Monthly Archives: March 2019

If there are too few gatekeepers – they are set up to fail

GPs as gatekeepers have been set up to fail as a profession. There are just not enough of them. In an unattributed and unreproduced on line article, an unknown source opines that “Gatekeeping by GPs called into question“. The rationing of medical school places, over decades, now results in so much spin that the public are dizzy with it. The fact that nurses and paramedics are not trained to do the job does not seem to occur to the media. The result will be disastrous.

NHSreality can only speculate on the source. The clue is to answer “who gains by the failure of the GP system?” Government wants a cheaper system, and is unconcerned with the health of individuals. As population controls have to take precedence, and more and more taxpayers choose to go private, the two tier system us here and now.  Life expectancy for the poor will decline further…

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The Dutch  and the English questioned gatekeeping in 2014: Is the role as gatekeeper still feasible? A survey among Dutch … – NCBI

Is the role as gatekeeper still feasible? A survey … – Oxford Journals

and in 2016: the BMJ says that GPs are much more than gatekeepers | The BMJ and 

Stop calling GPs gatekeepers | The BMJ

BBC News 27th March: Life expectancy drops among poorer women in England

Pulse 1st March: Scottish Parliament launches public survey on the GP independent …

The Daily Mail Scotland is very critical about having to ring before seeing a GP. Dangerous?

WANT TO SEE A GP? TALK TO NHS24 FIRST; Anger over ‘dangerous’ plan forcing 150,000 Scots to speak to helpline BEFORE visiting their doctor’Patients are pushed from pillar to post – that’s dangerous’


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how long to numbers recovery? Much longer for morale recovery!

The health services are all broken. The exodus of staff when the opportunity arises and the cynical disillusion with system and management is evident. The doctors who “go over to the dark side” (management) are looked on with suspicion by colleagues. GP commissioners are derided, ad they have to ration health care without using the word. Taxpayers in poorer regions (such as Wales) get inferior care, lack of choice and poorer outcomes….. It is getting to the point where two tiers of health service are available: National or Private. A few more exit interviews would help…

Peter Russell for Medscape reports 12th Feb 2019: NHS Staffing Shortfalls ‘Threaten Long-Term Plan’

NHS staff numbers in England have failed to keep pace with demand, according to a report by an independent health charity.

In its third annual review of staffing levels, the Health Foundation highlighted specific problems in primary and community care, nursing, and mental health….

This is not the first time: Nicky Broyd on the 15th November 2018: Staff Shortages Threaten NHS Long-term Plan: Report – Medscape

According to the first of two reports by The King’s Fund, the Health Foundation and the Nuffield Trust, staff shortages in the NHS in England now present a greater threat to health services than funding.

The group of leading health thinktank experts predicts an increase in NHS staff shortages from over 100,000 at present to almost 250,000 by 2030 and warns the figure could be over 350,000 if the NHS continues to lose staff, fails to adequately fund training places and can’t attract workers from abroad.

and 4 days ago Peter Russell: NHS Staffing ‘a Make-or-Break’ Issue, Says Report – Medscape

How can the NHS offer fulfilling, lifelong careers? The managers have no idea why doctors quitting in droves…. Exit interviews?

The exit interview is a rare event in the 4 health services. The BMJ opinion from Wilson and Simpkin is honest and powerful, but their drawing attention to the absent “exit interviews” now needs attention, and from a completely independent HR company. None of the staff will trust the “in house” services. Yes, its got that bad, and its going to get worse. Life expectancy has peaked already and went down this last year….

The BMJ offers some advice on workforce retention: How can the NHS offer fulfilling, lifelong careers? BMJ 2019;364:l1100

With morale and retention among UK doctors declining, The BMJ hosted a discussion at last week’s Nuffield Trust health policy summit, asking what the NHS can do to support clinicians throughout their careers. Abi Rimmer reports

“Enabling people to pursue their other interests is one key thing,” said Rakhee Shah, paediatric registrar and research associate at the Association for Young People’s Health, kicking off discussions. She highlighted the importance of giving clinicians more control over their working lives.

Ronny Cheung, consultant paediatrician at Evelina London Children’s Hospital, took this further, saying that it was also important to give clinicians control over their everyday workload. He said that his trust, Guy’s and St Thomas’ NHS Foundation Trust, had been “trying to make time and space for teams to come together.”

