The government's response to the EWTD petition

The government have just published their response to the petition asking them to allow surgeons to work more than 48 hours a week.

It's a pack of lies, and here's why:

The European Working Time Directive (EWTD) is health and safety legislation introduced in 1998. It will benefit patient safety

Will it? As the president of the Royal College of Surgeons has already pointed out, this is legislation "mainly concerned with the health and safety of manual workers. It was designed to protect Spanish lorry drivers or labourers working heavy machinery." I'll come back to the evidence on patient safety shortly, but fundamentally what we have here is some office-based staff in Whitehall, who have never looked after a patient in their lives, trying to tell surgeons across the country how they can best be trained to do operations the Whitehall mandarins have not the first idea about.

In addition, this completely fails to address the fact that there are huge gaps in the rota. There are not enough surgeons in the UK to have safe numbers of surgeons on duty if they can only work 48 hours a week. That is unsafe.

and the wellbeing of those healthcare professionals who treat and care for them.

Those selfsame healthcare professionals are adults. They are perfectly capable of deciding how their wellbeing is best safeguarded without your ill-informed opinion on it. Over 80% of a survey of over 1,000 surgeons in training recently supported a complete opt-out from EWTD.

By complying with the EWTD average 48-hour working week averaged over 26 weeks, we can ensure we have well-rested doctors who make good use of their training time and provide high-quality care for their patients.

Ah, the insinuation that the problem is just that doctors aren't making good use of their training time! Lovely. Also, I can vouch for the words of John Black: "Do not believe the Department of Health propaganda that under the EWTD doctors will be less tired. They will be more tired than when they worked apparently longer hours but had space to think, pause, rest and talk to colleagues."

No one wants or deserves to be treated by a tired doctor who may make mistakes.

There is certainly a cutoff in terms of hours at which mistakes become more likely. However, this implies that reducing hours to 48 on average means mistakes are impossible - which is of course nonsense. It also misses the point - the EWTD does not limit you to 48 hours in a given week. My last rota meant I worked one day on call a week plus 1 in 4 weekends, so that over a two-week period when I was working a weekend I would on paper work 9 to 5 monday, tuesday, and thursday, 9 to 10 on wednesday, friday, saturday and sunday, and then 9 to 5 all days in the second week except wednesday when I'd again do 9 till 10. So in the first of those weeks I worked 76 hours, and in the second 45. The average is worked out over four months, so you can and will do far more than 48 hours in a given week. The number has been plucked from the air, not as this implies based on any evidence doctors are more prone to mistakes.

Implementation of the Directive means that all NHS staff can enjoy a sensible work-life balance.

The survey I've already mentioned found that 71% of doctors reported that the reduction in working hours had not led to an improvement in their work life balance.

Junior doctors in training are the only group within the NHS whose working hours are not yet fully compliant with the EWTD. There have been reductions in maximum average hours to 58 hours in 2004, to 56 hours in 2007 and finally to 48 hours by 1 August 2009.

Meaningless, and misleading - consultants (who are the only group excluded from the above claim, I presume, as registrars certainly do more than 48 hours a week at present) regularly do additional private work on top of their NHS commitments, and again they are not less safe for it - quite the reverse.

NHS North West is demonstrating that EWTD compliance can be achieved consistent with the provision of effective services and training. By October 2008, about 95 per cent of doctors in the North West and 36 out of 38 organisations were compliant, a year ahead of the 2009 requirement. Most UK doctors in training already comply with the EWTD, and the overwhelming majority will do so by 1 August this year.

NHS North West? They must be brilliant - what Trusts can I go to there to take advantage of this terrific compliance rate? Oh - Mid Staffordshire NHS Trust, you say? Could this be the same Trust of which the DoH website recently wrote "It was a catalogue of appalling management and failures at every level for which the Secretary of State apologised on behalf of the Government and the NHS in his statement to the House the next day"? Er, yes. In addition, there is evidence those compliant figures are falsified because 10% of respondents say pressure was put on them falsely to under-report their hours.

We recognise that EWTD has meant challenges. We have listened to and acted upon concerns raised, for example through many surveys, conducted at different times. We appointed Dr Wendy Reid from the London Deanery as national EWTD Clinical Advisor. We have also established a EWTD Reference Group co-chaired by Dr Judith Hulf, President of the Royal College of Anaesthetists, and Professor Patricia Hamilton, Director of Medical Education at the Department of Health. The Reference Group includes the British Medical Association (BMA), the Royal Colleges, Strategic Health Authorities (SHAs) and the Deaneries. In addition, there is a task and finish and steering group.

Yes - but just as with MTAS, you have made these appointments token by ignoring their advice at every turn. Just appointing people doesn't solve problems - you have to act on what they say.

I now skip a lot more boring guff.

The NHS Workforce Census issued in 2009 highlighted significant increases in consultants and doctors in training. There are 34,910 consultants, which shows an increase of 3.7 per cent on the previous year and represents a 56.4 per cent increase over ten years. The overall number of doctors in training is 49,178, an increase of 5.1 per cent from last year and 59.4 per cent compared with ten years ago. There are more doctors than ever working in the NHS.

Of course there are - you've slashed the number of hours they're permitted to work, so more of them are needed. That's GCSE maths, not an indictment of your flawed policy change. The issue which this petition raised was over the quality of those doctors, not their numbers. In addition, there is already evidence that our training is suffering as a direct result of service reorganisations.

The Government has also provided funding by including £110million in allocations to Primary Care Trusts in England in 2008/09 to help support NHS compliance with the EWTD. This has been increased to £310million for 2009/10 and includes £50million to support changes needed for specialties such as paediatrics, obstetrics and anaesthetics.

And the old "we've spent money, look, it must be all right" card.

Finally, the Health Select Committee’s report on patient safety said, of EWTD and the Working Time Directive rules, that the Committee was not convinced by the more alarmist claims being made that these will seriously jeopardise patient safety when they are introduced on 1 August. The Committee consulted with a wide range of stakeholders in coming to its conclusions.

But you didn't look at the evidence, which all shows that you need to be working old-school hundred-hour-plus weeks for errors actually to increase. Instead, you cobbled together a study of 19 doctors in Warwick where you had to count patients falling over as 'errors' to get a significant result.

It's pathetic, and the sooner we get rid of this shower the better.

