A postcard for the NHS

Clare Gerada's speech to the RCGP conference

"Like blood, health care is too precious, intimate and corruptible to entrust to the market"

Woolhandler & Himmelstein "When Money is the Mission –The High Cost of Investor-Owned Care," New England Journal of Medicine. 1999

The full text of the speech in case you prefer to read it (and it is quicker to read) is below.







Thank you for all your support over the last year.

I’d like to tell you a story about a GP, a radiologist, a pathologist and a psychiatrist.

Sounds like the first line of a joke, but it isn’t.

The GP was me.

We were having dinner with our children at an open-air opera in Germany. The place was packed.

Everyone was having a good time – when the dreaded happened.

Out of the corner of my eye, I saw an elderly man fall headfirst into his plate.

The four of us looked at each other.

We knew our meal was over – and we swung into action.

Each working to type.

The psychiatrist tending to the man’s wife.

The radiologist searching for a defibrillator.

The pathologist pounding on the poor man’s chest.

Me giving mouth-to-mouth.

From the way he keeled over, it was obvious he was dead.

But we knew there was still plenty for us to do.

We had to comfort his distressed wife.

And we had to keep the crowd calm for 30 minutes, till the paramedics arrived.

When it was over my 15-year-old son turned to me and said,

"I want to be able to do that."

"Do what?" I asked him.

"Care for people", he said.

His reply surprised me.

Not just because impressing teenage children isn’t easy.

But because what impressed him wasn’t the glory and the drama of our public display of medical skill.

No. What impressed him was our simple act of caring.

Caring for a sick man. Caring for the man’s wife.

And caring for the people in the crowd.

That’s what inspired my son.

And that’s how my father inspired me a generation ago.

It wouldn’t be allowed now, but he used to take me with him on home visits in the post-war slums of Peterborough.

I watched him treat children with measles.

And care for the dying in their homes.

That’s when I knew I wanted to be a doctor.

Why did I tell you that story?

Because I believe each of us has a story about what inspired us to become a doctor.

A story that made us what we are today.

A story that lights our way to the future.

What’s yours?

Our stories have never been more important.

Especially now, when our profession is under pressure to replace the language of caring with the language of the market.

This is why I told you my story.

We need to remind ourselves why we entered this honourable profession in the first place.

When I come home from work and my son asks me what sort of day I’ve had, on a good day I want to be able to say ‘I saved a life’, not… ‘I met a budget’.

Of course, it’s important that GPs are mindful of resources.

We have a responsibility to spend the public’s money carefully – and wisely. That goes without saying.

But we must never lose sight of the patient as a person, at the heart of our practice. Patients are not "commodities" to be bought and sold in the health marketplace.

In this brave new cost-driven

Competitive

managed-care world,

I worry about the effect the language of marketing is having on our clinical relationships.

It’s changing the precious relationship between clinician and patient into a crudely costed financial procedure.

Turning our patients into aliquots of costed tariffs.

And us into financial managers of care.

We are already embracing the language of the market when we talk about: for example

Care pathways
Case management
Demand management
Productivity
Clinical and financial alignment
Risk stratification
We’re already accused of making "inappropriate referrals" whenever we put what’s best for our patients above what’s best for saving money.

We’re being forced to comply with referral protocols and so-called rules-based medicine, in an effort to control medical care before it’s delivered.

Referral management systems – already widespread – places a hidden stranger in the consulting room.

A hidden stranger who interferes with decisions that should be made by GPs in partnership with their patients.

Insulting terms, like "frequent flyers", are being used to describe people who are sick and need our care and attention.

The Archbishop of Canterbury attacked what he described as "the quiet resurgence of the seductive language of the deserving and undeserving poor".

If we don’t watch out, the deserving and undeserving poor could soon be joined by the deserving and undeserving sick.

I worry we’re heading towards a situation where healthcare will be like a budget airline.

There’ll be two queues. One queue for those who can afford to pay, and another for those who can’t.

Seats will be limited to those who muscle in first.

And the rest will be left stranded on the tarmac.

This can’t be right. After all, no one chooses to be sick. <

We must hold fast to the principle that good healthcare should be available to all, regardless of wealth.

Of course, there have always been health inequalities. But my concern is that despite all the talk of reducing these inequalities, the size looks set to increase, not decrease.

So what about GP commissioning?

Will it help us reduce health inequalities?

And will it enable us to deliver better care to our patients?

People often tell me that GPs make good commissioners because of the population-focus we bring to care.

After all as a profession we see 300 million patients per year.

If anyone can be said to have their finger on the pulse of the nation, surely it’s us.

It’s an argument I’ve supported for decades.

But we must tread carefully in this brave new world.

And do everything in our power to make sure it’s the public’s pulse we have our fingers on… not the public’s purse!

Which is why I believe that big decisions – decisions like whether to close hospitals – should be the responsibility of governments, not GPs.

It’s the government’s job to decide how much we invest in healthcare – and what services the NHS should provide.

Of course we should do our bit – we already do, by sitting on NICE, SIGN and other committees.

But governments should have ultimate responsibility for decisions about rationing healthcare, not GPs – guided and advised by us, for sure, but finally the decision must be taken by a publically accountable body, not an individual doctor or a group of doctors

We don’t shirk our responsibilities.

Governments shouldn’t shirk theirs either.

Rhetoric about putting doctors in charge doesn’t convince me.

In this brave new world it’s the market – led by CEOs, share-holders and accountants – that will be in charge, not doctors.

We mustn’t allow ourselves to be compromised.

Our first responsibility must be to the patient in front of us.

Our next is to the patients in the waiting room.

After that comes our responsibility to those on our list.

And then to our local community, and finally the wider population.

In that order.

I’ve always said that Good Commissioning is about being a good GP.

Its about understanding how we use resources fairly and effectively.

But whatever happens we must make sure that the commissioning agenda isn’t allowed to compromise our relationship with the patient in front of us.

We must not risk long-term benefits being sacrificed in favour of short-term savings.

How soon will it be, for example, before we stop referring for cochlear implant? -

An expensive intervention, but one that in the long term, saves enormous amounts of public money.

But not a saving from our budget.

How long will it be before we find ourselves injecting a patient’s knee joint – at Injections-R-us plc - instead of referring to an orthopaedic surgeon for a knee replacement?

And, once referred for hospital treatment, patients must be able to trust their doctors to base care on need and not on making money for the hospital.

If you think this is far-fetched…

The Economist calculated that in 2009 the market-driven, corporate-dominated US health care system generated around $300 billion dollars worth of charges for unnecessary care.

This represented 10-12% of US healthcare spending for that year.

• This means women having unnecessary hysterectomies

• This mean men having unnecessary angiograms

• This means adolescents being given antidepressants for no reason

Do we want that here?

As doctors we risk being doubly compromised.

We’ll have to choose between the best interests of our patients and those of the commissioning group’s purse.

And, to make matters worse, we’ll also be rewarded for staying in budget – and not spending the money on restoring that child’s hearing.

It goes by the quaint title of the "quality premium".

Now that’s what I call a perverse incentive.

What will you do when you’re presented with choices like these? Because you will be!

We are told that one of the reasons Clinical Commissioning is being introduced is to reduce the spiralling costs of health care.

But if the American experience is anything to go by, the opposite will be true.

Paul Ellwood one of the founders of the American Health Maintenance System in the 1970s, had this to say in 1999 about what happened there…

"A series of perverse economic incentives were instituted

from top to bottom

so as to seriously compromise the independent clinical judgments of physicians

and other health professionals…..

He describes Health Maintenance Organisations (which have the same function as our Clinical Commissioning Groups) as finding themselves in…

"A deepening swamp of commercialism over service,

of profiteering over professionalism,

of denial or rationing of care where such care is critically needed,

of de-personalization of intensely personal kinds of relationships"

Is this what we want here?

The NHS can always be improved, but we must do it very carefully, so as not to lose what we and previous generations of doctors like my father have achieved.

As Allyson Pollock reminds us, the NHS was not an experiment.

It wasn’t a mythical utopia either.

The reality is that for more than 50 years it has delivered high quality care for most patients, most of the time.

Can the market achieve similar outcomes?

There is plenty of evidence that market driven health services lead to:

• Limited choice
• Escalating costs
• Reduced quality

And let’s remind ourselves – the biggest health market in the world, the US, has achieved the remarkable double whammy of having the most expensive system in the world and the greatest health inequalities.

It comes near the bottom of the league for most health outcomes – and boasts an unnecessary death every 12 minutes.

So what can we do?

It would be easy to feel discouraged.

But I know we all want the best for our patients, we always have and we always will.

And as long as we do what we know to be right for patients, we will keep their trust.

And we can do this by ensuring that the systems we work in continue to allow us to work ethically and always as our patients advocates.

We must resist the encroachments of the market wherever it threatens our freedom to serve our patients and our communities. This is what those of you leading commissioning must promise us.

