“If Tesco can open till midnight every night, why can't our GPs open till midnight every night?”

At Dr Rant we suspect Mr MacKinnon may well be right that further OOH tragedies will occur. Despite all the wisdom of hindsight and regret it’s doubtful any lessons will be learnt. The fall out from such cases is one of the reasons GPs mostly avoid OOH work now.

Firstly we will express our sadness for the death of Penny Campbell. Whether as doctors we would have done better than those who did treat her we do not know. Dr Crippen discusses things well here. I’d echo Dr Crippen’s respect for the “rule of threes” which basically states “first time you see a patient you can do anything, second time you must get it right and if the patient presents for a third time you need to ask someone else (usually a consultant).”

However Mr MacKinnon asks a very good question about GP opening hours, and it seems worth a go at answering it.

There’s a simple reason why TESCO stays open so long. It gains a profit margin from it. Or it finds it needs staff on 24hours a day to accept night time deliveries, and restock stores, and decided to pay a few check out operators to work whilst all the deliveries are going on. So it may be an example of fringe costing, that expands availability, improves the service, at very little cost to TESCO and gets some extra revenue in. Whatever TESCO’s exact economics, they clearly gain from their long opening hours. But their income comes from the pockets of consumers who make the choice to shop with them.

Some weeks ago we published a piece on “The NHS: What is to be done?” Mostly the reaction was favourable, but two comments from right wing observers criticised us for rejecting market based solutions to the NHS’s problems. This criticism prompted Dr Rant to read more widely about economics and see whether he could make sense of their criticisms. He read John Kay’s book “The truth about markets” We don’t think that the NHS “internal market” bears any relation to any real market.

Now from this book Dr Rant learned about the joys of disciplined pluralism and order emerging without design. The risks of any enterprise should be spread throughout a population in a series of small scale experiments, frequently reviewed and with disciplined review of results. The joy of such systems is that they cannot stay too wrong for too long or they go bust. Also even if one enterprise goes bust, it doesn’t take the whole lot down with it.

The NHS is clearly not such a system, and it is probably best described as a centralised, bureaucratic monolith that measures its tractor production quotas each year for Comrade Splatzy to produce at the annual party conference.

John Kay’s book is excellent on the problems central bureaucracies have with getting supply and demand balanced by conscious means of measurement, commands and controls. The medical analogy could be diabetes mellitus. In most of us (those without diabetes) we can feed variable amounts of sugars to ourselves and the pancreas will produce just enough insulin to handle this sugar. Our blood sugar level will stay between 3 and 8 mmol/l. We don’t know this is happening, we can just take it for granted. Everything functions fine.

In the diabetic population the pancreas stops working, fails to produce insulin and therefore the patient has to administer their own insulin. What we find is that even with the best monitoring and control the blood sugar goes either too high or too low (hypos) Conscious monitoring is a poor substitute to the pancreas working normally, it takes a lot of effort, and is far from a smooth process. Supply of sugar and demand for insulin are never all that well balanced.

It’s a bit like the NHS. Sometimes too little. Then too much. Wild swings from feast to famine and back again.

Now to get back to Mr MacKinnon’s question, “If Tesco can open till midnight every night, why can't our GPs open till midnight every night?”

Now if GPs were true businessmen some of them would be trying things like longer opening hours. They might find they made some extra income and profit for their efforts or they might find there wasn’t really any demand for the service. However one or two practices would innovate, some practices would be early adopters and some would be late adopters and some would retire or go bust.

But GPs are hamstrung by a fixed central contract. The PCTs are hamstrung by rules. They can convene committees and meetings for hand wringing, but they don’t have authority to try things out. Nor do they have agreed criteria for success and failure of pilot projects and the NHS endlessly insists that “the views of all stakeholders must be considered” which means that no one can make a decision for fear of offending someone else. Passive aggression gets people to the top of such organisations as they can manipulate fear without appearing to do so. “All animals are equal, but some are more equal than others.”

So there is no room for small scale experimentation in most surgeries. And at the Macro level there are only fixed numbers of GPs available, and it’s a slow process even to get basic GP training completed (10 years minimum from med school entry to independent practice). So even if they the existing GPs have lots of slack time to spend on new enterprises, they will tend to do this at expense of existing commitments. The problem is of making a scarce product go round. Even using nurse practitioners is only a partial compensation for the overall lack of GPs.

So the reason why GPs are not open to midnight is that they work in a monolithic centralised system, small scale experimentation isn’t possible, and fixed supply of money and resources leads to ossification of decision making processes. The status quo staggers on, and somehow it muddles through.

This misdirection of government monies in the NHS is currently appalling and when we, as voters, fully appreciate this we will make the government pay dearly for its mistakes. In primary care we could have had improved GP surgeries, longer opening hours, and better phone access. The money has instead gone to QOF, to walk in centres, to expensive PCT reorganisations and NHS redirect. It has been wasted rather than used to improve existing structures.

Government as usual thinks it knows better than those who work in the service and so it tries to bypass the GPs.

MMC Fuckup in a Nutshell

Thanks to Aphrabhen for spotting this fabulous video montage.

This needs maximum exposure from the corrupt useless bastards in the mainstream media who barely yawned when a third of the junior doctor workforce marched on London and Glasgow simultaneously.



It appears we no longer live in a democratic meritocracy - we live in a neo-feudal society where power is concentrated and kept by an increasingly small cabel. They control the newspapers. They control TV. They even broke the BBC.

The poor get poorer. The rich get richer. The sick get sicker. The rich get richer. The poor die younger. The rich get richer.

Etc.

A Stale Approach

Dr Rant is an active member of RCGP, but he finds he cannot welcome the programme for this new conference. He can see what college wants to achieve, but the people involved in this conference reveal exactly who and why the college won’t achieve its aim.

Dr Rant enjoys conferences, but for this one he is out of the country and very glad he will be.

Let’s give feedback in the approved way. The good points first:-
Well the flyer has been done in the right colour, and the fresh zingy green, and the sharp flavoursome lime give the right impression. They'd be perfect for a trendy Edinburgh juice bar.

However let's open the flyer and see what will make members curl up and die like old fruit.

Well you could listen to Patsy Fuckwit spout forth about, "The Political Future of Primary Care" I’ll predict it's longer than hers. What on earth is RCGP doing asking a woman who personally, and collectively with others in her party, has done more to damage primary and other medical care in this country than anyone else to be a star speaker at one of its conferences? She should be persona non grata throughout any organisation concerned with health and healthcare.

You could hear Dame Carol Black expound on "Looking at Primary Care from an acute sector perspective" Well that'll be the view from the 'Quango Queen' covered then won't it?

