Category Archives: Medical Education

NHS managers still growing as GP posts fall

The Observer reports 15th April 2017: Number of NHS managers still growing as GP posts fall again – Doctors say ministers’ ‘bureaucracy busting’ shakeup has failed to switch resources and manpower to the front line

The number of NHS managers has grown by almost 18% in the four years since the government introduced a “bureaucracy-busting” shakeup of the health service, according to the latest official data.

The rise of about 4,650 in total management posts since April 2013, when the controversial Health and Social Care Act came into force, contrasts with an alarming fall in the number of GPs over recent months at a time of unprecedented demand for health care. The figures have drawn criticism from the British Medical Association (BMA), who say ministers are failing in their central objective of shifting more resources and manpower from back-office posts to the front line….

Managers are at odds over rationing, and management recognises the case, but the “rules” don’t allow them to speak out.


Decline and fall of General Practice

The decline of General Practice has been evident to all of us close to the “hot end” for some years now. Watch for Private healthcare development and demand as the systems implode and let us all down. It will begin with GPs in large towns and cities, and progress to private A&E departments. There is no plan and politicians are in denial. Standards are falling, especially in training, and it looks as if differential post-code outcomes and life expectancy will follow in the next WHO report on the UK. The hot end is getting so hot it might become a desert..

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Kat Lay reports in The Times 12th April 2017: Thousands of GPs plan to quit in next five years

Seven in ten GPs intend to stop seeing patients, take a career break or reduce their hours within the next five years, according to research.

Two family doctors in every five intend to walk away from the profession, according to the study, with the proportion rising steeply with age.

By age 56, almost 90 per cent said that they would quit within five years, compared with less than 20 per cent of under-45s.

The figures come from a survey of doctors in the southwest but GPs’ leaders said that they were indicative of the whole of the UK, with low morale pushing people out of the profession…..

Emily Fletcher and others in the BMJ open report:

Quitting patient care and career break intentions among general practitioners in South West England: findings of a census survey of general practitioners

Zara Aziz in the Guardian 12th April : Time for a rethink on GP numbers; The GP recruitment crisis is only going to get worse as overwork and low morale push doctors out of the profession. More funding is desperately needed

The training and competence of doctors – letters in the Times following Doctors who trained abroad ‘far more likely to be incompetent’

‘My private GP surgeries can take the strain off the NHS’



What – no crisis? The NHS’s biggest challenge is convincing the public it has a plan ….

The answer is an overtly rationing plan…..

Anastasia Cox reports in The Guardian 2nd March: The NHS’s biggest challenge is convincing the public it has a plan 

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The British public has begun to talk of an NHS in crisis. This is a perception based on headlines decrying the state of the service; reports from healthcare staff (the NHS is the UK’s biggest employer; most people have at least one person in their social circle who works in it); and occasionally participants’ own bad experiences (although most still receive a great service – a tension that can give rise to “I was lucky” syndrome). Meanwhile, according to Ipsos Mori’s January issues index, 49% of respondents said that the NHS is one of the biggest issues (pdf) facing Britain today, a nine-point jump since December 2016 and its highest level since April 2003.

Public opinion abhors a vacuum. In the absence of a clear, concerted and disciplined message, people fill the gaps with their own assumptions, experiences and prejudices…..

Tara Aziz in the Guardian 12th April 2017 reports: Time for a rethink on GP numbers 

On 21st February she reported: Don’t blame GPs for NHS crisis. Blame chronic cuts to social care

and also reports that “Two in five GPs in south-west of England plan to quit”, survey finds – Study exposes potential doctors’ crisis in NHS, with GPs found to be considering leaving the job or reducing their hours

Kailash Chand opines 8th April:  If general practice fails, the whole NHS fails

and Sarah Marsh reports: Record number of GP closures force 265,000 to find new doctors

Surge in number of patients having to change practice comes despite NHS pledge to invest £2.4bn in GP services by 2020

The Observer sees Brexit as a distraction, NHSreality agrees, and now Syria is also

Forces lobbying for equality, the NHS and social mobility will soon be in fierce competition with new interests – such as farming – for attention and resources

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Self Sufficiency is a dream Mr Hunt. Rationing of Med Students means it will take over 15 years – starting now

Mr Hunt could show he means business if he wants self sufficiency in UK Doctors. He could appoint to be trained all the 770 3 “A” grade rejected applicants….Self Sufficiency is a dream Mr Hunt. The historic Rationing of Med Students means it will take over 15 years – starting now – to correct the shortfall. If doctors trained abroad are a problem for complaints, they are the main reason that the service is not “crashing” out now. By the way, I did not get 3 As and neither did many excellent doctors… If there are still 11:2 applications for places there may be many more capable people being rejected.

