Category Archives: Medical Education

The reaality of cultural dissonance.. A GP Trainee recalls her hospital experience of discipline..

A letter in the Times from Dr Katie Musgrave 20th January informs readers of the reality of being a junior doctor in todays overmanaged health services. Read it at the end of this post.

The Bury St Edmonds terrorising of staff, threatening them with fingerprinting, and generally demoralising them further, is indicative of the whole of the 4 health services. 

The idea that managers can treat doctors as staff on a factory production line has led to this situation. Changing a culture is very difficult... especially for a state monopoly which most people still love the idea of… especially when the trust are all bust. No single person I have asked seems to realise that with the Brexit devaluation of the pound all costs have risen by 18%…

Add to this the overhead inherent in Wales (As opposed to Scotland and N Ireland) because of the Welsh Government..

Image result for love nhs cartoon

Bury St Edmunds Hospital in the dock. Cultures rarely change themselves. Reform is needed. Britain needs a truly independent body to which NHS staff can turn,

Missed appointments dont cost except in a factory model of General Practice. 20,000 missed appointments is actually welcome to most GPs. Now if there was a disincentive to make a claim….

Kent NHS ‘to send surgery patients to France’ – setting a precedent? Can the fragmented UK health services recover without some form of zero-budgeting and revolutionary reconfiguration based on overt rationing?”

Sir, Your report on West Suffolk Hospital (“Anger over ‘witch hunt’ in hospital”, Jan 17) will be shocking to many but did not surprise me. My husband (a GP) and I have just exchanged memories of times when, as junior doctors, we were both brought before committees accused of minor misdemeanours. He had logged into a results system online and forgotten to log out. Someone had subsequently used his account to look at a consultant’s personal medical results. He was made to “confess” and sign a document admitting his negligent behaviour. I was once accused of dropping a blood bottle into a regular bin rather than a clinical bin. The bottle had been traced to me and a committee put together to sanction me for this crime. At another hospital I was called to answer for having examined a child in the wrong clinical room. Apparently I had been anonymously reported. Such bullying tactics are widespread in the NHS and do indeed keep doctors from raising genuine concerns about patient safety. If, from your early years of training, you have been consistently threatened and undermined, it can be very difficult to maintain the resilience to speak up. We need independent advocates for NHS whistleblowers.
Dr Katie Musgrave, GP trainee
Loddiswell, Devon

Image result for love nhs cartoon

Image result for love nhs cartoon

Image result for love nhs cartoon

Private Health Care is expanding… and it’s strength reflects the weakness of the 4 Health Dispensations

The experts on trends in health care, and especially private health care, and Private Medical Insurance (PMI) are Laing and Buisson whose reports cost a great deal.

Their reports into “Private Acute Healthcare, Mental Health Hospitals, Cosmetic Surgery, Children’s HealthCare Services, Digital Health and the UK Healthcare” are all “Market Reports”. This is a market where you pay for what you get, and sometimes for what you cant get. In the case of taxpayers at the peripheries of the country, these lacunae of services are greater than centrally. Especially worrying is the report on Private Acute Healthcare. British citizens may all have to consider choices and whether to travel long distances to centres of excellence, even for emergencies, in the next decade. The figures provided by the BMA in 2018 have got worse, and remember these only apply to England!

Private Health Care is expanding… and it’s strength reflects the weakness of the 4 Health Dispensations, and the hard choices ahead for all of us. With obesity and diabetes the main demands.. But there’s always denial.

See the source image

PressReader and the Independent report 19th Jan 2020: Britons spend more than £1bn on private surgery.

The Nuffield Trust report in 2016 indicated that much more money was needed just to keep up with internationally comparable countries;

Since then (2009) , however, the gap has started to widen (particularly against countries that weathered the global financial crisis better than the UK) and looks set to grow further. UK GDP is forecast to grow in real terms by around 15.2 per cent between 2014/15 and 2020/21. But on current plans2, UK public spending on the NHS will grow by much less: 5.2 per cent. This is equivalent to around £7 billion in real terms – increasing from £135 billion in 2014/15 to £142 billion in 2020/21. As a proportion of GDP it will fall to 6.6 per cent compared to 7.3 per cent in 2014/15. But, if spending kept pace with growth in the economy, by 2020/21 the UK NHS would be spending around £158 billion at today’s prices – £16 billion more than planned.

