The NHS computer system

Back last year, I wrote a piece about totally crap software and how the government is totally incapable of specifying an IT system and is much less capable of delivering the project within budget and time scales, so it comes as no surprise to find that the latest multi-billion pound white elephant is to be subjected to yet another review.

One of the major problems with commissioning work from third party contractors is that there is no incentive to deliver the system. Every time the spec changes - which happens with government work continually - the price changes and, of course, if it doesn't work properly after delivery then there is the endless debate about what is and isn't chargeable. I liken it to driving your shiny new BMW off the forecourt only to find it breaks down 50 yards up the road and then being told you will be charged to fix it because it wasn't being driven properly.

The National Audit Office started to suspect this thing wasn't going to fly as long ago as August 2004 as you can see from their typically understated concerns here on the BBC website. In February 2007, the Daily Telegraph decided that it was doomed to failure and quoted senior sources at Fujitsu - one of the major suppliers - as voicing concern at the direction of the NHS programme and the lack of vision on how the health service can make best use of new technology.

"What we are trying to do is run an enormous programme with the techniques that we are absolutely familiar with for running small projects. And it isn't working. And it isn't going to work," he told his audience.

As with all things of this nature, there comes a time when the contractor and the government aren't going to agree and,as, usual, the government is going to blame the people who actually know what they are talking about so in May 2008, Fujitsu were fired. At this stage the project was already four years behind schedule.
So far the costs had escalated from £6.7 billion to £12 billion with worse news still to come when in January 2009, the Guardian reported that the system was on brink of failure, something which should cone as no surprise as some people had been on record as saying this for years. However, the issue refused to lay quietly around and die as hundreds of junior doctors were having their job applications screwed up!
 
So here we are in 2011, and the costs are now estimated at £20 billion and, according to the BBC, "things are getting worse"

The response? Well, the government announced there will be a review of the project. This is due to start this week.

Tory MP Richard Bacon, a member of the House of Commons' Public Accounts Committee and long-standing critic of the plans, said: "It is perfectly clear that throwing more money at the problem will not work. This turkey will never fly and it is time the Department of Health faced reality and channelled the remaining funds into something useful that will actually benefit patients. The largest civilian IT project in the world has failed."

But the Department of Health said while the original vision "was flawed", the project still had the potential to deliver value for money.

Yeah, right...

The NHS computer system

Back last year, I wrote a piece about totally crap software and how the government is totally incapable of specifying an IT system and is much less capable of delivering the project within budget and time scales, so it comes as no surprise to find that the latest multi-billion pound white elephant is to be subjected to yet another review.

One of the major problems with commissioning work from third party contractors is that there is no incentive to deliver the system. Every time the spec changes - which happens with government work continually - the price changes and, of course, if it doesn't work properly after delivery then there is the endless debate about what is and isn't chargeable. I liken it to driving your shiny new BMW off the forecourt only to find it breaks down 50 yards up the road and then being told you will be charged to fix it because it wasn't being driven properly.

The National Audit Office started to suspect this thing wasn't going to fly as long ago as August 2004 as you can see from their typically understated concerns here on the BBC website. In February 2007, the Daily Telegraph decided that it was doomed to failure and quoted senior sources at Fujitsu - one of the major suppliers - as voicing concern at the direction of the NHS programme and the lack of vision on how the health service can make best use of new technology.

"What we are trying to do is run an enormous programme with the techniques that we are absolutely familiar with for running small projects. And it isn't working. And it isn't going to work," he told his audience.

As with all things of this nature, there comes a time when the contractor and the government aren't going to agree and,as, usual, the government is going to blame the people who actually know what they are talking about so in May 2008, Fujitsu were fired. At this stage the project was already four years behind schedule.
So far the costs had escalated from £6.7 billion to £12 billion with worse news still to come when in January 2009, the Guardian reported that the system was on brink of failure, something which should cone as no surprise as some people had been on record as saying this for years. However, the issue refused to lay quietly around and die as hundreds of junior doctors were having their job applications screwed up!
 
So here we are in 2011, and the costs are now estimated at £20 billion and, according to the BBC, "things are getting worse"

The response? Well, the government announced there will be a review of the project. This is due to start this week.

Tory MP Richard Bacon, a member of the House of Commons' Public Accounts Committee and long-standing critic of the plans, said: "It is perfectly clear that throwing more money at the problem will not work. This turkey will never fly and it is time the Department of Health faced reality and channelled the remaining funds into something useful that will actually benefit patients. The largest civilian IT project in the world has failed."

