I Predict a Riot

At this time of year, it would seem to be the done thing for those who consider themselves to be experts in their fields to produce a list of 'predictions' for the coming coming year. If you've already lapped up the former Northern Rock CEO's predictions for global credit conditions, and you just want more, more, more - we present:

Dr Rant's Prophetic Prophecies 2008 ™

1. Alan Johnson to be found alive, and living in the wild with a troop of Barbary Macaques. For a while, we thought that no one had been selected to replace our dear Patsy Fuckwitt and for all intents and purposes, that would still appear to be the case. However, whilst gazing into the bottom of my mug this morning, the tealeaves were giving me a distinct 'Postman Pat' vibe, and I feel that 2008 will be the year Alan says/does something.

2. The MTAS junior doctor job application system to be replaced by a new Saturday evening BBC one reality show (hosted by Graham Norton) entitled "Any Job Will Do". 30,000 medical graduates from around the world will be whittled down do one, with the lucky winner given a job working for connecting for health as PA to Dr Simon 'Judas-Badger' Eccles.

3. The involvement of private companies in Primary Care, through APMS contracts, will be proven to be the disaster for patients, the taxpayer and healthcare workers that we all knew it would be. Did they listen? Like fuck they did! More specifically, the first and most obvious example will be the folly of awarding of the contracts to run two practices in Derbyshire to a private company instead of the doctors who were actually working there and making a difference.

4. The Conservatives to actually come out with an actual health policy. As improbable as it may sound, it will happen and I'm prepared to stick my neck out on this one. The current policy, of letting the shining beacon of fuckwittery that is New Labour's health policy illuminate itself for all to see, may be politically astute but there will come a time in 2008 when Dave will have to put his nuts on the table. Dr Rant knows exactly where in the shed his hammer is, so it better be good!

5. The third consecutive 0% annual increase in GP practice incomes. Practice staff like nurses and receptionists won't be getting a 0% increase from their GP employer however, so that means another take home pay cut for GPs. But, when one considers that we play golf all day and take home a quarter of a million quid, it doesn't matter really.

Dr Mustard demonstrates BMA approved Advanced Political Activism Techniques

6. Fight! Fight! Fight! Fight! There will be blood in the corridors of Whitehall because Gordon's picked on the wrong group of 40,000 professionals this time, and GPs aren't going to roll over and play dead. We will not do more work for less money, and neither will we chase political objectives instead of doing clinical work that has been proven to actually make people healthier. Opening on a Saturday morning may win Clunking Clunker a few votes, but it won't really make anyone healthier, and if opening on a Saturday morning comes instead of during the week, those who need access will lose out to those who want access. The resistance is getting organised, and the GPC are standing firm. This is one battle Gordo and the DoH admindroids aren't going to win. Of course, that nice man Dave might find it all interesting, assuming his nuts haven't been flattened by a GP with a hammer........

What is the fucking point? (part three)

The Government are a bunch of cunts.

No, that is too restrained. They are a collection of duplicitous cunts; reneging cunts; lying cunts; and utter fucking cunt-slime of the most dishonest kind imaginable.

And they are cunts who hate doctors. At every stage of a doctors career, New Labour has introduced barriers and obstacles to fuck them over.

Fresh A-level students now have to sit a 'clinical aptitude test' which was forcibly implemented to select candidates, despite the fact it never worked.

The syllabus of a medical degree has lost the core subjects of anatomy, physiology and pathology, to be replaced by the touchy-feely bollocks approaches of 'communication', so that doctors can now empathically tell relatives that their loved-ones have died due to the fact that they fucked up the surgery / internal medicine / disease management.

MTAS came along and bent a generation of doctors over a barrel, and fucked their present and future careers firmly up the arse.

And then came along the GP and Consultant contracts.

The government thought that doctors spend half their working hours on the golf-course, and wanted to get more work out of them, so entered into negotiations about performance related contracts.

Doctors realised that most of them worked 100+ hours per week, and despite the views of the conservative former health secretary, Kenneth Clarke, most of them didn't know one end of a golf club from another. And so the new contracts were born.

GPs received a pay rise, albeit it performance related. They were given the option of opting out of Out-Of-Hours (OOH), albeit for a massive pay cut. And GPs were allowed to choose whether they would do work not specified in their contract; roles like removing sutures and dressings applied by the local hospital could either be returned to the place that applied them, or charged for.

Things started to go wrong for the government when almost every GP decided to take a massive pay cut (£6,000) rather than take part in OOH. GPs found that OOH was a massively abused service. Whereas few GPs would object to visiting a patient with an attack of angina, OOH was mainly used by people wanting antibiotics for viral illnesses, or a letter for the council or for court. And so, like a shitty stain, GPs washed their hands of it.

Then came the Quality Outcomes Framework (QoF) results. Most GPs scored very highly, reaching targets for the management of chronic diseases, such as cardiovascular and respiratory illnesses. QoF was all about performance related pay, and high scoring GPs were paid accordingly.

Of course, the government ended up fucking up the contract. In thinking that GPs spent all their time on the golf course, they hadn't realised that well educated, highly motivated professionals would reach most of the targets.

And so, the government mission of fucking over GPs began.

First came the attack on pensions. Rather than pay the employer contribution part of a GPs pension, the government paid it into the GPs wages. And then announced it as a massive pay rise. And then taxed it.

Then came the attack on GP wages. Rather than take the approach of telling the public that GPs spent all their time playing golf, New Labour delighted itself by telling the public that all GPs were paid £250,000 per annum, and wouldn't open nights. Well, a typical salaried GP earns £60,000 per year, and a GP partner is given just over £100,000 per year to run his small business, which includes rent, staff wages, professional costs and pension, before he can afford to pay his own wages. And by their own figures, 84% of the UK population were happy with GP opening hours and current OOH services.

And then came the two highly generous pay rises. Yes, rather than the below inflation pay rises that most public sector workers got, GPs were awared 0% and 0% over the last two years.

And it continues. The latest act of the government is to openly flout the terms of the GP contract. Rather than renegotiate the contract, they have decided to ignore it.

The fuckwits in government have decided the most important health policy to force through is changes to GP opening hours, without paying for it.

If is bad enough that the spineless cowards in the BMA were prepared to offer two extra unpaid hours per week for every 6000 patients on a GP list.