“It’s about regaining control,” he said, “and investing in people to allow them to do that.” This not only made staff feel more valued but also helped to remind them what they enjoyed about their work. “It has a multiplying effect,” he said.

Claire Lemer, consultant at Evelina London Children’s Hospital, highlighted the importance of food for staff. She described a successful initiative at her hospital that encouraged the executive team to provide food for clinical and administrative staff……

……The demise of the firm structure of working in hospitals had reduced support for clinicians, said Morrow….

…The panel also discussed how the intensity of clinical work affects clinicians’ ability to maintain a long term career in the NHS. Lemer said that, in some specialties, “the pressure and intensity of work is so extreme that it’s not sustainable for a whole career.”…

…Cheung also warned that the rigidity of medical training pathways was denying doctors the flexibility they needed, as they were forced to choose a specialty so early in their career.

“If we squeeze people into these pathways we shouldn’t be surprised if people break free, and we shouldn’t be surprised that we’re developing a workforce that isn’t particularly happy,” he said.

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The NHS is failing to look after its staff and patients, expert warns

Abi Rimmer, The BMJ

Anne Gulland, The BMJ

Opinion from Hannah Wilson and Arabella Simpkin is honest and ends with the paragraph: (This was not available in the on-line edition)

Quitting in DrovesHannah Wilson and Arabella Simpkin P 473 of the BMJ

Surprisingly, while there is little literature that discusses both the quantity of doctors that leave the NHS and the factors that may drive them, there is no literature discussing the attributes and characteristics of doctors that leave. To understand what is driving the flight, we must first ask who are the doctors that quit? Surprisingly exit interviews are rarely held. Yet this is critical information to develop interventions and strategies to stem the leak.

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Another argument for no fault compensation. Longer waits will mean we are poorer…

An argument for no fault compensation was won in NZ and Scandinavia over 40 years ago. Why have we been so slow? Longer waits mean we will be poorer… through loss by money set aside for litigation.

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Kat Lay reports 22nd March 2019: Longer waits could increase negligence claims, NHS told

The NHS could face a rise in negligence claims because waiting times are getting longer, the spending watchdog warns today in a report that says too many beds may have been cut.

The report by the National Audit Office links the longer waits to a lack of beds, warning that the NHS has lost 8,000 since 2010.

The number of emergency readmissions to hospital within a month of a patient being sent home has risen by 14 per cent in five years. Doctors believe that the increase could be a sign of patients being sent home too soon to create space.

The report says that while “it may create efficiencies to reduce the number of beds to a certain level, after a certain point the capacity constraints this will introduce will impact on other resources such as staff and theatre usage”.

NHS chiefs do not know whether the health service has passed that point, according to the report. It points out that 40 per cent of negligence claims concern delays to diagnosis or treatment, adding: “Long waiting times may lead to an increased risk of more negligence claims against the NHS.”

The health service is treating more people each year but has not met its waiting time targets for non-emergency treatment since February 2016 and is planning to change them. The target is for 92 per cent of patients to be seen by a consultant within 18 weeks of referral by their GP, but in January only 86.7 per cent were seen in that time.

Key cancer treatment targets are also being missed, although the report says that this is largely because of action to increase the number of urgent cancer referrals and provide diagnoses sooner.

Figures published yesterday by NHS Digital show that readmissions to A&E within 30 days of discharge have increased from 756,020 in 2013-14 to 865,625 in 2017-18. Emergencies make up a growing share of these admissions.

Taj Hassan, president of the Royal College of Emergency Medicine, said: “Many patients have to be unnecessarily readmitted as they do not have the assistance they need to look after themselves after they have been discharged”. The government must urgently publish its green paper on the issue, he added.

An NHS spokesman said that extra money from its new long-term plan would fund more treatment and reduce waiting times.

NHSreality posts on “no fault compensation”.


