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The Telegraph follows up Tony Blair’s brilliant new idea of 24 hr operating theatres.

“Mr Blair’s suggestion to use operating theatres 24 hours a day would be laughable if it were not so idiotically ill-informed and irresponsible,” said Tony Harrison, a retired consultant surgeon from Horsted Keynes, west Sussex.

“Operating theatres require support services such as pathology laboratories, imaging, portering and cleaning, not to mention professional staff groups, especially nurses who are currently subject to recruitment freezes up and down the country.”

There is also of course this. I wonder who would willingly sign up for heightened risks of major illnesses.

The Guardian leads with the release of the infection control statistics from the ONS.

The Patients Association said it was not surprised by the continued rise in superbugs and warned that the government’s latest NHS reforms could make the situation even worse.

A spokeswoman said: “It reinforces the picture we already have of a substantial increase in C diff and MRSA rates and our worry is that these figures will continue to rise as other priorities take precedence.”

She added that the government’s announcement this week of plans to reduce hospital waiting times by conducting “round-the-clock operations” would further undermine hygiene controls in hospital as there would not be room to isolate infected patients.

I trust that this memo is in everyones minds.

The HSJ looks at Referral Management Schemes following the publication a few weeks ago of the guidance from the DoH.

Its document, Care and Resource Utilisation: ensuring appropriateness of care was published alongside the 2007-08 operating framework before Christmas.

‘In some cases, this will mean providing more care than at present. In other cases, it will mean changing the location of care. In others, it means changing the patient pathway. The common thread is that service redesigns will be owned and agreed by clinicians, working in partnership across primary and secondary care, to deliver integrated, well-designed services,’ it claims.

In the real world the picture is radically different. Many primary care trusts have implemented a range of demand management schemes, unilaterally issuing lists of routine procedures that they will not fund without prior approval, setting up referral management centres, attempting to place primary care staff in accident and emergency and halting consultant-to-consultant referrals.

With a few exceptions, these have pitched acute trusts against PCTs, doctors against managers and sent the British Medical Association and MPs shouting ‘foul’ to the media.

Among acute trusts and the clinical establishment, the feeling is that these schemes are simply a cover for financial cutbacks and have very little to do with improving patient care.

I wholeheartedly approve of & look forward to The Royal College of Surgeons in England auditing the outcomes achieved by the ISTC’s. It will be an improvement on the current situation where the Healthcare Commission complains about the quality of the data it receives.

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Today’s hot topics are

The deficit & the creative accounting surrounding it. The Telegraph

NHS dentistry (the lack of it). The Telegraph The Guardian Reports from either side of the ideological spectrum, do I see a trend?

And of course, the heavily trailed introduction of changes to medical regulation. Expect a few quibbles on that one, especially the part where the burden of proof is to be lowered to a balance of probabilities. Imagine that, these crazy doctors object to having their careers ended on the suspicion that they might be guilty, not proof. Somehow I do not see this standard being applied to lawyers. It is disingenuous to pretend that this proposal has more to do with preventing another Shipman than another not fully thought out response to public opinion.

And of course, the FT has its take on pharma in the NHS. Guys, you know better than that. More & early intervention is going to increase costs in the early stages due to improved detection of illness, not decrease expenditure. So while I would support it as good medical care & something we should be doing as a well-functioning health service, pretending it will save the struggling PCT’s money is not exactly playing with a straight bat.

As for the rest, lets see what the day brings.

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EXPLAINING NHS DEFICITS, 2003/04 - 2005/06

A Detailed Summary of the Key Findings and Lessons

Facts:
• The NHS reported an aggregate deficit in 2004/05 following four years in which it ran a small surplus. The in-year deficit persisted at a similar level in 05/06.
• When aggregate deficits emerged in 2004/05 they tended to be concentrated in a cone-shaped area above a line from Bristol to Southampton and below a line from Bristol to the Wash, whereas in 2003/04 deficit areas are more equally distributed across regions.
• Deficits are a problem for a minority of NHS organisations – 36% were in accumulated deficit in 2005/06. When organisations’ balances are combined to create health economies defined on the basis of patient flows, a larger share is shown to be in accumulated deficit – 48% in 2005/06.
• A growing heterogeneity of financial outcomes has been observed. About 90 health economies have an increasing deficit in 2004/05 but also about 50 health economies have an increasing surplus.
• Amongst PCT Health Economies with deficits over 5% of PCT allocations, the share of the Health Economy deficit with the PCT is 75% whereas in all other deficit PCT Health Economies the share is significantly less.
• Rural areas are more likely to be in deficit.

