The best thing about being a doctor

No, the best thing about being a doctor in the NHS today is having insider knowledge. Knowing the weak points in the system. Being able to identify where systems break down and having the know how, ability and confidence to intervene. Being able to remedy problems in a timely manner, averting disaster or just gently steering the plan back on course is something I am eternally grateful I can do. Not just for me but also for my friends and family.

Is knowing how to navigate the entirely fucked up bureaucracy of the NHS.

As an argument for wholesale reform it’s hard to beat, isn’t it?

83 thoughts on “The best thing about being a doctor”

  1. Same applies if you work in education, though to a lesser extent. The poor can take advantage of various loopholes in the benefits system if a family member works there. And so on. ‘Twas ever thus.

  2. The best thing about working at the Department for the Allocation of Labour, said Komissar Illyavich, is being able to make sure my friends and family don’t get shit jobs.

  3. So Much for Subtlety

    There is always a class divide. It is just that ours is increasingly based on secret knowledge, influence, pull, and connections.

    How this is preferable to wealth or birth I don’t know.

  4. Is there a health care system that doesn’t have a massively complex bureaucracy that people have to be guided through?

  5. Insider knowledge in extremely valuable, especially if your employer is one of the top five in the world, up there with Walmart and the Chinese Peoples Liberation Army.

  6. “My neighbour’s appointment that never materialised: she didn’t want to bother anyone (or didn’t know who to bother) to chase it up. Appointments get lost in the system delaying treatment and care. My friend’s mother-in-law, discharged from hospital on a public holiday with inadequate pain relief medication, unsure how to proceed. No information about her hospital stay accessible to the out-of-hours GP or accident department meant her further care began in the dark as she did not know what operation she had.”

    This is like the dark ages for most modern organisations. Appointments get lost? Patient data not moving around? This stuff was quite difficult 15 years ago, but everyone, from Tesco to Hilton to my local multiplex manages appointments, in the case of Hilton, globalised appointments, just fine.

  7. You almost lost an NHS consultant to his sunnier native climes: he considered his return before realising that, although he is never able to provide the best medical treatment (a source of disquiet to his conscience), he also does not have to put the patient first or even keep them alive for a regular income. He helps his friends navigate the system to ease the guilt.

  8. bloke (not) in spain

    The Stig quote. That’s exactly what’s going on here. Dad, a week discharged from hospital & the care company still not informed of his care requirements, despite repeated requests. I am, I gather, being regarded as “antagonistic” for not being sufficiently supine.
    Someone, later today, is about to find the true meaning of “antagonistic”.

  9. Father in law was in hospital for a week with some problem. Discharged of an evening, came home in a taxi and went to bed. We made sure he was up and OK in the morning and went to work. Was several days later that we found out the district nurses had tried knocking the door every day to see him. Being unaware they were coming or that he needed them he spent a lot of time sleeping or doing his hobbies, unable to hear the door.
    Would have been nice if they had communicated with us to let us know they were coming.
    Months later my wife was in hospital for a week, came home (again in a taxi organised by the hospital). And cared for her at home as you do.
    We kept getting questionairres to fill out about her stay at a convalescent place nearby. Someplace she has never been.
    Then we got a letter asking why she had not stayed there!
    Because she wasn’t referred? because she didn’t need that kind of help?
    Poor communication again.

  10. This can never be linked enough.

    Patients are given no information about how good or bad a particular doctor is, such as basic mortality figures, which they are in some other countries. The fiction that all doctors are equal ensures that bad ones have no incentive to improve. Too often, GPs have told me they would never send a member of their family to a certain hospital consultant, but they send their patients to him because they have to. Half of cancer operations are done by surgeons with no specialist cancer training, who have far lower survival rates than specialists, but there is no way you, as a patient, can find out.

  11. > This is like the dark ages for most modern organisations. Appointments get lost? Patient data not moving around?

    Don’t get me started. This is one of the factors that nearly killed my wife.

    She’s moved from the maternity ward to a medical ward (a thoroughly unethical move that we later discovered was almost certainly to get her bad outcomes off the maternity ward’s manager’s stats — but, like I said, don’t get me started). Nurse at the medical ward asks loads of questions to fill out his forms. One of the questions is “Do you have any children?” At this point, we start exchanging WTF looks. “How many?” One. “How old are they?” Ten days. You don’t fucking know this?

    This is being transferred from one ward to another in the same hospital — not that the new ward even knew that: they thought she’d been newly admitted via A&E. They didn’t even know her name. We’re pretty sure the sum total of data that came with her was “female, pulmonary embolisms”.

    That same ignorant cunt of a nurse kept Vic bedridden for two days, telling us bluntly that moving could kill her. This stopped when we discovered that that advice was based on her having only just started taking Warfarin when she was admitted, when she’d in fact been on it for days by then. Warfarin’s a fucking dangerous drug, and they didn’t even have records of how much of it she’d taken.

    I really will stop now, because I can rant for days about it. Eight years on, I still get really angry. Our eventual official complaint letter to the hospital, once we cut it down to the barest statement of the facts we could, ran to eight pages.

    Meanwhile, I can log onto Amazon and they can accurately predict what music I’ll like.

  12. bloke (not) in spain

    “..we found out the district nurses had tried knocking the door every day to see him…Would have been nice if they had communicated with us to let us know they were coming.”

    I have it, from the district nurse herself. District nurses are far, far too busy to submit to arrangements, appointments or any other impedance to their progress. We are expected to hold ourselves perpetually available to their convenience.
    So forget it.

  13. Hallowed Be,

    Yes, it most certainly can be monetised. An accountant is nothing more than a person who guides you through the jargon, bureaucracy, and specialist knowledge which is HMRC. A laywer is nothing more than a person who guides you through the jargon, bureaucracy, and specialist knowledge which is the legal system.

    You can even hire a Personal Shopper if you find the vertiginous floors of Harrods too tricky to navigate alone; although the analogy breaks down because the shop will happily provide you with one if you look like you’ll spend enough.

  14. “Not just for me but also for my friends and family.” Isn’t privilege nice? But money’s cleaner I think.

  15. “We are expected to hold ourselves perpetually available to their convenience.”

    Yep, relative of mine is undergoing long term treatment. Due to a complication she has recently had to receive twice daily injections. Local GPs surgery basically told her to bugger off when she asked to make regular appointments to get them done on her way to and from work. Disrtrict nurse would do them at her house, but could only give a 3 hour window for when she would come (morning and evening).