You could go to CMO question time. They've got the CMOs from England, Scotland, Wales and Northern Ireland booked. This session could be fun but I bet they'll exclude all the interesting questions such as "How exactly do you sleep knowing your role in the MTAS debacle?" and "How do you propose to deal with the lost tribe of 10,000 unemployed junior doctors created by your intervention?"

Rebecca Stephens, the first British Woman to climb Everest, gets the final show on "Facing the Challenges ahead." Now I don’t begrudge a mountaineer earning some cash, but there is a world of difference between "a mountain to climb" in physical reality which is what she knows about and "a mountain to climb" in the sense of sorting out the NHS "It's an 5.10 overhang into blue sky without a safety rope" and the kind of risk even Ms Stephens wouldn't dream of taking. It's the difference between a finite if big problem such as a mountain and a mess without limits and boundaries such as the NHS.

That well known friend of GPs Niall Dickson gets to chair the conference so the Blairite and Brownites can sleep easily as their agenda will get gently pushed.

Now what is absent from the programme?

Well there's no one speaking who looks like an ordinary GP. Everyone speaking has extra hats and roles. The feel from the programme is of the experts talking "de haut en bas" and I see little that will make any of us who live "en bas" want to go and listen. There’s a feeling that there are those of us who actually do primary care and see patients, and those who do non-patient contact medicine who look at those of us who see patients as a strange species of animal, one that they evolved out of long ago. Dr Rant must appear rather like a quaint old coelacanth to them.

There’s some practical sessions for GP trainers. Professor Onora O'Neill dissecting the notion of informed consent should be delicious. Claire Gerada and Gilles De Willdt tackling the issue of privatisation is probably as controversial as the programme gets, and sadly they’ll probably be voices crying out in the wilderness, and the NHS privatised anyway.

The college has assembled a great cast of old boys and girls, the great and the good and put them all in one place. You look at the pictures and realise that all the speakers are older than Hippocrates, and probably less wise. At least they'll make good targets for the dartboard.

It's a safe cast, that doesn't reflect current GP concerns, nor look likely to help Dr Rant and his partners raise more money, serve patients better, or flourish more in the forthcoming year. It doesn’t address the main problems of current general practice which are too little time to talk to patients, too little access to enough GPs, too few resources to anything for them, and too timid and useless primary care trusts.

It shows how far the college hierarchy ('twaterati' more like-Ed) has moved away from the day by day concerns of the ordinary GPs who are its members. But then again, this has happen to every other Royal College and BMA already, so why should us GPs be suprised?

Mr Beige Baloney MMC Tribute Video

One of our readers, the mother of a soon-to-be unemployed young medic, has put together a tribute video for Mr Beige's MMC masterpiece, Baloney.



I can feel a Dr Rant competition coming on.....

Dr Rant's Newsround

First day after a bank holiday and today's press makes great reading.

Let's start with NHS saves Patsy’s bacon by being under spent. That’ll be good news then for the nurses and midwives who are having their whopping pay rises staged over this year then? No it won’t be and the midwives and nurses are considering a revolt.

And here’s how money is saved by substituting untrained for trained staff.

The Guardian wonders why the professions are out of love with Labour but the themes are mistrust and mismanagement throughout schools, hospitals, the legal system, the military, the police, the ambulance service. The inability to trust professional staff to do their job properly, and the then excessive management needed to check that the staff do their jobs properly leads to bureaucratic idiocy. Every mistake by a professional is seized on as evidence of the need for more checks, bureaucracy and supervision, and as justifying the bureaucrat’s work.

Hence we get to Bullshit Britain so well described in Fantasy Island recently. We love management consultant types too.

Meanwhile Hazel “Nuts” Blear bleats on that the party needs to engage better with NHS professionals! We’re not falling for your lot again love. The Tories cannot be worse. Even nasty but competent would trump your party’s passive aggression, contempt and incompetence.

Today’s press has every reason displayed why Dr Rant, reflecting feeling within the wider community of health professionals, is so fed up with this duplicitous and mendacious government.

Patients should be worried. The NHS is falling apart and the attitude of staff to their printable at present.

The NHS is close to collapse. At Dr Rant we predict ever more fiddling and spinning whilst Rome burns.

This ship's getting damp! We're off!

More rodents from Dr Rant. You love it!

The Deputy Leadership of the Labour Party? What's all that about then?

Well, it would seem that it is starting to turn into a 200m backstroke race for RATS! Despite being amongst the last people in Britain to realise that the the S.S. NuLabour has long since lost it's watertight integrity, our 6 illustrious candidates are now falling over themselves to appear part of the solution to their party's disastrous and profligate meddling with the NHS, and not part of the problem. Their hitherto supine acquiescence and sycophantic support for Labour's pigshit-for-brains-cuntathon-fuckwittery that has masqueraded as 'health policy' since 1997 would appear to be somewhat at odds with their new positions.

Have a look at this article in the Times today. It presents a catalogue of banal truisms and disingenuous affectations attributed these rodents, and has been as instrumental as the cricket being rained off in turning this into a really shite bank holiday for Dr Rant.

Let's look at it shall we? I'll start with Hazel 'Working Class Heroine' Blears:

“I think we’ve got some of our language wrong. When we’ve talked about reform sometimes, its been about telling people that they’re not doing a good job.”

No Shit? You've also been telling some of them they're useless lazy scum who play golf all day and earn £250,000 a year. However, the 'honesty' is tempered by self interest:

“We’ve got 1.3 million people working in our health service. If those people are going home at the end of a hard day’s work feeling disgruntled with the Labour Government then we’re not going to win the next election.”

Really? The ends always justify the means then do they you Ginger Harpy? Health policy is about securing votes first, everything else is secondary. This brings us on to Alan 'Who the fuck am I' Johnson:

Alan Johnson, the Education Secretary, called for a “proper dialogue” with health workers, who still felt undervalued. He suggested that the Government “listened a bit too much to the BMA [British Medical Association] and not enough to unions like Unison. Maybe what we should be doing is bringing the unions in the health service much more closely into the social partnership”.

Duh? They haven't even been listening to the BMA you twat! The BMA may be shite, but if you'd actually listened to them, things would be a bit less shit than they are now. As for the other unions, I suppose Alan's referring to the ones that provide a significant proportion of his party's funding and hence votes for the deputy leadership?

So what's Harriet 'Wimin's Rights' Harman got to say for herself (presumably after dropping her kids off at a selective school)?

“We should never, ever be saying . . . we need the private sector to do the innovation because the public sector doesn’t innovate.” She criticised the “breaking-up of the NHS team” through “contracting out cleaners, caterers, healthcare assistants”. Ms Harman complained that the practice “has driven down pay and caused unequal pay between men and women”.

Where the fuck have you been for the past ten years you stupid dappy bint? All of the above was happening before your lot came to power in 1997, and has become entrenched and even promoted as policy in some cases. You have personally held positions of influence and power in that time, but done and said nothing.