Get your free guide: Medical School Reapplicant Advice: 6 Tips for Success

Chris Smyth reports in The Times 10th April: Doctors who trained abroad ‘far more likely to be incompetent’

Doctors who trained in Bangladesh are 13 times more likely to face competence investigations than those who qualified in Britain, analysis of official figures has found.

Doctors from every other country except South Africa were more likely to be investigated than those from Britain, researchers from University College London concluded. Those trained in Egypt and Nigeria were the next most likely to be investigated.

Poor training, language barriers and cultural problems could all explain the problem and patients could be prejudiced against foreign staff. Age and gender could also play a role.

A quarter of NHS doctors are from overseas and the health service is reliant on foreign staff, but uncertainty surrounds their place as Britain leaves the EU. Jeremy Hunt, the health secretary said that he wanted to make the NHS “self-sufficient” by 2025. Researchers have analysed almost two decades of data on doctors who were required to take a competence assessment by the General Medical Council because of concerns about their performance.

“It’s certainly a very big effect. We can say with confidence that foreign trained doctors are more likely to get into this procedure,” said Henry Potts, one of the authors of a paper published in BMC Medical Education.

“Where there’s enough data everywhere was higher than the UK except South Africa which was no different. Not a single doctor from Hong Kong has come through this process so it could be that they are less likely to, but the numbers aren’t really big enough.”

Doctors trained elsewhere in the EU were about five times more likely to be investigated than those from Britain.

Jane Dacre, president of the Royal College of Physicians and senior author of the paper, said that the numbers were small but that the NHS must not be “complacent” about the findings. “Factors around staff induction, training and prior assessment before entering the UK are clearly an area we need to address,” she said.

Dr Potts said: “There is a possibility about the sort of training people are getting in different countries . . . Another angle is where are these people going wrong? Is it raw medical competence? Or is it language? Or is it about understanding the culture?”

Dr Potts said that it could be that poor British doctors simply got away with it.

Few doctors face investigation and only 23 from Bangladesh are going through the process out of about 900 in the NHS. Dr Potts said: “I would say to patients that the vast majority of all doctors wherever they trained are highly skilled and competent.”

He said that it was important “to get to the bottom of what the problems are here. If a poor doctor makes a mistake it could have life-changing consequences for patients. So we do need to make sure that’s not happening and that all doctors are competent.”

Susan Goldsmith, of the GMC, said that its move to a test for all doctors wanting to work in Britain would help.

A world of difference
The likelihood of doctors who qualified abroad being investigated by the GMC, compared with doctors who qualified in Britain:
13 times more likely
Egypt 8 times
Nigeria 8 times
Iraq 7 times
Germany 6 times
India 5 times
Eastern Europe 4 times
Greece 3 times
Ireland 2 times
Rest of the world 2 times
Source: GMC/BMC Medical Education

Medical Schools: your chances – applications-to-acceptance ratio was 11.2.



Has the penny dropped? No repeal for ‘Obamacare’ _ a humiliating defeat for Trump

Update 27th March 2017: The Republican Waterloo by David Frum of Atlantic opines: Conservatives once warned that Obamacare would produce the Democratic Waterloo. Their inability to accept the principle of universal coverage has, instead, led to their own defeat.

Seven years and three days ago, the House of Representatives grumblingly voted to approve the Senate’s version of the Affordable Care Act. Democrats in the House were displeased by many of the changes introduced by Senate Democrats. But in the interval after Senate passage, the Republicans had gained a 41st seat in the Senate. Any further tinkering with the law could trigger a Republican filibuster. Rather than lose the whole thing, the House swallowed hard and accepted a bill that liberals regarded as a giveaway to insurance companies and other interest groups. The finished law proceeded to President Obama for signature on March 23, 2010.