Complaints

Shortly after noon today I walked past a group of people who were milling around in a corridor asking one another questions in the confused way that those who are lost in hospitals share with particularly slow labradors which are confronted by a glass door they keep walking into.

As I'm prone to do in such situations, I asked if they were lost.

"Yeah", said one, "The thing is - y'know that hand gel you put on to clean your hands?"

I nodded, wondering for a moment if they were after a boxfull to sell to the winos - don't laugh, it honestly happens.

"The things is, I was putting some on and it got on my top, and it's burnt my top."

I stood watching her a moment in incomprehension, probably looking not unlike a confused labrador myself, although it was true she had a small darker area of green about the size of a 50p piece on her XXL fuschia pink top.

"I'm looking for somewhere to complain. It's a brand new top."

I directed her to the general office, which alas she'd just come from, so I said I was sorry, but I didn't know, and left them to it.

It seems incredible to me that we live in a society in which people come into hospital and, in the process of using something designed to protect them and their nearest and dearest from seriously nasty illnesses (infection control is mostly a total crock, but there's no doubt that handwashing works), manage (a) to get it down their fronts and (b) to think this then gives them a right to complain to the hospital. Where's the sense of perspective? Where is the sense that they shouldn't be wasting people's time with a small stain to a T-shirt?

Perhaps bibs are the answer?

Where are the whistleblowers?

They're all down the dole office. This is what happens if you speak out in the NHS - that, and then a DoH idiot or junior government sleaze will go on telly and brazenly lie through their teeth about whatever atrocity their policies have produced...

Sorry: it is late and I am slightly sleep-deprived.

Hiving things off, or where the India posts have gone

None of you will have noticed, but I've moved my 2006 India missives off to their own separate blog; I felt they made more sense there. They're linked from the top left and doubtless in many other ways if you are interested in re-reading them. Others, particularly Toulouse, may follow if I continue to fail to go to bed.

"Central government strategically enabling and catalysing better services"

The internet disgust for the hypocrisy of a government which can continue to trumpet that "central government [is] strategically enabling and catalysing better services" despite the death toll in Staffordshire General Hospital is mounting. While internet disgust is, per my last post and more to the point David Mitchell's recent blog, a dangerous thing to take seriously at the best of times, the criticism has been surprisingly restrained given that death toll. I'd encourage you to read:

The Ferret Fancier: 'Individual management failures', where he outlines the absurdity of Gordon Brown saying that no reasonable person would deny A&E admissions should be seen within four hours in a week when that precise policy has been shown to kill by obliging Trusts (very intentionally plural) to prioritise the meeting of targets over everything else including patient care in order to get funding.

Dr. Grumble: Mid Staffs Investigation, which links a channel 4 news story and observes that junior doctors were pressurised into taking decisions they knew to be wrong to meet targets.

NHS Blog Doctor: It couldn't happen in Britain: Staffordshire General Hospital, which links the "dirty tricks" campaign used against Rita Pal, who tried to blow the whistle on Midlands hospitals several years ago, to the absence of doctors as whistleblowers

The Witch Doctor: A letter to Mr Brown, Mr Johnson, and Mr Bradshaw, which suggests that despite all the jargon (and although I am again criticising the government and civil servants, God Bless the Local Government Association, at least for today) and management-speak the government and the DoH are producing about leadership and "Leading Beyond Authority", part of the problem in Staffs and generally is that the real leaders in the NHS are being overlooked.

Angus Dei: NHS: Mid Staffordshire NHS Trust: The Killing Fields, observes that Monitor, the body set up by the government at a cost of millions to provide effective regulation of NHS Trusts and better patient care took the decision to award Staffs Foundation Trust status while all this was going on, and observes that this makes them look like a colossal waste of money. He also notes that the Healthcare Commission didn't pick up on any of these problems in their annual healthcheck (that channel 4 news story linked to from Dr. Grumble's post suggests it was an independent medical statistics group in London who highlighted the problem).

The Jobbing Doctor: All together, points out that the supposed figureheads of our profession, the senior figures who have chosen to case their lot in with the government and to support their reforms, have been in post for a decade, and must take some responsibility for permitting the system to be put in place which caused these deaths.

All I have to add is that - as with the MMR scare - the media are part of the problem here: we as a society must learn that beating up on people who are working under conditions outside their control (doctors and managers both) will not solve the problem. These situations arise because the government has set up a system whereby meeting pointless targets is rewarded financially, and conversely if doctors do what they are trained to do, that is treating patients according to the degree of their clinical need, their Trust misses targets and gets its funding cut. Let us be completely clear: the managers are not to blame. The managers do not create the rules of the game - they are employed to meet these targets, and even at Staffordshire they did it well. The government rewarded them for their behaviour. The system put in place rewarded them for meeting their targets, and indeed by the standards the Department of Health has chosen to judge Trusts by, they still are an excellent Trust. The inevitable stripping of their Foundation Status will not change that fact, and while it is probably the right thing to do, all it does in reality is to give them less money to address the problems with.

There is no point trying to demonise the managers (I disagree with Angus Dei here) nor the hospital - that is scapegoating. The system is at fault here, and it must be changed, as indeed must the soi-disant political (Brown, Johnson, Bradshaw) and medical (Donaldson, Carol Black, Paice, Needham) 'leaders' responsible for the state of our health service. Until they and the targets are changed, we - you - are part of a society that continues to incentivise seeing people within four hours because it wins votes over keeping them alive.

Mind you, it is an old political truism that the dead cannot vote, so perhaps the government are just playing the system they are part of perversely well...

Choose and Book is rubbish

A week or so ago a young woman came in to hospital with cholecystitis. It isn't serious, but for most people you wind up removing the gall bladder to stop it happening again. However, you don't do this acutely unless you have to because the complication rates increase by a third (as the gall bladder tends to be harder to separate from the liver when inflamed) - so you let it settle down and bring them back to have it done.

This particular young woman was one of the unfortunate people who, while waiting for her operation, had had another attack and so had come in to see us. From talking to her it sounded like the first one had been diagnosed and treated by her GP, so well done him or her, and she'd been booked to have the gall bladder taken out.