We have to get the actuaries, risk-adjusters and share-holders out of the health service, and put clinicians (not just medics) back in charge of it.

And then we need to bring in management staff to advise and assist us.
Staff who are truly committed to the values of our NHS.

We all became doctors because we wanted to make a positive difference to people’s lives.

It would be hard to devise a better and more inspiring way of achieving this than through the provision of excellent general practice care, within a universal health service.

In times of austerity, we need to come together so that we can collaborate, cooperate and innovate… not compete against each other.

You expected me to talk about the Health Bill in England, but this Bill, like other reorganisations across the whole of the United Kingdom will come and go.

Instead I have chosen to talk to you about what matters to our patients, now and for ever - a doctor who cares.

I am convinced that there are enough of us to create a revolution in health care. Not a revolution that the Government is talking about in the Bill –in structures, payments and competition.

But a revolution in values.
One that will provide excellent care to our patients.

Where in every interaction we pinch ourselves at the honour we have been given to be privy to their secrets and pain –

and as Don Berwick says:

"being allowed to be guests in their lives"

My message to you is simple and clear. My son wanted to do medicine because of what he saw me and my friends do – care

If we want to keep serving the best interests of our patients, we must reject the language of the market and embrace the language of caring.

And – keep telling our stories…

Thank you.

What to do with Lansley's rotten bill

The Liberal Democrats have let us all down on a grand scale but there are a few around with a great deal of common sense. Charles West is one. Read what he had to say here: pdf. Of course, any doctor with a modicum of nous could have written this. Not many politicians could. But then Charles West is a doctor.

What NHS managers think of the bill

97.1% of managers say withdraw the Health and Social Care Bill (pdf).

Open letter to the Lords

Here is the text of a letter from doctors in England to the Lords:

As doctors in England, we are writing to you to express our conviction that the Health and Social Care Bill will irreparably undermine the most important and admirable principles of the National Health Service, and to appeal for its rejection by the House of Lords.

Because it is universal and comprehensive, and publicly accountable, and because clinical decisions are made without regard for financial gain, the NHS is rightly regarded all over the world as the benchmark for fairness and equity in healthcare provision.

The transfer of services to private, profit-making companies will result in loss of public accountability and a damaging focus instead on low-risk areas that are financially profitable. A confused patchwork of competing providers will deliver a fragmented and inequitable service and any reliance on personal health budgets or insurance policies will further increase inequality. Because there will be a financial incentive for providing treatment patients will be over-treated, the potential costs of which are limitless. And the possibility of the commissioning role being outsourced to the private sector is also deeply concerning.

In forcing through this ill-conceived Bill, without an electoral mandate and against the strident objections of healthcare professionals, the Government is also ignoring overwhelming evidence that healthcare markets are inefficient and expensive to administer.

The public has been misled throughout, first by claims that no major reorganisation of the NHS would be undertaken, later by repeated denials that what is happening represents privatisation, and furthermore by suggestions that the Bill enjoys the support of the medical profession. We do not accept the argument that "things have already gone too far" - the enactment of some of the Bill's proposals has been premature and illegal, however some of its most damaging aspects may still be mitigated.

We believe that on moral, clinical and economic grounds, the Health and Social Care Bill must be rejected.

If you are a doctor in England and would like to put your name to this letter please email Jonathan.folb@nhs.net with your details. Feel free to circulate this letter further. Time is now very short. Do it now.

Lords save us

Here is the text of an open letter to the Lords from nearly 400 doctors:

Dear Honourable Members of the House of Lords,

As public health doctors and specialists from within the NHS, academia and elsewhere, we write to express our concerns about the Health and Social Care Bill.

The Bill will do irreparable harm to the NHS, to individual patients and to society as a whole.

It ushers in a significantly heightened degree of commercialisation and marketisation that will fragment patient care; aggravate risks to individual patient safety; erode medical ethics and trust within the health system; widen health inequalities; waste much money on attempts to regulate and manage competition; and undermine the ability of the health system to respond effectively and efficiently to communicable disease outbreaks and other public health emergencies.

While we welcome the emphasis placed on establishing a closer working relationship between public health and local government, the proposed reforms as a whole will disrupt, fragment and weaken the country’s public health capabilities.

The government claims that the reforms have the backing of the health professions. They do not. Neither do they have the general support of the public.

It is our professional judgement that the Health and Social Care Bill will erode the NHS’s ethical and cooperative foundations and that it will not deliver efficiency, quality, fairness or choice.

We therefore request that you reject passage of the Health and Social Care Bill.



Jo Abbott
Consultant in Public Health, NHS Rotherham

Dr Sushma Acquilla
International Faculty Advisor, UK Faculty of Public Health and Honorary Senior Lecturer, Imperial College London

Dr John Acres
Head of the School of Public Health, Wessex Deanery

Dr Mayada Abu Affan
Consultant in Public Health Medicine, Dudley PCT

Dr Nicholas Aigbogun
Specialty Registrar in Public Health, Health Protection Agency West Midlands

Professor Priscilla Alderson
Professor Emerita of Childhood Studies, Institute of Education, University of London

Dr Rob Aldridge
Academic Clinical Fellow (Public Health), University College London

Dr Kirsty Alexander
Public Health Directorate, Gloucestershire PCT

Martin Allaby
NHS Consultant in Public Health

Ben Anderson MPH, MFPH
Acting Consultant in Public Health, NHS Sheffield

Dr Elspeth Anwar
Public Health Registrar, Mersey Deanery

Dr Ike Anya
Consultant in Public Health Medicine

Charlotte Ashton
Public Health Specialty Registrar in London

Professor John R Ashton, CBE
Director of Public Health, Cumbria

Matthew Ashton
Assistant Director of Public Health, NHS Knowsley

Dr Esther Aspinall
Specialist Registrar in Public Health, West of Scotland

Dr Daphne Austin
Chair of the UK Commissioning Public Health Network

Dr Ishraga Awad
Consultant in Public Health Medicine

Dr Sallie Bacon
Associate Director of Public Health, Hampshire

Dr M R Bahl
Consultant in Public Health & Communicable Disease Control (retired)

Dr Simon Balmer
Consultant in Public Health Medicine

Dr Helen Barratt
Research Training Fellow/ Public Health Specialist Registrar, University College London

Prof Mel Bartley
Director of the ESRC International Centre for Life Course Studies, University College London

Dr Subhashis Basu
Specialist Registrar in Public Health and Accident & Emergency, NHS Rotherham and Sheffield Teaching Hospitals

Alison Bell
Consultant in Public Health, NHS Wiltshire

Dr Paul Batchelor
Consultant in Dental Public Health, Thames Valley and Senior Lecturer, UCL

Dr John Battersby
Medical Director, Eastern Region Public Health Observatory

Jackie Beavington
Associate Director of Public Health

Dr Charles R Beck
Specialty Registrar in Public Health

Jane Beenstock
Specialty Registrar, NHS County Durham and NHS Darlington

Dr Ruth Bell
Clinical Senior Lecturer/Honorary NHS Consultant in Public Health, Newcastle University

Professor Yoav Ben-Shlomo
Professor in Clinical Epidemiology, University of Bristol

Helen Bewsher
Public Health Intelligence Specialist, NHS Kirklees

Dr Sohail Bhatti
Interim Director of Public Health Medicine, NHS East Lancashire

Professor Raj Bhopal CBE
Professor of Public Health, University of Edinburgh

Amy Bird
Specialty Registrar Public Health, London, Kent, Surrey and Sussex

Dr Christopher A Birt
Senior Research Fellow / NHS Public Health Physician, Liverpool

Andrew Boddy
Director (retired), Public Health Research Unit, University of Glasgow

Sarah Bowman
Specialty Registrar Public Health, NHS Tees

Dr Ian Brown
Specialty Registrar in Public Health, NHS Hertfordshire

Dr Claire Bradford
NHS Consultant in Public Health Medicine

Dr Fiona Bragg
Specialty Registrar Public Health

Professor Carol Brayne
Professor of Public Health Medicine, University of Cambridge

Professor John Britton
Professor of Epidemiology, University of Nottingham

Dr Helen Bromley
Division of Public Health and Policy, University of Liverpool

Jilla Burgess-Allen
Specialty Registrar in Public Health, Derbyshire County PCT

Julia Burrows
Consultant in Public Health, NHS Bradford and Airedale

Dr Jenny Bywaters
Senior Public Mental Health Adviser, Department of Health (retired)

Dr Nigel Calvert
Associate Director of Public Health, NHS Cumbria

Dr Corinne Camilleri-Ferrante
Consultant in Public Health Medicine and Head of School of Public Health

Professor Simon Capewell
Professor of Clinical Epidemiology, University of Liverpool

Professor Francesco P Cappuccio
Professor of Cardiovascular Medicine & Epidemiology, Warwick Medical School