A few minutes after the House vote, I wrote a short blog post for the website I edited in those days. The site had been founded early in 2009 to argue for a more modern and more moderate form of Republicanism……

…It seemed to me that Obama’s adoption of ideas developed at the Heritage Foundation in the early 1990s—and then enacted into state law in Massachusetts by Governor Mitt Romney—offered the best near-term hope to control the federal health-care spending that would otherwise devour the defense budget and force taxes upward. I suggested that universal coverage was a worthy goal, and one that would hugely relieve the anxieties of working-class and middle-class Americans who had suffered so much in the Great Recession. And I predicted that the Democrats remembered the catastrophe that befell them in 1994 when they promised health-care reform and failed to deliver. They had the votes this time to pass something. They surely would do so—and so the practical question facing Republicans was whether it would not be better to negotiate to shape that “something” in ways that would be less expensive, less regulatory, and less redistributive….

…So, when the Democrats indeed did pass the law without Republican input, just as I’d warned they would, a fury overcame me. Eighteen months of being called a “sellout” will do that to a man, I suppose. I opened my computer and in less than half an hour pounded out the blogpost that would function, more or less, as my suicide note in the organized conservative world.

The post was called “Waterloo.” (The title played off a promise by then-senator and now Heritage Foundation president Jim DeMint that the Affordable Care Act would become Obama’s Waterloo, a career-finishing defeat.)

Even more provocatively to Republicans already fixed on a promise to repeal the Obamacare abomination, I urged: “No illusions please: This bill will not be repealed.”…

In that third week in March in 2010, America committed itself for the first time to the principle of universal (or near universal) health-care coverage. That principle has had seven years to work its way into American life and into the public sense of right and wrong. It’s not yet unanimously accepted. But it’s accepted by enough voters—and especially by enough Republican voters—to render impossible the seven-year Republican vision of removing that coverage from those who have gained it under the Affordable Care Act. Paul Ryan still upholds the right of Americans to “choose” to go uninsured if they cannot afford to pay the cost of their insurance on their own. His country no longer agrees.

Mark P Cussen for Investopedia in 2011 reports that over 60% of American bankruptcies are due to health costs…. Insolvency is handled differently in different countries.. In Canada it is usually die to occupational hazards, or financial mismanagement. In Australia and other countries with universal coverage they are rarely due to health costs. The UK health services may be losing us all money, but it does not yet affect individuals’ finances…. We can save our services if we pragmatically accept that there are some things we cannot afford and others that we should pay for individually. It can still be universal but only if standards are high and waiting lists short enough to ensure that even the richer citizens choose to use it. This may mean some form of adverse selection through charges related to means, but these charges need to be less than what it would cost for private care, or cover. The penny may have dropped in the US.

ERICA WERNER and ALAN FRAM from The Washington post, the Hamilton Spectator and all the 50 state newspapers, reported  March: No repeal for ‘Obamacare’ – a humiliating defeat for Trump. This was reported in Florida (where they want it to expand) and Michigan, in Alaska and even Texas, where the threat to repeal was acknowledged as based on a lie.

This is the rejection of the Trump plan to abolish the Affordable Care Act (ACA) (Obamacare). This decision alone, which confirms the value of the votes of 70 million citizens already covered (and rising annually) by the ACA. The republicans were rightly concerned that they would not be elected next time. The value of socialised medicine, the only way to cover a country, and one of the fundamental duties of government, was thus confirmed.

These figures are from several years ago and the trend has continued.

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The weakness of the ACA is due to the influence of big business, pharma and insurance industries. They have asked for the continuation of the current plans. This means that the self-employed without cover, the elderly, the sick and the poor and unemployed remain (see Hawaii News – Big Island Now), and they are exactly the highest risk and demand patients. The moral hazard is too big, and the solution is universal coverage. Big pharma and insurers need to be given due notice – and ignored.

The benefits of a large mutual apply to all insurance. Streets or housing estates would be cheaper for motor than individuals. The same is true of health… and smaller mutual such as Wales and N Ireland should take note.

