NHS and the general election

Chris Ham's BMJ editorial describes the situation in the NHS that the next government needs to improve:-

"... the destabilising effects of constant organisational restructuring, the negative consequences of a command and control style of leadership, and the lack of engagement of clinicians—especially doctors—in quality improvement."

There has been a "pervasive culture of fear" in the NHS, and clinicians are not always able to speak honestly and may be subject to disciplinary procedures if they do. For example, Mr Ramon Niekrash gives his story in the Independent on Sunday.

I'm not sure why three government reports prepared for the Department of Health only came to light through Freedom of Information requests from Policy Exchange (see its press release). It is clear that the government had indications that there was something wrong with healthcare regulation. Lady Young, who was chair of the Care Quality Commission (see previous post) was someone who may have been able to put it right. Her post-office interview in The Times reinforces that the problem is political sensitivity to criticism.

Breach of contract to discipline Gillian Mezey

Remarkable successes of John Hendy, QC, to obtain an injunction twice in the case of Gillian Mezey: firstly in September 2006 to bar her employing NHS Trust from suspending her from non-clinical duties; and secondly in December 2008 to restrain the Trust from taking disciplinary action. The court of appeal has recently upheld the second injunction (see BMJ story and court judgment).

Mezey gave one hour's ground leave to an informal, previously conditionally discharged, patient readmitted to a medium secure unit. This was at the end of a phone on a day when she was away giving a speech at a Home Office conference. Unfortunately, the patient absconded over the fence, attacked a stranger in the park with a knife and killed him. In retrospect, it is difficult to see what the purpose of the ground leave was, although the patient was informal anyway, and an investigatory panel set up under disciplinary procedures criticised her decision.

Mezey may have been fortunate in that new Maintaining Higher Professional Standards had not been implemented by the Trust, so this panel report was produced by a QC and two reasonably disposed psychiatrists. The court decided that it would be a breach of contract to proceed on this basis. It is possible though that intervention by the National Clinical Assessment Service could have had the same effect under the new procedures.

Nonetheless, Mezey has been humilated by Trust processes and the temptation to find a scapegoat in cases of homicide by psychiatric patients needs to be countered. As far as I know, her case for compensation is still outstanding (see story in The Sun).

Doctrine of the "new interventionism" is not the legacy Blair hoped for

Blair's case at the Chilcot inquiry was that intervention in Iraq had saved us from the more dangerous threat we would now face from a richer and more defiant Saddam Hussein. His beliefs behind his foreign policy are said to be set out in his Chicago 1999 speech (large sections of which were written by Sir Lawrence Freedman, a member of the Chilcot panel).

I think the Kosovo situation was different. Blair seems to be less clear now that he did get as far as advocating a "new interventionism" (see my webdomain page from March 2004). It was NATO that intervened in Kosovo. Article 2 of the UN Charter says: "All Members shall refrain in their international relations from the threat or use of force against the territorial integrity or political independence of any state." Blair decided he would act without UN support, and for that the Chilcot committee, even with Lawrence Freedman on it, should damn Blair's legacy, which meant so much to him.

Smart mental health services

The latest NHS 5 year plan NHS 2010-2015: From good to great. Preventative, people-centred, productive is written in the context of the Chief Secretary to the Treasury's document Putting the frontline first: Smarter government. The plan confirms the need for £15 - 20 billion in so-called efficiency savings over the three-year period from April 2011.

Growth in health services does not necessarily lead to improved outcomes. The myth of massive psychiatric need was pointed out in a paper More and more is less and less in 1985. Psychiatry does have its limits, as I described in my 2002 paper in the BMJ.

Mental health teams can recognise the limitations of what can be achieved and will respond to challenges to improve care in this context. Mental health is not a technologically driven service, although CNS drugs are now the highest net ingredient cost to the NHS of all drug groups. Still, drug costs are a fraction of the main expenditure on staff. There is evidence that mental health services create a vulnerability to relapse but they understand the need to encourage independence. Creating a more patient-centred service can actually reduce costs.

Dr Foster stepped in a puddle right up to his middle

Dr Foster believes itself to be the leading provider of comparative information on health and social care services. It's latest hospital guide has caused controversy.

Nigel Hawkes in his BMJ column notes that it is a company that has been "granted at least one sweetheart deal — and possibly two — by the Department of Health". It tied the Healthcare Commission up in knots with its results (see previous post) and may be responsible for Baroness Young's resignation from CQC (see my post today).