Dr Robin Carlisle
Consultant in Public Health, NHS Rotherham,

Dr Marie Casey
Specialty Registrar in Public Health

Dr Jacky Chambers
Director of Public Health, Heart of Birmingham tPCT

Dr Jennifer Champion
Acting Consultant in Public Health, NHS Forth Valley

Dr David Chappel
Assistant Director, North East Public Health Observatory

Hannah Chellaswamy
Deputy Director of Public Health, NHS Sefton & Training Programme Director, Cheshire & Merseyside, NW School of Public Health

Professor Aileen Clarke
Professor of Public Health & Health Services Research, Warwick Medical School

Professor Stephen Clift
Professor of Health Education, Canterbury Christ Church University

Dr RA Coates
Consultant in Public Health Medicine, Southampton City PCT

Prof Michel P Coleman
Professor of Epidemiology and Vital Statistics, London School of Hygiene and Tropical Medicine

Katherine Conlon
Speciality Registrar in Public Health, NHS South Gloucestershire

David Conrad
Specialty Registrar in Public Health, Knowsley PCT

Dr Joanna Copping
NHS Consultant in Public Health Medicine

Dr Gary Cook
Consultant Epidemiologist, Stockport NHS Foundation Trust

Professor Derek Cook
Professor of Epidemiology, St George's, University of London

Dr Emer Coffey
Consultant in Public Health, Liverpool PCT

Ellen Cooper
Public Health Specialist, NHS Stockport

Mary Corcoran
Consultant in Public Health, NHS Nottinghamshire County

Jonathan Cox
Specialty Registrar in Public Health, Norwich Medical School

Maureen Crawford
Director of Public Health, Sunderland Teaching Primary Care Trust/Sunderland City Council

Dr Tricia Cresswell
Consultant in Health Protection, Health Protection Agency/Deputy Medical Director, NHS North East

Dr James R Crick
Specialty Registrar in Public Health, Yorkshire and Humber Deanery

Denis Cronin
Public Health Consultant, NHS Cornwall and Isles of Scilly

Professor Ann Crosland
Professor of Nursing and Public Health Lead, University of Sunderland

Dr Elizabeth Crowe
Specialty Registrar in Public Health, SE Scotland

Dr June Crown, OBE
Former President, United Kingdom Faculty of Public Health

Professor Steven Cummins
Professor of Urban Health & NIHR Senior Fellow, Queen Mary University of London

Sarah Cuthberson
Specialty Registrar in Public Health, South Yorkshire Health Protection Unit

Dr Fiona Day
Consultant in Public Health Medicine, Sheffield PCT

Valerie Delpech
Consultant Epidemiologist Health Protection Agency

Prof Elaine Denny
Professor of Health Sociology, Birmingham City University

Martin Dockrell
Fellow of the Royal Society of Public Health

Dr Hiten Dodhia
NHS Public Health Consultant, Lambeth PCT

Professor Danny Dorling
Professor of Human Geography, University of Sheffield

Dr Flora Douglas
Lecturer in Health Promotion, University of Aberdeen/NHS Grampian

Dr Peter Draper
Freelance health policy analyst

Dr Julian Elston
Consultant in Public Health, Cornwall and Isles of Scilly PCT

Barry Evans
Consultant Epidemiologist

Professor David Evans
Professor in Health Services Research, University of the West of England

Dr Jamie Fagg
Research Associate in Epidemiology and Biostatistics, UCL Institute of Child Health

Andrea Fallon
Consultant in Public Health, NHS Oldham

Dr Tracey Farragher
Senior Research Fellow, Academic Unit of Public Health, University of Leeds

Dr Jill Farrington
Consultant in Public Health Medicine, NHS Calderdale

Greg Fell
Consultant in Public Health, NHS

Natalie Field
Public Health Consultant, South Gloucestershire

Dr Richard Fielding
Professor of Medical Psychology in Public Health, University of Hong Kong

Dr Tim Fielding
Public Health Registrar

Dr Alastair Fischer
Health Economist, National Institute for Health and Clinical Excellence (NICE)

Paul Fisher
Specialty Registrar in Public Health, West Midlands East Health Protection Unit

Dr Julian Flowers
Director, East of England Regional Public Health Observatory

Dr Alison Forrester
Clinical Advisor to NHS North Yorkshire and York

Kirsten Foster
Health Improvement Practitioner Advanced, Kirklees PCT

Dr David Foxcroft
Professor of Community Psychology and Public Health, Oxford Brookes University

Sue Frossell
Consultant in Public Health (Health Protection and Improvement), NHS Milton Keynes

Dr Tom Fryers
Hon. Professor of Public Mental Health, University of Leicester

Dr Alison Furey
Independent Public Health Consultant

John Gabbay
Emeritus Professor, University of Southampton

Dr Linda Garvican
QA Director, Cancer Screening Programmes, NHS South East Coast
Dr Alexander Gatherer
Former Director of Public Health, Oxford

Dr Katie Geary
Consultant in Communicable Disease Control, Health Protection Agency East Midlands

Dr Ivan Gee
Senior Lecturer in Public Health, Liverpool John Moores University

Dr Steve George
Reader in Public Health, University of Southampton

Dr Daniel Gibbons
NIHR Doctoral Research Fellow, School of Public Health, Imperial College London

Professor Ruth Gilbert
Professor of Clinical Epidemiology and Director of the Centre for Evidence-based Child Health, University College London - Institute of Child Health

Professor Anna Gilmore
Professor of Public Health, University of Bath

Dr Suzanne Gilman
Public Health Speciality Registrar, NHS Central Lancashire

Dr Michelle Gillies
Specialist Registrar Public Health and Clinical Lecturer Chronic Disease Epidemiology

Dr Jay Ginn
Visiting Professor, Institute of Gerontology, Kings College London

Professor Michael Goldacre
Professor of Public Health, University of Oxford

Chris Godfrey
Consultant in Public Health, Solihull Primary Care Trust

Sara Godward
Locum Consultant in Public Health

Dr Paula Grey
Joint Director of Public Health, Liverpool PCT/Liverpool City Council

Professor Selena Grey
Professor of Public Health, University of the West of England

Dr Carl Griffin
NHS Consultant in Public Health Medicine

Professor Rod Griffiths CBE
Former President, Faculty of Public Health

Sarah Johnson Griffiths
Consultant in Public Health, NHS Western Cheshire

Professor Sian Griffiths, OBE
Former President of the Faculty of Public Health

Rachael Gosling
Locum Consultant in Public Health, Liverpool Community Health NHS Trust

Dr Hilary Guite
Director Public Health and Well-being, NHS Greenwich

Dr Fay Haffenden
Consultant in Public Health Children & Health Inequalities, NHS Cambridgeshire

Professor Sir Andy Haines
Professor of Public Health and Primary Care, London School of Hygiene and Tropical Medicine

Dr Jennifer Hall
Public Health Specialty Registrar, London

Tom Hall
Specialty Registrar in Public Health

Mr John Hampson
Public Health Specialist, NHS Western Cheshire

Wendy Hannon
Public Health Commissioning Manager, Plymouth PCT

Dr Maggie Harding
NHS Consultant in Public Health (Medicine)

Dr Andrew Harmer
Honorary Lecturer in Public Health, London School of Hygiene and Tropical Medicine

Dr Ruth Harrell
Specialty Registrar in Public Health, West Midlands

Lynda Harris
Director of Public Health, Wales

Dr Shamil Haroon
Public Health Registrar, Sandwell PCT

Professor Stephen Harrison
Honorary Professor of Social Policy, University of Manchester

Dr Wayne Harrison
Consultant in Public Health

Martin Hawkings
Consultant in Public Health Medicine, NHS North Yorkshire and York

Hazel Henderson
Consultant in Public Health

Alan Higgins
Director of Public Health, Oldham

Dr Christine Hill
Consultant in Public Health Medicine, Cambridge

Dr Christine E Hine
Head of School & Training Programme Director, SW Public Health Specialty Training Programme and Consultant in Public Health, NHS Bristol & NHS S Gloucs

Julie Hirst
Public Health Specialist, NHS Derbyshire County

Dr Sue Hogarth
Public Health Specialty Registrar, University College London

Dr Jason Horsley
Specialty Registrar in Public Health Medicine / Honorary Clinical Lecturer

Dr Anita Houghton
Consultant in Public Health, London

Professor Walter W Holland, CBE
LSE Health and Social Care, London School of Economics

Dr Peter Horby
Senior Clinical Research Fellow, University of Oxford

Julie Hotchkiss
NHS Consultant in Public Health, Wigan

Dr Rob Howard
NHS Public Health Specialty Registrar

Dr Jonathan Howell
Consultant in Public Health, West Midlands Specialised Commissioning Team

Clare Humphreys
Specialty Registrar in Public Health, NHS Yorkshire and the Humber

Professor David Hunter
Professor of Health Policy and Management, Durham University

