Monthly Archives: April 2016

The new junior doctors imposed contract. “Free will”, and “strike or leave”… The result of abandoning the health services over a long term..

NHSreality commented 20th July 2014: Lets sell the family silver: abandon the health services to covert rationing and market forces. As empires fell in the past (Roman, Aztec) they had little insight into why. It seems our politicians remain blinkered and in denial, and will do until the inevitable knee jerk response

Two letters in The Times 28th April 2016 emphasises this:

Sir, The disaster of the junior doctors’ strike, whichever side wins, is the long-term effect it may have on the medical workforce. Foundation year applications to Scotland and Wales are up and to England are down. It is strongly rumoured that many specialty training places in hard- pressed specialties are for the first time unfilled. Many health trusts have difficulties filling rotas for various reasons and services can function only with the help of locum doctors.

The locum pay cap (a co-incidental and badly timed intervention), as well as rota staffing problems, mean that services are under real threat; some have reconfigured already. Locum pay rates are in the main not excessive, but now, at £20 per hour for mid-level trainees, when tax, national insurance and travel costs are deducted, what is left barely covers childcare.

It is bizarre for a government that espouses the free market and inflated salaries to captains of industry to exercise Soviet-style wage restraint through a monopoly employer. However, these talented and motivated young professionals have one thing that Soviet doctors didn’t have: a free will. It is to their sadness and our detriment that many will exercise it.
Christoph Lees, MD, MRCOG
NHS consultant obstetrician, London W14

Sir, Gregory Shenkman (letter, Apr 27) misses the point about striking doctors. There are two ways to withhold your labour from the NHS: strike or leave. Those who are striking (in their thousands) for a sustainable NHS show a stronger sense of duty and vocation than those who are leaving (in their thousands).
Mary Cole


Free markets in health workers distorted – a perverse incentive created by politics

Knee Jerk responses and short-term actions are not in the long term interest of health.. In a “free market” politicians threaten to cap agency/locum fees.

Which party espouses the market philosophy, and then tries to subvert individual response?

Our NHS is in serious danger – we should be scandalised – GPs are being paid not to refer cancer patients to hospital and free hearing aids are being axed. All the politicians are cowards.. This is a healthcare system under strain, but where is the debate?

In an undercapacity market who can blame the nurses or doctors? £190m is “comeuppance” for politicians. NHS nurse recruitment from EU ‘too aggressive’!

Who abuses free health systems most? Will the US have to ration overtly?

Lets sell the family silver – abandon your Health Service to market forces and covert rationing

Perverse incentives and unintended outcomes and consequences – an ironic, confounding and idealistic volte face. Short term policies are dominating. Knee jerk responses and rationing will follow..

“It’s all in your head”. The result of poor teamwork and no disincentive to make a claim.

Doctors may wonder if Suzanne O’Sullivans new book (It’s all in your head) and the information therein applies to other jurisdictions and medical systems where there are co-payments and/or disincentives to make a claim. In my own practice we discussed such patients as a team, and worked out strategies for them. If this is not done, and the team is dysfunctional or more like a chambers than a team, patients can play one doctor against another – and often do. Hysteria is very common, but in some cultures it is distracted into voodoo, witchcraft or the Shaman, or alternative medical models, not a burden on the state. The percentages are devastating. 60% of Gynae, 50% of Medicine, 35% of Rheumatology and 30-40% of GP work is on unexplained symptoms. That’s not to mention pain clinics, or worried about dementia elderly clinics, many without psychologists! The use of effective placebos has been virtually banished (apart from homeopathy). The pareto principle whereby 20% of the population give 80% of the work and costs seems an understatement for the UK Health Services. The information is well documented in GP Educational Literature (The Heartsink Patient 2011, and Suburban Shaman: Tales from Medicine’s Front Line Paperback – 27 Jan 2006  ) but has not been put together in a book for the politicians and public. If “free at the point of access” and from “cradle to grave” results in this expenditure we have to address it. Overt rationing and co-payments may not solve the problem, but NHSreality guesses it will reduce dramatically as a drain on the health service. It will still exist – but go elsewhere. The book may well reveal the gulf between GP training  and neurological training. The “Drug Doctor” has been well known since the work of Michael Balint..

