Monthly Archives: January 2018

Thousands die needlessly as NHS fails to boost cancer survival rate, and dead patients don’t vote. How about a posthumous vote?

For those of us in the know, the emperor has had no clothes for some years now, since well before NHSreality began 5y ago. What is evident to the profession is not yet evident to the politicians…. Since dead patients don’t vote, there is no concern for them – yet. How about giving all citizens one posthumous vote…?

Chris Smyth reports in the Times 31st Jan 2018: Thousands die needlessly as NHS fails to boost cancer survival rate

Britain has failed to narrow a cancer survival gap behind the best in the world, according to a global study that suggests that thousands of lives are being lost to mediocre care.

Despite improvements in survival rates over the past 15 years, British patients still die of cancer earlier than those in other rich countries that are improving just as fast, according to data on 37 million patients in 71 countries.

As well as trailing the world leaders in Scandinavia, the US, Canada and Australia, for some cancers Britain is doing worse than Latin American countries such as Brazil and Costa Rica.

A shortage of doctors, technology and money still hold the NHS back while repeated reorganisations mean that the health service struggles to focus on sustained improvement, experts said.

When the international group of scientists first published comparative survival data a decade ago, ministers pledged to close the gap. Researchers estimated that about 10,000 patients a year died within five years of a diagnosis who would have lived if British survival rates had matched the best.

Updated figures show that in 2010-14 Britain had still not reached where other rich countries were in the early 2000s. For example, 60 per cent of patients survive five years after a bowel cancer diagnosis, up from 52 per cent in the 2000-04 period. Yet in Australia, where survival was 63.7 per cent 15 years ago, it has increased to 70.7 per cent.

Overall, Britain sits 17th in Europe for bowel cancer survival, unchanged from the early 2000s, and 30th in the world. For prostate cancer Britain is 16th in Europe and 26th in the world.

Michel Coleman from the London School of Hygiene and Tropical Medicine, lead author of the study, said: “The UK is still underperforming compared with other countries. There has been an increase but it’s still not enough to catch up. It’s fair to say the UK has been improving but the UK isn’t, as politicians have often suggested it should be, up among the best in Europe.”

Breast cancer was the only area where Britain had closed some of the gap. However, Britain still sits 14th in Europe with 85.6 per cent survival, up from 79.8 per cent in 2000-4.

Professor Coleman added: “The UK needs to consider improving funding for health services and the number of specialists to treat cancer patients because by any published metric the UK is not doing well. It’s not only doctors and health professionals but resources like radiotherapy machines are less available in this country.”

He pointed to Denmark, which has closed the gap on other Scandinavian countries with a national cancer plan.

Lynda Thomas, chief executive of Macmillan Cancer Support, said: “Better cancer survival rates are achievable, but this requires wholesale improvement, from earlier diagnosis to access to the best treatments.”

The Department of Health and Social Care said: “We know there is more to do, and NHS England is implementing the recommendations of the independent Cancer Taskforce to save a further 30,000 lives a year by 2020.”

Bullying is a sign of desperation. It is caused by circumstances.. These will get worse… Dead patients don’t vote…

Protest while you can – Dead patients don’t vote. Rationing in action…

Dead people don’t vote… End-of-life care ‘deeply concerning’

The NHS and reckless election promises. How about posthumous voting?

 

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The West Wales options.

The West Wales options are now in the public domain, so readers of NHSreality can have access. The fact is that it is difficult, in an under-capacity market, to attract doctors to where there is no tertiary capacity, no research, and from where promotion is unlikely. When doctors do come and compete for jobs, is where there is a bribe, and a system that allows choices across Deaneries. This is present for GP training schemes, but is not yet facilitated for pre-registration F1 & F2 posts. The population demographic for Wales, and West Wales in particular, shows that Pembrokeshire has the highest population density, and that’s without holiday visitors in the  4 summer months…. Watch for the short term fixes, watch for nurses and other staff leaving, and the possibility of civil unrest. Whatever solution is proposed, the debate will be local, and a utilitarian solution will not come out of public meetings.

 

The official documents for the West Wales options are belwo.

6b. Feedback Form – Stakeholders (Template) vs2

3. Levels of Care and Menu of Services 08.01.18

2. Current ‘Long-list’ of Options 09.01.18

 

Good on you Mr Gavin Tait. Tell it as it is… and I bet you never got an exit interview.