The London School of Economics opines 1st October 2019: Flawed data? Why NHS spending on the independent sector may actually be much more than 7%

,,,the amount spent by NHS England on the independent sector was around 26% of total expenditure, not 7% as widely reported. 

Cannabis is not a frontline drug, but some people seem to benefit.. Just like with dementia drugs the value is very small.. Andrew Ellson in Jan 2020 reported in the Times; More than a million Britons buying cannabis illegally to treat illness

The French have rationed out dementia drugs, and will be able to give much more care. The same argument may apply for cannabis, depending on numbers, and remember demand always increases once a service is free.

The Scottish Daily Mail (Pressreader) points out that there are 3700 visits to A&E every day (In Scotland alone) which could have been dealt with by GPs is there were enough of them, with enough time and resources. What an incentive to start private general practice.

Mailonline December 2018 reports that: Patients spend a record £1.1BILLION on private healthcare to avoid soaring NHS waiting times which leave them ‘let down and suffering’ and this has been updated for just surgery by the Independent.

The BMA opines 7th Dec 2018 on: Hidden figures: private care in the English NHS (and its got worse since)

Breaking Point, NHS info graphics
Do (ISPs) independent sector providers give good and good value care? NHS spending on (ISPs) independent sector providers keeps increasing.

The health service in England is facing the greatest financial challenge in its history, and yet the independent sector is increasingly involved with the provision of patient care within the NHS.

The English health service is heading towards a projected £30 billion funding gap in 2020/21; the government has committed £10 billion to help mitigate the situation, although the BMA has argued that in real terms, and factoring in the cuts to other services, the figure is closer to £4.5 billion. Within this climate, one of the few areas where funding is increasing is amongst ISPs (independent sector providers) of NHS care.

We want to find out what this means for the provision of patient care.

Key points

Building on our 2016 report on privatisation within the NHS in England we’ve looked into the data behind these headlines.

Our analysis uncovered the following key points:

  • NHS spending on non-NHS and independent sector provision grows each year (there was an increase of £2.6 and £2.1 billion respectively between 2013/14 and 2015/16);
  • The proportion of the total Department of Health budget spent on ISPs is also increasing (from 6.1% in 2013/14 to 7.6% in 2015/16);
  • There needs to be more transparency about the level of private provision of NHS services;
  • The principal area of spending on ISPs is in the community health sector;
  • The NHS relies very heavily on a small number of ISPs despite acknowledged risks from individual ISPs having an excessive market share;
  • CCGs spending a higher proportion of their budget on ISPs received worse ratings from NHS England than their counterparts.

Claire Milne for Full Fact reports before the election on How much public health spending goes to the private sector? 

…..This takes as its starting point the £13.7 billion figure from the DHSC accounts.

The £1.3 billion spent by NHS trusts on services from non-NHS organisations is added to that.

Added to that is the £14 billion the NHS spent on commissioning primary care from the private sector. This includes things like GP services, pharmacies, and opticians. This may not be what everyone things of when they think of the NHS spending money on private providers, but technically they all are. Mr Rowland acknowledges there is “genuine debate” as to whether the provision of GP services fall under private spending “given that they derive almost all their income from the NHS”.

Finally, it includes the £830 million the NHS in England spends on social care services and a lot of these are provided by private organisations.

Another health think tank, the Nuffield Trust, has used a similar method to determine that, over the last decade, between 20% and 22% of annual public spending on health in England has gone towards procuring healthcare services from private providers.

Sensible rationing of dementia drugs – a lead from France

‘Wasteful practice’ CQC says is due to ‘ongoing issues with poor recruitment, training and safeguarding processes’ Private ambulances and Taxis: The Independent reports 27th August 2019. 




