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It Could Be Fatal

Posted by Dr No on 01 June 2011

third_man_0.jpgThe Today programme this morning fingered Jimbo as an Anglo-Sassenach. There wasn’t much he could do about it, except take a side-swipe at Humph by declaring that at least he wasn’t a Boyo, because the Sassenach evidence was in his DNA. It was the kind of case that Police Constables are wont to refer to as an open-and-shut case. The Bannock was laid bare, a faggot dressed as haggis. Auntie, on health and safety advice, thoughtfully provided a counsellor, in case it all proved to much for Jimbo. It was certainly too much for Humph, who could be heard in the distance cackling and laughing all the way to the allotment.

Quite why the BBC thought Jimbo’s genetics merited a slot in its flagship radio news programme is beyond Dr No. He supposes it might have something to do with the fact that DIY news is often cheap and easy, even if another slot of DIY news was anything but cheap or easy: Panorama’s revelations last night, covered again on this morning’s Today, that staff in a private hospital were subjecting patients to a ‘regime of physical assaults, systematic brutality, and torture’. Taken with the news that private care home operator Southern Cross is unable to meet its bills – which means, whatever the company may say to the contrary, that it is at significant risk of going bust – we can feel the first chill blasts of the storm of chaos that will surely be unleashed should the Tories’ ‘any willing provider’ plans be imposed on an unwilling National Health Service.

Now Dr No is not going to be as stupid as to say that all private providers are necessarily bad – such a statement is clearly ludicrous - just as it would be equally ludicrous to say that all state/NHS provision is perfect. But what he is going to say is that introducing wholesale private provision will introduce a step change in the risk of things going horribly wrong; and that risk, applied nationally, will lead to a sharp increase in the number of haunting outrages like Winterbourne View, and of companies like Southern Cross going pop.

The stark inescapable fact is that private operators introduce what Dr No calls the third man into the marriage between the welfare state and the individual. That third man – profit, not to mention the share-holders who covet it – can be, and all too often is, capricious and avaricious. Want and greed, the engines that drive that third man, are never far from the surface; and all too often, as we have seen time and time again, most recently with the banks, greed spills out into open recklessness. The roving eye of want takes its eye off the company’s core business, and throws caution to the winds; and all to often the company collapses in a welter of over-exposure. And all the while the third man isn’t causing collapse, he sits leech-like, a parasite draining lifeblood from the heart of the endeavour. In the pursuit of profit, bills and corners are recklessly cut, and in the wake of those cuts, the risk of another Winterbourne hoving into view rises starkly.

Of course, not all private providers are rotten cowboys, but the problem is – and this is the crux of the matter – that, because of what Dr No has previously called the collapse of the probability function, just as we cannot tell which twenty individuals will suffer a heart attack in a room full of a hundred individuals all at twenty percent risk of such an attack, so too we cannot tell which private providers will turn out to be bad eggs. All that we can know is that, by allowing that third man into the marriage, we increase the risk: the risk that in new and additional ways that want and greed will poison the marriage; and aggregate welfare be compromised.

Private provider supporters will of course claim that that is what regulators are for – to spot and weed out the bad eggs. But the idea that regulators are reliably effective in the face of private cunning is just plain fancy. We have seen recently how the financial regulators were powerless to stop the reckless lending that gave us the credit crunch; and time and time again, we hear of the Care Quality Commission’s hopeless inadequacy in the face of woeful incompetence and abuse. Winterbourne View was reported to them not once but three times; and on three occasions the CQC did nothing – a disgrace they have since admitted might have been a ‘misjudgement’; a remark which, Dr No might add, suggests their eye was so far off the ball as to be staring into outer space.

State/NHS provision is not perfect, but it is inherently both safer and more stable than private provision, because it lacks the corrupting influence of the third man. It is the central plank of the welfare state, a state of affairs that we in the United Kingdom are rightly and justly proud of. Reckless introduction of private provision on a wholesale scale risks corruption of that welfare state on a national scale. As Jimbo said of residents threatened with displacement by Southern Cross’s financial collapse, ‘it could prove fatal’; as indeed it could, not just to Jimbo’s residents, but to the welfare state as a whole.