    Her consultant found out and taught her how to do the injections herself.

    Current hassle is getting the GP and pharmacist to agree an ongoing prescription for the medication *which is keeping her alive*.

    NHS: it’s the envy of the world.

  16. This is the Guardian, where they’re against private health care (the rich buying better treatment) and they’re against giving your friends’ children a bit of holiday work experience (institutionalising privilege).

    But to judge from the lack of negative comment they seem quite relaxed about State employees condemning ordinary people to substandard health care whilst gaming the system to get the best for themselves, their families and friends.

    Really, hanging is too good for them.

  17. Glendorran, no, the NHS isn’t the envy of the world, it’s the wonder of the world.

    The world wonders why on earth we put up with it.

  18. Bloke in North Dorset

    @Richard,

    For Guardian readers this is a feature not a bug. They’ll see themselves as part of the class that has doctors as friends, and if they don’t know a doctor then they’ll know someone who does or can help them navigate the system and get the best treatment.

    I wouldn’t put it past some of them to expect to walk in to hospital with a copy of the Guardian under their arm and get special treatment.

    If we had a truly well run, ie private, free at the point of delivery system they might have to queue behind chavs and Tories.

  19. Andrew M- would be interesting if a few retired GPs set up their own agency.. to manage your case for you. In all likelihood like the guy who built a road, the monopsony would act to close it down,,, but you could perhaps provide them with legislative protection?

  20. A friend of mine claims that a referral letter that his GP wrote for him to Addenbrooke’s (Cambridge) began “This Senior Examiner in the Natural Sciences Tripos and Fellow of …..”

  21. Sorry, that’s a bit of a non-sequitur. I read the Portnoy thing and was thinking about how shocked American slebs are when they run into the NHS. Musicians, comedians… they all agree with each other, so near enough.

  22. Nomenklatura.
    Ellie May’s conclusion is to rejoice that she is a member of the nomenklatura and can bring its benefits to her friends and relations.
    @ GlenDorran Things have got vastly worse since the NHS introduced professional managers. 50-ish years ago if I needed to see a doctor I would go along to the surgery after school and queue up to see my doctor (or any of the others if he wasn’t on duty). Last time I needed to, the surgery was closed – it was Monday and the notice on the door said surgery closed 1-2pm Tuesday-Thursday for staff training; the bureaucrats had decided staff training had to happen every working day but not to tell us; so I went back later and the first available appointment was a week on Friday. Just as well it wasn’t critical. When I was a kid the doctor would have come round *himself* if needed – “Tommy”, my parents’ doctor until he retitred, was famous for driving at up to 70 mph (this is a decade or more before national spped limits were invented) at night to emergencies.

  23. bloke (not) in spain

    Jeez! The Whittington! When Americans seek to confront the realities of the NHS they sure go for the biggie. Must be the Western pioneer spirit. Wrestling grizzlies bare handed ‘n that.

  24. You’re all wrong. It’s not the bureaucracy to blame here. it’s the nominally Coalition-run bureaucracy. If it was a Labour arse sitting in the Health Secretary’s chair then everything in the NHS (pbui) would be just fine.

  25. Ellie May’s conclusion is to rejoice

    Judging by what she’s written elsewhere (e.g. http://tinyurl.com/oogdouj), I’d say that she is in despair. It’s primarily a critique of the NHS, not a smug celebration of being on the healthcare gravy-train.

    As an argument for wholesale reform it’s hard to beat

    And yet (as I recall), you championed the piss-poor 2012 Health and Social Care Act – the byzantine complications of which have made things exponentially worse. Fragmentation is increasingly the norm.

  26. lost_nurse,

    “Fragmentation is increasingly the norm.”

    serious question: what’s wrong with that? Compared to 25 years ago, business is far more fragmented than it used to be, far more about passing things to specialists to do things rather than having in-house staff, and that’s done because it works better.

  27. @ lost nurse
    Try bloody well reading what I wrote – “to rejoice that she is a member of the nomenklatura and can bring its benefits to her friends and relations”. NOT to rejoice about the mess that has been made of a well-intentioned attempt by Attlee before Nye Bevan sold out and stuffed the surgeons’ mouths with gold.
    The article that you reference does show that she knows the NHS is a mess, but then so does the one that Tim references.
    We all have our NHS horror stories (such as my father-in-law, tough as old boots having qualeft school

  28. Bah!
    We all have our NHS horror stories (such as my father-in-law, tough as old boots having qualified for grammar school as an orphan, left at 14 to earn money, joined the RAF as soon as he was old enough, navigator/rear gunner (much higher casualty rate than pilots) on the North-West Frontier in the 1930s, various other battlescenes 1940-60s – I think Aden was the last – staffing at Bisley into his 80s but killed by an infection picked up in hospital). My ludicrous story was the senior A&E nurse who wanted to put my left arm in an undoable sling and told me that everyone did and undid buttons with their right hand – fotunately the junior nurse who was delegated to strap me up either knew that men did up buttons left-handed, or was willing to listen, and gave me a collar-and-cuff sling.

  29. bloke (not) in spain

    To update on district nurses, mentioned above. Having held ourselves ready for a couple days, a district nurse was on the doorstep at 4pm. To change the dressing on Dad’s saucer sized bedsore became detached Saturday. The next bi-weekly change of dressing will occur Thursday at some unspecified hour – thus neatly spreading the task over their working week.
    Think on that for a moment, people.

  30. Oh, another of my glorious NHS tales:

    My wife’s uncle was in the end stages of stomach cancer. My wife and her mother sat with him throughout his last night. Mercifully, he was so full of morphine he was not (we hope) in any pain.

    However my wife’s lasting memory of her uncle’s passing is having to listen to the hysterical laughter and chatter of the night nurses as they giggled over Facebook. The thought that this was inappropriate for those looking after a ward of dying people seemed to escape them.

    Yes I know that they are not representative of all nurses, but every time some union thug appears on TV to talk about the selfless angels of the nursing profession my wife spits blood.

  31. @john77 – I understood your comment first time round, thanks. I’d also suggest that medical professionals “rejoicing” in their know-how is a feature of healthcare systems in all times & places. Her (rightful) charge is that the public do not have that luxury – and speaking as somebody who comes from a sprawling family of doctors and nurses (and the occasional vet), I would agree. But that doesn’t necessarily change the nature of the problem – the author is an anaesthetist. Gas docs are always bang slap in the middle of the tough stuff in acute care, where the most important thing (from the point of view of the patient & given all the variables up-to-and-including Murphy’s Law) is that risk and expertise are sufficiently pooled. My concern is less with how she utilises her knowledge to navigate that system herself, and more that she does her job properly.