We need independent academic opinion to publish comment on its latest hospital mortality data. Previous analysis in BMJ paper has suggested their "Claims that variations in hospital standardised mortality ratios ... reflect differences in quality of care are less than credible".

Rough NHS politics

Why's Baroness Young leaving the Care Quality Commission (CQC)? As CQC says on its website she resigned on 26th November. It can't be a coincidence that this was the day before the regulators demanded improvement at Basildon and Thurrock University Hospitals NHS Foundation Trust. It's also true that she has been a breath of fresh air in NHS regulation and to my mind a sad loss.

The Mail on Sunday story says Government sources have personally attacked her for causing problems because of her strong personality. It's only someone with strong opinions that can produce the necessary reform. I think the wrong person has gone (see previous post).

Who's bullying whom in the NHS?

More on better direction for NHS (see earlier post). Mike O'Brien, health minister, has described the kind of NHS manager that will be named and shamed (see HSJ article):

“It’s those who duck the difficult decisions, who hide in the quiet safety of their offices, or employ consultants to make decisions for them - who won’t put their heads above the parapet, not daring to engage staff and patients, putting off the inevitable for another day and not learning from others.

“These are the ones who should worry. But we will continue to support leaders and managers who show how we can deliver better care for patients”.

Managers are not used to this. They've even accused O'Brien of bullying them when he says he doesn't want them to slash and burn budgets. Managers have become more used to "top-down", centrally driven management, which could in itself become bullying when clinicians were not involved (see another previous post - Why do staff report high levels of bullying in the NHS?).

I guess the political stance must be gearing up for the election next year. It's about time Labour got it right on the NHS. O'Brien's speech even talks about looking at how a bigger proportion of budgets could be devolved to primary care trusts. This may not be that different from the Tory policy of giving GPs real budgets.

And anyway, clinicians have always said there needs to be better integration between primary and secondary care. I'm not saying that there wasn't a need to shift care from being too doctor-centred to more patient-centred, but the underming of professional values and opinions in doing this has been very damaging for the NHS.

New accountability framework required

The theme of a "call for evidence" by the Local Government Association (LGA) is liberating local public sector partners to serve local people rather than serving the machinery of Government.

For example, LGA has set an agenda for Ofsted, which says it should:

■be a voice of reason rather than feeding people’s fears
■be independent of external influence, basing its conclusions on facts and research
■use expert and knowledgeable inspectors who can offer advice and support
■assess how well children are being looked after and protected rather than measuring processes and procedures
■be focused on making services better rather than on delivering detached, public judgements

Barry Sherman MP, chair of the Children, School and Families select committee spoke out about Ofsted on BBC2's Daily Politics.

Better policy direction for NHS

Speech by health secretary to King's Fund spells out that the NHS for a fourth-term Labour government will be "preventative and people-centred, placing quality at the heart of all that it does". He also made clear that the NHS is moving on from top-down reform. "It led to a feeling that reform was imposed; done to people, rather than with them. It gave unintended messages at ward level – ‘public bad, private good’ – and process targets implied a lack of trust." He also recognised that "there is a danger that people in the service try to read the runes and conduct their own mini spending reviews".

The NHS chief executive took up the comment about the NHS as preferred provider and sent a letter to SHA and PCT chief executives. He again reiterated that "Service improvement and re-design should not be something which is imposed on NHS staff but something which they own and lead." The preferred provider policy has union support eg. as Mike Jackson from Unison says in a letter to the Guardian, "NHS services will not be improved by wholesale tendering, fragmentation and privatisation."

Are medical professionals conscientious?

Article in Student BMJ about medical professionalism. It notes how professionalism is viewed differently by doctors, nurses and patients. A conscientiousness index has been proposed as a measure of professional behaviour in medical students.

This issue is complicated if medical students playing loud music or having a messy kitchen in halls are regarded as being unprofessional. In fact, doctors can be defensive about their income, style of practice, prestige, and power. It's actually the conscientious doctors that can be seen as different and difficult by their colleagues in this context.

The article mentions a roadshow to engage medical students in the issues round professionalism. This project by the King's Fund and others has already produced a report Understanding doctors.

Read Norman Lamb in Mail Online

Norman Lamb, MP for North Norfolk, has written about the Cawston Park fiasco (see my previous post) in Mail Online. I agree that it is important to get to the bottom of what happened to Andrew Breeze and Dominic Wilson. I still think there must have been envy (or similar) motivating the criminal prosecution. The background national scandal of shipping difficult to manage and place psychiatric patients out of the NHS into expensive private care barely figures in public statements about central NHS mental health policy thinking.