BBC News reports: Wellcome Prize won by book about psychosomatic illness and Helen Rumbelow in The Times writes: What if your illness is all in your head? – A neurologist’s book on psychosomatic disorders could revolutionise our healthcare

It was late when Suzanne O’Sullivan was called to the hospital. One of her patients, Lorna, was writhing in severe pain, which escalated into full-blown seizures. The woman was thrashing so hard on the floor that two doctors and a nurse were struggling to protect her: the only option seemed to be to prep her for an emergency operation to address the cause. “Why didn’t you give this girl treatment for her seizures!” the anaesthetist shouted when she arrived at the panicked scene.

O’Sullivan, a senior neurologist, “suppressed the words that were perilously close to the tip of my tongue” and didn’t reply. Instead, she told all the medical staff, some now nearly crying at the woman’s trauma, to leave the room. She already knew what Lorna was suffering from. Five minutes later, Lorna was sitting up in a chair: upset and confused but physically healthy.

“I have met a lot of Lornas,” O’Sullivan writes in It’s All in Your Head, which won the Wellcome Book Prize on Monday night.

It’s not only a beautifully written book, in homage to other neurologists turned authors such as Sigmund Freud and Oliver Sacks, it’s also a book to start a revolution in healthcare, to make us see what no one has seen so clearly before.

O’Sullivan is the first doctor to sound this alarm: the modern healthcare system is juddering to a halt because of people experiencing physical illnesses that have no physical cause. Their endless quest for treatment may be costing the NHS double that of even a burden such as diabetes, yet they are looking in the wrong place for relief. Their suffering is real but has been invented by their unconscious.

If you’re like me, then you’ll find the sheer scale of this problem hard to grapple with. But these strange maladies — so reminiscent of something from Freud’s casebook — are blocking up hospital clinics and surgeries across the land.

I meet O’Sullivan at the Wellcome Collection in London after her win; she sips black coffee and claims to be the worse for wear (she originates from Dublin and had celebrated with her large family after winning the £30,000 prize), but her grasp of the figures is precise. From the moment she became a consultant in 2004, she realised that no one was talking about these patients, let alone properly beginning to treat them. And yet the crisis is endemic.

“It was most of the people coming into hospital with really bad seizures,” she says. They would run every test, and all would come out clear. No physical cause.

“I was astonished at first at the numbers. It’s astonishingly common. And yet every time I told someone the diagnosis, they were mystified. No one talks about it. Doctors don’t talk about it and the patients don’t tell anyone as they are ashamed.”

These people are not consciously faking. O’Sullivan has courted some hostile attacks from ME sufferers for lumping their affliction into this group of psychosomatic illnesses. However, her stance is sympathetic. They are not hypochondriacs, malingerers or crazy. That their illness originates in the unconscious does not mean it isn’t disabling; in fact they are often profoundly disabled and live miserable lives. You can no more tell them to “buck up” than say to someone with depression: “It’s all in your head.”

“I always say to them, ‘What you’re going through is real,’ ” says O’Sullivan, who is now an epilepsy expert at the National Hospital in London, an international centre of excellence in neurology.

Something in their unconscious has flicked a switch to turn on symptoms that mimic serious illnesses. These patients cannot consciously turn off their illnesses but, unlike other physical diseases, the cure is psychological, and poorly understood.

O’Sullivan is in charge of six beds at the Epilepsy Society specialist ward. She says roughly half to all of them in any given week will be filled by people who will go on to be diagnosed with “dissociative seizures”, ie caused by their unconscious mind and not physical epilepsy. Studies show that people who have psychosomatic complaints cost the healthcare system twice as much as those who do not. Standard treatment doesn’t help, so they spend their lives in and out of hospitals.

“In my epilepsy clinic, it’s about one in three people, but as they tend to have more frequent and longer seizures than people with epilepsy, 70 per cent of the people I work with coming into hospital with seizures don’t have epilepsy. They have more seizures, and more out-of-control seizures.