But the government want more. Much more. They want three hours per 6000 patients, in longer blocks, and they want to re-allocate some of the QOF points to make them based on OOH, too.

It may not sound like much. But this will cost the average GP practice over £36,000 per year in terms of both unpaid work, and employing support staff.

Well, New Labour - Merry fucking Christmas, you fucking Scrooges. In order to get yourselves re-elected, you are destroying General Practice. Utterly and Completely. You seem to think that GPs should alter their opening times to suit the few who demand OOH care, rather than the majority who need it, the elderly, the young, and the disabled.

The jewel in the crown of the NHS was the continuity of care that primary care could provide. New Labour wants to replace this jewel with a turd; this turd being an amalgamation of walk-in centres, Polyclinics, NHS direct, community noctors, and all other forms of faeces devised to turn GPs from the gatekeeper of primary care into a politically expedient wage-slave.

It is time for a fight. Not the kind of leaflet campaign that the fucktards running the BMA would probably recommend. It is time for GPs to take the offensive.

There are many ways to do this. There is the "Don't use Choose and Book / NHS-IT" approach, refusing to use the poorly-functional NHS computer systems, which have cost more than the 2012 Olympics. There is the "Refer everything" approach, which could fill outpatient and A+E departments in days, as GPs refer every case that they are not 100% certain of, to ensure patients get as many possible opinions as possible. And there are other approaches, including the above, which would not be considered industrial action, which would thoroughly fuck-up the government's 18-week targets.

And there is the "let's do what the dentists did and fuck off" approach, for GPs who are not anchored by PFI/PCT contracts to pay the mortgage or rent on their surgeries.

There is of course, the all-out 'have a strike' approach, which will fail due to a combination of New Labour spinmongering and BMA cowardice, and the fact that most GPs have patient interests at heart.

However, New Labour will not get the whimpering capitulation that they are after. If they want a fight, they will get one, and it is their nose that shall be bloodied.

And they can get it seen to in one of their fucking Polyclinics.

Merry Christmas

Family Rant would like to wish all our readers a very Happy Christmas.

God bless us, every one.

What is the fucking point? (part two)

This is a guest piece, 'Extended Opening Hours: A View from the Coalface', by Dr Ian Rubenstein.

Sorry if it comes across as a rant but I just felt moved to tell it like it actually is from someone who has to do the job and make sense of what actually is government nonsense.

In an ideal world our surgeries would be open 24 hours a day, we'd be well funded and have the freedom to organise things as we want. GPs would be able to employ people round the clock. In fact in the mid-nineties this is what we almost had in my surgery: we had a local co-op of 35 GPs based at our surgery. The problem was that our patients over-used the service and the other GPs complained that they were always seeing our patients. However left to its natural conclusion I'm sure that we would have worked closer together, set up some sort of super-surgery, pooled resources etc. We actually all enjoyed meeting each other on shifts, even though out of hours was still a pain, and we took a pride in running a service which was extremely popular with out patients.

However: the dead hand of the DOH decreed that we were too small, that we had to answer the phone on three rings etc. The quality issues were ludicrous and, despite the fact that it all worked well and the patients loved it, we couldn’t meet the requirements. The only option was to get bigger and we thought: hang it, we'll merge with the local big co-op. It actually cost us less (economies of scale) and we didn't have to do any shifts if we didn't want to.

Then, of course after a few years we were encouraged to drop OOH completely (the money we gave up was used by the PCT to fund the large local co-op).

The problem is this: This was all in 1996. I've been a GP for 25 years now. For the past 8 years I haven't had to do any out of hours. I'm 52 years old, my colleagues are mostly over 40, and two in their sixties and this applies to most GPs in our area. I've re-arranged my life as have my partners and frankly we've all got other commitments in what used to be our OOH time. New GPs all seem to want to have a better work-life balance than I ever had: we couldn’t recruit any new partners until we were part of a co-op.

I now have a life outside work and it has actually made me a better doctor. My work has changed: In the old days we had 15000 patients and five partners. Surgeries could sometimes have thirty patients and there might be five or six home visits for EACH doctor after morning surgery. Now we have seven partners and 12000 patients. There are less demands for home visits and the work has shifted more from acute stuff (our nurses see a lot of this) and more to managing chronic disease that when I first started would be managed in hospital. Try to get a decent generalist consultant opinion nowadays: the only ones who can seem to manage an overview are the geriatricians. So we have to be more clinically astute. If we go back to the old days, then we’ll have to do everything we used to do, plus a load of the stuff the hospital used to do (and we are doing now).

The entire GP OOH infrastructure, receptionists, special computer system, office space has been swept away. That's all been taken up by all the staff we need to manage QOF. There really is no money to fund this plus extended opening hours. All this nonsense about GPs earning megabucks is just so much hot air. In my practice we have seriously financial issues and are worried about where we are going to get the money to fund staff. We actually had to make one member of staff redundant.

To all my non-GP colleagues out there: this stuff doesn't just happen, we have to make it happen. Plus we have to see all the patients, and take the flak for all the fallout from a hospital system which is failing. When I first qualified I remember being amazed that elderly people didn’t want to go to hospital because they equated it with the workhouse. That generation died off years ago. Now, amazingly, I have another generation of people (young and old alike) who don’t want to go to hospital in case they get C.diff, MRSA and who tell me horrendous stories of the care they received. My patients really cannot understand why it takes three weeks for me to get a routine X-ray report! (it used to take a week back in 1982).

GPs get all the flak for this, however much we try and deflect it. It’s incredibly demoralising.

Also: what the hell's the point? I used to be very enthusiastic with stuff like fund holding etc. But as soon as we set up one system, the government change it! There is no stability at all and we waste time and resources going round in circles. It's not just a waste of time, it's a dangerous waste of time.

A good many of us were concerned about the implications of the new contract and in fact the government were warned (if they had listened) that the sums didn't add up. They didn't listen.

They now have the consequences of their extreme stupidity and I'm buggered if I'll take the flak for this from anyone.

If we expend money and energy trying to make this work (having spent money and energy dismantling a structure that did work in pursuit of some wild goose chase) who's to say that five minutes later we might not have to dismantle this in favour of some other hare-brained scheme.

