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The Independent pontificates that junior doctors should develop a sense of proportion.

At the heart of this controversy is the new computerised system established by the Department of Health to allow 34,000 junior doctors to apply for 18,500 training posts. The new process has clearly been a shambles. The website crashed repeatedly and has been subject to two security breaches. To this extent the junior doctors have a perfectly legitimate grievance against the Government.

Not really. This was just the flashpoint but there has been deep unease about the entire MMC juggernaut for a long time.

But a sense of proportion is necessary. The complaint of many junior doctors is that a great deal of talent is about to be squandered by the NHS because the best doctors are losing out to those with the best literary skills. But this is quite separate from the alleged shortage of posts. The shortage is of training posts that lead on to consultant status for which there is, quite rightly, stiff competition. Those junior doctors who are unsuccessful will not be excluded from the NHS. They will still have options open to them of staff grade posts, doing the same essential work of the NHS, but in non-teaching hospitals. Moreover, they can always re-apply for training next year.

It is not an alleged shortage of posts. On the one hand there are claims that the EWTD is responsible for a shortfall in the number of doctors & is used to justify cuts in services but on the other over ten thousand overseas doctors working in the NHS have been forced to leave the country with the axe remaining on those still left, not to mention of course the thousands caught up in the current debacle. If the staff at the Indy need to be educated on the facts concerning medical education without basing all their claims on unsubstantiated propaganda from the DoH, I am available to do so as are so many others.

Only someone who has not paid the slightest bit of attention to the proceedings & does not understand the first thing about medical education will claim that the affected juniors will be able to move into staff grade jobs (remind me again, why the delay on the new contract?) & that they will be able to apply again next year. The number of posts available this year is not yet known, just how are they supposed to believe the figures for next year that have in all likelihood been pulled out of a hat.

The plain fact is that not all doctors can be senior consultants. There will always be a need for support staff. The problem seems to be that British doctors have traditionally tended to get the top jobs, and doctors from overseas have come in to fill the gaps below. But since 1997 there has been a massive expansion in the intake of the UK’s medical schools. The result is that in Britain we are now self-sufficient in medical staff for the first time. So it is hard not to conclude that one of the things these doctors are also angry about is the greater competition they are facing for the best jobs. This may not be to their liking, but patients surely gain from an abundance of doctors. Incidentally, we should also remember that all doctors have been awarded very favourable pay deals in recent years. Despite the ferocity of their complaints, there is no immediate financial penalty for junior doctors who miss out on training.

Seriously deluded is the best I can say.

Coming from a paper that has not been very supportive of the struggle to stop MTAS / MMC so far it is hard to imagine that this will be taken seriously.

As pointed out in the letters to the Times,

Getting the process completed fairly and transparently would much more successfully protect these interests. The method being employed currently is neither fair nor transparent. In fact, it is endangering the quality of care the NHS is able to provide its patients in the future. A system which failed to identify talented and well-qualified individuals initially, modified to give these individuals a single chance, is unlikely to be able to employ the most appropriate candidates for the job.

Especially since the attempt by the DoH to play games with Data Protection Act disclosures has just been thrown out.

The Department of Health has breached the Data Protection Act by refusing to reveal to junior doctors the scores they achieved in the failed Medical Training Application System (MTAS).

Many young doctors unable to get interviews in the first round of the MTAS system have applied to the department or its subsidiary bodies seeking details of the scores they were awarded to understand why they failed to be interviewed.

The response of the deaneries, the regional organisations responsible for setting up the interviews, was that MTAS was akin to an examination, and that this exempts them from providing the information until the results of the exam are complete, after the second round of interviews.

But applicants who appealed to the Information Commissioner about this interpretation of the rules have had their claims upheld. The DoH has misapplied the examination exemption, the Commissioner says, and is in breach of the Act in failing to respond to these “subject access requests” within 40 days.

“The DoH has already made an announcement of the results of the ‘examination’ by informing candidates whether or not they have been successful in obtaining an interview,” the letter from the Information Commissioner’s Office to one disgruntled doctor says.

“In these circumstances it is our view that the DoH cannot use this exemption to delay responses to subject access requests. We have made our view known to DoH and informed them that they should now take steps to respond to all the subject access requests.”

More about choice.

Rather than be corralled into a perpetual critical assessment of their public services, patients would like the government and the NHS to get its house in order and deliver decent local services. Most patients do not believe it is their responsibility to ensure that happens; nor do they fall for that old saw that choice will “drive up” standards.

Safety concerns about rosglitazone mean that Glaxo is suffering. It would indeed help if there were proper longer term monitoring studies, especially as the other glitazones are automatically suspect in peoples minds. The NEJM article gives the details.

I have mentioned wet Age-related Macular Degeneration (AMD) previously & a survey of 105 members of the Royal College of Ophthalmologists to be published today found that only 48 per cent were able to get access to Lucentis and Macugen.

As for CRB checks for staff employed by the NHS before 2002, I wonder where the money is going to come from.

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So what did the outside world make of the chairman of the BMA council falling on his sword?

Mr Johnson, a surgeon, wrote yesterday to the BMA tendering his resignation. “My letter caused an absolute furore,” he admitted. But he was unrepentant about the letter, signed jointly with Dame Carol Black, which defended the Chief Medical Officer, Sir Liam Donaldson, regarded as the chief architect of the new medical training system.

The comments he has made since resigning are worse.

Nigel Hawkes in the Times links it to the MTAS issue but the roots of the disillusionment with the current leadership go a lot deeper than that.

“I think there is a huge amount of anger in the medical profession about the direction of the reforms and privatisation agenda.

“It is the worst I have known it for over 30 years since my involvement with the BMA started.”

Somehow I fear that quoting Simon Eccles was not the brightest thing the BBC could have done. A red rag to a bull would be another way of putting it after his comments earlier re MMC which have been used to great effect by Patricia Hewitt.

And just who said this?

Some doctors the BBC spoke to expressed anger over the actions of junior doctors involved with the pressure group Remedy UK with one describing them as a “rabid mob”.

I do not know very much about the people behind Remedy UK beyond what is in the public domain. But given a choice I would rather have them looking out for my interests rather than the ineffectual fools who have held court for so long.

And MMC / MTAS was not the product of just one person, however much James Johnson epitomised the closeness of the BMA to ministers. There were a great deal many fingers in this & other pies and it is hard to believe promises of real change with a united way of moving the profession forward unless some of the dead wood is cleared out.