Louise Hurst
Public Health Specialty Registrar, University College London

Dr Sandra Husbands
NHS Consultant Public Health Medicine

Dr Sabina Fatima Hussain
Specialist Registrar in Public Health

Jan Hutchinson
Director of Public Health

Paul Iggulden
Independent Public Health Specialist

Dr Chikwe Ihekweazu
Consultant Epidemiologist, Health Protection Agency

Kathryn Ingold
Public Health Speciality Registrar, Leeds

Dr Maggie Ireland
North East Public Health Doctor

Dr Helene Irvine
Consultant in Public Health Medicine, NHS Greater Glasgow and Clyde

Dr Richard Jarvis
Consultant in communicable disease control and public health medicine, NHS Merseyside

Charlotte Jeavons
Programme Leader, Public Health, University of Greenwich

Dr Anna Jones
Teaching fellow at Brighton and Sussex Medical School

Margaret Jones
Consultant in Public Health, NHS Sefton

Lesley Jones
Deputy Director Public Health, NHS Bolton

Professor Frank Kee
UKCRC Centre of Excellence, Queens University Belfast

Dr Gifford Kerr
Consultant in Public Health, NHS Blackburn with Darwen

Dr Anuj Kapilashrami
Lecturer Global Public, University of Edinburgh

Dr S Vittal Katikireddi
Clinical Research Fellow, MRC/CSO Social and Public Health Sciences Unit & Specialty Registrar in Public Health Medicine, NHS Lothian

Dr Marko Kerac
Specialty Registrar & Academic Clinical Fellow, Public Health

Dr Mark Lambert
NHS Consultant in Public Health Medicine

Professor Tim Lang
School of Health Sciences, City University London

Dr Rajalakshmi Lakshman
Clinical Scientist and Honorary Consultant in Public Health, Addenbrooke's Hospital, Cambridge

Dr Bruce Laurence
Acting Director of Public Health for Derbyshire

David Lawrence
Consultant in Public Health, NHS SE London

Mike Leaf
Acting Director of Public Health, NHS North Lancashire

Ben Leaman
Specialist Public Health Registrar, Yorks & Humber

Dr Conan Leavey
Senior Lecturer Public Health, Liverpool John Moores University

Dr Joyce Leeson
Retired Senior Lecturer in Public Health, Manchester University

Dr Nicholas Leigh-Hunt
Public Health Registrar, NHS Leeds

Professor David Leon
Professor of Epidemiology, London School of Hygiene & Tropical Medicine

Valerie A Little
Director of Public Health, Dudley

Mary Lyons
Public Health Specialist, NHS Central Lancashire

John Lucy
Associate Director of Public Health, Liverpool Primary Care Trust

Dr Helen Maguire
Health Protection Agency, London

Dr GJ MacArthur
Academic Public Health Training Fellow, University of Bristol

Professor Alison Macfarlane
Professor of Perinatal Health, City University London

Dr Frances MacGuire
Specialist Registrar, Public Health

Dr Paul Madill
Specialty Registrar in Public Health, NHS South of Tyne and Wear

Dr Alexis Macherianakis
Consultant in Public Health Medicine, Sandwell PCT

Shepherd Masara
Associate member of the Faculty of Public Health

Dr Mashbileg Maidrag
Consultant in Public Health, NHS Suffolk/Suffolk County Council

Alan Maryon-Davis
Hon Professor of Public Health, Kings College London and Immediate Past President of the UK Faculty of Public Health

Dr Christina Maslen
Clinical Effectiveness Lead, Public Health Directorate, NHS Bristol

Dr Rebecca Mason
Specialty Registrar (Public Health), Mersey Deanery

Sue Matthews
Public Health Specialty Registrar, Hertfordshire PCT

Dr Eleni Maunder
Retired Senior Lecturer in Nutrition, Bournemouth University

Janet Maxwell
Director of Public Health, NHS Berkshire West

Dr Melanie Maxwell
Associate Medical Director and Public Health Specialist, Wirral University Teaching Hospital

Dr Gerry McCartney
Public Health Consultant, NHS Health Scotland

David McConalogue
Speciality Registrar in Public Health

Dr David McCoy
Associate Director of Public Health and Consultant Public Health Medicine, Inner North West London PCT, NHS

Amy McCullough
Public Health Specialty Registrar

Professor James McEwen
Emeritus Professor in Public Health, University of Glasgow

Lynne McNiven
Public Health Consultant, Assistant Director of Public Health, NHS Lincolnshire

Dr Sarah McNulty
Assistant Director of Public Health, Quality and Health Protection, NHS Knowsley

Professor Klim McPherson
Visiting Professor of Public Health Epidemiology, University of Oxford

Dr Jeff Mecaskey
Fellow of the Faculty of Public Health

Elaine Michel
Interim Director of Public Health, NHS Tameside & Glossop

Professor Susan Michie
Professor of Health Psychology, University College London

Dr John Middleton
Senior NHS Director of Public Health

Dr May Moonan
Clinical Lecturer in Public Health Medicine and NICE Scholar/Specialty Registrar in Public Health, University of Liverpool

Professor Robert Moore
School of Sociology, Social Policy and Criminology, University of Liverpool

Dr Gemma Morgan
Academic Public Health Training Fellow, University of Bristol

Maria Morgan
Lecturer in Dental Public Health, Cardiff University School of Dentistry

Dr Andrew Mortimore
Director of Public Health, Southampton

Dr Anna Morris
Specialty Registrar in Public Health, NHS Hampshire

Maggi Morris
Director of Public Health, Central Lancashire

Aldo Mussi
Senior Lecturer in Public Health, Birmingham City University

Dr Bernadette Nazareth
Consultant in Communicable Disease Control, HPA Norfolk Suffolk and Cambridgeshire

Professor Angus Nicoll, CBE
Former Director, Communicable Disease Surveillance Centre, Health Protection Agency

Dr Rory O’Conor
Consultant in Public Health, Wakefield PCT & YHPHO

Claire O'Donnell
Clinical Effectiveness Specialist in Public Health, North West Specialised Commissioning Team

John O'Dowd
Consultant Public Health Physician (Child Health), NHS Scotland

Professor Eileen O’Keefe
Professor of Public Health, London Metropolitan University

Dr Donal O'Sullivan
Consultant in Public Health Medicine, NHS South East London

Dr Ifeoma Onyia
Public Health Physician

James Lindley Owen
NHS Consultant in Public Health

Dr Kishor Padki
Consultant in Public Health Medicine, NHS South West Essex

Dr Arun Patel
Associate Director of Public Health, South West Essex PCT

Dr Matthieu Pegorie
Specialty Registrar in Public Health, NHS Trafford

Dr David Pencheon
Director, NHS Sustainable Development Unit (England

Sarah Phillips
Public Health Intelligence Analyst, NHS South Gloucestershire

Professor Kate Pickett
Professor of Epidemiology, University of York

Dr Mary Pierce
Clinical Epidemiologist, MRC Unit for Lifelong Health and Ageing

Dr David Pitches
Locum Consultant in Public Health, NHS Walsall

Professor Tanja Pless-Mulloli
Institute of Health and Society, Newcastle University

Dr George Pollock
Honorary Senior Research Fellow, University of Birmingham

Professor Jennie Popay
Professor of Sociology and Public Health, Lancaster University

Dr Debora Price
Senior Lecturer, Gerontology, King's College London

Alison Pritchard
Consultant in Public Health, Derbyshire County PCT

Dr Angela E Raffle
Consultant in Public Health, Bristol

Professor Rosalind Raine
Professor of Health Care Evaluation, University College London

Thara Raj
NHS Public Health Manager

Dr Giri Rajaratnam
Deputy RDPH, East Midlands NHS

Professor Salman Rawaf
Director of the WHO Collaborating Centre for Public Health Education, Imperial College London

Mr Abdul Razzaq
Joint Director of Public Health and Senior NHS Public Health Consultant

Dr Arif Rajpura
Director of Public Health, NHS Blackpool

Dr Boika Rechel
Clinical Lecturer in Public Health and Honorary Consultant in Public Health Medicine, University of East Anglia

Dr Paul Redgrave
Consultant Public Health

Professor Margaret Reid
Professor Emeritus, Public Health, University of Glasgow

Dr Mark Reilly
Assistant Director Public Health Intelligence, NHS Tees

Becky Reynolds
Speciality Registrar in Public Health, Yorkshire and Humber Deanery

Professor Jammi Rao
Visiting Professor in Public Health, Staffordshire University

Prof Jennifer Roberts
Prof Emeritus in Economics of Public Health, LSHTM

Dr Heather Roberts
Director of Postgraduate Education, School of Community Health Sciences, City Hospital, Nottingham

Professor Paul Roderick
Professor of Public Health, University of Southampton

Helen Ross
Hon Member of the Faculty of Public Health

David Ross
Consultant Public Health Medicine

Dr Eleanor Rutter
Public Health Specialist Registrar, NHS Sheffield

Prof Harry Rutter
Director, National Obesity Observatory

Dr Alison Rylands
Director of Public Health, North West Specialised Commissioning Team

Dr Vanessa Saliba
Public Health Specialty Registrar, Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine

Martin Schweiger
Consultant in Communicable Disease Control, West Yorkshire Health Protection Unit

Dr Sonya Scott
Specialty Registrar in Public Health Medicine

Dr Alex Scott-Samuel
Senior Clinical Lecturer in Public Health, University of Liverpool

Dr Anjila Shah
Consultant in Public Health, NHS Sefton

Professor Prakash Shetty
Professor of Public Health Nutrition, Southampton University

Dr Mohit Sharma
Specialty Registrar in Public Health, Oxford Deanery and University of Oxford

Dr Sally Sheard
Senior Lecturer in History of Medicine, University of Liverpool

Jessica Sheringham~
Specialty Registrar in Public Health, North London

Dr Khesh Sidhu
NHS Consultant in Public Health Medicine

Professor Peter Sims
Honorary Teaching Fellow, Peninsula Medical School

Dr Katherine Smith
Lecturer in Global Public Health, University of Edinburgh

Professor Alwyn Smith CBE
Past President, Faculty of Public Health

Dr Jenifer Smith
Director of Public Health and Chief Medical Advisor, Isle of Wight NHS PCT

Victoria Smith
Health Improvement Officer, Blaby District Council

Dr Tasmin Sommerfield
Consultant in Public Health, NHS Lanarkshire

Dr Rosamund Southgate
Public Health Specialty Registrar, Oxford Deanery

Dr Dan Seddon
NHS Public Health Consultant and Public Health Educator

Dr Ruth Stern
Honorary Visiting Fellow, London Metropolitan University

Dr Alex G Stewart
Consultant in Communicable Disease Control, Cheshire & Merseyside HealthProtection Unit

Professor Tony Stewart
Professor in Public Health / NHS Consultant in Public Health, Staffordshire University

Dr Alex Stirling
Specialty Registrar in Public Health, NHS Greater Glasgow and Clyde

Dr Ljuba Stirzaker
Consultant in Public Health Medicine, NHS Buckinghamshire and Oxfordshire Cluster

Laura Stroud
Lecturer in Public Health, University of Leeds

Dr Graham Sutton
Consultant in Communicable Disease Control, Leeds

Professor Stephanie Taylor
Professor in Public Health and Primary Care, Queen Mary University of London

Dr David Taylor-Robinson
Clinical Lecturer in Public Health, University of Liverpool

Alison Tennant
Specialist in Pharmaceutical Public Health, NHS Dudley

Sarah Theaker
Specialty Registrar in Public Health, NHS Nottinghamshire County

Richard Thomson
Professor of Epidemiology and Public Health, Newcastle University

Martin Tobin
Professor of Genetic Epidemiology and Public Health, University of Leicester

Dr Daniel Todkill
SpR in Public Health Medicine

Julie Tolhurst
Health Improvement Practitioner, Public Health Directorate, NHS Kirklees

Dr Caroline Tomes
Public Health Specialty Registrar, NHS Cambridgeshire

Dr John Tomlinson
Deputy DPH, NHS Nottinghamshire and FPH East Midlands Local Board Representative

Dr Paul S Turner
NHS Consultant in Public Health

Pat Turton
Senior Lecturer, University of the West of England

Linda Turner
Consultant in Public Health, NHS Sefton

Paul Turner
Consultant in Public Health, NHS Ashton, Leigh and Wigan

Ruth Twiggins
Head of Public Health: Health Inclusion Team, NHS Wakefield District

Louise Unsworth,
NHS Public Health Consultant, North East Public Health Observatory

Emily van de Venter
Public Health Speciality Registrar

Professor Edwin van Teijlingen
Centre for Midwifery, Maternal & Perinatal Health School of Health & Social Care, Bournemouth University

Dr Marie-Noelle Vieu
Fellow of the Faculty of Public Health

Dr Rebecca Wagstaff
Deputy Director of Public Health, NHS Cumbria

Dr Andy Wakeman
Senior NHS Public Health Consultant

Alice Walsh
Deputy Director of Public Health, NHS Gloucestershire

Sue Wardle
Public Health Specialist, South Staffordshire Primary Care Trust

Professor Richard G Watt
Department of Epidemiology and Public Health, UCL

Dr Joanna Watson
Unemployed Public Health doctor, Leicester

Dr Helen Webster
Speciality Registrar in Public Health, West Midlands

Sarah Weld
Public Health Specialty Registrar, NHS Wiltshire

Dr Jane Wells
NHS Public Health Physician, Oxford

Professor Robert West
Director of Tobacco Research, Department of Epidemiology and Public Health, University College London

Dr Ben Wheeler
Research Fellow, European Centre for Environment & Human Health

Professor Peter Whincup
Professor of Epidemiology, University of London

Professor Martin White
Professor of Public Health, Institute of Health & Society, Newcastle University

Professor Margaret Whitehead
Professor of Public Health, University of Liverpool

Dr Lisa Wilkins
Consultant in Public Health Medicine, NHS Oldham

Dr Ewan Wilkinson
NHS Public Health physician, Liverpool

Professor John Wilkinson
Professor of Public Health, Durham University

Professor Charles Wolfe
Professor of Public Health, King's College London

Dr Ingrid Wolfe
Child Public Health Research Fellow and Paediatrician

Dr Fiona Wright
Assistant Director of Public Health, Haringey

Huda Yusuf
Specialist Registrar Dental Public Health, North West & North Central London Primary Care Trusts

Dr Helen Zealley, OBE
Former Director of Public Health, NHS Lothian

Dr Rosemary Millar
Specialty Trainee in Public Health, NHS Tayside

Jay Succaram
Senior Lecturer, College of Nursing, Midwifery and Healthcare, University of West London

Dr Rachel C Thorpe
Specialty Registrar in Public Health, NHS Lanarkshire

Dr Celia Duff
Specialty Training Programme Director, East of England

Dominic Mellon
Specialty Registrar - Public Health, South West Public Health Training Programme

Helene Denness
Specialty Registrar in Public Health, Babington Hospital

Dr Ayoola Oyinloye
Consultant in Public Health Medicine, NHS Swindon

Dr Ardiana Gjini
Consultant in Public Health Medicine, NHS Bristol and NHS North Somerset

Dr Hynek Pikhart
Senior Lecturer in Epidemiology, University College London

Dr Joshna Ahir
Specialty Registrar in Public Health, Yorkshire and The Humber

Dr Nora Pashayan
Senior Clinical Lecturer in Applied Health Research, University College London

Shaukat Ali
Public Health Specialist, Sandwell Primary Care Trust

Julie George
NIHR Doctoral Fellow, University College London

Dr Andy Liggins
Director of Public Health, Peterborough

Dr Tasmin Sommerfield
Consultant in Public Health, NHS Lanarkshire

Dr Rosemary Millar
Specialty Trainee in Public Health, NHS Tayside

Professor Eileen Kaner
Director of the Institute of Health and Society and Professor of Public Health Research, Newcastle University

Dr Alison McCallum
Director of Public Health and Health Policy, NHS Lothian

Dr Eleanor Hill
Public Health Specialist, Stockport PCT

Kevin Elliston
Interim Associate Director of Public Health and Visiting Professor in Public Health, NHS Plymouth

Dr Jo Williams
Specialty Registrar in Public Health, NHS Bristol

Dr Merav Kliner
SpR Public Health, Yorkshire and Humber

Jan van der Meulen
Professor of Clinical Epidemiology, London School of Hygiene and Tropical Medicine

Dr Lynne Hamilton
SpR in Public Health Medicine, Tayside NHS Board Public Health

Carl Mackie
Advanced Health Improvement Practitioner, Huddersfield

Veronica Killen
Senior Lecturer in Public Health, Northumbria University

Helen McAuslane
Public Health Specialty Registrar, Leeds

Anna Middlemiss
Specialty Registrar in Public Health

Elisabeth Smart
Consultant in Public Health, Dumfries

Dr Jane Bethea
Specialty Registrar in Public Health

Rachel Sokal
Public Health Specialty Registrar, NHS Derbyshire County

Lucy Douglas-Pannett
Public Health Specialty Registrar, NHS Leicester City

Dr Sakthi Karunanithi
Specialist Registrar in Public Health, NHS North Lancashire/NHS North West

Dr Brijender Rana
Consultant Public Health, SEC Specialised Commissioning Group

Dr Pratibha Datta
Consultant in Public Health, Outer North East London (ONEL)

Dr Jennifer Mindell
Clinical Senior Lecturer, University College London

Dr Amina Aitsi-Selmi
Specialist Registrar in Public Health, London

Jo Peden
Public Health Specialty Registrar, South West (North) Health Protection Unit

Dr Imogen Stephens
Consultant in Public Health Medicine, Solutions for Public Health, Oxford

Stephen Turnbull
Assistant Director of Public Health, NHS Barnsley / Barnsley MBC

Jonathan Gribbin
NHS Consultant in Public Health

Dr Kate Ardern
NHS Senior Public Health Consultant

Catherine Chiang
Consultant in Public Health Medicine, NHS Greater Glasgow and Clyde

