Blogs and writing

view:  full / summary

When I get older

Posted on February 25, 2017 at 12:05 PM Comments comments (0)

Scrap universal state pension and help the young instead

Birthdays are to be celebrated, but crossing the decade marks in your life (29 to 30 for example) is often regarded as an achievement you would rather not shout about, although failing to achieve these milestones would be of more concern. Fifty sounds a lot older than 49, but I never realised how much there was to celebrate when I recently passed my 60th Birthday. Overnight I became entitled to substantial discounts on a wide range of goods and services from cinema tickets to rail fares. Suddenly I was living in discount heaven a ‘pensioners poundland’. I pay no prescription charges despite the fact that I am likely to impose an increasing financial burden on the already overstretched NHS as I get older. I get free eye tests and may even be entitled to a free wig! And yet I am still working full time in the NHS earning a salary, which is at least 30% more than my newly appointed colleagues receive.

I enjoy motor insurance at a fraction of the cost that a 25 year old would have to pay. In a few years I will be entitled to winter fuel allowance, a state pension and a free bus pass. If I lived in London, I could already be travelling free of charge on all buses, underground and overground trains within the capital. Just imagine, a 60 year old banker using his ‘senior’ Oyster card to get to the city from his dockland penthouse free of charge. Surely this is not right

The fiscal divide between the rich and the poor widens year on year. The hope that ‘trickle down’ economics would narrow this income gap has evaporated. But last week the Resolution Foundation highlighted an even more striking variation in earnings according to age. Since 1881 (when records began) people in their twenties have always earned more in real terms than the generation before – until now. Over the last seven years there has been only a tiny rise in real income. But those over the age of 60 have enjoyed an 11% rise while those in their twenties have seen a 7% fall. Thirty years ago people in their twenties were earning 15% more than those aged over 60; now the situation is reversed. Of the nine million people living in the UK aged between 19 to 24, almost one third are living in poverty. Those with children are more likely to find themselves in this situation. And children raised in poverty are far less likely to realise their full genetic potential.

You would be forgiven for thinking all of this poverty is a consequence of long-term unemployment combined with reductions in benefit payments. But you would be wrong. The charity ‘Shelter’ has data showing almost half of the London homeless have a job. They are the young people who pull your pint, deliver your pizza and grill your hamburger. Although it is likely that employed homelessness is less common in the south west where housing costs are much lower, the reality is that zero-hours contracts, the minimum wage and sessional work through a temping agency simply don’t pay enough. Even those fortunate enough to be in a well-paid job are likely to be paying off their student loan for many years and will need to work well into their late sixties to earn a decent pension.

Nearly three-quarters of pensioners own their own home outright so have no outgoings in rent or mortgage repayments; a luxury enjoyed by only one fifth of working age people. Newspaper headlines trumpeting the boom in property prices may delight the elderly homeowner, but for many this simply means higher rents and the possibility of home ownership becoming an increasingly distant dream.

We baby boomers belong to a generation whose parents and grandparents fought two world wars and endured a cold one. We thrived with the prosperity that long-term peace brings. We enjoyed free education and the safety net of a welfare state. We expected the earth, got it and then ruined it. Now we expect our children to pay the repair bills. And yet I will soon benefit from a state pension with the ‘triple lock’ guarantee to increase the state pension every year by matching the highest of inflation, average earnings or a minimum of 2.5%. Ensuring my pension income will not be eroded by the gradual increase in the cost of living. I have no doubt that this is essential for many, but pensioner poverty is now largely restricted to the very elderly. The new pensioners from the baby boom have never had it so good.

It is time to turn the discount culture upside down and shift wealth from the old to the young. Those, like me, who do not need a state pension, should not get it. The money saved should be reinvested in the younger generation giving more support to those raising families or trying to pay rent or mortgage. We cannot simply dump austerity on the millennials. Our goal should be to relieve this jilted generation of the financial burden of education fees, build affordable housing and maintain a supportive welfare state. And if you are 60 today; many happy returns and welcome to my world.

Western Morning News 25th February 2017

Crisis, What Crisis?

Posted on January 18, 2017 at 11:40 PM Comments comments (0)

It’s a black alert, a humanitarian crisis, a major incident, exceptional measures are demanded. Where in the world could this be? Syria? Sudan? Or perhaps a terrorist attack in a major European city? No, it’s just a normal working day at your local hospital in January. No one, even those of us who have served the NHS for a long time (38 years for me) have witnessed anything quite like it. We are underfunded, understaffed and at the moment, desperately overstretched. In comparison with other European countries we have fewer beds, fewer doctors and nurses and fewer scanners. But when challenged the prime minister and the health secretary repeat the same mantra about the huge amounts of extra cash the NHS is receiving. You may feel that The Red Cross have overstated the problem by labelling this as a humanitarian crisis, but if you end up dying in A&E after waiting 36 hours on a trolley for a bed to become available, where is the humanity in that? If you wait months for an operation, only to have it cancelled at the last minute, or see your elderly relatives looked after on inappropriate wards by exhausted staff, you may well wonder whether this is a humane way to run a health service. None of this happens because of a lack of compassion amongst those in the hospital, it has been allowed to happen by depriving them of the resources they urgently need. As a member of the council of the Royal College of Physicians, representing Devon and Cornwall I am a co-signatory on an open letter to the prime minister laying out these facts.