Local politics and health: Hundreds from West Wales (Pembrokeshire) to protest at the Senedd against ‘downgrading’ of Withybush Hospital

The BMA Hustings – an uninformed line up of hopeful politicians. Withybush Hospital degenerates further.

Cancer doctor (Ann Barnes MBE) quits over understaffing at Withybush

Hywel Dda under pressure as doctor says ‘Glangwili will not cope’ once Withybush has been downgraded..

West Cornwall Penzance), Cromer and now Withybush. All become minor injury clinics…

Whilst Nurses leave, “Extra funding to help NHS used on short-term fixes”, report finds. Conspiracy theorists may be right..

 

 

 

 

Good on you Mr Gavin Tait. Tell it as it is… and I bet you never got an exit interview.

The importance of a “utilitarian” approach in the restructuring for improved standards cannot be overstated. The debate in West Wales, although driven by financial constraints, should place it’s remedy on higher standards.  The planned 5 sites for 2.5 million people, in 2014, and not implemented, is too many – one site may be enough. Orthopaedic operations are the most common, give the most life-years quality gain, and are prone to infection if the conditions are less than perfect. There are short term temptations to try and make do, and to ignore the experts appointed to help us.

SURGICAL SERVICES – A letter in the Times 29th Jan 2018
Sir, I have recently retired from the National Health Service and have spent almost 20 years trying to have elective and acute surgical services geographically separated in my health trust. I support Alan Mackay (letter, Jan 25) and advise Eleanor Walsh (letter, Jan 27) that it is usually the public and politicians who are resistant. Any suggestion that orthopaedic surgery leaves an acute site is viewed in the public eye as a threat to A&E, and is resisted even with street protests.

Historically, elective orthopaedic surgery was always on dedicated sites until they were closed in the 1980s as they were considered to be unsafe. Waiting lists were never disrupted.

Surgeons who are prevented for months each winter from operating as the beds are taken by acute medicine become deskilled and bored, and trainees get little experience. The sooner we return to past arrangements the better.
Gavin R Tait

(Retired consultant orthopaedic surgeon)

As it gets worse, YOU are going to have to wait longer and longer – or pay up. A “grim reality”..

The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

Orthopaedic waiting lists: time for more, and equal access to, non-urgent centres

South Wales NHS: Plan to centralise services on five sites

Whilst Nurses leave, “Extra funding to help NHS used on short-term fixes”, report finds. Conspiracy theorists may be right..

Image result for hip replacement cartoon

At last – a legal challenge to covert rationing

Lets be clear, NHSreality feels rationing is essential, and is happening as sensibly as the surrent rules of the game allow: covertly and by post-code. This case, if it is won, will force politicians to address the rules of the game, and hopefully to change them. Rationing should be overt. We have a right to know what is not available.

Clare Dyer reports in BMA News: NHS England faces legal challenges over proposed changes to services (BMJ 2018;360:k328 )

NHS England faces two High Court challenges to its proposed introduction of accountable care organisations (ACOs) in England, both arguing that the move is unlawful.

Both legal actions are being brought by campaign groups that say that the plans, which they fear could lead to rationing of resources and part privatisation of the NHS, have been launched without full public consultation.

A grassroots campaign, 999 Call for the NHS, has won permission to apply for a judicial review of the proposals, with a hearing set for 24 April. The case has been brought against NHS England and NHS Improvement.

The other group, JR4NHS, which includes the renowned cosmologist Stephen Hawking, expects to hear shortly whether its case against NHS England and the health secretary for England, which has raised £150 000 (€170 000; $210 000) through crowdfunding, can go ahead. Other members are the former consultant eye surgeon Colin Hutchinson; Allyson Pollock, professor of public health at Newcastle University; Sue Richards, professor of public management at Birmingham University; and the former deputy chief medical officer Graham Winyard.

In accountable care organisations, which began in the US, one provider or a group of providers takes responsibility for the healthcare needs of an entire population, usually receiving an annual capitated budget to deliver contractually agreed healthcare outcomes. Integrating primary care, hospital care, and community would deliver a more joined-up service for patients, NHS England has argued.1

In August 2017 the Department of Health for England published a draft ACO contract. The department consulted between 11 September and 3 November on proposed changes to regulations that would allow a model contract to be introduced. The department said it wanted the regulatory changes in force by February 2018 to allow a few clinical commissioning groups to try out the draft contract, with a full consultation on ACOs to follow later.