But the Department of Health said while the original vision "was flawed", the project still had the potential to deliver value for money.

Yeah, right...

The Garden of Eden

Today's lesson is taken from the Book of Genesis, Waterstone's 2011 edition...

1. In the beginning God covered the earth with broccoli, cauliflower and spinach, with green, yellow and red vegetables of all kinds so Man and Woman would live long and healthy lives.
2. Then using God's bountiful gifts, Satan created Dairy Ice Cream and White Chocolate Magnums. And Satan said, 'You want hot fudge with that? And Man said, 'Yes!' And Woman said, 'I'll have one too with chocolate chips'. And lo they gained 10 pounds.
3. And God created the healthy yoghurt that woman might keep the figure that man found so fair.
4. And Satan brought forth white flour from the wheat and sugar from the cane and combined them. And Woman went from size 12 to size 14.
5. So God said, 'Try my fresh green salad'. And Satan presented Blue Cheese dressing and garlic croutons on the side. And Man and Woman unfastened their belts following the repast.
6. God then said 'I have sent you healthy vegetables and olive oil in which to cook them'.
7. And Satan brought forth deep fried coconut king prawns, butter-dipped lobster chunks and chicken fried steak, so big it needed its own platter, and Man's cholesterol went through the roof.
8. Then God brought forth the potato; naturally low in fat and brimming with potassium and good nutrition.
9. Then Satan peeled off the healthy skin and sliced the starchy centre into chips and deep-fried them in animal fats adding copious quantities of salt. And Man put on more pounds. God then brought forth running shoes so that his Children might lose those extra pounds.
10. And Satan came forth with a cable TV with remote control so Man would not have to toil changing the channels. And Man and Woman laughed and cried before the flickering light and started wearing stretch jogging suits.
11. Then God gave lean beef so that Man might consume fewer calories and still satisfy his appetite.
12. And Satan created McDonalds and the 99p double cheeseburger. Then Satan said 'You want fries with that?' and Man replied, 'Yes, and super size 'em'. And Satan said, 'It is good.' And Man and Woman went into cardiac arrest.
13. God sighed ......... and created quadruple by-pass surgery.
14. And then ............. Satan chuckled and created the National Health Service.

Here endeth the leson...

The Garden of Eden

Today's lesson is taken from the Book of Genesis, Waterstone's 2011 edition...

1. In the beginning God covered the earth with broccoli, cauliflower and spinach, with green, yellow and red vegetables of all kinds so Man and Woman would live long and healthy lives.
2. Then using God's bountiful gifts, Satan created Dairy Ice Cream and White Chocolate Magnums. And Satan said, 'You want hot fudge with that? And Man said, 'Yes!' And Woman said, 'I'll have one too with chocolate chips'. And lo they gained 10 pounds.
3. And God created the healthy yoghurt that woman might keep the figure that man found so fair.
4. And Satan brought forth white flour from the wheat and sugar from the cane and combined them. And Woman went from size 12 to size 14.
5. So God said, 'Try my fresh green salad'. And Satan presented Blue Cheese dressing and garlic croutons on the side. And Man and Woman unfastened their belts following the repast.
6. God then said 'I have sent you healthy vegetables and olive oil in which to cook them'.
7. And Satan brought forth deep fried coconut king prawns, butter-dipped lobster chunks and chicken fried steak, so big it needed its own platter, and Man's cholesterol went through the roof.
8. Then God brought forth the potato; naturally low in fat and brimming with potassium and good nutrition.
9. Then Satan peeled off the healthy skin and sliced the starchy centre into chips and deep-fried them in animal fats adding copious quantities of salt. And Man put on more pounds. God then brought forth running shoes so that his Children might lose those extra pounds.
10. And Satan came forth with a cable TV with remote control so Man would not have to toil changing the channels. And Man and Woman laughed and cried before the flickering light and started wearing stretch jogging suits.
11. Then God gave lean beef so that Man might consume fewer calories and still satisfy his appetite.
12. And Satan created McDonalds and the 99p double cheeseburger. Then Satan said 'You want fries with that?' and Man replied, 'Yes, and super size 'em'. And Satan said, 'It is good.' And Man and Woman went into cardiac arrest.
13. God sighed ......... and created quadruple by-pass surgery.
14. And then ............. Satan chuckled and created the National Health Service.

