Monthly Archives: July 2019

My own advanced directive. A timely death is a choice everyone can make for themselves.

A doctors own personal choice is not usually talked about, but more and more are doing their own advanced care pans, which used to be called a living will. Here is mine: Final ADRT DR RB. The media led society does not sustain debate about the way we die, and charities such as our local Hospice at Home in Pembrokeshire, are reluctant to advertise a service for fear of being accused of bullying patients, and of being in collusion with the local health board. After all, the state has an interest in shorter periods of dying because of the expense.

My previous “Living Will” is out of date. Readers are welcome to copy and adapt the one above. I am most grateful for the free service, and recommend it to others. Just contact the Paul Sartori Foundation if you live in Pembrokeshire.

At present we are prolonging death. The care and nursing homes are taught to sit patients up, Death comes much sooner when patients lie flat. There is no need for pain with modern drugs, but we are moving to a world where a timely death is a choice everyone can make for themselves.

In a briefing paper in 1997 the government of the day was advised on the options for Social Care funding. No action has been taken. Social care: Government reviews and policy proposals for paying for care since 1997 (England) by Tim Jarrett. We are in a terrible mess as standards are different in different dispensations, and this report applied only to England.

It does seem ironic that, in a system that we all know is rationed (Politicians all deny this), that so many resources (state or private) are given to prolonging death.

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Live longer with dementia: Mr Hunt pillories the profession. Most doctors will be making “living wills” to avoid over-zealous care and prolonged demented lives… March 7 2016

An advanced directive or living will – It’s important to specify, especially lying flat. Good news if you take action.April 14th 2014

Health postcode lottery: The Mirror’s online tool shows how many years of illness you can expect – but only for those living in England….21st November 2015

Living through the NHS’s famine years. Quality reversals and increasing deficit November 7th 2014

s are symptomatic of deeper problems

Late cancer diagnosis… and poor cancer care. Let GPs have access to tests, and when there are enough, involve them in key treatment decisions.

The neurosurgeon Henry Marsh on why assisted dying should be legalised

Suicide clinics a preserve of middle class A report says only sharp-elbowed Britons are able to access assisted dying at Swiss centres

Families asked to feed dementia patients…. How do we design a system that is fair to both the well spread, and the very locally based families?

Advanced directives needed. Choice in death and dying. Lord Darzi warns of “draconian rationing”. GPs need to be involved at the interface of oncology and palliative care.

Don’t get old and frail – if you can avoid it – in our covertly post-code rationed services


Scotland calls for a new training philosophy and paradigm for General Practice. Its the shape of the job that matters, and it will take a decade to get enough GPs for 15 minute appointments.

The supply of doctors is finite, and has to be planned a decade ahead. Not only are doctors well paid (and regarded) but they are a moveable feast: transferrable skills mean they could work in one of many dispensations. The Commonwealth countries are particularly popular..

If the UK were to train 5 times as many doctors as we needed many more as a % would go overseas. There is a net 20% loss of all graduates from Wales, mainly to the UK, and a net 40-50% (my estimate) loss of medical graduates over 5 years.. SO it we don’t want the whole to be impractically expensive we have to persuade other countries to train enough doctors as well as the UK.

It would help if fewer women (more men) as a percentage of the total were trained. It would also help if there were a move to graduate as opposed to undergraduate entry. But even these changes, without insisting on 5 years “National Service” could fail unless the shape of the job is changed. 

The fact that Scotland suggests a new paradigm emphasises the 4 different dispensations, and the lack of a “National” health service.

Adrian O’Dowd for OnMedica 6th June 2019 reports: Call for new GP recruitment target

GP leaders in Scotland are calling for new recruitment targets to be set to boost the GP workforce north of the border and a 11% slice of NHS funding.

The Royal College of General Practitioners (RCGP) Scotland has published a new report called From the Frontline *, which draws on feedback from GPs across Scotland and their thoughts and experiences within the profession.

It has also launched a new campaign called #RenewGP, which calls for 11% of the Scottish NHS budget to make Scottish general practice “fit for the future”.