JR4NHS argues that under the proposals clinical commissioning groups would be delegating their responsibilities, which was not allowed under the NHS Act 2006. It says in the summary of the grounds for its challenge, “It is of the highest public importance that this model is subject to legal, democratic, and public scrutiny rather than introduced by stealth.”

The group accuses the health secretary, Jeremy Hunt, and NHS England of breaching “their common law duties to publicly make clear their proposals to reorganise the NHS in England using ACOs.” Hunt and NHS England, the group alleges, “have failed to make it clear to the public that the ACO model means a switch of resources and decision-making power to newly created legal entities, distinct from any established NHS bodies, which could be wholly or partly private, would be non-statutory, and would not be subject to the duties imposed on CCGs by Parliament.”

Meanwhile 999 Call for the NHS argues that ACOs are “unlawful under current NHS legislation because the new ACO contract does not link payment to the number of patients treated and/or the complexity of the medical treatment provided, as required by the 2012 Health and Social Care Act, but is based on a fixed budget for an area’s population.”

The Department of Health and Social Care has described the groups’ claims as “misleading” and insisted that ACOs were “simply about making care more joined up.”

Update 31st Jan 2018: BBC News – Stephen Hawking to take Hunt to court over NHS

 

Thank god the Welsh were wise enough to avoid PFI

The collapse of Carillion was foreseen. In May 2013 there was a campaign not to use PFI in Liverpool. The BMJ summarises the history of a tempting short-termism idea, which has made some parts of the country even less well served. It has led to great wealth for the directors and officers of PFI companies as well.

Richard Smith in an editorial in the BMJ opines (BMJ 2018;360:k311 ):  Failure of the private finance initiative

Was predictable and predicted

In 1999 TheBMJ called the private finance initiative (PFI) “perfidious financial idiocy,”1 and in 2017 the Office for Budget Responsibility described it as a “fiscal illusion.”2 Now a data driven report from the National Audit Office shows that PFIs have been more expensive than the use of public financing for the building of hospitals, schools, and other public buildings and has mostly not realised the benefits hoped for.3 Published in the same week as the collapse of Carillion, a large company fulfilling PFI contracts, the report has helped propel private financing and provision of public services high on the political agenda.

The difference between conventional public procurement of new buildings and PFIs lies in the financing. In both cases private contractors do the work, but with PFIs the money comes from the private sector. The public sector then pays back the private sector over some 25-30 years from when the building is delivered. The UK has over 700 PFI projects with a capital value of around £60bn (€68bn; $83bn). Annual charges were £10.3bn in 2016-17, and even without any new projects charges will continue into the 2040s and cost £199bn. It’s important to note, however, that over the past 20 years the contribution of PFI, at around £3bn a year, is relatively small compared with public capital investment of around £50bn a year.3

The main attraction of PFI to the government is that privately raised capital does not add to national debt. Nevertheless, it is paid for from the public purse in the form of annual charges, and the Treasury knew when it launched PFI in 1989 that it would be more expensive because privately raised capital is more expensive than publicly raised capital and carries other costs (insurance and management costs). It hoped, however, that it would achieve value for money through efficiencies and better outcomes. The National Audit Office report dashes those hopes.

Even the National Audit Office does not have access to all the government’s PFI contracts, but its study of a group of schools found that PFI costs are about 40% higher than funding with public money. A study in 2011 by the House of Commons Treasury Committee found that a PFI hospital cost 70% more than a publicly financed one.4 The Treasury disputes these findings.

Save now, pay later

PFI is also attractive to government ministers because there are savings in the early years: the costs come later. The National Audit Office’s study of the schools showed that despite the overall costs being higher, costs were lower for the first 15 years. The Department of Health had greater flexibility in its budget between 1997 and 2009 because the capital investment was greater than the charges, but by 2015 charges were almost £2bn greater than capital investment. This lack of flexibility is much more severe in some NHS trusts, with one trust paying 20% of its turnover in PFI charges.3

The National Audit Office analysed the hoped for benefits to see if they outweighed the extra costs. It found that PFI projects are more often delivered on time and within budget than non-PFI projects but did not find any savings in construction costs. Similarly, it found no evidence of operational efficiencies, and there were higher maintenance costs in PFI hospitals but also higher standards.