Exit interviews, especially if done by outsiders, will tell health boards, politicians and the public the truth. There is no way to get sufficientt GP diagnosticians in time…

There are no exit interviews in most of the 4 health services. All 4 dispensations, health boards, politicians and the public are in denial. Witness the repeated postings since 2012 in NHSreality. here is no way to get sufficient GP diagnosticians in time… The rationing of medical school and GP training places has come home to roost.. 

A letter in the Times 29th December 2019 from Dr Douglas Salmon, a retired GP:

Concern at falling numbers of GPs has been expressed by the Department of Health, the Royal College of General Practitioners and other bodies (“Top doctor warns of £6.2bn black hole in NHS funding”, News, last week). However, at a recent reunion of GPs from my training group who had taken early retirement, none recalled being asked by any of these organisations why they were leaving. These are doctors who have retired five or 10 years early; the lack of interest in their reasons suggests retention is unlikely to improve any time soon.
Dr Douglas Salmon, Birmingham

2019 reports

Practice Business 12th November 2019:  Tories promise 50m more GP appointments a year and 6000 extra GPs (But by when?)

BBC News 2019: General election 2019: Tory pledge to boost GP numbers …

BMJ 2019: Tories promise 6000 extra GPs by 2024

The Guardian: NHS needs 5,000 trainee doctors a year, says GPs’ leader …

 2016 reports

2016 reports: Government to miss the extra 5000 GP target. Pulse March 2016. ,

Why Hunt’s pre-election promise of 5,000 new GPs is a long …way off. , for Pulse March 2016.

The Tories’ NHS Lies (Tribune Magazine)



We are still not training enough doctors, and the gender and undergraduate bias needs to be changed.

So there are more applicants for medical school. We need (at least) 5000 more (Per annum) and we are training an extra 900 per annum. With part time and early retirement we are still going to run out of doctors.… Virtual Medical schools would be a great help… Graduate entry only would be even better… And then there’s the debt..

In the Times today 7th November Rosemary Bennett reports: Fight for Oxbridge place tougher than ever after applications surge

…..More want to take medicine
Applications to study at medical schools have risen by 6 per cent compared with last year. There were 23,710 applications to medical schools for courses that had an early deadline of October 15. Of those, 18,500 came from prospective doctors within Britain, an increase of 5 per cent. The rise in interest to become a doctor comes after five new medical schools opened their doors within the past year. These include schools at the universities of Sunderland, Lincoln and Edge Hill, in Ormskirk, Lancashire. Other long-established medical schools have increased the number of places available.

Some good news on new medical schools. Lets hope the politicians sieze the real opportunity for virtual medical schools living in local communities

Its more than a thin front line, as half timers take over from deserters…

There’s a horrible smell around the Health Service(s) battlefield: it’s more than an “ill wind”.

After promising to clone GPs, and failing, Mr Hunt promises to “make” more radiologists… Importing them will block our own for years. Exporting films abroad is an option…

NHS needs 5,000 trainee doctors a year…..!

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

Health Services might be designed wrongly: In praise of dissenters.. Currently there is little ability to speak out, “without fear of sanction”.

The Different health services in the UK are not open to the suggestion that they might be designed wrongly. They are failing more quickly than anyone imagined (other than those in the profession, and NHSreality). An interview with Helen Stokes-Lampard (RCGP chair) In “You and Yours” on Radio 4 17th October 2019 tells it straight: its going to take at least 12 years to remedy the failure in forward and manpower planning. (The interview is at the end of the recording) The culture of fear means that opportunities to learn constructively are being lost, educational standard are falling, and engagement with the politics of health is minimal. One route to honesty is the exit interview, and these collated together could give messages that lead to the changes needed. Meanwhile……  “Winter is coming”. We will all be hearing how they will listen (See Jill Patterson in Walesonline below), but NHSreality can tell you that even if they hear, they don’t have the human resources to act. 