Since the government says it is not their fault, who is to blame? Well, the boss of the NHS, Simon Stevens, has been sharply criticised for failing to make the necessary efficiencies and for pointing out the rather inconvenient truth that the government has got it’s sums wrong and there simply isn’t enough money to fund the NHS. The doctors are also to blame for striking last year and for failing to provide a full 7-day service, although the government has never been clear what it means by this. And of course, it’s your fault. Yes, you – for going to the Accident and Emergency department for problems that are neither accidents nor emergencies and wasting our precious resources. If, like me, you are a trifle sceptical about Jeremy Hunt’s handling of statistics, you would not be surprised to hear him claim that 30% of A&E attendances are unnecessary. But it is often difficult to say whether a hospital visit is needless until the patient has been fully assessed. Every day I see a number of patients with suspected heart attacks that turn out to be nothing more than indigestion. They are not at fault; they are not wasting our time or resources. It is far worse when people think they have indigestion and only come to hospital after munching handfuls of Rennies to no effect, by which time it is often too late to effectively treat their heart attack.

Over the last 14 years the number of beds in the NHS has fallen by over one third while the number of admissions has risen by over 50%. How have we coped? By reducing the length of stay in hospital. When I was in training 40 years ago a minor operation such as a hernia repair would require three to five days in hospital. Now the vast majority are day case procedures. But the intention is to cut the number of beds even further with the expectation that admissions will fall. The musical La La land may well have swept the board at the Golden Globes, but anyone who believes this plan will work should receive a special ‘cloud cuckoo land’ award. It is doomed to failure. Every attempt to reduce the number of emergency admissions has failed, the numbers rise relentlessly year on year.

I am sick to the teeth of hearing that the NHS is simply inefficient and would run like clockwork if it were reorganised. What, again? For pity’s sake, we are only just recovering from the fiasco created by Andrew Lansley’s reforms in 2010. The NHS is like a battered leather football, kicked around by each new government in turn. If anything what we need is to de-politicise the NHS and let the professionals run it.

The NHS deficit in Devon alone is expected to exceed £500 million by 2020, the highest in the country. But the financial crisis in the NHS is not bad news for everyone. Some believe that the underfunding is a deliberate ploy by the government to kill off the NHS by a death of a thousand cuts then sell it off to the private sector. Indeed, the chief executive of the private health company Spire said; “…as the gap between supply and demand grows, by nature people will turn to a private product.” So, if the NHS perishes, the vultures from the private sector, already circling overhead, are ready to pick off the juicy bits from the carcass.

Of course, the government denies this is their plan and reaffirms its commitment to a publicly funded, comprehensive national health service. They also claim that they have provided enough extra money to sort out these ‘winter pressures’. And at the time of writing this article, it is clear they do not intend to give any more. But the UK is the fifth largest economy in the world and spends less than almost all of its European neighbours on health. We would need to spend an extra £45 billion by 2020 to catch up with the average European Union health expenditure. I don’t want the NHS to fail, so I have written to ask for a meeting with my local MP (so far no reply), why don’t you do the same?

Western Morning News 19th January 2017

The Era of Stupidity

Posted on November 25, 2016 at 10:05 AM Comments comments (0)

Debate should be based on facts, not hearsay or ideology

I am normally a good sleeper. But twice this year I have awoken from a peaceful slumber into a nightmare about clowns; it’s always clowns. In one of my nightmares I am a passenger on a plane where the pilot dies and a professional clown with a terrible comb-over and absolutely no experience with flying an aircraft takes the controls and prepares for a crash landing. Those of us in the back realise that there are quite a number of passengers on board who are fully qualified pilots, but the clown’s friends block the way to the cockpit and say he is undoubtedly the right man for the job; he told them so. Meanwhile we are in a rapid descent and the runway is fast approaching.

The second nightmare involves another clown, also with hair issues, who says he has a fortune to spend on our beleaguered health service as long as we join his campaign to cut ourselves adrift from continental Europe. It sounds like a great idea, so we do it. But when I wake up in a cold sweat I hear his fellow circus performers on the radio announcing deeper cuts in NHS spending. When the clowns wipe off their make up, it is clear both nightmares are reality. On both occasions the polls said I could sleep easily, on both occasions the polls were wrong. But what disturbs me the most about the outcome of the EU referendum and the election of Donald Trump is that we now appear to be entering an era of stupidity where mere facts can be swept aside by a fool’s opinion. And that, more than anything else, is likely to keep me awake at night.

The next US president will be a man supported by the Ku Klux Clan who has smeared his black predecessor in the harshest, indeed racist manner and who will now be in possession of the nuclear weapons codes. His narcissism, temper tantrums and manner of speech make him appear like a child trapped in a man’s body. But his rudimentary grasp on even the most basic facts of politics would make a ten-year-old of average intelligence blush with embarrassment. I suspect almost all politicians distort the truth to some degree, but this man’s habitual lies and disordered thinking is something that I have seldom witnessed outside a mental institution. His cabinet is a clown car packed with ideologues and religious fanatics. He has been a punch line in jokes for decades.