The last of the 'big four' to impart his wisdom upon us is Peter 'The Badger' Hain.

Peter Hain, the Northern Ireland Secretary, called for a moratorium on structural alterations, saying that health workers were “sick to death of constant change” and should be allowed to get on with their jobs.

Aaaarrrrggghhhhh!!! The next contestant on Mastermind is Peter Hain, specialist subject 'the bleeding obvious'.

There are another two candidates who I won't bother to discuss, and they weren't quoted in the Times article. Despite the fact I don't really agree with their politics, both of them appear infinitely more sincere than the four I have talked about, and I have a sneaking suspicion that they may actually have 'principles' and 'stick to them'. They also have the advantage of not being as complicit in what has happened to the NHS since 1997.

I'm off to lie down now.


Having written the above, I've just come across this in a copy of the Daily Telegraph that I happened upon. D'oh! That just leaves Hilary Benn as the only one who might have 'principles'. Arse.

Fandabidozi! It's Wee Jimmy Johnson.

Oi! Jimmy! Enough Gobshite! It's time to shut the fuck up!

The next time someone in the 'meeja' asks your for your opinion as a 'former' BMA Council Chairman - do us a favour........

Would You Still Trust This Lot (2)?

Kaiser Permanente: Bunch of Cowboys?

Kaiser Permanente are an American health provider who look to computers to help them care for patients. Just like the NHS system it seems the same old flaws of security and reliability plague it. Nice to see it isn't just the UK that has these problems.

And then the UK government’s system for registration of hatch, match and dispatch falters.

Meanwhile the NHS health informatics site is down as MTAS continues to be. There are still significant concerns over its security This week we have seen the farce of personnel officers in the NHS not knowing (nor being able to find out) which doctor should be coming to which interview! There are serious concerns that there may not be enough junior doctors in post for the August change round.

Garth Marenghi on Devil’s Kitchen posts a superb article about NPunFIT for any purpose Richard Granger’s casual dismissal of people with a concern for the privacy of the doctor-patient encounter as “Privacy Fascists” is surely evidence of Mr Granger’s unfitness for purpose.

More news about “minor inaccuracies” here Also some inaccuracies go undetected for years as the Scotsman reported in January.

Ann Treneman beautifully sums up the malfunction of Patsy Hewitt.

All in all who can we trust to keep our personal medical information accurately and safely on computers? Certainly not the team at NHS Completely fucking hopeless!

The Death of Ambition

14th April, 2007

Is anyone else experiencing an eerie silence within their own hitherto tortured souls? After I had finished my most recent (and final) interview I felt as though a weight had been lifted off my shoulders. This is paradoxical, of course, because there is now nothing more I can do to influence my chances of continuing to practice medicine in this country in the way I feel best suits my interests and abilities. Paradoxical, because all the ranting and thinking and writing and phoning and posting I have done over the last year to try to influence the process has, ultimately, been in vain. Nevertheless, I feel totally spent. I've noticed it in other people at work. For example, lots of people who weren't shortlisted for their first choice are now saying they're not going to ask for an interview. They too just can't be fagged any more.

A more worrying aspect is that this attitude is also spilling over into patient care. Colleagues don't seem to have a spring in their step any more. I know that I don't. I have to make myself go to radiology to cajole someone into doing a scan, whereas before I used to quite relish the sparring match that usually ensues. People sit slumped in chairs in the office rather than re-examining patients to look for something they might have missed. Exam successes are met with flat resignation rather than the joy and sense of achievement that should follow.

All of this may be a temporary calm-between-the-storms kinda phenomenon. But I worry, both for myself and for colleagues who I like and admire very much, that I am actually witnessing the death throes of medicine as a vocation and as a profession.


Dr James Good

Originally posted on DNUK, 14th April 2007. Dr Rant would like to thank Dr Good for allowing us to publish it here.

A Democratic BMA?

Jonathan Fielden, the Consultant Committee Chairman of the BMA, was being interviewed on Channel 4 news over the problems assailing the BMA.

The report accurately picked up on the fact that DNUK, the doctors-only online discussion forums, now has more members than the BMA (around 90% of UK doctors vs 70% for the BMA). Channel 4 spoke to Neil Bacon, founder of DNUK. Neil can be a bit of an arse, but he has done a brilliant job of creating and nurturing a site that is surely the largest online community of doctors in the world. Dr Rant has been an active member of DNUK for years, and I agree that DNUK (and some of the older discussion groups like GP-UK) provides a far better vehicle for doctors' views than the stuffy, quisling, collaborator BMA.

After dismissing 1000+ members tearing up their BMA cards in under 36 hours as 'a very small number' - a loss of around 1% of the BMA's members, mainly juniors, amounting to a total loss of over £10 million in fees over the lifetime of those members (three months like that and the BMA would vanish all together) - Jonathan tried to counter that the BMA is a democratic institution with a mandate to represent doctors.

Interestingly I had just been talking to another member of the Dr Rant team about this very subject not an hour before. Our discussion centered around the fact that the BMA's problems stem from the fact that it is not a democratic organisation. The BMA is not 'one member, one vote'. Instead, leaders are chosen from committees, which means a pyramid effect. The closer you get to the top, the less people get to vote for you. This results in a dilutional process that favours the bland.

What the BMA needs is one member, one vote. Until then the BMA cannot claim to be democratic, or to reflect the views of the membership at large.

Dr Rant has long argued, on DNUK and elsewhere, that only external pressure can bring about democratic change in the BMA.

That external pressure may finally be here in the form of RemedyUK.

The Boot Is On The Other Foot Now....

I must say that I'm finding the fall out from James Johnson's resignation highly entertaining, but his resignation underlines the fact that the tide has turned in a most spectacular fashion.

A quote in this BBC article caught my eye:

However, this was a far from universal view. Some doctors the BBC spoke to expressed anger over the actions of junior doctors involved with the pressure group Remedy UK with one describing them as a "rabid mob".

But all were too worried about being named because of the momentum the campaign has gathered.

This shyness is in stark contrast to an unsavory event earlier this year when a senior member of the medical establishment emailed one of the more vocal junior doctors on DNUK with a 'Shut up or I'll see to it you never work again' type threat. Somehow I don't think this type of thing will happen again for a while.

How things have changed!! Senior members of the medical establishment are worried about the reaction their 'opinions' will get! The are frightened to pass comment in case they are held to account by those they are supposed to represent. They are also probably frightened of the forthright views and opinions of emboldened junior doctors and medical bloggers who have become justly uninhibited.

It betrays a complete lack of insight into reality on behalf people like Johnson. They are suprised at the strength of feeling and tenacity of 30,000 junior doctors who are faced with the possibility of their careers in medicine being ended by a computer? Highly educated, motivated and student-indebted young doctors who feel distinctly unchuffed at the fact that if they are actually lucky enough to get a job that it will probably be at the other end of the country to their family or the house that they are paying a mortgage on. Ungrateful impudent bastards the lots of them.