So the problem is not with 'the third man' or making 'profit' as such but, as you say, with 'over exposure' and incompetent 'regulators', right?

Dr No sees both the wholesale introduction of the third man - the profit motive - in healthcare and the conspicuous failures by regulators across different sectors - the banks and Winterbourne View are just two examples - as problems, because it will happen again and again. Part of the problem is that the profit motive is so strong that the smart private money always hires the sharpest brains, and so are always one step ahead of the regulators. If we do get 'any willing provider', expect to see the private sector running rings anyone and everyone - all the more so if Monitor - a supposed regulator - actually ends up assisting them, by fostering competition.

I wonder if we really want to know how much abuse is going on, Dr No and if that is why we are reluctant to do spot checks, because then we would have to deal with the consequences. Sometimes people just don't want to see what's there.

Julie - I agree. It is a huge minefield. It is something we should come back to.

"both the wholesale introduction of the third man - the profit motive - in healthcare and the conspicuous failures by regulators across different sectors - the banks and Winterbourne View are just two examples - as problems"

So again, and as Julie says too, it is the 'regulators' ... not the profit. Profit can not be the constant here simply because, as you say, loads of private providers are good and will remain good because it is in their interest to remain above board. Meaning that much like yourself, they deserve the money they earn; you make a wage, they make profits and both are for services rendered. Only, earnings wise, they are risk takers and you are not. Surely they are then allowed to make a bit more money if they can also accept that they may actually make much less than your guaranteed income sometimes? So, there is no problem with working hard and innovating to make profit, it should be encouraged and celebrated too because it's how people advance and better themselves ... much like your continuous professional development.

As for the banks or Winterbourne, 'regulation' is the one to blame for over exposure and/or collapse ... and not the money or the idea of making profit itself too.

Which brings us to the application of any willing provider at this moment, as in 'now'. In the absence of an 'experienced' and effecient system of regulation, how can the doors be let opened wide all of a sudden to allow anybody and everybody into the NHS in the absence of regulators with proven track record?! Can you imagine the rush, even the stampede that will ensue if that happened? How can the exsisting regulators or the more novice monitors be expected to cope with such tsunami of providers?! 'Too soon' is where the second problem lies, not with the idea of competition or making 'profit' itself. The public sector having been protected for so long, can't just suddenly and without warning be thrown to the cut throat competition lions and be expected not only to survive but do well too! The novice monitors would be so overwhelmed, they may themselves be shredded to bits if things are not done gradually so that they too have a chance to mature ... step by step to ensure stability and that things don't get out of control - but I think this will shape things to come in the future - globally

Since that is not here at the moment, I do not like the idea of the ensuing mess and the perhaps en mass American style letigation that may be the result of that 'any willing provider' competing on price being applied 'now'. It is too ambitious, but 'fair' competition [MTAS was unfair] itself is nothing to be afraid of - personally, I fear the stagnation that comes with anything guaranteed more, too comfortable ... what do you do with your brains then?!

Wingnut made one sensible remark (most of the time he had been airily singing the praises of using economics to put a price on environmental green space) on the Today programme this morning. His interviewee had fingered the CQC as the villain on the Winterbourne View case, but Wingnut properly pointed out that when the Police bungle an investigation, that doesn’t mean we should let the criminal off. The real villain, he suggested, was Castlebeck, the company which runs, or rather in this case didn’t run, Winterbourne View. In other words, to get a system failure, we need both villain and regulatory failure.

More information has come to light about Southern Cross. It appears that some American (not them again, surely) private equity sharks (Blackstone) bought the company in 2004, dumped all its capital assets properties off the balance sheet (sold the care homes, and then leased them back), and in 2006 floated the company on the London Stock Exchange, promising to ‘drive value’ for shareholders. The City loved it. Blackstone is said to have made a profit of £1 billion.