This is not good management. In fact it's dangerous nonsense. I remember the "old guard" when I was young debating proposed changes to the NHS. The accusation then was that "it's a waste of medical time". Of course everyone then thought that medical time was a precious resource. And it still is: just ask our patients. The government seems intent on squandering this in just the same way as it has squandered billions on ephemera.

Having said all this I still enjoy being a GP. The patients are just the same and the only way I can cope is by trying to ignore all the crap and focus on the patient. But it gets harder and harder. My wife is a doctor and she works in family planning and is the one of the few doctors locally who can do difficult coil insertions, plus she is a trainer. She has similar problems with her department.

If you are healthy and have a job you like, why retire even at 65? That’s how I used to feel. But the way the things are going we actually are wondering how we could afford to retire sooner.

It beggars belief that a government can spend so much on the health service and thoroughly piss off the very people who have to make it work.

Gerry Robinson: where are you?

This piece was first published on DNUK on the 22nd of December, 2007.

What is the fucking point? (part one)

Why do doctors in the NHS go on? I mean, what exactly is the fucking point? What is to be gained from slogging on day after day in the certain knowledge that the lying, cheating, evil, murderous scumcunts in power could not care less about anyone or anything except themselves.

It's not easy to know where to start with the news that the government is going to unilaterally rewrite the GP contract to force GPs to open evenings and weekends in exchange for less money after the BMA negotiators decided there was no fucking point in them going on either. So let's summarise.

In the early nougties there was a crisis in General Practice in the UK. Everyone was leaving practice - either by retiring early, or by resigning and doing locum work instead, or by emigrating, or by simply giving up and doing something else, or by really giving up and killing themselves. Experienced GPs were almost universally approaching their fifties as alcoholic divorcees, and those of us coming up behind them wanted none of it. The long hours. The endless unpaid work. The 24 hour demands of selfish twats who knew nothing of the post-war 'gift economy' that had produced the NHS but instead knew only the Cult of the Individual chant of 'I Want, I Want, I Want' and who cared not a jot that their desire to have their two week old ingrown toenail looked at at 4am would harm the care of more needy patients.

Dr Rant was a GP then. The practice budget was based on the archaic 'Red Book' of payments which no-one understood, but which had bizarre perversities to it. The collapse of General Practice seemed imminent. The negative cycle was as follows:

Five partner urban GP practice with 10,000 patients:
1. Stressed out GP number 1 burns out of practice suddenly.

2. The other GPs have to take up the missing GP's workload, so GPs 2-5 go from working at 120% of their maximum capacity to 145% overnight.

3. Practice advertises for a new partner in the BMJ (and bloody expensive it was too - BMJ must have been coining it in because the ads section for partners was the size of a telephone directory) but gets no response because no-one wants to be a GP partner.

4. Practice is forced to get in a locum to cover the extra workload. Locums are not easy to find either because of the sharp rise in demand for locums due to all the unfilled parnership vacancies. Locums can charge a lot of money as they are in such demand, so practice has to pay out twice what a partner would have cost.

5. Locums are very expensive (if available at all) overnight, so remaining partners have to increase the amount of on call work they do.

6. Because the practice is a partner down, and due to Red Book complexities, the partnership LOSES money from their NHS budget.

7. Remaining partners are now working harder for a lot less money and one by one they start to retire early or leave.

8. The partnership implodes as the workload for any remaining partners becomes unbearable (Last One Out Syndrome).


It was not immediately obvious to most people (certainly not the government) why the massive shift of GPs from traditional partnerships to locum work had the effect it had. However, the Locum Effect occured as follows:

1. Partners had to do whatever work they had to do. There was no way to say 'no' to extra work, and as the government cuts to hospital services gathered pace, more and more work was shunted onto GPs without any extra money.

2. Locums doctor's rates of pay had been controlled by the BMA, which was controlled by partners and so had an interest in keeping these rates low.

3. In 1999 the Office of Fair Trade ruled the BMA's setting of locum rates as anti-competative and the BMA was forced to abolish them.

4. Locum rates shot up, doubling and trebling within two to three years.

5. GPs now had, for the first time since the NHS started, an option that allowed them to work a reasonable number of hours and earn a good wage.

6. New GPs became locums in large numbers, exacerbating the shortage of principal GPs (partners in practices) caused by early retirement, emigration, and increased rates of death (from suicide and alcoholism, rates of which were both running at multiples of the national average).

7. Locums were doing less hours for more money, which meant that more GPs were required to do the same work as before. This increased the market value of locums even further, which meant locums could charge more, which meant they could work less to earn the same money, which increased their market value even more, which meant they could charge more, which meant....well, you get the picture.


As practices closed altogether (and some large practices closed as well as many, many small ones), the Primary Care Trusts assumed responsibility for their patients. The PCTs had only one option - they had to throw money at locum agencies to put medical bums on seats and avoid a total collapse in the service. This of course, made locums even more scarce for the remaining practices. Also, some GPs resigned as NHS GPs and simply went back as a locum to essentially the same job being paid a lot more by the PCT but for less responsibility.

The average time to fill GP vacancies was being measured in years (really) and the Primary Care Trusts were bankrupting themselves paying for more and more locums as everyone jumped ship.

This was a true crisis.

The solution came in the form of the 2004 New General Medical Services contract (New GMS, or GMS 2). There was much discussion on the medical forums regarding the new contract. Basically, the government wanted performance related funding (in the form of Quality Points payments) and an end to the crisis that was threatening to bankrupt the Primary Care service. Exhausted GPs wanted just two things in exchange: 1, to be able to give up out of hours care (it was literally killing some of them) and 2, to be able to say 'no' to new work unless it was funded (the so called 'No New Money, No New Work' requirement).

The Aquward Squad GPs at the time had concerns. Firstly, that the new contract could be unilaterally changed by the government without the agreement of GPs, and secondly that giving up Out of Hours - tempting as it was to exhausted and demoralised front line troops - would inevitably be fucked up by the government. There was also the concern that the government's real objective was to break up GPs' monopoly of primary care to make privatisation easier, and that they were willing to pay through the nose to achieve this.

However, unsurprisingly in view of the BMA's stance that there was 'no plan B', GPs voted overwhelmingly in favour of the new contract. As it turned out everyone was right. The BMA was right that the contract brought improved pay and better conditions for GPs which quickly reversed the crisis in General Practice recruitment and retention. The Government was right that they were able to use GPs high quality scores for political gain. The Awquard Squad was right that primary care was easier to parcel off to private companies now that GPs no longer had a contractual monopoly and that Out of Hours care would become a shambles.