The Guardian review: It’s All in Your Head review – enduring mystery of …

The Telegraph review: It’s All in Your Head by Suzanne O’Sullivan, review …

The Suburban Shaman by Cecil Homan 2006

Placebo – is a cheap and useful option for doctors and patients



Some words from the USA that strike a chord with Doctors in the UK

Link to original full article below

“The doctor’s autonomy is now nonexistent,” one doctor lamented. “We are being dictated to by insurance companies, hospital administrators, national medical boards, and state medical boards. We are being recurrently credentialed by the same entities. All of this constrains our ability to perform as physicians. We are cogs in a system designed for the maximum profitability. There is no continuity of care, and younger doctors are perfectly happy to work from 9 to 5. Mindfulness training and yoga can’t cure those problems. There has to be mass action to get insurance companies, politicians, and government out of the practice of medicine, and physicians need to take back their responsibilities.”

……… a physician wrote. “The problem is a crisis of professional identity, work overload, powerlessness, and job insecurity. We are responsible for the operational capacity of the system [and] are held accountable for all the outcomes, but have little say in how decisions are made and the direction in which things are going. The only effective treatment is physician independence! The employment model is bad for patients and bad for healthcare costs. Worst of all, it is destroying physicians. Burnout is a symptom, not the problem. We are not suffering burnout. We are suffering because of feelings of helplessness and deep dissatisfaction.”

This applies in  the NHS but with different titles to each of the factors implicated above substitute NICE / NHSE / Jeremy hunt and the DOH / LHB/GMC /    etc etc

Its relationships that matter – more than a career in a brutalising profession

When people don’t feel cherished or cared for, and if they are employable,  they vote with their feet. When I went to my first job interview outside London the hospital offered me very good married accommodation, and by the time the interview came around I had been shown the accommodation and had a dig in the ribs from my wife and a thumbs up – as well as you had better get this job.. There is no junior doctors mess. 80% are female…. Continuity of care has gone. Over-management is endemic, and yet change is improbably slow. Fear and bullying abound.. Absenteeism in non doctors is one of the highest in the world.. There are other countries and jurisdictions who will cherish them, and some close at home with the old contract. No wonder over half could quit. The same errors have been made in General Practice, once the envy of every health minister in the world…

Dennis Campbell reports 25th April 2016: Junior doctors: ‘over half could quit NHS England over Hunt’s contract’

Survey finds negative impact on childcare and relationships are key reasons that could drive trainee medics away

More than half of junior doctors are thinking about quitting the NHS in England in protest at the contract Jeremy Hunt is forcing on them, a survey has found.

The research said difficulty in arranging childcare and the impact of even more anti-social shifts on doctors’ relationships with their partner and children were the key reasons for widespread disillusionment.

More than 52% of the respondents said they were likely to or will definitely give up medicine, or are considering moving to Wales, Scotland or abroad to avoid working under the health secretary’s new terms and conditions from August.

Respondents were asked how they would continue their career if the contract compelled doctors below the level of consultant to work more at weekends, overnight and in the evenings than they already do.

The contract Hunt is set to impose on trainee medics in England will extend the hours that count as part of their normal working week from 7pm-10pm on weekdays and include Saturday from 7am-5pm for the first time.

In all, 72 (6.84%) respondents said they will leave medicine. Another 206 (19.58%) said their future was uncertain, but they were likely to leave medicine.

Seventy-nine (7.51%) said they were considering a move to Wales or Scotland, where the devolved governments are agreeing new working patterns for junior doctors by discussion.

A further 199 (18.92%) said they were considering moving to Australia, New Zealand, Canada or another country.

“This survey turns any assertion that work-life balance will be improved for junior doctors under the new contract on its head,” said Dr Sethina Watson, a trainee anaesthetist and mother of four in Bristol, who carried out the survey. More than nine out of 10 of the 1,056 respondents were junior doctors, and 40% were either married to or in a relationship with a medic.

Watson said: “Jeremy Hunt’s rush to impose the contract threatens to create a potential timebomb that could explode as early as August as thousands of junior doctors struggle to find childcare or quit their jobs.”

The findings echo the concerns already raised by a series of leading doctors – including bosses of many medical royal colleges in a letter to David Cameron on Monday – that the revised terms and conditions for all junior doctors in England will deter recruitment and exacerbate the worsening shortage of medics.

Watson initiated the survey after the Department of Health’s equality impact assessment of the contract admitted that female junior doctors, including those who have children or other caring responsibilities, would lose out as a result of it.

The DH had not responded to a request for comment by the time this story was published.

