blogs passim) or Sarah Baxter in the Sunday Times (who sees no need for GPs) dutifully spout his line.

Jeremy thinks we should google skin rashes to make a diagnosis. He thinks this is feasible. This from a man who thinks the privatised NHS 111 is 'successful', and not a disaster as we all predicted - especially as it is run by Care UK (a private firm who gave Mr Hunt's predecessor £29,000 for his private office).

Have you ever seen the rash of meningococcal septicaemia, Mr Hunt? Do you know its significance?

Oh Dear.

I used to think that Patricia Hewitt was the worst Secretary of State for Health: and she was awful. But at least she didn't jeopardise people's health.

Jeremy Hunt - a new nadir.

New man at the helm

There are many people who work in the NHS who are quite clear about the Government's agenda for the NHS, and are not fooled by he apparent muddle of policies that have been proposed, which largely seem a smokescreen.

The agenda has been much the same within the Department of Health since 1990, and has been followed by successive Governments in order, ultimately, to get rid of their responsibility for healthcare in the UK by a slow process of privatisation.

Margaret Thatcher started it, John Major and Tony Blair continued it, and we are now approaching the final denouement.

The return of Simon Stevens, former senior executive of UnitedHealth Europe and special adviser to Tony Blair is the latest example of how an obvious appointment has been given the spin treatment, and the media and many commentators have fallen for it.

The NHS is turning into a mighty mess. Much of the additional funds that could have modernised and made the service fit for purpose in a first world country have been squandered on reorganisations, institutional paralysis and transaction costs of a market model for health care which simply does not work. Does anyone feel that the market model for energy, water and railways has worked to the advantage of the ordinary member of the public or the average worker in these industries? If so take a long hard look at your utility and travel bills.

Simon Stevens is a clever man. He does, however, work for the private health care industry. He will now be at the helm when the NHS is starting to be parcelled out to the private sector, and I cannot accept that he won't see the whole process continue to support the private health industry.

It is a bad day for the ordinary man. Neil Kinnock said famously that he warned people not to get ill or old. We all thought that was typical welsh oratory: it turns out to be scarily true.

Goodbye NHS.

Open letter to Steve Field, inspector designate of General Practice

Dear Steve,

May I congratulate you on your new post of Chief Inspector of General Practice. You are certainly well qualified for the post, having been a GP, a Course Organiser, a Regional Director of GP Education, Chair of Council of the Royal College of GPs, and Chair of the Future Forum. You have also been made a Professor, and have received awards from the Government for your work. A stellar career, for sure.

Meanwhile, I stayed a course organiser and a full-time GP.

We now see things from different perspectives.

The NHS is lurching towards a crisis. All those who are working at the front-line state that the service is hugely overstretched, and nearing crisis point. I'm sure that you have received this message from many front-line workers. The Government's solution is to marketise the system, seek cuts to be made (variously called the 'Nicholson challenge' or 'efficiency savings') . As the Chief Inspector of General Practice - a new post - you will be able to see this first hand.

The profession is as demoralised as I have ever known it. The causes for this are complex, but are based around a number of factors: firstly, the constant and vindictive sniping from aspects of the media, and also the Department of Health; secondly, increasing control from the centre through perfomance-related pay initiatives and revalidation of doctors by the generally dysfunctional GMC; thirdly the lack of investment in General Practice; fourthly, the seeming impossibility of those in power to listen to anyone at the front-line (except a few hard-line supporters in leafy shires); fifthly, the increasing demands on the service from demographic changes, as well as increased general demand. I could go on (and some of my colleagues will point to areas in this list that I have not mentioned).

There are very few people with the power and influence to affect the way in which Government policy since 1990 has been leading us to this point. The NHS was the unique selling point of this country, and in England it is being destroyed at a rapid rate. We wish to save it if we can, and you are one of the people that Government listen to.

You can achieve a lot by focussing on the role that you want, rather than the brief you have been given. Inspection should be a neutral process, and should have people doing it who are fiercely independent and are willing to point out mistakes, not only in front-line services, but how policy has caused this.

There are two role models you can follow. The first is Chris Woodhead, the second is Stephen Tumim. They were both chief inspectors - one of Ofsted and one of Prisons.

Chris Woodhead was a zealous promulgator of Government policy, and was more extreme than most of the politicians he reported to. He was, in my view, overpromoted because he was willing to do the Government's dirty work, and say things that ministers were thinking, allowing them to distance themselves from the more bizarre elements of right-wing policy. He was loathed by teachers as a hatchet man.