Why then did deficits erupt in 2004/5?

The allocation of income for PCTs in 2004/5 was known in December 2002, so the deficits did not arise from an unanticipated loss of income but must have been due to either unanticipated or “optimal” high expenditure. Not due to the new resource allocation model in 2003/4. The explanation of the NHS deficit in 2004/5 appears to lie either with accounting changes or on the expenditure side of the budget for these low-needs areas, although a very small (under 10%) of the new deficit pattern may have arisen from the new allocations.

Important information relating to the use of capital to revenue transfers is missing and/or that unobserved management quality amplifies the impact of the factors for which reliable evidence exists.

HM Treasury introduced a new system of government accounting in 2001/2, and while the DH was allowed dispensation to delay its full introduction from 2003/4 until 2004/5, DH has sought to eliminate various opaque accounting practices. The issue that appears to have been of particular consequence is the amendment of arrangements which permit virement from capital to current accounts i.e starving investment to support operations.

The accounting practice change effectively withdrew between £200-300 million that had in 2003/4 been available for current expenditure. In some PCTs this would amount to as much as 1% of their projected expenditure.

NHS organisations were obliged to undertake additional expenditure in 2004/5 to achieve a range of targets designed to improve patient welfare, and that the NHS was unable to address these objectives by “doing things differently” or reallocating resources provided by the HD from other specialities, but instead increased expenditures on inputs- largely staff, to meet these objectives. The difficulty here is not so much targets per se but the unequal distance to target in different areas that was not recognised.

Modelling the implied costs of one of the targets – four hours waits in A&E - Most of the money had already been spent by 2004/5 and the large number of extra staff were still on the payroll. In 2003/4-2004/5, the mean PCT achieved a 4.4 percentage point improvement in the proportion of A&E patients seen within four hours and that this may have impacted on expenditure as much as £1.1 million per PCT with additional national estimated expenditure of about £330 million.

Employment growth at 128,000 FTE staff refutes the suggestion that the incremental resources have merely provided higher wage rates. Slower growth of employment prior to 2004/5 would have allowed reserves to have been built up & allowed flexibility of options. But the pressure of targets did not allow such caution.

The National Plan and Manifesto promises of rapid employment growth were not followed by the promised productivity increases. The financial and human resource decisions in NHS organisations have not been well joined-up, which undermined both productivity gains and the maintenance of financial balance.

A critical influence on decision taking appears to have been the concern that resources might be lost if not spent within the financial year (use it or lose it); and to spend a significant sum quickly normally resulted in recruitment. The one year time horizons do not allow for rational budget planning and favour the quick fix of recruitment, rather than the design of new approaches to treating patients.

Poor financial management is almost an inevitably found to be present in the event of a large deficit, but that poor management is not necessary for large deficits since some poorly managed organisations do not have large deficits. Managerial capacity interacts with and magnifies the impact of the (unevenly distributed) factors.

The £13 billion increase in resource to 2004/5 greatly expanded the available opportunities, but the combination of major policy pressures and workforce targets, set in a context of organisational turbulence as commissioning powers were devolved from HAs to PCTs, and SHAs restructured, provided a context in which the probability of financial control withstanding the various pressures and achieving balance, was diminished.

Deficits became more common in the South and East. National targets gave quite uneven “distances to travel” in different parts of the country. In the low age-needs areas – frequently in the South and East - there was a greater “distance to travel” for 5 of the 11 secondary sector targets – including inpatient and outpatient waiting and the A&E four hour wait, and no correlation for the other secondary sector targets. Emergency admissions growth was higher in low age-needs areas. Moreover, given that primary sector QOF payments were also higher in low age-needs areas, these incremental costs were largely higher in low age-needs areas.
The consequences of the change in accounting practices and in particular capital to revenue transfers were also more likely to have been more important in the South/East and low age-needs areas. These impacted in 2004/5.
A third influence on the advent of regional patterns concerns the cost of living in London and parts of the South and East, and the need to use agency staff due to inadequate pay for permanent staff.
Finally, noting the large share of PCT as opposed to NHS Trust deficits that arise in the highest deficit health economies (>5% of allocation) all of which are located in the Southern half of England. This may indicate that PCT management in the low age-needs areas was less strong than that elsewhere and when exceptional financial pressures were applied in 2004/5, were less able to avoid financial difficulties. (Seems unfair to me, why would southern PCT staff be less capable than northern ones)

It was not anticipated how far national targets would impose unequal burdens in different regions of the country. Should unequal national targets have received differential funding. If the funding model is already reflecting patient “needs” and the costs of meeting those needs, in a symmetric way to that in other regions, then the answer should be no.
But then you have to ask whether targets should be appropriate to local circumstance, and acceptable costs of adjustment.
How far needs based on usage can be accurately modelled, if in different parts of the country, the secondary sector is offering quite different standards of service and thus attractiveness to patients in areas such as A&E.