Non doctors are not so lucky…

The costs and returns: facts and figures

Chris Smyth in The times 26th April reports: So who is right? The rival arguments

….More than 11,000 extra doctors will be trained over the next five years but they need to be employed on the right terms. …

In a graphic in The Times 26th April 2016 comparisons are available. According to the Times graphic 26th April 2016 it costs:

£508,000 to train a consultant, £385,000 to train a GP, £80,000 to train a nurse’ £70,000 to train a Physiotherapist

Earnings 10 years after graduation are:

Medical Male  £55K, Female £45 K, Economics Male £44k & Female £38K, Law Male £30K and Female £26K, Nurses and Midwives Male £28K and Female £22K

Average lifetime earnings are also shown, as are Pensions on retirement, under the present system (which is far less generous than it’s predecessor but is better than most others). You can download the graphic for clarity..

Counting the cost

Sources: Personal Social Services Research Unit; IFS; HSCIC Earnings Survey; Government Actuary’s Department.

Chris Smyth in The times 26th April reports: So who is right? The rival arguments

Government case
No one seriously disputes that care isn’t as good at weekends as during the week and the government has a duty and electoral mandate to fix this. Arguments about whether this claims 11,000 lives, 6,000 lives or some other figure shouldn’t distract from the need to tackle a real problem.

More than 11,000 extra doctors will be trained over the next five years but they need to be employed on the right terms. Compromises were offered on 16 areas of disagreement in the new contract, and the BMA was willing to talk about 15 of them. It was the BMA’s refusal to discuss any change to Saturday pay that led to the collapse of the talks.

The BMA agreed that the current contract was outdated and should be changed. After more than three years of talks the government was advised by Sir David Dalton, one of the most respected chief executives in the NHS, that there was no realistic chance of a negotiated settlement and the uncertainty was damaging the health service. Junior doctors are well-paid professionals and will become very well-paid consultants or GPs. The contract will not cut the total pay bill and no current junior doctor working within legal hours will get a pay cut. This is not about saving money.

Automatic annual pay rises for time in service are unfair and ought to be linked to performance. The government has offered protection for those who take time out for research or to raise a family. Maximum working hours will actually be cut.

BMA case
Anyone who has ever been in a hospital knows that junior doctors already work seven days a week. The health secretary has insulted dedicated professionals by saying they don’t. Any problems with weekend care are much more about the lack of consultants, diagnostic tests, other support services and social care.

If the government wants more doctors working at the weekend, it will have to pay for more of them. Otherwise care during the week, already overstretched, will suffer. Britain spends less than comparable countries on healthcare and the government should not pretend that the NHS can offer more without more resources. When the BMA agreed to negotiate a new contract in 2013, weekend care was not mentioned as a problem. Hospitals are making changes to working patterns to improve treatment at weekends without the need for a new junior doctor contract.

The BMA still has concerns about work-life balance. It is false to claim Saturday pay is the only point at issue. The government’s own equalities assessment says women, especially single parents, could be disadvantaged. Doctors need time for a family life and paying more for weekend work acknowledges it comes at a cost.

Junior doctors voted 98 per cent in favour of industrial action. If even a small proportion of junior doctors abandon an already-struggling NHS to work abroad, the impact on patients will be disastrous.

There is an issue between treating someone as a professional and as a tradesman. Your plumber will come out of hours, but at a price.

It is interesting that there are still too few applicants for Wales and Scotland for Medical Training posts, and they have the old contract. This may change next year if the strikes continue – and emphasises that there is no “NHS” – something WHO agrees with.

The way to control a profession is by overcapacity. Germany and Holland have done this for years, and once there is an inevitable loss abroad, the competition to stay becomes more intense. Also the pressure on pay rises is less.

We have neglected capacity in the Medical Profession for years now, depending on imported doctors from overseas, and especially from countries who can least afford to lose them. We have also prejudiced against male students coming into medicine by undergraduate rather than graduate entry. We have allowed the better suburb schools to win most of the places and these students have no intention of working in the shires or in rural areas.

Adverse selection is needed in recruitment, but it would also help to re-structure medical schools so that their “graduate” entry students were trained based in a community (DGH and GP based), using on line learning supervised by their Deanery.

Continuing to ration medical school places is wrong. With 11 applicants for every 2 places we might have 5 times the number…. Why not?

A striking day in the history of the health services. Mr Hunt has managed to facilitate a “first”, and break the record of 40 years without a strike for emergencies.. Is there a difference between a professional and a tradesman?

