Category Archives: Medical Education

We are creating a “caste” of doctors – by neglect. Neglecting to change our electoral system is equally crass..

Not everyone wants to be a doctor. It needs some intelligence, memory, staying power and determination, as well as all round education and communication skills. This is why “graduate” entrants are better bets for the state’s investment. If it costs £250,000 to train a doctor, then we as taxpayers want the best value from our investment.

Currently the drop out rate and the emigration rate are high. Preventing nurses and doctors from the EU from coming here will make the short term skills crisis worse.

There is a new advert in the media, for a medical school in Malta with training and exams run by Barts and the London Hospitals trust.

Studying in Malta.

This is basically a second private medical school for UK provision. The first was at Buckingham, and there is competition for places. Costs and overheads will be cheaper in Malta… With 11 applicants for every 2 places in the UK Medical Schools, there should be plenty of aspirants.

So who will apply? I have no idea of the fees, but lets assume that it will be in the order of £250,000 over 5 years, and add to that travel and accommodation, say £10,000 per annum. The total is a minimum of £300,000. This opportunity is a beginning for what goes on in the Indian subcontinent, where most training places are private. Doctors in the UK from the Indian subcontinent are more likely to be privately trained than not. They are also more likely to come from affluent families who have invested in their children’s education for the long term.

If all 9 failed applicants went to private medical school, and remember that their careers officers all recommended and supported their applications, there would eventually be the same excess of private doctors in the UK. If the government is tempted to reduce the places it funds because of oversupply, then the caste system gets worse.

The short-termism of governments in a first past the post electoral system is now evident to everyone in the UK. (Particularly those who have died early as a result of system failures) But the politicians and the media collude to be against any form of PR (proportional representation) Fair voting systems mean everyone feels they have a chance to influence power.

The protest vote at Brexit referendum was because we don’t have PR. The referendum on PR was ill timed, and mismanaged by Mr Clegg and colleagues, but now there is a real feeling that the time for PR is here. It is present in Scotland and Wales, and could easily be applied to change the House of Lords, and reduce it’s overheads. Would we like GP education to be privatised in the same way?

Don’t be led by the media ring in your nose: vote Liberal for a longer term view, and Proportional Representation. (which form is another debate).

Image result for maltese falcon cartoon







GP leaders to debate future of NHS, industrial action and ‘zombie GPs’. “GPs’ first priority must be their own health”..

The most important word any resilient GP needs to learn is how to say “No”. Our profession is well paid, and the argument is not about pay. The conditions of work, the restriction of choices, and the shape of the job have become so onerous that many feel like zombies. In a national incident such as a train crash the Drs need to ensure they are safe before treating the victims. They need to secure the site. They need to make decisions which perhaps amputate on site, or allow some victims pain killers only, whilst others are saved. The train crash which the UK health services are now having is similar. As Clare Gerada is correct; “we have to look after ourselves  first”.

Nick Bostock reports on GPonline 3rd May 2017: GP leaders to debate future of NHS, industrial action and ‘zombie GPs’

GP leaders at next month’s LMCs conference will discuss whether the NHS can survive chronic underfunding, whether GP contractor status has ‘reached the end of the road, and whether industrial action should be back on the table to defend the profession.

The conference in Edinburgh on 18-19 May could also discuss whether deceased GPs could be resurrected to ease the GP workforce crisis, and call for health secretary Jeremy Hunt to be sacked ‘for presiding over the worst time in the history of the NHS, missing targets, longer waiting lists and low morale’.

Pressure looks to be growing from the profession for a wide-ranging overhaul of GP funding, with LMCs set to warn that overall funding is too low, and that distribution through the Carr-Hill formula and other contract mechanisms is unfair.

Motions put forward by LMCs warn that no funding mechanism will deliver fair funding for GP practices until overall funding is increased. The GPC warned earlier this year that despite pledges to raise funding through NHS England’s GP Forward View, the profession remains underfunded by billions of pounds.

GP funding

But LMCs will question whether the existing funding formula gets the balance right between different priorities, with a motion put forward by Glasgow LMC warning that ‘careful consideration has to be given to the balance of the funding formula between deprived patients, remote and rural patients, elderly patients and those patients not in any of these groups who may face their funding being eroded’.

GP leaders will also call for a list of core GP services to be defined – a step the GPC has long opposed – in part to maintain services as new care models take shape across the NHS. The GPC has consistently argued that it is simpler to define non-core work, for example using its Urgent Prescription document to list services that practices should receive additional funding for.

The conference will also hit out at the rising cost of indemnity, warning that increased fees are driving GPs out of the profession. LMCs will argue for greater transparency from medico-legal organisations about risk criteria that can lead to sharp rises for individual GPs.

GPs will also warn that contract uplifts have not covered rising indemnity costs in full, and that direct reimbursement of costs would be a better option for practices than payments based on list size.

Locum GPs

Plans to improve communication with sessional GPs, with a proposal for a ‘national communications strategy to secure adequate communication of guidelines and patient safety communications to locums’ will also be discussed at the conference.

Broader ‘themed debates’ at the conference will discuss issues such as NHS rationing, independent contractor status, working at scale and workload.

One debate will look at whether the NHS can survive given overall underfunding, and whether co-payments for services should be considered. Another will consider whether independent contractor status has reached the end of the road and how it could be protected.

Further debates will look at whether GPs should remain within the NHS – in Northern Ireland GPs have suggested they will quit the NHS en masse if two thirds of practices hand in resignations – and whether there is ‘still a need to consider appropriate forms of action, and would this be effective or counter-productive’.

Another debate will encourage GPs to discuss whether the QOF has reached the end of its useful life – as NHS England chief executive Simon Stevens has suggested.

A motion put forward by Shropshire LMC, meanwhile, suggests ‘the urgent funding of a bioengineering program designed to immediately triple-clone all UK GPs, including the recently retired, in order to facilitate our prime minister’s glorious vision of a truly 24/7 health service’.

It adds: ‘The project should ideally extend to exploration of the resurrection of deceased general practitioners, though conference acknowledges that some health consumers might find zombie GPs unpalatable at first (assuming they even notice the difference.) However, we believe that public fears about human cloning and the walking dead could be swiftly allayed by the persuasive powers of the undisputedly veracious Mr Jeremy Hunt.’

Alex Matthews-King in Pulse 24th April reports: NHS England asks CCGs for rationing heads-up following media scrutiny

Isabella Laws on 2nd May reports Clare Gerada: GPs’ first priority must be their own health, warns former RCGP chair – GPs must put maintaining their own health above caring for patients and running their practices, former RCGP chair Dr Clare Gerada has warned.

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

NHS ‘is like a train just before a crash’ (and it is now happennin g in slow motion)

Image result for each for himself cartoon

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..

Image result for decline and fall health cartoon

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 

Image result for what no plan cartoon

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

Image result for what no plan cartoon

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.

Image result for obama care open enrollment graphic

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

Image result for health trumped cartoon