High deficits in the more rural areas need further study.

Local health economies in surplus tended to have older building stock & how they will invest in new facilities in the new regime needs study.

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I have just had to return my latest set of accounts / projections to my accountant. They go into detail of my current trading position & the fact that FrontPoint Towers could do with a little more in the way of footfall. I run a deferred gratification accounting system i.e I spend the money when my clients actually get around to paying me. And my accountant would not be amused if I told him that I was going to use the money set aside for his fees to plump up the business so that the Director (yours truly) could claim a bonus / congratulate myself on a job well done & move on.

The third quarter report for the 2006-07 financial year is in & makes waves in all the outlets.

The BBC

The Telegraph

The Guardian

The NHS has slipped even deeper into debt over the last three months with the total deficit reaching £1.318 billion, over £150 million more than predicted in the second quarter. 35 per cent of NHS organisations are forecasting deficits for this year compared with 33 per cent last quarter.

So how do you balance the books in an organisation facing this kind of business environment?
Well, it is done by forcing Strategic Health Authorities to topslice 3 per cent of the budgets of the best performing trusts into a contingency fund that counts against the total deficit.

In addition £450 million has been found by slashing the amount spent on training NHS staff.

Other strategies include:

Trusts are delaying payments to creditors.
PCT’s are refusing to pay for services beyond a minimum.
Patients are being asked to wait longer for treatment.
GP’s on PMS contracts are being forcibly moved onto GMS.
The cuts in services available to patients have been covered elsewhere.
Referral Management centres are springing up like a rash with little or no evidence behind them.
There has been no training / education funding worth the name for the past year.

I quote Norman Lamb, the Liberal Democrat health spokesman:

Deficit-ridden trusts are paying a heavy price for the Government’s political priorities. There is little cause for celebration in these figures.
Scores of trusts are under immense pressure to clear historic deficits, and are forced to make cuts in so called ’soft target’ services.
The Government is employing all sorts of tricks by shifting debts from one organisation to another.
These accounting rules would make Del Boy proud but won’t make the problem disappear.

I would have to concur. Just what is being achieved by the NHS meeting this artificial deadline in such a disingenuous way at immense cost to the long term effectiveness of the service?

References:

Just where did these deficits come from?

Causes of Deficits (paraphrased):
• Increased numbers of staff employed in the NHS in response to previous targets.

• Resource allocation – Primarily due to increased expenditure rather than reduction in income. The persistence of deficits beyond 2004/5 to the present may however be aggravated by movement to allocation targets.

• Cost pressures – Spending more on staff costs while spending less on pharma meant not much of a factor.

• Performance targets – Areas that spent more to achieve targets have larger deficits.

• Changes in accounting practices – RAB in addition to loss of £200- £300 million of local virement flexibility have contributed to the emergence of aggregate deficits in 2004/05, and together with performance targets, may well help explain the uneven geographical distribution.

• Organisations with large deficits are frequently found to have had weak management capacity. However, geographic and age-needs patterns of deficits are not easily explained by management alone. Management skills may interact with economic drivers, so that in areas experiencing adverse economic circumstances good management may moderate the consequences, but weak management may exacerbate the underlying causes and result in large deficits. So some PCT’s did not need turnaround teams, thank you.

The Government’s Response to the Health Select Committee’s Report on NHS Deficits: So what does the govt do?

RAB is not going away.
ACRA to report later this year re funding formula.
Still tinkering with PbR.

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Returning to the theme of constant change in the health service, Scott Greer has been looking at the Department of Health & has this to say:

The Department of Health is a high turnover organisation with pared-down middle management, questions about retention…..

There is no reason to expect that the DoH understands how it all fits together on the gritty, technical level on which policy must work.

The attitude to criticism is another weakness. Paraphrasing Michael Portillo:

It sadly goes for denial and obscurantism as its initial reaction to most problems. It is disgraceful that the impact of its bureaucratic arrogance and indifference is felt most (by patients up & down the country in addition to hardworking NHS staff).