Obviously Johnson got a personal slagging (mostly richly deserved) prior to his resignation. This was because the rank and file members of our profession were pissed off! Pissed off not just at the way in which the BMA 'Twaterati' were doing the exact opposite of what the rest of us thought they should be doing, but also our perceived inability to stop them.

So there you have it - the oppressors now consider themselves oppressed, and our elected representatives are now falling over themselves to appear representative as the bun fight to succeed Johnson starts in earnest. We will of course cover this 'battle' in great detail as it also promises to be hugely entertaining, and another demonstration of the new feeling of empowerment amongst grass roots doctors (those you haven't already resigned from the BMA of course).

One of the early runner would appear to be arch wanker Simon Eccles:

Simon Eccles, a former chairman of the BMA's junior doctors committee, said it
was right for Mr Johnson to go over the issue of the letter which was at odds
with the view of the wider membership.
But he also stressed the wider
context. "There is a real tension in the medical profession about the best way
forward."

No shit Sherlock! Iit's a pity you weren't saying that before things got really fucked up and you could have helped! It would seem you were too busy dreaming up helpful soundbites for Patsy Fuckwit to defend herself with in the House of Commons. I hope you hadn't thought that we'd forgetten that.

Doctors don't like targets for a reason

"Doctors don't like targets - lots of people don't like targets - but you have to say that waiting less than four hours in A&E is a good thing", said Jo Revill on Newsnight a few weeks ago. Jo used to be the Observer's Health Editor and was seen by doctors as one of the best medical journalists in the business.

Tony Blair said roughly the same thing on his Tony's Goodbye Tour™. Waiting times. It was all about waiting times.

Yes, but waiting times for what? Apparently waiting to be admitted in many cases. So, now you get admitted much faster, which would be great except for the fact that there is no guarantee that you will actually get any treatment. You see, the target measures your admission - not the care you get once you are in. So, you spend a night in a bed and then you are discharged. Now you are just as sick as before, and you need to wait for an outpatient appointment arranged by the team that admitted you. Since these OP appointments are not part of any target, you can wait month.

It's so brilliant, that you can see why people wonder at us pesky doctors not liking them.

Jo and Tony can't possibly be as stupid as thier comments make them out to be.

Rabid? No, just fucking angry.

The aftermath following the resignation of James Johnson continues. The BBC has been quick to interview the departing BMA chairman. True to form, they have repeated his argument that MMC and MTAS is in the profession's best interest, and have even invited Simon Eccles, former JDC chairman, to give his view.

They also print the views of 'some doctors'. These unnamed sources describe Remedy UK as a 'rabid mob'.

Well, Dr Rant also has several unnamed sources. And, just like the BBC, Dr Rant respects the right to protect his sources' anonymity.

One unnamed source describes James Johnson as 'A walking fucking disaster, who has stuck his head up so many arses in his search for a gong that he fails to recognise shit, even when the whole profession is charging headfirst into a steaming great pile'.

Another unnamed source describes Simon Eccles as a 'rent-a-gobshite, always willing to come out with the latest pro-government bullshit, his breath rancid from all the cocks that he has sucked'.

And yet another unnamed source describes the BBC as 'an organisation so afraid of upsetting the Blair government following the extreme butt-fucking they they received as a result of the Hutton report, that as soon as Nu-Labour gets even a hint of a semi-on, they collectively bend over, spread their buttocks and say 'come and give it to us, Tony'.

The piss-poor reporting of the MTAS fiasco by BBC should make every person in the UK ashamed to pay their license-fee. Until Channel 4 showed the BBC how the biggest ever potential disaster to face the NHS should be reported, they kept remarkably quiet.

And now, they claim that the superbly professional approach taken by Remedy UK is 'rabid'.

BBC, just what is your agenda?

Nothing like a graceful resignation

The Guardian this morning is covering the resignation yesterday of the BMA Chairman, James Johnson.

Jimmy is a nice guy, we keep getting told. Judging from the quotes in the Guardian, for nice you should read 'passive aggressive'. We are told that 'Mr Johnson said he was surprised at the vehemence of the reaction against him, which "has really got very nasty"'. Jimmy thinks this is designed "to take people's attention from the fact that they have lost their case. The possibility that he was surprised because he was completely out of touch with grass roots opinion, and that he took a napalming because he was being soft on a government in the process of destroying medical training in the UK, obviously never occurred to him.

Seemingly bereft of any sense of personal responsibility, he goes on to blame RemedyUK for all his problems. "They were calling for the whole thing to be scrapped and started again. They have withdrawn that argument." He peddled the same falsehood on the BBC news yesterday. I've been reading what remedy members have been writing on the DNUK forum since the start, and I've seen no '180 degree U-turn'. I've seen a dynamic group of junior doctors making sensible policy decisions. I'd choose them over the BMA to defend the NHS training programme any day.

Listening to Johnson, and reading his quotes in the papers, is a fascinating insight into why the BMA is so useless. It's pretty clear from these that Johson did not resign. He was made to walk the plank. And he appears to have gone to his watery grave without any clue as to his own failure.

A wise man giving a graceful resignation speech, would say 'I misjudged the mood, and I'm sorry' and would then stand aside to let his successor get on with getting the job right. But here we have a man who spends his last few media miles repeating the rubbish that got him sacked, and attacking the very juniors that he so badly let down in the first place.

But then Mr Johnson shows no sign of being a wise man - if he were, then he would have avoided being made to resign, but even that irony appears to elude him.

And this was nothing like a graceful resignation.

Silly Old Coote

Now, it is well known that we are not Patsy Hewitt’s biggest fans. However even our jaws dropped when we saw this article by Anna Coote in the Guardian.

Now we have scraped them back up off the flaw, it’s time to speak about this article.

Dr Rant admires people standing up for their friends. However this piece may do as much for Ms Coote as did James Johnson’s standing up for his mate Liam "McCaverty" Donaldson.

A glance at Ms Coote’s CV show her true (Labour) colours:

“Anna Coote joined the Healthcare Commission in 2005 to lead its work on engaging patients and the public. She was formerly director of health policy at the King’s Fund, deputy director of the Institute for Public Policy Research, and deputy editor of the New Statesman.”