    @The Stigler: re fragmentation – in the sense of a proper market operating, yes (and here’s the eternal argument re viability of a market in healthcare… some services are going to be amenable to competition, some things less so – see above re acute settings). My concern is what’s happening right now – continuity is breaking down left, right & centre. There’s less and less in the way of single-point-of-contact and joined-up care… and that’s exactly what patients (& their families) need.

  32. lost_nurse

    It would be great if NHS staff had representative bodies that could point out and argue for the correct reforms and improvements. We could really do with their input.

  33. “the mess that has been made of a well-intentioned attempt by Attlee”: the idea of an NHS was accepted by the Conservatives and Liberals long before Labour. I’ve often wondered whether Labour’s late adoption of the policy explained the ballsed up version they introduced.

  34. @ lost nurse
    “I understood your comment first time round, thanks.” Well, why pretend not to?
    “My concern is less with how she utilises her knowledge to navigate that system herself, and more that she does her job properly.” Fair enough – I agree with that
    However nothing else that you said (apart from your family medical history: mine goes in for maths & Computing) justifies treating patients so badly. “Go to work as an Actuary in the City of London in a dozen-year-old running vest because I as the great glorous A&E nurse think you don’t need to use buttons.”. (And that was after a three-hour wait to see a competent junior doctor who correctly diagnosed the infection in about one minute fllowed by two or three double-checking all alternative possibilities). The thing which totally revolted me was when we took no 2 son to be told of a diagnosis (having to take a day off work to accompany my wife to be told something already decided is and was not a problem relative to this) we got put in a waiting room full of very pregnant women every one of whom was told to attend from 9 am although the last was not scheduled to be seen until 1 pm.

  35. @ Jack C – It seems the only current input is from seconded management consultants, for whom Monitor is a job creation scheme – all at some remove from the sharp end. DoH is as secretive as ever, of course – but the unprecedented level of public scrutiny is encouraging. Twitter sees all.

    It would be great if incompetent staff were sacked.

    I’ve no problem with incompetent/negligent staff being disciplined and/or sacked (and don’t get me started on the self-styled ‘Muskeeters’ at Morecombe Bay…). I don’t equate representation with protectionism.

    That said, it would also be great if wards were properly staffed – clinical incidents often arise from the simplest things: the lack of a spare nurse to escort a patient to a scan… and it snowballs from there.

  36. justifies treating patients so badly

    I’m not going to act as an apologist for the NHS where it falls down, but I’m certainly going to stand up for it where it deserves defence. We can sit here and trade andecdotes about treatment – but the only thing that will resolve issues on the ground is proper organisation, adequate manpower and suitable capacity. A monetised-front-end system will still require investment in all three – the French and Germans ain’t doing more-with-less, though there is much we could productively borrow.

    Also… I don’t mean to belittle your problem with the buttons (and – ask any OT – it’s a major factor in physio/rehab), but – frankly – if you are otherwise fit and well, having to (temporarily) wear alternative clothes to work isn’t a life and limb (ergo A&E) issue. IME, senior A&E nurses can be somewhat brusque, especially if they have been managing a busy resus/majors bay – that’s not to excuse it, merely an observation. Anyway, it sounds like the nurse who strapped you up had better customer care skills – hopefully, he/she is still out there, putting ’em to good use.

  37. @ lost nurse
    You attack my reference to ludicrous behaviour while ignoring my reference to appalling behaviour. Making heavily pregnant women wait for hours and hours because the NHS bureaucrat cannot be bothered to schedule an appointments system is scandalous. Not as bad as Mid-Staffs but stillscandalous.
    “having to wear alternative clothes for work” Bullshit!
    Have you tried turning up at work with neither skirt nor trousers or without either a bra (that usually requires two hands) or blouse?
    *Now* I could do a lot of work from home but at the time that was not an option and turning up without a shirt and suit would have been totally unacceptable and marred my reputation for the rest of my career. It wasn’t totally sexist at that time to ignore shoelaces because some men wore slip-on shoes just stupidly inconsiderate.

  38. So Much for Subtlety

    lost_nurse – “I’m not going to act as an apologist for the NHS where it falls down, but I’m certainly going to stand up for it where it deserves defence.”

    Come on. Surely you can see how ridiculous that sounds? You are going to do your usual Union Rep speech about how all of this is the fault of the management and the only solution is more money and more members.

    “We can sit here and trade andecdotes about treatment – but the only thing that will resolve issues on the ground is proper organisation, adequate manpower and suitable capacity.”

    See? The fact that private businesses can do customer service and the NHS can’t is proof of what? That the NHS needs more managers, more nurses, more money – and less accountability to their clients. It is like you are stuck in the 70s. Only without the cool cars.

    “A monetised-front-end system will still require investment in all three – the French and Germans ain’t doing more-with-less, though there is much we could productively borrow.”

    Such as? Go on. Tell me what you would accept borrowing from the French or Germans? Let me suggest what you won’t accept – diverse suppliers, a market of suppliers in fact.

    “IME, senior A&E nurses can be somewhat brusque, especially if they have been managing a busy resus/majors bay – that’s not to excuse it, merely an observation.”

    Sure they can. They work for the government. They don’t need to be nice to people.

  39. We can sit here and trade andecdotes about treatment

    Isn’t it interesting that such a small sample size (there can’t be more than a couple of dozen regular commenters on this blog) has so many NHS horror stories?

    One might think the failings in the NHS were chronic, systemic and endemic.

  40. See? The fact that private businesses can do customer service and the NHS can’t is proof of what?

    Customer service like this, you mean? http://tinyurl.com/lgokfmx

    The reference to the 70s is pretty telling – the good ol’ binary language of left/right & markets/unions, shorthand for not engaging with the present. Even more telling that you accuse me of desiring “less accountability” – do you have any grasp of current commercial confidentiality clauses in the UK private healthcare sector?

    Euro-land: perhaps you can tell me how the “market of suppliers” operates in acute care (the patch I know best) in Franco-German systems? FWIW, I’ve nothing against rigorous (non-exclusion), better-invested mixed-economies in healthcare (e.g. their lead times in cancer screening). But even in said systems, platitudes about competition tend amount to very little in acute care – in other words, if I’m in a bad way, get me to a big teaching hospital asap. Besides which, this kind of mixed-economy isn’t what is happening under the ’12 HaSC Act (which, in extension of NuLav reform, has merely shifted public money – but not risk – into private supply pockets). All very well gushing about Amazon predictive purchasing – UK healthcare privatisation will be more like the cartel-cluster-feck that is rail and utilties. And even in the best Euro systems, marketisation in healthcare invariably pushes up costs – get ready for it.

