Category Archives: Perverse Incentives

The skill of “doing nothing” is valuable, and is what makes the GPs so efficient.

The UK trains many doctors, especially Scotland, and some of them go abroad. We import some 30% of the doctor labour force. Wales trains many GPs. But we then have too few. We export them to England, and places where they aspire to bring up their families. Better infrastructure and education plays a great part in where doctors choose to live. With 80% of medical school places being allocated to female candidates, there is more incentive to stay near their home. Inner city and suburban schools provide most doctors for training. Whatever plan the government comes up with it needs to reverse these trends.. Inducements for doctors to work in poorer areas could be a lot greater….

Meanwhile we are promised a new brand of fast track doctor, who might have been a pharmacist or a paramedic beforehand. Lets hope they cut the mustard, and are asked to pass the same exams. NHSreality predicts that these people will not be able to live with uncertainty. Doing nothing for a short period of time allows diseases to take a natural course… The skill of “doing nothing” is valuable, and is what makes the GPs so efficient. If they cannot do this, and we know consultants find it hard, they will elongate the waiting lists for investigations. This will cause adverse outcomes, and those right enough will go privately. The perverse outcome of well intentioned but ill thought through change.

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

Welsh NHS has ‘nothing to hide’, says health minister. Listen to Mr Drakeford…

Wriggling on the hook of Dr under capacity. Any solution, ethical or not, will be considered. On the other hand anyone who passes the final exams, however they learned, should be allowed to be a doctor.

Nurses and pharmacists to replace GPs for 1 in 4 visits

Cutting pharmacists may be possible in cities, but it will be very inconvenient in rural areas. Who is off their trolley?

Teetering on the edge? Living with uncertainty… something consultants are never trained for.. General practice is not a retirement home for hospital physicians (Let alone pharmacists and paramedics)


Wriggleing on the hook of Dr under capacity. Any solution, ethical or not, will be considered. On the other hand anyone who passes the final exams, however they learned, should be allowed to be a doctor.

What an admission of 40 years of manpower mismanagement. NHSreality warned that politicians would be “wriggling on the hook of under capacity” in October 2018 when the news was that GPs would see patients in groups. The perverse incentive to risk standards is too strong. So much for personalised care as far as politicians are concerned, but it has not happened. The same outcome is likely for the suggestion that pharmacists could become doctors…. It will require extra training, then 2 “fellowship” years to register, and then 3 years to become a GP, or more for the other specialities. If the pharmacists are allowed to work after F2 years, then we may see come in 6 year’s time! Becoming a surgeon is an unlikely outcome.. and robots are more likely.

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NHSreality advocates virtual medical school(s) and a unified national exam. As far as I am concerned anyone who passes the exam should be allowed to be a doctor. We need 500% more, so there is no room for rationing places any longer. The main problem once we are training enough will be practical experience… There will eventually be an over capacity, and then some will need to go abroad.

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Chris Smyth reports 31st Jan 2020: Pharmacists could retrain as doctors to boost NHS

Pharmacists and paramedics will be helped to become doctors through a fast-track conversion course as ministers seek to use Brexit to loosen medical training rules, The Times has learnt.

EU rules requiring doctors to do a five or six-year medical degree could be scrapped as Britain seeks to resolve an NHS workforce crisis by making it easier for experienced staff to retrain.

The move is likely to be controversial, with medical leaders warning against a “quick fix” that lowers standards……

Why has it been left too late to be honest about health provision?

Doctors to see groups of patients – is probably madness. The fox is waiting..

Wriggleing on the hook of rationing health care in different ways, means that we will see many experiments until the numbers of diagnosticians increases. if a GP is needed for a 2 hour group surgery he could have seen 12 new 10 minute appointments in that time, along with the opportunity to examine and personalise the consultation.