Donald trump is contemptuous of science and proudly announces that climate change is a hoax generated by the Chinese to undermine US trade. He has appointed Myron Ebell a leading climate change skeptic to lead the Environmental Protection Agency. He intends to repeal the Affordable Care Act (or ‘Obama care’;) and replace it with…well, nothing. Effectively depriving up to 22 million Americans of access to health care insurance.

Back home, before the EU referendum Michael Gove said: ‘people in this country have had enough of experts’ and last month criticized ‘experts’ such as Mark Carney, the head of the Bank of England for ‘wreaking all kinds of economic disasters’. He is not alone in his distaste for expertise. The secretary of state for health, Jeremy Hunt who has been heavily criticised for using false statistics to impose a new junior doctor contract said at the Conservative Party conference: ‘let’s not argue about statistics’. But the correct application of statistics is fundamental to science and there is an intimate relationship between science and democracy, scientific thought flourishes in democratic countries and withers in autocracies where the tyrant replaces the expert. Like everyone else, I have my areas of ignorance. But when these are exposed I seek information from reliable sources, from people who have knowledge and experience to fill that gap. It is healthy to be skeptical about statements from experts until you can satisfy yourself that they are indeed experts and that the evidence base for their comments is sound. Debate should be based on facts, not hearsay or ideology.

Yet distrust of expert opinion is not uncommon, many people take so-called ‘complementary therapies’ even when there is not a shred of evidence that they have any medical value beyond the placebo effect. And many parents have put the future health of their children at risk by withholding vaccines based on discredited evidence that the MMR vaccine may lead to autism. The overwhelming majority of climate change scientists are of the view that the earth is warming up at an alarming rate and that this is related to greenhouse gases, but they are just the experts and surely anyone is entitled to their own opinion? Many people subscribe to the vast number of conspiracy theories they read about on the Internet and believe in the ‘fake news’ from websites that pay their writers by the click of a mouse rather than the integrity of their journalism.

If you disagree with me and share Michael Gove’s contempt for experts: good luck when you allow the clown to take control of the cockpit.

Western Morning News 25th Nov 2016

The Junior Doctors Strike

Posted on September 6, 2016 at 5:25 AM Comments comments (0)

I have never liked the term 'industrial action' because what is planned is always the exact opposite – industrial inaction. 'Strike' is better; it suggests a blow is being delivered. And that is precisely what the UK's junior doctors are planning; more blows. Blows to try and force the government to reopen talks about their contracts. When you heard the news, did your heart sink? Mine did.

During the junior doctors' strikes earlier this year, the banners on the picket lines did not read: 'doctors demand more money' but 'not fair – not safe' and 'save our NHS'. Clearly they felt there was more to this dispute than a simple spat about wages, the safety and even the survival of the NHS were at stake.

Before the strikes earlier this year the ballot of British Medical Association (BMA) members showed overwhelming support (98% voted for strike action with a turnout of 76%) and the number of doctors who walked out was very high (almost 100% downed stethoscopes in the hospital where I work). The junior doctors grievances had the overwhelming support of consultants and general practitioners. Many of whom felt that they would be next on Mr. Hunt's hit list. Most doctors expressed regret that it had come to strike action but felt that they were left with no alternative.

They justified the decision to strike on the grounds that it would not compromise patient safety. But this is disingenuous. Although consultants did cover the emergency work on strike days, in order to do this they had to cancel operating lists, outpatient clinics etc. And we know that some patients die while waiting for 'elective' procedures such as coronary bypass operations and prolonging the waiting time will inevitably increase the number of deaths.However, an agreement was eventually reached between the BMA and the Department of Health in July but was then rejected in a subsequent ballot by a much narrower margin of 58% to 42%, with a turnout of 68%. There has been no further ballot on strike action; that decision was made by the BMA council. Leaked sources revealed that the vote in favour of striking was very close. I doubt the next round of strikes will enjoy as much support from junior doctors as the ones earlier this year.

The Prime Minister said that the government was…'putting patients first' while the doctors were 'playing politics'. This sounds like an episode of 'Job Swap' I would really not want to watch. She went on to say that "the NHS enjoyed record levels of funding", and that there are "more doctors now in the NHS than we've seen in its history".

Both facts are true, but fail to recognize that many hospitals do not have enough doctors to fill the on-call rotas and 40% of advertised consultant posts remain unfilled. Patients are frequently extremely complimentary of the care they receive from the NHS and if you are on the receiving end of emergency treatment, I doubt it could be bettered by any other country. But if you are at the end of a three-hour queue in A&E or the bottom of a six-month waiting list for a hip replacement, you will see at first hand how poorly an underfunded, understaffed and overstretched health service functions.I was one of the many consultants who covered the emergency duties of striking junior staff.

