Monthly Archives: December 2014

BMA chair also ducks the issue

A letter from Dr Mark Porter to BMA members is revealing. He also is in denial, but the illusion to meltdown is correct. This is a virtuous and altruistic letter in every respect except that it avoid the funding and demographic issues. (There is a string of copied text with empty boxes between – so please follow down the pages)

Melting Snow cartoons, Melting Snow cartoon, funny, Melting Snow picture, Melting Snow pictures, Melting Snow image, Melting Snow images, Melting Snow illustration, Melting Snow illustrations

How the NHS is like a snow globe:

Here’s a paradox. How can a national consensus also be a source of constant dispute and contention? You might have guessed that I’m talking about the NHS, and it’s during an election year that we notice this paradox most of all. When the parties start publishing their manifestos, you can guarantee that each will contain a strong statement of support for the NHS. The support will sound convincing. Every day in the NHS, we work hard to maintain the trust that our patients place in us. They in turn want the NHS to thrive, and the parties reflect that. But all too often politicians make promises as if words alone can improve the NHS. Resources and commitment are vital too. They pledge thousands more GPs, for example, but with no apparent recognition of the growing and unsustainable pressures faced by general practices, and when the numbers entering GP training in England have actually dropped by 15 per cent this year alone. And after each election, the new minister has the power to make us feel as if we’re in a giant snow globe.




A colossal hand reaches for the NHS, and we’re being shaken up again with some new laws and organisations




After the turmoil the snow settles; everything’s in a different place, but little has been made better than it was. The time and endeavour would have been better spent in protecting what we are in danger of losing through starved resources and an obsession with competition and markets. The NHS is, according to the highly respected Commonwealth Fund, the highest-quality and most cost-effective healthcare system of 11 leading economies, including Germany, France and the US. And so our many foreign admirers ask the same question: if the system is that good, why do your governments keep playing around with it? For doctors, it’s doubly frustrating when there has been so much unnecessary reorganisation, while real opportunities to improve services have been repeatedly passed over. There is nothing more demoralising than trying to make failed policies work, but doctors have never been a passive or a reactive voice. It’s down to all of us to articulate and create an NHS that serves our patients best, in whichever nation we work. The BMA has already produced its own manifesto for the UK general election and this year we will be building on our existing policy work to create a detailed vision for the future of the NHS in England – an NHS in which change must be evidence-based, clinically led and right for patients. Reviving our marginalised, fragmented and underfunded public health services will be a major part of this vision. Whoever is in government, we must lobby for every policy to be a health policy. Sir Michael Marmot, a former BMA president, has laid bare the deep and increasing inequalities that shape health outcomes. Health is devolved to national governments, but there will be many policies enacted at UK level that have a profound effect on our patients’ lives. Anything, anywhere, that betters or worsens the health of our patients is our business too.





DDRB must prove its mettle



Only in Westminster does the world begin and end with a general election. Unlike Parliament, our hospitals and GP practices do not go into recess. Patients are always with us, and so too are the issues that affect their care – issues on which we will continue to work before, during and after the election. Over the past 18 months, we have been trying to agree a new UK junior doctor contract and a new consultant contract for England and Northern Ireland. We negotiated in good faith and were very disappointed when the contract talks stalled. However, in the absence of credible evidence to underpin proposed changes and for the sake of assuring the safety of both patients and doctors, we could not accept changes to either contract that removed key safeguards against working dangerously long hours. No patient wants to be seen, or should be seen, by a doctor who is too tired to function properly. The juniors contract for all four UK countries, and the consultant contract for England, Wales and Northern Ireland, have now been referred to the DDRB (Doctors and Dentists Review Body) by the national governments for observations and recommendations. In the case of Welsh consultants, we think it wholly wrong that the DDRB has been asked to step in given that there have been no prior negotiations between BMA Cymru Wales and the Welsh Government. All the other DDRB referrals follow extensive negotiations.