“I think they [the BMA council] are all incredibly nervous about the effect the Remedy situation is having on the BMA.”

It is good that the BMA council are nervous. I look forward to a little more robustness from the BMA, not more of the cosy dinners in oak panelled rooms.

Morale is not very good as can be measured by the rate of absenteeism which has worsened under the MMC regimen.

So how did things get to this stage?

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

This is bordering on negligence. I cannot believe that the Royal Colleges could allow this to happen and ASSUME that it would turn out OK.

There is rather too much of this happening these days. Time for me to get back on my soapbox re the Commercial Directorate & the DoH.

Dr Richard Vautrey, a member of the British Medical Association’s GPs committee, said Mr Johnson had faced a tricky task over recent years.

“Sometimes some of our members have great expectations that if the BMA says something it will happen.

“But that has not been the case with a government with such a huge majority. We have to have realistic expectations.”

If however your expectations are so low even at the outset, then you might as well roll over & play dead.

Dr Rant examines the evidence underlying MMC.

Dr Grumble takes a look at the rationale expressed in Unfinished Business for MMC.

I have questioned Carol Black’s relationship with the truth before & am glad to see that others have picked up on it.

The BMA attempt to smooth over the cracks is given short shrift by Dr Crippen in Cut the crap Sam. I have to say that I agree with him.

So finally, what of the future?

Last weeks HSJ says that Deputy CMO Michael Martin has been appointed to the post of director of Medical Education. David Nicholson is quoted as saying medical education was “fundamental to patients receiving beter care” & that it had to be a “key part of the NHS engaging with clinicians about things that matter”. The dust hasn’t settled over this current imbroglio & as part of the team that forced through MMC & MTAS, I fail to see just how the above attributes have previously been demonstrated as part of his skillset.

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We are indeed living in interesting times with James Johnson the first to feel the change in the climate.

His letter in the Times along with Carol Black looks to have been the last straw leading to even his colleagues in the BMA expressing their lack of confidence in him. Not that he is repentant, continuing to make statements to the media blaming everyone but himself, his friend the CMO or the DoH for the mess.

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High dudgeon today as GPs are accused of overprescribing medication & generally being responsible for wasteful supply of medication to the tune of between £85 million to £300 million a year.

A few home truths then for those interested.

Not all generics are created equally. Some might not be suitable for a proportion of patients because of side-effects / efficacy / convenience, being usually atleast a generation older than the medication still on patent.

Using statins as an example, not all patients can be switched to generics from the newer versions due to the significant numbers who develop musculoskeletal problems.

Three cheap pills a day that a patient does not take are not better than the more expensive single pill regimen he or she does comply with.

Patients stockpiling drugs or simply not taking them account for a large proportion of the waste highlighted.

Of course No Free Lunch is pretty important in this effort.

“One in five GPs indicated they felt that pharmaceutical companies have more influence than [the primary care trust] prescribing advisers,”

Perhaps pharmacists might be better used to provide advice on medicines management rather than becoming diagnostic assistants treating patients independently.

A look at Diabetes related illness & the fact that it accounts for 10% of NHS spending.

The Guardian profiles a GP practice that provides an interesting model of midwifery care. But we are told it is too expensive. I wonder if we have our priorities wrong.

Many women see different health professionals throughout their pregnancy, labour and birth, and postnatally, but Oakwood’s women are given a named midwife who carries out nearly all of their antenatal and postnatal appointments and in many cases delivers their baby at home or in hospital.

“This type of service offered by Oakwood is considered too expensive and too demanding for midwives by many in the NHS,” said Newburn, “but if you look at the overall ratios of midwives to women it looks like it could be possible for far, far more women to have this kind of care.”

And I am surprised that there are not more stories like this one.

Despite asking instead if she could stay in the waiting room until someone could come and collect her as she couldn’t afford the £40 taxi fare, she was discharged at 2:30am. Miss Beale, who has no family, then spent six hours on a bench in the hospital grounds before walking into the city in her hospital slippers.

Once upon a time this would have been dealt with sensibly.

I used to work in Manchester around the turn of the millenium & was thankful for the introduction of unbreakable pint glasses there. I can’t believe that there is still a reluctance to introduce them nationally.

The MP John Grogan, chairman of the All-Party Parliamentary Beer Group, said: “We are calling for a sensible approach rather than a blanket ban. Banning glass is the wrong way to attract a wide and diverse set of customers.”

Nathan Wall, operations director at JD Wetherspoon, who attended the BEDA meeting, said: “There’s a philosophical difference between us and the police. They are of the view that one glass injury is one too many, but ultimately we have to consider that we are punishing the vast majority.”

Alcohol awareness campaigners claimed recently that a typical glassing incident costs the NHS £184,000 to deal with, before the cost of a police investigation is added to the equation.

Now I am not able to understand the reasoning behind these statements but I guess that I am not qualified to be a connoisseur. What exactly is the punishment? On second thoughts, don’t bother explaining. But aren’t metal tankards more traditional?

A clutch of letters in the papers today with some propounding the view that “Increased spending is not the answer” for the NHS. To me it is part of the answer as the correspondent quoted explains.

The answers are simple and well known within the service. First, the austerity years under the Tories led to a massive backlog in capital expenditure, notably for repairs and rebuilding. Redressing this has soaked up funds with little immediate effect on care outcomes. Secondly, and more importantly, the NHS for 50 years was predicated on the basis of the trust and sacrifice of its workers at a time when vocational commitment meant long hours for little reward. When politicians, in a desperate attempt to find cheap solutions to NHS ills, declined to believe the hidden value of this benevolence, and demanded contractual rigidity and centralised control, they dissipated that goodwill and found to their cost that they had underestimated its contribution severalfold. To their shame they are now engaged in a desperate scramble to reverse their largesse.

And “Choice” is debated as well with a few interesting participants.

So is this realism or undue pessimism?

“Today only 30%, we estimate, of our projects and programmes are successful. Why shouldn’t it be 90% successful?” he said in a speech to this week’s Government UK IT Summit, reported in Computer Weekly. “It’s about improving performance in projects and programmes and our day-to-day services as well as our procurement processes.” Predictable weaknesses such as inadequate requirements were often to blame.

I have to agree & these are not limited just to IT projects. I have raised the same concerns regarding a number of DoH programmes.

Stephen Timms, chief secretary to the Treasury, was more upbeat in a speech to the same conference, brushing aside criticisms of the NHS IT programme, describing the scale of the scheme as “heroic”.

Not sure that I wan’t heroic to be the word used.