It also calls for GPs to be able to have minimum 15-minute appointments with patients in order to give them better care, but warns this would only be possible with more GPs in the system.

Tackling health inequalities was also crucial, said the report authors, who wanted GPs serving areas with high socio-economic deprivation to be appropriately resourced.

Central to all of the RCGP’s desire to improve general practice was planning for the future workforce and the report and campaign argue that as the population was living longer with more long-term conditions, Scotland needed more GP capacity to build and lead community healthcare teams………

There is no sustainable ideology – so leaders find their staff disengaged and that their job is impossible..

An exodus because of poor planning and the shape of the job. Deprofessionalisation….

Unreal manpower planning. It’s too late for a decade. GP services face ‘retirement crisis’. It’s the shape of the job silly.

Checklist will help decide if it’s time to die – as the shape of the job has reduced, recruitment has declined…

2014: Severe shortage of GPs is reaching crisis-point in Derbyshire – only 37% of GP training places filled – due political rationing of Medical School places 10 years ago, and the shape of the job

It’s the shape of the GP’s job that needs to change. The pharmacist will see you now: overstretched GPs get help…The fundamental ideology of the Health Services’ provision. Funding of this type admits 30 years’ manpower planning failure

2016: Martini GPs or Dead end jobs. The option is in the hands of politicians..

It was the best job in the world – for me 1979-2012 – but now there are not enough of us to cover the country

A GP in Milford Haven exposes the Inverse Care Law as applied by successive Governments, perversely and neglectfully..

fewer women should be allowed to train as doctors because men are ‘better value for money’… The answer is graduate entry to medical school.

Women perform better at 18, so change the age at entry to med school



David Oliver: Don’t blame GPs for late cancer diagnoses

Recent articles in the media, published after a study by cancer research on 135,000 people. Medical education teaches GPs to “live with uncertainty” because of the need to ration resources effectively. The access to sophisticated tests is rationed by hospital trusts who wish to limit demand as they have inadequate capacity. If we want earlier diagnosis we have to accept greater expense, more technology, more false positives, and more hopeful and unnecessary treatments…..

Laura Donelly in The telegraph 28th June reports: 

The study by Cancer Research UK found that just 37 per cent of all cancer diagnoses in England involved patients who had been given an urgent referral by their GP, because the disease was suspected. Just 32 per cent of diagnoses for bowel cancer and 28 per cent of 
diagnoses for lung cancer were identified this way.” Many other news media repeated the problem including The Yorkshire Post

David Oliver opines in the BMJ: David Oliver: Don’t blame GPs for late cancer diagnoses BMJ 2019;366:l4625

Being a GP isn’t easy. Under-resourcing, workforce gaps, the rising complexity and volume of work, and a media narrative too often laden with blame add to the challenges. On 28 June the Daily Telegraph ran a column entitled, “GPs failing to spot two thirds of cancers.”1 The article was more measured than the headline. But readers’ fear and anger are rarely tempered by less conspicuous details.

It reported a Cancer Research UK study, which had focused on two common cancers (lung and bowel), analysing 135 000 cases.2 The Telegraph mentioned “average waits of more than eight weeks for diagnosis,” adding that “the vast majority of cases that turned out to be cancer were never suspected by family doctors.”

The study, based on data from 2014-15, had concluded that only 37% of all cancers had been diagnosed after urgent referral by a GP suspecting or wanting to rule out the disease. This was true in 32% of bowel cancer cases and 28% of lung cancer cases. Patients who had not been referred for urgent assessment waited weeks longer for diagnosis. And 35% of lung cancer cases and 28% of bowel cancer cases were diagnosed only when patients presented to hospitals as an emergency.

GPs see a whole range of conditions, often in early stages with undifferentiated symptoms that could easily be many things other than newly presenting cancer. The 2015 NICE guidelines on recognising and referring suspected cancer lowered the positive predictive value threshold for referring cases from 5% to 3%.3 Cancer Research’s Cancer in the UK 2019 report showed that, even in 2015-16, only 19% of cancers were diagnosed as emergencies (and only 6% through screening programmes)—so most were in fact diagnosed through GP assessment and referral.4

The data on Public Health England’s bespoke GP profiles illustrate that cancer still represents only a small percentage of a GP’s overall caseload.5 And some patients, with vague symptoms of cancer not specific to any one organ, risk being sent urgently down the wrong specialist route.