The DDRB has been given a highly significant role and it must demonstrate its robustness and independence




For years, despite compelling evidence of declining morale and increasing workload, its recommendations have been very similar to those of the governments. Our real-terms pay has lost value year by year. This year, we expect the DDRB to test and challenge all the evidence that comes before it. We expect searching questions, and we are able and willing to answer them. This scrutiny should highlight the fact that we were asked to sign on the dotted line with neither a definition of weekend services nor evidence as to the impact on doctors, or your families. For GPs, it’s not so much a case of which party marches into Downing Street as who or what can rescue primary care from an inexorable rise in demand. I’m not even sure that giving GPs the resources they need can be described as a ‘political’ issue given that their need is utterly beyond controversy. Another issue with a lasting and potentially negative impact is the Shape of Training report, which could substantially reduce the experience and training that junior doctors acquire before becoming consultants. So much so that the word ‘consultant’ may not continue to mean what it does now. The first of the four UK health departments that commissioned the report is likely to give its response early this year. It might not be a big election issue for 2015, but if some of the changes go ahead and patients can no longer access the specialist skills they need, it certainly will be in future elections.





Asking big questions on your behalf



There are ‘events, dear boy’, as Harold Macmillan famously put it, and then there are the changes in our culture that tend to get missed in a politically noisy year. Nearly 40 per cent of UK doctors with a licence to practise have already undergone revalidation, and by the end of 2015 this figure is likely to be more than two-thirds. We are less insular as a profession, and we are the better for it. If the goodwill and energy that doctors have put into the process is to be maintained, it is essential that it should not be burdensome. Sessional GPs are among the doctors who have reported an unsupportive and unrealistic appraisal process. We have published seven principles for a robust and fair revalidation process.




There is little more deeply rooted in our hopes and fears than how and when we die




This year, we are beginning a major research project, which aims to engage doctors and patients in exploring the practical and ethical issues around end-of-life care and physician-assisted dying. We are planning a number of events around the UK with the public and doctors, and we hope to compile the most comprehensive body of qualitative research carried out on the subject in the UK. How people die, and how well they die, are means by which we characterise and judge societies. We are fascinated, and often appalled, by how ancient societies handled it, and we might wonder how our own will be judged. This is a reminder, although I think only the politicians need one, that it’s the government that changes on election day; other changes in society can take a little longer.


With best wishes for 2015,


Mark Porter

BMA council chair

Being able to get a GP appointment is people’s number one priority for the NHS to address over the next year

Healthwatch England says “Being able to get a GP appointment is people’s number one priority for the NHS to address over the next year”… The full report 31/12/2014 is on line here.. NHSreality feels that even more important is to have the realistic debate which covers pragmatic, ethical and educational approaches to rationing overtly rather than covertly. Putting more money into the bucket with a hole in, or spreading the jam thinner than ever just wont work… (A first debate in West Wales BMA – on rationing – wins a majority in favour)

Improving access to GPs

Being able to get an appointment with a GP is the number one priority for the NHS to address over the next year, according to a survey of local Healthwatch.

Asked to outline the biggest health and care issues for their local residents, our network of 152 local organisations identified people’s struggle getting to see their family doctor as the key concern for 2015.

In total 63 local Healthwatch flagged primary care services as their focus, citing reports from the public about poor appointment booking systems, short appointment slots and poor staff attitude, particularly from receptionists.

Anna Bradley, our Chair, said:

“It’s not surprising to hear access to GPs coming out as the top issue. Everywhere I go I hear about people’s frustrations getting an appointment with their doctor.

“There are lots of ideas on the table at the moment about how this can be improved, from evening and weekend opening to setting new targets around guaranteed waiting times, but the real key here is to ask people how they want to be able to access primary care.“Over the next year lots of local Healthwatch will be having this discussion locally and at national level we will be giving people a chance to share their views with decision makers – whether they want GP drop-in centres put in supermarkets or 24 hour access by Skype.”