Sign the Brexit petition – and have more wealth for better health

The Stop Brexit petition

The 4 UK health services need more staff: not less. The 4 UK health services need more money and new infrastructure, not less. Health is so closely related to wealth that in population terms they are virtually indistinguishable. There are only a few poor countries whose life expectancy has exceeded the richer countries, but this is mainly due to politics, warmongering, and subject populations in the richer ones. (Nepal has a better life expectancy than Russia, Venezuela and Zimbabwe, despite no natural resources, and with only tourism to bring in foreign currency). The threat from Brexit is closing fast, and the indicative voting from most recent polls is that there could well be a majority for remaining in the EU now. We will have fewer people, especially carers, less money, and poorer health after Brexit.

Informed consent is better than uninformed consent. The opinions of rich, self employed businessmen, and media owning magnates, are not important except that they have informed the first vote with false assertions. People are wiser now and more informed, which makes the peoples vote petition that much more important. This may be our last chance….

We all know that many elderly people are not “on line” and will not write. We all know the petition is self selecting for those with e ability. BUT this does not negate the need for another vote. Those of us who voted to remain will be much more accepting of another Brexit vote and the country will unite whatever the result. If Brexiteers ask for a third, fourth and fifth referendum, then this is the price we have to pay for Mr Cameron’s idiotic decision to replace representative democracy with a peoples democracy for a single issue. We can all make mistakes…

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The Stop Brexit petition is at

27th November 2018: Seeking informed consent on Brexit

26 Jan 2019 On the Brexit slipway…. There is a problem: there may be too many to save, all at once.

23 December 2018: The Brexit deadline and the Health Services planning – standards and services are going to get worse..

8th December 2018: BREXIT will negatively impact the NHS and health services regardless of a deal, a new report has revealed, with devolved nations set to suffer the most.

August 2018: Patients should not be looking forward to a “hard” Brexit. Make sure you have a good stock of medications..

and Successive increases in the health budgets in Wales have not helped….. Brexit will make it worse… We all seem agreed, so why not change direction?

and Doctors warn “Brexit bad for health”, as calls grow for new EU vote.

Beware the tyranny of the mob. Brexit will harm those suffering from rare diseases.

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

Health is closely correlated to Wealth – If you are poor you get no choice (Wales), and live a shorter life, but if you are rich, or born abroad, you live longer and you do get choice! So much for equity…

Just for Health – “MPs must be brave and tell us we were wrong” December 29 2018

This made me laugh, but its sick.

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Read the damning nature of this joint report.. GP shortages …. Our very own post-code lottery.

Just read the joint report of the Nuffield Trust, Kings fund, and Health Foundation reflect on the retired doctor commenting below the Times report. Developing a strategy for the Health and Care workforce In England: Summary of a roundtable discussion. 

This crisis was seen 20 years ago. What the media and the politicians should be asking is why nothing has been done, and what options are possible. The implications of doing nothing are too important. There are not enough physiotherapists, nurses, Occupational Therapists, Psychologists etc. as well as GPs and Oncologists. 

The report does not cover the other 3 health dispensations, and the situation is just as bad in Scotland N Ireland and Wales. Wales in particular has a tradition of exporting professionals, and at least 20% of all graduates leave. It will be much more for the medical professions….

I have no good news to counter this abrogation of planning. I can only apologise to the Times for reproducing their whole article as it is so important. There is a world shortage of doctors…. If we still believe in open markets then every country has to train more. Meanwhile it has to get worse, and private care will flourish, especially in cities. The Health Divide will worsen. 

Chris Smyth reports this in the Times 21st March 2019: Experts warn shortage of GPs will last for at least a decade

The shortage of GPs will last for at least another decade and patients will have to be treated by physiotherapists and pharmacists instead, a report on the NHS staff crisis has concluded.

The shortfall of nurses will also triple to more than 100,000 unless almost £1 billion is spent on training and hiring thousands from abroad, it added.

“Dire” workforce planning may derail the NHS ten-year plan because there will not be the staff to hire with £20 billion budget boost, three think tanks have said. The Nuffield Trust, King’s Fund and Health Foundation united to warn that a dearth of qualified professionals has become the critical problem facing the NHS.

They said it “defied all logic” that training budgets have been cut by 17 per cent to funnel money into NHS England as the shortage worsened. The NHS has 100,000 vacant posts in a workforce of more than 1.2 million.