Now the New Statesman is a well written magazine with an honestly described left wing bias. The IPPR is a left wing think tank, whose alumni include on P. Hewitt. But the King’s Fund is supposed to be an impartial (non-partisan) observer of the health scene. But it has clearly employed someone in a senior position who is a mate of Patricia Hewitt’s and whose politics are left leaning. Also this mate of Patricia’s has held high office in another supposedly non-partisan body, the Healthcare Commission, whose latest report seems to have triggered this gushing piece in the Observer

One commentator described Ms Coote’s piece as,
“Astonishing on so many levels. That Anne Coote who has held senior positions in health policy should have such a glib understanding of the issues in question. astonishing that she should take at face value flawed statistics and poorly collated data that amounts to propaganda.” Dr Rant would back this comment, and add that the demonstrated lack of understanding may well explain some of the silliness of New Labour's health policies

New Labour’s health policies have been a disaster on so many levels, as we and others have described in many ways previously. I think New Labour have realised this and are using the only remedy they know, spin doctoring, to try and cover their tracks. The longer they try this tactic the worse the final reckoning will be for their incompetence, and the worse the health of patients, and the greater the waste of taxpayer’s money.

Anna Coote’s piece exposes a network of old lefties with contacts moving seamlessly between journalism, think tanks, consultancies and well padded quangos. The sooner we can put Mrs Hewitt and Ms Coote out to pasture the better for the country.

It seems to be the weekend for silly old coots. There’s another one at work in the Observer today with encephalitis journalistica or New Labour induced vertigo.

The charitable explanation would be that she’s written it as atonement to the New Labour spinmeisters for this piece last year. When we have taken some intellectual stemetil we’ll get around to taking the article apart.

Foolish James Johnson Resigns

By all accounts James Johnson, the BMA leader who has just resigned, is a very nice chap.

I've just listened to him on the Channel 4 and BBC news. He does indeed sound like a nice chap. Sadly, he is also a fool.

He's a fool for being too nice, for a start. He is a fool for thinking that it was the BMAs place to support the Chief Medical Officer (his pal, no less) because he is a civil servant who 'can't defend himself'.

James, if the government is taking a perfectly fair kicking, then the civil servant that advises them can either (1) take the kicking too and lump it, or (2) resign in protest. That's life in politics (and so it should be). However, only a fool would think that the publicly defending him as BMA chairman was a good thing to do when so many juniors have had their careers ruined and so many patients face poorer care because of a training disaster.

He is a fool because he thinks there are 'no alternatives' to just plowing on. There are lots of alternatives, such as delaying the changeover date. These are favoured by RemedyUK and 85% of junior doctors responding to a recent poll.

He is a fool because he did not realise just how ANGRY!!! doctors are about this. In fact, during his interviews he still seemed to have no concept of what ANGER!!! really is. He was just a nice guy saying things like 'we're in a mess, and it's no-ones fault in particular' (if this blogger's notes are right - I did drop my pen at that point). Actually, it is quite a few people's fault. Sadly, one of them is you, James.

There is one thing I don't understand though. If James is such a nice chap, why did he stab RemedyUK in the back with a surprise use of BMA lawyers to defend the DoH in the High Court? Is that a 'nice' thing to do. Or is James just 'nice' when it comes to sucking up to the government?

Either way, I don't think Jimmy Nice has been very Juniors Nice. I don't think junior doctors' can take much more niceness.

No, Dr Rant hopes the new BMA leader will be a total bastard. A wise, honest, and fair total bastard.

Next Hamster Please...

I thought it might be fun to continue on the subject of domesticated rodents, thereby creating 'a theme'. The more astute reader will no doubt already be suspecting that my new medication is kicking in nicely after this week's excitement. I'm sure Dr Ray is relieved.

There's an interesting article in the Telegraph you may find mildly diverting. It is entitled Do we pay our doctors too much?, and contains a rather pointed truism that caught my eye. I'd like to share it with you if I may:

Dr Prit Buttar, a GP from Abingdon, Oxfordshire, concedes that, on paper, he has enjoyed a substantial rise in the past two years, earning more than £100,000 a year but says that this year, in real terms, he has made a loss.

"My practice will receive no increase in income this year from the NHS - but my costs, such as utility bills and salaries still go up. I believe that my staff are my greatest asset. So even though I won't be getting a pay rise, I will still be giving the people who work for me an increase," he says.

"Per patient, per year, I am paid approximately £50, regardless of how many times I see them. That's a year's unlimited cover. The cheapest policy I could find for pet insurance - for a hamster - was £65 a year, plus £50 excess. So your health care costs less than your pet rodent's. GPs are excellent value for money."

It rather puts the cost of primary care into perspective doesn't it. Not only do GPs earn less than vets, they look after you for less than your kid's hamster costs to insure.

Of course the NHS financial crisis has nothing to do with the £12 billion they're spending on a useless computer, has it......

Dr Guinea Pig I Presume....

This piece was written by Dr Clive Peedell, whom Dr Rant greatly admires. His words have appeared here several times in the past. It was originally posted on DNUK, and provides the evidence that shows MTAS was used a research project for Professor Fiona Patterson to help validate her ideas for selection of doctors into higher training.

This is a scandal.

The lives of thousands of junior doctors have been turned upside down by an inadequately researched and unvalidated selection system - MTAS. I am shocked that the Royal Colleges let this happen. In fact there is evidence that the colleges “assumed” it would work form this document from the Royal College of Paediatrics and Child Health.

“Though not entirely reassured by this we, like most Colleges, assumed the process would nevertheless run better than has since transpired”

This is bordering on negligence. I cannot believe that the Royal Colleges could allow this to happen and ASSUME that it would turn out OK. We are talking about the lives and careers of thousands of doctors and they just let it happen without a serious fight and without the need to consult their members and fellows!

Please see these notes from the Royal College of Surgeons' Regional Representatives Meeting in June 2006. I refer you to pages 4 and 5, (but there is also some interesting stuff later in the document about cutting training numbers and DGH reconfigurations).

The document provides the evidence that the basis for MTAS was incompletely researched and unvalidated particularly for surgical training. It also confirms that this years MTAS was going to be used to validate the methods! Here are the crucial paragraphs:

"The background was to design a selection system that was defensible, reliable, valid, cost-effective and feasible as well as to develop and validate current criteria"

How are her selection methods validated and what is the evidence? There's nothing solid on the medical literature search facility Pubmed. This is widely accepted as the first place to start when looking for 'evidence'.

"In terms of progress, the stakeholder consultations (stage 1) and job analysis and literature review (stage 2) have taken place. The current phase is the third
which is the design of selection tools and scoring frames. The other stages are;
• Conduct pilots and evaluate outcomes
• Train selectors
• Implementation"

This meeting was held in June last year. MTAS opened in January! No publications of her work on this have been seen in peer reviewed journals.

"A strong recommendation from the pilots was that it is extremely important to get standardisation of assessors/selectors"

But what is the evidence that a rushed half day training session achieves standardisation of assessors/selectors? Again, a PubMed search found nothing.

"Although a literature review of 25 years worth of research was relevant, the challenge in designing a model for surgery was that none of this research had been validated for surgery and currently in the process of doing that"

She admits the lack of evidence herself!