Patients’ own circumstances or care preferences also play a part in delayed diagnosis. A study by Abel and colleagues on 4647 NHS patients with a cancer diagnosis from presenting as an emergency found that 29% reported no prior GP consultation. Percentages were substantially higher in older, male, and deprived patients.6

Also consider that, if more patients were referred as urgent cases, our hospital services in radiology, specialty medicine, oncology, and surgery, which already have their own major workforce and workload challenges, would struggle to cope. Indeed, they’re already struggling, not least in balancing patients with suspected cancer against those with equally pressing clinical (if not target) priorities.

A Nuffield Trust analysis7 of performance against cancer waiting time targets showed that, since measurement started in 2009, we’ve generally maintained the operational standard of at least 94% of patients who are referred by GPs as “urgent” being seen within two weeks, with only a recent dip in performance. However, it also showed that the metric of at least 85% of such patients starting treatment within six weeks of referral has been breached for the past four years and has recently declined further. NHS England’s clinical review of national access standards is ongoing,8 partly in response to such issues.

Cancer Research UK has a fantastic track record of raising awareness, in line with its charitable mission. It’s just a shame that, in this case, the resulting media narrative placed excessive blame on GPs, using old data. I’m not sure that this helps patients or doctors.

Laura Donelly in The telegraph 28th June reports: Revealed. GPs failing to diagnose 2/3 of cancers

GPs are failing to spot two thirds of cancer cases, study … The Sun

The Yorkshire Post




The value of the UK’s health information – and only partial value at that.

Most of the useful data in the 4 health services has been collected by GPs. It is this data which is valuable. Hospitals collect data in un-co-ordinated and dysfunctional ways which are not team based. As long ago as 1996 I suggested joined up systems but this was rejected. We are not much further forward today, and your complete real time medical records will NOT be in your local A&E, some 23 years later, unless you are very lucky. The value of the information would have been MUCH more today had this opportunity been taken. Reading the article below suggests that all dispensations are joining in with the agreement with google. Lets hope it does not backfire.. The information could be used to expose differences in treatment and outcomes in different post codes, and for research opportunities for many doctors in the profession. Lets hope these opportunities are not rejected…

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Philip Aldrick opines and reports in the Times July 20th: NHS patient data has £10bn price tag

The value of NHS patient data has been set at almost £10 billion, the first time it has been given a market value.

The professional services company EY said that by charging private health companies to develop new products with the data, the health service would benefit by £4.6 billion a year in better targeted, more personal care and would gain £5 billion a year in operational savings and new income streams.

Getting NHS records into a condition in which they could be used by companies would not be cheap. EY said: “There will be significant process and technology costs associated with aggregation, cleaning, curating, hosting, analysing and protecting the transformation of these raw data records.”

Although it is common in the US to sell health data, it is one of the first attempts to put a market value on Britain’s 55 million patient records, which are increasingly being used by health tech companies to develop diagnostic tools and medicines.

In the US, Flatiron Health was sold to the pharmaceutical group Roche last year for $1.9 billion (£1.5 billion) for its patient records.

EY said: “NHS patient data holds an indicative market value of several billion pounds to a commercial organisation.”

The government has been championing the use of technology to improve patient outcomes and give the health science industry a boost. Babylon Health, Sensyne Health and Google’s Deepmind are among the companies mining NHS data with artificial intelligence. Among the opportunities are better diagnosis, new procedures and personalised medicine.

A code of practice was recently published by the Department of Health and Social Care on the use of health data by businesses. The NHS is a unique dataset because it covers the population from birth to death. In other countries the data is broken up, making it harder to collate in large volumes.

Lord Drayson, the chief executive of Sensyne Health, said: “The quality and scale of NHS data, covering a population of over 50 million people, provides the UK with a competitive advantage.

“Policy that encourages ethical and fair collaborations between the NHS and the life sciences industry could help to fund NHS services in future, as well as significantly improving the quality and affordability of care.”