This isn't the first article that Norman Lamb has written for Mail Online. The other describes his successful investment in Tinchy Stryder via his son.

Would you vote Tory because of James Murdoch and Rebecca Brooks?

Observer story about Father and Sun highlights how James Murdoch, Rupert's son, is steering the Sun, together with Rebecca Brooks, previous editor, and now CEO of News International.

There must be a question as to whether James can really step into Rupert's shoes. Rebecca Wade (as she was) has a lot to answer for in Sun campaign against Sharon Shoesmith, and previous misdemeanours as Sun editor.

Has David Cameron backed the right horses?

The Sun says Gordon Brown doesn't even know how to write his own name

The Sun says it's bloody shameful that the Prime Minister doesn't know how to spell his own name. Instead of putting Gordon, he's put Gorm. Instead of putting Brown, he's put Bum.

We do expect a Prime Minister to be able to dot the i's. And he shouldn't have to repeat the word "sincere".

It's serious that young British soldiers are dying in Afghanistan.

Improving patient experience in the NHS

Patient experience can't be the be-all and end-all of NHS care. After all, doctors have always been easily able to please patients with quackery.

However, medicine has tended to be more doctor-centred than it should be, so an emphasis on patient experience may help to right the balance. An editorial in the BMJ discusses the use of patient experience within pay for performance (P4P) programmes. This sounds as though it has more merit that service-line reporting and management (SLM) promoted by Monitor, although the way SLM has been implemented locally where I live in Norwich has focused on the patient experience (see Monitor example of SLM implementation).

Don't say you feel let down by inpatient psychiatric care

If you do say you feel let down by psychiatric inpatient care, you might incur the wrath of Louis Appleby, the Mental Health Tsar. Thank goodness the Care Quality Commission (CQC) is independent of government, because Appleby thinks they've "deliberately distorted" the results of a survey of mental health acute inpatients (see Community Care news). At least Kay Sheldon, one of the CQC Board, who has herself been detained under the Mental Health Act and received a payout from the NHS for wrongful diagnosis of schizophrenia, has answered him (see blog).

Highly popular teacher of pathology

Sorry to see the Times obituary for Austin Gresham, who was my Professor of Morbid Anatomy and Histopathology when I was a clinical medical student in Cambridge. I was hopeless at pathology, but I turned up fairly regularly for the 1.30pm meetings in the dissection room when the results of postmortem examinations were presented. Gresham's morbid interest in pathology fascinated me, as did his gruesome particular interest in forensic cases.

Mixed feeling about mental health

My chief executive retires today (see EDP story). Her legacy is said to be a Norfolk's first NHS provided psychiatric intensive care unit (which is locked) whereas her "biggest goal has been to keep people with their families and out in the community wherever possible".

Is this mixed? I'm still working at the NHS Trust.

England win the Ashes

Oval test scorecard. Pity about my fifth day ticket.

Lookalike

Lockerbie Bomber

Robin Gibb

Does Colonel Gadaffi like the Bee Gees?

What's wrong with affecting private insurers' business in health care?

More on the anti-rational opposition to the Obama health reforms (see Guardian article).

"We cannot stop until this attempt to open what could be one of the biggest gates of hell into our country is stopped", says Rick Joyner. His fear is rationing and the collapse of "the whole system". He goes on, "Through this crisis, we may be looking at the ultimate form of controlling people, which the present Administration is obviously trying to do in many ways. This has to be stopped."

Betsy McCaughey says the proposed legislation is a "violation of your rights and a threat to your health".

"Downright evil"

The Obama health plan has created emotive language. See Sarah Palin's post on Facebook. Must be powerful vested interests involved.

And yet PhRMA (Pharmaceutical Research and Manufacturers of America) is supporting health care reform, although it still believes the "best way to expand coverage and reduce the number of uninsured is through private health insurance with businesses and families having a range of private options".

We need to be cautious, though, about Barack Obama's apparent support for personalized medicine and innovation - see Innovation.org (a PhRMA project) welcoming the nomination of Dr Francis S Collins as NIMH director and the Personalized Medicine Coalition case. Let's hope the President is not going to stuff PhRMA's mouth with silver to get his health care reforms through.

Globalisation benefiting from the recession.

The rundown of the high street is worrying (Guardian article). Pubs are also closing but branded pubs and cafe-style bars are expanding (BBC News online). Globalisation, at least, seems to be benefitting from the recession - as am I. (See My perspective on the economic crisis).