Here endeth the leson...

Smokey drinkey...

I don't usually get involved in the arguments about smoking and drinking other than to say it's up to the individual how he treats his own body, but I thought this piece might just cheer up my old friends the Filthy Engineer and Leg Iron.

This is Arthur Langran. Last month, Arthur celebrated his 100th birthday. Congratulations, Arthur.

Arthur was asked to what he attributed the secret of his long and active life. He told us that he had smoked al least 10 ciggies every day since the age of 20 and religiously drinks a glass of Macallum single malt scotch every night before going to bed.

So that's over 300,000 cigarettes and few hundred crates of scotch. Oh, and he also smokes a pipe. So how has this effected him?

His son, who fortuitously for Arthur's scotch habit owns a pub, says "His doctor has said it's not worth telling him to give up the cigarettes. He's still in good health and gets up stairs whenever he wants."

So take heart - there are lies, damn lies and statistics...

Smokey drinkey...

I don't usually get involved in the arguments about smoking and drinking other than to say it's up to the individual how he treats his own body, but I thought this piece might just cheer up my old friends the Filthy Engineer and Leg Iron.

This is Arthur Langran. Last month, Arthur celebrated his 100th birthday. Congratulations, Arthur.

Arthur was asked to what he attributed the secret of his long and active life. He told us that he had smoked al least 10 ciggies every day since the age of 20 and religiously drinks a glass of Macallum single malt scotch every night before going to bed.

So that's over 300,000 cigarettes and few hundred crates of scotch. Oh, and he also smokes a pipe. So how has this effected him?

His son, who fortuitously for Arthur's scotch habit owns a pub, says "His doctor has said it's not worth telling him to give up the cigarettes. He's still in good health and gets up stairs whenever he wants."

So take heart - there are lies, damn lies and statistics...

New superbug set to sweep the world

News today from the Department of Health that a new superbug has been discovered.

The bug, "Americanus 4nPolyC", seen pictured on the left is easily identified under the microscope by its distinctive red, white and blue stripes. It contains the deadly enzyme US4Fr which is resistant to all attempts to control it.

A spokesman for the DoH, Dr. Quango Gravietrane, said "We have tried everything to stop the progress of this bug, but nothing we do seems to make any difference. If left unchecked, it could dominate the world!" A frightening thought indeed.

The bug is believed to have originated in the Pakistan region possibly crossing the border from neighbouring Afghanistan and brought home by American troops.

There is, however, one glimmer of hope; In Scotland, a man given only three months to live has survived for a year. US officials have called for his medical records to be examined but the Scottish administration so far has resisted this call saying "We have the situation firmly under our control."

New superbug set to sweep the world

News today from the Department of Health that a new superbug has been discovered.

The bug, "Americanus 4nPolyC", seen pictured on the left is easily identified under the microscope by its distinctive red, white and blue stripes. It contains the deadly enzyme US4Fr which is resistant to all attempts to control it.

A spokesman for the DoH, Dr. Quango Gravietrane, said "We have tried everything to stop the progress of this bug, but nothing we do seems to make any difference. If left unchecked, it could dominate the world!" A frightening thought indeed.

The bug is believed to have originated in the Pakistan region possibly crossing the border from neighbouring Afghanistan and brought home by American troops.

There is, however, one glimmer of hope; In Scotland, a man given only three months to live has survived for a year. US officials have called for his medical records to be examined but the Scottish administration so far has resisted this call saying "We have the situation firmly under our control."

Drinking - a Doctor's view

A short while ago, I promissed to get my friend "Old Sawbones" to give me his professional view on the latest NICE proclamation on how to interrogate patients about their drinking habits.

This is what he had to say :

"Anyone and everyone knows you shouldn't (1) smoke, (2) overeat, (3) drink daily above the recommended amount, but life can be (1) cruel, (2) short, (3 )unfair and we need no lectures from the 'great and the (not so) good' on how we live our lives.

The patronising medical establishment have a vested interest in cosying up to the politicians, and parroting their 'guidance' as to how to live a healthy life - as if we didn't know - and, of course, with an eye to appearing in the forthcoming honours list. (Don't rock the boat.)

Anyway, as if there wasn't little enough time during the average consultation to deal with the medical problem itself, I suspect that advice on drinking may be one of the issues for which GPs get additional payment, as with advice on dealing with obesity."