I thought it might be useful to stress the Audit Commission’s recommendations published last year & see whether there is any sign of progress.

For the boards and executive management of NHS trusts
Senior clinicians should form part of the mainstream budget holding and budgetary accountability structure of all NHS trusts. Observed more in the breach with institutionalised resistance to the whole idea. It should also apply to PCT’s & SHA’s who are increasingly the ones that make the decisions.

For the boards and executive management of PCTs
Notwithstanding the introduction of practice based commissioning, the principal business of PCTs should always be seen as commissioning. This is because of the very material resources at risk within commissioning portfolios and the long-term commitments that commissioning entails. I wonder how outsourcing commissioning fits into this?
PCTs should publish the financial rationale underpinning all significant changes in commissioning policy and all commissioning decisions involving the investment of significant new resources, alongside any consideration of social or clinical issues. Information sharing is in its infancy & the various consultation exercises have shown up this Achilles heel.

For SHAs and the Department of Health
The metrics for assessing in-year financial performance should be reviewed alongside how they should trigger performance management action. Earlier, sharper intervention would have helped in a number of cases.
SHAs should introduce, where they have not already done so, systems for ensuring the accuracy of the monitoring returns by PCTs and NHS trusts. Some progress being made but hampered by the target regime.

SHAs should routinely compare the income assumptions of NHS providers within their boundaries with the spending assumptions of NHS commissioners, and actively pursue resolution of any material differences alongside prompt closure of service level agreements.
When mergers of NHS organisations are expected to achieve significant financial savings, the financial analysis and timescale supporting these expectations are made public during the consultation process. Information sharing again, must do more.

The burden placed on NHS management capacity by large building projects, and by private finance initiatives (PFIs) in particular, should be explicitly recognised. How the risks to effective management of the whole organisation will be addressed should form a key criterion for judging whether intended schemes should proceed. Political pressure makes this extremely difficult.

While no one will deny that there has been a lot of money poured into the health service, the efficacy if the reform that has accompanied this influx is more variable. And as noted yesterday, staff morale is at a very low ebb.

No wonder this is reflected internally as over 80% of senior DoH staff are dissatisfied & only 37% have confidence in their leadership according to an internal survey carried out in October 2006.

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Well, what do you know, they are all at it!

As I said, political editors ought to talk to their health desk counterparts. After all, they have a different take on the whole idea. He even adds his thoughts on the reasons why.

The Times / Doctors.net poll reveals that while few doctors are openly contemplating a move to the private sector, almost half of respondents said they were planning early retirement or taking up positions outside Britain. Just over a third said they expected to work for the NHS until normal retirement age.

And it gets worse.

The poll, carried out by doctors.net, Britain’s busiest medical website, shows a profession disillusioned with central control, angered by the growth of bureaucracy, and deeply sceptical of initiatives such as the £20 billion IT system. Even more worrying for Labour, more than two fifths of the 3,092 doctors who responded are young, having graduated since 2000.

More than half of respondents (56 per cent) said that there had been no improvement in the NHS since 2002, when the Government increased funding. Only 27 per cent thought there had been.

Almost three quarters (72 per cent) did not believe that the extra money had been well spent, while 11 per cent said that it had. Similar views were held on the quality of care: 72 per cent said that there had been no improvement; 15 per cent said that there had been.

So thats alright then. Chalk up one for clinical engagement.

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This was going to be a measured article about the current state of the 18 week target but The Times carries news of a proposed new initiative by Tony Blair to “end waiting for treatment as we know it”. I would never have known! They might want to talk to their colleagues on the health desks before publication. What short memories these journalists have!

Hospitals are to be asked to work through the night & they will also have to expand the use of the private sector and develop “one-stop” community health centres where GPs and specialists work under one roof. Some patients could be sent abroad.

Andy Burnham, the minister of state for health, will this week tell hospital managers they must do whatever it takes to hit the target, with no restrictions from Whitehall.

He will highlight a scheme at Yeovil District hospital in Somerset, where staff work late four nights a week in return for time off in lieu. Keeping clinics and theatres running “out of hours” has enabled the hospital to process patients more quickly and efficiently, leading to dramatic falls in waiting times.

Pardon me for being sceptical but is this a new policy or an old one being ministered to by the spinners? It was controversial enough back then but in the current climate of deficits & treatments denied, does it really have a place or is it being pushed to meet political timetables?