And now the Awkward Squad's biggest concern has been proved correct. The main selling point of the new contact was 'no new money, no new work'. After years of being abused and put upon, GPs wanted control of their workload. They wanted to be able to say 'no' to being dumped on. They wanted to stop being the slave-like kicking stool of a government hell-bent on saving money by closing services and then dumping the work onto GPs instead. GPs were the cheapest labour in the NHS because they could be made to do an infinite amount of work for a flat rate of pay.

Well, as pointed out way back in 2003, if the contract can be changed unilaterally by the government at any time then you don't have a 'no new money, no new work' contact. What you have is the same slave-labour contract plumped up with a loss-leading hook of new money for quality work.


Lets not forget that the vast majority of patients report that they don't need evening and weekend appointments (even when asked in a loaded government questionnaire designed to get the opposite response), and those that do need them need them because employers have become much less willing to give employees time off to see their GP. (Is that really a reason to provide a worse service for the majority of patients?).


Now that every GP can see the new contract for what it really is.

Now that every GP can see that the media-blitz of lies and spin trying to claim that GPs are paid more for less work was an orchestrated artillery softing up before the battle.

Now that all the GPs are really, really, really fucked off.



What will happen next?



Who knows? But one has to ask, what is the fucking point of being a doctor in the NHS?



Continued in part 2.

Dropping the Baby: Part 3

Evidence today from the National Audit office about just how badly the NHS is managed. Basic care, basic staff not in the right place at right time. Facilities provided but not staffed. Massive increased funds into NHS…but they go on other things such as management consultancy, PFI and NPunFIT.

Sadly the report in today’s Guardian is not entirely surprising to Dr Rant. We’ve commented on dropping the baby before here.

In the same paper Simon Jenkins gets another diagnosis right- That British administration in NHS and other government departments has become, “Over-centralised, over-sized and overbearing, public administration in Britain is rendered exhausted and incapable”

It’s getting depressing. I’m off to read Nick Sedddon’s new book from Civitas. I wonder if those continentals know something we don’t. After all we have got such good results from our NHS investment haven’t we? Almost as good as we’ll get for our £1800 each into Northern Crock.

Meanwhile, it would appear that a young actress, who quit the dizzy heights of Hollyoaks to train as a midwife, is one of 22 from her class of 25 to be unemployed. However, in a not too distantly related field, it it would appear that despite an increasing proportion of newborn babies requiring special care, the NHS is having increasing trouble finding trained staff to look after them. Don't you just love joined-up, centralised, reconfigured, top-down fuckwittery?

Computer says 'fuck'!

Dr Rant was most amused to read this report about 'potentially offensive' passwords being issued to 220 GP practices to enable them to access the new NHS choices webshite website.

The problem is thought to have occurred when a computer program used to generate the passwords was not checked for potentially offensive word combinations that could be produced when two words were put together.

What readers may not know is that The Dr Rant Foundation IT Consultancy Solutions Division LLP™ has in the past tendered for work under 'Connecting for Health', as we also wanted a slice of the £12bn cake that was getting dished out. It's nice to see the our hard work has at last been recognised.

Sir Gerry Robinson gets his diagnosis right.

Sir Gerry Robinson was well worth watching last week (this would have been sooner but Dr Rant’s internet access played up recently). You can watch it by clicking here. His diagnosis was straight and accurate.

It looked like Rotherham DGH had more or less got its house in order. However it was now about to be destabilised by external policies driven “by dogmatists not pragmatists”

Sir Gerry rightly picked up on the contradiction between “care closer to home” and the need to collect expensive kit and skills in one centre. He also rightly picked up that a DGH is a major part of its local community. The government’s current policy to break up and destroy DGHs is clearly misdirected. Indeed a lot of the government’s drive is to concentrate the most severe cases in very specialised centres serving large populations, is a response to the need to keep expensive kit and specialised staff in one place.

Yes some stuff could move to primary care settings, but actually a closer integration of primary care and secondary care would be of greater benefit to patients. The present move to pit primary care commissioners against secondary care providers is crazy, will increase management time and drive a greater wedge of fear and bureaucracy between the two sectors. Meanwhile patients are moved between the two sectors ever more quickly, but information moves ever so slowly. A letter, or discharge summary, from Rantingshire DGH and The Ranting Shack Surgery can take over 4 weeks to cover 4 miles.

The failure of NPunFIT for anything to even think about bridging this communication gap is huge. It is a top down system, drawn up without good local input, and not to meet local needs and specifications. For the cost of £20 billion we still do not have quick reliable communication between GPs and Hospitals. The Newsnight discussion between Sir Gerry and Sir David Nicholson (NHS Chief Pointy Haired Boss) was classic,

“Surely you must admit that the NHS computer project can only be described as a complete shambles?”

Sir David of course could not admit any such thing, but insiders say CfH will be dropped as soon as it can be passed off as a strategic masterstroke, and not an admission of failure. Meanwhile the cost of 60,000 staff nurses for 10 years is pissed away down a government black hole and as Sir Gerry remarked:

“no one will be held accountable for this.”

Sir Gerry made the Primary Care Trust Chief Exec look a little silly. The site of the new “polyclinic” was displayed proudly. A new £12million building was going up to provide care to people who feel “a bit iffy in their lunch hour.” The medicine would be provided by nurses, and it wasn’t clear who needed this, or why provision was being made for them. But it’s bang in line with government policy so we can summarise current government health policy as, “iffy medicine, by iffy practitioners, for iffy reasons.”

Dogmatism trumps pragmatism any day, and meanwhile really sick people are looked after in run down GP premises (which are currently starved of funds) and a DGH threatened with instability, and the creaming off of easy cases by various private providers, and being left with less money, and all the harder, more complex cases.

The government is simply running the NHS in a way that can only be bad for patient care. And that will squander ever more money on anything other than what will get the right patient to the right treatment.

UPDATE: Horsing around with your blood results

A horse is a horse, of course, of course.........