    They don’t need to be nice to people.

    I’ll tell you the qualities I like in an A&E nurse: battle-hardened, no-nonsense, firm-but-polite, will keep a beady eye on me (even sit on me) if I need it, and – equally – will tell me firmly-but-politely to piss off if I’m wasting ED time. I can’t believe that you have no grasp of what an A&E department is, what constitutes an acutal emergency, or why it can sometimes be a brutally horrible, deeply distressing place. Buttons are very low on the scale of concerns.

    marred my reputation for the rest of my career.

    You have got to be taking the piss – if you think temporary difficulties with work attire in an otherwise healthy individual constitute an “issue” in emergency care, then you need to grow up. As for pregnant women in clinic waiting rooms – well, increasing the number of admin staff (usually identified as “bureaucracy” in the media assault on the NHS) would be a good start. But, no, let’s cut them back instead (as is happening).

    This thread has descended into realms that are beyond pathetic – buttons, FFS.

  41. So Much for Subtlety

    lost_nurse – “The reference to the 70s is pretty telling – the good ol’ binary language of left/right & markets/unions, shorthand for not engaging with the present.”

    Amusing. You are stuck in the past, defending a system that has failed, sounding like a 70s Unionist, and not the good sort, and yet you manage to accuse me of not engaging with the present. As I said, you talk a good talk but you don’t mean it. You are not here to do anything but shill for the NHS.

    “Euro-land: perhaps you can tell me how the “market of suppliers” operates in acute care (the patch I know best) in Franco-German systems?”

    Of course you do. Move the subject away from anything that could suggest competition for the NHS. Move it to somewhere you feel safe demanding a return to the 70s.

    “FWIW, I’ve nothing against rigorous (non-exclusion), better-invested mixed-economies in healthcare (e.g. their lead times in cancer screening).”

    I kind of think you do. You have a track record after all.

    “UK healthcare privatisation will be more like the cartel-cluster-feck that is rail and utilties. And even in the best Euro systems, marketisation in healthcare invariably pushes up costs – get ready for it.”

    It hasn’t in Singapore. Which is the model we should be following. I agree that anything this government does will be a cluster-f*ck of monumental proportions. But that is because the same useless gits who run the NHS run the rest of the government as well.

    “I’ll tell you the qualities I like in an A&E nurse: battle-hardened, no-nonsense, firm-but-polite, will keep a beady eye on me (even sit on me) if I need it, and – equally – will tell me firmly-but-politely to piss off if I’m wasting ED time.”

    Sure. And yet none of that was the problem was it?

    “Buttons are very low on the scale of concerns.”

    But an interesting in the continuing functioning of the patient in his normal life should not be.

    “marred my reputation for the rest of my career.”

    That was not by me. Don’t quote it as if it was.

  42. bloke (not) in spain

    “All very well gushing about Amazon predictive purchasing – UK healthcare privatisation will be more like the cartel-cluster-feck that is rail and utilties.”

    Of course French & Spanish ( I don’t know German) healthcare isn’t the slightest like UK rail & utilities. But then their rail & utilities aren’t like UK rail & utilities. If privatised UK health care ends up like its rail & utilities it’ll be because it too has been bequeathed the inheritance of the immediate post war decades of nationalised endeavour. Achieved what the Germans failed.

  43. bloke (not) in spain

    However i do find John’s obsession with his buttons puzzling. I’ve never had the slightest difficulty doing up buttons with either hand.(or undoing them either 😉 Does anyone? How odd.

  44. @ lost nurse
    Deliberate ignorance of the patient’s dress code is not the point. It is the refusal to listen to facts. Which has a very close parallel to Mid-Staffs and Furness. Fortunately I survived (I might not have if the junior nurse had strictly followed the self-important senior nurse’s intructions – which were *not* dictated by the doctor – since I might not have been able to get back into my flat).
    As for pregnant women, the deterioration in caring about patients (not the same as “patient care”) follows a massive increase in the number of admin staff, so a further increase would not be a start, let alone a good one.

  45. In short order:

    That was not by me. Don’t quote it as if it was.

    @SMFS: Yes, to be clear – last paragraph of my comment was directed at john77. I should have attributed quotes.

    You are not here to do anything but shill for the NHS.

    Shrug – most of my concerns reflect what I see on a day-to-day basis, good and bad. I speak as I find. Good luck transferring the Singapore model to an utterly different (social, economic, geographical) setting.

    @B(n)IS: I probably shouldn’t have introduced trains into the argument – it’s a whole ‘nother thread.

    @john77: “the deterioration…follows a massive increase in the number of admin staff” – don’t confuse admin & managerial staff (especially not the variety of managerial staff who took their eyes off the ball at MidStaffs…. this aside from the fact that the NHS needs good – inc non-clinical – managers). I’m talking ward clerks, IT, back-office etc. It is precisely these staff who keep things like clinic lists running in orderly fashion (as an acute area, we have the luxury of ward clerk cover at weekends – it makes a huge difference). Nonetheless, job losses among admin staff are frequently reported by politicos as “cutting bureaucracy” – which is ironic given that the bonkers HaSC commissioning process has actually increased bureaucracy, seemingly tenfold. All a good earner for Crapita, McKinsey etc, of course – in blunt terms, the “NHS” is now just a kitemark.

    Anyway, that’s enough rancour & mutual bafflement for one evening.

  46. lost_nurse,
    I was pulling your leg about representative bodies. I mean, how many do you need?

    Booking everyone in at the same time, and it’s not just pregnant women, is NHS normality and has nothing to do with staffing. No one else has thought of organising things in this manner, and no one else would. It’s simple selfishness; the inefficiency it causes (ie having all those bodies on site) is just a by-product.

    It’s good back-up for “we’re so over-whelmed” whinging though I suppose.

    And who else would have staff car-parking nearest the doors, especially if the clientele were often ill, elderly, infirm, etc? Again, a high reading on the Kuntometer.

    I don’t think you can bring A&E into this; there’s not the room for bullshit there. Bet you want to string up some of those lazy GP’s though? (Privately, no word to outsiders obviously).

  47. lost_nurse,
    There are always spare staff in hospitals, they’re not exactly hidden.