Dr Olusola Aruna
Consultant in Public Health Medicine, NHS Gloucestershire

Professor Ian Watt
Professor of Primary and Community Care/Hull York Medical School

Dr Nigel Field
Academic Clinical Lecturer, University College London

Dan Seddon
NHS Halton and St Helens / Merseyside and Cheshire Cancer Network

Gaynor Scholefield
Public Health Manager, NHS Calderdale

Prof. Rod Thomson
Director of Public Health, Shropshire County PCT

Dr Katherine Russell
Specialty Registrar in Public Health, NHS North Central London

Dr Angela Bhan
Director of Public Health, Managing Director - Bromley BSU

Abigail Knight
Specialty Registrar in Public Health, NHS Camden

Dr Lucy Reynolds
Consultant Paediatrician, Maternal and Child Public Health Team, NHS Greater Glasgow and Clyde

Dr Tim Daniel
Consultant in Public Health

Dr Julian Mallinson
Consultant

Dr Mike McHugh
Consultant in Public Health

Glenda Augustine
Specialist Trainee in Public Health

Sue Weaver
Public Health Manager, NHS Gloucestershire

Dr Stephen Watkins
Director of Public Health, NHS Stockport

Dr Sian Williams
Consultant in Occupational Medicine, London

Crossbench peers invited to Downing Street?

Dr Grumble is beginning to move in high circles. Yesterday he learned from two independent sources that the crossbench peers are being invited to Downing Street to discuss Lansley's Health and Social Care Bill.

The problem with parliament, the Commons particularly, is that most MPs just do what they are told. To be fair, MPs are busy. The NHS Bill is just one of very many things they have to do. Reading it, for most, is not an option and failing to follow party orders has dire consequences for an MP's career progression. Doctors in the new NHS know what this is like. Dr Grumble is anonymous because he wants to say what he believes and not what his NHS masters want him to believe.

The Lords is very different from the Commons. While some of the people there are career politicians who have been pensioned off and given a seat in the best day centre in the land, many others have found another route there. Quite often these will have special expertise in one area or another. This, of course, is vital. Dr Grumble is actually a supporter of the House of Lords. He is even a supporter of the only elected members of the Lords, the hereditary peers. It can't be justified. All Grumble can say is that over the years he has met a few MPs and a few lords. Most of the lords he has met have been patients - all NHS patients (including one hereditary peer). He has been impressed by every single one.

Grumble met another peer when he was a civil servant nearly two decades ago. Grumble had to go to a deprived part of the country to open a new facility. It doesn't matter what it was. To say exactly would identify Grumble. Few if any of Grumble's readers would ever have visited one of these places. Grumble, because of his own special expertise, has lost count of the number he has visited including some abroad. Suffice it to say that a private company had been given sweeteners to set up one of these facilities in a deprived part of Teeside. The Minister was to open it but, as ministers do, he cancelled at the very last moment and a lord was sent up from London instead. The occasion was actually exceedingly boring and Grumble and the noble got chatting over the canapes. The lord had taken the train North and he told Grumble that at one stop a whole lot of mentally impaired people got on the train with their minders and sat next to him. At the next stop the minder called them all off leaving the noble alone in the carriage. Then the minder called to Grumble's noble friend and dragged him off too. "No, no, I'm from the House of Lords!" he said.

You can only tell that joke if you are from the House of Lords and it made Grumble chuckle. He has remembered it all those years. It's not really PC but Grumble liked it. He has liked all the lords he has met and he likes the House of Lords.

Now what is the point of all this sycophantic rambling? It is to explain that these people in the House of Lords are nice fair-minded types who have a sense of vocation and dedication. Some of them can be relied upon to look after the NHS, which they too use. Many members of the lords are spoken for. They wear a party badge just like most of those in the Commons. And, mostly, they will do what they are told. But, in the Lords, there is a big group of crossbenchers. These are people will no overt party affiliations who will do what is right according to the evidence. Already they are exerting their influence.

So, if it is true that the crossbench peers have been invited to Downing Street, you can be sure that there is a reason for this. And you can be sure that they will only hear the side of the story that Downing Street wants them to hear. So if you want them to hear what they should be hearing about the NHS Bill, you may need to get in touch will them. You can find out which lords are crossbenchers here along with their email addresses. Get writing now.

With thanks to Baroness Hussein-Ece (actually a Liberal Democrat), who has advised Grumble that brief emails with bullet points are appropriate, and to @UKHouseofLords with their helpful tweet. Yes, peers tweet!

Block the Bridge. Block the Bill.

"The National Health Service is the most important institution we have ever had in this country."




"It's not theirs to sell."

A doctor's touch

Closing NHS hospitals

"Every year, demand for NHS health care – mainly from the greater number of older people – increases. Over the next five years it will grow by about 20 per cent, yet financing will increase by only one per cent. This is no longer viable."

The solution according to Paul Corrigan is to close hospitals. Yes. You read that correctly. The solution to 20% more old people needing more healthcare is to close hospitals - at least 40!

Dr Grumble would be the first to admit that the NHS estate needs rationalising and he would agree that the more you do of one thing the better you get at it but to imply, as Professor Corrigan does, that general hospitals should become specialist centres with one hospital doing one thing and another another is arrant nonsense.



Dr Grumble's masters used to teach him about the unifying diagnosis. The patient presents with various symptoms and signs and the key is to put them all together and find the single diagnosis that accounts for them all. It can work well. Previously fit young people who are acutely unwell are unlikely to have more than one thing wrong with them but it is not the case for the elderly.

It's no good being in a hospital that specialises in the treatment of heart disease and fancy ablation treatment for atrial fibrillation if your heart disease causes a stroke which is treated elsewhere. Or, if you are elderly and need a hip replacement, you do not really want to go to a slick privatised specialist hip replacement centre if you also have diabetes and heart failure as well as your arthritis. You need to be in a large general hospital where there is the right expertise available to cope with every contingency. You need specialist care for your hip but you may well also need specialist care for your heart and for your diabetes and any number of other possible complications. These scenarios are not unusual. In an increasingly elderly population they are the norm.

Paul Corrigan is right. Though he doesn't quite say so, the NHS estate is in a mess. The problem has remained, despite the NHS being a planned service, because politicians have always fought shy of any hospital closure. We can manage with fewer hospitals. But please lets not have small specialist hospitals with ring-fenced work. We need fewer but bigger strategically-placed hospitals with specialists doing sufficient work to do their jobs well with other specialists alongside them.

If demand is increasing by 20% over five years and financing by 1%, hospitals will have to close because there just won't be the money to pay for them. This is a financial solution forced on us by the marktet. But let's not kid ourselves that this is any sort of a solution to the clinical problems we face. What is to happen to all the increasing numbers of frail elderly people for whom there will simply be no hospital beds? Can they really be looked after in the community? Will this be any cheaper? Or does care in the community mean less care or, perhaps, no care?

Still time to save the NHS?

Dr Grumble's reader has been in touch with him to find out why he has not been posting recently. The answer is that he has been worn down. The progressive changes that have been taking place to the NHS are approaching their zenith. Always inexorable they are now unstoppable. The faux listening exercise and the apparent response has silenced the dissent. For Grumble it is very sad. The service that he has devoted his working life to is on the verge of destruction. The NHS the public loves will be no more. Not, anyway, in its present form.

That is the negative view. Others, like the redoubtable Clare Gerada, take the alternative view. Clare, or St Clare as Dr Grumble likes to call her, takes the view that all is not lost. Is she right?

Mrs Grumble has noticed the depths of Grumble's depression over the reforms. She took Grumble back to the time of the Iraq war when millions protested and reminded him that he stayed at home that day and left others to waste their time demonstrating. And she reminded him that this is a decision that he now regrets. Not, of course, that it made a blind bit of difference. Is there any point in simply registering a protest when it's clear that it's not going to alter anything?

Is a masked man ever trustworthy?

What puzzles Dr Grumble most about major governmental decisions is just how wrong they can be. You just would not think that any committee of sensible people could get things so utterly wrong. Committees do make mistakes but not on the scale the government does. There must be a reason for this.

What is the reason when it comes to the NHS? There is evidence that relatively dispassionate parliamentary committees, after listening carefully to the evidence, can actually see the truth. Here's what Kevin Barron, Health Committee Chair, said about commissioning:

"It is a sorry story if, after 20 years of attempting to operate commissioning, we remain in the dark about what good it has actually done. The Government must make a bold decision: if improvements fail to materialise, it could be time to blow the final whistle."

The final paragraph of his Committee's report reads:

A number of witnesses argued that we have had the disadvantages of an adversarial system without as yet seeing many benefits from the purchaser/provider split. If reliable figures for the costs of commissioning prove that it is uneconomic and if it does not begin to improve soon, after 20 years of costly failure, the purchaser/provider split may need to be abolished.