In Bartleby in The Economist 12th October 2019 “In praise of dissenters – It pays companies to encourage a variety of opinions “

The ability to speak up within an organisation, without fear of sanction, is known as “psychological safety” and was described by Amy Edmondson of the Harvard Business School in a book on the issue. Mr Syed cites a study of teams at Google, which found that self-reported psychological safety was by far the most important factor behind successful teamwork at the technology giant. ….“In praise of dissenters

As many practices disintegrate, I give a link to a local practice in the news.

Eleanor Philpotts in Pulse 12th October 2019 reports on Ferryside practice.: Practice set to close after 3 years without a GP

In Walesonline Sandra Hembury on 14th October reports: The GP surgery that hasn’t had a GP for over 3 years..

A doctors’ surgery hasn’t had a GP working there for three years and is now being threatened with closure.

The Mariners Surgery in Ferryside has only had nurse sessions since 2016, because there were no GPs available to operate from it.

Now plans have been unveiled to close the surgery and relocate services to other practices, forcing patients to have to travel for miles to receive treatment.

A public drop-in session is being held to consult with patients at the Three Rivers Hotel in Ferryside between 2pm and 7pm tomorrow (Tuesday, October 15).

But there are fears those less mobile patients will struggle to get to the next nearest surgeries in the Meddygfa Minafon practice – in Kidwelly or Trimsaran.

Cllr Mair Stephens is ward councillor for St Ishmael and deputy leader of Carmarthenshire County Council.

She said the Carmarthen Road practice had been there for a number of years.

“There’s traditionally been a dispensing surgery, which is exactly what we do need,” she said.

“The majority of people who live in the area are older, and the surgery has been on the decline in recent years, but it still has such things as foot clinics and heart clinics.

“They are now going to close it, which is out of all proportion.”

She said the nearest surgery in the group was Minafon in Kidwelly, which was about four miles away. But it was difficult to get to if patients needed public transport. The nearest bus route to the Kidwelly surgery dropped passengers off at least 10 minutes away from the practice, which wasn’t suitable for the less mobile, she added.

She suggested the practice could set up a bus route taking passengers without suitable transport from the Ferryside surgery to Kidwelly.

Cllr Stephens added: “This is about moving services from their locality.

“What older people want to do is to see a GP. They don’t necessarily want to see a nurse.

“Once they have seen the doctor they are quite happy to meet a nurse or practitioner. That’s where the whole system seems to be falling down.”

She felt the consultation was not being spread out enough to the wider community, including nearby Llandyfaelog.

A petition has been set up to maintain the surgery in Ferryside.

Started by Ute Eden, it says: “We feel very strongly that it is essential to maintain a surgery in Ferryside.

“We need a doctor, a nurse and a dispensary to provide the vital services required by a village where most residents are over the age of 50.

“It is an integral part of Calon y Fferi Community Centre, which is very accessible.”

The petition, which has been signed by 44 people, said it would be a backward step to oblige all residents to leave the village for treatment.

Jill Paterson, director of primary care at Hywel Dda University Health Board, said: “As a health board we are committed to listening to and engaging with local populations around our proposals to relocate our primary care services from Mariners Surgery to neighbouring surgeries.

“We would therefore like to invite residents to come along and get involved in the conversation.

“Following a review of how services are used by patients at the surgery, it is becoming clear that these services are limited and not fully utilised and could be relocated to Minafon and Trimsaran Surgeries.”

A&E standards fall – the end game means an opportunity for private A&E and Ambulance services in richer areas

Don’t wait until you are ill, or your next of kin needs emergency care. Try and think ahead to what options you have in your post code. In reality most of us will have no choice, but there may be a choice in the bigger cities. Certainly NHSreality expects market forces to mean private services expand. As A&E standards fall – the end game means an opportunity for private A&E and Ambulance services in richer areas. And its going to get worse…

It is all very well having long waits for access to GP and cold hospital care, but it is quite another when one of the holes in the safety net gets so large that the net has been removed. I can attest to the fall in standards from personal experience with a recent Right hand compartment syndrome that was ignored at first, and then operation was delayed, for a total of 18 hours. The recovery will be longer, and more painful than it might have been, but thank goodness I have kept my hand.