She was obviously keen to have it done sooner given that she'd had the repeat episode, but was happy once we explained the reasons we tried not to do that. I did say I'd try to bring her date forward if possible, but ran into problems - I couldn't find any record of the operation with the secretaries. I went back to ask her about this, and it turned out this was because she wasn't booked with us, but at Other Hospital half an hour down the road. I asked if she'd rather have the op done there, and she said no, we were more convenient.

This begged the question - why had she been booked there to start with? The answer, inevitably, was Department of Health stupidity, specifically the diabolical Choose and Book. She'd been booked through that because the government now makes GPs use it if they want to hit their targets and get paid, and the quickest appointment had been at Other Hospital. So even though that meant her travelling three times as long to get to hospital, and being operated on somewhere they didn't know her (because acutely she comes in to her local hospital, us, when she's sick), it lets the government say people are treated faster!

I booked her with us and cancelled the Other Hospital appointment.

Rating doctors and the "enormous democratising power of information"

While his partner in crime has been dancing his way to glory (genuine glory) for Comic Relief, David Mitchell has been commenting on the Supreme Leader's plans to make public services more transparent.

To my mind, Mitchell hits the nail pretty much on the head:
"He's invoking the collective wisdom of the nation to pass judgment on and improve our public services. Unfortunately, he'll mainly attract the same self-selecting bunch of inexplicably livid weirdos who infect the comment sections on all websites."

He goes on to discuss a comment on his own work which was censored as it ended with the words "you fat cunt", and observes:
"So if I, as someone whose work doesn't really affect people's lives, am subjected to this online abuse, what are GPs, nurses, consultants, police and teachers in for? They're obliged to tell people things that they don't want to hear: to arrest them, give them homework, make them stop eating fried breakfasts, announce that their gran died on the table."

Which is all pretty much spot on. The only reasons I am reposting what he said here are that (a) he is exponentially funnier than me and (b) he neglects to comment on the actual pronouncement Gordon Brown came up with. The BBC report on it is titled "EBay-style feedback for services". This raises a couple of questions.

Firstly, how will doctors, or postmen, or teachers, be able to feedback on their "customers"? As more profane bloggers than I have observed, we can hardly respond to a potential "one-way torrent of cyber-vitriol from semi anonymous heartsinks" by observing that "Mrs Lardbucket is a malingering, workshy waste-of-space, who manages to lower the quality of life of everyone at the practice when she drags her trivial, hypochondriacal existence into our threshold." The point is a serious one, and was also made by David Mitchell: there are people who will not want to hear what we have to say, or who will not listen, or who will blame us when things go wrong. The best doctors, arguably, are the ones who do this routinely, who tackle the patients whose default mode of engagement with the medical profession is to come in to see someone and then to ignore or argue with what they say. This system will punish those doctors with poorer ratings even though they are doing more difficult jobs.

Secondly, do we have "customers" in the same way that an ebay vendor does? Ebay introduced its feedback system because they are a peer-to-peer transaction site, and you are buying from someone you have never met who could, frankly, be taking you for a ride. Fraud has always been a problem on the site. Is Gordon now deciding that the default position of patients needing medical attention should be that doctors are all frauds who are looking to take their money in exchange for nothing? The model is difficult given that, er, we don't take any money from them and have nothing to gain from misleading them - unlike the ebay fraudsters who made 300,000 smackers conning people out of money for non-existent goods.

In addition, there is already a rather good "feedback" mechanism in place. If you don't like your NHS doctor, you can go and see a different one. For free. Without spending any money at all. In some cases this requires that you negotiate that bastion of Department of Health stupidity, "Choose and Book", but you can already vote with your feet. (So oblivious are the government to this simple fact that they actually reward unpopular GPs as things stand - if you have available slots, so that patients can see you the same day, for example, you are deemed better than the person in the next consulting room who is booked up until thursday. Never mind the fact that the person who is booked up is booked up because patients prefer to wait to see them than to see the crap partner - that doesn't let the government trumpet that you can now see a GP within 24h, so it must be rubbish!)

If you can bear it, read the document in which Brown lays out this wholesale stupidity. There is no rationale for it - just a lot of patting-self-on-back coupled with cross-promotion of several other of the DoH's lunatic policies, including polyclinics, dressed up here as "health centres" and offering "a nurse-led minor illness service". This is wonderful given the success of dumbing-down medical treatment in A&E at the Mid Staffordshire NHS trust, where prioritising was often done by totally untrained staff thanks to budget cuts: I wonder if these will kill as many patients? There's also a bit of stating the obvious (it turns out we have an aging population - why did no one tell me?). My favourite bit, though, is this:
"The NHS, having turned 60, is therefore embarking on a further major stage of improvement set out in the Government’s Next Stage Review of the NHS, driven primarily by empowered patients and front-line staff working together to improve health, with central government strategically enabling and catalysing better services." I cannot think of a single service which central government 'enabling' has improved at all, unless some DoH oaf thinks "catalyse" means the same as "cripple".

It also suggests "Self-Directed Support and Personal Budgets" are a good idea, paving the way for capping state-funded medical provision, congratulates itself because two-thirds of GP surgeries are now open in the evenings when it is this government that gave GPs the too-good-to-believe offer of opting out of providing 24-hour care in exchange for six grand less a year. Most despicably of all, it has the gall to say that "Government will publish information about public services in ways that are easy to find,easy to use, and easy to re-use, and will unlock data, where appropriate, through the work of the Office of Public Sector Information." On Sunday some such information was released by the House of Commons' Health Committee. It showed that the gap between rich and poor had widened over the past decade despite ministers throwing money at the problem. In this case a DoH spokesman said "Our health inequalities programme is backed by a wide evidence base and an independent scientific group. Major programmes - such as Sure Start, and efforts to tackle obesity - are based on research and are being evaluated." This is indicative of the government's response to any policy criticism, which is to ignore their own data - as in this case where it is "based on a wide evidence base" and "being evaluated", ignoring the fact that there is data right now that it isn't working - and to repeat that they've spent a lot of money as if this is somehow a good thing when it's being wasted. As an aside there is an interesting-looking book out suggesting that it is precisely this gap which is at the root of most societal problems.