"Early implementation is expected to take place next spring with the intention to do early validation work"

The smoking gun! She admits that the validation work will be done during in the Spring of 2007 i.e the actual MTAS process itself! THIS IS SCANDALOUS:

-"The next steps would be the piloting of the selection tools and validating them as that is the missing link"

-"There are a number of challenges to the project including timeframes and engaging stakeholders, pitching assessment at the right level, calibrating of assessment and selectors as well as feasibility in the short term. Along with the challenges are opportunities"

Too right! Of course - the opportunities for Professor Patterson to churn out lots of research are incredible. The amount of data that she has amassed from 34,000 doctors is phenomenal.

It is clear that MTAS has been used as a research project for the future selection of doctors into specialist training. This is an absolute scandal. The Royal Colleges have allowed 34,000 junior doctors be guinea pigs for an unevidenced and unvalidated selection process.

We have ended up with a complete crisis because the colleges “assumed” it would be all OK. This has coincided with situation where 33,000 doctors are applying for 18,500 training posts, which is clearly a situation when you want the most robust selection method possible in order to ensure the best got the best chance of getting a training post. What we ended up with was a bloody pie in the sky research project with 34,500 guinea pig doctors.

Were any of the 34,500 junior doctors actually asked for their consent to be experimented on? Was ethical approve sought and granted for this 'research'?

This is an absolute scandal. When are the Colleges, Deaneries, CMOs and DH going to put their hands up and admit that this was a terrible mistake and they are all to blame?

Don’t hold your breath….

Republished to open up comments

When a person thinks only of money, they can do anything

Mr Song, the Chinese man who just confessed to murdering six women to sell their bodies for money, allegedly said:

"I felt very jealous when I saw successful businessmen. I dreamed of becoming a millionaire....When a person thinks only of money, they can do anything."

Just think what a whole society is capable of when it thinks only of money.

Cancel your BMA membership NOW!

Hundreds of BMA members have resigned today in disgust at the letter BMA president James Johnson had published in the Times this morning.

Doctors who have phoned the BMA membership department today are reporting on the DNUK discussion forums that call handlers admitted to each having handled dozens of such resignations from disgruntled members. BMA call handlers were able to guess the reason for the call before being told, such was the scale of the problem.

Dr Rant has canceled his BMA membership and urges all doctors to do the same.

RemedyUK speaks for British doctors - the BMA does not.



Email link to cancel your BMA membership.

(simpler link if that one does not work)

BMA Quisling Fucks Shore Up Whore Hewitt

Dr Ray look away now, mothers lock up your children, because Dr Rant's brain has gone Chernobyl.

Those useless, spineless, self-serving, lying bastards that run the BMA. Yes you, you evil lying Quisling fucks! I've just had to suffer listening to that slimy narcissistic cunt Hewitt on Channel 4 news. Jon bombed her flat and machine gunned her so-fuggly-you'd-never-get-tired-of-kicking-it face as she crawled from the rubble. But do you know what she kept using to shield herself? Do you know what useless tosser institution she is using as a rotting gangrenous stump to prop herself up with and limp away on? The fucking BMA. That bunch of useless, lying, self-important, bastards. The words spilling out of her undead mouth, like maggots squirming over each other in the mouth of a week old corpse, were about how she was working 'with the leadership of the medical profession'.

Quisling collaborator fucks. The BMA leaders should be singled out and have their heads shaved, hoping that the allied troops arrive before the angry mob finish tying the noose round their necks.

How dare they. How dare they 'speak' for the profession in this way. They have been saying in every media interview that they do not support the Remedy legal challenge in the High Court (oh, Remedy, we are not worthy!), yet every poll shows that their members OVERWHELMINGLY support this challenge. The BMA have the gall to do this in spite of the Junior Doctor Committee's successful motion at their conference supporting legal action and the abandonment of the entire MTAS process (including the desperately unfair first round).

Shame. The BMA should feel shame.

The BMA only got a little bit butch with Patricia at all because the anger of the junior doctors had spilled over into an attempt to get enough signatures to hold an emergency BMA general meeting and have the current leaders voted out (a plan that has only failed because the vast majority of doctors with a spine left the BMA years ago in disgust).

Since this attempted coup, I've had three letters from General James Petain-Johnson, the BMA president in Vichy London, telling us all that we need to direct our anger at the 'right target' - ie: not him.

Well I think our anger is directed at exactly the right targets. The evil cunt, Hewitt, who should kill herself but doesn't even have the decency to resign, and the BMA who are helping her.

Hewitt, if my wife hadn't hidden my AK-47 for my own good, you'd be in a lot of trouble, you putrid cleaver-faced little gargoyle.

Go Remedy, Go!

MTAS 'monitoring' what exactly?

So MTAS has been stopped. Or rather, the DoH statement says, it will now be used for 'national monitoring'. I'm not sure what 'national monitoring' means - although I'm more sure that the DoH spokesperson who wrote the press release has less idea of what 'national monitoring' means than I do - but doubtless tens of thousands of juniors up and down the country are crying into their NHS canteen coffees at the thought. Imagine being monitored by a system that is the A-Z of IT cockups: one mouse click you're an high flying surgical trainee from East Kilbride with your whole career ahead of you, the next you're an homosexual, Zen Buddist, Iraqi national dermatologist working here illegally and scheduled for deportation on the next flying suitcase bomb home. Game over. Meanwhile the cleaner on ward 61 is being 'monitored' all the way into the fast track specialist training neurosurgical post at St Tertiary Center and a glittering career as a consultant brain doctor is an absolute certainty.

Terrifying.

Of course, 'monitoring' is an euphemism for 'this system is totally fucked up beyond all repair, is not working at all, has not been working since we pulled it's plug to stop Channel 4 hacking doctors' unprotected sexual orientations off of it, but now we need to save face so the PR guy in Section 14 came up with the idea of saying we would use it to monitor something, anything'.

The only monitoring that is going on is signs of life to see if the MTAS computer program really is brain dead, or whether it needs to have it's central processors stomped on a few more times by the nerd with the biggest boots.

They Think It's All Over......

"This is an 'ex' computerised training application system"

MTAS IS DEAD!

Common sense has at last prevailed with the announcment that the incompetent and injust computersied junior doctor careers mincing machine - MTAS - has been ditched!

BBC news article here.

I particularly like the way that the government has tried to present the decision as a 'choice' by them when there was no other option, and it shouldn't have dragged on this far in the first place.
The first battle has been won.

The war over 'Modernising/Murdering Medical Careers' has now begun.

Junior Doctors - All You Need To Know In 10 Minutes

Last night, in just 10 minutes, the superb Channel Four News managed to summarise and expose the scandalous incompetence that is currently ravaging the training of junior doctors in the UK. I urge everyone who can to watch it and comment on it below.