Incompetence and injustice damaging democratic politics

Charles Clarke (Independent article) is right to point out the damaging nature of arbitrary power. I'm not sure how much of this comes from Gordon Brown personally, as Charles Clarke seems to think was behind his own demise from the cabinet. However, a society that panders to public opinion and a government that is not motivated by principles, creates an unreasonable, bullying culture. I'm not convinced Ian Gibson's was the best test case, but the point needs to be taken seriously. Living in a state of denial doesn't help either, which at least the Queen realises (Observer article). The irony is that, as Will Hutton puts it, "At last Brown may be getting it right".

Ricky Ponting gracious in defeat

Ricky Ponting was gracious in his comments after the defeat by England at Lords. It may have earnt him some credit.

If the last wicket had fallen at Cardiff, things would have been very different for Ponting's reputation. His captaincy would have been acclaimed. He plays to win. He would have succeeded in getting the most out of a side without as much talent as previous Australian sides he has captained.

As it was, he just became a target for his pressurising tactics. When he complained about England's time wasting, it seemed like something he would have done himself.

Congratulations to Andrew Strauss, although I'm not convinced he's the best captain in the world. Surely he should have had more of a plan than waiting for the new ball when Clarke and Haddin took control on Sunday evening (I was there). Let's look forward to the rest of the series.

People who are feeling ill not wanted in hospital

A notice has gone up at my NHS Trust saying that people who are feeling ill should not come into the building. Actually when you look at the small print, what it says is that people with symptoms of swine flu should not come in. But has the hospital unconsciously disclosed its real wish?

Cawston Park hospital fraud trial collapses

The criminal case against Andrew Breeze and Dominic Wilson has collapsed - see EDP story. See Andrew's video statement and read Judge's closing remarks.

There must have been envy motivitating this trial, mustn't there? And I'm not just talking about from the two witnesses whose statements did not agree.

There has been an issue, if not scandal, about the way in which difficult to manage and place psychiatric patients have been shipped out of the NHS to private care (eg. see my comments on National Director of Mental Health's 10 year report). The problem is that it has been easy to make money out of this situation, not that there has been any fraud involved. Tony Chancellor, who set up the company that owns Cawston Park, made millions of pounds out of his business over a short time (although the Times story overstates how much he made - as Andrew Breeze himself pointed out at the time).

Good luck to Andrew in trying to find out what was behind this. Both Dominic and he were dismissed by Chancellor Care, so I imagine this story has got some way to run legally. Who was advising the NHS Counter Fraud Service?

New NHS chief executive needed

Nigel Hawkes understands the current situation in the NHS. Would Neil McKay do a better job than David Nicholson? McKay was Deputy Chief Executive for the NHS Executive. Following Nigel Crisp's appointment as Chief Executive/Permanent Secretary in November 2000, Neil McKay became Chief Operating Officer for the Department of Health and Chaired the NHS Operational Board. He became Chief Executive of the Leeds Teaching Hospitals NHS Trust in April 2002. He's now at the Strategic Health Authority in the East of England.

Why's David Cameron got a mortgage?

There's nothing to lose by taking out a mortgage if the interest payments get paid. Still, the focus has been on David Cameron repaying £680 for repairs on his Oxfordshire cottage, which included clearing wisteria and vines from a chimney.

No-win situation in child protection

On the day that the Badman review of Baby Peter was published, with Badman saying that social workers were not interventionist enough, a High Court judge refused to overturn a decision by the GMC to strike David Southall off the medical register for being too interventionist. True, the judge said that Southall was "speculating on non-medical matters in an offensive manner". I do not know the full circumstances to say whether Southall was offensive. I understand there was a social worker in the room at the time. Southall admitted that the mother may have perceived his questionning as aggressive and hostile, but he denied he had accused her of murdering her son. There are plenty of doctors who can be offensive, who don't get struck off.

The judge found the mother a credible witness. I am not saying she wasn't credible. To lose a son through him hanging himself is a tragedy. However, I don't understand why child protection is not a medical matter. Maybe the judge finds it difficult to appreciate what people can do to their children. Isn't this what the shock about baby Peter case is all about?

The danger is the polarisation in the debate. There needs to be open discussion about the issues. Our best hope is the Social Work taskforce. However, the position of Ed Balls, as secretary of state for children, schools and families, is compromised by his legal battle with Sharon Shoesmith, ex-head of Haringey's children's services. Hopefully, Balls will get moved in the cabinet reshuffle, but he can't go to chancellor yet, as he would like, I'm sure, if only because of his involvement in the MPs' expenses fiasco.

