Monthly Archives: February 2018

Oh dear. More money from Taxation will make no difference.. Digging the hole deeper?

NHSreality has spoken out against hypothecated taxation on several occasions.  This is at least a recognition of crisis, but the solution proposed will never work as the pace of technological advance and demographic change (more elderly) exceeds the ability of the state to pay for them. The solution proposed, without overt rationing, will be digging the hole deeper..

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BBC News reports 5th Feb 2016: NHS ‘should be funded by new tax’

A new ring-fenced tax to fund the NHS and social care has been proposed by a panel of health experts.

The panel, set up by the Liberal Democrats, says the NHS in England should be given an extra £4bn on top of inflation in the next financial year.

It has suggested replacing National Insurance with the new tax to close the funding gap.

A Department of Health and Social Care spokesperson said NHS funding “is at a record high”.

“[It] was prioritised in the Budget with an extra £2.8bn, on top of the additional £2bn already provided for social care over the next three years, and an additional £437m of funding for winter,” the spokesperson said.

The future of NHS money has been hotly debated as hospitals struggle to cope with the pressure on resources.

Last month, tens of thousands of non-urgent operations were delayed.

The 10-member panel included former NHS England chief executive Sir David Nicholson, Peter Carter, former chief executive of the Royal College of Nursing and Clare Gerada, former chairwoman of the Royal College of GPs.

It said on top of the £4bn extra needed for next year, an additional £2.5bn would be required for both 2019 and 2020.

Prof Gerada said that one of the issues is that working people over the age of 60 benefit from a significantly reduced National Insurance contribution, and people over 65 do not pay it at all.

She said National Insurance, which currently funds the NHS and social care, is inadequate as older people are living longer, and not contributing to the ring-fenced tax.

She said: “Old age is now between 85 and 95, so old age has significantly moved.

“Why shouldn’t I pay for my fair share of contributions if I’m working?”

As part of the recommendations, the panel also suggested reinstating a cap on the costs paid by individuals on social care.

In December, the government scrapped proposals to cap fees at £72,500.

It supported creating an office for budget responsibility for health and called for a series of incentives to get people to save more towards their adult social care.

The idea of a levy dedicated to funding the NHS was also suggested by former minister Nick Boles.

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How do we end the culture of fear? Doctors and families must be able to work together for safer care….

Much as I agree with Ms McCartney, I also believe that Exit Interviews by an independent third party HR company is essential. These need to be amalgamated, themes exposed, and discussion to be open about how to change, redress, and correct. The ideology has to be seen to be “built on a rock”, both financially and ethically before the professions are on board.

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Margaret McCartney: writing in the BMJ ( BMJ 2018;360:k443 ) opines: How do we end the culture of fear? Doctors and families must be able to work together for safer care

A little boy, Jack Adcock, is dead. This is horrendous, and accounts of the background to the case clearly show mistakes and shortcomings that could and should have been avoided. But how?

Jack’s treatment included clinical mistakes and numerous systemic ones, particularly regarding staff absence and IT systems. This was the “Swiss cheese” model writ large and fatal: the holes in the system aligned and let tragedy happen.

The overwhelming feeling among many doctors reading accounts of the case background1 is, “There but for the grace of God go I.” There’s no suggestion that Hadiza Bawa-Garba was doing anything except working hard, with two doctors down, covering six wards on four floors, and providing medical advice to other professional groups.2

Will striking her off the medical register ensure that a death like Jack’s can’t happen again? I don’t believe so. Professional regulation and accountability are vital. So, too, is patient safety. But the way we administer the two are often at odds.

The regulation of doctors is an adversarial system that seeks to deliver blame and sanctions to individuals. Blame and sanctions clearly have their place. But it’s taken a long time for us to regard human factors as the problem in many medical errors and safer systems as the solution—as well as outstanding efforts by people such as Martin Bromiley, who founded the Clinical Human Factors Group,3 a charitable trust that promotes best practice around human factors. As the group says, “A safer, more reliable and efficient NHS will remain a pipe dream until we create a culture where human error is seen as normal, inevitable, and as a source of important learning.”4

As Bawa-Garba’s reflective notes were used as evidence against her in court, such a culture is unlikely any time soon. And the words of Mr Justice Ouseley, giving the leading judgment on the case in the High Court, are of particular concern: “There was no suggestion, unwelcome and stressful though the failings around her were, and with the workload she had, that this was something she had not been trained to cope with or was something wholly out of the ordinary for a year 6 trainee, not far off consultancy, to have to cope with, without making such serious errors.”5 This seems to imply that doctors can be trained to have limitless capabilities. None of us can be.