Should NHSreality not congratulate Mr Hunt – A striking day in the history of the health services. He has managed to facilitate a “first”, and break the record of 40 years without a strike for emergencies.. Across the country local news/media reports. The sympathy for juniors will disintegrate as there are more strikes and possible deaths, so it is worth recording todays reporting before it regresses. The immediate scapegoat should be Mr Hunt: please remember this in the weeks ahead. The longer term blame should be on the successive ministers of health who have trained too few doctors. We have yet to have the result of “Ambulance threatened strike” and the “consultant’s contract” negotiations. (Francesca Robinson – March 4th, 2016 in Hospital Dr). Is there a difference between a professional and a tradesman? Is it the “moral high ground“, and has it been lost by striking?

Chris Smyth and Sam Coates report 26th April 2016 in the Times : Now ambulance workers threaten summer strike…. Tens of thousands of paramedics and ambulance dispatchers could go on strike after three unions accused Jeremy Hunt of breaking a promise on pay. ….

Across England local papers report the junior doctors strike. Reporters fail to mention that the doctors can move to Wales, Scotland or Ireland and keep their current contract.

Jessica Long in the EDP Norfolk: What you need to know about the junior doctors’ strike today

Over 1,500 appointments and operations have been cancelled in Norfolk as junior doctors prepare for the first all-out strike in NHS history.

Oliver Clay in the Liverpool Echo reports: NHS Halton CCG reminds residents of junior doctors’ strikes this week 

Patients should consider alternative services for non-emergency ailments and illnesses

Siobhan Ryan in the Sussex Argus reports: Hospitals facing major disruption as junior doctors poised for full walk-out

Joshue Coupe in Tonbridge reports: Maidstone and Tunbridge Wells NHS Trust prepares for junior doctors’ strike

Lyn Barton reports from Plymouth: ‘Patients will be safe’ say senior doctors in Devon and Cornwall as they support strike action

Jane Kirby in Sunderland Echo reports: Junior doctors begin first all-out strike in NHS history

Freya Leng in Cambridge reports: How will Cambridgeshire hospitals cope with junior doctors’ historic two-day strike?

Anuji Varma for the Birmingham Post reports: 4,000 appointments cancelled ahead of two-day junior doctors’ strike 

Keep the moral high ground…. Do something but don’t go on strike. It’s the public support which matters..







The effects of dishonesty, denial and the wealth divide in other systems needs to be considered in the UK

Wealthy people are usually healthier, especially if they are educated and have the opportunity to fulfil their potential in life. Self harm occurs across the social classes. A worrying report by Boer Deng from Washington in the Times 25th April 2016 reminds us that some systems are worse than ours, and going backwards. Drug abuse needs resources to support victims, rather than these same resources being directed at traffickers. Legalise and tax is a better solution to the drugs problem, and then we will have the resources to treat the victims. The denial Americans are suffering from has ideological similarities to the denial of the UK regarding our NHS. Just as they need an honest debate, so do we…..

Originally entitled “suicides among white women in US”, and then “White women in America are dying younger” reads:

A sharp increase in suicides and deaths caused by substance abuse has cut the life expectancy of white women in America.

According to a government report, lifespans for white American women fell between 2013 and 2014 by about five weeks, from 81.2 years to 81.1 years. All other groups of US women increased their life expectancy.

An analysis of death records by The Washington Post suggested that rural communities were worst affected. In some rural regions the death rate among white women in their forties had risen by 30 per cent. In some places, it had doubled.

The data extends findings published last year by Angus Deaton, the Nobel prizewinning economist, which showed mortality rates climbing among middle-aged white people in America. The study argued that a combination of economic distress and an increase in availability of opioid painkillers was to blame. White school leavers drove the overall pattern.

Another Washington Post analysis found a strong correlation between counties with high death rates and a large proportion of voters supporting Donald Trump.

The politics of health.. The Lemmings of the left leave a vacuum where Mr Stevens’ debate will not happen… Are we all lemmings as far as our health system is concerned?

Nov 22nd 2014 – A dishonest and covert dialogue is all that is happening at present.. Simon Stevens says he would like to change this.

The National Drugs problem: Stop Prohibition – even Mr Clegg might be getting there..

Self harm as a drain on the UK Health Services