The failure in manpower and forward planning in general, the over supply of doctors who wish to work part time, and under supply of those who wish to work full time, rationing of medical school places, and lack of increased reward for working a shift pattern career are all part of the problem. There is no valuing of what are seen as temporary staff, and it has to get worse…

The Care Quality Commission

Henry Bodkin in the Telegraph 15th October: More than half A&E services failing

More than half of A&Es are now failing because patients who should be treated at home or in clinics are flooding through emergency departments’ “ever-open doors”, inspectors have warned.

The Care Quality Commission said breakdowns in provision for dementia and mental health patients are fueling the deterioration of standards….

ITV News: A&E under tremendous pressure as more departments need improvement (Standards fall)

Shaun Lintern in Health Service Journal: Regulator warns of ‘extraordinary’ winter for A&Es

  • Chief inspector warns of “extraordinary circumstances” for emergency departments this winter
  • Care model failure leaves hospitals overloaded
  • Watchdog warns of deterioration on mental health, learning disability and autism wards

A failure to provide the right models of care is forcing thousands more people to attend emergency departments each day, the Care Quality Commission has said, while warning of a “perfect storm” for the health service this winter……

Dennis Campbell in the Guardian: More than half of A&Es provide substandard care, says watchdog – Hospitals struggling to cope with rising numbers of patients who cannot get help elsewhere

Kaya Burgess in the Times: More than half of A&Es not up to job, says care watchdog

The health watchdog has warned that A&E departments are under “tremendous pressure”, with more than half now deemed inadequate or in need of improvement.

The Care Quality Commission’s annual State of Care ( England only) report also warned of a “perfect storm” across health and social care where people cannot access the services they need or where care is provided too late.

The regulator found that A&E standards had slipped over the past year and that emergency departments were the most likely part of a hospital to be ranked as inadequate.

In 2018-19, 44 per cent of urgent and emergency services were rated as requiring improvement — up from 41 per cent the year before — with a further 8 per cent deemed inadequate, up from 7 per cent the year before.

Inspectors said that A&E departments had not had their usual “breathing space” over the summer months to prepare for the perennial winter pressures.

He said: “We know that it’s a combination of increased demand and challenges around workforce [that] are creating something of a perfect storm and if that perfect storm is allowed to continue we will have a number of problems.”

He said that the 18-week waiting list for planned hospital treatment had grown from about 3 million people to 4.4 million over the past five years.

The CQC also warned of a “serious deterioration” in the quality of inpatient services for people with mental health problems, autism or learning disabilities. About 7 per cent of child and adolescent mental health services were rated inadequate last year, up from 3 per cent the year before.

Mr Trenholm said: “We also know that adult social care remains fragile. We know that the failure to agree a long-term funding solution is driving instability in the sector.”

Sally Warren, director of policy at the King’s Fund health charity, said: “The CQC’s report provides further evidence that staffing is the make-or-break issue across the NHS and social care. Staff are working under enormous strain as services struggle to recruit, train and retain enough staff with the necessary skills.”

Nick Scriven from the Society for Acute Medicine said: “At some point in the near future all these sustained and repeated problems with increasing demand, inadequate workforce that is haemorrhaging senior cover, the pension tax crisis, crumbling estates, insufficient community medical care and community social care in general totally under-provisioned, we will reach a vital tipping point and care will be compromised despite all the heroic efforts by the human side of this, the staff in post.”

An NHS spokesman welcomed the watchdog’s finding that quality standards had remained stable when taken as a whole and said: “While the NHS Long Term Plan set out an extra £4.5 billion to ramp up GP and community care, the CQC rightly highlights the need for a long-term solution to adult social care so that older and vulnerable people get the right care when they need it.”