Many PCTs are abusing referral management schemes, in flagrant breach of Government guidance, as they desperately seek to reach financial stability.

The DH’s operating framework for this year stipulates that triage schemes such as referral management centres and clinical assessment services should not be mechanisms simply for managing demand.

The guidance states that they must not lengthen the patient journey, and must abide by ‘clear protocols that provide clinical benefits to patients’. Additionally, it says the schemes ’should not be imposed on practices without their agreement’.

But GP leaders warned that PCTs across the country were now turning to such methods simply to cut deficits, despite opposition from GPs who were becoming increasingly frustrated in their attempts to refer patients to named consultants.

GPC deputy chairman Dr Laurence Buckman said that the centres were being misused by PCTs anxious to cut costs. He said: ‘There are very few PCTs now that aren’t using [centres] to slow up referrals. This is a device to save money, masquerading as improved patient management.’

There are close to one billion pounds (US thousand million rather than the UK million million) hanging on the Diagnostics procurement from the Independent Sector after all.

The Journal of the Royal Society of Medicine (JRSM) asked a year ago whether the 18 week target was such a good idea.

What happens to the hospital when the night staff are on holiday (the time off in lieu mentioned)? Do we employ more people to work the daytime shifts?

Did we just not cut hospital staffing, especially at night? What are we to make of this “working round the clock” idea when “Hospital at Night” was introduced claiming that there were not enough doctors to man the shifts properly due to the European Working Time Directive? Are the nursing rosters not at bare minimum strength as it is?

And speaking of the JRSM again, they carry an article questioning the current standards of nurse training.

Professors Linda Shields from the University of Hull and Roger Watson from the University of Sheffield argue nursing is under threat and being replaced by technicians, minimally educated healthcare assistants and unqualified health workers. Professor Watson said: “The government has gone for a quick fix to alleviate NHS financial pressure however nurses are being cheated out of a proper university education“.

On the face of it, yes, it is a good idea that people are not kept waiting unreasonably long periods for treatment. But the feeling that this is something aimed at a political sound-bite rather than a well thought out plan of service improvement lingers.

There are a few things the rest of us on the front-line are concerned about. I have seen enough drunk 10 - 14 year olds during my time in A&E, a number of whom progress to repeat attendance for self-harm (cutting themselves, overdoses etc., take your pick since the paucity of psychiatric support leaves them vulnerable) that I would try to fix those problems first.

I mean, it is not too edifying to read these headlines, is it? I know, clinicians share responsibility for not setting appropriate priorities but since the 80’s when they abdicated the administration of the NHS to non-clinical staff, they are feeling rather rudderless.

The question is, do PCT’s have the money to meet this challenge on a sustainable basis? On that, the jury is in & it is a slam dunk for the “No” team. If money has to be found for the contracts for ISTC facilities, then that money has to perforce be denied to an existing service.

And just for the heck of it, I want to highlight this again.

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Full sized image

Choose MMC. Choose MTAS. Choose a region. Choose a career. Choose a fxxxing big lottery. Choose portfolios, on-line application forms and years of uncertainty. Choose a cut in training posts, career choice and job security. Choose FTSTA’s no one knows anything about, middle grade rotas being run by juniors who’ve never worked in the specialty before, foundation programmes you have no control over, and hospitals you don’t want to work in. Choose being treated by ‘trained doctors’ rather than ‘doctors in-training’, even though the average consultants training hours have been cut from 40,000 to 10,000. Choose Hospital At Night and no-one knowing the patients anymore. Choose being an SHO lost in the middle of it all, with nothing but a sparsely updated web-site to inform yourself. Choose seniors who know nothing about the system and seem powerless to influence it. Choose an internal office with no windows in your brand new PFI hospital while the doors fall off and middle managers sit in their swanky boardrooms munching on biscuits that your taxes are paying for. Choose paying £10 a day for the privilege of parking at your work-place while you work non-compliant rotas and get bullied into lying on your EWTD monitoring forms. Choose sitting at that PC filling-in mind-numbing, spirit-crushing objective assessment questionnaires. Choose PMETB-approved curricula and competency-based assessments no-one has properly validated. Choose your third choice career path and wondering who the fxxk you are on a busy post-take ward-round. Choose rotting away at the end of it all, pishing your last in a miserable Non-Consultant Career Grade post, nothing more than an embarrassment to the under-experienced, ‘fit for purpose’ FY’s you’ve trained to replace yourself.