June 15th Philip Aldrick: If NHS patient data is worth £10 billion, put it on the balance sheet and save lives too

Google ‘poised to profit’ from NHS patient recordsAldrick Nov 24th 2018 in the Times and August 18th: Peer holds key to unlock the value of NHS patient data

General Practice is “Closing Down” … Presentation for a unified IT system rejected 1996 / 2001

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Whistleblowing Champions – in Scotland only (for now). Apply through NHSreality, or Holyrood.

With permission (I assume) from Peter Gregson in Scotland, I can publicise the new Whistleblowing Champion, in Scotland only for now, then apply for the job through the link below. The other 3 UK dispensations may follow suit, but you never know: after all there is no National Health Service any more, except for emergencies. Congratulations to Pete for getting this success… Now we need to measure outcomes, especially longevity in post and unemployment rates..

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This is Pete’s e-mail to me:

Here is the video of the event at Holyrood  –

It lasts 90 minutes, but I think it’s good stuff.

The PA to the Health minister Jeane Freeman has asked for the link and says he’ll send it onto Jeane. I’d be impressed if she watches it.

I will send the link to the members of the Health Committee.

One of them, Alex Cole-Hamilton (LibDem) has asked to meet Rab and I. That should happen before the end of July.

Would any of you be interested in a new job? These are paid Whistleblower Champion posts.

Finally, if you know of anybody who wants to log a whistleblowing concern with us, give them this link  We’ll make sure the new Independent National Whistleblowing Officer, Rosemary Agnew, takes note.

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NHS Scotland must tackle bullying problems ‘head-on’ – Dr Lewis Morrison for the BBC News 25th June

Third high-level resignation from NHS Highland board in as many .. NHSH vice-chairwoman Melanie Newdick .Press and Journal 16th July

Surge in calls to Scotland’s NHS whistleblowing hotline – 19th April

Holyrood: NHS Whistleblowing champions ‘can come straight to me’, says Jean Freeman October 2018

Non-executive Whistleblowing Champions – NHSScotland – Apply here

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This is the future for the next decade: fewer GPs and more distant access to all medical skills if you live in rural areas. Breakdown of many systems. Private Health options pending..

There are, according to the Daily Mail, over 10m people who are short of their normal GP service. This is an inexcusable dereliction of duty in a civilised society. Poor manpower planning, poor politics, unequal educational opportunity and standards, and poor funding are responsible, along with the decentralisation of control (devolution) in a system where doctors are free to move. Don’t forget that, as it implodes, you can go abroad for treatment.

You still have the option of private care, and as one doctor explains he knows that the queue-jump goes against everything a mutualised service stands for.

The Nuffield Trust reports on the uncertainties which will follow after Brexit. Staff shortages, drug supply chain problems, are just two. The structure of Social Care may break down as it is dependent on overseas staffing. But whatever shortages there are now will be worse after Brexit. GPs are an international commodity and can take their skills overseas. Most of the former British Empire and Commonwealth countries are also short of GPs, so there is a ready market waiting for newly qualified, or disillusioned GPs.

This temptation to move abroad also applies to consultants whose pension rules make it unproductive for them, however keen they are, to reduce waiting lists. James Phillips for Professional Pensions reports: Pensions tax issues leading to longer NHS waiting lists

The Kings Fund reports on the Health and Social Care system, and its threatened breakdown.

In my own area there is no “choice” (West Wales, Hywel Dda) so that if someone needs a “greenlight laser” they will not get referred. Older fashioned TURP (Transurethral resection of the prostate) has far more side effects and is far more intrusive, with slower recovery times. Consultants in Hywel Dda will not refer for this treatment under the Welsh Health Service, as the money would move with the patient and Hywel Dda would lose cash. There are plenty of other examples of improved care but they are always concentrated on cities, and rural citizens will get them less. In England, provided patients are prepared to wait and to travel themselves, “choose and book” (e.g. Cumbria) allows them access. This does not apply in Wales.

Yes, it would be a good idea to recruit retired GPs, and many like myself would help out, but there are issues around medical indemnity and speed, and most of us would want to see the system founded on a financial rock rather than the quicksand of today.