So there we have it from the expert. Looks to me like another hangover from the good old nanny state New LieBore days of inventing ways to pay people for meeting targets rather than letting them alone to get on with their jobs - which in this case is healing the sick...

Drinking - a Doctor's view

A short while ago, I promissed to get my friend "Old Sawbones" to give me his professional view on the latest NICE proclamation on how to interrogate patients about their drinking habits.

This is what he had to say :

"Anyone and everyone knows you shouldn't (1) smoke, (2) overeat, (3) drink daily above the recommended amount, but life can be (1) cruel, (2) short, (3 )unfair and we need no lectures from the 'great and the (not so) good' on how we live our lives.

The patronising medical establishment have a vested interest in cosying up to the politicians, and parroting their 'guidance' as to how to live a healthy life - as if we didn't know - and, of course, with an eye to appearing in the forthcoming honours list. (Don't rock the boat.)

Anyway, as if there wasn't little enough time during the average consultation to deal with the medical problem itself, I suspect that advice on drinking may be one of the issues for which GPs get additional payment, as with advice on dealing with obesity."

So there we have it from the expert. Looks to me like another hangover from the good old nanny state New LieBore days of inventing ways to pay people for meeting targets rather than letting them alone to get on with their jobs - which in this case is healing the sick...

NHS Consultants' bonuses - Are they justified?

When our new coalition government looks for ways to save money in the NHS, perhaps we should be looking closely at the way the NHS Consultants' Merit Awards system works, and ask whether it is time for a review?

The following is taken from an article in the Sunday Times in 2008 :

"Figures obtained by The Sunday Times under the Freedom of Information Act suggest hundreds of NHS consultants earned more than £190,000 in the financial year ending in March – more than Gordon Brown – putting them in the top 1% of earners.

By contrast with highly paid workers in the private sector, who now face widespread unemployment, they also enjoy full job security.

Previously NHS consultants turned to private work for extra income. The figures show they can now more than double their basic salaries by sticking with the health service, thanks to bonuses inflated by incentives to meet government targets to cut waiting lists.

The generosity of the NHS towards its senior staff may anger patients who have recently been deprived of modern cancer or osteoporosis treatments because they have been deemed too expensive."

Here's the views of "Old Sawbones", our Consultant in the know :

"The prioritisation of resources available from the tax payer to fund health care in a world of increasing financial restraint becomes ever more important, and the contentious issue of consultants' distinction awards should be open to public scrutiny.

The present system appears to be more equitable and transparent than when I was appointed to a consultant post in 1975, at which time it had many features of an "old-boy network". Committees were dominated by previous recipients, and the whole procedure was shrouded in such secrecy that one often did not know who had an award, and often quite why .

Indeed, I can recall the dilemma of a newly appointed consultant who was threatened with not being considered for one, if he did not toe a particular medico-political line.

Of course, this would not and indeed could not happen today. However, whether these awards are justified is a subject that now requires an open debate. When I left the NHS, the committees set up to award the discretionary points, given as a preliminary to the more major awards, were more democratic and a real attempt was made to ensure that the process was as fair and objective as possible. I am sure this has evolved further.

It would be helpful however, if the public and the profession could be reassured that the procedure for awarding the major B, A and A+ awards was transparent, and that the magnitude of these awards is justified.

Clinical excellence may not always be easy to assess, and it can be invidious to compare one medical speciality with another, when the pressures and challenges may differ widely. Service redevelopment, administrative duties and medical audit appear to be popular themes, but how easy can it be to quantify dedication, compassion and exceptional commitment to patient care, without true 360 degree appraisal, including nursing staff input and patient feedback?

It may be that the public and the profession can be reassured that the assessment of merit is now a fair and objective process, without political patronage or sycophancy. Perhaps however, one is left with the feeling that it is a privilege to be a doctor, and the professional rewards of a well remunerated job should be sufficient to prevent a consultant from being attracted to what may be a more lucrative elsewhere."

I think it is clear that the system needs to be looked at again and that there is a clear understanding why these payments are made and how they are justified. Employing armies of managers to create and monitor arbitrary targets just to support a bonus system, simply doesn't cut it.

Performance related pay structures for doctors would seem to me to be contrary to the welfare of patients and wholly inappropriate...

NHS Consultants' bonuses - Are they justified?

When our new coalition government looks for ways to save money in the NHS, perhaps we should be looking closely at the way the NHS Consultants' Merit Awards system works, and ask whether it is time for a review?