So the document is loathsome, meaningless, and fails within its own pages to do what it claims to be setting it to - so it is also hypocritical. No great surprises there. But this rating idea is wholesale stupidity, and ignores the glaring differences between feeding back on commercial transactions and healthcare ones, ignores the inequity of a system allowing anonymous feedback without the right of reply or any independent verification, it undermines the bond of trust that doctors work very hard to create with our patients (further proof that Ara Darzi's comment that we need to "separate that fantastic relationship between the doctor and the patient" was not a 'mis-speak'), and worst of all suggests that what is right for you is right for me. If you like your GP, excellent, but I may not - interpersonal relationships are like that. Some people love doctors who tell them what they should do, others hate them. Some people want a no-nonsense approach to sorting out specific problems, others just want a chat. The great thing about the healthcare service at the moment is that all these people exist, and if you go to see your doctor and don't like him or her you just go and see someone else: you aren't committing any money to the process as you are if you're buying a pair of shoes off ebay.

Once again, central policy is being driven by people without any understanding of what it means to develop a relationship with your patients and to earn their trust, and for that reason alone it should be canned now.

Maternity in a spin

So it appears that the NHS is struggling to meet demand from expectant mothers, with almost half of trusts surveyed by the Tories reporting having had to shut their birth units at least once last year. That's not necessarily worrying in and of itself, except that the number is rising compared to 2007, and there obviously comes a point where you can't divert a mother in labour to a different hospital to give birth because the next hospital along has also run out of beds. My experience is that we aren't at that point yet, but it is nonetheless a worrying trend.

More to the point, the DoH response to it is revealing. They trumpet "we are also investing more money in maternity care than ever before" and talk about the number of midwives they'll be recruiting. There are two key things they don't tell you:
(1) What the money is being spent on
(2) That they are simultaneously reducing the number of hospitals with doctors present in the maternity unit
In 2007, the government's "children and maternity tsar" announced plans to close maternity units locally in favour of regional centres. She called them "super-centres", but that's a meaningless puff-phrase which I refuse to apply, particularly when part of the package is "more support for home births[...]to give women greater choice". To deal with that last point first: home births are dangerous. They have repeatedly been shown to be dangerous. They are dangerous for simple, easily-explained reasons: if something goes wrong in pregnancy - which is admittedly and thankfully rare - typically the foetus dies within 5 minutes (placental abruption and cord problems are two examples). If you are in hospital, that can be dealt with urgently - but only if there's a doctor present to do a C-section. Most women do not live within five minutes of a hospital, so most women who suffer serious complications during a home birth will lose the baby. Medically, therefore, this is a dangerous option and one which we should not be offering - but politically, it's brilliant. Why? Because you can dress up something which costs less money as "patient choice", and you can pretend you're enabling individuals to take decisions about their own care while at the same time costing the NHS less money. If it weren't for the fact it endangers the lives of mothers and babies both, it would be perfect.

There's also the recurrent theme of the dangers of the European Working Time Directive here - the tsar, Dr. Shribman, comments "EU restrictions on working hours meant specialist services could not be safely provided in every local hospital". The obvious solution, therefore, would be to opt-out of the EWTD in the interests of patient safety (as an aside, the surgeons feel the same way) - but no, instead the solution is to dress up what are simply cuts to services as "networks of care" and "integration of services".

The first point is important too - where is all this money that the DoH claims is being invested in maternity services going if we're having to cut local services in hospital? Well, firstly it seems doubtful that what the DoH are saying is true given that there were early-day motions tabled in March last year expressing concern at cuts in the NHS budget to maternity care. That doesn't take specialist knowledge to find, incidentally - if you google "NHS maternity spending", it's item six on the list. So why did the journalist responsible for the article not quiz the DoH PR person on what exactly the numbers were and where the cash was going? And why was the damning report from the government's own health watchdog from the middle of last year not mentioned? Why was the author not aware of research showing that this promised money isn't reaching frontline maternity services because it hasn't been properly ring-fenced?

We're left with a situation where there is clear evidence of a service struggling to meet demand, with endemic ongoing problems, centrally-mandated cuts in local services, frontline staffing levels which are falling year-on-year, and data obtained under the Freedom of Information Act showing that government funding is not being spent on frontline staff. So why, then, are journalists letting the Department of Health get away with responding to these damning data by saying "but we're spending lots of money"?

Estuary towns

On the walk from the station to the hospital I'm currently at this morning I routinely pass groups of schoolchildren doing schoolchildren-y things: e.g. listing swearwords they know, smoking and showing off to one another.

Today was really special, though. At quarter to nine in the morning I passed three girls of 14 or 15, in school uniform, and as I passed one looked guilty and slung the can of white lightning they'd been swigging from onto the pavement.

Fucking white lightning! That's seven-point-five per cent of pre-school pre-alcoholism goodness.

A little voice in my head at that point said "welcome back to [name of awful town redacted]".

"Double-weakness"; and the proof of the pudding

It has just been announced that six trusts around the country have been rated "double-weak" by the Healthcare Commission, meaning that they have been judged weak on both "quality of service" and "use of resources".

One of these trusts is the Royal National Orthopaedic Hospital, Stanmore. Now, I am not an orthopod. I have never worked at RNOH. I have no particular desire to. However, I can tell you that if I had a bust cruciate, or a child with a bone cancer, or indeed anything else orthopaedic and I was able to get referred or to get my child referred to Stanmore, I bloody well would, and I know the majority of doctors I have worked with would feel exactly the same.

Stanmore does many different things. Perhaps the most emotive is the one I've already mentioned: it treats bone cancers in children. This is relevant not because it's emotive, but because it is important in understanding these ratings, which are based in part on patient surveys. Bone cancer in children is by and large a brutal diagnosis for the child and for the parents. They are frequently incredibly aggressive, crippling, and basically deeply nasty diagnoses to make and to have. To get an idea of how bad, check the blogger's friend Wikipedia, in particular the page on Osteosarcoma.

Stanmore runs a national service covering sarcoma. This means they get referred children from around the country who have developed cancers with have some of the worst survival rates of any childhood cancer, and they have to manage these children and their parents through surgery and follow-up treatment.

I wonder why their patient satisfaction ratings are lower than a trust that deals primarily with deranged and grateful elderly patients?

This sort of research will put people off going to Stanmore who absolutely should, and will mean they get treated at centres less able to deal with their problem. It is for that reason utterly contemptible. So if you're thinking of not going to RNOH because of this survey, ask your doctor first what they'd do, and then ask whether you want to be treated by someone who deals with your condition every day of the week, or someone who sees four a month.