Any GP you want: so long as you’re healthy

Sir, No one wants their operation done by a “have-a-go” surgeon. Nor do they want their medicines reviewed by an amateur pharmacist. In their desperation to plug workforce gaps, the spin doctors at No 10 have seized on the idea of putting pharmacists to work as hospital doctors (“Pharmacists could retrain as doctors to boost NHS”, Jan 31). However, since there is no surplus in either profession, the idea amounts to robbing Peter to pay Paul. Existing rules require surgeons to spend six years obtaining a medical degree. Specialist surgical exams follow, with practical training working alongside experienced colleagues, before anyone is let loose transplanting a heart, or removing a cancer. Those of us who develop surgical training programmes are wholly focused on making surgery ever safer for patients. Although we do need more trainees entering surgery, we cannot raid other equally hard-pressed professions to fill posts.
Professor Derek Alderson

President, Royal College of Surgeons England

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

Image result for surgeon training cartoon

Image result for surgeon training cartoon

Perverse incentives and results will mean new antibiotic development is slower than it need be..

The perverse incentives in the Pharma Industry extend to what they spend their money researching. In search of profit lifestyle drugs dominate, as these are long term prescriptions. Short term drug regimes for antibiotics are not high on their priority list.

SO new antibiotics will be led by the Welcome Trust, and the former Medical Research Institute which is now the Crick Institute. The Bill Gates foundation is also altruistic at the expense of profit, as is shown by their focus on population health and new vaccines for the developing world.

This is an opposing perverse incentive to that of the government, who restrict cancer drugs.

Times letters 30th Jan 2020: ANTIBIOTICS CRISIS
Sir, Tim Jinks (Thunderer, Jan 27 and letter, Jan 28) makes very clear the urgency of developing new classes of antibiotics. One factor determining Big Pharma’s attitude in this respect is that a successful antibiotic cures the condition for which it is prescribed, often in a matter of days. Thus the income from its prescription is limited. In contrast, common chronic diseases, such as Alzheimer’s and cancers, involve long-term prescription, and are more profitable. It is probable that only significant amounts of taxpayers’ money will adequately fund antibiotics research.
John Drewe

Former adviser to Ciba-Geigy Pharmaceuticals; London NW2

Two waiting lists for cancer patients needing new drugs. The insured and the uninsured….


Two waiting lists for cancer patients needing new drugs. The insured and the uninsured….

NHSreality has warned readers that there is a perverse incentive to delay the release of newly patented drugs; even for cancer. The pace of technological advance is faster than any government can afford. Hence France has decided to ration out dementia drugs, and to spend the money saved on looking after demented patients. Overt rationing of this type is sorely needed, and extends to other areas of health care. We can afford all the newest proven treatments IF we ration out the high volume low cost treatments, and encourage autonomy. There are now two waiting lists for cancer patients needing new drugs; the insured and the uninsured.

‘Your insurance doesn’t cover acts of God, like age related illness and accidents.’

Governments need to address the needs of populations ahead of those of individuals. They are right to ration, and all dispensations do this, BUT surely it is more ethical to ration overtly, so that people can plan for what is excluded, for them.

Prostate cancer has overtaken breast cancer to become the third deadliest type of the disease in Britain, but is it appropriate that less money goes into this disease as the victims are older? Most men with advancer prostate cancer do not receive chemotherapy: why not? (only one in four men with metastatic disease gets recommended chemotherapy BMJ 2020;368:m120 ) 

The only reason has to be RATIONING.

4th December 2019 in Science Business: Despite rapid innovation, UK patients wait up to 14 years for new cancer drugs.

Dennis Campbell in the Guardian 10th Jan 2019: Record 20,000 patients a month are suffering delays in seeing a consultant or starting therapies

Kaya Burgess reports in the Times 29th Jan 2020: Patients wait 14 years for groundbreaking cancer drugs.

Cancer patients are having to wait years for groundbreaking drugs because the approvals process has not fast-tracked them, a report has found.

Innovative drugs licensed between 2000 and 2016 took an average of 14.3 years to be available to NHS patients after patenting, according to a study by the Institute for Cancer Research (ICR). Conventional cancer drugs took 11.1 years.

The charity said the approvals process was too “risk averse”. Paul Workman, chief executive of the ICR, said the system was not keeping pace with advances in science. “Alarmingly, delays are longest for the most exciting, innovative treatments,” he added.

The government said the system had improved substantially since 2016.

Once a drug is licensed, the National Institute for Health and Care Excellence (Nice) assesses whether it is cost-effective for the NHS.

The ICR found that Nice had shortened the time between approval and the start of appraisal from 21 to 6.5 months but the appraisal process itself had sped up only from 16.7 to 16 months. “There was evidence that Nice had not been prioritising the most innovative treatments,” the ICR said.