Southern Cross – whose core business is running care homes – was now playing games on the Stock Market. It has taken its eye off the ball of its core business. Initially, they made a killing; but as we all know, the value of investments can fall as well as rise. And sure enough, just as Northern Rock crashed after taking its eye off the ball, so to did Southern Cross. It’s sale and leaseback model collapsed as the property market collapsed; and all the while its operational arm was twisted still further by the twin levers of an ever increasing rent bill (the leaseback contracts it was locked into – PFI ring a bell here?) and falling revenues (their care homes were falling into disrepute, and bed occupancy was falling). It was a recipe for disaster, and it is that disaster we are now seeing unfold.

The bottom line is that the financial sharks (the third men) have no place in care/healthcare. Their raison d'être is diametrically opposed to that of the care/healthcare sector; and it is inevitable that, once they are allowed into the marriage, it will end in tears.

"The real villain, he suggested, was Castlebeck"

inexecusable, but Castlebeck is not a villain as such, it's a business that failed itself after feeding the original owners with gold then it over exposed itself and couldn't manage. What happened was because they were trying to break even in an unstable market somehow but failed because they cut corners instead of, perhaps, downsizing to limit liability and reduce overheads. That said, I agree with you that failing to monitor it's own employees was criminal. Of course Winterbourne is but one branch of said company, so are all the rest as bad for us to call the whole setup 'criminal', as in villains? What happened is wrong, Yes, and they admitted that and issued a very long apology after Panorama was aired. I am sure they will do everything they can to try and fix and heads will roll as a result because they can't afford not to do so if they want to heal their injured reputation, or they may end up having to close shop and suffer all the loses.

Please tell me a similar example of that happening when the public sector messes up, Staffordshire perhaps? Was there ever a chance they may go down? No! On the contrary, a prominent figure who was inolved in the saga was promoted to head the regulators!! ... and we have Tubridge Wells too, what happened to it's CEO? ... they got money out of it! MTAS, 'they' got promoted then honoured despite being found 'inept' ... etc. All incompetent 'employees' with proven track record and all got away with it! Where do they get all this 'power' from?!

Back to Castlebeck. I have near to naught idea of who regulates what in healthcare, but had there been proper regulation they wouldn't have been able to expand unchecked or sell their assets and keep the money for themselves while they had vulnerable residents on their premises too! Absolute power corrupts the best of us, since one can do whatever they like unchecked - in this case, this was all under the nose of the 'regulators' too! Don't they at least get licences to operate?! Do these, if any, not have conditions attached to them?! ... like, 'Thou shalt not sell a huge property portfolio full of 'vulnerable' residents' ... for example! :-)

And why are they being regulated by a free government body only if they are private businesses? Surely, there should also be the equivelent of the likes of 'IATA', or your RCs and GMC, where they have to pay to be regulated and for the privilage of being members ... and like the majority of reputable businesses related to most service industries; hotels, airlines, travel agencies, resorts ... endless

At the end of the day Dr No, there will always be those who are greedy or those who are plain stupid, even criminal, and they will mess up whether they are in the public or private sectors. But that's how private sector regulators learn and better themselves. The public sector can't regulate themselves as much because they are not as accountable they always find ways to get away with it. I may be wrong, but it is very possible that the regulators who failed to respond despite being alerted 3 times will escape scot free in the case of Winterbourne when heads will definately roll at Castlebeck. It shouldn't be like that.

Good then this new government is trying to reform and good luck to them too. Will anybody pay this time though, or it's going to be business as usual? Let's wait and see

... but it ain't about 'profit'! :-)

“Now Dr No is not going to be as stupid as to say that all private providers are necessarily bad – such a statement is clearly ludicrous – just as it would be equally ludicrous to say that all state/NHS provision is perfect. But what he is going to say is that introducing wholesale private provision will introduce a step change in the risk of things going horrible wrong, and that risk, applied nationally, will lead to a sharp increase in the number of haunting outrages like Winterbourne View, and of companies like Southern Cross going pop.”