    If senior NHS staff genuinely cared, reform would be insisted on from the inside.

    Taking responsibility is tough, but usually rewarding.

    Oh, and this is revealing: “especially not the variety of managerial staff who took their eyes off the ball at MidStaffs”

    Did no one else notice? Doctors and nurses for example? “Not my job” I suppose.

  48. Ah, at the close:

    I was pulling your leg about representative bodies

    I did wonder – the caveat being that IMO the various existing rep bodies do a generally shite job of representing the interests of anybody (patients and staff).

    Bet you want to string up some of those lazy GP’s though?

    There’s many excellent GPs out there – and much of the good work & graft goes unrecognised. But OOH cover can still be an issue – inappropriate referrals/buck-passing to hospital and ambo services. Lots of GP posts are going unfilled, too.

    Anyway, I’m well past sensible hours. Over & out.

  49. Oh, and this is revealing: “especially not the variety of managerial staff who took their eyes off the ball at MidStaffs”

    Read the Francis Report. It doesn’t excuse individual (clinical) neglect – but it has much to say about the prevailing managerial culture, and how clinical priorities were distorted (e.g. by the drive for Foundation status).

    There are always spare staff in hospitals

    Spare nurses? Spare physios? Spare porters? Not in my experience.

  50. I have not a horror story, but a ludicrous example of misallocation of resources.

    I was admitted, via A&E, to hospital on a Friday night with kidney stones. On Sunday I was informed that, as they were not emerging of their own accord, they would be removed by surgery on Thursday. I suggested that I’d return to hospital on Thursday but was told that if I left I would lose my place on the surgery queue. So, despite being in no pain or danger, I had to fill a hospital bed for four extra days to satisfy their procedures.

    As they couldn’t lock me up, I left in the mornings and returned in the evening, but they were mighty pissed off about it.

  51. Lost nurse,

    > Buttons are very low on the scale of concerns.

    Fair enough — if anyone were asking for an entire A&E department to band over backwards to use lots of resources to get the super high-tech button-doing-up machine. But that’s not the case. All John was actually referring to was a simple request: “Could I have one of those normal and readily available slings that you’ve got plenty of, please, instead of these ones?” Acceding to that request wouldn’t exactly have involved telling someone with a fractured spine to wait three hours. But it would have involved giving the remotest fuck about patients — something far too many NHS staff are far too bad at.

    I think you’re going over-the-top about the buttons thing — it’s hardly the only anecdote in this thread — but it is quite a good indicator of the prevalent attitude in the NHS. It’s all very well your saying that they have better things to worry about than our ability to do our jobs, but the thing is, when you take on a state monopoly for a vital service, then yes, you need to care about how people can do their jobs — because you’re treating everyone, and if everyone can’t do their jobs, the economy collapses. The NHS assigns us a doctor based on where we live rather than where we work, then allows us to see that doctor only during normal working hours. Because NHS staff shouldn’t have to work unsociable hours to accommodate us but we should have to take time off work to accomodate them. I once had to spend hours trawling a hospital at a weekend to try and find a doctor to tell a nurse not to give my wife a dose of a drug that we knew was too high (the dose was dependent on a reading; the reading had changed considerably; but the nurse flat-out refused to change the dose, even when we were telling her it was extremely dangerous, because IT WAS WRITTEN DOWN, for fuck’s sake). It took most of a day. It was made clear to me at every turn how unreasonable it was of me to expect a doctor to be available at the weekend in a fucking hospital, and how grateful I was supposed to be that the sole one at work eventually got round to seeing a patient. Working in call centres, in IT suppoprt, in software development, and in finance, it has been entirely routine for my entire working life for me to work anti-social hours, nights, weekends, etc. And none of that stuff is as important or urgent or as well-paid as working for the NHS. Yet NHS staff either refuse to work outside office hours or want a fucking round of applause when they do.

    The discussions of NHS costs and NHS waiting lists are interesting to me, in that the calculation of costs never takes into account the economy-wide loss of productivity caused by having people not able to work at full capacity or at all for months at a time while they wait for operations. Or the time wasted by millions having to take half a day off work for a routine appointment. The NHS costs a lot more than the official figure.

    > As for pregnant women in clinic waiting rooms – well, increasing the number of admin staff (usually identified as “bureaucracy” in the media assault on the NHS) would be a good start. But, no, let’s cut them back instead (as is happening).

    Oh, what absolute utter fucking bollocks. Just how many staff do you think it takes to schedule appointments? My wife alone handles this for an entire charity. It’s pretty easy with paper; with computers, it’s trivial.

    The reason patients have to sit around waiting is that, from the NHS’s point of view, it’s a feature, not a bug. This is basic queue management: you can maximise the productivity of your staff by minimising the amount of time they spend between patients, and one way you do this is by making sure the next patient is always ready and waiting. Assuming that some patients will always be late, and that some appointments may even occasionally be over more quickly expected, you achieve this by getting the patients to turn up early. At the Ulster Hospital’s maternity ward, for instance, you might be (and we were) given appointments at 1 or 1:30, even though the entire staff are at lunch from 1 to 2. The staff aren’t struggling to provide convenient appointments but sadly failing because they need more resources; they are succeeding at their task of making people sit around waiting because that optimises workflow. If they had more staff, they’d get even better at it, which would be even worse for patients. Again: we the bastard public are expected to sacrifice time for the convenience of the NHS.

    This is the same reason some call centres make you sit on hold for ages, and sometimes the bad ones even have a computer phone you and put you on hold for a few seconds before they start talking to you. You can also watch Ikea pull staff off the tills when they have queues, to make the queues longer. They’re not understaffed; they’re fucking you around for money.

    > That said, it would also be great if wards were properly staffed – clinical incidents often arise from the simplest things: the lack of a spare nurse to escort a patient to a scan… and it snowballs from there.

    An excuse this lame would not be accepted from a bank or an IT firm. Nor should it be.

    Jack C,

    > Booking everyone in at the same time, and it’s not just pregnant women, is NHS normality and has nothing to do with staffing. No one else has thought of organising things in this manner, and no one else would. It’s simple selfishness; the inefficiency it causes (ie having all those bodies on site) is just a by-product.

    See above. Much as I’d love to just blame the NHS for this one, queue management comes from the world of telephony — it was studied and used for optimising exchanges long before we even had call centres, who of course took it to a whole new level. The point is that call centres and the likes of Ikea have to try and strike a balance between optimising their own efficiency and pissing off their customers. It’s that other side of the see-saw that the NHS is missing.