Choose not to choose your future.

Choose MMC.

Courtesy of Dr Rant

Dr Rant loves this - sounds great when done in a strong Ewan McGregor accent. It was first posted on DNUK, and Dr Rant would like to thank the original author for permission to republish it here. Also the image

I can only say LIKEWISE. It illustrates perfectly what I said below.

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Following on from my previous posts regarding the plunge in morale amongst NHS staff, The Times is reporting on the recruitment drive being carried out in the UK by other countries. Recruiters from Australia & New Zealand are focussing their efforts on disillusioned NHS staff with nurses being the prime target but other professions are not far behind.

The hospital in the Midlands being referred to is the University Hospital of North Staffordshire (UHNS) which was in the news recently threatening wholesale redundancies & (where Anthony Sumara spent a few months before upping sticks & moving to Hillingdon PCT where he is expressing his enthusiasm for mass seppuku) where I understand a team of recruiters came calling, with shiny DVD’s & offers of relocation assistance. And what is the betting that quite a few capable & ambitious staff members whose jobs were not threatened & whom the trust could ill afford to lose upped sticks & left as well, in addition to the hundreds already made redundant. The extensive history of unintended consequences from voluntary redundancy schemes ought to have warned us all.

Doctors are turning down the chaos of MMC to take up stable positions at Antipodean hospitals where they might even receive decent training & this I can confirm from personal knowledge. There is a massive difference between the “take it or leave it” attitude presented to staff here with them being asked to work for free & the impression I get of friendly & helpful Oz & Kiwi hospitals pulling out the stops to impress. It’s a pity I am not a decade younger.

The US has 30 percent less doctors graduating each year than the number needed to fill U.S. hospital residency slots. Were it not for the fact that they would need to take the USMLE & possibly retrain, there would be a higher incidence of doctors leaving for there too.

What the people at the top appear to have forgotten (or in the case of some of them, never learnt) is that healthcare is a “people business”. It cannot be automated or reduced to a standardised process in the same way that a manufacturing assembly line can & that the staff who deliver the service are the main asset of the industry.

In the same way that the healthcare industry is becoming part of the global marketplace, so is the free movement of skilled people across borders. It is not just jobs & capital that can move across borders, there is a global marketplace for healthcare staff too. Agencies exist all over the place to manage this process with not too onerous requirements. Currently in the United States, there are 126,000 unfilled nursing positions. The gap is projected to be 400,000 by 2010, 500,000 by 2015, and nearly 1 million by 2020, not to mention the assorted thousands of other healthcare professional staff. Inertia & family ties keep people around, leading them to put up with conditions I doubt any of the people responsible for these policies would tolerate.

I wonder where the NHS will be in 10 years time given the ageing demographic & the disillusioned workforce.

A few resources:

Nurses on the Move: Migration and the Global Health Care Economy - Mireille Kingma

Shortages of Medical Personnel at Community Health Centers - JAMA

Human Inputs: The Health Care Workforce and Medical Markets - Cooper and Aiken
Journal of Health Politics, Policy and Law 2001;26:925-938.

Chen LC, Boufford JI. Fatal Flows – doctors on the move. NEJM. 2005;353:1850-1852.

Joint Learning Initiative. Human resources for health: over coming the crisis. Cambridge, Mass.: Harvard University Press, 2004.

Mullan F. The metrics of the physician brain drain. NEJM. 2005;353:1810-1818.

Changuturu S, Vallabhaneni S. Aiding and abetting – nursing crises at home and abroad. NEJM. 2005;353:1761-1763.

Ahmad OB. Managing medical migration from poor countries. BMJ. 2005;331:43-45.

An action plan to prevent brain drain: building equitable health systems in Africa. Boston: Physicians for Human Rights, 2004.

Buchan J, Dovlo D. International recruitment of health workers to the UK: a report for DFID. London: Department for International Development, 2004.

World Health Organisation Web site. “Outlining the World Health Report 2006.”

World Trade Organisation Web site. “Background Paper.

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E-Health Insider reported the other day on the ongoing auction for Isoft which I touched upon earlier this year.

So we have McKesson being the frontrunner with IBA Health & General Atlantic in with an outside chance. But it appears that IBA might have something up its sleeve, going by the report in the Guardian today and the Financial Times today which reveal that an all share offer might just be going forward after all.

I just have difficulty visualising ISOFT as the blushing bride, CSC the stern uncle & CfH the bishop making sure everyone behaves.

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