“You have to run to stand still in the NHS,” said Anita Charlesworth of the Health Foundation. Ministers must restore bursaries for nursing students, giving them £5,200 a year to reduce an attrition rate in which only three in five who enrol become full-time nurses, she said, adding that overseas recruitment should grow from 1,600 a year to 5,000 annually.

The report said that for GPs there was no prospect of closing the gap for at least a decade. In 2015 ministers promised 5,000 more GPs by next year but numbers have since fallen by 1,000.

The shortfall of 2,700 will triple in five years without action, but even an intensification of efforts to train more and stop early retirement will produce only 3,500 more over a decade, leaving the NHS more than 7,000 short, the report estimated. The gap can be closed only by sending more patients to see physios and pharmacists for problems such as back pain and medicine reviews, it suggested.

Efforts to hire GPs from abroad had been unsuccessful Richard Murray, chief executive of the King’s Fund, said. “We are just not that competitive on pay and lifestyle. The numbers just haven’t come through but that isn’t for want of trying,” he said.

Baroness Harding, chairwoman of NHS Improvement, welcomed the review. “Our staff are our biggest asset and so it is vital we do more to retain, recruit and develop them,” she said.

Times on line comment:

“Baroness Harding, chairwoman of NHS Improvement, welcomed the review. “Our staff are our biggest asset and so it is vital we do more to retain, recruit and develop them,” she said.”
Staff are treated abysmally so what is actually being done. Not much. Anyone who works in a hospital who trys to raise a problem is silenced and hounded out.

World shortage of doctors:

Research Shows Shortage of More than 100,000 Doctors by 2030

U.S. faces 90,000 doctor shortage by 2025, medical school …

Canada’s doctor shortage will only worsen in the coming …

On solutions to the shortage of doctors in Australia and …

NZ’s doctor shortage: What needs to be done? – NZ Herald


The rationing of medical school places has led to a shortage of Cancer Care and Radiology specialists

It can take an awful long time to get the required tests in the UK. No wonder people are choosing to go privately when they can afford it. (BBC News today: Pressures increase fears of seeing cancer patients in time)

The rationing of medical school places has led to a shortage of Cancer Care and Radiology specialists. Its going to get worse still…… This was a political choice, made repeatedly, and against the advice of the royal colleges, and is one of the greatest threats to life expectancy in the next two decades. Proton beam therapy  (Daily Mail) may have arrived 10 years late, but is now predicted to save potentially 9000 lives: will everyone have access? There are just not the specialists for Commissioners to employ…..

Nick Triggle for BBC News 18th March 2019: Cancer doctor shortage ‘puts care at risk’

Kate O’Neill in The Times: Patients ‘paying the price’ for shortage of consultants

Owain Clark for BBC Wales 20th March 2019: Cancer specialist shortages in Wales ‘a real risk’

Cancer doctor shortage ‘will impact patients’, says Royal College

A shortage of cancer doctors in the NHS is likely to impact patients, according to a new report.

The study, from the Royal College of Radiologists (RCR), points to a growing shortage of staff, with 1 in 6 UK cancer centres now operating with fewer cancer doctors, called clinical oncologists, than 5 years ago.

And this gap between supply and demand is expected to widen, concludes the report.

The RCR estimates that by 2023, the NHS will need a minimum of 1,214 full-time cancer doctors. Based on current trends, there will only be 942.

Cancer Research UK’s Emma Greenwood said: “NHS staff are working incredibly hard to give patients the best possible treatment, but these figures reinforce that NHS cancer services are drastically understaffed.”

The study shows the UK is now short of at least 184 cancer doctors, and that the number of vacant posts is double what it was in 2013. More than half of vacant posts have been unfilled for a year or more.

Cancer doctor increase not keeping up with demand

Despite these figures, there where 46 more full-time cancer doctors employed in 2018 than the previous year. But the RCR said the increase is not keeping up with demand, with the number of trainees needing to at least double to close the gap.

“With cancer cases increasing and bold ambitions to improve cancer survival in the NHS Long Term Plan, we urgently need a workforce strategy supported by enough funding to resolve these severe staff shortages,” said Greenwood.

The report also says that without more investment in workforce, patients will not be able to benefit from cutting-edge cancer treatment, such as immunotherapy and proton beam therapy.