  52. lost_nurse
    Weasel words again: “There’s many excellent GPs out there – and much of the good work & graft goes unrecognised”

    You could say that for any job. Meanwhile, GP’s are not just inferior to dentists and vets in terms of organisation and customer service, they’re shockingly bad by any measure.

    And, no, they don’t need more money to solve this.

  53. > much of the good work & graft goes unrecognised

    In this country, you are lectured at length from the moment you start school about how the NHS is a completely wonderful national treasure and that everyone who works for it is some sort of angel. Speaking as someone who’s been doing quite a lot of good work and graft for RBS lately, I’ll take some of that lack of recognition.

  54. Well, there are many excellent bankers out there, and much of the hard work and graft goes unrecognised.

    Some managerial staff took their eyes off the ball in the period leading up to the crash, but compliance teams were clearly under-resourced.

    We should also be looking at how we can properly fund the England ODI team.

  55. “> much of the good work & graft goes unrecognised”

    negelcting that *doing the job you are paid to do* is recognised by, you know, being paid your salary.

    In the words of Chris Rock: “What do you want? A fucking cookie?”

  56. lost_nurse,

    “My concern is what’s happening right now – continuity is breaking down left, right & centre. There’s less and less in the way of single-point-of-contact and joined-up care… and that’s exactly what patients (& their families) need.”

    But it isn’t joined up now, with a GP, walk-in centre and the local hospital dealing with my child’s infection. We don’t turn up, give a name, confirm our details and up pops a record of everything that’s happened. I suppose our GP is our point of contact, but they aren’t there on a Sunday, or even available at 5 minute’s notice.

  57. @Jack C

    Weasel words again:

    GPs get routinely slagged off – by graft going “unrecognised”, I meant in the sense that things running smoothly is slow news day stuff, not that they should be showered with honours and tears of loving gratitude. The good GP practices do the lion’s share of keeping patients from inappropriate hospital admissions (or bothering Ambo crews for ECGs – it happens), running proper district/pallative care, etc. But twist my words to suit yourself, whatever.

    @Squander Two.

    the nurse flat-out refused to change the dose

    Aside from certain specialist roles, nurses do not prescribe medication. I don’t know what meds you are talking about (an anticoagulant? insulin?), but amending a prescription is a good way to get struck off the nursing register.

    As for eventually finding a doctor to amend that dose, you are talking about how the NHS organises weekend medical cover, not NHS staff being “unwilling” to work unsocial hours. I work in an area where emergency surgery carries on 24/7, regardless of the time or day of the week. We manage – but all would agree that the levels of medical cover at the weekend should be improved.

    Admin: as a busy admissions unit, we function far better with a ward clerk than without – and on the days when we have two, even better. Where I work (a large-ish inner city teaching hospital) does a good job of managing its appointments, even when they have to resort to running elective surgical lists through us (as sometimes happens, to make best use of theatre slots). Certainly, across the country, there has been queue-gaming in terms of waiting lists, but – right here – we see patients promptly, according to clinical stability – which is as it should be. We don’t game the queue like IKEA, for pity’s sake. The kid with the potentially perforated appendix who just arrived will take priority, and so on – even if you were here thirty minutes earlier. And ward clerks make that process flow properly: taking details, printing admission documents, putting them on the system. I can walk into a clinical area and instantly tell if they haven’t got sufficient clerical support. My point was simple enough: when clamouring for cutting dead wood, “admin” staff are frequently treated as “bureaucracy” in tabloid head-counts of NHS staff. They ain’t.

    Which leads me onto…

    An excuse this lame would not be accepted from a bank or an IT firm.

    Is the corrollary to this statement that you believe wards (especially general medical and elderly care wards) are sufficiently staffed? Given your extensive comment on time management, you must have some fairly firm ideas on what constitutes an adequate (i.e. “safe”) nurse:patient ratio. Give me some numbers.

  58. But it isn’t joined up now

    It should be, it often isn’t. I’m reasonably lucky in that I live in a city well-served by GP practices, med centres (and walk-in clinics – the ones that are left) all in proxmity to large teaching hospitals. My worry is that many of the “willing providers” now being fudged in by CCGs aren’t interested in actually providing, so much as buck-passing to acute care. There’s a certainly an ongoing decline in “old school” GP practices, and empire building by larger GP conglomerates.

    That said, the call-up for digitised patient data/records should be easy enough – I don’t know what’s going on there. Hope your kid is feeling better, anyway.

  59. (or bothering Ambo crews for ECGs – it happens)

    Comments written in haste – and I’ve just realised how some on here will read this. I mean GPs (not patients) bothering Ambo crews for ECGs.

  60. S2,

    “The point is that call centres and the likes of Ikea have to try and strike a balance between optimising their own efficiency and pissing off their customers. ”

    But they’re constantly working to improve both. Buying insurance used to be a PITA. Go into town, queue, go through everything. Inconvenient for me, and expensive for them (and hence, for me). Phone insurance comes in – not much difference in convenience, much cheaper for them. Internet – much more convenient for me, even cheaper for them.

    Many NHS supporters have a Malthusian outlook – they see increases in output as only coming from increases in inputs. Referrals are still done by post – what’s the cost of people dealing with those, filing them, chasing lost ones, instead of the consultant just recording the results in a web form and passing it back to the GP?

  61. lost nurse,

    > you are talking about how the NHS organises weekend medical cover, not NHS staff being “unwilling” to work unsocial hours.

    Are you seriously trying to claim that those are unrelated?

    > Aside from certain specialist roles, nurses do not prescribe medication. … amending a prescription is a good way to get struck off the nursing register.

    I could go into the details of what had gone wrong here, but, frankly, who cares? The patient does not care whether the fuck-up is that the doctor left the wrong instructions or the nurse is following the right instructions wrongly. The unavailability of the doctor is a problem either way.

    A number of diabetics — who give themselves their own medicine every day — are killed by NHS hospital nurses every year, thanks to the policy that patients must not be allowed to adminster their own drugs while in hospital and it must be handled by qualified medical professionals. Some of those patients get to watch themselves being given what they know to be a lethal dose against their protestations. Some have had security called and been held down because their refusal to take their medicine can only mean that they are being uncooperative. Imagine that horror. And spare me the sob-stories for the fucking nurses who did it. If they hadn’t killed that patient, they might have been struck off? Oh, the poor things.

    Thankfully, my wife’s endocrinologist was excellent and had a policy of telling the maternity ward that his patients were allowed to administer their own insulin and to take it up with him if they had a problem with it. Not everyone’s that lucky.