Dr Rant is delighted to bring an update on our story about the proposed outsourcing of GP blood testing in Cambridgeshire to a company that normally does blood tests for the area's horse racing industry. Here's a little note from our source:

"The article on Addenbrooke's and HFL's plans to set up a lab for GP samples was well received (outside Addenbrooke's) - The "Addenbrooke's twateratti" phrase was particularly enjoyed and has entered the local vocabulary. I have heard from several sources that the plan is now dead. Thank Dr. Rant for his invaluable assistance."

We are very happy to have helped, and are very happy to hear from anyone who thinks that something deserves a wider audience.......

A taste of their own medicine?

Many of you will know of Mark Thomas (above), the comedian and scourge of Britain's less than illustrious parliamentarians. He's come up with yet another brilliant wheeze to embarrass them and prove that they don't like it up 'em.

Recently, Mark has been focusing on the outrageous banning of spontaneous public demonstrations in Westminster. Allegedly a response to 'increase terrorist threat', this hastily passed legislation obliges people to apply in writing for permission to demonstrate in Parliament Square, and the Police the ability to deny that right. A somewhat strange paradox in the cradle of democracy is it not?

In this article in today's Guardian, Mark has accused MPs of breaking the law by giving interviews outside parliament without prior written permission. Apparently, this is not an explicit exemption in the legislation, and the most candid example of law flouting thus far has been Gordon Brown's unveiling of a statue of Nelson Mandela outside the house!

Mark wants to mount a legal challenge, and is asking for your support - click here.

I think that's a mighty good idea, and could be rather fun.

Democracy: DoH style.

The Deputy CMO demonstrating 'consultation process' yesterday.

The ferret fancier has pointed out just how our medical leaders at the Department of Health regard the opinion of their fellow professionals, and it makes pretty depressing reading. Martin Marshall, the deputy CMO, let slip some home truths upon interrogation by the Commons Health Select Committee:

When he was asked what the profession was saying at the time:

"There were a lot of letters, emails, blogs on websites that said that the process should be stopped, but I felt that the voice of those that felt it should continue was muted, particularly in the spring in the heat of the problems, their voice were expressed very strongly, by a lot of the candidates who had had interviews who wanted them to stand, by the service who didn't want a vacuum on August 1st, and by a lot educationalists as well"

Then when asked if there was an equal balance of people who wanted it scrapped and people who wanted it to continue?

"Not on volume, not on noise, certainly not, the people who wanted it stopped were making a much louder noise"

So then what was the justification for not listening to this noisy majority?

"It had to be a rational one, not one based on noise"

Sir Lame Donaldduck - Still hasn't resigned.

This is a shocking admission. The Deputy CMO is openly admitting that a majority of the medical profession wanted the MTAS process scrapped, in fact he refers to the majority of opinion as a nuisance-like 'noise'. He arrogantly assumes that he and his cronies at the DoH know best and that only their decision could possibly be the right, or rational one. The DoH approach resembles a corrupt Soviet style command and control system, an approach that is doomed to dismal failure as Gerry Robinson has recently found out. A functional NHS would listen and respond to the opinion and concerns of highly educated professionals on the ground; the current regime's dysfunctional nature is betrayed by the cowardly contempt that it shows towards the very people that it should be listening to.

Revalidation, relicensing, recertification and appraisal. Sir Liam’s confused legacy to the NHS

Sir Lame Donaldduck: Still only here for the beer?

Bad cases make bad law, and the case of Sir Liam Donaldson is becoming a very bad one indeed.

One of Sir Liam’s greatest concerns has been concern with issues of professional performance. So he will have welcomed Dame Janet Smith’s reports into Harold Shipman. The fact that Shipman is an entire one off, who actually performed very well as a GP is not noted. Shipman was not in any sense a representative of the profession when he carried out his murders. Shipman’s actions are his own, and he must carry the can for them. There is no reason that doctors should live their professional lives as an attempted expiation for Shipman’s crimes. Realism says shit happens, and that Shipman was shit. It does not say anything about anything else.

However the Shipman case is regularly trotted out by the bureaucrats and other twaterati as the justification for a nasty new affliction called PROBOPHILIA. This illness is characterised by the sufferer’s fundamental inability to believe that any professional can do his job if left alone. Professionals to these twats are irresponsible and reckless, and highly dangerous. They must be thoroughly inspected and regulated as without this they might actually get on and practise some real medicine.

Not if the twaterati and other probophiles have their way. No the goal must be “reflective practice” and evidence of “reflection in action” No case is complete when the patient leaves the room. It must be analysed, and reflected upon, and you should wonder if you could have done anything different, or whether the room was too hot or too cold. A reflective journal should be kept, and Personal Development Plans (PDP) drawn up as well as copious records of room temperature and anything else that might just be relevant. And it should all be reviewed with a supportive colleague in appraisal sessions. The fact that these are only once a year is bitterly to be regretted.

The fact that such reflection sets the twaterati’s pulses racing with excitement does not alter the fact that navel gazing is largely an abysmal use of time. Look long enough into the abyss and it starts to stare back into you.

And anyway there are other patients to see, and access targets to meet. So if I reflect sufficiently on my reflections I reach the conclusion that rumination does not get patients seen, staff home, or let me get to the end of the day in peace!

So we have a process that on reflection is time consuming to little purpose.

Now Sir Liam has been the driving force behind the introduction of appraisal into the NHS. At one level it makes sense. In its current form it takes about 6 hours preparation and about 2-3 hours for the appraisal interview. It’s currently a formative (supportive, peer to peer review) process and it is supposed to lead to reflection and some changes in practice. Evidence as to whether it achieves useful change in practice or not is very limited so far. It’s also taking about 12 hours of doctor time per appraisal. Applied over the 130000 doctors in the NHS it’s a large number of doctors taking a lot of time away from patient care. Are the patients getting a good deal from this NHS investment?

Well if it leads doctors to sort out their rough edges it may help. But if all it achieves is identification of the lacunae in medical systems (which there is no political will to acknowledge or fill in) then little action will follow from the appraisal. It doesn’t matter at present- an unachieved PDP goal is simply deferred or dropped next time around and some equally useless goal substituted for it. But reflection on why a goal was a noble failure is fascinating, but ultimately it’s intellectual cud chewing.

At least appraisal is up and running. It’s probably of some use to some doctors, and may help patients indirectly by keeping doctors saner and better supported.