There must be a better way to investigate deaths—one that examines human factors and systemic problems, which doesn’t only insist on evidence based change but can also command the confidence of bereaved families, as well as honesty from the medical profession.

A culture of fear is looming, but it needn’t be this way. Doctors, patients, and families should be able to work together to make systems safer. We need to move forwards, but this judgment risks taking us far back.

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Editorial: Criminalising doctors by Navjoyt Ladher, Fiona GodleeBMJ 2018;360:k479  )

What must we learn from Jack Adcock’s death?

Fear is toxic to both safety and improvement, and health systems must abandon blame as a tool. So wrote Don Berwick in his report after the Mid Staffs care scandal.1 He called for a commitment to learn from mistakes and to act on that learning. “Rules, standards, regulations and enforcement have a place in the pursuit of quality,” he said, “but they pale in potential compared to the power of pervasive and constant learning.”

Recent events have set those wise words at nought. Last week the tragic case of 6 year old Jack Adcock, who died from sepsis in 2011, reached what may be its final punitive phase, with the erasure of a trainee paediatrician from the medical register. Jack Adcock’s mother has said she wanted justice for her son and to ensure that no one else would suffer in this way.2 Sadly the opposite is more likely. This case, and a growing number of others,3 risk driving doctors towards defensive medicine, discouraging them from discussing errors, and denying health systems the chance to improve.

Hadiza Bawa-Garba was convicted of gross negligence manslaughter in 20154 and later temporarily suspended from practising medicine by a medical practitioners tribunal. But the General Medical Council wanted her struck off and has now won its appeal against the tribunal’s decision. Her criminal conviction and the GMC’s actions have caused an outcry among doctors, distressed that one doctor has been made a scapegoat and understandably fearful that they too are now vulnerable to criminal charges if they make mistakes.

Should this case ever have gone to court? Not if Berwick’s report had been acted on. “Recourse to criminal sanctions should be extremely rare and should function primarily as a deterrent to wilful or reckless neglect or maltreatment,” it said.1 No one in possession of the facts and an open mind could call Bawa-Garba wilfully or recklessly neglectful. Delays in assessment, acting on test results, and administering antibiotics meant that the diagnosis of sepsis and recognition of the seriousness of Jack’s condition came too late. Also, when Jack arrested soon after he was given enalapril by others without her knowledge, Bawa-Garba mistakenly interrupted resuscitation, having confused him for another patient. But she was doing two doctors’ jobs, managing acutely sick patients across four floors, with no breaks in her 12 hour shift, juniors doctors who had both recently rotated onto the team, agency nurses, breakdowns in IT, and inadequate senior cover.

However, the jury weren’t told about many of the corrective actions subsequently deemed necessary to make the hospital safe. The prosecution argued that these weren’t relevant to the circumstances in which Bawa-Garba was practising on the day.5

Many questions remain. Was it not the consultant’s, medical director’s and management’s responsibility to ensure adequately supported medical and nursing provision? Given the hospital’s inherent conflict of interest, why was there no independent review? Why did the GMC feel compelled to pursue an appeal? It says it could not allow its tribunal to go behind the decision of a jury in a criminal case and wanted to avoid a loss of trust in the profession.6 But the Medical Practitioners Tribunal Service (MPTS) was able to hear about important system factors that the jury in the criminal case was not,7 and other doctors with criminal convictions have been allowed to continue to practise.8

By the GMC’s reasoning, it now seems impossible for the MPTS to consider any options other than erasure in cases where doctors have been convicted of gross negligence manslaughter, whatever the circumstances.

In an unprecedented show of support, crowd funding has raised over £200 000 for Bawa-Garba’s legal representation, so her criminal conviction may yet be overturned. And perhaps most importantly of all, people from across the health and regulatory system are now talking to each other about what needs to change.