Stephen Tumim inspected prisons and told Governments not only what the service could do to improve the system, but also castigated Government for decisions that made it more difficult to run the service. He was independent, widely-respected and a force for good in the system.

So, Steve, I want you to ask yourself if you will follow the Woodhead model or the Tumim model? The way your colleagues see you will be directly affected by what you make of this.  You have an opportunity to make a big difference.

Can you do it?

Kind Regards,

Dominic.

Always something to discover....

What is it?

I would have described myself as a pretty experienced GP, and certainly 33 years in a full-time job would prepare you for anything, and I have seen pretty much every condition in my time, including a lot of rare ones.

I have seen and diagnosed Wegener's granulomatosis, and Hayley-Hayley disease, I have seen all the rare childhood cancers including Wilms' tumour, so I wasn't expecting to be surprised by a condition I had not heard of.

Since retiring, I have started to do quite a bit of walking. It is hard work when you have the physique of a prop forward, and the weight to match (and a bit extra for the added pies), but I am persevering. This means that I am meeting with people who walk, and have come across a condition that is new to me: Golfer's Vasculitis. This is an irritating purpuric rash that occurs in people after they have walked for a while. It seems more common in older people, and in women. It occurs after longer walks, and not in runners.

It is entirely benign, and is diagnosed on the history and examination (tests aren't necessary provided the walker is well), but is a little unsightly, and takes a few days to subside.

You can take the doctor out of medical practice, but can't stop a doctor thinking and analysing like a doctor!

Travels if France - Poitou

Friday 23rd August

Chateau d'Eveques

Another travelling day, when we made a slow and enjoyable trip south of Poitiers towards our next stop East of Limoges. We started by visiting the ancient medieval city of Chauvigny, and wandered around the citadel looking at ruins, churches and the like.

There was a rather striking ruined chateau called the Chateau d’Eveques (of bishops) but it was getting very hot so we curtailed the walking around. 

The afternoon took in St Dorat, and we were surprised at the number of British people in quite a small, out of the way place. Lovely old church, mind.

Travels in France - Poitou

Thursday 22nd August

Old town in Poitiers

Today we visit the main city in the Poitou. Poitiers has a resonance being the site of two battles, one a victory for the Franks in the 8th Century, and the other a decisive conflict in the 100 years war in 1356, won by the English. Funnily enough, only one battle is mentioned in the tourist information.

Cathedrale St Pierre

Poitiers is a smallish city, considering its strategic importance and its role as the one-time capital of France, and that is its strong point. Three routes were neatly laid out in coloured paints, and we did two of them, one to the old town (route jaune) and one to the cathedral of St Pierre (route bleu). Each walk was around a mile long which was plenty. There were some lovely old buildings, but we were unfortunate to arrive at the ancient Baptistery de St Jean just into the French lunch hour.

The facade of the Cathedral of St Pierre was pretty amazing and we enjoyed looking at all the little figures painstakingly carved in the stone of the Portico.

Frescoes on ceiling of the Abbey

In the afternoon we went off to see the frescoes in the Abbey of St Savin, which was around 30 miles due East of Poitiers. They depicted scenes from the bible including the stories from the first 5 books of the bible. It was interesting, although the exhibition was only in French, which made it hard work to translate. That was enough for one day and we returned to the Chateau for a lovely evening meal.

Travels in France - Loire valley

Travelling again, but at quite a leisurely pace. We called into Saumur and had a look around, including the old town. The Eglise St Pierre was closed for major works, and as we had seen 2 Chateaux yesterday, we decided that a beer was better. So we pootled off to Chinon for a beer, and a light lunch (assiette de charcuterie for me)and a trip to the Hypermarche for some wine. Then we had a short stop in Loudun, prior to arriving late afternoon at the Chateau du Boise Doucette. It is lovely and relaxing and very quiet. It is around 7 miles from Poitiers.

Sunflowers galore!

Madame is very talkative, but speaks French in a Poitevin accent, that makes Biere sound like Pierre. Talking only french is hard enough without this - I suppose it is like understanding a geordie accent in England. 

The sunflowers are amazing outside. Indeed there seem to be only two regular crops in the Poitou - sunflowers and Maize.

Travels in France - Loire Valley

Tuesday

Chateau de Chenonceau.