Lack of flexibility may prove to be one of the biggest problems with PFI projects lasting 25-30 years. The report describes how Liverpool City Council is paying £4m a year for a school that is empty; overall it will pay £47m for a school that cost £24m to build. Most observers of the NHS recognise the need to shift services from hospitals to the community.5 Inflexible, long term PFIs preserve the domination of hospitals at the expense of community services.

Health authorities and local authorities have, however, now recognised the idiocy and seen through the illusion: between 2002 and 2007 there were an average of 55 PFI deals a year, whereas there was only one in 2016-17. Nevertheless, the public sector will be paying average charges of £7.7bn over the next 25 years, and the National Audit Office concludes that it is difficult to reduce the costs.

Despite the criticism of PFI since its inception, the overall performance of PFI has never been quantified. In the face of higher financing costs and continuing criticism, the Treasury relaunched PFI as PF2 in 2012, but the National Audit Office concludes that it’s not much different—hence the low uptake. Yet the poor state of the nation’s finances means that there may have to be some continuing use of PF2.

The combination of the National Audit Office report and the collapse of Carillion has led to calls to end all use of the private sector for providing public services, but this would probably be a mistake. The Financial Times points out that if there is a market in the service, performance can be easily measured, and the service isn’t integral to the purpose and reputation of government, then outsourcing to the private sector can work.6 Catering meets all three criteria, whereas probation services meet none of them.

The public sector should be smart rather than ideological and avoid the illusion of a “free lunch,” as The BMJ said in 1999.1

Footnotes

  • Competing interest. RS wrote the 1999 editorial on PFI, when he was editor of The BMJ. He worked for UnitedHealth Group, a private company supplying services to the NHS from 2004 to 2015 and still has shares in the company. He is also the chair of Patients Know Best, a private company selling into the NHS. This position is unpaid but RS owns share options (about 1% equity) in the company. He is also a paid consultant for an artificial intelligence company Medial EarlySign, which hopes to sell into the NHS.

 

 

 

English Health Service to reject more PFI – but not the hedge funds!

NHS ‘leaking millions’ in PFI contracts. No PFIs in Wales…. unless GP premises count.

Ending the Blair/Brown short term mania for PFI Hospital Builds

Campaigners urge bosses not to use PFI to build new Royal Liverpool Hospital

A cash injection alone won’t cure NHS ills. Lets be clear: there is no more money, and no Brexit dividend.

David Smith in the Sunday Times opines 28th Jan 2018: A cash injection alone won’t cure NHS ills and I have been warning the Liberals that extra hypothecated or otherwise tax would solve nothing without the ideological and philosophical changes which will win the support of the professionals. All health systems are rationed: most overtly, but not the UKs 4 health services. Lets be clear: there is no more money, and no Brexit dividend.

If it is winter, there must be a National Health Service crisis — and indeed there is. There was one last year, which was described by the Red Cross as a “humanitarian crisis”, and there is one this year. There was one in 2005, halfway through the biggest increase in NHS spending in its history, and there was one in 2008, even further into that splurge.

Look hard enough and there is a crisis every year, though they vary in severity. I do not diminish the distress for people caught up in this one, but it would almost have been bad manners not to have a crisis in this, the year the NHS celebrates its 70th birthday.

The question is what to do about it. This one has provoked much debate, and two things should be clarified at the outset. The first is the idea that there will be some kind of Brexit dividend available for the NHS, as claimed by both Boris Johnson, the foreign secretary, and Liam Fox, the trade secretary.

There will not be. Any saving on Britain’s next contributions to the EU budget — and we are yet to see whether there will be any — will be swamped by other effects on the public finances. Britain will be borrowing more, not less, in future years and, as the Institute for Fiscal Studies put it a few days ago: “Brexit has reduced rather than increased the funds available for the NHS (and other public services), both in the short and long term.”

The other thing this winter crisis has done is bring forward an old chestnut: a dedicated, or hypothecated, NHS tax. There are many reasons why this is a bad idea but two will suffice.