So there you have it. The problem is not with committees. The problem is at the highest level of government where decisions are made based on a prevailing dogma driven by intense outside financial interests. The latter have enormous resources at their disposal and they use them to maximum effect. They are very clever, clever enough to defend the indefensible. Only this week Grumble nearly crashed his car as he heard somebody from KPMG extolling the virtues of PFI. The piece was masterly. But wrong. All the pros came across but none of the cons. It didn't take Grumble long to find evidence of a vested interest.

What interests Grumble are the drivers to the government's NHS reforms. Why have successive governments got it so wrong? How is it that the ConDems are able to press on with their misguided plans to essentially sell off our NHS against the wishes of the electorate? Read Liberating the NHS: source and destination of the Lansley reform to find out more.

Anonymity

@drgrumble are you going to 'come out' soon? :) I think you might!

So read the tweet from @amcunningham. Yes, Dr Grumble is on twitter. A waste of time? Not really. Teaches brevity you see. Only 140 characters. It's a good discipline. Could change the character of this blog.

Long ago Dr Grumble decided against posting anything about patients. It is a great shame. In his initial naivety, Grumble was hoping to post the odd clinical vignette based on real but anonymised cases. For a while he did. To preserve anonymity he changed the details of the cases he had seen to make them unrecognisable. Genders, ages, dates, places and ethnicity were all changed or randomly allocated. It didn't work. Sometimes the details were tweaked so much that comments would be made pointing out some inconsistency that didn't exist in real life but arose because of the disguise. Then there was always the possibility that while nobody could possibly recognise the patient, the GMC might think that the patient could be recognised from the information provided or, if the case was rare or had some unusual twist, the patient might recognise themselves. Dr Grumble's anonymity was a part of trying to keep his patients anonymous.

But there are other reasons for having a nom de plume. There are other people whose identity you might want to conceal: friends and acquaintances for example. Take yesterday. OK, it might not actually have been yesterday but let's say it was. Yesterday Dr Grumble had some friends around. One had not long ago had her 60th birthday and she regaled us with the tale of her pooh sample. For those of you without a 60-year-old in the family you may not have grasped what this is all about. Once you reach your sixtieth birthday, if you are lucky enough to live that long, you will receive a letter, not from the queen, but from the NHS. It will tell you that you are to be offered a pooh test to look for bowel cancer. Just as you have come to terms with this, a little pack will arrive in the post with the testing kit and instructions. The first challenge is to catch your pooh. You cannot let it plop into the loo. That's not allowed. Somehow you have to catch it. According to Grumble's friend an old ice cream container works well. Your poohs will turn out to be heavier than you expect. You crouch, do the business and catch your plops. Those of you familiar with German loos will know that this is a smelly experience. You then take the sticks, kindly supplied by the NHS, and spread your pooh in the appropriate cardboard window. Two spreads from different parts from each motion. And you do this three times. As Grumble's friend said, it makes a new meaning of the phrase Poohsticks. But the funniest thing of all, if any of this is funny, it that they give you an extra special envelope to send your sample back in and, just after you have sealed it up (no, you don't have to lick it), you will read on the outside "Business post".

After you have tested your pooh, you get an invitation to have some sort of a check-up at the GP's. It is done by a nurse. Just what the nurse does Grumble does not know. Probably she tells you to stop smoking and takes your blood pressure and things like that. In the case of Grumble's friend she discovered an irregular pulse. Good you might think. But it wasn't atrial fibrillation it was just the odd ectopic. This is something that Dr Grumble would have dutifully recorded and would not even have told the patient. But Grumble's friend was sent to the hospital where she had numerous tests paid for under payment by results and was then told there was nothing to worry about. Very costly one would think.

Since Dr Grumble has been tweeting he has had a few contacts with the great and the good, the powerful, the odd celebrity even. No less a person than Alan Maynard tweeted about how nurse practitioners could do some of the jobs of GPs. Mrs Grumble, who used to be a GP does not share this view. Clare Gerada concurs tweeting that there is no such thing as a trivial consultation - which, interestingly, was Mrs Grumble's exact point. It's annoying when management types claim to know more about a job than the people who do it. Many of us will know of some nurses doing doctors jobs who cost more than they save. The same has been shown of some GPs doing consultants' jobs. Dr Grumble generally avoids such anecdotes because he doesn't want to cause upset. In any case, Grumble is employed. He needs to keep his employer sweet. His employer wants more healthcare assistants to do nurses jobs, more nurses to do doctors jobs and more GPs doing consultant jobs. Pointing out that this is not always the right way forward is unwise. Nurses for nursing, doctors for doctoring, GPs for general practice, consultants for consulting and managers (not doctors) for managing is not the way you are allowed to think any more. But that is what Grumble thinks and that is just one reason why he is going to stick to his nom de plume.

Radical policies for which no one has voted

If a government is pursuing radical policies for which no one has voted what can you do? Not much really. Writing to your MP is worth a try. It might be more worthwhile if your MP happens to be in the cabinet.

A friend, briefed by Dr Grumble, sent this letter to his MP, a well-known cabinet minister:

Dear Cabinet Minister,

Health and Social Care Bill 2011

I am writing to express my concern about the general direction of the proposed NHS reforms. We have been repeatedly told that the NHS has to change. The evidence for this assertion is lacking. We do have a problem: health-care spending is predicted to rise because of the increasing numbers of elderly and the ever-increasing costs of treatment. That is the problem, not the current structure of the NHS.

The Commonwealth Fund has found the NHS to be the most cost-efficient healthcare service in the world. The World Health Organisation recognises the French system as being the best in the world but the French spend 11.2% of GDP on health care compared with our 8.6%. Despite this, our figures are improving much more rapidly than those in France.

I am particularly concerned about the move towards privatisation and a more American-style system. In the United States spending on health care in the year 2005 was £3921 per person whereas the figure for the NHS was £1603. Are their results any better? No. The British have generally better health and live a year longer. And the cost of administration of the US system is three times that of the NHS.

Why can we not accept that rationing is a fact of life in all health care systems. We need to ration on the basis of need. The National Institute of Clinical Excellence has led the way on this, is admired throughout the world and has ensured that we provide the best treatments to the greatest number of people.

We all accept that there is a need to keep healthcare spending under control but allowing the NHS to fragment into a loose association of multiple providers all in competition with each other is hardly the route to cost-effective integrated health care. I do hope you will do what you can to ensure that the Bill is shelved.

Yours sincerely,

A Grumblefriend

The reply he received is as follows:

Dear Mr Grumblefriend,

Thank you for your letter. Our plans to modernise the NHS have a simple aim: to ensure everyone is provided with healthcare - free at the point of use - which is the best in the world. At the moment, and despite years of extra investment productivity has declined by 15 per cent over the previous 10 years. We have to modernise the NHS to ensure that it is ready to meet the twin pressures of an ageing population and rapid advances in medicine.

We have already made several changes in response to concerns voiced by healthcare professionals - this includes strengthening the provision that competition will be based on quality not price. I can also assure you that the Secretary of State will still have a duty to promote a comprehensive health service. Now that the Bill has passed through the Commons there is a natural pause before it is considered by the Lords. We will be using this break to listen to the concerns that people still have. Where those concerns are genuine we will engage with those who want the NHS to succeed and make amendments to improve the Bill.

Yours sincerely,


A Cabinet Minister

The cabinet minister signs off with just his first name. Grumble's friend moves in high circles. The letter is clearly a standard reply. It even mentions a major concern that Grumble's friend neglected to raise: the crucial change in the responsibility of the Secretary of State who now only has a duty 'to promote' a comprehensive health service. Plainly it is not just a few maverick medical bloggers who have spotted this fundamental change to the law.

This bland mollifying reply, sent doubtless to numerous constituents, actually reveals that they are not going to budge one iota on this crucial point. No longer will the law state that the Secretary of State

"must...provide or secure the provision of [National Health] services.."

The duty to provide comprehensive health care has gone. The requirement that previous benevolent governments took upon themselves at times of great hardship to provide healthcare for us all, rich and poor, has been taken away. It has gone forever.

‘The NHS will last as long as there are folk left with the faith to fight for it.’

Aneurin Bevan

Are there still enough folk out there with the faith to fight? Possibly not. Not in parliament anyway. People are afraid. Very afraid. And they are right to be.

Let's make it safe for bikes

Just how much can you get from a pint pot?

Never in the history of the NHS has a parliamentary Bill met with the level of opposition that has confronted the Lansley Health and Social Care Bill. What Lansley lacks in drafting skills he makes up for with tenacity and nobody would be surprised to learn that he is now fighting a rearguard action to drive through the changes he and his henchman have decided are necessary. Now you might think that Grumble is a bit antagonistic towards Mr Lansley. And you would be right. But Grumble is a fair man and he likes to look at the evidence and, if there is no evidence, the arguments. So it was with interest that Grumble read Lansley's recent article in the Telegraph. Unsurprisingly there is quite a lot wrong with it.