How so very insightful Dr No. I work in the private sector and concur with the above statement wholeheartedly. I am lucky – but more so the residents that I care for – in that I work in a small group of homes where residents are genuinely cared for, but nevertheless profit is required and indeed paramount as otherwise the business could not exist, for it is indeed a business and its commodity is living, breathing human beings.

The owners have social services/nursing/medical backgrounds and however altruistic their original purpose may have been – altruism is meaningless if it doesn’t pay the bills. Local authority contributions to fees have not risen in the past two years and have indeed been cut this year. Banks despite being baled out by taxes paid by the general public – are now restricting mortgage arrangements and tightening the noose on care homes and yet inflation increases the outgoings of utilities and food provision.

Staff members have not had an annual rise in pay for three years – but we don’t mind this. Nevertheless inflation has meant a tightening of belts and the high level of care – although not affected yet - could be in the future. We operate with staffing levels above legal requirements, but as needs musts - staff leaving (unless nursing) are not replaced at present.

I have worked in homes run by charitable concerns who despite their charity status are still reliant on ‘profits’ gained by given contributions and local authority fees.

I have worked for national chains who despite their claim to be committed to the health and welfare of the residents – what a dammed lie – are interested in profit only. Have you ever given a physically fit strapping man two measly biscuits for his supper and despite pleas that he was still hungry could not give him more for they would have been outside his daily food budget? (Biscuits were counted by management the next day!)

The home I worked for as described above was owned by Ashbourne Healthcare – now part of Southern Cross.

Private providers as in ‘any willing provider’ scare the hell out of me. Profit will be the only driver. The CQC is not fit for purpose – we have friends who are inspectors who tell us that they do not know what their remit is as the goalpost changes on a daily basis and if Monitors role is to drive competition… then God help us all!

Private concerns have no place in healthcare.

Anna :o]

Anna - Thanks for giving it to us from the horses mouth, so to speak.

Sam - Dr No has not adopted a public is always good private is always bad position. Indeed Anna quotes a relevant passage. Instead, Dr No's premise is that, to put it another way, a man cannot serve two mistresses, or yet another way, three in a bed will end in tears if, as is almost by definition the case, the third person - profit - is by nature greedy. His premise is that given a hundred public sector homes and/or hospitals, ten may go wrong, while in a hundred similar private homes and/or hospitals, twenty may go wrong, because of the additional stress placed on the system by the demands of what Dr No, to return to the original theme, called the third man.

The problem with relying on regulators is that, in the real world, they don't work very well. This may be partly because there is an element of gatekeeper turned poacher - certainly this happens in the financial sector: an individual may learn the rules as a regulator, and then move to the private sector with insider knowledge and an ability to game the system. It may also be that, as Dr No suggested earlier, that the private sector can always attract the sharper brains, such the regulators will always be one step behind. Or it may be that micro-regulation - as in regulating every aspect of every organisation - is simply unrealistic in the real world.

What could work is what we might call macro-regulation (ie law) - keep the SoS responsible for a comprehensive health service, and legislate in such a way (as historically we have done) that favours public provision over private provision, and so keeps the private sector (which Dr No is not going to suggest should be banned outright) naturally within tight bounds.

"keep the SoS responsible for a comprehensive health service, and legislate in such a way (as historically we have done) that favours public provision over private provision, and so keeps the private sector (which Dr No is not going to suggest should be banned outright) naturally within tight bounds."

We are in total agreement here Dr No because that's what I have been saying all along too, please read my 'NHS' Wars' post for but an example.

As for profit/greed/third man/business romps ... etc, I always get this vibe from anyone one working in the public sector that making money or showing off money is wrong somehow but at the same time they mentally tie their regularly guaranteed money to livlihood in a guardian like way. Risk takers regard money as a tool to living not 'livlihood' itself and for them it doesn't hurt that much if it gets lost through ambitious endeavours going the other way as they can always try again. There are also those public sector employers who regardless of the high and sometimes very well paid positions they hold always pride themselves that they, for example, drive bangers to fend off peer jealousy [We had a discussion about that with Dr Grumble before too :-] Of coarse, when you make it on your own, you pride yourself on the opposite ... and enjoy the jealousy! ... and it is that mentality about making and enjoying of money that the public sector needs to change if it is to sucessfully adapt to the future if we are to get this country UP to where it should be again. Making money is 'not' a sin, fraud of whatever nature is ...