One is that tying something as important as NHS spending to the stream of revenue for one particular tax would be hugely risky. What happens when revenue falls short? You might respond by putting up the tax but there is no guarantee that a higher tax rate means an increase in revenues.

Second, hypothecation destroys the ability of governments to spread revenues across popular public services, such as the NHS, and unpopular ones, of which there is a fairly long list. If the NHS is to be financed out of taxation, it should be out of general taxation (which includes national insurance).

The financial backdrop to this crisis is that the NHS is four-fifths of the way through the tightest decade for spending in its history. NHS spending has risen by an average of 4% a year in real terms since 1948, an increase that accelerated to 5%-6% in the 2000s. In the current decade, real increases in NHS spending are averaging 1% to 1.5% a year, alongside a rising population.

As long ago as the 1980s, it was discovered that NHS spending needed to rise by 2% a year in real terms just to keep up with higher medical inflation and technological advances. That figure may have increased. When the population is adjusted for age (an ageing population puts greater demands on the NHS), per capita spending is now essentially flat. Money is tight.

So what should be done? It would be folly to pretend that next year’s winter crisis could be averted by action taken now but, over time, we should be able to do better than an NHS that lurches from crisis to crisis.

There are five things that can be done. The health service can be helped over time by taxing more, borrowing more, rationing more, charging users more (which itself could ration use), or introducing genuine efficiency improvements.

Taxing more is always a possibility. This was the route used by Gordon Brown in the early 2000s when, much to the distress of business, employer and employee, national insurance was raised to put more money into the NHS. These days there is not much low-hanging fruit for the Tories when it comes to tax increases for either business or individuals. A Labour government would be much less constrained.

The second route is to borrow more, which was what Philip Hammond did in November. Faced with an underlying deterioration in the public finances, he chose to spend more, notably on the NHS. Will it be enough, and the last time that happens? No. There will be more borrowing in future.

What about rationing? A problem for the NHS is that the range of services, and treatments, increases in line with medical advances and demographics. Nice, the National Institute for Health and Care Excellence, has the task of issuing guidelines, including guidelines on which new treatments should be used, based on a budget impact test, but some costs of healthcare rise naturally — for example, because of the ageing population — and are not easily rationed.

Many people favour a different kind of rationing by dropping the NHS “free at the point of delivery” maxim. Prescription charges were introduced early in the NHS’s history and people have for many years expected to pay when visiting an NHS dentist. Paying for a GP appointment, as is the practice in many other countries with state healthcare systems, or charging a penalty for patients who do not show up for appointments, could be a way to go. But the politics of that is very tricky and charging for GP appointments might have the unintended consequence of directing more people to already highly pressured casualty departments.

That leaves efficiency. Three years ago, NHS England, having identified a £30bn funding gap by the early 2020s, committed to £22bn of efficiency savings in return for £8bn more in government money. It is fair to say that progress in achieving those efficiency savings has been disappointing.

As in the past, top-down pledges of this kind tend not to work. Tony Blair and Gordon Brown’s NHS spending splurge was supposed to be a return for reform and greater efficiency. We had the splurge but not the efficiency.

Far better, as the think tank Reform argues, is that ideas that reduce waste and improve efficiency develop on the ground and are spread around the NHS. Some of that happens now. Not enough of it does. An excessively bureaucratic organisation that employs at least 1.5m people across the UK is not an obvious candidate to be fast on its feet when it comes to efficiency savings. There is good practice in the NHS, however, some of which has eased the pressure on A&E departments in some parts of the country even this winter, and it needs to be spread. Otherwise, each winter crisis will stretch, unbroken, until the next.

PS
In one bound, Britain’s job market was free. After two months in which the Office for National Statistics had reported falling employment, the latest release showed a strong bounce. Employment in the September-November period of last year was up by 102,000 compared with June-August, and by 415,000 on a year earlier. While self-employment fell, full-time employee employment rose strongly.

This was good news, although, as I sometimes get reminded by statisticians, the margin of error on these figures is large. So the small falls in employment of the previous two months may not have been falls at all, and the latest rise may have been exaggerated.

One oddity of the latest figures was that a good rise in employment coincided with a 0.5% fall in hours worked in the economy, despite an increase in full-time employment. That will be good for one measure of productivity, output per hour, which should show another robust rise in the fourth quarter of last year. But the other measure, output per person employed, may well go in the opposite direction.