The wording of the article is below:

WASHINGTON — In a humiliating failure, U.S. President Donald Trump and Republican leaders pulled their bill to repeal “Obamacare” off the House floor Friday when it became clear it would fail badly — after seven years of nonstop railing against the law. Democrats said Americans can “breathe a sigh of relief.” Trump said the current law was imploding “and soon will explode.”

Thwarted by two factions of fellow Republicans, from the centre and far right, House Speaker Paul Ryan said president Barack Obama’s health care law, the Republican Party’s No. 1 target in the new Trump administration, will remain in place “for the foreseeable future.”

It was a stunning defeat for the new president after he had demanded House Republicans delay no longer and vote on the legislation Friday, pass or fail.

His gamble failed. Instead Trump, who campaigned as a master deal-maker and claimed that he alone could fix the nation’s health care system, saw his ultimatum rejected by Republican lawmakers who made clear they answer to their own voters, not to the president.

He “never said repeal and replace it in 64 days,” a dejected but still combative Trump said at the White House, though he repeatedly shouted during the presidential campaign that it was going down on Day 1 of his term.

The bill was withdrawn just minutes before the House vote was to occur, and lawmaker said there were no plans to revisit the issue. Republicans will try to move ahead on other agenda items, including overhauling the tax code, though the failure on the health bill can only make whatever comes next immeasurably harder.

Trump pinned the blame on Democrats.

“With no Democrat support we couldn’t quite get there,” he told reporters in the Oval Office. “We learned about loyalty, we learned a lot about the vote-getting process.”

The Obama law was approved in 2010 with no Republican votes.

Despite reports of backbiting from administration officials toward Ryan, Trump said: “I like Speaker Ryan. … I think Paul really worked hard.”

For his part, Ryan told reporters: “We came really close today but we came up short. … This is a disappointing day for us.” He said the president has “really been fantastic.”

But when asked how Republicans could face voters after their failure to make good on years of promises, Ryan quietly said: “It’s a really good question. I wish I had a better answer for you.”

Last fall, Republicans used the issue to gain and keep control of the White House, Senate and House. During the previous years, they had cast dozens of votes to repeal Obama’s law in full or in part, but when they finally got the chance to pass a repeal version that actually had a chance to become law, they couldn’t deliver.

Democrats could hardly contain their satisfaction.

“Today is a great day for our country, what happened on the floor is a victory for the American people,” said House Minority Leader Nancy Pelosi, who as speaker herself helped Obama pass the Affordable Care Act in the first place. “Let’s just for a moment breathe a sigh of relief for the American people.”

The outcome leaves both Ryan and Trump weakened politically.

For the president, this piles a big early congressional defeat onto the continuing inquiries into his presidential campaign’s Russia connections and his unfounded wiretapping allegations against Obama.

Ryan was not able to corral the House Freedom Caucus, the restive band of conservatives that ousted the previous speaker. Those Republicans wanted the bill to go much further, while some GOP moderates felt it went too far.

Instead of picking up support as Friday wore on, the bill went the other direction, with several key lawmakers coming out in opposition. Rep. Rodney Frelinghuysen of New Jersey, chair of a major committee, Appropriations, said the bill would raise costs unacceptably on his constituents.

The defections raised the possibility that the bill would not only lose on the floor, but lose big.

The GOP bill would have eliminated the Obama statute’s unpopular fines on people who do not obtain coverage and would also have removed the often-generous subsidies for those who purchase insurance.

Republican tax credits would have been based on age, not income like Obama’s, and the tax boosts Obama imposed on higher-earning people and health care companies would have been repealed. The bill would have ended Obama’s Medicaid expansion and trimmed future federal financing for the federal-state program, letting states impose work requirements on some of the 70 million beneficiaries.

The nonpartisan Congressional Budget Office said the Republican bill would have resulted in 24 million additional uninsured people in a decade and lead to higher out-of-pocket medical costs for many lower-income and people just shy of age 65 when they would become eligible for Medicare. The bill would have blocked federal payments for a year to Planned Parenthood.

Republicans had never built a constituency for the legislation, and in the end the nearly uniform opposition from hospitals, doctors, nurses, the AARP, consumer groups and others weighed heavily with many members. On the other side, conservative groups including the Koch outfit argued the legislation did not go far enough in uprooting Obamacare.