The GMC are incompetent too

I have just received an e-mail from the General Medical Council regarding my Fitness to Practice application. In English, that's the checks they do to make sure I'm a fit and proper person to become a doctor in the UK.

The process seems simple enough: every final-year medical student in the country completes a questionnaire promising they've been good little boys and girls, and the GMC charges each of them one hundred and thirty-five pounds, in exchange for which it takes everyone at their word and lets them become doctors. Quite what the 135 quid goes on I'm not sure, but I'll be astonished if it is on any form of check beyond the one they pay whoever provides them with their champagne and smoked salmon.

The e-mail they've just sent reveals they aren't spending the money on IT either - they said:

I am writing further to your recent application for registration. In your application you completed a Fitness to Practise (FtP) declaration.

Unfortunately, due to a technical fault in our system, whereby we cannot confirm your answer to question 3 of the declaration, we need you to complete that part of it again. I regret the inconvenience this causes and am sorry to have to trouble you. However, I do require that you provide your answer to Question 3 again. The question is as follows:

‘Have you ever been issued with a penalty notice for disorder, or harassment notice, in the UK or another country?’

Please answer this question by replying to this email with the word ‘YES’ or ‘NO’. Please do not attempt to revise the original declaration that you completed online.

I presume that what this means is that whatever bunch of shysters they paid to build their online application system - which requires a username, password, pin, and the answer to a personal question just to get onto - has lost everyone's question 3.

At least, however, they haven't followed the government's lead and simply given everyone's answers to the general public.

Medical incompetence: the GMC join the party

I have just received an e-mail from the

GPs opening hours, or why Alan Johnson is a liar

So it seems dear old Alan Johnson has written to GPs asking them to bend over and accept the new pay deal he and his cronies have refused to negotiate with the BMA.

At this point it is worth noting the sheer gall of the oleaginous Ben Bradshaw when he says that he and his ilk have "a concern" that the BMA "don't really speak for the profession at large". He is of course quite right - but the profession at large feel like this because the BMA are led by folk who are far more interested in crawling up the arse of the nearest politician than in actually representing their membership, which gives you an idea of just how unreasonable the government must have been in their negotiations to get the spineless bastards at the BMA to stand up to them.

More galling yet, however, is that Alan has written in his little letter that, "significant numbers of patients consistently tell us that improving access to GP services should be a priority for the NHS".

Why is this galling? Well - because he's lying.

I know he's lying because his own poxy department paid MORI to survey the general public last year and found out that 84% of people were satisfied with opening hours at their current practice. And that no individual practice in the country - not a single one - had less than 60% satisfaction with opening hours.

So how exactly is he defining "significant numbers"?

I've thought about this, and I'm going to send a letter back to Alan Johnson myself, as another blogger has suggested he will, to say roughly the following:

Dear Alan,

Thank you for your kind letter. Unfortunately, significant numbers of voters consistently tell me, and indeed the pollsters, that improving access to Westminster for someone other than you should be a priority for the government. In light of this, perhaps you would be good enough to ask someone to explain the word "significant" to you before you come back bothering us again.

Yours most sincerely,
Nick.

Leslie Ash

Is loathsome. That is all - carry on.

That said, a thought strikes me - could we, as taxpayers, ask a panel of experts how likely it was that it was her falling out of bed and hitting a table caused multiple injuries including a collapsed lung and a cracked rib as opposed, say, to pluck an example from the air, to her having been beaten up? And could we then find the person responsible and sue him for our five million quid back?

FY1 applications: Proofreading, Professionalism, and Fucktards

I have just logged in to the Foundation Application system. Before I can find out which tenth of the country I will be within next year, I had to fill in a questionnaire.

Bear in mind at this point, that this questionnaire will be viewed by every one of the doctors allocated to jobs by the system - every medical student in the country will see it. Bear in mind also that last year the rank incompetence of the unaccountable DoH imbeciles who set the system up shafted a generation of young doctors. Bear in mind therefore the importance of this year's system as a marker of improvement.

Then read the fourth and fifth questions on the questionnaire below.


I wonder what they meant to ask?

I wonder just how unprofessional, lazy, and shit at your job you must be not to bother proofreading something even once before it goes out to thousands of junior doctors around the country?

Why people are missing the point about Radiohead

Ok - In Rainbows. Biggest music news of the past pick-a-number-and-square-it years. The Death of the Music Industry (±as we know it). "A good move" (Joe Goddard of Hot Chip, who calls it this despite paying, er, nothing for the album himself). "Not like eggs" (Lily Allen, who also called it "arrogant". Given that she achieved her fame by writing good music and then, er, giving it away via myspace, this makes her "hypocritical".). "Kind of demeans music" (Nicky Wire of Manic Street Preachers, a band who should know about demeaning music per everything they've released since Everything Must Go). "Are you on fucking crack?" (Gene Simmons of Kiss, a man who almost certainly is or has at some point been on crack). "One-trick pony" (the splendidly-monikered Maynard James Keenan of Tool). "[bungee-jumping]" (the ever-quotable Courtney Love). "Genius" (Jay-Z).

Aren't musicians a great bunch? That's comedy gold right there, although irritatingly Rolling Stone's Lily Allen gag is much funnier than mine ("Little does Allen know, you do choose how to pay for eggs. You can use cash or credit, or checks if you have photo ID. We could discuss supply and demand and how bands make money off live shows and merch sales, but until Lily Allen can find us an egg that wrote “Paranoid Android,” we’re not even starting that fight.").

A lot of this misses the point, however: they understand how the digital age works. They understood it way back when they were one of the pioneers of viral advertising with Kid A (when their virals had a click-through rate of 153% versus the web-wide average of 5%). They understood it when they set up their own website independently of EMI, and ensured it was representative of them, and relevant; they embraced fansites like ateaseweb; they built an online brand reputation which was in keeping with their onstage band reputation (like that?). They ran with mp3s and napster early, and although I can't find it on teh internets, I'm keeping the lovely memory I have in my head of Thom Yorke calling Lars Ulrich of Metallica a tosser when they sued napster.