However we now have the impending approach of three linked but separate policies of relicensing, revalidation and recertification

Relicensing comes from the work of Sir Donald Irvine who pointed out that doctors get their GMC licence for life and never have to prove they deserve this again. He may have a point here. The GMC has some idea of what it is asking for with relicensing. Relicensing is about the doctor as a doctor and maintaining his or her right to practice medicine signified by GMC registration.

There’s going to be a five yearly relicensing cycle, beautifully illustrated by this diagram which to most doctors looks like a circular saw into which poorly performing doctors will be fed as punishment. One colleague said it reminded him of a Masonic Pentagram.

Recertification is about the doctor as a specialist. It is supposed to answer the question “Is the doctor still fit to practice in his or her speciality?” (General practice is a speciality, just like cardiology or gastroenterology) It’s not clear how this differs from relicensing, or maybe relicensing is subsumed within it?

Potentially we could end up with a mess in which a doctor is recertified but not relicensed or relicensed but not recertified. Quite what would happen in such a scenario is currently unknown.

Recertification (the specialist part) is going to be the responsibility of the ever popular and deeply loved Medical Royal Colleges. Yes, Twaterati Towers will swing into action.

The problem the royal colleges face on recertification is that the process they use has to convince several masters. So it has to convince the GMC that it is valid. It has to convince ordinary doctors that it is fair, accurate and not too onerous. It has to convince the DH and the public that it is sufficiently onerous. And it cannot take too much time as there aren’t enough spare doctors to cover sessions missed whilst we go and revalidate ourselves. “The patients couldn’t be seen as the doctor was being revalidated” doesn’t make much sense really does it?

IF challenged legally, the revalidation process has to be robust enough to demonstrate its reliability as a process, and the process is likely to be challenged legally either by a disgruntled doctor wanting his certificate back, or by an aggrieved relative saying, “You recertified this doctor last year and this year he’s gone and killed my old mother. Why didn’t you anticipate this problem sooner?”

The colleges are going to have great fun finding a way past all these potential problems. They also don’t want to do revalidation by means of an exam, although there will be “explicit standards” and “pass-fail criteria” Any test of my performance against a pass/fail criterion is an exam- no matter what you call it. They’ll need the medical equivalent of a flight simulator for pilots, but no-one seems to have come up with one yet.

And collecting a big girly folder of appraisal evidence and personal development plans is useless. I write well enough to fill several such folders…but it would give anyone reading it little real idea of how well I did or did not treat patients in practice. And anyway there isn’t enough time in the world to read all the guff doctors would produce if necessary. Just who will the time to read it and assess it thoroughly? And if anyone has the time to do this why aren’t they doing something more important?

However the circles are squared eventually, and at present the concept that the profession is going to be revalidated by means of relicensing, recertification, re this, re that and re the other, is faintly ridiculous. The confusion around these issues (which has been present ever since they were mooted over 10 years ago) is still present, and the initiative is at risk of “slippage.” I wonder if it will slip away before or after Sir Liam’s departure?

(P.S. Apparently a similar re-accreditation scheme was suggested for barristers some years ago. For some reason it got dropped).

Exculpation via medicine?

“Full willing was he to give penaunce

There as he wist ye have a good pittaunce”

With these words Chaucer damns the Pardoner in Canterbury Tales. In this essay I want to damn his latter day followers who in this secular age indulge their patients by supplying them with that modern equivalent of indulgences, the doctor’s note.

Indulgences were sold to achieve expiation and exculpation from sin. Convenient for the sinner, and profitable for the Church. Unfortunately they came to be sold widely and cheaply for profit, and eventually there arose scepticism as to whether St Peter would read them at the Pearly Gates Clinic for Reformed Sinners. Indeed there even grew up a view that he might treat such papers with contempt, as showing a lack of integrity and no effort at all at any kind of thinking, let alone the hard thought needed for repentance. Shakespeare described it thus

“I knew one Devil, that could equivocate in either scale, against either scale, but still could not equivocate to Heaven”

How many of us poor medical devils, the modern world’s secular clergy, are trying to equivocate in various scales against various scales to various outside bodies on behalf of our patients? What notes do our medical notes strike?

The main function of our medical notes is exculpation, to get someone else off the hook about deciding about something. Should I let this lady into the Jacuzzi? Better ask the doctor, just to be safe. Eric Wilkes pointed out that GPs are ideally placed both to be reassuring and to take blame when reassurance turns out unjustified. Better safe than sorry and you cannot be too careful nowadays can you? Actually yes you can, and if this is the way the public behaves, then patient empowerment as a goal of policy is an utter delusion.

The drive in our times is to avoid consequences, avoid responsibility and to be reassured. We seek to avoid our own version of the Garden of Gethsemane, and to have every cross taken away from us. “Ooh you might get splinters,sir, and there’s a tetanus risk from those nails. It is rather a heavy burden to carry isn’t it?”

Yes it is, and that is precisely why it matters to carry responsibility, to learn to handle consequences. Life, health, vitality, and empowerment all depend on accepting the responsibility to accept consequences. Accepting feedback is the way of learning, and achieving growth. Anything which stops us from doing this is acting against us achieving our potential and is fundamentally unhealthy to us.

Our current culture is discouraging us from doing any of those things, and this diminishes us as people, diminishes us as a society, and leads to a general feeling of helplessness. This feeling of helplessness then drives another round of seeking advice just in case, more avoidance behaviour and return for extra reassurance. Have you wondered how the more reassuring you are the more people return to you for more reassurance? Of all disciplines medicine is the least reassuring. It describes tens of thousands of diseases by which you can die and no way of being healthy. Why does anyone come to a doctor for reassurance? We cannot give it with conviction, we know too much, and present fears can easily turn into horrible imaginings. To all the neurotics who are worried they might have a disease, don’t worry as one day you are sure to be proved right.

The drive for a doctor’s note is the symptom of this epidemic neurosis in our surgeries. The demand for secondary confirmation of every statement shows just how afraid we have become of other people and our judgement as to whether they are honest or not. We trust neither ourselves nor others and instead we turn to the doctor to bail us out.

What doctors haven’t told you yet is that they don’t believe half what they hear in their surgeries. We repeat what the patient has told us to outsiders. (with patient consent of course, but confidentiality seems of very low value when someone might get an insurance payout or more benefit by telling all and sundry about their dreadful disease!)