Ryan made his announcement to lawmakers at a very brief meeting, he was greeted by a standing ovation in recognition of the support he still enjoys from many lawmakers.

When the gathering broke up, Rep. Greg Walden of Oregon, chair of the Energy and Commerce Committee that helped write the bill, told reporters: “”We gave it our best shot. That’s it. It’s done. D-O-N-E done. This bill is dead.”

The Associated Press

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Educating a nation. Obama;s legacy: “..weaving into the American fabric the notion that everyone deserves access to healthcare.”

The 1948 NHS was originally sold on reducing or replacing fear. In Place of Fear A Free Health Service 1952 Chapter 5 In Place of Fear. Now there is fear in patients, and equally worrying in staff. ( Whistleblowing and the NHS culture of fear. Times letters ) Obamacare or the AKA took away a large chunk of fear. The republican media may hold off the tide for a while, but eventually socially mutualised medicine,, in some form will come about in the US.

Courtney Subramanian for The rise of Obamacare. Why is AKA so popular?

 Nobel-winning psychologist Daniel Kahneman famously pioneered the idea that people tend to fear loss twice as much as they prefer gains.

Loss aversion, he said, is when people feel the pain of losing something more than they feel the pleasure of gaining something else, which can leave some wary of taking risks.

That could be why the threat of losing the Patient Protection and Affordable Care Act (ACA), known as Obamacare, has led to more support for the healthcare law than ever before.

Can Obamacare be repealed?

Why is Obamacare so controversial?

President Donald Trump has urged Congress to repeal and replace Obamacare, while Republican lawmakers have suggested they could do so before the end of the month.

But the congressional plan to remove Obamacare has been hobbled by the Republicans’ inability to present a clear replacement scheme, leaving some Americans unnerved as the healthcare law’s expiry date looms.

“People are looking at what they’re losing and it’s not clear what they’ll be gaining,” says Thomas D’Aunno, director of the health policy and management at New York University’s Robert F Wagner Graduate School of Public Service.

An uncertain future about the country’s healthcare is “playing into people’s stronger attachment to the ACA”, he says.

That sentiment is felt by Americans like Cathy DeLoach, who changed her mind on the ACA after her son was diagnosed with testicular cancer and her family spent $29,000 (£23,000) on treatment costs in 15 days.

“I stayed with him in the hospital and I had a lot of time to think about how grateful I was for the Affordable Care Act,” she told the BBC.

Mrs DeLoach, who did not vote for Mr Obama in 2008 and 2012, said she was not a fan of the law when it was first passed, but now worries for her son’s future.

“This really is something that could be so awful for so many people, and so many poor people, and it’s wrong.”

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How has public opinion shifted?

A recent Health Tracking Poll from the Kaiser Family Foundation found the highest level of favourability for the ACA in more than 60 tracking polls since 2010, when President Barack Obama signed it into law.

The poll found that 48% of Americans approved of the ACA while 42% said it was unfavourable.

At its lowest favourability in November 2013, just 33% approved of it.

Ashley Kirzinger, a senior survey analyst at Kaiser, said that while it is not a majority of Americans who share this view, the shift underscores American concerns amid a heated debate about its replacement in Washington.

A handful of other polls echoed these findings….

….”The single most important part of Obama’s legacy on the ACA is weaving into the American fabric the notion that everyone deserves access to healthcare.”

The fear of losing Obamacare has been exacerbated by a grassroots movement at town halls nationwide, where hundreds of constituents have aired their grievances to Republican lawmakers over Mr Trump’s policies – including the ACA’s future.

“Looking your representative in the eye and saying, ‘I am deeply concerned that I am going to lose my health insurance’ is a lot more powerful than a clever chant,” Mr Williams says.

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The difference between the UK and the USA is that they are destroying Obamacare deliberately, whereas we are destroying our service by neglect and denial.