Radiohead didn't just tolerate bootlegging - they embraced it not just with the album, but with the whole recording process. Thom Yorke said in a recent NY Times interview, Pay What You Want For This Article, "The first time we ever did 'All I Need,' boom! It was up on YouTube. I think it's fantastic. The instant you finish something, you're really excited about it, you're really proud of it, you hope someone's heard it, and then, by God, they have. It's O.K. because it's on a phone or a video recorder. It's a bogus recording, but the spirit of the song is there, and that's good. At that stage that's all you need to worry about."

By contrast, their record label have just rush-released a 7-CD box set of all their albums so far, including online access to a stream of a live show from 2003! (And claimed Radiohead left after they wouldn't give them 10m quid despite the fact that they have since taken, er, not a penny from their new distributors for the record...) Whatever hip-hop-and-happening cat at EMI thought the box set up had the brilliant idea of including it on a USB key in the shape of the grinning bear! Apart from the obvious flaw in this plan (everyone already has all the albums. Why pay for them again, particularly when the files on that USB key are guaranteed to be copy-protected to fuck?), they've ruined the only appealing part of it - the live album. I would consider buying an official Radiohead live album. I would consider it even though I have 123 different albums, singles, or live shows by Radiohead in my mp3 collection (I didn't count - computers are good like that), and seven other live shows or parts thereof just from 2003.

What I won't pay for is temporary access to a stream of a live show. If you're going to include the album and I'm paying for it, you need to give it to me. Yes, I could record the audio feed from the live stream - but I don't want to do that. Not when you're asking me to pay £80 for it. That's the second problem, incidentally: the USB key is twice the price of the actual cds (£40), and the digital downloads are still £35. Why would I not just pay the extra fiver, get the cds, and spend half an hour ripping my own mp3s? Could they get the digital age any less? Why would I pay double for a USB key I am going to use precisely once, to transfer the files on it to my mp3 player? Mike Leonard, Managing Director at Parlophone, said "We are particularly excited about the USB stick, which gives fans an easy and portable way to carry the box set and provides another way of bridging the world between on-line and off-line content."

Two words, Mike. mp3 players? That's how people carry music around these days, and indeed for the past decade or so. Good luck with your second career.

Compare and contrast. I've just watched a high-quality webcast of Radiohead which they released at midnight on New Year's Eve. For free. I can't download it - yet. But I got the last one within a couple of weeks of it being broadcast, i.e. as soon as I looked for it. I recorded this one - slight jitter in the second song, but otherwise I now have session versions of every track off their latest album, free.

That's how they wrote the album - they debuted tracks as they went along. Reckoner used to be pretty much a stomp-along rawk song (e.g. on 23rd June 2001 in Washington - see what I've done there, EMI?); it has evolved into something containing the line "because / we separate / like ripples on a blank shore". The point isn't that the songs are unrecognisably different - the point is that the evolution of these tracks has always been a matter of public record if you happened to be hoarding radiohead mp3s in 2001. Radiohead have taken that on board and are using it to help them control their own music - they knew people would watch webcasts, they enjoyed doing them, and it gave them an audience which stayed in touch with them - and then bought the album direct from them without blinking. The model doesn't stop there - they've discussed releasing tracks as and when they're ready.

There's a second, more important point to this. Other artists have shafted the record industry before (Prince gave away his album on a newspaper magazine, for free, to publicise his 21-night residence at the London O2 arena), just not in a way you could do without being famous already. The assumption with Radiohead has been that they'll make their money touring and in merch sales. I'm not convinced by the former. Their merchandise is and always has been fabulous (especially the baby clothes). But the band hate the eco-footprint of touring - and they already have a route for getting tracks to people via the webcasts.

The big question for the music industry, then, shouldn't be "how can be blacken the names of the best band in the world?", it should be "how are they going to make money giving their live shows away?". Because history suggests they'll get it right.

I have ideas, but it's late (early 2008), so another time...

A change of direction: no more medicine on here

Yup. I think it's time to stop posting medical stuff on the blog (I will think of a new title in due course) - on reflection, despite all my it's-fine-none-of-it's-personally-identifiable bluster, from now on I think I'm going to vanish into the anonymous blogosphere when talking about the UK healthcare system.

Of course, this may simply be a cunning double-bluff to make you all think someone who turns out to bitching about the rank incompetence of the DoH and the government far more effectively than me is me. But it's not. Honest.

So next - a post about Radiohead!

Dumbing down

I know on occasion I can be harsh on my medical school, accusing them of allowing bitter, stupid failures far too much say in the design of the course.

Never let it be said, however, that they don't offer help when it's needed. Next week we have to present a poster of our elective experiences; I plan mine to be as provocative as possible. The guidelines on this thing are already lengthy and shambolic - but we all got an e-mail this afternoon which included instructions on how to hang them, and best of all, this:

I'm just not sure I can add much of value to this, except to comment that it takes a very special person indeed to assume people about to present posters on their experiences acting as doctors in the third world might need help on where to stick the fasteners, including that they should go on the, er, back of the poster.

Sweet Jesus.

Festive update: Christmas songs

I got the form to work.

It was so bad they should have made the deadline halloween. The worst thing about it isn't even how bad it is at selecting decent junior doctors: the worst thing about it is that it takes what are incredibly important attributes in a doctor - integrity, reflecting on your own practice, teamwork, dedication, empathy, critical ability - and turns them into a revolting mark-grubbing, box-ticking exercise. It makes you a worse doctor and a worse person to try to take examples from your experience, which are complex in the way that anything involving people tend to be, and to turn these delicate, affecting, complex, nuanced events, which demand an understanding of their context in every sense of the word, and then to strip out everything which makes them important in favour of cramming as many bullshit buzzwords as possible into 150 words.

Or, to put it more simply, if you set questions like: "Describe one example of a recent clinical situation where you demonstrated appropriate professional behaviour. What did you do and what have you learned? How will you apply this to foundation training?" and then give people 150 words, you do select people who are good at something. That thing is called being a sociopath.

Anyway, by way of lightening the tone, here are some Christmas records which I find myself wanting to listen to in June as well as throughout the festive period, with the annual blight that is Cliff Richard returning to the airwaves...