John Hebditch reports from Aberdeen: Warnings of GP crisis as Abderdeen GP surgery will shut its doors next week.

and also Nearly 60% plan to cut hours and 25% to leave in near future.

Retired doctors urged to relieve rural NHS recruitment crisis

North-east medical practice to close after GP recruitment issues

17 overseas medics offered jobs at Shropshire’s A&Es

150 new medical staff taken on by Shropshire hospitals trust

Call for emergency meeting on Shrewsbury GP surgery closure

Shrewsbury GP surgery closure to affect thousands

Manchester Evening News July 4th.

People across Greater Manchester say they struggle to get GP appointments; “It really is a disgrace for those who genuinely need to seek medical advice urgently”

The Nuffield Trust reports: How far do the NHS’s financial problems really go? The bottom line: Understanding the NHS deficit and why it won’t go away

I still get e-mails advertising jobs in other countries with far less bureaucracy, more clinical freedom, and less intense time pressures, and a far greater income. It is this we are competing with. The only answer is to agree with all our G8 countries that we train more than enough doctors.

Queue jumping – The view of a GP David Wrigley in the Independent 2017

Going Abroad NHS

There is still little Private Practice option in General Practice, but this will change. As delays for serious symptoms become intolerable and all the ruses the experienced use to gain access fail, Private GP, like Private Dentistry will emerge..

A Private GP or a paramedic? Paramedics to replace north Wales’ GP home visits

London GP services crisis pending… Overseas doctors will probably fill the vacancies. Watch for private GPs and Private A&E departments in the capital…

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

Private Medical Insurance options… Going to get more popular? Our leaders show us the way.

A general practitioner is trying to follow the dentists into private practice – clients will initially be the retired rich, but eventually many more of us.


Denial for 5 years. On 4th June 2014 Mr Stevens asked for an honest debate…

The reality that Health and Social Care are not either of them free, has not sunk in to the politicians yet. We cannot have “Everything for everyone for ever” and for free, and in their denial, both houses thus conspire to avoid the important debate that Mr Stevens called for on 4th June 2014, almost exactly 5 years ago. If Social Care is means tested, why not Health Care? 

The unedifying spectacle of two potential leaders trying to bribe 160,000 older and richer people who happen to be their members, is the reality of todays politics. No wonder so many people dont vote. We need an honest party to speak “hard truths” to the nation. NHSreality believes the first party to do this, and be understood as honest and working for the overall good of us all, fairly, will eventually win a landslide. It will also win the hearts and minds of the medical professionals….. and they are trusted, and speak to many people daily.

Our political (moron) representatives need to permit commissioners and trust boards to ration overtly, so that their citizens know what is not available. Initially this will have to be by post code, but national guidelines from NICE would help. Eventually, for those services and treatments that none of us can afford, cancer and big operations for example, there can be a National Health Service again, and for cheap and cheerful, high volume low cost services, we can have local post code rationing if we still want it…

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BBC News reports 4th July: Social care: Hunt and Johnson urged to consider NHS-style free service

Public Service Executive reports: Peers call for NHS-style free social care system and an extra £8bn to tackle funding crisis

and the Guardian today also reports the Peers asking for an extra £80m for “vulnerable elderly people”. 

The reality is that for most of us the state safety net is absent. If social care is means tested, then why not health care?

New and higher taxes will never solve the problems of health and social care…

There is a toxic culture, and disengagement everywhere in Health and Social Care. Also in the CQC …

What principles should underpin the funding system for social care? Surely an ID card with tax status and means is now essential….

The reality of the post-code lottery and rationing of health and social care. It will just have to get worse before the “honest debate”…

A Happy Brexmas to everyone as our leaders duck health and social care funding crisis.. The media failure, and political denial can only get worse..

Nov 2016 NHSreality: NHS funding and rationing: The debate (and the denial) intensifies… It’s going to get worse..

Reality is a word rarely used in Health debate and discussion. The Economist comments on post election realities..

A dishonest and covert dialogue is all that is happening at present.. Simon Stevens says he would like to change this. (U tube 4th June 2014)

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