At first this was a bit of a lark, nurses on the wards were amused to see me struggling to type out a discharge summary. But the novelty wore off. What ground me down was not the huge amount of tedious and repetitive work I was expected to do, nor the ludicrously disjointed IT systems (seven different systems, all with different log-ins) but the feeling that I was not furthering the junior doctors' cause. Indeed we ran the emergency services much more efficiently without them.

I have enormous sympathy for the junior doctors' plight and nothing but scorn for the secretary of state. My fear is that continued strike action will achieve nothing apart from a progressive decline in public support (an almost inevitable consequence of long industrial disputes) and a generation of increasingly demoralised doctors. Despite imaginative and evidence-free speculation on social media I see no sign of the government changing its position. Many UK trained junior doctors have already voted with their feet rather than the ballot box by leaving to work overseas. The majority have no intention of returning. If this stand-off continues I worry the exodus will escalate.

We need to replace ill-informed spin about the state of the NHS with honesty and realism that there is now a widening gap between what the NHS is being asked to deliver and the funding available. Former conservative health minister, Dr Dan Poulter, recognized this and suggested a 'health tax' generated by raising National Insurance contributions. We urgently need a plan to close this gap. The last thing we need is a protracted battle between the government and core medical staff.

Western Morning News 6th September 2016

Brexit and The NHS

Posted on August 23, 2016 at 11:15 AM Comments comments (0)

Today I was introduced to someone extraordinary: a newly recruited nurse who is not from continental Europe, but from the UK - Taunton to be more precise. In the hospital where I work 20% of the registered nurses are from overseas, the majority from the European Union (EU). Chatter in the common room is a mongrel mix of Spanish, Italian, Greek and even Catalonian. To help them communicate with our local population I have encouraged them to use some West Country expressions. Hearing a nurse from Barcelona tell the patient that we have done a ‘proper job’ always makes us giggle.

In his commencement address at Yale University in 1962 John F Kennedy said: “The great enemy of truth is very often not the lie; deliberate, contrived and dishonest, but the myth; persistent, persuasive and unrealistic…”

I doubt that many voted to leave the EU because they really believed that this would result in a massive cash boost for the NHS, but this is precisely what was promised. Up to £350 million per week extra was promised at one stage of the campaign. This was downgraded to £100 million per week later on when the leave campaigners realised the sums did not add up. And as the referendum day drew near this amount was reduced even further or not discussed at all. Now that the vote to leave has been won and our new Prime Minister clearly intends to follow Brexit through, no one in power is talking about extra investment in the NHS.

According to an analysis by the independent think tank, The Health Foundation, any potential savings the UK might make in payments to the EU “would be more than cancelled out” by the economic consequences of leaving. It said that even if the UK remained in the European Economic Area (EEA) after leaving the EU, the NHS could have a funding shortfall of at least £365m a week. But if the UK does not remain part of the EEA, the report said that this could be as high as £540m a week. Anita Charlesworth, director of research at the Health Foundation, said: “The recent decision for the UK to leave the EU will create additional challenges both in terms of finances and the ability to attract and retain valuable European staff. It is widely anticipated that leaving the EU will lead to lower economic growth, and when the economy sneezes, the NHS catches a cold. The NHS is already half way through its most austere decade ever, with finances in a truly dire state—it cannot afford to face another hit.”

Despite these dire warnings, the government has consistently reassured us that the NHS is adequately funded (it isn’t), adequately staffed (it isn’t) and the cause of the huge deficit is lack of ‘financial discipline’ (it isn’t). Patients are given high expectations (such as seven day access to a GP) and then encouraged to complain when they fail to materialise.

The Health Foundation report highlights that the NHS is short of 28,000 nurses, 2,300 consultants and 2,500 junior doctors. The EU has provided rich pickings for employers looking to fill vacant nursing and medical posts. So can we expect our new Prime Minister to encourage overseas recruitment? It seems unlikely. The Daily Telegraph described her speech at last October’s Conservative Party Conference as a cynical bid to scapegoat immigrants, whip up anger at foreigners in order to win support as a leadership candidate.

If you voted to leave the EU to reduce immigration, how did you think gaps in hospital staff would be filled? We certainly cannot do it from our local population. Even if we massively expanded medical school places in the UK today, we would not see any expansion in home grown hospital consultants or General Practitioners until 2033 at the earliest. There is understandable concern amongst the EU workforce already working for the NHS as to what will happen after Article 50 is triggered. People are planning their futures and thinking about where they want to be in two to three years' time and I doubt they will wait to find out. We need to move on from simply reassuring our EU workforce that they are valued to giving them some security and certainty should they choose to remain in this country. If we don’t we could see a lot of people who are already here leaving. And it seems certain that many EU nationals who were considering a future working in the NHS will think again. And if you voted Brexit for a much-needed massive cash injection for the NHS you may well see exactly the opposite. All the talk now is of further cuts in public spending.

JFK concluded his address: “…too often we hold fast to the clichés of our forebears. We subject all facts to a prefabricated set of interpretations. We enjoy the comfort of opinion without the discomfort of thought”. If you had the chance to vote again, would you still vote leave?