Greater focus around discharge planning

The second most important issue was ensuring that people are given the support they need to help them recover properly when they leave a hospital or care home came.

This will require a much greater focus on discharge planning and greater communication between services, with local Healthwatch focusing on challenging providers to improve current practices to ensure everyone experiences a safe and dignified discharge.

Ensuring people are properly engaged and involved in discussions around changes to local services

In at number three, local Healthwatch said they would be focusing on ensuring local commissioners properly engage and involve their communities in the crucial conversations around changes to local health and care services.

Listening to the people they serve about how and why they currently use services and having an open conversation about options for the future is the only way those in charge of hospitals, GP surgeries and care services can truly co-design sustainable services.

What else is on the list?

Other issues that appeared in the top ten include access to mental health services, the quality of domiciliary care and complaints handling by health and social care organisations.

The people’s top 10 health priorities for 2015 according to local Healthwatch are:

  1. Access to GPs
  2. Hospital Discharge
  3. Service changes issues and the impact of the Better Care Fund
  4. Involvement of children and young people in health and care decisions
  5. Quality of care homes / residential care
  6. Access to children’s and adolescent mental health services (CAMHS)
  7. Access to adult mental health services
  8. Dementia services
  9. Domiciliary care
  10. Complaints

Everything Healthwatch says and does is informed by our connections to people in every town, city and county in the country. This list of priorities compiled by local Healthwatch will therefore shape our work over the next year to put people at the heart of their care.

This list was compiled from a survey of all 152 local Healthwatch conducted during in November and December this year.

For more information please contact Jacob Lant, Media Manager at Healthwatch England, on 020 7972 8036 / 07768 648 128 /


Lesson Learned? There is no substitute for clinical experience and judgement

Judgement and experience is something Pauline Cafferkey obviously had, and the ability to see the weakness of the protocols on entry to the UK. Despite this she was let in. An Australian type system would negate an already low risk, but 3 weeks quarantine would deter volunteers and be expensive. Chris Smyth reports 31st December 2014 in The Times: Ebola nurse was cleared after testing ‘shambles’

…Ebola can be passed on only via infected bodily fluids, and Dame Sally said that someone would have to be “spat upon with a sneeze very close-up” to be at risk. Patients in Aberdeen and Truro are also being tested for ebola after returning from west Africa, but are thought unlikely to have the virus.

Jonathan Ball, professor of virology at the University of Nottingham, said that many scientists were sceptical about screening because symptoms can take three weeks to appear, and passengers leaving affected countries are tested. “Many of us, when the announcement about screening was made, said it wouldn’t be effective because you’re reliant on someone developing a temperature during the journey, and that’s a very small window,” he said.

Physician Assistants (“Physician Assistants”, as proposed by ministers, trained for 2 years, will increase inequalities and litigation. Back to Health Post workers?) will work to protocols and algorhythms. There will be missed diagnoses, and sub-optimal care (Heuristic decision making – ignore part of the available information, basing decisions on only a few relevant predictors.), but it is better than being completely without staff. Australia has opted for the lowest risk approach. (Australia stops processing visas from West African nations affected by Ebola ). Have lessons been learned? There is no substitute for clinical experience and judgement…

Is this the way we descend from being 1st world to being 2nd or 3rd world?

Morland cartoon

Letters in the Times point out (30th December 2014) how little the comparison holds between an airline and a Hospital: Can the NHS learn about risk from airlines?

We urgently need to address the causes of drug and equipment errors which kill or harm patients

Sir, You suggest that the NHS has a lot to learn from airlines about avoiding unnecessary risk (“Safe as Planes”, leader, Dec 24). This is an analogy commonly used to berate NHS staff, carrying the implication that “many harms could be avoided if only the doctors and nurses were to follow sensible procedures”.