Much credit for this must go to Jenny Vaughan, a consultant neurologist who clinically led the successful appeal of conviction of David Sellu.9 She cofounded Doctors and Manslaughter (manslaughterandhealthcare.org.uk) and has worked with the Ministry of Justice, Department of Health, Crown Prosecution Service, and royal colleges to highlight the negative impact of criminalising healthcare.3 A recent meeting at the Royal Society of Medicine discussed a range of measures to ensure that the right cases come to court in future—those involving persistent dishonest or malicious practice rather than unintended honest errors.10

It is tragic that a child has died. But no one is served when one doctor is blamed for the failings of an overstretched and understaffed system. We must channel the sadness at Jack Adcock’s death, and the anger at Bawa-Garba’s fate, into positive change for safer patient care.

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President Trump is not always wrong. His harsh reality, or hard truth, is what many professionals feel.

Some 4 years ago a large number of GPs were considering retiring. Now their 2014 thoughts have become reality. The neglect of Primary Care by politicians who are afraid to discuss the truth is endemic, and the distraction of Brexit has not helped. Aneurin Bevan’s great idea is dying from a political collusion.. Exeter University research tells the citizen how it is, but they don’t really want to hear. The living prefer to forget about the dead, and dead patients don’t vote. The harsh reality is pushed home by a US President …

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BBC News today 5th Feb 2018: GPs leaving profession: ‘We’re not valued’

GPs are leaving the profession at an increasing rate because they feel “undervalued”, research by the University of Exeter Medical School has found.

Doctors have spoken of concerns about the risk of litigation and problems with their own health due to work pressures.

Dr Charlotte Ferriday (pictured) quit her GP partnership in Devon in 2015. She said the job left her burnt out.

“I woke up one Monday morning and I couldn’t get out of bed,” she said. “For six weeks it was difficult to leave the house and it was catastrophic.

“I found it was increasingly difficult to do the job because I didn’t have the resources and services that supported my patients.

“It felt like we were ignored and GPs were not valued by the government.”

The government says it has committed to an extra 5,000 GPs by 2020.

Sick Notes g2 column 160615 Ian Wiliams

The flock of geese that laid golden eggs has been culled. It takes years to rebuild, and the fox is at the door.

Just cry at the bribery, and the Death of the Goose that used to lay the golden eggs that used to make the Health Service(s) so efficient, and the envy of the world.

In Wales they really can waste money: £68m unveiled for health and care hubs

The decline of General Practice.. Bribes may be too late…

GP practices close in record numbers – Wrexham patients protest about GP staffing levels. This is only the beginning…

The public will only miss what they had – when its gone. GP indemnity fees spiral out of control with 25% rise last year..

Six in 10 family doctors considering early retirement  March 2014 – 4 years ago

President Trump: NHS ‘going broke and not working’

 

 

 

“The NHS cannot save itself”. (Let alone it’s citizens)

Toni Saad for The Spectator 9th January reports “The NHS cannot save itself”. (Let alone it’s citizens)

Rationing did not end in the 1950s. The largest-scale rationing programme is still in existence: our beloved National Health Service. Its austere regime is part of our national life. We no longer queue for bread or sugar, but we most certainly do to see the doctor. We no longer wait in line at the butcher’s, but we do in A&E departments and on interminable lists for appointments and procedures. There are no books or coupons, but rationing it remains. Indeed, the government has announced it is withholding elective operations and routine appointments this month. Rationing by any other name would smell as sweet.

And, like our drawn-out post-war rationing, it is ours alone. Nowhere else in Europe must one wait until one’s knee is arthritic to the point of incapacity before a surgeon will set eyes on it. Are your unsightly and painful varicose veins making you miserable? Terribly sorry— come back if you develop an infection or an ulcer. You’re worried you have cancer? Would you mind waiting two weeks to have ten minutes of your GP’s time? This would be unthinkable to our European neighbours. Good thing we have a stiff upper lip.

You might say that rationing is necessary in a system like the NHS, and you’d be right. Some are bound miss out. And you might say that more funding is the solution. But this misses the point. Rationing and austerity are not a Nasty Party conspiracy to dismantle the NHS. The problem is the NHS itself. It is an unwieldy bureaucracy incapable of responding to demand, and has all its patients and workers at its mercy.