Western Morning News 20th August 2016

Safe Cycling

Posted on March 18, 2016 at 11:10 AM Comments comments (0)

According to a recent European study, I am one of the 4%; I do it every day (well, almost every day). If you never do it, you are amongst the majority of UK residents (69%). In Holland the picture is strikingly different, 27% do it every day and only 13% never do it. I am referring to cycling, of course. But why on earth would anyone want to cycle on West Country roads? Well, I’ll tell you why I do it.

Firstly, I enjoy it; even though England seems to have replaced winter with a monsoon season and there are times when it feels like I am cycling in a war zone. The rhetoric of road war is fuelled by the likes of Jeremy Clarkson, labeling cyclists as “lycra Nazis” and “pushbike Bolsheviks”. And asking the question…"When will people understand that roads are for cars and that there is no danger at all from speeding motorists if walkers and cyclists steer clear?" I can also put up with the abuse I get, indeed the often-heard taunt: “you don’t pay any road tax” is false: I do, and when I’m on my bike and my car is in the garage I’m doing much less damage to the roads and the environment.

Secondly, it is the fastest way to travel in cities, especially during peak hours. There used to be an annual ‘commuter challenge’ from the outskirts of London to the city centre. An average cyclist was pitted against a taxi, or public transport. Every year the bike won easily – even after a helicopter was introduced into the competition.

Thirdly, cycling is the healthy way to travel. When I bump into colleagues in the corridor at work wearing my cycling gear, many feel the need to justify why they do not cycle to work. Safety usually appears high on their list of reasons. But the risks of cycling are overestimated. A cyclist would need to commute every day for 8,000 years before they would be killed on the roads. The extra years of life gained by the regular exercise of cycling far outweighs the risks of death. I appreciate that cycling in the UK can feel dangerous, but it needn’t be like that. Hop across the Channel and you will find cities full of people on bikes wearing everyday clothes and almost none wearing helmets. Space for pedestrians and cyclists is frequently shared and no one seems to get het up about it. So why is cycling such a popular means of travel on the continent, but not in the UK? Of course, some countries have the advantage of being as flat as a pancake whereas it is almost impossible to travel any distance in Devon and Cornwall before being confronted with a hill to climb. More importantly, these countries have invested heavily in separating bikes from cars (and more crucially lorries) making it feel a lot safer.

Finally, it is clearly the right thing to do from an environmental perspective. If you are physically capable, you should walk or cycle short trips (40% of all journeys in the UK of less than two miles are made by car). We read about the harm caused by rising levels of CO2 and exhaust pollutants almost every day, but this discourages few from motoring. I suspect this is because they are not directly affected by global warming. If the water level in your house rose an inch every time you turned the ignition key in their car, I bet you would take climate change more seriously.

What is needed is a change in mindset and this requires a change in legislation. For starters we need laws that protect cyclists. In Holland if there is a collision between a car and a bike, the motorist is held responsible unless he can prove he is innocent. Penalties for injuring cyclists are severe. Open a car door in Amsterdam in the path of a passing cyclist and you may well end up in jail. In the UK, the law favours the motorist, the onus for safety is put squarely on the shoulders of those who choose to cycle.


Cyclists should be allowed to pass through red traffic lights if the road is clear. This is widely considered to be dangerous, but the greatest risk to cyclists comes from lorries turning left at junctions, so allowing the bike to go ahead would improve road safety. This fact has been grasped by many European cities, including Paris, and even some in the USA, the spiritual home of the motorcar. Also, employers should have schemes that encourage their staff to cycle to work, providing secure cycle storage and facilities for workers to shower and change clothes.

You might feel that such changes are unconscionable, but just reflect on what has happened to smoking. There was a time when it was deemed perfectly OK to smoke almost anywhere you liked; including pubs, cinemas, restaurants and even on airplanes. But all that has changed and the same could happen for cycling. Am I dreaming? Well, maybe not. The day after the BBC sacked Clarkson (no, that’s not in my dream); journalists mobbed him leaving his home … riding a bike. Surely if he can do it, so can you.

John Dean March Western Morning News March 2016

Trust me I'm a doctor

Posted on February 27, 2016 at 10:55 AM Comments comments (0)

It is often said that there are three types of lies: lies, damned lies and statistics. But statistics never lie, unless they are abused or misinterpreted and this usually requires the input of a politician. Recent statements by the secretary of state for health illustrate this perfectly.

Firstly, he wants consultants to work a seven-day week and highlights the importance of this by quoting an excess of 11,000 deaths amongst patients admitted to hospital at the weekend. He said that doctors have a “nine to five weekday culture” and have “lost a sense of vocation”. He overlooks the fact that over two thirds of consultants, like me, already work weekends and assumes that forcing the remaining one third to follow suit will cut the weekend death rate. He ignores the fact that consultants do not and cannot work in isolation, we work in teams. So without the investment to fund a full complement of supporting staff, our sole input would be almost valueless. Of course, we all want to be sure that when we fall ill, the care we receive will be top quality irrespective of the day of the week or time of the day, but this is no way to go about achieving that goal.