Nice said it had worked with NHS England to “accelerate the evaluation and adoption” of cancer drugs since 2016 and had approved 75 per cent of cancer drugs since then, up from 47 per cent in 2012-13.

The Department of Health and Social Care said: “Three years ago we introduced the Cancer Drugs Fund, which is already delivering faster access to the most promising medicines.”

If you had CF would you think health and drugs were rationed, or not?

Call to end NHS rationing of HIV prevention drug PrEP

Drugs giants challenge NHS rationing plans in court. If the government wins the case should be appealed to the European Court before it no longer has the right to judge – after Brexit.

Fast-track plan cuts wait for newest drugs by years… will cost more in an unrationed service

Increasing the “Heath divide”? – Dementia victims to have drugs rationed. The “affordability test” is reasonable and sets a precedent at the high cost end..

Sensible rationing of dementia drugs – a lead from France

The cost of curing just one congenital disease…. The pace of advance of technology is faster than any government can afford

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Ways of reducing the bill for NHS negligence – The perverse incentives and outcomes …

Every doctor and student of medical systems needs to understand the perverse incentive. I define this as a “driver within a system that works against the overall objective of the system”. Claims for medical Negligence in our tort driven system are necessary to arrest or slow down the continuing decline in standards. Unfortunately Dr Barton is correct: the 4 health services have lawyers who are salaried and paid win or lose, and 80% of claims result in success! The argument for no fault compensation has been addressed properly in NZ and several other countries, and Australia appears to have found a half way house…

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Times letters 24th Jan 2020: Ways of reducing the bill for NHS negligence

Sir, Your article “£4bn budget for legal fees in NHS negligence claims” (Jan 22) points out that the health service faces legal costs of £4.3 billion as part of a compensation bill for clinical negligence claims of £83 billion. The extent of this crisis cannot be overemphasised, as over the past three years the bill appears to have risen from £54 billion, according to the Department of Health. Apart from the usual platitudes about being careful, no one appears to be interested in addressing this parlous situation.

I previously worked for seven years in Australia, where this became a big problem and was addressed by an act of parliament transferring the liability risk away from the provider, unless it was ruled criminal negligence. This has led to a year-on-year fall of medical protection and indemnity fees for colleagues in Australia, while those in the UK have risen inexorably, providing yet another reason why doctors are giving up in droves and taking early retirement.

The start of a new government offers an ideal moment to address this festering sore on the NHS’s future.
Professor Angus Dalgleish

Foundation professor of oncology, University of London

Sir, As medical litigation costs spiral and threaten the future of the NHS, the case for a no-fault compensation system becomes overwhelming. At present, if a patient cannot prove medical negligence, they will receive no financial compensation — the decision sometimes having more to do with inadequate record-keeping than true clinical incompetence or negligence. As a result, two patients may have identical medical injuries but one will receive nothing whereas the other may be well compensated after perhaps years of litigation.

New Zealand has had a successful no-fault compensation scheme since 1974, with changes in 2005 ironing out some of its early anomalies, resulting in most claims being resolved in weeks rather than years. Litigation lawyers are the only people benefiting from the system in the UK.
Dr Andrew Quayle

Retired GP, Martock, Somerset

Sir, The cost of medical negligence (or accidents) is indeed high, but the possibility that the size of a giant claim might be reduced means that many cases end up in court because the legal fees justify an expensive defence. However, with court and legal costs of about £2,800 per day on top of barristers’ and solicitors’ fees it is often cheaper for an NHS Trust to settle a little case for a small sum than to defend it. While this is often done without an admission of liability it is open to abuse, because once word gets around it may generate frivolous or spurious “me too” claims that result in a payment of a few hundred pounds without many questions being asked. The system needs to address this as well as the top-end settlements.
Dr Andrew Bamji

Rye, E Sussex

Sir, NHS legal costs are inflated partly because of perverse incentives. NHS lawyers are paid win or lose, which encourages “deny, delay, defend” behaviour and promotes speculative defences. By contrast, claimant lawyers are generally paid “no win, no fee”; payment is by result, which imposes commercial prudence. This is amply borne out by NHS Resolution figures which show that compensation is paid in 80 per cent of cases where proceedings are issued. NHS lawyers should be paid by result and not rewarded for failure.
Dr Anthony Barton
Solicitor, Medical Negligence Team