CLICK HERE

Then click on 'Watch this report'.

In the meantime, start praying that you don't get ill in August. Undertakers are cancelling their holidays as we speak.

Patients Choose Not to Choose Choice™

Choice™.

Tony Blair chose Choice™ as the choice of choice for NuLabour's policies. Whenever a choice was needed for policy, Choice™ was chosen over any other choice available.

Patricia Hewitt, dead in the water from the neck up Health Sec (now that Tone has chosen to officially announce his choice of departure date) chose to make Choice™ her number one choice of policy for the NHS.

Choice™. Choice™. Choice™. More Choice™ was better, so total Choice™ must be utopia. What no-one seemed consider was that a Choice™ of five uniformly under-funded over-targetted opted-out PFI-endebted dirty hovels was no choice at all. If total choice Choice™ is Utopia, then zero-choice Choice™ must be Hell.

Crippen and Dr Rant have been Stuka dive bombing the non-choice of the Choice Agenda™ for what seems like forever. Patients want to know that their local hospital will be clean and well staffed and will provide good care. Patients don't want non-choice Choice™. Patients want good local services.

Well now patients have been given a real choice. They were asked to choose what they thought was important in health care. Unsurprisingly they chose not to choose Choice™ as their top choice.

In fact, Choice™ was so far down their choice of priorities that none of the three Choice™ questions placed higher 73 out of a list of 83 health priorities. That's worse than Briain's entry in the Eurovision song contest - possibly because Malta and Ireland didn't get a vote in the health care poll, but more likely because Patricia and Tony's choice agenda stinks even more than Scooch's Flying the Flag.

So, in summary, the top Choice™ of Tony Blair and Patricia Hewitt and the rest of NuLabour is the bottom choice for almost everyone else in the country.

Kind of sums up the Blair health policy, really.

Disgrace!

Dr Liz Spencer

There was rather interesting story in the Telegraph yesterday. It's hard to work out what is most disturbing about it; the story itself, or the complete lack of suprise at this kind of thing happening, even within the medical profession.

Dr Liz Spencer, a leading luminary of the 'National Association of Clinical Tutors', is effectively one of the establishment 'whips' trying to railroad the disgraceful 'Modernising Medical Careers' and the 'MTAS' computer job lottery through the majority of the profession's opposition.

She claims that her instructing other clinical tutors around the country (some of whom have consciences and actually give a shit about the junior doctors for whose training they are responsible) to "refrain from passing on negative, anecdotal and unhelpful information" has been taken out of context!

Out of context? For fuck's sake! That is a 'gagging order' almost by definition. It is top down 'advice' to members of a professional organisation. More to the point, they are highly educated and influential senior doctors who are more than capable of acting in a way that they see fit. The fact that some of them have been expressing concerns should be publicised, NOT suppressed.

Dr Rant would like to refer Dr Liz Spencer to a little publication called 'Good Medical Practice' published by the General Medical Council. She may be aware that it contains a concise passage entitled The Duties of a Doctor. Particular attention should be paid to the bit about being honest and open and acting with integrity.

There are other examples of coercion and bullying going on behind the scenes to push through MMC and MTAS. Examples have been recorded, and names have been taken. Remedy UK will this week engage on a high court action, and the truth will out. Some senior members of our 'profession' are going to find the kitchen's a bit hotter than they were expecting.

The words 'refer' and 'General Medical Council' when uttered in the same sentence should sharpen the mind........

The 'Brown Eye' of the Beholder

Two Cheeks of the Same Arse

One pouting arse cheek has been replaced by another, but will this have any effect upon the filthy excrement that is streaming forth from the government's back passage? I think not. The 'brown eye' looks certain to sanction many more 'brown trouts' of policies being ejected from within.

Gordon thinks that the NHS has been a great success of late, he is keen to repeat the same old tired New Labour propaganda, what great achievements they are:

'more nurses on strike, shorter waiting lists for your portacabin pyeloplasty, more unemployed junior doctors, more quacks and more useless quangos than ever before, and importantly statistics you cannot trust'

Gordon has been behind many of Labour's failing NHS policies; he is the man who has brought us the 'brown daisy' of PFI and the financial enforcer who has crippled numerous trusts with artificial deficits in an attempt to privatise the NHS. His idea of 'competition' is to throw money at inefficient private providers while starving the NHS front line of funds.

There are more brown bear's noses around the corner. Gordon is a big fan of pharmacists taking over the work of GPs, he's also a great fan of walk in centres; seems funny that Gordon has always insisted upon consultant led care for his own family, surely not a case of double standards here? Would Gordon be happy for members of his family to be seen in a walk in centre by a nurse who doesn't know which end of a fisher-price stethoscope to position on the praecordium?

One of the most worrying elements of Brown taking over is his desire to free the NHS from any democratic control; he seems intent on allowing the same festering bunch of cronies to run the show with a token friend of big business thrown in for good measure. How on earth can an even more unaccountable bunch of brown nosers running the NHS be seen as progress?

I think the only option for our government's derriere is a radical surgical resection, the waiting list for radiotherapy is far too long; the malignant bastards have taken over both butt cheeks and the distal hind gut, and it seems that Gordon is in total control of government excretions thanks to his position firmly clamped around the 'brown eye'. The brave surgeon will need a large tank of nitric acid on standby, as whatever is hacked away would be far too dysmorphic for any pathologist to safely analyse. Fuck the two week wait, this New Labour filth needs resecting now!

"I'll tip my hat to the new constitution
Take a bow for the new revolution
Smile and grin at the change all around
Pick up my guitar and play
Just like yesterday
Then I'll get on my knees and pray
We don't get fooled again"

Pete Townshend 1971

The 'Internal Market' of Doom

Fundamentalist Islam seems to grab all the headlines these days, however there is another kind of fundamentalist lurking in our midst: the market fundamentalist. The latter type of fundamentalist have the dogmatic belief that the wondrous market will rescue any situation, no matter what the context. It doesn't take more than a little research to find some rather gaping flaws in this market-based ideology; market fundamentalists also exhibit similar characteristics to the worst religious extremists as they react with disproportionate vitriol when confronted by reasoned argument that questions the validity of their unerring faith in the market.

The 'free market' has taken a lot of credit for various successes, even when state protectionism has had a far more prominent role in the development of certain successful economies throughout the world. Even today 'free trade' is only engaged in by the wealthy developed nations in their areas of strength, state protectionism is still a vital tool which countries such as the US rely on in several key areas. Organisations such as the the WTO enable complex negotiations between countries as regards trade barriers and tariffs, compromises between tariffs and protectionism are haggled over at great length. The 'Washington consensus', a virtual bible of the 'free marketeers,' has arguably been to blame for several recent economic crashes, including the Argentine recession of 1999; the consensus consists of certain economic policies including privatisation, deregulation and trade liberalisation.