Secondly, he has rather messed up the figures for his proposed contract for the junior doctors. He said that overall these doctors would be better off by 11%, but the total pay budget would be unchanged. How can this be? Unless he is planning to reduce the workforce, I can only think of one explanation…politicians use magic money rather than the normal money you and I use. Probably the same magic money the banks used in 2005 before the financial crisis. Despite the title of ‘junior’, the striking doctors are highly educated professionals in their 20’s and 30’s; not children, so they had no trouble spotting the flaws in Mr Hunt’s sums. Without access to the book of spells, junior doctors were forced to base their calculations of income on normal rather than magic money and it appears that many of them will be worse off. In particular those who work unsocial hours in the emergency services that the secretary of state wants to run seven days a week. Junior they may be, but they certainly have a better grasp of maths and statistics than Mr Hunt.

Thirdly, it is often claimed that the main problem with the NHS is inefficiency. This allows the government to justify imposing £20 billion ‘efficiency savings’. One spokeswoman on BBC ‘Question Time’ recently claimed that Germany enjoys a much better health service than we do in the UK, but only spends 2% more. This is misleading because they spend 2% more of their GDP. If the UK spent the same proportion of GDP on health as Germany does, the NHS budget would increase from £150 billion per year to £185 billion. Now that really would make a big difference.

Although maths may be a weakness for members of the government, when it comes to spin, they certainly excel. They are already trying to demonise the ‘greedy’ junior doctors by saying this is simply a dispute about money and one national newspaper has joined in, labelling their leaders as ‘Moet medics’ enjoying a lavish lifestyle on their current salaries. The junior doctors, in turn, have responded on Twitter with their usual good humour.

But this is much more than a simple spat about wages. Most of the medical Royal Colleges (which do not engage in disputes about doctors’ terms and conditions of employment) have made statements supporting a negotiated settlement. They have highlighted the potential long-term harm to the health service that may well occur if this is not achieved.

Polls suggest that about two thirds of the population and the overwhelming majority of consultants and GP’s support the junior doctors cause. I am sure that not one of them wishes to see patients come to harm, but they realise that if a solution is not found and the government goes ahead with it’s threat to impose an un-negotiated contract, this will seriously threaten the future of healthcare in this country. Over 70% of junior doctors balloted said they would leave the UK to work abroad if this goes ahead. This cannot be allowed to happen – they are our future consultants and GP’s. I for one will need them as I get older.

When it comes to the public perception of trustworthiness, politicians rank even lower than estate agents and bankers (I know, hard to imagine isn’t it?). While doctors and nurses have the highest scores. But I do have concerns about the aftermath of strike action. I fear that sympathy for the junior doctors will wane if the conflict escalates. But take it from me; the NHS is in serious trouble already and we cannot cope with any more. Almost all of the independent health-watch organisations such as the King’s Fund argue that substantial investment is needed to maintain an acceptable level of health service. The current conflict between the government and the junior doctors is just the tip of a massive iceberg. And if you are a patient, you are sailing on the Titanic. Whatever the politicians say, there are no quick, easy fixes. Trust me, I am a doctor

Western Morning News 27th February 2016

Pacemaker battery scandal

Posted on February 3, 2016 at 11:55 PM Comments comments (0)

Much can and should be done to maximise the longevity of existing devices

Imagine spending £3000 on a new watch with a battery embedded in the mechanism that cannot be replaced or recharged. Although the battery is predicted to last 10 years or more, after six years you discover that it is running flat and you’re advised to replace the watch immediately, even though it may keep good time for a year or more.

This mirrors the dilemma faced by all patients with cardiac implantable electronic devices such as pacemakers and implantable cardioverter defibrillators (ICD). But for them the stakes are much higher as replacing the battery exposes them to a risk of serious complications, including life threatening infection.

Over half of all patients with pacemakers require a replacement procedure because the batteries have reached their expected life.(Ref 1) Some 11-16% need multiple replacements.(Ref 2) The situation is worse for recipients of an ICD, since the risks of infection at the time of implant and device replacement are higher than with pacemakers and the batteries have a shorter life.(Ref 3)

What is the risk of infection?

With no standard definition or reporting system, infection rates vary widely, and the commonly quoted risk of 0.5% for new implants and 1-5% for replacement procedures may be wrong.(Ref 4) Infection, even if it seems superficial, usually necessitates extraction of the entire system. Simply treating the infection with antibiotics results in a much poorer outcome.(Ref 5) The increased risk of infection associated with battery replacement makes it critical that we prolong the life of implantable devices as much as possible. The health economic grounds for minimising the number of replacements are also compelling.(Ref 6)

The current financial model discourages the development of longer life devices. Increasing longevity would reduce profits for manufacturers, implanting physicians, and their institutions. With financial disincentives for both manufacturers and purchasers it is hardly surprising that longer life devices do not exist.

Patients are often assumed to prefer smaller devices, but when offered the choice, over 90% would opt for a larger, longer lasting device over a smaller one that would require more frequent operations to change the battery.(Ref 7) And given the risks that patients are exposed to during replacement, there is an urgent need to improve longevity by developing longer life batteries and using those in current devices more prudently.