The employment news boosted the pound to its best level against the dollar since before the EU referendum. So too did the belief that something is stirring on wages, which in turn could bring forward the next interest rate rise from the Bank of England. Friday’s slightly better and expected fourth quarter GDP figures pointed in a similar direction.

The uptick in wages in the official figures was tiny. Average earnings growth for total pay was 2.5% in the three months to November, the same as the upward-revised figure for the previous month, but lower than the 2.6% and 2.7% of a year earlier. Regular pay growth edged up from 2.3% to 2.4%.

There was a bit more excitement in the latest figures for pay settlements from XpertHR, a firm that monitors them. Early 2018 pay settlements have moved up to a median of 2.5%, it says, after being stuck at 2% last year. Indeed, this was the highest since early 2014.

There have, of course, been false dawns before. This might be another, but it could be that, at last, in what economists would see as evidence of a classic Phillips curve relationship, wages are responding to low unemployment.

Planning overall change without evidence that it will be effective, and the probability that it simply encourages duplication…

In Search of the Perfect Health System – a new book reviewed

BBC News 27th Jan: Paper headlines: NHS ‘rationing’ ops and Brexit turf wars

 

Planning overall change without evidence that it will be effective, and the probability that it simply encourages duplication…

“Every patient deserves an examination”, or do they? These words were on the wall behind the patients head in one of my training practices. The GP recognised his temptation to omit, especially when hurried, the examination.

Image result for doctor substitute cartoon

I remember a “sore throat study” as a trainee, wen we were shown a number of mostly normal pictures of “sore throats”. With each case there was a description of symptoms, an occupation, and a social situation. If you had a wedding the next day, even if your throat looked normal, you usually got an antibiotic from most doctors. If you were a diabetic you were more likely to get one, etc. What I am trying to explain is the context in which a GP works, and the need not to offend. Sore throat is only a symptom, and everyone needs an examination. We know that throat examination alone cannot predict bacterial or viral infection, and that for the one patient in front of us, their only concern is a speedy recovery. I confess that, in the middle of a winter of excessive sore throats, I once chuckled when the lady in front of me complained of the same. Without allowing me to examine her she left the room indignantly.. When she saw another doctor he diagnosed tonsillitis and gave penicillin. I never assumed anything on sore throats from that point on. This allowed me to pick up several cancers (tonsil and tongue) which others had missed. We are looking at a “Skill Mix change” as the numbers of GPs declines over the next decade. We hope that sore throats will be seen by competent people, and that the occasional cancer, or glandular fever will be picked up correctly.

The Journal of the RCGP Pauline Nelson et al. from Manchester, in the February 2018 edition ends: “…Evidence about the wider system effects involved in workforce re-design is currently lacking but crucially important in light of the aspiration to new models of care. Given these challenges, Buchan and colleagues’ question ‘If changing skill-mix is the answer, what is the question?’11 remains a pertinent one to ponder in primary care today.” Skill Mix change and the GP workforce challenge..full

Just like the NHS 111 system, and the Apps planned to get access, we are planning change without evidence. Commissioners are doing the only thing they can, within the rules of the game, and it is politicians who set the rules. Watch for missed and late diagnoses, increased litigation, poorer outcomes, and perhaps, in view of increasing dental caries, for the return of Subacute Bacterial Encocarditis. The advice is not to fail to examine, but to stop prescribing. But WHO is going to examine, and will they be competent to make the rare but serious early important other differential diagnosis?

My surgery tried it with nurse triage as well.  We gave up... Duplication of effort….

Kat Lay in the Times reports 26th Jan 2018: Stop prescribing useless antibiotics for sore throats, doctors are urged.

Methods of rationing in the news… Telephone triage, scrutiny of referrals, larger practices, reducing standards, reducing access, excluding treatments. So many different and covert methods of rationing. No political party offers the honest option. No wonder we are disengaged.

Controlling antibiotics in farm practice is most important to reduce superbugs …. but doctors and planners can help.

Harassed doctors hand out antibiotics faster than ever – There are big inequalities in General Practice

Nurses and pharmacists to replace GPs for 1 in 4 visits

Primary care telephone triage does not save money or reduce practice workload

The apps attempting to transfer NHS 111 online

Image result for doctor substitute cartoon