A DWP spokesman said the figure Mr Harley quoted came from an independent report with “very narrow criteria”, which was also highly critical of private sector projects. “Only projects which were on time, on budget and exactly to specification were deemed a success. If they never saw the light of day they were deemed a failure. Anything in between - around 63% of the projects - was deemed neither a success nor failure.”

Seems fair to me & not particularly narrow, though details of the report would be welcome.

Not a get out of jail free card this time but better than James Johnson / Carol Black at the very least given that the BMA is haemorrhaging members after its recent shennanigans (700 resigning in just one day). This is unlikely to cut much ice.

As you are aware, the failure of MTAS, the application system into the new ‘MMC’ training programmes has been one of the most negative and destructive events in medical training in recent years and has damaged confidence in those bodies involved. Among those are the Royal Colleges, whose statutory responsibility for training doctors was taken away and transferred to PMETB but who are still perceived by many junior and senior doctors to have failed to intervene – indeed been complicit – in the failures of the last few months. We have been deeply damaged by insistence that “The Royal Colleges’ agreed to these changes”. As responsible professionals we have worked with the Department of Health in its wish to train a medical workforce in a way it perceives as appropriate for the NHS for which it has responsibility. We have however repeatedly expressed concerns and caveats that have gone largely unheeded. There has been consultation but little true listening.

Th Royal College of Physicians has been slightly ahead of its compatriots by virtue of having a more switched on PR department & has responded to the concerns of its members. This letter would have received a much stronger welcome a few months ago & the medical establishment needs to learn when to walk away from futile exercises. But they are trying & that is a sign of progress.

Especially curious is the revelation by the Department of Health during the hearings for the judicial review that MTAS was work in progres

The legal team for the Secretary of State for Health presented a second witness statement by Mr Nick Greenfield from the Department of Health.

In it he states that the matching algorithm (that underpins the MTAS computer system) was not, and is not, functional or reliable.

Mr Greenfield states “The decision not to proceed with MTAS for matching candidates to training posts was taken as a result of recent security difficulties and the fact that the Defendant could not be certain that the algorithm necessary to operate the ’single offer system’ would be effective.”

Further, this had been raised with the Review Group in early April. To add insult to injury he concludes “the required algorithm… was a ‘work in progress’”

The judgement is expected in a week or so.

And as for the Tooke inquiry, I will update this later.

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The claim that nearly half the A&E departments in the country are under threat has people up in arms.

“Current Department of Health and strategic health authority guidance suggests that, to be viable in terms of patient need, patient safety, staffing numbers and clinical training requirements, a full A&E department in the future would need to be supported by a catchment population of between 450,000 and 500,000 people.”

So where does this figure of 450,000 come from?

A report published last year by the Royal College of Surgeons recommended that the minimum catchment population of a fully resourced A&E department should be at least 300,000. But there is debate about whether catchment areas alone should be used to allocate NHS services. Local geography, healthcare needs and staffing levels may have to be taken into account.

Common sense I would have thought.

A Department of Health spokesman said there was no such official guidance from his department. “It is absolute rubbish to suggest that we are demanding the closure of A&E departments.

But he admitted that the recommendations were taken from a report by the Royal College of Surgeons supported by Sir George Alberti, the former director of emergency care. He recently recommended the closure of an A&E department in North London. The remaining two A&Es serving the area will be left with catchment populations of 450,000 each.

There is a difference between densely populated north London (not that I am in possession of detailed knowledge about the area & hence am not commenting on the specific merits of that particular proposal) & the greater geographical spread in Surrey, not just in matters of distance but also in terms of demand for services. Surely decisions at SHA & PCT level do not just parrot “guidance” but involve public health experts & frontline clinicians in the design of services? I have been increasingly concerned at the lack of clinical involvement in these decisions.

The RCS has clarified that it is only asking for major trauma facilities to be concentrated.

Dermot O’Riordan, of the Royal College of Surgeons, said: “Very major trauma cases with multiple injuries like road traffic accidents are more likely to survive at specialist centres, but local emergency departments should stay open to focus on what they do well.”

Yes, but how do you get them there in time? Are we prepared to invest in an increase in HEMS / med-evac helicopter capacity? Or will existing ambulances simply have to travel further? There is a lot more to this & the intemperate closure of existing services without having appropriate validated replacements in place is rather dangerous.

Though the argument is made that time is not an issue.

Ambulance crews are now well-trained paramedics able to stabilise patients and give emergency treatments. Except in rare cases, the time taken to reach hospital is not critical.

“Long ambulance journeys do not lead to more deaths,” said Sir George Alberti, the former national director for emergency access.

Specialist A&E units, fewer in number and therefore farther for most people to travel, would save more lives, the Government asserts.

So do we “scoop and run” or “stabilise and treat”? The fashion varies over the years (the discussion of the treatment recd by Diana Princess of Wales was a case in point) & I am not too sure that members of the ambulance services would claim to be capable of doing what is suggested. Especially since I have highlighted earlier the move to replace one of the paramedics on a two man crew with a driver / technician with 8 weeks training. It is called integration, or one hand knowing what the other is doing.

Yes, we need to be more flexible with ambulance protocols, not just dumping patients at the nearest hospital. But these reconfigurations need to be based on the practical, not a theoretical possibility.

The doctors either disbelieve the claims, or use a more subtle argument to justify retaining an A&E. They say that loss of emergency services risks destabilising the hospital, and reducing its capacity to do other things.

An A&E requires the services of orthopaedic surgeons. Without an A&E, it is harder to sustain the necessary numbers, and the ability of the hospital to do elective orthopaedic operations is diminished. Costs rise, and it becomes uncompetitive. So closure of the A&E can have knock-on effects.

They ask why these clinical arguments for closures have emerged at a time when the NHS is short of money. The coincidence suggests that cash, and not best practice, is driving the changes.

I have to concur.

So who came up with this?

This was endorsed by the National Leadership Team, a body that advises the Department of Health, and a document produced by a local primary care trust described this as “national guidance”.

Either this is an oversimplification of the output from the advisors (with all caveats removed) or they have become remote from the day to day struggle to provide care & do not any longer represent professional consensus.

The DoH frequently sends out “guidance” of this nature procured from a variety of sources. It is incumbent on PCTs & SHAs to apply their minds to these documents & not take them as gospel. That is the whole reason why the professional component of NHS structures needs to be strengthened.

The proposals in the expected update of the Human Fertilisation and Embryology Act 1990 are highlighted in the BBC with implications for abortion services as previously mentioned.