Dr Tom Roques, the lead author of the report, said: “The UK is seeing more and more fantastic innovations in cancer treatment.” He added that cancer doctors “are vital to the rollout of these new therapies but we do not have enough of them and our workforce projections are increasingly bleak.”

Overseas recruitment to plug staffing gaps was also reported to be unsuccessful due to several factors, including differences in how doctors are trained and a lack of HR expertise in the area.


Helen Salisbury: Dis-integration of cancer care BMJ 2019;364:l1220


Indicriminate Rationing: Cataracts are just the thin edge of the wedge

The Post Code nature of locality indiscriminate rationing means that the poorest half of the country will be asked to wait, whilst the richest half will pay. Just as they do for dentistry: patients are being levered into paying, either directly, or by insurance. The Commissioners are put in an invidious situation where life saving procedures are more important than cataracts, and they have to stay within their budgets without “rationing” officially, as this term is not allowed. So long term priorities and perverse incentives dictate that cataracts are unavailable to many people on their version of the UK’s Health Service. The result: less independence, less quality of life, more chance of falls, more depression, and possibly more chance of dementia as stimulation of all sorts helps delay. Remember there is no “N” HS, and the media and politicians are colluding to pretend there is. NHSreality feels that devolution has not helped health care, where being part of a large mutual is most important.

When will the debate on rationing overtly take place ?

March 20th 2019 in the Times. Chris Smyth reports: Cataract surgery doesn’t work, says NHS in cost‑cutting drive

Patients in half of the country are being denied cataract removal operations by NHS cost-cutting policies that wrongly suggest the surgery does not work, according to a study.

People needing hernia surgery and hip replacements are also routinely refused care by “indiscriminate rationing” policies that class common treatments as ineffective, it concluded.

Doctors and campaigners have condemned the policies as “wrong” and “shocking” but health chiefs said that they did not have the money to treat everyone. Cataract removal is the most common procedure carried out by the NHS, with 300,000 operations a year.

In 2017 the National Institute for Health and Care Excellence concluded that cataract surgery was virtually always a good use of NHS resources because patients who struggle to see are more likely to injure themselves. Its guidance demanded the health service end rationing of the 20-minute procedure that restores sight.

A study by the Medical Technology Group, a forum for patient charities and device manufacturers, found that 104 of 195 clinical commissioning groups (CCGs) that pay for care locally are classing cataracts as “procedures of low clinical value”, in defiance of the Nice guidance.

This means that they will not fund them unless doctors make an exceptional case for individual patients. The figure includes a third of groups that pay for surgery only when patients’ vision has deteriorated past a certain point.

Barbara Harpham, chairwoman of the group, said: “It’s simply not fair that patients up and down the country are being denied access to vital treatments because of where they live. This indiscriminate rationing by local NHS organisations must stop now.”

Helen Lee, of the Royal National Institute of Blind People, said: “It’s shocking that access to this life-changing surgery is being unnecessarily restricted.” Mike Burdon, president of the Royal College of Ophthalmologists, said that there was no justification for the policies: “CCGs must take notice of the Nice recommendations which reinforce the message that cataract surgery should be delivered at point of clinical need. It is one of the most efficient procedures in the health service.”

The survey also found that 78 groups class hip and knee replacements of limited clinical value and 95 limit access to hernia repair via the same method or in policies that say surgery must be delayed for more tests. Twenty-five CCGs limit all three procedures. Bedfordshire also restricts continuous glucose monitoring for diabetics.

The Royal College of Surgeons said: “It is wrong to label hip and knee replacements, and hernia surgery, as of limited value. With the NHS about to receive a cash boost in April, we need a clear message from government that restricting such treatment is wrong.”

The NHS Clinical Commissioners, which represents CCGs, said: “The NHS does not have unlimited resources and ensuring patients get the best possible care against a backdrop of spiralling demands, competing priorities and increasing financial pressures is one of the biggest issues CCGs face.

“They are forced to make difficult decisions that balance the needs of the individual against those of their entire local population. There are tough choices to be made, which we appreciate can be difficult for some patients.”