... and when the NHS has regulators that match ABTA [Association of British Travel Agents] in it's rigour, rest assured that most of the health atrocities that we keep hearing about today will become a thing of the past

I am not sure whether I understand the matter correctly but the matter of private firms making a profit in the NHS doesn't seem to me to hinge simply on the morality of profit making per se in this context. In an NHS free at the point of use but largely made up of private providers paid from the tax take it seems to me that the level of expenditure the public must make is the larger because it must in this case take account of that which is taken as profit. Further, it seems to me that this increased expense with enforced extraction of profit from the public will largely be exacted by businesses which won't bear anything like the true costs of their business because these will rather be based on the usufruct of staff who have been trained out of public funds and likewise buidlings and facilities.

I agree that there's nothing wrong with businesses making profits for that indeed is the economic basis of our wealthy society, but it is the political process which determines the rules within which this operates and the manner in which the taxation generated from the wealth so accruing is spent. And so it seems to me that the debate about profits and morality in the NHS should be about the morality of a politics which seeks to dictate an increased extraction rate out of taxation to furnish the profits of private firms who are given the usufruct of staff and facilities paid for by the public purse. Or have I got this wrong and that all willing private providers will in fact be asked to pay an amount equivalent to the costs of the training of all the NHS staff they employ and the NHS buildings and facilities they use? But perhaps I have misunderstood something basic in this process.

Excellent Milosz! You understand perfectly.

A private provider in any health setting is only interested in profit and morality does not play a part in it.

A NHS that it seems is destined to become more of a market place that it already is (thanks Labour) will lose the humanity that is essential to its very existence as a place of care.

While lazing in the bath, the memory of food provision in the home I mentioned in my previous comment took on a new light - for I remembered that catering had been sub-contracted out to another private provider. Supper (overlooked?) had not being part of the contract so in essence, residents were not allowed supper at all. As a concession two measly biscuits were allowed.

You must take into account that this particular home was not stand alone therefore all homes in the chain were subject to the same contract. The contract was binding for five years and those in management, truly remote from the residents they apparently served, did not care.

Private providers are only interested in profit - pure and simple.
The health and well-being of the patient is not a factor - merely a source of income.

Anna :o]

I think you are right in that regulators are nearly always ineffective. In practice they just force work and hassle on the innocent, and ignore the guilty. Regulation, like accountability, in the NHS or social services seems to be all about knowing who to blame when the turd hits the fan, rather than preventing flying turds in the first place.

If the government really believed in the free Market they would not need regulators. Big American corporations are happy to be regulated, it is a major barrier to new competitors being set up.

Anna's tale of two biscuits for dinner is a scandal, but shouldn't the inmates guardian or relatives have moved him out? Surely this would apply pressure better than some inspection, likely to be of Potemkin villages?

"Private providers are only interested in profit - pure and simple.
The health and well-being of the patient is not a factor - merely a source of income."

This is why you need good regulation Anna. That however doesn't mean that everyone in business doesn't have a heart. There are the majority of businesses out there who, besides wanting to succeed and make profit, expand if possible and prosper, still have a conscience and will provide good service for the money they charge. Your employer is one of those, since they chose you, a kind nurse who does care for the residents in the home she works in. Or, if noone out there can be trusted, mums should not trust all private nurseries, nannies, or whatever and just stay at home and not dare venture out to work, for example ... since those are out to make a profit too!

"I think you are right in that regulators are nearly always ineffective. In practice they just force work and hassle on the innocent, and ignore the guilty. Regulation, like accountability, in the NHS or social services seems to be all about knowing who to blame when the turd hits the fan, rather than preventing flying turds in the first place."