Predicting the market for polypill

Malcolm Law, Professor of Epidemiology and Sir Nicholas Wald, Professor of Environmental and Preventive Medicine, at the Centre for Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine, hold patents (granted and pending) on the formulation of a combined pill (polypill) to simultaneously reduce four cardiovascular risk factors - low density lipoprotein cholesterol, blood pressure, serum homocysteine, and platelet function.

They argue that the motivation for the patent for the Polypill is to help ensure its development and to fund the necessary clinical trials, which are costly. According to the Independent, they have had talks with the Government's Heart Czar, Roger Boyle, and the Medicines and Healthcare products Regulatory Agency (MHRA) about obtaining a licence. Progress has been held up by a lack of funding and charitable foundations are being approached for support. I think the argument will have been that the NHS should pay for the necessary trials.

Keep up to date with the Polypill news blogspot. The blogger, Shaun Holt, is an enthusiast for the pill, not least because he's launched the polypack, which packages the polypill medicines into daily sachets. "The benefits are massive," Holt argues. He admits the polypill is several years away if it is going to produce data on mortality and morbidity, as the estimates of reduction in cardiovascular risk are predictions and projections. There's probably no money in it for drug companies as the drugs are off patent.

Other people are also enthusiasts, such as Richard Smith, the ex-editor of the BMJ, who takes the 5 pills every night. The BMJ has this week published an article by Law and Wald said to be providing evidence that everyone over 55 should take medication to reduce blood pressure. They should get their money out of the patent eventually.

Who were the first MPs to show contrition about expenses fiasco?

Who were the first MPs to start the my shirt's hairier than yours competition? I think it was Andy Burnham and Ed Miliband.

I'd bet on them to do well out of the cabinet resuffle. They must also be positioning themselves for the labour leadership.

System of pursuing allegations against doctors is failing

The Guardian reports that GMC statistics obtained by the Liberal Democrats show that the number of all doctors suspended in the UK has risen from 216 in 2004 to 388 last year. This is despite guidelines being introduced in 2003 called Maintaining Higher Professional Standards in the Modern NHS (MHPS), which made it more difficult for doctors to be suspended. So it looks as though the momentum to suspend and discipline doctors has not been curbed by MHPS. But without it, numbers of suspensions are likely to have been even higher.

I am someone who has been suspended twice - it's actually now called exclusion. Not many doctors get back from one suspension. According to a report from the National Audit Office in 2003, only 40% get back to work. They found the average length of suspension to be 47 weeks. This average figure is likely to have come down with MHPS - which would suggest the number of suspensions has increased.

I have gone public about my first suspension eg. BMJ letter and Times Higher Education Supplement article. I am not yet in a position to go public about my second exclusion.

What I can say is that MHPS does not place enough emphasis on informal resolution. Almost certainly the number of formal investigations is too many. This could be prevented by people talking about whatever the problem is and solving it. It may not be a disciplinary problem at all.

There is inevitably conflict between management and clinicians, but they should work together. Management should not misuse its disciplinary power to deal with what it doesn't want to hear from clinicians. As a letter in this week's BMJ says, leadership is not management.

Is it just women that eat breakfast in the army?

Or maybe it's only women that turn up for the photoshoot. Good idea to show that the army's not just made up of men, but is Gordon sexist? I doubt it. It wasn't Sarah Brown's idea this picture, was it?

Why do staff report high levels of bullying in the NHS?

As mentioned in the previous post, Ian Kennedy has finished at the Healthcare Commission, which has now been taken over by the Care Quality Commission. In a farewell interview for the Heath Service Journal (HSJ), he talked about bullying "permeating the delivery of care in the NHS". He, at least partially, comes to this conclusion because 1 in 6 staff say in the NHS annual surveys that they have experienced bullying, harassment or abuse from either their line manager or other colleagues.

Why should this be the case? In the HSJ interview article, Sian Thomas, joint acting director of NHS Employers is quoted as saying that chief executives needs to take a lead in encouraging an open culture. Why have CEOs not been doing this?

NHS Trusts have been measured by targets. Believe it or not, it's only recently that reporting requirements have put quality at the top of Board agendas. It remains to be seen whether this intervention from Monitor will change the target culture, but at least they've got the focus right.