The following is taken from an article in the Sunday Times in 2008 :

"Figures obtained by The Sunday Times under the Freedom of Information Act suggest hundreds of NHS consultants earned more than £190,000 in the financial year ending in March – more than Gordon Brown – putting them in the top 1% of earners.

By contrast with highly paid workers in the private sector, who now face widespread unemployment, they also enjoy full job security.

Previously NHS consultants turned to private work for extra income. The figures show they can now more than double their basic salaries by sticking with the health service, thanks to bonuses inflated by incentives to meet government targets to cut waiting lists.

The generosity of the NHS towards its senior staff may anger patients who have recently been deprived of modern cancer or osteoporosis treatments because they have been deemed too expensive."

Here's the views of "Old Sawbones", our Consultant in the know :

"The prioritisation of resources available from the tax payer to fund health care in a world of increasing financial restraint becomes ever more important, and the contentious issue of consultants' distinction awards should be open to public scrutiny.

The present system appears to be more equitable and transparent than when I was appointed to a consultant post in 1975, at which time it had many features of an "old-boy network". Committees were dominated by previous recipients, and the whole procedure was shrouded in such secrecy that one often did not know who had an award, and often quite why .

Indeed, I can recall the dilemma of a newly appointed consultant who was threatened with not being considered for one, if he did not toe a particular medico-political line.

Of course, this would not and indeed could not happen today. However, whether these awards are justified is a subject that now requires an open debate. When I left the NHS, the committees set up to award the discretionary points, given as a preliminary to the more major awards, were more democratic and a real attempt was made to ensure that the process was as fair and objective as possible. I am sure this has evolved further.

It would be helpful however, if the public and the profession could be reassured that the procedure for awarding the major B, A and A+ awards was transparent, and that the magnitude of these awards is justified.

Clinical excellence may not always be easy to assess, and it can be invidious to compare one medical speciality with another, when the pressures and challenges may differ widely. Service redevelopment, administrative duties and medical audit appear to be popular themes, but how easy can it be to quantify dedication, compassion and exceptional commitment to patient care, without true 360 degree appraisal, including nursing staff input and patient feedback?

It may be that the public and the profession can be reassured that the assessment of merit is now a fair and objective process, without political patronage or sycophancy. Perhaps however, one is left with the feeling that it is a privilege to be a doctor, and the professional rewards of a well remunerated job should be sufficient to prevent a consultant from being attracted to what may be a more lucrative elsewhere."

I think it is clear that the system needs to be looked at again and that there is a clear understanding why these payments are made and how they are justified. Employing armies of managers to create and monitor arbitrary targets just to support a bonus system, simply doesn't cut it.

Performance related pay structures for doctors would seem to me to be contrary to the welfare of patients and wholly inappropriate...

NHS - The death throes of a sacred cow

"Old Sawbones" is an established consultant
surgeon with many years experience working both
inside the NHS and private practice who cares
passionately about his vocation

An insider's view by "Old Sawbones" - our man in the know inside the NHS

I admit to being an anti-establishment critic. I have written about 100 letters to broadsheets and medical journals over the past 10 years, but there has been little public reaction.

Off the record, many apparently agree with what I write, but they daren't put their head above the parapet for medico-political reasons such as conflict with their work on committees or private practice. Basically, the motivations are money, power and prestige -the self interest factor.

In it's present form, our NHS was unsustainable even before the credit crunch, but as a country in collective denial and with politicians of all shades terrified to say the unsayable, we muddle along. Cancer cure rates and other indicators of success in medical treatment are already near the bottom of the European league.

No other country has a Healthcare system funded purely from taxation alone. Our NHS is not free, and there are financial restrictions on what care we receive. Whilst emergency care remains free, dental care certainly does not, and many people still pay for prescriptions. There is a post code lottery, and "NICE" admits that it's recommendations over cancer drugs have to be influenced by the cost. Thus we don't necessarily receive the life prolonging treatments available in some other European countries.

We have been graded as low as 18th by the OECD in the European league, and while health care systems throughout Europe (and indeed the world) struggle to contain costs, the most successful ones had mixed funding. Sources include "top up" patient's private medical insurance (in some cases compulsory), "Social Insurance" paid by the employer as in France and Germany, and voluntary contributions. So, with rising costs from expensive new treatments for an ageing population, I see no alternative to some form of direct payment such as charging to see a GP - as in Eire.