About ten years ago, when I was clinical director of the medical admissions’ unit in a medium-sized acute hospital, I was invited to a meeting organised by the Department of Health. The (then) chief medical officer lectured us on safety, taking the approach “what can we learn from the aviation industry?” The more he talked, the more it appeared that he did not know what it was like in a medical admissions’ unit, and that the things he advocated — although desirable — were totally impracticable. I was unwise enough to pursue the aviation analogy with him later. I explained that, whenever I’d been on a plane, the number of passengers was limited to the number of seats, and that the plane didn’t take off until the pilot thought it was ready to do so. I asked him if there was anything useful that the NHS could learn from this. He didn’t give an answer, and I haven’t been invited back since.

Dr John Firth
Consultant physician, Cambridge

Sir, Whether addressing the causes of drug or equipment errors which kill or harm patients (report, Dec 24), or road and aviation accidents, there are two principal lines of investigation. First, was the health professional, driver or pilot up to the job in performance terms; and second, was the task they were expected to undertake made overly difficult — beyond their ability to cope — because of poorly designed equipment or delivery systems?

What is known is that operator error is to blame in a high proportion of incidents, no matter the field of activity. And to try to improve performance both individually and across the board is a costly hit-and-miss affair. Professor Reid is right to focus on the need for co-operative redesign action by the NHS and its equipment and drugs suppliers; and, if necessary, the NHS should wield its considerable purchasing power.

If the NHS needs any persuasion it can look to the reduction in motor vehicle accidents that has occured largely as a result of better designed roads and safer cars.

With hospitals under pressure from increasing throughput and the consequent risk of error levels increasing, and with many patients self-administering drugs, it is of increasing importance that the operation of equipment and systems should adhere to a lowest common denominator approach, to reach a wide variety of “operatives”, if errors and deaths are to fall.

Morton Warner
Emeritus professor, University of South Wales

Sir, The avoidance of unnecessary risk in hospitals must indeed be minimised. Your airline analogy is, though, perhaps unfortunate. The National Institute for Health and Care Excellence recommends that women with straightforward pregnancies should have babies at home because it is “generally safer”. But suppose you are on a flight. The intercom crackles to life and a voice says “Hello! I am Gordon Brown and I am your pilot today. I thought you would like to know that I have been fully trained except in the details of what to do if an engine fails or there is a major fuel leak. But I am pleased to say that my senior colleague, who does know how to deal with those, is waiting at the end of a telephone in case of an emergency.”

Would you happily take off? Change the words and ask yourself whether you would like your sister, wife or daughter to fly in a midwife-led unit. If we are to learn from airlines we must be consistent; the risk of an out-of-hospital birth may be small, but if the untoward occurs the result could be catastrophic.

Dr Andrew Bamji
Rye, E Sussex

Sir, The NHS is good at product innovation; adopting in new drugs and procedures, but process innovation is more challenging. It is much easier to innovate in applying new services. It is much more difficult to change practices.

By intention or oversight, the NHS practices “distraction management”, focusing on technological innovations while ignoring or neglecting the basic activity of improving the existing service — which is far more important.

Dr David Allen
Management tutor, School of Medicine, Manchester University



The Future for our Health Services

The Times has a series of articles on line titled “The future of the NHS.. None of them addresses the reality of covert rationing, dishonest debate, gagging, over management and poor information technology… None of them addresses the holistic nature of the service or the deliberate introduction of sub-optimal care (Heuristic decision making – ignore part of the available information, basing decisions on only a few relevant predictors.) In a special report in The Telegraph 29th December 2014 Robert Colvile describes watching a “Night one of our brightest and best hospitals was defeated by the dire state of the NHS”.