Whilst the Americans destroy Obamacare on the grounds of cost and perverse incentives, we are destroying something much better – the rump of the former NHS. It’s not easy for politicians in denial to admit their mistakes.. Good and experienced GP gatekeepers are valuable commodities. They have all round experience, know their limitations and when to ask for help. Asking too often is just as bad as asking too infrequently. Unfortunately GP Training is not universally equal. Psychiatry and Paediatrics can be omitted quite easily… Other countries such as Canada insist on adequate all round training and we should do the same. Referral management centres would not then be demanded.. There is no cross party consensus, and the difference between the UK and the USA is that they are destroying Obamacare deliberately, whereas we are destroying our service by neglect and denial, (and long term covert rationing).

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Kailash Chand in the Guardian opines on 4th January 2017: 2016 was the worst year in NHS history – we must fight for its survival and Richard Vize says 6th Jan 2017:  Improving NHS services should not feel like a quest in a labyrinth . Also today BBC reports “Social care funding: MPs urge ‘swift’ cross-party review”, …a letter signed by Clive Betts, chairman of the Communities and Local Government committee, Public Accounts Committee chairman Meg Hillier and her Health Committee counterpart Dr Sarah Wollaston says a long-term solution can only be found if there is cross-party consensus…

Chris Smyth reports 5th Jan 2016 in the Times: NHS paying private firms to block hospital referrals – (Referral Management Centres) whilst the Guardian’s take on this is “NHS groups ‘paying millions to private firms that block GP referrals’ – Referral management centres being used by some NHS bodies to scrutinise patient referrals to hospitals, BMJ inquiry finds

….In an investigation, the British Medical Journal (BMJ) sent freedom of information requests to all 211 CCGs in England. Of the 184 that responded, 72 (39%) said they commissioned some form of referral management scheme.

Almost a third (32%) of the schemes are provided by private companies, while a further 29% are provided in-house and 11% by local NHS trusts. Some 69% of the CCGs with schemes gave details of operating costs. These CCGs combined have spent at least £57m on schemes since April 2013.

Most CCGs were unable to provide evidence showing the scheme saved money…..

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In the Guardian letters on 3rd jan 2017 Taxing questions about NHS funding Alan Bailey, and Nicholas Suaraz, comment:

Steve Richards’ proposal for a referendum on whether to tax more to invest in the NHS (Opinion, 3 January) is interesting. But his first “drawback” – that “the Treasury hates any form of earmarked taxation” – is not quite right. What the Treasury objects to (stating awkward facts, as usual) is that hypothecating an existing tax to a particular programme will put an unacknowledged extra burden on other programmes (actually or potentially). The problem with this proposal, as with any referendum, is that a “vote for change” lands the government with the further question: what change? In this case, what new tax? Indirect tax (VAT) is regressive. A straight proportionate increase in income tax looks unfair to low earners and harms incentives to work; but a steep increase in direct tax on rich individuals, or companies, will drive them to base their money, or themselves, abroad. This leaves a progressive tax on the value of fixed assets (land and buildings) – for example a reformed council tax; but how much would a government dare to tax “ordinary” property owners when house prices are already so high?
Alan Bailey

As this winter is indisputably showing, the NHS is slowly dying, and no doctor or nurse can save it. The cure can only be ministered by the British people. As the year turns they must decide whether or not they believe, as they did in 1948, that “illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community” (Aneurin Bevan). If they do, they should indicate through their elected representatives that they are willing to open their wallets and pay the cost through increased taxation. If they do not, they should accept that our health system, the envy of the world, will perish, leaving behind the country’s poorest and most vulnerable.
Dr Nicolas Suarez

Image result for cartoon uninsuredUpdate: also in the news today 6th Jan 2017 is Norovirus, a disease of overcrowding in Health Service Hospitals which is never seen in private ones, and

Katie Gibbons: Call for extra NHS cash as norovirus hits 5-year high its a direct result of “undercapacity” rationing, and Mark Porter’s advice is good in the emergency but denies the longer term structural reasons. Dr Mark Porter: This season’s norovirus looks like a bad one. Here’s how to deal with it

There is a similar denial regarding Mental health. Rosemary Bennett reveals the well intentioned but mis-directed intentions of coroners trying to protect families (and life insurance policies): Thousands of suicides hidden to comfort grief-stricken families: Thousands of suicides hidden to comfort grief-stricken families