What can be done now?

At present the main drive to improving longevity of pacemakers has been through programming changes aimed at reducing the amount of pacing8 or minimising the drain of current during pacing—for example, using high impedance leads. But devices are usually replaced when there is still substantial life left in the battery. For example, when a pacemaker reaches elective replacement indication, it is usually 3-12 months before it will reach its end of life. And even then, the battery may continue to function for several months. Early replacement may be reasonable for high risk patients (such as those who are entirely dependent on their pacemaker). However, we could delay replacement of the pulse generator until the batteries are virtually depleted in lower risk patients. The increasingly popular innovation of home monitoring of devices would facilitate this.

For ICDs the waste is even more striking; devices reach their elective replacement indication when they are still capable of delivering at least six full energy shocks. Each shock reduces the battery longevity by about 30 days. So for patients who receive no shock therapy we are prematurely discarding a device costing up to £25 000 (€33 000; $36 000), which could last at least another six months (current devices last four to seven years on average). We need to review the timing of replacement of implantable devices in all patients.

What could be done in future?

With existing technology engineers could design and build pacemakers that would last for 25 years or more, with an increase in volume of the device of about 40%. Further developments in battery technology might enable smaller or rechargeable devices.

There is an urgent need to minimise the requirement for replacement of these devices (box). Doing so will save lives, minimise suffering, and reduce costs.

Steps to minimise replacement of cardiac implantable electronic devices

  • Maximise the longevity of existing devices by:
  • Smart programming
  • Allowing batteries to deplete for longer before replacement
  • Invest more in research in rechargeable technology and energy harvesting
  • Manufacture pacemakers with a ≥25 year life expectancy so that patients can be offered this choice
  • Consider whether device replacement is necessary—every time

BMJ 2016;352:i228 4th February 2016

High time to honour Elsie Knocker, a true heroine for the South West

Posted on December 17, 2015 at 10:50 AM Comments comments (0)

A little while ago I wrote about the scarcity of statues in and around Exeter and proposed that new ones and replacements were in order. Some readers chastised me for my all male list of possible candidates. And I have to confess; I was indeed unable to think of a single Exeter woman worthy of a pedestal. But following a recent visit to Flanders fields, I stumbled on the story of Elsie Knocker, a largely forgotten heroine of the First World War. Born Elizabeth Shapter in Exeter in 1884, she was orphaned as an infant and raised by adoptive parents. Although well provided for by her inheritance, the relationship with her new family was not a warm one. She was tormented by her school friends and adopted siblings for being ‘a charity child’. She trained as a midwife and in 1906 a marriage was arranged with Leslie Knocker. One year later she gave birth to her only child, Kenneth. But the loveless marriage to her violent husband disintegrated shortly afterwards. Divorce was rare in the Edwardian era and for women a shameful act, so Elsie maintained that her husband had died in the Far East, leaving her a widow.

At the outbreak of war in 1914, she and her close friend Mairi Chisholm (who shared her obsession with motorcycling) volunteered for service. After a spell in London as dispatch riders, Dr Hector Munro took them on as ambulance drivers in Belgium and in September 1914 they set sail for Flanders. Elsie soon became frustrated in her role, realising that the majority of the injured that she picked up at the front, even those with fairly minor injuries, died in transit to the medical station. The pair decided to establish a field hospital as close as possible to the trenches to offer immediate treatment for the casualties. She said; “It takes a woman to know these things. Men are so blind, and often insensitive to suffering”. Her request for support was rejected by her superiors (“too dangerous for ladies”;) so she and Mairi left the Flying Ambulance Corps to set up a dressing station in the cellar of a ruined house in Pervyse, close to Ypres and only a few paces from the allied trenches. Elsie spoke fluent German and French and was able to communicate with the German troops. An agreement was made that if she appeared in no-man’s land to tend to casualties wearing a headscarf they would not shoot at her, but if she wore a tin hat they probably would, being unable to distinguish her from enemy soldiers. Elsie patched up the wounded (including civilians and German soldiers) while Mairi transported them to the base hospital 15 miles away. Starved of funding, they raised their own money to finance the enterprise, reinforcing the bunker with concrete and even persuading Harrods to donate a steel door.

Elsie thrived in the war environment “I was happier than ever before in my life, happy, perhaps, for the first time in my life”. They became known as ‘The Madonnas of Pervyse’ and enjoyed celebrity status on the front and back home. They were decorated by Royalty, visited by military top brass and VIP’s including Marie Curie who had set up a mobile X-ray unit nearby. Even the future Prime Minister Ramsay MacDonald visited them. Inevitably, after five months of enthusiastic approbation the military authorities were forced to recognise their work. They were without doubt the most photographed women of the war, which ended prematurely for Elsie after she was gassed in March 1918 and evacuated home to recover.

In 1916 Elsie met and married a Belgian airman and became Baroness de T'Serclaes, but the marriage fell apart after the war when it was discovered that she had lied about her widowhood to cover up the ignominy of being a divorcee. Mairi never spoke to her again.