Professional Liability Insurance : Market Global Report Jan 2020 – Fusion Science Academy

New York Telecast: Global Liability Insurance Market Status (2015-2019) and Forecast (2020-2024)

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Lexicology: Wright Hassall LLP The most notable medical liability case in 2019

United Kingdom August 27 2019

The NHS is facing an existential crisis. The negotiations over junior doctors’ pay and conditions and widespread dissatisfaction among GPs, combined with a £2.45bn overspend by NHS Trusts, is impacting on patient care. The NHS is treating more patients than ever before, including a rapidly growing number of elderly people whose care, in many cases, is caught in a Mexican stand-off between the NHS and social services.

The NHS announced it has paid out more than £1.63 billion in damages for medical negligence in 2017/18; this is an increase from £1.08 billion in 2016/17 with the highest number of claims coming from emergency medicine. The number of claims made as a whole has decreased slightly (0.12%), but the cost to the NHS continues to increase.

The cases outlined below are some of our most notable and an indication of what can go wrong when the caring services come under pressure – and these are just the tip of the iceberg……

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Update 29th Jan Times letters 2020:

Sir, I would be delighted to accept the challenge from Dr Anthony Barton that NHS lawyers should be paid by results (letter, Jan 24) so long as in return he accepts that claimant lawyers should pay NHS costs when they lose. This should include the more than 80 per cent of cases that never reach court, often because they were frivolous claims which were pursued regardless of commercial prudence. These nevertheless incur NHS legal costs and waste vast amounts of NHS staff time, which often leaves them inadequate time to care for their patients.
Martin Sheppard

Retired NHS consultant
Haverfordwest, Pembrokeshire


An extra tax of £66.66 per head. The cost of “English” health litigation, and its rising…

Litigations: There is a choice, but the “short term” attitude of every administration has ducked the right option. No fault legislation …. Those of us in the know, and those working at the coal face can only laugh cynically at the DHSS statement:

‘Our ambition is for the NHS to be the safest healthcare system in the world and it has been recognised that the rise in costs of claims is not due to a decline in patient safety.’ ( !!! Ed )

The finances of Wales, Scotland and Ireland are no different, and probably worse. Poorer people have less means and ability to litigate, but on the other hand the services in Wales are worse. So much too for a “National” health service.

( No Fault Compensation claims are handled by Government run schemes that each have their own set of rules and regulations. The amount that is paid out, if the claim is successful, is usually less than you would normally get in a standard personal injury claim.7 Apr 2016 )

How about some trial areas, a report on comparisons with other countries, and a costing. Surely it has to be cheaper than £4.3 bn, which works out at £66.66 each assuming 60m people in England. Best to be either very poor or very rich to make a claim.

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BBC News today: NHS faces huge clinical negligence legal fees bill

The NHS in England faces paying out £4.3bn in legal fees to settle outstanding claims of clinical negligence, the BBC has learned through a Freedom of Information request.

Each year the NHS receives more than 10,000 new claims for compensation……

The Mail: NHS England faces £4.3BILLION legal bill to settle negligence

…The Department of Health has said it has no option but to tackle ‘the unsustainable rise in the cost of clinical negligence’.

According to a Freedom of Information request by the BBC, the figure includes existing unsettled claims and projected estimates of future claims…..

Patient complaints hit a ‘wall of silence’ from NHS – No fault compensation would help change the culture…

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

The blame game. The proliferation of compensation claims – needs a “no fault compensation” cure, possibly through a social insurance fund.

£500 each citizen, man, woman and child, paid for “negligence” annually by 2010. Why no “no fault” compensation?

Cancer sufferer urges patients to stop suing NHS – No fault compensation is the answer.

No fault compensation systems BMJ 2003;326:997

William Gaine opines in the BMJ: Experience elsewhere suggests it is time for the UK to introduce a pilot scheme BMJ 2003;326:997

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A&E waits are symptomatic of a complete failure. The safety net has been removed, and fear is returning – in spades

We need investment in buildings, plant and people. The crisis is here and now. A&E waits are symptomatic of a complete failure. The safety net has been removed, and fear is returning – in spades.