Now if Grumble were to write an article on the NHS he would start with a little homily about the wonders of the health service. It is the obvious way to start but we don't get this from the Secretary of State. Oh no. Quite the opposite. He sees the NHS not as something to be valued and cherished but a burdensome yoke. Keeping it going as it is will inevtiably lead to a 'crisis tomorrow'. What is his evidence? It is that there are 'enormous financial pressures looming on the horizon'. You have heard it all before. This is the 'something must be done' argument which politicians use to justify almost anything that they want to change - especially when they have no better argument for change.

Now nobody doubts that there is going to be a crisis ahead as far as funding the NHS is concerned. But this is not to do with the NHS itself. This is a problem which is going to face every modern healthcare system in the world. There are various reasons for this. Lansley enumerates them - one of the few things he has got right.

Another thing that Lansley probably has got right is the funding gap. He tells us that by 2015 the health service will need £130 billion per year and that this leaves a funding gap of £20 billion. OK. Dr Grumble believes him. Something does have to be done to deal with this. But what is his solution to this problem? The answer it seems is that the NHS is going to have to work smarter. Then, in the same breath, he trots out the already discredited but now standard political tale of the poor cancer performance of the NHS and the equally discredited heart disease figures. What has this to do with saving money? If he is right and we are doing so badly, this is going to need more money not less. This is not just about 'working smarter'. And, in any case, if you save people from these diseases they live longer to die of something else and that ends up costing the NHS more not less. It is actually the success of the NHS with rapidly increasing numbers of elderly that has caused the impending healthcare spending crisis. It is not the poor performance of the NHS that is responsible for the looming crisis, it is the opposite.

Then he trots out the oft repeated mantra of 'no decision about me without me' and 'patient empowerment'. Laudable though these may be, how can patient empowerment possibly fill the funding gap?

So now Grumble is really left wondering about what the Lansley Bill is really about because saving money through improved efficiency does not seem to be it. Empowering the patient and chopping up the NHS into multiple providers each competing with each other is hardly likely to save money. The reason why there are now so many managers in the NHS is because of the preparation for privatisation. Running a market inevitably wastes money. It requires managers to commission services and it requires regulation. What is even worse is that organisations which get paid per item of work will, surprise, surprise, do more work. That might be good for waiting lists but it is not good if you want to save money. Saving money is about minimising healthcare and, believe it or not, you probably can do that without necessarily damaging the quality of care. That is smarter working but you won't get that from a market that pays you more if you do more work.

What is this Bill really about? How is Lansley going to make up the £20 billion shortfall when the new NHS he is creating will be less and not more efficient? There can be only one answer. This is the beginning of the winding down of the NHS. Patients will somehow be persuaded that they need to pay for some of their healthcare themselves. That is where 'empowering the patient' comes in. What other explanation can there be?

Oh, one more thing Grumble nearly forgot. Messrs Lansley and Cameron like to compare healthcare in France with healthcare in the UK to demonstrate how rotten the NHS is. It's doubtful if the figures they give you are at all reliable but one thing they always fail to tell you is that in France they spend 29% more on their healthcare than we spend on the NHS. If we did the same we wouldn't have a funding shortfall. We would be in credit.

Mr Lansley is never going to get a quart out of a pint pot and he knows it. The real intent is in the title of the Lansley article: "Why the health service needs surgery". Notice the NHS doesn't need medicine, it needs surgery. And we all know what that means. Surgery involves cutting and Dr Grumble is suspicious that the Lansley Bill will ultimately lead to exactly that: cuts.

The devastating power of words

Everybody now knows that there is widespread disquiet over Lansley's Bill. There is no argument about that. And it is becoming increasingly clear that Mr Cameron's pause and listen is really just a political ploy to enable what will essentially amount to the original bill being railroaded through parliament much as was originally intended.

What was originally intended? The answer is in the draft Conservative Manifesto published in 2010. Here it states:

With less political interference in the NHS, we will turn the Department of Health into a Department of Public Health so that the prevention of illness gets the attention from government it needs.

Just one sentence. Innocuous enough you might think. When Grumble read this he thought this was a cosmetic name change. Governments like to change the names of things. It gives the illusion of progress when in fact all that has happened is that the label over the departmental portico has been repainted. But when it comes to the health service the real intent is not always spelt out. It is not just the Conservative party that has been calculatedly vague: New Labour were masters of obfuscation. Read that paragraph carefully and extrapolate and all is revealed.

You see Public Health is actually only a very small part of health. About 3% in fact. It is important but it is hardly what most people would call healthcare. It is about preventing the spread of infectious diseases and the like. It is something that government has to be involved in because these things cannot be dealt with just at a local level. There has to be an input from national government. It is not a duty you can palm off on others.

OK so far? The next bit is where you have to read between the lines. If the Department of Health is going to do Public Health which will have "the attention from government it needs" what happens to everything else the Department of Health (and government) used to have a responsibility for? The answer, if Grumble's interpretation is correct, is that these other things do not need the attention of government. That is essentially the meaning of "less political interference in the NHS". It is a euphemism for government abandoning the NHS to its own devices. OK. Dr Grumble is sensitive to how his sceptical readers may be thinking. This could be an extrapolation too far.

So let's now take a look at the new Bill. But before we do we need to know where we start from. Here is a key responsibility for the Secretary of State as laid down in the National Health Service Act 2006.

National Health Service Act 2006

1 Secretary of State's duty to promote health service

(1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

(a) in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of illness.

(2) The Secretary of State must for that purpose provide or secure the provision of services in accordance with this Act.

Take a look at (2). Here you see a clear statement that the Secretary of State has to provide or secure the provision of services to prevent, diagnose and treat physical and mental illnesses amongst the people of England. That anyway is Grumble's interpretation of the words of the law. Grumble could be wrong. He is not a lawyer but that is how the law seems to read. To be frank, it is a pretty tall order. Our government has to provide for the health needs of each and every one of us. It is a very British thing. Electing governments to look after our health is something we in England do. It is something the electorate wants and expects. It is one of the things we have governments for. They need to defend the realm and look after us, including our healthcare. It has been like that for more than 60 years. And we want it to stay that way.

Of course this is an enormous responsibility for a government so it is no surprise that all the major political parties want to be rid of this commitment. Just as they do not want to run the railways, schools or universities or, well, anything. Today's citizen must stand up on his own two feet and look after himself. It is inconvenient for the old Etonians in charge that the public might actually expect them to provide some infrastructure for the country like decent roads and a rail network and schooling for our children and universities. But there it is. We do. And we are not impressed that students with no money have to pay for their own education. We are not at all impressed. It might be OK for your children, Mr Cameron. It might even be OK for Grumble's children but it is hardly fair on the children from the council estate.

Grumble is digressing somewhat but you can see there is a theme here. And the theme extends to the NHS. Because they don't want to provide that any more either. Who do they expect to do that? Well, it's your GP isn't it? You might think your GP was busy enough seeing patients. And you might well be right but he now has to run the NHS as well - instead of the Secretary of State.

Now we come to the important bit because Grumble has, up to now, been speculating. It could be that things aren't really quite this bad. So let's now take a look at the Mr Lansley's Bill. Is there anything in the new words of the law that gives credence to Grumble's eccentric suspicions? Here is the relevant bit :

The Lansley Bill

Secretary of State's duty to promote health service

(1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—

(a) in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of illness.

In other words, whereas previously the Secretary of State had to "provide or secure the provision of services" he now only has to "promote a comprehensive health service".

Please forgive Dr Grumble if he has got this wrong. Grumble has no legal training. The law is perplexing but Grumble can read and it looks very much as if Lansley is largely washing his hands of any responsibility for having to provide healthcare to us all. This is a momentous change. It is one that those of us who do not have the time to trawl through the legal gobbledegook may have missed. These words are crucial. For the NHS they are devastating.




Acknowledgement

Grumble was made aware of this drastic change by Dr No. Richard Blogger has also contributed to Grumble's understanding as well as the Witch Doctor who has also heightened Grumble's concern over this crucial element of an insidious bill. Dr Grumble thanks them all.

Right wing, wrong approach

Which of these can you trust?

Can you trust this man?

Can you trust this man?

This what not quite the sort of action Dr Grumble had in mind.

March to save the NHS

Saving healthcare costs with technology

Dr Grumble is often being told by management consultants and the like that his patients can now be looked after in their own homes instead of the hospital with the aid of various bits of innovative kit that will monitor their condition and alert doctors via the internet when they are becoming unwell. Grumble has always been somewhat baffled these claims. Can technology really be the answer to rising costs in healthcare? The question is addressed in this video.





The answer is no surprise to Dr Grumble. Perhaps it is not obvious to the management consultants. They know about finance but they really do not seem to grasp the fundamentals of healthcare. Healthcare as a business is rather different from what most managers are familiar with. They understand the problem: healthcare costs. But soultions like privatisation are never going to solve this. Quite the opposite. A very different approach is needed. The video makes that clear.