We have no independent means of knowing whether the patient is telling us the truth or not. So our comments about a patient’s capacity for anything should not be taken as pure truth. The doctor cannot act as honest broker about illness and its effects and we need to step back from accepting this role that society is trying to thrust onto us.

At a time when we are being scrutinised to provide ever quicker access to the doctor we really need to ask the question “Access; for what?” These note requests are absurd, and a misuse of doctors’ time and energy. They are increasingly common and taking up a lot of appointments unnecessarily. They distract NHS staff time and energy away from clinical and organisational priorities (e.g. NSFs, diagnosing and managing illness) and squander it on useless paperwork that really achieves nothing for anyone. Is this really the kind of service Gordon Brown thinks he is buying with all the billions he is pouring into improving the NHS? Is this what the treasury and DOH want to achieve? A service that acts as universal excuse generator for patients, employers and councils? Another cog in the great bureaucracy of British life.

“These things must not be thought of after this way. Methinks it will make us mad” So said Macbeth, and I think he was right. We need to get out of this idiotic dance of asking doctors to arbitrate on things they know next to nothing about. Stop asking us to make decisions for other people and organisations who could, should, and actually do know better than any doctor what they need to know.

And where medical information is needed it must be requested formally by the organisation that wants it with a named contact, and an assurance to pay the appropriate professional fee for provision of information.

A doctor’s note may get you out of some problems in this world but I am sure that ultimately, at the Pearly Gates, St Peter will look at your doctor’s note and laugh. I am sure that some of his good sense will percolate down into this world.

Polyclinics 'on the hoof' make no sense

Gerry Robinson is on the BBC website about the improvements in Rotherham since he was asked to 'fix the NHS' (ho ho) and the threat to the hospital from a polyclinic proposal for the area.

Actually, Dr Rant could not agree more with him about how daft an idea 'care in the community' is when it is presented as closing community district hospitals while providing piss-poor-with-a-trendy-name services such as polyclinics, community matrons, and emergency care practitioners.

"A polyclinic is to be built just two miles from the hospital which will replicate a lot of what the hospital does from minor surgery to diagnostics.

The argument that this is "care in the community" makes no sense to me. Surely the hospital is in the community, in fact at the heart of the community.

There just doesn't seem to be any overall planning. It is being done on the hoof.

It would also save a great deal of expense if every move was made against a well thought through overall plan."

Dream on, Gerry. But don't worry about the policlinic - it too will get it's comeuppance. A couple of years after it opens, after huge effort and upheaval, and after the local hospital has been downgraded to a minor injuries unit, the Next Big Thing will come along and the policlinic will be shut down too.

There really is nothing like wanking while Rome combusts, eh?

The Southcall Case

Hot Potato! Hot potato!

Well, the after effects of Southall case continue. There is a somewhat mixed picture in the press, both pro and anti Southall so far. The appeal is awaited with great interest.

Nigel Speight in the Observer- supporting Southall and saying decision is bad for children.

Minette Marin on “deformation professionelle” When all you have is a hammer, everything looks like a nail. Basically sees Southall as misguided, and as having become mono-focused over time so that everything looks like child abuse. I sense her analysis is very sensible.

Cassandra Jardine in the Sunday Telegraph

I think key point of this case comes down to the balance between factual and expert evidence. In many of the cases the factual evidence available (Post mortem, video, medical records and measurements, notes) did not provide evidence of harm. There may have been suspicion of parents harming the children, but this must go unspoken if the evidence is not present to back it up. The presumption of innocence is too strong.

False, or unfounded, accusations of “The parents did it” are dangerous, especially when the defence team ask “how do you know this?” “What facts do you have to support this accusation?” No amount of “expertise” can work if the basic facts are not established. (And in this context the failings in the pathology evidence in the Sally Clark case were dreadful. If the pathologist cannot get things straight, then only a crooked case can go forward.)

Southall’s biggest failing may have been not to start backwards (from how he would answer barristers in court) And also apparently not to consider the question, “I pray you, consider you might be wrong.” He appeared to know more than actually he could have known.

Medicine as a profession is eminently not philosophical. Too few doctors are fully aware of their personal and collective epistemology, and therefore struggle to answer the questions "How do you know that?" and "how do you know that you know that?"

The barristers and judges who seem to have allowed Southall’s expertise to trump the analysis of basic forensic facts need to think about their part in this story. The fact barristers have not gone back to the basics “How do you know this?” and “On what basis?” questions shows a lamentable lack of curiosity.

Having read the GMC transcript I think the appeal hearing may be very interesting, and quite difficult to overturn on appeal. However both sides will have good barristers and the argument will get more interesting still.

(The Dr Rant team reserves the right to kind an open mind on this issue and will not be harangued by either camp who patently do not have open minds, and no you can't have OUR GMC numbers - Ed.)

On summarising notes

At the Ranting House surgery we have embarked on a plan to get all the patients summarised into a more usable form. Now we have got a summariser in to most of the work.

But Dr Rant and his partners have agreed to shoulder one part of the project. They are summarising all the fat file (Often 2 or 3 full files) patients themselves. That’s because these patients take up so much time and would delay the summariser and stop him getting up any flow at all.

Now these fat file patients are a challenge. They are an example of the 80/20 rule in action, and they are the top consumers of medical services in our practice.

When you spend an hour summarising their notes you start to realise certain patterns about these fat file patients.

Firstly some fat file patients have long term illnesses that guarantee the need for a lot of fully justified medical correspondence and treatment. These patients are medically complex and have significant chronic diseases. So for example we have patients with rheumatoid arthritis with complications, chronic renal failure/dialysis/transplantation scenarios, long term effects of congenital heart disease, cystic fibrosis. These patients cannot avoid having large medical records- they have needed a lot of medicine. You learn a lot of medicine just reading their notes.

And then there are others. I can usually summarise these down from 300,000 words of medical verbiage into 3 word summaries such as “useless fat lump”, “manipulative moaning minnie”, “feckless, futile and fecund”, “painful persistent problem”, “histrionic helpless harpy” and similar. “Candidate for RADA” used to be a medical code but we’re not allowed to use such phrases any more. It might upset the Guardian reading teachers (GRT) and funny looking kids (FLK) too much.