The Secretary of State for Health has the unenviable job of divvying up the pie across this vast system. That a government minister has the power to prevent thousands of operations from going ahead should tell us something is wrong. Patients are rightly up in arms, as are the earnest junior doctors, still reeling from the (mostly favourable) contract imposed upon them. Knowing nothing but the NHS has blinded them to the nature of the problem. Don’t they see that it is the very fact of the NHS which gives Mr Hunt the power to treat them en masse, cancel thousands of operations at the stroke of a pen, and do countless other things against which they rail? Mr Hunt is the popular scapegoat, but he has inherited a system which gives him and others great power to give, but also to take away.

Moreover, though we fawn over the NHS, in the ways that matter most (e.g. cancer mortality), it is giving us poor outcomes. On the international stage, we are holding the wooden spoon.  The NHS is not fit for purpose. But the solution to its problems lies outside of itself. It must look to other nations for inspiration, and cease the cycle of cuts and funding drives which treat only the symptoms of its malady. Its top-down approach is unresponsive to demand, makes beggars of all its users, and rations services in a way which would be intolerable to anyone else. And, yet, it is still taboo to talk seriously about the NHS. It is high time that politicians braved the subject. Serious alternatives to the NHS need to be put on the agenda.

Toni Saad is a final year medical student at Cardiff University

“No end to NHS crisis in sight, nurses warn”, and “Compensation payouts ‘could bankrupt NHS’

Elizabeth Burden, reports Feb 1st in the Times on line: Compensation payouts ‘could bankrupt NHS’

Clinical negligence payments must be capped or the NHS will be bankrupted, health service leaders have warned the justice secretary.

In a letter to David Gauke, senior members of the NHS Confederation, the British Medical Association and the Academy of Medical Royal Colleges called for limits on compensation paid to patients who suffered injuries through medical errors. The cost of such payouts has almost doubled since 2011, they said, and if all claims in progress were successful it would cost £65 billion.

The NHS leaders argued that compensation was channelling money from frontline services. Niall Dickson, chief executive of the NHS Confederation, told The Daily Telegraph: “We fully accept there must be reasonable compensation for patients harmed through clinical negligence. Yet this must be balanced against society’s ability to pay.”

The letter claimed that many doctors were having to practise defensive medicine, undertaking unnecessary tests for fear of being sued.

It came as the Royal College of Nursing announced yesterday that the NHS crisis would continue long after winter. The latest performance statistics show that eight hospitals had no free beds on some days last week.

Kat Lay reports 1st Feb 2018: Hospitals are left without any free beds amid worst NHS winter crisis (Originally no end to the crisis in sight)

The NHS is in the midst of its worst winter crisis, doctors in accident and emergency departments have warned, with many hospitals without even a single free bed.

One consultant said that he could not even make any more space in the department’s corridors for new patients to be admitted.

The warnings came as Jeremy Hunt, the health secretary, said: “We are moving into what is always the most challenging and stressful week of the year for the NHS.”

NHS figures show that some hospitals have had barely a single free bed since the middle of November, recording night after night of being “100 per cent” full.

On December 11, the busiest night to date, 18 large hospitals in 12 NHS trusts across England did not have a single spare bed.

Average bed occupancy for the winter so far is 93.8 per cent, compared with 92.1 per cent at the same stage last year. Experts say that anything above 85 per cent is unsafe because of the increased risk of dangerous infections and delays.

Only seven NHS hospital trusts out of 153 had average bed occupancy below 85 per cent last month, down from 17 the year before.

Taj Hassan, president of the Royal College of Emergency Medicine, said: “Last winter we said, ‘This is the worst in 15 years.’ But I think this winter it’s even worse.”

The lack of beds meant that “boarding” patients on trolleys was common, he said. “A ward might have 20 patients in 20 beds but it might be expected to take an extra two or three patients on trolleys placed in the middle of the ward or outside in the corridor.” He said it was the only way to let A&E departments function.

He said A&Es regularly had between 20 and 40 patients in that situation, adding: “In some cases I’ve heard of 50 patients in an emergency department waiting for a bed. We have to try to manage them as best we can, in cold, draughty corridors, while dealing with new emergency patients.”