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Nick Triggle for BBC news 13th December reports: Every major A&E misses wait target for first time

and BBC produced a report on the “Accident and Emergency crisis”.

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The search for waiting time failures in A&E reveals an epidemic of failures.

New builds, particularly under the PFI initiative have been catastrophes of long term mis-management and perverse incentives leading to perverse outcomes. These are exposed by Louise Clarence-Smith in the Times 17th Jan 2020: Soaring costs and delays expose lack of scrutiny at Carillion hospitals and “Beware the real costs of Hospital Failures”

one of which is demand for Private Treatment centres….

In The Guardian opines that A&E wait times matter. But the key issue facing the NHS is investment


A service run ragged – and meaningless pledges for mental health provision

The perverse incentive for health boards and commissioners to prioritise oncology or surgery above psychiatry is disturbing. Whenever we listen to the politicians and managers watch out for the word “priority” or “prioritisation”: it means rationing. And remember, the spending plans (outlined at the end – graphic|) dont apply outside of England. MIND can help, but it can only fill some of the gaps..

Andrew Molodynski is the BMA consultants committee mental health lead and opines in the BMJ Doctor supplement: Mental healthcare – a service run ragged

Mental health staff face unmanageable workloads, depleted teams and poor access to training, BMA research finds – with government promises of new recruits sounding ever more hollow. Keith Cooper reports

Bold pledges to recruit vastly more members of staff, as a means of easing the pressure in mental healthcare, are often deployed with aplomb by politicians.

More than 10,000 extra would be recruited this year, said the Conservative manifesto in May 2017.

Its opponents back then believed it was based on ‘thin air’, they told the BBC. Two months later, the Government’s official plan, Stepping Forward to 2021, pushed the figure up to 19,000 additional staff.

Leap forward to 2019 for an even more ambitious scheme. The NHS England Mental Health Implementation Plan called for a further 27,000 staff, a mix of psychologists, psychiatrists, nurses, social and peer and other support staff, to make up the ‘multidisciplinary’ approach it envisioned. An influx of new staff into mental health would certainly help the patients who suffer the traumatic, sometimes tragic, consequences of shortfalls and those in the service who struggle to cope with ever-rising demand….


20190746 thedoctor January issue 17

…Mental health has been high on the political agenda for some years now, with bold promises from Government in recent times: more staff, more services, more funding, no patients being sent around the country for care, reduced waiting lists, fewer suicides. However, what we have seen outlined in this article and numerous academic and mainstream publications is essentially the opposite: longer waiting lists; increasing out-of-area placements; slimmed-down services that cannot cope with demand; and most worryingly a rising suicide rate for the first time in decades.

In microcosm, my own team (a general community team for people like you and I with mental health problems) has recently been audited as having 50 per cent too few staff. We knew that already. Will things be put right? Almost certainly not. If we were an oncology or paediatric team would they? Almost certainly yes.

…BMA recommendations on parity of resources, access and outcomes – what does it look like?

On funding: Clinical commissioning groups should double expenditure on mental healthcare. More should be spent on mental health wards, research, and in primary care and public health.

On access: Standards for access to services which are fully funded. Reviews of all trusts who place high numbers of patients in beds far from their homes.

On workforce: Realistic and measurable workforce goals. Targeted recruitment campaigns for the hardest-to-recruit sub-specialties, such as old-age psychiatry and learning-disability psychiatry.

On prevention: A cross-government body established to draw up a joint strategy on public mental health. National and local Government adopt a ‘mental-health in-all policy’; mental health impact assessments for all new policy proposals.

Read the BMA report

The pressures on doctors, in and around an election… The social contract has been broken. This is why there is so much anger, and more to come.

Doctors should be able to say how they feel. In my own practice there was some comment when I put a poster showing my voting choice on my office door. There was no implication that the whole practice should support my choice, but several of the partners were uncomfortable. … Doctors are under great strains: overworked, gagged, humiliated (The suggestion that many GPs are corrupt) and there is more and more evidence of early burnout.