Perhaps we should turn a blind eye to the European Working Time Directive, as already happens in many, mainly Southern, European countries which don't slavishly follow it in every detail. This may be politically unacceptable, but there is no reason why today's doctors cannot work a reasonable amount out of hours, as still is the case in many parts of the world.

How can doctors bear to simply shut up shop at the end of the day?

There is some truth in the aphorism that from being a vocation or profession, medicine is now just a job. It is no longer a way of life, and a privilege to practice. I fail to see why today's GPs cannot work out of hours on a reasonable rota or with acceptable cover. With regret, I suspect it may simply be that they haven't got the resilience, stamina and staying power to do so. The "new" GP contract must be rescinded. If motivation were a patient, it would surely be on its last legs!

Another controversial measure would be to allow direct patient referral to specialists as occurs in many countries world wide. Patients know or can find out with help from the internet what specialist they need to see. But the GP as the gatekeeper to secondary care has to validate this. Often this is a waste of GP time and, of course, money. Unfortunately, there are too many vested establishment interests at heart here and the BMA trade union exists to preserve them.

And then of course there is immigration with its attendant costs to the NHS, the myriads of managers and jobsworths, "health and safety", and the compensation culture to consider...

I don't see our health service surviving in the long run, it's time expired, but the public and politicians have a blind spot - and our devious deluded dissembling PM wants to "protect" it!

NHS - The death throes of a sacred cow

"Old Sawbones" is an established consultant
surgeon with many years experience working both
inside the NHS and private practice who cares
passionately about his vocation

An insider's view by "Old Sawbones" - our man in the know inside the NHS

I admit to being an anti-establishment critic. I have written about 100 letters to broadsheets and medical journals over the past 10 years, but there has been little public reaction.

Off the record, many apparently agree with what I write, but they daren't put their head above the parapet for medico-political reasons such as conflict with their work on committees or private practice. Basically, the motivations are money, power and prestige -the self interest factor.

In it's present form, our NHS was unsustainable even before the credit crunch, but as a country in collective denial and with politicians of all shades terrified to say the unsayable, we muddle along. Cancer cure rates and other indicators of success in medical treatment are already near the bottom of the European league.

No other country has a Healthcare system funded purely from taxation alone. Our NHS is not free, and there are financial restrictions on what care we receive. Whilst emergency care remains free, dental care certainly does not, and many people still pay for prescriptions. There is a post code lottery, and "NICE" admits that it's recommendations over cancer drugs have to be influenced by the cost. Thus we don't necessarily receive the life prolonging treatments available in some other European countries.

We have been graded as low as 18th by the OECD in the European league, and while health care systems throughout Europe (and indeed the world) struggle to contain costs, the most successful ones had mixed funding. Sources include "top up" patient's private medical insurance (in some cases compulsory), "Social Insurance" paid by the employer as in France and Germany, and voluntary contributions. So, with rising costs from expensive new treatments for an ageing population, I see no alternative to some form of direct payment such as charging to see a GP - as in Eire.

Perhaps we should turn a blind eye to the European Working Time Directive, as already happens in many, mainly Southern, European countries which don't slavishly follow it in every detail. This may be politically unacceptable, but there is no reason why today's doctors cannot work a reasonable amount out of hours, as still is the case in many parts of the world.

How can doctors bear to simply shut up shop at the end of the day?

There is some truth in the aphorism that from being a vocation or profession, medicine is now just a job. It is no longer a way of life, and a privilege to practice. I fail to see why today's GPs cannot work out of hours on a reasonable rota or with acceptable cover. With regret, I suspect it may simply be that they haven't got the resilience, stamina and staying power to do so. The "new" GP contract must be rescinded. If motivation were a patient, it would surely be on its last legs!

Another controversial measure would be to allow direct patient referral to specialists as occurs in many countries world wide. Patients know or can find out with help from the internet what specialist they need to see. But the GP as the gatekeeper to secondary care has to validate this. Often this is a waste of GP time and, of course, money. Unfortunately, there are too many vested establishment interests at heart here and the BMA trade union exists to preserve them.

And then of course there is immigration with its attendant costs to the NHS, the myriads of managers and jobsworths, "health and safety", and the compensation culture to consider...

I don't see our health service surviving in the long run, it's time expired, but the public and politicians have a blind spot - and our devious deluded dissembling PM wants to "protect" it!