Richard Fawcett, a consultant at one of the largest A&E units, tweeted on Saturday that patients at the Royal Stoke University Hospital had to wait 12 hours to see a doctor. He followed that with a message that the A&E had “run out of corridor space”, another casualty department had closed to ambulances and patients were having to wait in ambulances to be seen.

An NHS England spokesman said: “At this time of year hospitals are extremely busy but thanks to hardworking NHS staff and robust plans in place to cope with winter pressures, they are generally coping.

“The latest weekly figures show hospitals reporting bed occupancy levels of 90.9 per cent — down from 95.0 per cent the previous week.”

Other parts of the NHS were also under pressure. Yesterday Zoe Norris, a GP, said on Twitter that there were five-hour waits in walk-in centres, adding: “A doctor has just driven a patient to A&E because both the GP admission line and 999 were permanently engaged.”

In the northeast of England, nurses and doctors have been told that pressures on the ambulance service meant that they may need to go out to patients aged over 65 who have called 999, and act as “first responders”.

There is a “need to put doctors in charge and force them to take account of patients’ views. Cancer survival rates are (just) one of the prime examples of NHS mediocrity.”

There is plenty of room for improvement. Whilst we have got good outcomes in Breast Cancer, the rare cancers                  and Prostate Cancer in men do worse.

Chris Smyth reports 3rd Feb 2018: NHS is crippled by top-down culture

Autocratic management is a leading cause of poor NHS care, according to the compiler of a European health service league table that ranks Britain 15th.

The UK trails Slovakia and Portugal while the best performers such as the Netherlands and Switzerland pull away, according to the Euro Health Consumer Index. Treatment is Britain is mediocre and there is an “absence of real excellence” in the NHS, the report concludes. Only Ireland does worse on accessibility measures such as availability of same-day GP appointments, access to specialists and waits for routine surgery.

The findings come after a global study this week found cancer survival in Britain still lagged well behind the best in the world.

Arne Björnberg, who compiles the Euro Health Consumer Index, said: “Cancer survival rates are one of the prime examples of NHS mediocrity.”

More money is needed to improve care, according to a study that finds a strong correlation between treatment results and how much countries spend on health.

However, Professor Björnberg said that the most urgent lesson the NHS could learn from other countries was about the corrosive effects of an “autocratic top-down management culture”. He said: “As a Scandinavian what strikes you when you visit the UK is British management is extremely autocratic. Managing 1.5 million using a top-down method doesn’t work very well. If you go and ask a secretary or a receptionist anything out of the routine in Scandinavia, the most negative response would be: ‘I’ll see what I can do’. But in the UK they will say: ‘I’ll have to talk to my manager’. Subordinate staff are not allowed to use their brains in the UK and managing a professional organisation like healthcare like that is not a good idea.”

The Netherlands has consistently topped the rankings, which some have attributed to a system of competing insurance companies. However, Professor Björnberg said that the main lesson to be learnt from the Dutch was not about market forces but the need to put doctors in charge and force them to take account of patients’ views.

“If you have intelligent people and make them talk to customers frequently, that is a good idea,” he said.

“You have 1.5 million intelligent and dedicated people working for [the NHS]. Liberate the medical profession and put politicians and amateurs at arm’s length.”

NHS bosses dismissed the findings, preferring an index compiled by the US-based Commonwealth Fund, which ranks Britain top of 11 global health systems. The NHS scores well on measures such as equal access, but ranks tenth at keeping people alive.

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

 

Compared with 11 other countries UK ranked first – for it’s system and not for it’s outcomes

The Commonwealth Fund compares health systems. Unreality of MPs. ..

Performance relative to other countries. Commonwealth fund “mirror”.

Other countries have sensibly funded healthcare. (Scandinavia and NZ), & “the schemes used by most countries on the Continent are preferable to the NHS model.

Our state-run healthcare model makes winter crises inevitable: the healthcare crisis seen from abroad, and publicised in the City.

Waiting times matter -especially in Wales – to see your GP, for investigation, and diagnosis as well as treatment.

Sky News 2nd Feb: Prostate cancer now killing more people than breast cancer – While breast cancer has benefited from a screening programme and significant research, prostate cancer has been lagging behind.