Healthy Service 18th October 2014


The NHS will not withstand another botched revolution. But without evolution it will continue to underperform

Mental health still surviving on the crumbs 16th October 2014

Mental Health Trusts have lost £250 million in funding since 2012, with the six leading mental health charities warning cuts “will put lives at risk”

Health advice from chief medical officer

Dame Sally Davies says she doesn’t want to be the nation’s nanny, but insists the government must encourage healthier lifestyles

In the illness lottery, cancer is winning

Some worry that the postcode lottery has been replaced by a disease lottery, in which access to treatment depends on the illness a patient has

NHS chief calls for cancer drugs scrutiny

Patients face more rationing of treatments on the government’s Cancer Drugs Fund, as health chiefs said the present system was not working

‘I want my wife’s death to liberate doctors’

Lord Saatchi’s Medical Innovation Bill, which is debated in the Lords next week, is intended to liberate doctors to try new treatments

Inadequate GP practices will have to shut

Hundreds of GP surgeries are not good enough and many will have to close, the chief inspector of family doctors has said

‘Cut social care and the system stops working’

Andy Burnham is championing an integration of the health service and social care that would help elderly people

Where did Labour’s prescription for treating the Welsh go wrong?

The doctor will skype you now

GPs must think big to cope with the strain

Unions threaten a winter of strikes

Heuristic (sub optimal) decision making – ignore part of the available information, basing decisions on only a few relevant predictors.


Marewski JN and Gigerenzer G. in PubMed based on Dialogues Clin Neurosci. (2012 Mar;14(1):77-89.) write on Heuristic decision making in medicine. As described, this fits in well with a theme of the 2014 Reith Lectures, in that algorhythms used in Surgery and possibly all aspects of medicine may improve outcomes and reduce mistakes. Heuristic implies sub-optimal care, something that the Regional Health Services are living with, but without coming out with it. Inevitable rationing results. The only debate is whether it should be overt or (as now) covert: In other words honesty as a virtue should be present rather than absent in our discussions of health, and the inevitable sub-optimisation of care when whole populations are considered.


Can less information be more helpful when it comes to making medical decisions? Contrary to the common intuition that more information is always better, the use of heuristics can help both physicians and patients to make sound decisions. Heuristics are simple decision strategies that ignore part of the available information, basing decisions on only a few relevant predictors. We discuss: (i) how doctors and patients use heuristics; and (ii) when heuristics outperform information-greedy methods, such as regressions in medical diagnosis. Furthermore, we outline those features of heuristics that make them useful in health care settings. These features include their surprising accuracy, transparency, and wide accessibility, as well as the low costs and little time required to employ them. We close by explaining one of the statistical reasons why heuristics are accurate, and by pointing to psychiatry as one area for future research on heuristics in health care.

I realise it is sub-optimal to eat red meat as much as I do… Hannah Devlin reports in The Times 30th December 2014: Sugar in red meat may explain a sausage’s links with cancer but then, we do need to have choices so that we can run the risk of living shorter if we choose..

Access is also sub-optimal, especially to appointments in General Practice where queues in the early hours hit the headlines over the pre-Christmas period. In The King Canute GP appointment system in the British Medical Journal (BMJ 2014;349:g7228 Ron Neville and Simon Austin write on how the practice stopped fighting the tide and let patients have appointments when they wanted…

Reading this article shows that the change helped parents with young children, and that the elderly evidently tolerated it. The longer term evaluation, in areas where there is competition,  may find that patients with a choice might move to a practice with more predictable appointments…..

The Pyramid of Project Payoff. Alternatively, the Mountain of Mediocrity or the Slag Heap of Sub-Optimal Outcomes.



Parliament needs to decide on assisted dying. Without it we are increasing inequalities….

The Telegraph leader opines 29th December 2014: Parliament needs to decide on assisted dying … And you can listen to Lord Falconer as well.. NHSreality supports a Dutch Style legal process, as without it we are increasing inequalities.. The BMA and our elected representatives have rejected the option – I believe against their members/constituent’s wishes. Something is really wrong with our democratic structures when 20% of voters rule the parliament, and doctors opinions are excluded if they are too busy to attend conference.

Editorial Cartoon: Jack Kevorkian

It is right that there is a vote on assisted dying. But its supporters must accept the result if it is not the one they want

Few subjects excite greater controversy or divide opinion more than helping the terminally ill to die. For several years now, efforts have been made in the House of Lords to frame legislation that would allow doctors lawfully to assist in bringing a life to an end in certain circumstances.