Although Elsie served with distinction during and after the Second World War, it is clear that she never again experienced the fulfilment of her work in the cellar-house in Pervyse. She died in 1978 at the age of 93.

Bullied as a child, battered as a wife, shunned by the church and her closest friend and now, largely forgotten in death. Although a statue of Elsie and Mairi was unveiled in Ypres last year, I am not aware of a single memorial to Elsie in this country. Surely it is time to put that to right? In 1916 Elsie spoke to a packed Barnfield Hall (now the Barnfield Theatre) in Exeter during a period of respite from the war, raising £184 4s (equivalent to over £14,000 in today’s money). If we could match that sum today (why not become a friend of Elsie Knocker Memorial on Facebook), we could commemorate the centenary of that event next year with an appropriate monument.

In the present day where the title of ‘hero’ is devalued by overuse, there is no doubt in my mind that Elsie was a true Exeter hero and as such deserves our recognition. Her pioneering approach to the battlefield treatment of war casualties is now firmly established as good medical practice. There seems little doubt that her work saved hundreds if not thousands of lives. She was a woman ahead of her time, outstandingly courageous and confident in speaking truth to power. There is definitely a place for her on my vacant plinth.

Western Morning News 17th December 2015

Perfect storm brewing as NHS struggles against 22bn 'cut'

Posted on October 14, 2015 at 11:25 AM Comments comments (0)

The government seems to be dismantling our treasured health service

There is never a good time to be sick, but if that is your destiny, I suggest you do it sooner rather than later. Why? Because there is a perfect storm brewing and if your illness is bad enough to need admission to hospital, there is every chance you will get caught up in it. Firstly, so-called ‘winter pressures’: the inevitable influx of emergency admissions that swells our hospitals is about to start. Despite attempts to stem the tide, the number of admissions increases year on year. So much so that hospital managers have been forced to invent a state of readiness beyond ‘red alert’: they call it ‘black alert’. What lies beyond black is anyone’s guess, but when your hospital is already bursting at the seams it is hard to imagine things getting any worse, but they can. During black alert, all non-urgent admissions are cancelled to make room for the emergencies. If you are unfortunate enough to be admitted to hospital during a black alert, you may find yourself on a ward staffed by a highly skilled team of nurses, doctors and therapists, it’s just that they are not necessarily skilled in looking after your ailment. It’s rather like a football manager asking his top striker to act as goalkeeper for a while. He might be OK, but he is not really playing in his best position.

Secondly, cuts in funding to the NHS (The government calls this £22bn of ‘efficiency savings’ have left the regions hospitals massively overspent. This is a situation hospital trusts clearly want to avoid (the penalties can be severe) but when you have already trimmed off off all the visible fat, what is there left to cut? If you reduce the number of frontline staff, you pose a risk to patient safety and if you fail to satisfy a Care Quality Commission inspection you may find your hospital subjected to ‘special measures’, something to be avoided at all costs. To compound the situation, cuts in social care funding are having a significant negative impact on the health service. About one quarter of all patients who are admitted as an emergency are detained in hospital despite being medically fit to be discharged, there is simply nowhere safe for them to go.

And finally, the junior doctors who will attend you if you are admitted to hospital may be about to go on strike. And I wouldn’t blame them if they did. From August next year the government intends to impose a new employment contract upon them that will extend their standard working hours and reduce their pay by up to 15%. Those who work unsocial hours providing emergency services will be hit the hardest. Even if they decide not to strike, do you really want to be seen in your hour of need by doctors who feel exhausted, undervalued and demoralized? If we continue to treat our doctors in this shabby fashion, the exodus from this country will accelerate. There are already about 500 trainee emergency doctors who qualified from UK medical schools working abroad (mostly in Australia and New Zealand). More than 90% of these have no intention of returning home. A quick glance at their working conditions, their prospects for training and their quality of life will make you understand why.

Those who choose to stay in this country have already seen an attack on their pensions such that junior doctors face the prospect of having to work well beyond the age of 65 and pay higher contributions. Also a heavy-handed approach to the introduction of seven-day working for hospital consultants (as if most of us are not doing this already) has made them feel enough is enough.

Although this government repeatedly states its commitment to the NHS, it appears to be systematically dismantling it. Behind a smokescreen of good fiscal governance, it is starving hospitals of essential funding, claiming that more efficiency measures are all that are needed to maintain (indeed improve) standards of care while selling off the profitable bits to the private sector. Yet the UK spends just over half as much on health as in the privately funded system of the USA and still (despite ‘Obama care’ a significant proportion of their population have no access to the sort of healthcare that we take for granted in this country.

So is there anything you can do? Well, bear in mind that this government has a slender majority of 12 seats. It would only require a minor backbench rebellion to make them think again. So why not write to your MP today? Unless you live in Exeter, he or she will be a member of the ruling party. Let them know how you feel about the disintegration of our public health service. The NHS is a national treasure to be cherished. Over the last few years this gem has become rather tarnished, but rather than buff it up it looks as if this government is determined to prise it out and send it to the pawnbrokers. So stay healthy this winter, if you can.

Western Morning News October 14th 2015