    > Certainly, across the country, there has been queue-gaming in terms of waiting lists

    No, the discussion wasn’t about long-term waiting lists; it was about short-term queues measured in minutes and hours, not months.

    > We don’t game the queue like IKEA, for pity’s sake.

    Good for you. Some wards and clinics do. It is in fact a perfectly rational thing to do, given the incentives.

    > The kid with the potentially perforated appendix who just arrived will take priority, and so on

    I specifically said I was talking about maternity appointments. Just to be clear: these are the appointments for routine pre-natal check-ups at a maternity ward. There are no emergencies — and, if there were, they’re handled elsewhere by other staff. We went to these a lot (my wife’s complications mean she got checked every two weeks), so got to see how it was being done. And the appointments are simply made at least one hour early, as evinced by the fact that you can get a 1 o’clock appointment when the entire staff take lunch from 1 till 2. You can’t dispute that by talking about emergency appendectomies.

    > even if you were here thirty minutes earlier.

    You say that as if we’re talking about people turning up early. I’m not: I’m talking about patients turning up at the time they were told to turn up.

    > My point was simple enough: when clamouring for cutting dead wood, “admin” staff are frequently treated as “bureaucracy” in tabloid head-counts of NHS staff.

    But that wasn’t your only point: you specifically responded to a tale of pregnant women all being told to turn up at 9 and then made to wait for hours by saying that more admin staff would solve that problem. My point was very simple: if the staff are trying to make patients turn up early (and, in some wards and clinics, they are), then more admin staff will not change that. Giving a fuck about the patients’ lives would change it.

    It would also cost money: those little two- or three-minute gaps between patients add up to a large cost — which is precisely why queuing is arranged to avoid there being any gaps. The centralised funding structure of the NHS will therefore always create pressure to maintain queues at the expense of patients’ convenience.

    > Given your extensive comment on time management, you must have some fairly firm ideas on what constitutes an adequate (i.e. “safe”) nurse:patient ratio.

    Er, why?

    Given my experience of nurses and midwives and doctors, I would say with some confidence that, as long as it remains damn-near impossible to get the bad staff out of the system, there is no magical staff:patient ratio that will make everything OK. I have no doubt there are understaffed wards. I have also been in wards where the care could have been dramatically improved by cutting staff numbers in half — as long as you cut the right half.

    The NHS may or may not have a problem with staff numbers. But no increase to the number of staff will fix its current problem with staff attitudes.

  62. And spare me the sob-stories for the fucking nurses who did it. If they hadn’t killed that patient, they might have been struck off?

    With respect, you are conflating several different issues. It’s an enviroment in which a decimal point in the wrong place can kill. If a nurse is worried about a prescribed dose, they shouldn’t give it. And if a patient is concerned, they should refuse it. There are no gounds (beyond highly specific “best interest” emergency situations) for making patients take medication without consent, still less calling security. That doesn’t mean nurses should start re-writing drug charts – I don’t think you would be so rash as to advocate an ad hoc approach to prescription, medication management or double-checking (I’m excluding valid self-administration here – the patient is the expert). By way of bringing all this to close, I should should stress that I am entirely in agreement re diabetic patients (particularly susceptible to complications if admitted as surgical emergencies) – and thankfully, as with your wife’s endocrinologist, we (generally) have good support from the relevant medics, specialist diabetes nurses & ward pharmacists. I’m not claiming it’s like that everywhere.

    Re clinics: yes, triage and routine clinics are two different kettles of fish. It doesn’t change the fact that both require sufficient clerical support. I can’t speak for where you & your wife attended ante-natal clinics, but I know that here they make maximum use of flexible booking, text alerts, ring-backs etc – so as to keep things moving. Acute admissions is different, obviously – and (bar those critically-unwell patients who need theatre ASAP) there is inevitably a certain amount of sitting round waiting for blood/X-Ray/scan results to return & then be reviewed by the senior surgeons – but most accept that in good grace, if they can see that wheels are turning. Many generic presentations (e.g. “abdo pain”) may not have an immediate & obvious diagnosis – which often means a watch & wait approach (are blood results improving?). That in itself can be frustrating… but there is no easy short-cut. As to the general availiablity of doctors – yes, give us more of ’em (and beds). Bring us up to a respectable Franco-German number… but however you bake & slice the cake, provision-wise, it will require European levels of investment. (http://www.nhsconfed.org/resources/key-statistics-on-the-nhs)

    I have no doubt there are understaffed wards.

    In my view, general medical and elderly care wards can’t be considered safe until there is a trained nurse:patient ratio of 1:4. Sure, fire those who are negligent – but it won’t solve poor care if competent staff are run ragged. If buzzers are going unanswered – ask first if they are being deliberately ignored, and then ask why. If it’s because lard-arses are polishing their rears whilst checking Facebook, then fair enough – feel vindicated. And whilst I’m not denying that possibilty, it’s more likely that nursing & ancillary staff are too overstretched to give proper care (care which must also be legally documented). All here are welcome to enrol as care assistants and tell me if I’m wrong. You may well view this as whinging – but it’s the simple reality of the matter. In two decades (on and off), I’ve seen more go wrong because of under-staffing than any other factor.

    Anyway, it’s a nice evening – I’m off out.

  63. PS For info: current RN:patient ratios on general medical/elderly care wards are usually between 1:6 – 1:8 (tending towards the latter – wards are required to display staffing numbers, you should be able to check). It’s not sufficient.

  64. @lost_nurse:

    Thanks for your last few responses. I know that you take (and give) a lot of abuse round here, but your exchanges with SQ2 have been civil and informative.

    You’re right, I don’t know the ins and outs of healthcare, just my own personal experience (and that of others). But that has been enough for me to realise that the NHS doesn’t work. What pisses me off is the immediate response of a certain section of society who don’t want any change to the Holy and Sacred NHS, despite all evidence presented to them.

  65. Some of those patients get to watch themselves being given what they know to be a lethal dose against their protestations. Some have had security called and been held down because their refusal to take their medicine can only mean that they are being uncooperative.
    Hold on there. The law is clear on this: except if mental incapacity is established, treatment cannot be administered against the patient’s wishes. So if what you say is true, the medical staff responsible are criminally liable. Can you back up what you say?

  66. the immediate response of a certain section of society

    @GlenDorran: I certainly don’t mean to dismiss experiences of poor care – I see it myself, all too frequently. I suppose my chief concern is that reform amounts to meaningful improvements… and that “good” services don’t get trashed in the process.