Last July, peers gave a Second Reading to Lord Falconer’s Assisted Dying Bill and in November an amendment was agreed to include the additional safeguard of judicial oversight. However, it is highly unlikely that this measure will complete all its stages before Parliament is dissolved at the end of March for the general election.

In a letter to this newspaper today, supporters of the Falconer Bill, including doctors and leading clerics, urge the next Parliament to resolve this issue once and for all. They argue that the progress of the legislation leaves Britain “closer than ever” to a change in the law and they want the political parties to commit to providing legislative time to make it a reality.

Although we have long opposed the legalisation of assisted dying, we agree that Parliament needs to reach a settled conclusion on this issue. It cannot be gainsaid that opinion polls consistently show large majorities in favour of such a reform, though we would maintain that when the arguments are fully aired and understood, this support will diminish.

One problem is the “slippery slope” potential, which proponents of the Bill refuse to acknowledge. Their argument is that strict safeguards have now been attached to the legislation, requiring the assessment of two doctors and a High Court judge before assisted dying could be made available. But as we have seen with abortion, it is not long before such apparent protections are watered down, however good the initial intentions may have been.We only need to look at countries such as the Netherlands and Belgium to find the “normalisation” of euthanasia despite a host of so-called safeguards. Just as the signatories to today’s letter have strong views in favour of assisted dying, it would not be hard to gather together an alliance of opponents who could put an equally powerful – and equally well-intentioned – case against.

For this reason, it is right that Parliament should find time to see this legislation through to a conclusion, rather than leaving such an important matter to ad hoc rulings from the courts and prosecutors. This is precisely the sort of debate MPs and peers should be having. But it also means that if they vote against assisted dying then its supporters should accept the outcome and not keep coming back time and time again until they get what they want.

Mark Tran reports in The Guardian 29th December 2014: Assisted suicide campaigner Debbie Purdy dies aged 51

Activist won landmark ruling that led to clarification of law on right to die


And Kat Lay in The Times 30th December 2014: Assisted suicide campaigner Debbie Purdy dies in hospice 

Update 30th December 2014 from Peter Harvey in The Telegraph under the title: Letters: Legitimacy of hastening death must not be decided by public opinion polls

SIR – I am interested in the claim (Letters, December 29) by those writing in support of legalising the hastening of death that “an overwhelming majority” of the public supports such a change in the law.

I suspect that, given the choice, an overwhelming majority of the public would support many things, but acquiescing on the part of those who govern us is not the purpose of representative democracy, and even minority views still have legitimacy.

So, speaking as one who has supported a close relative through his last days and, while not acting to prolong that life (as this was not his wish), did not act to hasten death, which was finally and by any measure painless, I would like to record that I, for one, do not support the legislation that so many apparently advocate. I suspect I am not alone in that.

Peter D Harvey
Walton Highway, Norfolk


The rise of the £300,000 NHS fatcats – they are not worth it.

Laura Donelly for The Telegraph 29th December 2014 reports: The rise of the £300,000 NHS fatcats. This is where rationing needs to happen as well. They are just not worth it..

Investigation discloses doubling in number of NHS managers being paid equivalent of at least £300,000 a year, with some on as much as £620,000 annually

The number of NHS managers being paid the equivalent of more than £300,000 a year has doubled in just 12 months, it can be disclosed.

In some cases, cash-strapped health trusts are hiring temporary executives for hundreds of thousands of pounds, an investigation by The Telegraph has found.

Patients’ groups said the “exorbitant” rates could not be justified, and nursing leaders said the sums were a “kick in the teeth” for junior staff who were refused a one per cent pay rise.

NHS board reports indicate that during 2013-14, 44 “interim” executives were employed on rates of £1,000 a day — the equivalent of £228,000 a year — compared with 24 the year before……