When in the Loire valley you have to visit  a chateau, and so we chose the Chateau de Chenonceau, around 10 miles south of Amboise. This lovely chateau that straddles the river Cher is steeped in history - Catherine de Medici, Diane of Poitiers, Louise of Lorraine,  Charles VIII of Frances, Francis 1st of France, and even up to the second world war when Jews were smuggled through the property to freedom.

Lunch was back at Amboise, and after that we went to see the Chateau where Leonardo da Vinci lived for 3 years prior to his death. We were on the English-speaking tour of the chateau, and there were only two of us on that tour. Hugely enjoyable. He is actually buried in Amboise, in the chapel of St Hubert.

Note to self, Vouvray is very nice as well.

Travels in France - Loire Valley

Monday

Travelling day, and we hope to spend a lot of the day in the ancient city of Tours. This is deep in the Loire valley, and definitely wine-drinking country (Saumur and Vouvray particularly).

Cathedral of St Gatien, Tours

Today was spent mostly in Tours, and we visited a number of the more interesting parts of Tours. Firstly we saw the imposing cathedral of St Gatien, and marvelled at some of the amazing stained glass windows. Many of the windows had stories to tell, including the lives of St Martin and St Nicholas.

A short walk across the city to the old town, which is now full of restaurants and boutiques. Lunch was essential, and we then followed that with a trip to see the Musée des Beaux Arts. Having settled into our new residence (which I discovered later had WiFi) we went to the village of Vouvray, which was blighted by a hailstorm in late spring and many of the vines were damaged for this year. Vouvray is tiny, so we looked at the church and bought some wine (Vouvray, of course). The evening meal was terrific at a local restaurant, and we shared a bottle of St Nicolas de Bourgueil [Note to self - I really like St Nicolas de Bourgueil]

Travels in France - Western Loire valley.

Saturday 

Another day of travelling, this time from Bayeux south past Le Mans and into the Loire countryside. The venue is Chateau de Montaupin at Oizé, and the whole building is quite imposing. It also has a small swimming pool and the water is very cold. I might just have an early morning dip, although, on the other hand, I might not.

The evening meal was a meal for 18, with all the guests being English speakers. The meal was magnificent, and tired we went to bed.

Sunday 

Le Mans - old town

Slightly overcast this morning, but is probably going to be very hot today. The weather never really made its mind up and we had both sunshine and showers. 

A good day for a trip into Le Mans, which is known as an automobile city, but not for the quaintness of its old town, and the majesty of its 13th Century Cathedral. As it was a sunday, when we walked though the old part of town, inside the ramparts, there was virtually nobody there. 

We saw the cathedral at the second attempt, the first one being sabotaged by the fact that there was a mass on. We wandered off to a local museum (Museum of Reine Berengère) and saw the cathedral at the second attempt.

By this time the weather was changing, and we dodged a heavy shower by dint of being in the car.

Travels in France - Upper Normandy

The first two days of our holiday have mostly involved travelling. Home to Dover is a reasonably quick route involving a series of different motorways: the route was direct, although we did hit the obligatory traffic jam on the M25 near Hertford, because of roadworks.

View from our bedroom

The crossing was quick and efficient, without any problems to speak of, and from Calais, the main aim is to get out of the flat and boring countryside that is the Nord Pas-de-Calais as quickly as is possible. We elected to take the more coastal route that took us  towards Le Havre. The journey was a lot longer than was predicted on google maps, so we stopped at an Aire, where we had cold drink, and saw ducks and a load of enormous fish - they looked like carp to my inexperienced eye - there must have been dozens of them. They were is a canal that ran alongside the Aire, and were being fed by other travellers with pieces of bread.

We headed for Le Havre, and drove through an very impressive series of three bridges across the harbour and the estuary of the river Seine. The view was stunning, and one of the bridges (they were all quite new - presumably built after second world war damage to older bridges) must have had a gradient of at least 1:2. I was the passenger so could linger on the view. 

More travelling afterwards - indeed with the four hours in England and the five hours in France, it made for a surprising day. We arrive at La Suhardière around 6 pm local time, and the house is really pretty. Off the road, just before Caumont ‘l’Eventé, and quiet.

There are two other guests, a mother and her adult son, who are having dinner with us. They speak no English at all, so I have to manage with my ‘O’ level French! It seemed to be satisfactory, however. The food was lovely, and home made, of course. Courgette tart, then Escalope de Dinde with haricots verts, then a rhubarb tart, and then cheese. Très typique! Madame started with a lovely home made aperitif/digestif. It was quite refreshing!

So tiring, so we went to bed.