- Low, Christmas EP. Highpoint: Just Like Christmas
- Sufjan Stevens, Songs for Christmas LP. Highpoint (tied): That Was The Worst Christmas Ever! / Star of Wonder
- Tom Waits, Christmas Card from a Hooker in Minneapolis - on Blue Valentine. Highpoint: "but someone stole my record player, now how'd you like that?"
- Manic Street Preachers, Last Christmas (live) - on Lipstick Traces. Highpoint: it isn't George Michael singing.
- Arab Strap, Christmas (baby, please come home). Highpoint: Aidan Moffat's voice. It's very festive.
- Christina Aguilera, Have yourself a merry little Christmas. Highpoint: let's face it, she can sing. And this works.
- Porn Orchard, This Holiday Season. Highpoint (apart from the *flawless* impersonation of Tom Waits and Peter Murphy): the couplet "the hooker in my bed is ugly and fat"
- Eels, Everything's gonna be cool this Christmas (live) - on Electro-Shock Blues show. Highpoint: sod new year, Christmas is a good time to be optimistic. And this rocks.
- George and Antony, Happy Christmas, War is Over - on Help: A Day In The Life. Highpoint: Antony manages the switch to the titular "war is over" line simply perfectly, and the song's just as optimistic in a different way to the Eels track.

Welcome to December. Good luck with the shopping.

MTAS II: Foundation Job Applications

It being almost Halloween, it's appropriate that the spectre of having to register to apply for jobs as a Proper Doctor next year has loomed up in front of every medical student in the country (except the bastards with academic jobs) like an unholy battle against terrifyingly inept organisers, hideous wannabe-yuppie-executive questions ("Tell me about a time when you...", and nightmarish technology.

For instance, the terms and conditions you have to accept to register (and, by extension, to have a job in August next year if you're a UK medical student) opens with this Disclaimer:

"While the Department intends this site to be continuously available, virus free, and to contain accurate information, the Department does not guarantee that it will. The Department and its contractors accept no liability for any consequences arising from inaccuracies, viruses, the unavailability of the site, misuse of the site, or any User's inability to access or use the site."

Summary: if we fuck up, it isn't our fault.

They might as well have written: "last time we made a horrendous, amateurish mess of the whole thing. If we do that again, you can't blame us for it, because you checked the box, you checked the box, nya-a-a-ah."

I checked the box, and tried to register using an eight-character password containing both digits and punctuation.

"Your password has to be at least nine characters."

I wonder if anyone fell for that. "Hey! They made it more secure - your password has to be longer!"

I changed my password and registered.

Then I waited for the e-mail with my authentication code in, and clicked the link to authenticate my account. It worked first time! - so I closed the window it had opened, and tried the "My application" link on the left hand side. The result is below.



So at this point I have registered and authenticated my account. Now I need to enroll, too? Hey - this is the most secure system in the world! They really sorted out that MTAS fiasco, huh? Good on 'em!

Now, where do I enroll...

Oh.

There, um, isn't a link.

Wait! If I go all the way back to the "register" page (strange thing to do given that I've already registered, mind you), there's a link there! Hallelujah! Join me in celebrating by finding it in the picture below:


That took me to the next screen, which confused me.


Can you spot the deliberate mistake? HAL, as I had by now dubbed son-of-MTAS, is telling me I'm logged in as a guest! Damn! I must have not logged in, or some-

Hang on. If I'm logged in as a guest, how does HAL know my name?

Uh...guys? Making a system which doesn't let me authenticate my account - that's taking security-consciousness that bit too far? I mean, I see what you were thinking - if no one can get onto the system, that means it's guaranteed to be secure, right? And heaven knows I can see any number of Brave New Labour apparatchiks standing up and saying, well, we listened to what you wanted, junior doctors of Britain! You complained that our system was too secure, and we gave you more security. Verily, you are grunting savages who should be grateful that we are even considering giving you jobs, even if you have no way of knowing what you'll be paid, what your hours will be, or whether you have accommodation in Colchester until five months after your application goes in.

But it would be helpful if all these fucking error screens - heck, even just one of them - had hyperlinked the word "enrolled" so it took me to, er, the enrollment page.

They must have let that evil old witch Patsy design the interface.

Year 5 introduction - time-saving summary

Well, there I was sitting by the beach in Senegal doing very little of anything, when to my delight I got an e-mail from the university outlining my schedule for the first couple of weeks when the final year starts again in October.

As I'm feeling in the holiday spirit, I figured I could save everyone a lot of time and effort by summarising what I'm confident will take place during each of the sessions. Actual descriptions are in italics.

3pm-6pm Opening Session (Dr Richard Phillips) – an overview of the year, including how to make it a success for you. There may also be a surprise guest…
"Welcome back! I hope you all had good electives. Crap joke about suntans and/or diarrhoeal illnesses. Gosh, if you thought year 4 was hard are you ever in for a shock in year 5. Blimey, it's difficult! I hope you're all ready to do lots of work."

"So this year is split into three bits (although we may change our mind about this midway through). You'll do medicine, surgery, and GP in that order (or another order - we'll let you know as soon as we've decided) for three months at a time, with the rotations starting on the 17th October 2006 (that date will be confirmed on the VC by friday by way of an e-mail promising it for a new deadline of monday, when further e-mails will first release and then retract the dates for this year, much as happened with the elective periods)."

"It's extremely important not to cheat. We take it very seriously, and have extremely sophisticated anti-plagiarism methods in place; not only do we make you sign a piece of paper saying "I promise I didn't cheat" and hand it in with everything, but we bought the costume of that psychic out of Minority Report and I dress up in it at least once a month, drink an entire bottle of absinthe, and lie in a paddling pool for several hours. So just be careful."

"Similarly, on no account should you forge your logbooks, because even though you may have gotten away with signing them off yourself in the past, this time it's different, darling you'll see."

"You should turn up to everything in the Campus Blocks - we take a very dim view of you going on holiday in them, and two years ago we may actually have ritually disembowelled a student who went skiing in January like lots of you did last year. While this may seem like we're treating you like children, ultimately we rely on you having the common sense to lie to us if you do go on holiday, and the maturity to recognise that the sleuthing abilities of an organisation incapable of deciding what date something starts on more than a week in advance are going to be less Sherlock Holmes and more Inspector Gadget."

"The most important thing, as it is every year, is that you should not worry about the exams. The total ineptitude of the university administrative bodies should be far more alarming, particularly given that we use the same exam paper every single time. Have fun!"