What palliative care? I would be hard pressed to find many such services.

I have my differences with the hospices as I feel that they give up too easily. Patients are promised visions of personalised inpatient care in clean comfortable facilities if they decide to cease intensive treatment, as compared to the mad bad & dangerous world of acute hospitals.

But my argument is that every patient should be receiving such care, not just the ones at deaths door & hospices should not force patients to make such a choice, especially given the advances in medical treatment. And children’s wards are an idyll compared to adult wards.

The speculation over Isoft’s future takes up more space with questions being asked about IBA’s health.

IBA’s full-year results show very poor conversion of profits into cash. In the year to June 2006, profit after tax was A$15.3m (£6.4m), while cash inflow was just A$421,000. Profits after tax in 2005 were £14.4m, but the company recorded cash inflows of £6m.

I presume that the advisors at both ends earned their money having examined the books in detail but will wait to see what comes out.

A move to Sydney is also mentioned.

The group at the heart of the NHS software upgrade will move to join its suitor, IBA Health, in Sydney after it struck a £233 million deal to create the biggest healthcare IT company outside the United States.

Size isn’t everything. All companies have to start small somewhere & it is their products that determine prospects & reputation. Isoft’s current products are at-least 2 generations old & need to be replaced soon.

Especially as the BMJ highlights the dangerous state of information systems currently.

One hospital IT manager told researchers: “It’s been urgent that [the system] is replaced all the time I’ve been here, which is about three and a half years … It is a clinical risk.” Another said the system still being used at his hospital was “not just obsolescent, it’s obsolete”. The trust had had to buy computer parts on eBay and get them shipped from the US.

The last four years have been a distraction & a disappointment. But trusts have put off any IT plans since at-least 2001 with the expectation that the DoH would deliver, strangling any innovation in their own backyards in the meantime. This is a failure not just of CfH but also of business planning at the various trusts themselves.

The expected public sector summer of discontent comes closer to reality as the RCN vote to ballot their members for strike action as promised at their annual conference.

The RCN met on Wednesday to discuss their options after an emergency motion passed unanimously at the RCN conference in April called on the government to implement a full 2.5% pay rise as recommended by the independent pay review body.

The Royal College of Nursing ballot will ask NHS members whether they want to be balloted on what would be the first ever national industrial action.

The first move to coordinate strike action was announced yesterday when Dave Prentis, general secretary of Unison, the country’s second biggest union, released a letter saying it and the Public and Commercial Services Union (PCSU) should coordinate industrial action in hospitals, health centres, Whitehall departments, jobcentres, courts, museums, art galleries and the coastguard service.

The PCSU conference voted unanimously to escalate strike and industrial action in Whitehall. There have already been two one-day strikes, with the Cabinet Office acknowledging that 119,000 people took part in the last action on May 1, which hit jobcentres, tax offices, driving tests, courts and museums and art galleries.

And what of medical training, with the second day of the judicial review scheduled for today in the High Court?

Thomas de la Mare, representing Remedy in the High Court, said key decisions with a direct and serious impact on doctors were being made “without any form of notice or consultation”.

In a court packed with junior doctors and their supporters, he said MTAS was now “so conspicuously unfair as to amount to an abuse of power”.

And he said it was mystifying why the British Medical Association, the doctors’ trade union body, was not supporting its call.

Ah, but the BMA & the Academy of Medical Royal Colleges are busy brown-nosing.

We restate our support for the Chief Medical Officer and his role in improving junior doctors’ training. He pioneered the principles underlying the reform programme. Serious though they have been, it would be a far-reaching shame if those principles were obscured by recent problems with the online application system.

The problems with the applications were just the tip of the iceberg. Unvalidated educational theory is being forced down an unwilling profession in the form of the current implementation of MMC. Yes, it would be nice for example to cut the period of postgraduate training from 12 years to eight but to do so without increasing the educational content of those eight years is not realistic & can only deliver decreased standards. First show concrete proposals to improve the quality of training & then we can talk about cutting the time required.

There are a number of letters related to healthcare in the Telegraph today with Monitor coming on board to defend it’s handling of the Royal Brompton.

The application from the Royal Brompton and Harefield NHS Trust is being dealt with in exactly the same way as is any other applicant’s, and the standards required of it are no different. The assessment is in process and no decision has been made.

William Moyes, Executive Chairman, Monitor, London SW1

MTAS & budgets get a mention too.

Sir - You report (May 16) that the notorious online application process for junior doctors is to be scrapped. Unfortunately, as you imply, this will do nothing to alleviate the present crisis. The appointments of doctors to thousands of posts, due to start on August 1, have yet to be made.

This week, doctors are being called for interview with no more than 48 hours’ notice. Indeed, I know of candidates being telephoned abroad to attend for interview the next day. Regrettably, this callous approach by administrative staff to dedicated young men and women has prevailed in the NHS for some years now.

Thousands of doctors will have less than two months to prepare for their next job. Many will have to move considerable distances to find new homes, with consequent serious effects on their spouses’ careers and family life. Other well-trained physicians and surgeons will simply be unemployed.

Professor Robert Rubens, London SW19

The view from the gallery:

Immediately after Mr Prescott, Patricia Hewitt came to the Dispatch Box to answer an emergency question about junior doctors put down by the Tories. Miss Hewitt was, if possible, even more useless than Mr Prescott.

She is another member of the doomed and discredited crew who no longer even pretend to have any kind of control over the ship of state.

Simon Carr

The day developed a theme. Before the debate on Home Information Packs, the Speaker allowed an Urgent Question on Patricia Hewitt. The question was: “Why on earth is she still Minister of Health?” I thought the answer was obvious but Andrew Lansley muddied the waters sufficiently to let her escape into the murk.

The computer isn’t that important to the doctors’ training places fiasco. The first rule of computing is: sewage in, sewage out. It isn’t the computer saying that one failed interview prevents you ever becoming a consultant.

No, it’s Mrs Hewitt saying that, or someone very like her. It is she who should pick up the can of sewage and carry it outside, closing the door behind her.

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Since the BMA with all their infrastructure were not able to survey members about MTAS & MMC, a number of doctors have decided to help them out.

It took them just a couple of weeks & some time on the telephone to gather statistically valid detailed information regarding the views of those affected by this debacle.

This message addressed to consultants working in the NHS tells us more.

