Past Posts...

The Heart of the NHS

Who, or even what, we might ask, lies at the heart of the NHS?

The short Ester Rantzen answer is of course the patient.

But this is the glib answer. It ignores, for example ‘why’ questions: why, for example, is the patient in the NHS at all?

The answer of course is to avail him or herself of what we now call ‘healthcare’, which is in fact medical care, and medical care is provided by medics – doctors. The doctor is as central to the NHS as the patient. Like a ship and her captain at sail on a sea of sickness, patient and doctor sit together at the heart of the NHS; for a ship without a captain is apt to founder; and nothing is bleaker than a captain on the beach.

MMR Killed My Hamster

The Daily Mail, truncheon bearer to the lunching classes, has once again been trying to hit the MMR-Autism nail on the head. Softened, perhaps, by the indolence of a quiet August Bank Holiday, The Truncheon last weekend let slip a dossier of drivel that managed to combine monumental insult to an honest story about a vaccine damage payout with a level of disingenuity that would have even the Prince of Darkness blush.

The bare facts of the story are straight-forward. Some years ago, a Master Robert Fletcher developed severe brain damage shortly after receiving the MMR vaccine. The family alleged causation, and now, after a 13 year appeal, a medico-legal panel has decided, by a two to one majority, to allow the claim, on the grounds of temporal association. Robert and his family have been awarded £90,000 compensation.

God Will See You Now

It being August, and so the Silly Season, TweedleNaughtie and TweedleWebb presented the Today program on Radio 4 this morning. Both are science-lite, but this morning TweedleWebb surpassed even himself. In an attempt to force a bun-fight between a medical sociologist and a doctor – normally as easy as torching petrol – about a study looking at the effect of religion on a doctor’s end of life practice, he declared he didn’t want to ‘get bogged down in a discussion about the representativeness of this study’. So absurd was this remark that it quite fused all combativeness out of the two contestants. The doctor emitted a curt ‘sure’ and dried up like a prune, while the sociologist started a bizarre love-in with the doctor.

Keir Cooks Goose but No Burton For Barton

So – The Goose is to be roasted in the oven of the courts. The CPS has decided that Ray ‘I did it wiv t’pillah’ Gosling has led the police on one big, err, goose chase, and that he should be charged with, err, leading the police on a wild goose chase.

Meanwhile, the very same CPS has decided that Gosport’s Diamorphine Queen, Dr Jane Barton, should not go for a Burton, despite a sea of inquest findings suggesting Barton’s overzealous opiate prescribing contributed to a number of deaths.

The Gatekeeper and the Gotcha

Nobody, least of all doctors, seems to know whether doctors themselves have an addiction problem. Smart-arse wise-cracking punters may define an alcoholic as someone who drinks more than their doctor, but, as with most smart-arsed wise-cracks, real evidence is hard to come by. What is more certain is that most doctors have problems with crack heads and cotton shooters. Substance misuse – to give the subject its sanitised, politically correct name - remains very much a Cinderella specialty, while many GPs – despite touting themselves as generalists happy to take on all-comers – refuse to admit drug addicts to their lists.

Negative Pressure at the Anus

As a medical student, Dr No was greatly impressed by a particular surgeon. This surgeon was that rare thing, a surgeon whose mind was even sharper than his scalpel. He taught Dr No perhaps the most important surgical lesson of all: that surgery is not about how to operate – any competent surgeon can do that – it is about when to operate; and it is fidelity to that decision that distinguishes the great surgeon from the average surgeon. That same great surgeon taught Dr No much else, often in the vernacular, and none more certain than that which holds that the only sure-fire way to advance one’s medical career is to apply regular and consistent negative pressure at the anus of one’s superiors.

Actuarial Design of Risk Pools

Americans, Fanny Trollope observed in that acetic manner of hers, pursue the DOLLAR with such a unity of purpose, such a sympathy of feeling as found nowhere else, except, perhaps, in an ants' nest. “The result” she added “ is exactly what might be anticipated. This sordid object, for ever before their eyes, must inevitably produce a sordid tone of mind, and, worse still, it produces a seared and blunted conscience on all questions of probity.” To which we on Blighty’s shores might happily reply “Amen to that”, were it not that American ants’ nests have lately appeared with pestilential frequency in NHS offices up and down the land.


Those whom the Gods wish to destroy, they first send to the King’s Fund. The current Chief Pongo at the Fund, an academic cove who was publishing papers when Dr No was still in cap and shorts, has spent a life-time studying health policy and management at a variety of red-brick institutions. The trouble with studying health policy and management is that it is so dull that it addles the brain. Over a period of years, a selective memory loss sets in, leaving victims unable to recall what happened last time the NHS was re-jigged. The condition, known as hamnesia after the eponymous Professor, is progressive, and has no known cure.

Schrödinger Decisions

Up and down the land, clipboard operatives guided by local PCTs are stomping through care home lounges, offering, as is the way these days, the Gilberts and Biddies all manner of advice and assessments. Those who are found to have mental capacity are read their rights, including the right to refuse treatment; and, if they are so minded, offered a DIY death warrant, or Advance Decision to Refuse Treatment (ADRT), as they are more formally known.

For some, no doubt, an ADRT will be just the ticket. No more futile and burdensome treatment; and no more gratuitous delays at the departure gate. Dr No has no trouble with such arrangements when they are the right arrangements: they are humane and sensible. Indeed, given certain circumstances, Dr No thinks he might even sign his own ADRT.

The GPs’ Den

By a coincidence last week saw both the announcement of the coalition government’s shake up of the NHS, and the start of this summer’s season of ritual humiliation in The Dragons’ Den. On the face of it these two events have little in common, but it does not take long to see that The Dragons’ Den is in fact the model for the coalition’s vision of GP based commissioning. Most jobbing doctors will see it as an irritation and a diversion, but a hardcore of latent fundholders will emerge – indeed already have emerged – to grasp what some have called a poisoned chalice, but what Dr Dollar will see – indeed already has seen - as a Golden Opportunity. Before we know it, Dr Dollar and his pals will form up into consortia, and the BBC will spot a chance for another easy reality show. The GPs’ Den will be the new Dragons’ Den.