Purdah rules shouldn’t stop NHS doctors speaking out  (BMJ 2019;367:l6679  )

Charles Lamb (Psudonym)  for the BMJ talks about the “4 major errors in medicine” and asks: Please do not feed the lawyers

Tim Locke, Dr Rob Hicks | October 1, 2019 for Medscape opine: Sexual Harassment of Uk Doctors: report 2019

Thank goodness some do speak out, and even on video.

Patients are waiting twice as long for an ambulance if their GP asks for it at their surgery. Perverse outcomes are everywhere, and arise because of perverse incentives. ( Alex Matthews-King in the Independent 4th January 2019)

Emergency Beds are now used all the year round. Trolley waits are routine. But why is it that a child having his treatment on a perfectly safe mattress, gains more sympathy and publicity than multiple grannies on trolleys? At least treatment was being given.. In some emergency situations we could have two children to a bed. Better than refusing them..

We have rationing by delaying decisions – gaming, arbitrary rules, and bureaucracy  (Obfuscation of the truth) – as described by David Oliver ( BMJ 2019;367:l6620 ) 

No wonder the doctor patient relationship is being threatened. Without continuity of care and an ongoing trust relationship, we are going to get more burned out doctors. If it helps here is a good description from Jonathan Glass in “How not to be the heartsink doctor” ( BMJ 30th November 2019)

The social contract has been broken. Social care crisis wastes £½m of NHS money a day and is not free but means tested. (The Times 4th December) This was followed by Social care crisis wastes nearly £30000 of NHS money an hour by This is why there is so much anger..

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?

NHSreality is a “heretic”. The NHS has become the greatest cult of our time. As a “holy relic” it is granted immunity from meaningful change.. If social care is means tested, why not medical care?


The Election Horror Show, and denial… The political spin doctors are leading us into a health-less “black hole”. The Health services are too toxic for honesty…

The main reason for the problems with beds is that 80% would not be occupied at all if there were alternatives … Such as home or community Care.
The main reason there are too few staff, both diagnostic and caring, is that it takes decades to train them, and concern to retain sufficient. There have been 3 parties in power over the last two decades. Austerity has not helped, but the problems were incubated well before 2008.
There is no NHS where patients are concerned, but there is for staff, who often aspire to work and educate their children in better areas. The 4 dispensations are controlled by Westminster with regard to finding, but Scotland has more than Wales due to their different methods of funding. They all choose to spend their money differently with different outcomes. This experiment ,without honesty or the possibility of sustaining the 4 services, and done without the consent of the professions, is going to reveal serious differences in the next few years. (See WHO and IFS reports)
We need to ask why no other country has chosen to imitate us. We need to abandon the experiment of devolution in health. The media needs to stop using the abbreviation NHS.
Outside of health we need to review the rules of referenda, to change to PR, to have a constitution, to control false news, and to institute a fairer tax system, particularly addressing capital ( Land Rental Tax. ).

California and Ireland have addressed referenda well.

We need to bring back choice as a virtue and this election is making most of the professionals sick.

The political spin doctors are leading us into a health-less “black hole” because they can get away with it and the perverse incentives to fail to address the issues are too strong. The Health services are too toxic for honesty.

The Economist talks about the “nightmare” before Christmas and Endorses the Liberals despite their mistakes:

Economist endorses the Liberals Dec 5th 2019…

….Next week voters face their starkest choice yet, between Boris Johnson, whose Tories promise a hard Brexit, and Jeremy Corbyn, whose Labour Party plans to “rewrite the rules of the economy” along radical socialist lines. Mr Johnson runs the most unpopular new government on record; Mr Corbyn is the most unpopular leader of the opposition. On Friday the 13th, unlucky Britons will wake to find one of these horrors in charge.

December 9th in the Times Chris Hopson reports: We asked politicians to be straight on the NHS. They’ve not listened

The leading article on the same day: Election Promises – Times leader 9th December  accuses the politicians and by implication the media themselves, of denying voters the truth.

Shaun Lintern for the Independent reports 3rd December: Leaked NHS document reveals government plan to use cheaper staff to fill nurse vacancies

We even have the possibility of “foreign influence” demoralising the population with false truths.

Shanti Das and Andrew Gregory reveal the incompetence of the short term politicians: Amazon ready to cash in on free access to NHS data (The Sunday Times 8th December)