Tuesday 9th
9am Full morning session on Chemical Pathology from Prof Swaminathan (LFTs, thyroid and endocrine) and on Death Certification from Prof Lucas
Prof Swaminathan is one of the most tedious lecturers alive, so we have paired her with Prof Lucas and not told you who's speaking when in an attempt to sucker you in.

2-3.30pm Application for Foundation – Dr Jan Welch, Director, and Marc Terry, Manager, of the South Thames Foundation School talk about applications, about STFS in particular, and answer many of your questions
We know you've been to two talks by Jan Welch already, and that at both she failed to know how exactly she was going to do her job, that being to organise your careers for the two years after this one. We hope that her willingness to admit the catastrophic system failures she's presided over already will be refreshing.

The cynical among you may be thinking that she still won't know how we're going to apply, what systems are going to be used (last time she said "MTAS"), or what the contingency plan is. This time it's, um, different, darling you'll see...

4-6.30pm Principles of Surgery. A hugely successful session in March last year, Ms Seema Biswas is back to talk you through basic surgery; part one this evening, part two on Thursday.
Ms Biswas is the first of a number of hugely successful and/or popular speakers, the number in this case being all of them.

Wednesday 10th
9.30am Psychiatry refresher – a favourite and entertaining lecturer, Dr Sarah Stringer, will help remind you of some psychiatry basics that you will need this year, for the exams, and for work on the wards.
See? Dr. Stringer's wonderful too! Aren't you all lucky?

2pm Practical Prescribing – another of last year’s successful innovations, Gillian Cavell from King’s College Hospital, and a leading expert on teaching prescribing skills, starts you off with some basics so you can become more confident at this vital skill.
On reflection, it may not be entirely right to call Gillian Cavell an "innovation", in that we didn't think her up last year whereupon she sprang fully-formed into existence, but it sounds better than "another of the things we only thought about doing last year". You should expect "innovations" to include advice like "try not to kill your patients", "ask for advice", and "look things up". And probably "write clearly".

6pm Deans Drinks – Prof Greenough and Prof Rees and others will be around to hear your elective exploits, and welcome you back.
But only after they've popped more prozac than a particularly grief-stricken hippopotamus.

Thursday 11th
9am Professional Development – Diana Bass and her colleagues will run the first of three sessions designed to help you look at your own development from student to doctor, facing the challenges and stresses of practice, exploring things often not touched on in the ordinary curriculum, but which constitute an important part of your education.
Prepare To Be Patronised As Never Before.

2pm Ophthalmology Refresher – Prof Miles Stanford’s lecture is perennially popular and useful
As, indeed, is everything else. Doubles and trebles all round!

4-6.30 Principles of Surgery – more from Seema Biswas (see Tuesday)
(for how brilliant, popular, and useful she is).

Friday 12th
9am A full morning of Public Health sessions from experts in their fields; topics to be covered include Needs Assessment, the governance of the NHS as well as something on clinical governance, public health emergencies, and Communicable Disease Control. Your elective might have changed your views on Public Health.
What won't have changed is your impression of the teaching you get on it, which is by and large a succession of utterly unmemorable and pointless terms used in lieu of the perfectly serviceable alternative, that being 'English'. Rest assured that unless you went to Bognor on elective, this morning will be about as relevant to your last three months as concorde.

1pm-3pm ILS handbooks to be available – hopefully a presentation on ILS also
[No jokes here: I can't remember what ILS stands for. See above re: refusal to use English]

3pm Skills Demonstration (Sally Richardson) on one of the vital Y5 skills
Hopefully, this will be on Effective Methods for Forging Signatures in your Logbook.

4pm Microbiology – the ever popular John Philpott Howard
Of course, he's only actually popular at christmas, when he dresses up as Santa and works afternoons away from the lab at the local shopping centre.

5-6.30 Haematology – Dr David Rees and colleagues on the use of the lab and the old chestnut of Anaemia.
This may be useful; it is emphatically not a chestnut.

The second week follows the same template as the first (innovation, innovation, always popular, special guest) and adds in communications skills which will almost certainly be taught by someone in whom communications skills were the only ones which couldn't be definitively be excluded on close examination, and some roleplay.

Niger elective

For those interested, I'll be updating you all on how I get on in Niger over the summer in a separate blog, just so you don't have to read all the political stuff if you don't want to.

MMC: executive summary

Philip Smith, the junior doctor who took Patricia Hewitt to task over the MTAS fiasco on question time (available on youtube), has written a rather moving summary of the whole disaster. I'd recommend you read it.

Revisavoidance, junior doctor's salaries, and quality vs. quantity

I've posted a couple of times on Dr. Crippen's blog recently (it makes a great substitute for revision), and one of these was during a discussion about the relative cost of nurses versus doctors. An anonymous blogger wrote:

So how about this? Doctors can have the roles back that the HCPs are taking off them, and the autonomy that they think the managers are taking away. The quid pro quo will be that they henceforth earn "upper half graduate salaries" rather than "very top end graduate salaries".

This irked me slightly, as having spent five years retraining as a doctor, I will be starting paid work again next summer on pretty much exactly the same as I was on as a graduate in January 2000 - and 18,500 wasn't an "upper half graduate salary" even then. It's certainly not upper half compared to the 24k someone posted to say that nurses get.

Another blogger, Becky, then posted:

I can't help but wonder what real affect this has on the quality of doctors that are graduating out of medical schools now. Would this lead to a "quality" problem, or really just too few that will be graduating?

To which I'd say simply "both". People are going to piss off out of the profession and go earn genuine upper half graduate salaries working for the pharma companies, where I'd expect someone with a medical degree could earn £30k minimum with rises exponentially greater than staying in the profession. There's your quantity issue.

The quality issue is even simpler: we're already going to have a third of the experience when we hit consultant level because the government have pissed around with medical training in pursuit of favourable-sounding headlines and short-term vote-grabbing. If we don't get paid any bloody money either, why on earth should we put the extra hours in? My first grad job was a piece of piss - you could get away with working a bare 37 hours most weeks, and a good third of those you'd be surfing the net or asleep. As junior doctors, we'll be doing up to 48 hours a week for less money, and with far worse hours (e.g. the week of nights) - now when you're being paid a decent amount of money to do that, you'll go the extra mile, and some of us will anyway - but would you, honestly, work the 49th and 50th hours in a week for eighteen grand a year?