The Telegraph: More than half of NHS authorities rationing cataract operations

The Express: Outrage over NHS postcode lottery for eye and hip operations

The Express comments: That means it is wrong that the quality of care and access to treatment should be different depending on where you live. After all, we all pay the same taxes for it, so we all deserve the same access to treatment. Therefore, the latest revelations on the scourge of the so-called postcode lottery is another sad reminder of a variable quality of care.

Thousands are dying after NHS emergency surgery

After reading the article by Chris Smyth below it is tempting to ask consultants to stop private work, and use that time on their 4 Health Services work. This was suggested in the responses…

What a thoroughly Liberal suggestion, but it would achieve little as these doctors would simply take the time off. They have disengaged (as a whole) from the 4 health services. Lack of exit interviews virtually throughout the systems, means that the truth is rarely heard by boards and commissioners.

In a free society we need to reconsider why we have got to this situation, why it is going to get even worse, the poor manpower planning, the perverse incentives to train too few doctors and nurses, and the lack of control that consultants have over their now non-existent teams.

An honest language about what is and what is not possible in health, where rationing is reasonable (and overt) and where it is unreasonable is needed.  We also need to return to “teams” managed by consultants rather than managers, and a depoliticised system of health care funding which is sustainable. Models are available from other countries but we never look at them.

A system of PR should help health care more than a first past the post system.

This is too serious a subject for a cartoon, but I have tried at the bottom.

In the Times letters ” Treating the root causes of a ‘dysfunctional’ NHS”. Feb 18th 2019:

….Yes, the NHS must change. But this time around, let the people who work in the system design and lead it.
Professor Carrie MacEwen
Academy of Medical Royal Colleges

Now, one month later, Chris Smyth in the Times reports on the declining standards: Thousands are dying after NHS emergency surgery

Thousands of patients are dying because of chaotic management of dangerous surgery, doctors say.

The Royal College of Surgeons said that patients who need emergency general surgery were “systematically discriminated against” because of an NHS focus on routine operations. Inaccurate scans and operations carried out by junior doctors are routine for life-or-death cases in a way that would be unthinkable for planned care. Death rates for common procedures vary from 4 per cent in some hospitals to 22 per cent in others and improvements are urgently needed. About 25,000 patients a year have emergency surgery for abdominal pain, blockages and tears and three times as many choose not to have operations.

One in five patients has surgery without being assessed by a consultant surgeon and one high-risk procedure in ten is carried out without a consultant surgeon being present, the report says. For operations in the middle of the night, when the risk of death doubles, barely half of cases have both a consultant surgeon and consultant anaesthetist present. One in five CT scans for such patients is not looked at by a consultant radiologist, despite evidence that there are four times as many inaccuracies when interpretation is outsourced. Additionally, emergency general surgery patients are often denied critical care beds after an operation, even though these are required for less risky elective procedures.

Nick Lees, a consultant bowel surgeon in Salford who wrote the report, said: “For every patient who dies there are others who have complications. These patients are receiving a lesser standard of care because they happen to present as emergencies and, generally speaking, NHS resources are better [at] dealing with patients undergoing lower risk, planned operations, such as hip replacements.”


The access to services (especially emergency ones) is getting worse, and worse, and worse….. and its going to get even worse.

In the last few days I have had some close connection to the health service in Wales. Welsh NHS as it calls itself, is under tremendous pressures. The response times are appalling. The banal nature of phone triage has caught me out on two occasions in the last month.

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The first time was when NHS111 advised me to ring a GP surgery when the problem needed quick hospital assessment for a post natal problem, which turned out to be an infection needed immediate antibiotics. The second was for a lady who collapsed and needed full assessment to exclude serious conditions, but there was no transport for 4 hours. Both these patients were taken to hospital by relatives. They were lucky to have transportation. Delays in either case could have led to serious problems.

I have been told stories of GPs who have decided it is better to ask a lay person to ring the ambulance in any situation. This is because the services are so stretched that the telephone operators are advised to assume that a GP surgery is a safe place to be. The fact that GPs are never exposed to emergencies, and that emergencies are outside their contract ( and their competency in many cases ) does not occur to them.

The result of all this, all over the country, is that private services will take hold, and flourish. The health divide will get larger. The access to services (especially emergency ones) is getting worse, and worse, and worse….. and its going to get even worse. Don’t live in the wrong area.

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Access is the most important point, and even this is failing.


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