There have been several feasible solutions proposed - none of which have come from the Review Body. 81% of 813 consultants and 85% of 2422 juniors rejected the current arrangement, and requested a consultant boycott in the absence of fair reforms. Prof Brown’s national online Poll revealed that over 80% of us are willing to remain in our current jobs to ensure patient safety and allow time for our fair and revised recruitment.

But what do your Juniors actually want? Will we feel betrayed if you proceed with interviews or be angry if you pull out and deprive us of our “one shot”?

With support from Professor Morris Brown, we decided to provide you with an “evidence base” from which you can make your decision with confidence. We have conducted multiple hospital based telephone surveys in regions across the country. By surveying via telephone we hoped to minimize responder bias - rather than a self-selected minority, we aim to show that this accurately represents the opinions of the majority of doctors caught up in the process, in some cases including those working at your hospital.

We asked trainees 3 key questions;
1) how many interviews you had?
2) are you awaiting any Review Group Round 1b interviews? and
3) do they want Consultants to boycott interviews or proceed?

Our results are compelling. You will notice a range of trainees have been interviewed - some with no interviews, pinning their hopes on a Review Group interview for their “one shot” and some with up to 4 interviews who would be set to lose those if we abort.

Results are published with permission from all participants. Please review this table (and the personal situations of each SHO) and take time to analyse it for yourself. We hope this will give you the confidence to know you will be doing the right thing.

We thank you in advance for your support,

Mei Nortley
St George’s Hospital, London

Sara McNally - UCL Psychiatry Rotation, London
Kiran Kulkarni - St Mary’s Hospital, London
Keval Patel - The Hillingdon Hospital, Middlesex
Baha Taha - Buckinghamshire NHS Trust
Ciaran Mc Garvey - Bedford Hospital
Emma Clow - Queen Elizabeth Hospital, Norfolk
Hui Tan - John Radcliffe Hospital, Oxford
Mark Carswell - Bournemouth Hospital
Patrick Murray - Hull Royal Infirmary
Rajeev Krishnadas - Northumberland, Tyne & Wear Trust
Caroline Blakey - Royal National Orthopaedic Hospital
Clare Gardner - Cheltenham General Hospital
Kate Thompson - UCL Psychiatry Rotation, London
Alex Thomson - Mausdley Hospital, London

Survey Results

Survey breakdowns

It is funny then that the BMA have submitted affidavits in court opposing the judicial review in direct contravention of JDC Conference mandate below.

That this conference

i) Is appalled and outraged at the ongoing catalogue of failures with the implementation of MMC for August 2007
ii) Deplores the recent MTAS security failures
iii) Believes that MTAS cannot continue to be used and should not be used again (taken as a reference -for an explanation see below).
iv) Believes that now no single solution that will satisfy all applicants this year
v) is concerned that the impact on the NHS of implementing MMC Specialty Training will have grave consequences for patient care.

And therefore demands that the junior doctors committee should use the following negotiating position to protect the interests of junior doctors

a) that no junior doctor should be unemployed as a result of the failures of this system

b) All eligible applicants must be interviewed for all their original choices throughout the UK, starting their posts in 2007
OR
the whole of MMC Specialty training is postponed and a return to SHO anf SpR post for a further period of one year while a new application process is devised.

and that
c) all offers should be made on the same day throughout the UK
d) the start date may be delayed if eligible applicants cannot be interviewed in time for a UK wide single start date of 1st August
e)if the start date for MMC specialty training is delayed, any interim arrangements must preserve doctors training and employment
f) a ranking system should continue in future systems to maximise the proportion of people offered their preferred job
h) The Academy trainees group should withdraw from the current MMC review group.

All except a iii) was passed as a motion, a iii being taken as a reference.

In written statements to the Royal Courts of Justice in London, BMA junior doctors committee chair Jo Hilborne, pictured, said the association was the proper body to consult with on remedies to the recruitment problems.

Dr Hilborne said it would have been inconceivable to consult with the 32,000 affected doctors given the practicalities of such an exercise and, in particular, the urgency of the review.

Even MTAS for all its faults could manage to contact all 32,000 applicants by email & obtain a response. Was it beyond the capability of the BMA to poll its members in the same way that the juniors above have managed?

From the debate today in the Commons:

The overall total for the UK as a whole is about 23,500. That includes the general practitioner posts, which have been dealt with under a separate system. The remaining posts have been made available via MTAS. Of those posts, just under 12,000 are run-through training posts, 3,488 are fixed-term posts and 182 are academic posts. Those figures are for England. For the UK as a whole, the figures are just over 14,500 run-through training posts, 4,392 fixed-term posts and 185 academic posts.

And now we come to the meat of the matter. 14500 training posts for 34500 applicants. (2000 excluded by the DoH criteria in addition to those who didn’t apply at all)

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Nigel Hawkes in the Times:

In a move apparently designed to outflank a legal action by junior doctors due to be heard in court today, Ms Hewitt told Parliament yesterday that the Medical Training Application Service (MTAS) would not be used for the second round of interviews.

As stated before, the outcome of the process so far still stands & so this is not very significant.

Her announcement did not impress RemedyUK, the junior doctors’ group which is bringing the action. It said that if the first round were allowed to stand, 80 per cent of training posts would be determined on the basis of a faulty system. Good candidates would have been denied a fair chance, and poor ones accepted because of the vagaries of MTAS.

The challenge should continue. Though one correction, it is not being suggested that poor candidates will be appointed. With most trainees having fought through A levels, medical school & on average 3 years of work in the NHS already, I would be hard pressed to describe them as poor candidates. As has been said before, the real scandal is that there are so few places for these doctors to continue their training when the UK has one of the lowest numbers of doctors per population & the Chief Medical Officer goes around telling everyone that more should be trained.

“She is hoping people will consider this is a concession,” said Matt Jamieson-Evans, of RemedyUK. “It is not. Abandoning the MTAS system is not really news, as far as we are concerned. It hasn’t worked for the past three weeks, so saying it won’t be used in the second round is meaningless.

“The point is that the majority of jobs will be decided on the basis of the first round, which was flawed. So of course we are going ahead with the legal action.”

MTAS in electronic form has been replaced with a paper version & this is a travesty where the review has produced an outcome worse than the original situation.

And considering that the DoH can’t resist poking a stick in a beehive:

A Department of Health spokesman said the MTAS system was not being scrapped entirely. It would continue to be used to monitor appointments this year and may be reintroduced next year, subject to an review of the selection process.

Right, we take comfort from the concern the department has for medical training.