When you stare into the abyss of chronic polysymptomatic bio-socio-psycho-sexual-relationship-dysthmia-acopia dysfunction for too long it begins to stare back into you. And what I realised summarising these very thick sets of notes is that:-

1. The patient is the one with the disease and I’m glad it’s not me
2. I’m glad these patients are not related to me
3. I couldn’t stand to be married to any of them
4. The symptoms presented were mostly not the problem
5. The patient rarely wanted the true problem to come out
6. Or to do anything about it.
7. How little actual medicine (pathology) was ever diagnosed
8. How little purpose these people’s lives had ever had
9. How much psychological and social stress is turned into medical symptomatology (both by some patients, and by many doctors)
10. How as much help avoidance as help seeking behaviour was often happening simultaneously

These folk would play at getting their symptoms treated. They’d come demanding referrals to local hospitals, far away hospitals, famous centres of excellence. And then they’d want counselling, or cognitive behavioural therapy. Or they’d want yet another opinion. Or shift to a different speciality.

And having demanded the 94th opinion they might or might not bother attending the appointment. All the characteristics of self-sabotage and effective ineffectiveness were in action. Oh and jobs were lost, reports written to employers, benefits forms completed and so forth.

In surgery I mostly manage to stay polite to these patients, although I try and avoid them as far as possible.

But when you review their cases from one step removed you realise how much time, energy and resource (your tax pounds) these patients have sucked out of the NHS and not for medical need.

As a rule Dr Rant has a low tolerance for those people who he feels have a severe case of plumbum oscillans or who are otherwise breaking the rules of the sick role. And he tries to obey the Hippocratic dictum to “First, Do no harm” and these patients give him endless opportunities to break this rule. It’s hard to avoid doing harm when a patient wants every test under sun done before she’ll believe it’s not cancer. And then wants them repeating in six months time, just to make sure…again.

And he gets frustrated when he realises his colleagues have done them all again!

Fortunately there are not too many of these patients per GP (and we rarely take them off our list as we know our neighbour down the road could simply offload one of his similar ones on to us). However collectively these patients are a huge drain on the NHS for very little demonstrable medical need.

As Moliere put it, “Ils n’ont pas le malade, Ils n’y a que malade”
(They don’t have an illness, they’re just ill)

The fat file patient is a symbol of something gone wrong, and I don’t know anyone who has an answer to the problem.

Suggestions welcome.

And in the meantime at least summarising the notes gets the bones of the story clearer, and should make it easier to spot patterns as they are played out for the 94th time.

Justice: GMC style

So, Professor David Southall has finally been struck off by the GMC.

Those that have been following the case will realise that it has aroused strong opinions both for and against the leading paediatrician, and there seems to be little middle ground. However, Dr Rant has tried to take a step back and differentiate the forest from the tall leafy things covered in bark.

The most obvious result of this is a further set back for child protection in the UK, and a weakening of the string suspending the sword of Damocles above the heads of the dwindling number of doctors working in this field. It also happens to a controversial, but hugely necessary and important field that is effectively still in it's infancy. Without Southall and Meadow, it has lost the opportunity to learn from mistakes that have been made.

Let's face it. Southall may have been wrong on occasion, and also rash. However, the only people who would deny that he was wrong all of the time are the disturbingly numerous lunatics who refuse to accept that child abuse ever occurs.

What disturbs Dr Rant and other doctors is the manner in which the GMC dealt with the case. Have a listen to David Southall being interviewed by John Humphreys this morning (click here). It would appear that he was removed from the medical register by a panel of 5 people. In the Western world, a trial by a jury of ones peers seems to have been adopted as 'quite a good idea'. However, the GMC haven't quite managed to 'get with program it' would seem, and due to political pressure, now think that 'protecting the public' is less Jurisprudence and more Jeremy Kyle.

A 'jury of ones peers' means you are judged by your equals i.e. people who are able to understand the issues and frame the case through their own experience and expertise. What did David Southall get?

David Southall: Professor of Paediatrics with year of experience. A leader in the new discipline of forensic paediatrics.

The Panel: Chaired by 'Dr' Jacqueline Mitton an astonomer and author of books for children. An orthopaedic surgeon and 3 'lay people'.

In summary, a stargazer, an orthopod and three 'disgusted of Tunbridge Wells'.

So in response to unfounded innuendo that that the GMC was 'matey' and that 'doctors looked after their own', it was NuLaboured to become the opposite extreme - a media driven witch hunting club for self appointed busy bodies. I don't think that requires any further exploration really does it?

How does this serve either the interest of justice or the protection of the public? It certainly doesn't serve the interests of vulnerable children.

Break out the tar and feathers boys - we got ourselves a lynchin!

Healing the binds that tie us. Part two: Examples

Following on from part one Dr Rant thought he’d have some fun with readers by describing various double binds that he has encountered in his long and illustrious medical career. He's sure readers will recognise the game and supply others from their experiences and fields of work.

Here they are:-

“You will be a self-motivated student……but we will say in just what direction your motivation should go.”

“We value your opinion very much indeed, especially after we have told just what it should be.”

“You must make care of the patient your first concern…..but not if we cannot afford to pay for it!”

“This is a high trust system……..we trust our bombproof audit trail to tell us exactly what you’ve all been up to.”

“We believe that GPs carry out excellent work….but we’re putting the money into NHS direct, walk in centres etc.”

“You must reduce the levels of cardiac risk found in your patients…but you mustn’t exceed the drugs budget with all those expensive extra statins you lot seem so keen on prescribing.”

“Whenever we praise GPs ……..there will always be a sting in the tail”
(Timeo Danaos, et dona ferentes!)

“We want to reduce the burden of GP paperwork. To help us document the success of this scheme please fill in this comprehensive form every month to update us on the progress of our initiative.”

“We will teach you great consultation skills…..and then launch you into a world of extras, hassles and interruptions where the only good GP is a quick one.”

“Explore the patient’s ideas, concern and expectations fully…….within eight minutes."

“We care about your problems deeply……there have I shown enough empathy now?”

“You must be reassuring……whilst explaining that running risks akin to those of a kamikaze fighter pilot is not really entirely healthy!”

“You must not admit too many patients to hospital…….but if you ever once get the decision wrong we’ll direct all the medico-legal flack straight at you.”

“You must be reassuring….without being paternalistic. But if your father was a reassuring figure in your life you can borrow just a teeny-weeny bit of his paternalism.”

“You must counsel the patient in an unbiased way about the risks of a procedure…