Proper regulation doesn't occupy itself with blame but is there to protect the innocent and punish the guilty. I gave ABTA; The Association of British Travel Agents, as an example before and that's exactly what they do and the reason why you 'Trust' a member travel agent when you see this logo in their shop window and on all the correspondance. Because not only is your money safe with member agents but your safety is paramount to them too hence is paramount to your travel agent, who is out there to make profit, too. Sometimes things will go wrong despite the many precautions taken by everybody involved to protect you and your holiday. In this case ABTA does not engage itself in blame, but sets her machine up promptly to investigate, punish naughty agents and severely fine them if found guilty and compensate you if you are entitled to same ... and this is the kind of regulation we need to see replicated in health and social care. For that, new regulators need to be established on similar lines to ABTA, ie, be paid for through membership by those operating in their specialist field, like care homes, for example. Money wouldn't be a problem for those regulators then since they get that through memberships and not wait for government hand outs ... hence can not blame their failings on 'staff shortages due to government cuts' as the CQC has now done, which I though was a hillarious thing to say by 'a regulator'! Here, it was 'blame' the goernment for their own failure! Why haven't they shouted loud about those cuts then 'before' catastrophies like Winterbourne happen?! ... Have you ever heard ABTA or the like talk like that?!

'Make them pay for their own regulation' is the answer, or expect more and more Winterbournes on a regular basis and forever!

Sam - not for the first time has the travel/aviation industry been cited as the way to go (sic). A few years ago there was a Personal View in the BMJ from a father asking (Dr No thinks he recalls correctly) why his airline pilot son was so well looked after while his junior doctor son was treated like dirt. From time to time, we measure mortality in units of 747s falling out of the sky. And of course medicine, particularly at the surgical end of things, and flying are procedure heavy activities. And when things go wrong we often ask the same question: was it an individual (surgeon/pilot) at fault, or a system failure?

The first trouble Dr No sees with the interesting ABTA model regulation idea is that ABTA is the Association of British Travel Agents, and in healthcare there is no agent as such (unless we say - and no doubt some will - that GPs are the patient's medical travel agent to secondary care).

The second difficulty is that ABTA isn't a regulator in the sense that say the CQC or the GMC is. Instead, it is what, for want of a better way of describing it, Dr No is going to call club/confederation regulation: if your club/agent belongs to this association/confederation, then you can expect certain standards of service/care (and if they don't belong, then Heaven help you; if they do belong, and then they fail, Heaven help them). Sports are also regulated in the same way - for example, the Royal Yachting Association recognises (after assessment) sailing clubs and schools, and members of the public can expect RTE's (recognised training establishments) to meet certain standards (and Heaven help RTE’s if they don't etc). The bottom line is that, all said and done, ABTA is a trade organisation, albeit one that properly promotes professional standards, but, as a trade organisation, its primary purpose is to strengthen its members position. Indeed they are quite clear about this. On their website they say:

"Our purpose is to help our Members to grow their businessess (sic) successfully and sustainably..."

before adding

"...and to help their customers - the travelling public - have confidence in their travel experience."

Which conveniently brings Dr No to the second point about the value and virtues of ‘good service’. Helping customers in any business sector is not an end in itself, but a means to an end. It is not being done for its own virtue, but because it makes good business sense, and so is being done in the service of the Greater God of Profit. Indeed, Dr No posted on this earlier this year, when he asked why don’t we bring in Mary Portas to fix the NHS?

Dr No is not an anti-entrepreneurial anti-capitalist - he fully appreciates the importance of entrepreneurial market based capitalism in our modern commercial world. Despite its failings (and there are many), it is, a bit like democracy, the least bad system of all those that have been tried.

But - and this is the big butt (sic) - what works least bad in the market place risks corrupting truly vocational services. Dr No recalls that as a Casualty Officer many moons ago (we had proper titles in those days, not ThingumaJig2, as we now have), he once had a tramp in one bay, and a hereditary peer in the next. Both had genuine medical needs (the tramp had pneumonia, and the peer a broken wrist), and Dr No did fixed both eyes on each in turn, and did what needed to be done. The trouble with introducing the third man (profit) is that it encourages the doctor to develop a third eye, an eye that looks not at the patient, but at the third man; and so the doctor ends up torn between two masters; and more often than not, it is the poor – in all sense of the word – patients who suffer the most.