    Very little time today to comment, but PaulB is right regarding breach of consent in the treatment of patients with capacity – it’s a serious offence. That’s not to underplay the wrongful/mistaken (i.e. wrong dose) administration of insulin, which is an enduring issue (again, diabetics are the classic “expert” patient – they will know). In short: right medication, right dose, right patient, right time, right route – and properly-written drug chart!

  67. “…and that “good” services don’t get trashed in the process.”

    And I know that such services exist. My relative who is getting the long term treatment has been receiving excellent care from the specialist hospital ward she attends. Nurses, doctors, auxiliaries all caring, attentive and professional. It just reinforces how terrible some of her other experiences are.

  68. > If a nurse is worried about a prescribed dose, they shouldn’t give it.

    Agreed. But, in some cases (including in front of my eyes), a patient repeatedly telling a nurse that the dose is dangerous and explaining exactly why is not enough to worry the nurse.

    > And if a patient is concerned, they should refuse it.

    Agreed. But of course many patients are at nurses’ mercy. Some can’t move; some can’t talk. I’ve watched my wife be given the wrong medication by nurses at least three times, two of them dangerously.

    > There are no gounds (beyond highly specific “best interest” emergency situations) for making patients take medication without consent, still less calling security.

    Agreed. And yet it happens. Because far too many medical staff think another valid reason is “I’m an expert and you have to do what I tell you.” To be fair, I think that’s a problem with the medical profession in general, not just the NHS. But the NHS’s structure makes it harder to fight against it.

    Paul B,

    > Can you back up what you say?

    Reported in Diabetes UK’s magazine some years ago. So no, I’m going from memory. Until her endocrinologist explained that he insists his patients be allowed to self-administer, my wife was terrified of going into hospital. We’ve seen so much routine incompetence, she had every reason to be.

    > if what you say is true, the medical staff responsible are criminally liable.

    Yes, and, as we’re seeing in the news lately, all you need to bring them to account is a five-year public inquiry after more than a decade of way too many deaths. Simple.

    It’s interesting to read Lost Nurse’s reassurances about following procedures and double-checking and bowing to expertise. There were many lessons we’ve learnt the very hard way, and one of the chief ones was this: the person in charge of your care is the person nearest to you right now. Between a consultant head of department who’s been treating you for years and a nurse who first met you five minutes ago, the person who will have the ultimate decision-making power over your treatment is the one who’s at your bed. If they’re not in the room, their opinion counts for nothing. Expertise and rank are overruled by geography. And it’s not just fuck-ups: I personally have witnessed staff waiting for someone they disagree with to finish their shift so they can overrule them.

    My wife once went into hospital for an operation. It was an in-and-out-in-one day procedure for most people, but she was admitted the night before to be put on a drip, because she’s diabetic. So the ONLY REASON she was in hospital that night was to be put on a drip. And what did the nurse do? “Oh, sure, you’ll be fine, I don’t think you need that.” Operation cancelled the next day, of course. And this is entirely normal.

  69. Expertise and rank are overruled by geography.

    That is an excellent description of the risk. One benefit of acute/high-care settings is the (fairly) steady & concentrated presence of senior medical/nursing staff, keeping Mk1 eyeballs on everything. That kind of proximity tends to thin out on general wards. It also underlines the supreme importance of proper communication (including a willingness to raise concerns – and, indeed, to question/challenge other staff, regardless of rank). If there’s poor lines of communication between medical & nursing staff, patients will suffer – painfully obvious, yet it still happens. Good rapport within and between a competent team makes all the difference.

    Diabetic patients being made NBM for surgery – and then (for whatever reason) being cancelled is a particular concern. There is so much potential for harm.

  70. And I know that such services exist.

    As you say, there can be a stark contrast (even within the same hospital) – the gap needs closing.

  71. > One benefit of acute/high-care settings …

    I get the impression you would be driven to despair working anywhere else. Is this a problem in hospitals: the good staff gravitate to the areas where they are allowed to be good, leaving the crap ones elsewhere?

  72. This paper looks at medical error rates in seven countries, as independently reported by patients. “Australia, the United States and Canada ranked the worst among the seven countries”. The UK compares quite well: Germany does best.

    Germany has more nurses and many more doctors than the other countries in the survey. Which tends to suggest that lost_nurse is right: staffing levels are key. The funding model has got little to do with it.

  73. > staffing levels are key. The funding model has got little to do with it.

    The funding model has little to do with staffing levels? Seriously?

    Having been in a German hospital, I can think of dozens of other reason why they’re better than British ones. Attitude, for a start.

  74. @S2:

    the good staff gravitate to the areas where they are allowed to be good

    IME, it’s a pretty common admission among, for example, ITU nurses that they go there in order to be able to “do everything” (i.e. all care). In terms of giving adequate time & attention to individual patients, (good) RNs on general wards often get stuck between a rock & hard place. And patients suffer as a result.

    @PaulB

    staffing levels are key

    Absolutely, which is not to excuse neglect… but until RN:patient ratios are improved, much of the reform/change rhetoric (especially from supposed nurse leaders & educationalists, let alone politicians & the media) about nursing won’t make any difference – boots on the ground, first & foremost.

  75. Having been in a German hospital

    I was born in a German hospital (dad being a military doc), although I do not recall much about it.

    But, German efficiency: of course. Not to repeat previous arguments, but I still don’t view the current (so-called – i.e. pseudo) marketisation reform of the NHS in the same light. We’ve an incumbent political class who seem hellbent on parcelling off services to Crapita & co, regardless of cost or consequence… and you don’t need to be an unreconstructed socialist to be alarmed by it, or to view DoH/Monitor/NHS.E intentions with deep distrust. At its best, the NHS punches above its weight in terms of value… at its worst, quite the opposite. The same kind of issues tend to pile up in developed healthcare systems everywhere, and I guess my chief problem with this blog is that it is so easy to dispense platitudes about competition, without really thinking through the messier situation in complex/acute care (to which, like Rome, all roads eventually tend to lead), and in which co-operative networks tend to be key. A properly-regulated, sufficiently safety-netted (better-funded!), social-insurance system can certainly offer gains in terms of responsiveness – but in some respects it simply swaps one set of problems for another. In short: I don’t want to see NHS services run into the ground for the sake of vague rhetoric (which has characterised both NuLav and Condem Govs)… and, yes, please gawd, let there be a sensible debate.

    Borrowed time again today, so that’s probably it for me.

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