The Telegraph has more to add:

Patricia Hewitt, the Health Secretary, faced humiliation last night after being forced to jettison the controversial online job application system for junior doctors.

The climbdown also leaves Miss Hewitt’s political future in tatters, with growing speculation at Westminster last night that she will be one of the biggest casualties in Gordon Brown’s first Cabinet reshuffle.

Miss Hewitt last night rejected calls for her resignation. During a hesitant performance on Channel Four News she insisted she wanted to stay on to sort out the problems that have crippled the recruitment system.

And we should have confidence in her because?

Simon Carr returns to the topic in the Independent.

Time is running out for Tony’s oldest crony

It’s a fiasco with a triple F. The job application program for doctors is in such disarray it’s been scrapped. Morning Report told us that the Department of Health wouldn’t be answering questions about it because there was a Commons statement later in the day. As there was. A written statement.

The written statement laid the responsibility for withdrawing this f-f-fiasco on two groups. 1) Criminals (they found that confidential files were in the public domain and alerted the media to the fact), and 2) junior doctors. Yes, “Given the continuing concerns of junior doctors about MTAS, the system will not be used”. The only wholly innocent parties were in the government. It’s a daring defence and deserved to be tested on the floor of the House.

The Telegraph gets back in there:

Only a profoundly unimaginative bureaucrat bolted to a Whitehall desk could have dreamt up such a hare-brained scheme. The result has been chaos - mismatches galore, and thousands of doctors facing the prospect of no placements at all. Is the NHS so over-burdened with clinical talent that it can deal with its brightest and best in such a careless way? Where was the political oversight that should have seen the flaws inherent in this scheme before it had left the ground?

Miss Hewitt deserves to go on grounds of sheer, blistering incompetence.

And Nigel Hawkes in the Times goes further in his commentary.

Is this a resignation issue? It is getting perilously close.

When ministers are forced to backtrack not once but twice or three times, finally conceding the very points made from the start by their critics, their position is fatally weakened. Had Lord Warner, the minister who could most plausibly be blamed for the junior doctor appointment system, not chosen to retire at the end of last year, he would be on his way any day now. His absence leaves Patricia Hewitt, the Health Secretary, rather exposed.

She may not be directly culpable for the failings of the application system, but she is culpable for the political error of not seeing early enough that this was an issue that could not be finessed. At every stage she has been a yard off the pace. Today’s court action by RemedyUK is the key. If the court rules that doctors’ reasonable expectations of fairness were not met, then she will face another retreat. If, on the other hand, it finds for her, she will be home clear – winged but still defiantly flapping.

As last night’s appearance on Question Time showed, she is still floundering.

But he has more:

Law firms would never tolerate their trainees being selected in such a way: nor would newspapers, or any properly run business. Will hospitals really put up with the wrong doctors being imposed on them for the next five years?

It is symptomatic of the arrogance of NHS management that such a “Year Zero” approach was ever adopted. In the attempt to undermine the old boy network that, it claims, characterised the old interview system, the department came up with something infinitely more sinister. And where were the defenders of medical professionalism? The royal colleges were silent, the Postgraduate Medical Education Training Board denied responsibility, and the British Medical Association equivocated. Not my problem, guv.

It is no surprise that so many doctors despair of their profession when there are so few prepared to defend it.

Good luck to Remedy on the legal challenge.

Perhaps the BMA spokesperson (Andrew Rowland from the JDC) would care to pay attention to the resolutions passed at the recent conference where the BMA spoke in favour of the legal challenge & it was explicitly agreed that if it was not possible to agree four interviews in England as is the case in the devolved nations the BMA should withdraw altogether from the proceedings.

A lesson perhaps for other organisations seeking co-operation from the profession: Take what you are told by the dead wood with a pinch of salt. They do not speak for everyone.

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As mentioned a couple of days ago, the 2006 Patient Survey results were published today by the Healthcare Commission. The Guardian

The Healthcare Commission found 30% of inpatients have to share bathrooms or shower areas with the opposite sex, in spite of government guidance that the practice is upsetting, particularly to women.

It identified a handful of trusts where most patients have to wash in mixed-sex facilities, which rarely exist in public buildings outside the health service and which ministers claimed to have eradicated. At St Mary’s teaching hospital in central London, 59% of patients shared mixed-sex bathrooms.

The commission’s huge survey of 80,000 inpatients’ experiences also found that 20% of people who could not eat without assistance said they did get enough help.

The target culture is of no benefit whatsoever in producing real improvement.

The commission praised the NHS for achieving persistently high levels of patient satisfaction. The survey, conducted last autumn, found 90% rated the overall standard of care as excellent or good, with only 2% saying it was poor.

But after drilling down into the details of patients’ experiences, it found many hospitals failed “to get the basics right”.

You can give a building that is in disrepair a new coat of paint but that does not fix the structural problems.

Straight talk from the BMA:

British Medical Association consultants’ committee chairman Dr Jonathan Fielden said: “It is gratifying that this survey reflects the immense efforts from doctors to improve the quality and experience of care for their patients despite the financial pressures placed upon the health service.”

“It is the political meddling that gets in the way, diverts attention and leads to so much of the waste.”

The Guardian goes on to suggest a path for Gordon Brown to follow.

Compare now the patients’ views about what the NHS is really like with opinion polls showing what the public thinks about the government’s handling of the service. While the inspectorate was questioning patients last autumn, an ICM poll for the Guardian found only 25% of voters thought the NHS had improved since Labour came to power in 1997, compared with 30% who said it had got worse and 39% who said Labour had made little difference. In spite of all the extra billions that Brown, as chancellor, poured into health, Labour has been trailing behind the Conservatives on territory that it used to dominate.

Brown’s advisers must ask why the NHS’s reputation is so bad when its service is regarded by users as so good. Perhaps the most plausible reason is the persistent bad-mouthing of the NHS by its staff and by the media. A service with 1.3 million employees, including many of the most trusted professionals in the land, ought to have 1.3 million goodwill ambassadors. Instead they are, for the most part, disgruntled and fearful that their service is on a slippery slope towards privatisation. In spite of substantial pay rises over recent years and recruitment of extra staff that should have reduced work pressures, the mood of optimism that greeted the NHS plan in 2000 has dissipated.

The disregard shown towards staff is being repaid in full.

The Times expands on this.

Every health minister I can remember has gone on a listening tour, or held an expensive consultation exercise, round and round the roundabout, and they got the same answer: patients want shorter waiting lists, a GP who will visit them, an A&E reasonably near by. Health service staff want more pay and fewer reorganisations. Who do you listen to?