March 2015 NHSreality: From bad to worse: “NHS medical accidents investigation unit ‘needed’”

Jan 2016 NHSreality: Accident and Emergency – departments understaffed – report suppressed

Doctors let dying patients waste their last days in Accident and Emergency

The Care Quality commission has different standards and reports in different jurisdictions


Diversity in training is good, but “Dumbing down medical schools could be lethal”, unless exams are discriminateory.

In a letter to the Times published 11th August in response to an article on easing admission criteria to medical school, Dr Simon Rose points out the risks in lowering standards. those of us who have been through the brutality of medical training, house jobs and specialist training know that although a certain basic intelligence certainly helps, it is determination, stickability, bloody mindedness and long term planning that get one through, and the grades at admission bear no relation to whether the doctor becomes a specialist, a professor or a GP. We do not want standards to fall, but there are exams in medical school, and with these and final exams it should be possible to weed out those who might become “lethal”.

What really would help is graduate as opposed to undergraduate entry, as this would equalise the sexes, and to aim at overcapacity. Staff who feel valued make fewer lethal mistakes, so this too needs addressing..

Letters to the Editor: Dumbing down medical schools could be lethal

Sian Griffiths had reported 4th August in the Times: Medical schools ease admission rules in name of diversity

Top universities are dropping some of the hardest A-levels from their entry requirements to attract more girls and poorer pupils on to courses dominated by male and middle-class students.

Physics is no longer an A-level prerequisite for some engineering degrees, or chemistry for some courses to study medicine.

The move was condemned this weekend as “social engineering gone mad” by one expert who said it could lead to engineers building dangerous bridges and doctors missing diagnoses.

Bristol University said it hoped its decision to stop insisting that applicants to its main engineering course had A-level physics would “increase the diversity of students”. Civil engineering courses at University College London and some at Southampton no longer require A-level physics either.

Only about 20% of A-level physics entries are from girls, and research suggests it is the hardest subject in which to get a top grade.

Medical schools are also changing their entry requirements in an attempt to break the stranglehold of affluent and privately educated students.

At Manchester University, those studying medicine no longer have to have chemistry A-level, a prerequisite for decades. Psychology is accepted as a science subject.

Drew Tarmey, head of medical school admissions at Manchester, said selection tests and interviews could help selectors to spot the best candidates when more liberal entry requirements came in. He said: “As far as subject requirements go, we are thinking, ‘Where do we go from here? Does somebody have to have two sciences? Would biology, history and French, for instance, be any different?’”

From 2020 Norwich Medical School, part of the University of East Anglia (UEA), will not require applicants to have A-level chemistry. Neither will new medical schools at Sunderland University and Anglia Ruskin, in Chelmsford.

Chris McGovern, chairman of the Campaign for Real Education, said: “If bridges start falling down or diseases are missed because the students were not properly prepared, we will all suffer. This is social engineering gone mad.”

Dr David Barton, engineering admissions officer at Bristol, said parts of A-level physics had been incorporated into first-year courses to plug any gaps.

Alix Delany, UEA’s head of admissions, said: “Allowing students studying either biology or chemistry for A-level to apply for medicine gives us the opportunity to interview a wider variety of prospective students, where we want to see them demonstrate their caring and empathetic attitude, which is a quality that is just as important to us as academic ability.”

Dr Simon Rose letter: 

The head of admissions at the University of East Anglia says that for prospective medical students, a “caring and empathetic attitude” is as much a qualification as academic ability (“Medical schools ease admission rules in name of diversity”, News, last week). This is shocking.

If I am an unconscious patient on a respirator in intensive care, with complex ventilatory requirements, renal failure and disordered blood chemistry, I need someone able quickly to apply academic rigour and scientific knowledge to stabilise my condition.

Doctors selected for empathy, but not so good at chemistry, may be better at telling my children that I have died, but that might not have been necessary had they met the entry requirements at a more rigorous university.
Dr Simon Rose, Bath