Its good news: “More people dying from rarer cancers” so less are dying from the more common ones..

 

When doctors know the system is failing, should they tell their patients? Yes. From East Anglia to Pembrokeshire….

Norfolk is facing a double hit. The Trust is victim of a PFI, and the CCG is underperforming in respect to cost cutting. Services are threatened…. Warnings were given over many years and Geraldine Scott of the EDP (Eastern Daily Press) reported: Commissioners in West \Norfolk could be stripped of their powers if £10million deficit is not solved. Add to this the cost of litigation as per previous posting, and Norfolk is bust.  \\\\\\\\\\\\\\\\\\\\\\\politicians have tried to put rationing decisions at arms length from themselves, but now gross failure means they will have to take responsibility. Message is, for the moment, don’t get ill in East Anglia.  David Oliver is a writing journalist doctor and his comments are perceptive. “Should NHS doctors work in unsafe conditions?” and “Let the NHS be honest with the public”, by which he means doctors are not telling their patients the truth…despite the statutory duty of candour.

Gareth Iacobucci reports in the BMJ: CCG criticises NHS England after being ordered to cut GP funding (BMJ 2018;360:k247 )

The head of a financially stricken clinical commissioning group (CCG) has launched an outspoken attack on NHS England after the group was ordered to cut GP funding to balance its books.

In a starkly written letter to local GPs sent on 12 January that was leaked to The BMJ, Paul Williams, chair of West Norfolk CCG, said that the group faced a “dire” financial situation, warning of “very unpleasant consequences” from decisions it was being forced to take.

Williams said that the CCG had been ordered by NHS England to cut local enhanced services payments to general practices, which fund work outside the core GP contract such as minor injury consultations, wound care, and phlebotomy. He wrote that “it is highly likely that there will be some reduction or possibly even cessation of LES [local enhanced services] payments.”

The CCG’s overspend is expected to reach £10m by the end of this year. Williams said that the situation had escalated because of “unreasonable assumptions” about what the CCG could achieve within its available budget.

As a result of the group’s financial position Williams said that the CCG board had been summoned to face “a star chamber of NHS executives” that had ordered it to cut services or face being taken over by NHS England.

He wrote, “At the end of the meeting, we were left in no doubt that unless we immediately start reducing expenditure then NHSE [NHS England] would not hesitate to disempower the government body and current executives and send in managers under legal directions to turn things around. They would have little regard for the long term consequences of their actions, their prime imperative would be to simply save money.

“I know this will be very disappointing for primary care and will no doubt produce some financial pressure in some practices, but unfortunately the CCG are being forced down this route by NHSE.”

Ian Hume, medical secretary of the Norfolk and Waveney local medical committee, said that any loss of income from LES payments would be damaging to local practices and would fly in the face of NHS England’s national commitment to invest in primary care.

Hume said, “It would give completely the wrong signal to general practice, which needs to be part of the solution. To cut enhanced services or primary care budgets is counterproductive.

“There seems to be an inconsistency between the approach from NHS England’s regional office and NHS England nationally. Cutting money in one place may have an increased cost to the system elsewhere. There is an incongruity about the whole approach.”

In a subsequent statement supplied to The BMJ, West Norfolk CCG said that the letter set out “the worst case scenario.” A spokesperson said that the group would not cut any payments to practices this financial year but added, “The CCG will review all [local enhanced services payments] for 2018-19. We shall want to look at their effectiveness, to make sure that every pound we spend delivers maximum quality and value for money. If any are changed, core GP services will not be affected.

“We shall continue this efficiency drive across all areas of the NHS to deliver maximum efficiency and maximum quality of care and reduce the deficit we face.”

Andrew Pike, director of commissioning operations for NHS England’s East region, said, “The current financial position of the CCG is of concern. The CCG has a duty to the taxpayer as well as to patients to ensure it delivers the agreed financial plan for 2017-18. The CCG has been requested to improve its financial position this year.”

The storm is coming: All Regional Health Services are unsustainable. The PAC are telling us the truth..

Telling harsh truths about the NHS is a bitter but necessary pill

The finance officers tell the truth: “NHS cannot make £22bn cut sought by government”..- there is no way forward under current philosophy

Candour and Transparency? – what a farce