And finally: Dr No is going to go out on a limb. He is going to suggest the primary external regulation of the professions is a ludicrous conceit. Instead, in Dr No’s Utopian vision, practitioners would naturally internally self-regulate. The ethos of their profession, and the nature of their training, and their contempt for commercial pressure, would bring about a body of practitioners that routinely behaved itself. Only on the rare occasion that a rogue practitioner emerged would an external regulator be required – and that regulator should have the eye of a hawk, and the fury of a Greek God.

Dr No has in fact been here before. It is all about implicit vs explicit trust; and it is why we need revalidation like we need a hole in the head.

The commercial side of things – the third man – on the other hand does need routine external regulation. ABTA style club/confederation pseudo-regulation might even work well here.


This is not a well thought out response as I am tired and just about to set off to work - but it is a response that is needed.

Care homes have always paid a fee towards external regulation - indeed they cannot operate without doing so. The CQC is presently 'it' - and is as much use as a chocolate teapot as Winterbourne, some care homes - uncluding some in the Sourthern Cross chain and indeed hospitals show.

Cynthia Bower is at the helm of this useless organisation and we all know of her excellent track record of not seeing problems at Stafford Hospital.

GPs, dentists, hospital trusts and all health care providers will eventually or already now contribute to this pot of regulation.

The comment by Anonymous 5/6/11 @ 2.47pm describes the CQC perfectly.

Anna :o]

" A-BMA: Association of British Medical Agents?"

But we never spoke about that Dr No, the ABTA like organisation is meant to be for 'private businesses' contracted by the NHS to provide services involving people and their care and not doctors. But since you bring up this subject, which implies doctors becoming independant providers working from their own 'rooms' like barristers, then yes, that would be a great idea because your GMC and RCs regulation would leave the 'commerial' aspect exposed. Hence you'd need a 'trade' organisation similar to ABTA. ABMA is not bad! Nice innovation Dr No ... and before I get my head bitten off by anyone reading and not liking, it was Dr No who mentioned this one not me ... and that too doesn't mean full privatisation of the NHS, which we all do not want to see happening :-)

"a father asking (Dr No thinks he recalls correctly) why his airline pilot son was so well looked after while his junior doctor son was treated like dirt."

;-) ... need I say more Comrade No?! And you couldn't have found a better example so, well done again! ... Both juniors, both need training, one works for the private sector, the other for the 3rd biggest 'do as I please' monopoly on earth! And part of the reason why I like the foundation trusts idea so much, because it breaks the unmangeable monopoly and in doing so services will be streamlined for patients and for staff. Meaning less waste -> less cost and better results for everybody. Plus 'good' staff will have a value too because it is them who keep the 'business' ticking ... much like an airline and it's 'valued' and very well trained pilots since they are 'assets' and not a 'liability'! When all your pieces, and no more, are in place, you get an 'operation' that 'flows' effortlessly and that's a 'perfect' operation that doesn't discriminate between people or put cielings above their heads, but allows everyone an opportunity to shine - proper use of talent ... and good riddens to the timewasters, or those with huge piles of paper on their desks or forever running around corridors with same looking busy. Much the same as when docs operate in a streamlined and flowing theatre where everything is in place, rings a bell doctor? Such 'healthy' invironment makes you 'want' to be involved, 'want' to do things better, so you use your 'intelligent' brains more, not just the auto pilot part, but the creative part too ... and you docs have those, with proven track record - never, but modestly, forget this 'fact'.

No need to reflect on revalidation because I think you can guess what I think About that already ... you're very special people, but the monopoly makes you forget that!

I thing the listening excercise was for real and we will hear good news of a more realistic and streamlined reform soon ...

Great post!!!

In Iceland a third of the bank regulators were employed by the banks they were looking at during their visit.

Years later in memoirs or the like: I did not realise!!!

The Cockroach Catcher