Quite often what patients want & what staff advocate are not too different, within the realms of the possible of course. There will always be a few quibbles.

We have had new types of hospital and a far wider use by the NHS of private treatment centres, walk-in centres and NHS Direct. Everyone has had new contracts, with nurses taking on greater responsibilities, consultants taking on extra money and GPs devolving responsibility for out-of-hours services to others (while taking on extra money). There has, generally, been a public consensus supporting all of this. Taxes have risen a little to fund it.

And then Patricia Hewitt came along, brandishing a Bold Reform Agenda that encompassed closing down much-loved hospitals across the country in the name of “care closer to home”, greater efficiency and super A&Es not yet established. At the same time the Treasury cracked down on previously hidden debts and, hey presto, like a too busy consultant magicking a private appointment out of his diary, the Government magicked defeat out of triumph. Its ratings on the NHS have plummeted and with them trust in the Government, and the Tories have taken the lead – despite having no health policies to speak of at all.

Masterful inactivity has something to be said for it after all.

After all, just how does one re-negotiate a contract signed just three years ago?

The Health Select Committee has looked at hearing aid provision but there is more to come.

Paul Hodgkin who runs Patient Opinion evangelises the benefits of a two way conversation in the Guardian.

The NHS concentrates on efficacy and efficiency but these are aesthetic aspects of care. Questions such as: were you included in decisions? Did staff make you feel precious or worthless? are just as important. Too small to be dealt with by formal contracts, they gain some bite by being voiced on the public space of the web. Add comments from patient groups, and feed these conversations back to hospitals and primary care trusts, and the small voice of the individual can become the kernel of real change.

Again, paying attention to the requirement for basic care might be an idea.

It looks like IBA Health have finally bought Isoft for £140 million along with liability for debts to the tune of £89 million. Let us hope that they have rather more luck with Lorenzo.

Update:

It appears though that CSC has still not given its blessing.

IBA had come close to abandoning a combination with iSoft less than two months ago after becoming frustrated at CSC’s position. A number of other potential bidders for iSoft - which has been in talks with a string of suitors for seven months - are understood to have lost interest soon after talking to CSC.

So in this game of hardball, I imagine that CSC is having to satisfy CfH of the fitness of IBA to complete the deal.

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Patricia Hewitt has just been on the lunchtime news to admit what we all know, which is that MTAS is dead.

Health Secretary Patricia Hewitt said that after the first round of recruitment, the system would only fulfil a monitoring role.

Instead, the recruitment process will be handled at a local level by medical deaneries.

And in other news, the sky is blue. The website has been down for weeks & has served no useful purpose except for the deaneries to access data, though most of it is suspect as already known. However spinning it as the end of the matter would suit only those who seek the continuance of the process by another name. The faulty process & results so far would only perpetuate the inequality.

The following appears to be the position at the moment:

First round job offers will start to be released from 21 May 2007 until 7 June. Once an offer has been made trainees will have 48 hours to respond to the offer. It is expected that 80% of jobs will be filled at the end of Round One.

There will be a Round Two which will be a Deanery-led process (not involving MTAS) although it is still not clear when this will take place. Adverts will be placed in the BMJ or via NHS jobs. It is anticipated that there will still be gaps at the end of Round Two, particularly in Paediatrics, Obs & Gynae and Psychiatry.

The actual statement:

15/5/07

WRITTEN MINISTERIAL STATEMENT

Recruitment to Medical Training

In my oral statement on 1 May 2007 (Column 1367) I notified the House that there had been two security breaches of the medical training application service (MTAS) that arose on 25th and 26th April.

MWR Infosecurity has now completed a full security review of the MTAS system. Action has been taken by the contractor (Methods) to address the weaknesses identified. Both MWR and CESG (Communications Electronic Security Group), the national technical authority for information assurance, have confirmed that appropriate and sufficiently comprehensive action has been taken. The site was therefore re-opened last week, restricted to postgraduate deaneries only, to support the next steps in the recruitment process.

Because the investigation has made it clear that criminal offences may have been committed, the MWR analysis and report have been given to the police.

Ongoing Recruitment process

Following the recommendations of the review group chaired by Professor Neil Douglas, every eligible applicant for postgraduate medical training has now been guaranteed at least one interview for their first preference post. An additional 15,500 interviews have therefore been arranged as part of Round 1 and are now taking place. I am extremely grateful to the consultants who have made themselves available for these additional interviews.
The review group met again on 9 May to consider the process of offering posts to candidates who are successful in their Round 1 applications. The group agreed that offers for the current round will be managed locally by individual deaneries, on the basis of published MMC guidance.

Offers will be made to successful candidates on a phased basis as interviews for each specialty are completed. Subject to the outcome of the current Judicial Review, the first offers for hospital specialities in England will be made on or after 21 May 2007, with all initial offers made by early June. This process of making offers will continue until late June 2007, at which time Round 1 will close, ensuring that candidates and employers have time to prepare for appointments commencing on 1 August 2007. Given the continuing concerns of junior doctors about MTAS, the system will not be used for matching candidates to training posts, but will continue to be used for national monitoring.

As we have stressed before, not all training posts will be filled in the current round and there will therefore be further substantial opportunities for those who are not successful initially. The review group has agreed that this further recruitment will be locally planned and managed by the deaneries. An announcement of the process will be made shortly. Deaneries are continuing to work with the NHS and the Postgraduate Medical Education and Training Board to establish what additional training posts will be made available beyond the 23,000 training posts already available across the UK.

Patricia Hewitt

I could pick more holes in this but it is not worth the time.

After all inspite of her promise to answer all the questions submitted after her appearance on Question Time, she has apparently only answered five whole “representative questions” out of the over thousand submitted. I wonder who was responsible for choosing.

Q: If as you say that the Royal Colleges and BMA were in agreement with MMC/MTAS, then why is there a petition with over 3,500 signatures saying to stop MMC and why were consultants not told the full story as to what they agreed to with regard to reforms?
Eleanor Tiangga, London

A: Professor Douglas and his review group colleagues said themselves that the principles of Modernising Medical Careers (MMC) continue to secure widespread support among professional leaders in the Royal Colleges and the BMA.

I could copy the other responses here but they are best characterised as hiding behind the Royal Colleges, the BMA & other “leaders of the medical profession”. What leaders?

But I am looking forward to her appearance on the 7 pm news tonight on Channel 4. I wonder what the strategy is for court tomorrow.