This moves me on to the relevance of the market to the NHS, the internal market was created by Thatcher in 1990 and it set out to improve the service by promoting competition between NHS providers. Before coming to power Blair and New Labour were fierce critics of the internal market, but following their election to power in 1997 they only went about strengthening this market-based strategy. The idea behind the 'internal market' is based around the assumption that competition between providers will drive down costs and hence improve the service provided. Unfortunately there is precious little evidence of this happening since the internal market's introduction, as productivity and efficiency have been on the slide ever since. Some leading economic opinion has also criticised the assumptions behind this approach, arguing that cooperation between providers combined with a 'competitive' environment is needed for the cure. Interestingly the internal market has arguably left to a breakdown in cooperative relationships in the NHS and a less 'competitive' environment in many cases, as contracts are frequently handed out in an uncompetitive manner.

Reform programs such as Choose and Book, the gimmicky 'Patient Choice', NPfIT, Payment by Results, Practice Based Commissioning, PFIs et cetera are all part of the same privatisation agenda that is claimed will improve the service by deliberately pushing more work to the 'super efficient' private sector. The fundamentalist proponents of the internal market assume that the private firms involved in PFI, ISTCs, WICs et cetera will automatically do things cheaper and better. It may surprise them to learn that there are numerous examples of the exact opposite being true, there is also an embarrassing lack of audit and quality control in place to monitor the performance of these private sector operations. It must be noted that there is virtually no similarity between the way in which the private sector is used to provide health care in the UK compared to the best health care systems in Europe; private health care providers in France for example are bound by law to a form of social contract to ensure that a certain standard of service is maintained.

The phenomenal cost of creating and maintaining the internal market is something that is rarely commented on by the government, this may well be why the billions wasted on centralised initiatives in CFISSA are conveniently brushed under the carpet. It is therefore very revealing that the NHS deficits, that the government has been enforcing upon the NHS, are scarcely out of the news; these deficits are a very convenient way of reducing NHS capacity so that more work can be spooned to the private sector.

The appalling value for money obtained from PFI deals has already been excellently deconstructed by Professor Pollock, incidentally she is someone that the government should not be ignoring. The poor value for money and the poor quality of work provided by ISTCs and WICs is also never far from the news. The poorly though out payment systems are also driving good services into the ground, this is expertly explained here; even the NHS confederation is speaking out against the never ending march forwards of the faulty payment systems:

"NHS Confederation policy director and PbR supporter Nigel Edwards agrees. The idea is in the latest PbR discussion document, although only as an idea. ‘I am concerned that the PbR team’s approach is to unbundle, unbundle and unbundle and put a price on everything,’ he says. ‘They seem to recognise the problem but not do anything about it."

Excellent NHS services are being closed as a direct result of Payment by Results not rewarding them proportionately for trickier more complicated work, while private providers cherry pick the easiest work and get paid fully even when they don't fulfill their contracted obligations. This is symptomatic of HMG's woeful program of reform based solely on upon flawed ideology. It is also impossible to put a price on the damage done to the morale of the NHS workforce thanks to this destructive reform program, the spirit of cooperation that used to exist in the NHS is also dying. Any attempt to create a better system must do better as regards retaining the most skilled staff, current reforms are forcing many brilliant doctors abroad or into the city.

The internal market would still be doomed to failure even if it wasn't run as badly; this is because a state funded health care system must be rationed effectively to provide the greatest net health gains overall, meaning that 'patient choice' and market mechanisms are anathema to any purely state funded health service. That is not to say that the private sector has no role to play, far from it, but we have seen an abundance of evidence showing this type of direct funding of the private sector with tax payers cash is an incredibly bad idea.

There is no ideology that will magically solve the NHS' problems, this is an extremely complicated problem that will take a massive amount of expertise to solve and even then there is certainly no perfect solution. The advantage that state run care has is that it can be incredibly efficient as it can be rationed to provide a good basic standard of care for all, this is provided that the money burning 'internal market' is binned for good. The private sector can be used in a way that will benefit us all, provided that the government rethinks the way it goes about this; the current direct funding of private providers in a way that is running the NHS into the ground is clearly not the best way to do this.

Lessons should be learnt from the overt failings of the internal market so that a more workable solution can be reached. Ideologies will not dig us out of this pit of doom. The essential beast of capitalism needs to be kept in check, otherwise short termist economic gains will have a disproportionate emphasis placed upon them in the design of new government policy; slash and burn capitalism can quickly lead to a situation where the long term health of society is placed in grave danger as inequality and social problems exponentially balloon. It must be remembered that there are many things that cannot be measured in absolute economic terms, understanding these limitations in our understanding will be key. In any potential successful solution the state must have a key role; whether this is as a provider of good rationed services for all or as a tough regulator of private providers, or possibly both, remains to be seen. There is a diverse mix of health care systems around the globe, with no particular system being acknowledged as the divine champion. It is very hard indeed to compare system to system, as there are so many unclamped variables; for example the NHS has been massively underfunded for many years when compared to other health systems, this factor alone makes it very hard to tease out any possible cause and effect.

Whatever the solution, it is key that all future policies and reforms are brought to us in a thoroughly democratic manner. This means that the government must consult the public properly and not railroad through reforms against the will of the majority. It means that the government must debate these issues and formulate policy out in the open, as currently policy making is done behind closed doors in a way that allows the real motives of reform to be hidden. The anti-democratic nature of the free market must be remembered so that unaccountable power bases do not grow in a way that can damage the health of the nation. The successful use of the private sector in the future can only be done with tight regulation that ensures all health care providers respect the social contract and provide a high quality equitable service; this will ensure that a productive dynamic is set up that sees public and private sectors working cooperatively towards the same goals. Whether public or private, the key factor seems to be that the long term needs of the population are considered when providing the service; absolute short termism will be the death of any system.

Of course the actions of 'the state' are not necessarily democratic, this is very much dependent on the strength of a number of key democratic pillars. In fact Tony Blair's rule has seen a rather worrying erosion of several of these pillars; policy making decisions are now routinely hidden from the public thanks to new legislation, while a network of unelected unaccountable hand picked special advisers have a massive amount of power as regards pushing through this flawed Blairite ideology. A lot of progress could be achieved by making statistics independent of government control, as the current government stifles progress by concentrating on spinning propaganda as opposed to actually improving services.

The debate about the direction of reform needs to be had, even if the politicians do not agree; in fact some very interesting ideas are appearing on the horizon, sooner or later the politicians will have to engage. The only way forward is with open and transparent democracy, as without this both state and private health care systems are doomed to failure because they will not be set up to serve the interests of the majority. As far as how to achieve a functional mix between public and private, I'm open to suggestions however it is clear the current 'internal market' is doomed to failure.