Update: Watch that segment from Channel 4 again.

She has just had to sit through a complete recap of the problems with MTAS for about 5 minutes.

Jon Snow: “You yourself have to resign”.

Unfortunately she was not challenged about her assertion that the Foundation Programme had been without problems.

Humphrey Hodgson, Professor of Medicine at UCL offered a clear alternative analysis.

And continual skewering of Patricia Hewitt by Jon on the application form.

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PFI deals are again in the headlines with the Commons Public Accounts Committee coming out with an update published today.

To date, proceeds for government from refinancing under the voluntary code amount to only £93 million. This amount is well below the indication provided by the Office of Government Commerce at the PAC hearing in 2003 that proceeds would be in the order of £175-200 million. The shortfall may be a reflection of some investors opting to defer refinancing in favour of realising gains through selling their shares in the secondary equity markets.

With more than 750 schemes costing £54.5bn already approved by the Treasury, Edward Leigh MP, chairman of the committee of public accounts, said: “Local public sector officials taking forward PFI projects such as hospitals or schools are often painfully lacking in commercial experience. The ill-conceived Norfolk and Norwich hospital refinancing in 2003 demonstrated this all too clearly.”

The Guardian & the Independent are interested with both feeling that the City runs rings round the public sector.

So do we have 3000 more community nurses or do we not?

A pledge made three years ago to have 3,000 experienced nurses in post by March this year has been delayed, with social workers and less qualified staff having to make up the numbers looking after patients with chronic illnesses.

The department’s latest estimate is that there were 1,470 community matrons working in the NHS in December, with an official NHS workforce survey suggesting that fewer than 100 were recruited last year.

What people do not seem to realise is that once services are slashed, it is very hard to build them back up again. Of course by then policymakers have lost patience & gone on to the next flavour of the month. From that bastion of management, the HSJ:

Breaking up an established ward and re-deploying large amounts of staff can destroy a ward and its team in four to eight weeks.

Is it a pledge for another day?

An £8bn increase in NHS spending in England this year will buy 390,000 extra operations, 400,000 more outpatient appointments and a new outreach service to help thousands of vulnerable people with long-term medical conditions such as diabetes and asthma, Patricia Hewitt, the health secretary, said yesterday.

The biggest-ever hike in health spending would dramatically reduce waiting times. By the end of next March, 85% of patients needing hospital treatment will have been admitted within 18 weeks of referral by a GP. Ninety per cent of those patients who can be treated without admission to hospital will get the care they need within the same deadline.

Other priorities over the next 11 months will include building up a squad of 3,000 community matrons to treat 220,000 long-term patients in their homes, avoiding the need for repeated visits to hospital.

And I saw the porcine aerial display squad practising manoeuvres nearby. This is what comes of not asking enough searching questions.

Does Gordon Brown’s proposal to make GPs work unsocial hours rank up there with Tony Blair’s pipe-dream of surgeons operating 24 hrs a day? What has happened to that policy anyway?

A number of letters take aim at the idea.

Despite all the spin, patients are not fools. They recognise a continuing therapeutic relationship with their doctor is more powerful than any polyclinic where they can see the next generic doctor on a taxi-rank principle and have to start from scratch again at each consultation. Patient satisfaction is at an all-time high - including with access.

Sure, if you ask people if they want us open at weekends, they might say yes - until they realise that we will then not be there on Monday; I already work 55 to 60 hours a week. We do not work in isolation. Other services are closed out of hours and we cannot work efficiently unless they are open, too.

The FT looks at Patricia Hewitt’s performance yesterday & wonders about management structures.

David Nicholson, the National Health Service chief executive, last week announced a new “leadership team” that had a single post of “director-general for commissioning and system management” in place of separate roles that reflected the “purchaser/provider” divide in the NHS.

With some in the private sector worried that Gordon Brown’s accession to the premiership might lead to a dilution of, or even a halt to, the government’s market-based reforms, Ms Hewitt said the decision to end the distinction between the two roles should not be seen that way.

The responsibility for ensuring that more hospitals became foundation trusts, and that more staff moved out of the NHS to create not-for-profit “social enterprises”, was being devolved to the 10 strategic health authorities, she said.

The move towards making NHS providers more independent needed to be pursued “primarily at the regional level”. London had led the way by creating its own separate purchaser and provider organisations, she said.

The new leadership team would not have a formal annual agreement with ministers over what the NHS should deliver.

Hmmm, an increased emphasis on social enterprises at a time when she needs to sell this idea to the NHS. Or am I being too cynical?

Is cleaning coming back in-house?

Health Investor (May) says that NHS managers have asked the Department of Health to keep cleaning services in-house and stop them being included in Private Finance Initiative contracts.

The Telegraph makes the case for co-payments as discussed yesterday.

Moving on to MTAS & the application for review is being heard in the courts today. Channel 4 produced a very good segment in the news last evening highlighting its pericious effects & which can be watched again online.

And more comment in the papers.

The BBC has just joined in with a review of the situation.

In a further sign of the mood of militancy, 72% of those who took part in the survey disapproved of the way the doctors union - the British Medical Association - had handled the situation.

And the Today programme on BBC Radio 4 got there too.

The BAPIO judgement is reviewed in the Times though I think they erred in basing their claim on just the issue of consultation.

Now for some wishful thinking. Doctors should be treated like gods says the Daily Telegraph. Now why would they want to do that? Am I dreaming?

In a truly decent world, surgeries and schools would be like palaces. Places such as the Brompton would be like cathedrals. Head teachers would earn as much as chief industrialists and hard-working GPs would be subject to the admiration of teenage wannabes and local authorities proud to pay more for their heroes. Great hospitals would be filled with art and would stand glittering on the hill of every city.

But we don’t think like that. We live in a society that is much prouder of its regiments than of its hospitals - keener to protect its citizens against alien ideologies than opportunistic diseases - and that is a terrible shame. It is shallow. It lacks hope and courage and goodness. In a perfect world, our nurses and doctors would fire our imaginations and our teachers would bang the drum. We would treat them like gods and pay them like rock stars.

Instead, we want to cut their wages. Politicians want to use doctors as something to kick around when the polls are against them. I don’t know where it comes from, but there has lately been a natural inclination in our culture to reward excellence with resentment - or even the bid for excellence, as no one would say that our services are always and everywhere as good as they should be. But neither are they the fag-end of hope, as some people would have us believe.

It is nice to be appreciated sometimes. Now for converting the other 54 million residents of the UK. One person at a time, that is how you build support.

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