Professional staff have found it difficult to get their voice heard in a culture centrally driven by business notions and targets, which do not always relate to patient care. To speak up about how such manageralism is affecting health services is not welcomed. The Royal College of Physicians has produced a report Doctors in Society: Medical professionalism in a changing world. At least the most recent Darzi review Our NHS, our future includes a focus on clinically led services.

Healthcare Commission ends its time with "appalling" report

At the end of the month the Healthcare Commission gets taken over by the Care Quality Commission. In its dying pangs, it's published an investigation report criticising Mid Staffordshire NHS Foundation Trust for significant failings in emergency healthcare, leadership and management. As I've noted before in this blog, Ian Kennedy, the outgoing chairman, really does think the Healthcare Commission has improved quality of health care.

The Commission in its press release says that it began the investigation at the trust in March 2008 "in response to concerns from local people and when it became clear that the trust stood out statistically in terms of the high death rates of patients admitted as emergencies". They've produced findings from the investigation but don't say how those findings compare with other hospitals. For example, are they sure the Trust was the only hospital where A&E triage is routinely carried out by receptionists? Is A&E consultant cover any worse than anywhere else, producing inadequate supervision of juniors? Was it the only hospital to have had "dumping grounds" to avoid breaching the A&E 4 hour target? Was it really the only hospital not to have enough nurses to care for emergency patients or inadequately trained EAU nurses? Or where there were delays in operations? I could go on. At least the Commission admits the findings are potentially relevant to the whole NHS. And this is the Commission that Ian Kennedy says has improved the NHS!

The trust’s data on outcomes for patients had caused the Dr Foster Unit at Imperial College, London to bring concerns to the attention of the trust and the Healthcare Commission. Dr Foster’s Hospital Guide showed that the trust had a hospital standardised mortality ratio (HSMR) of 127 for 2005/06. For the three years from 2005/06 to 2007/08 that the Heathcare Commission examined, the trust’s SMR for patients admitted as emergencies aged 18 and over varied between 127 and 145, statistically significant at the 5% level. There are trusts with a higher HSMR. Dr Foster says it has the fourth highest HSMR for 2003-6. Where are the inquiries into those Trusts with a higher HSMR? I'm not saying Mid Staffs is a particularly good Trust but someone's got to be at the extremes of a distribution of HSMRs.

Do you loathe me?

Like Terry Wogan I worked in a bank for 5 years. He was in Dublin; I was in Lancaster and Preston. We both got out, so we can't be blamed for the current crisis.

Still Gordon Brown is putting people before bankers. "In short, we need stronger business banks, mortgage banks and savings banks." And there's nothing wrong with getting rid of more than 100% mortgages.

She is a woman and has to die; after all

Watching someone die

Lenrie Peters

Watching someone die
is a fraudulent experience
The deep significance is felt
the meaning escapes
like a child's first punishment.
The dying ravish your strength
whether by throttle of convulsive gasp
or tideless fading away
like ancient familiar sounds in sea shells
the moment is the same
reinforced brutality to life
a rugged cliff bloodstained
with the agonising rhythm of many heads.
A cold demise; each
successive moment a banishment.
The terror is in leaving behind
the ache is in departing.

Humming fantasies crowd their stings
to seize and record the moment
the hands curl in spasm
to hold it back; this life, this infidel.
It is too late. Everything and nothing
has happened. A huge machine
the earth, grinds to a bolt-knocking halt.

It is the changing of the tide
at the boundary hour
Life like handful of feathers
engulfed by cliff winds
one like yourself swept
Oh so swiftly into the anchorage of history
Tears and sighs; sighs and tears
stamping the leaden feet
the solid agony of years
they all abound.
One life or a million
contrived by nature or by man
greatly obscures the issue.

Face to face with dying
you are none-the-wiser
Yet it seems most ignoble epitaph
'He was a man and had to die; after all.'

Lenrie Peters was born in Bathurst (Banjul), The Gambia, in 1932. He studied medicine at Trinity College Cambridge and later trained as a surgeon. He currently practises in The Gambia. He has been Chairman of the West African Examinations Council. He has published one novel, The Second Round, and four volumes of poetry - Poems (Mbari Press, 1964), Satellites (Heinemann, 1967), Katchikali (Heinemann, 1971) and Selected Poetry (Heinemann, 1981). He is the Officer of the Republic of the Gambia.

I would like to hear David Lammy's mother's experience as a young woman in Guyana

Sad story of death of David Lammy's mother. Glad to see a politician being so willing to talk about their person forming experiences. Another example. Must be taking a leaf out of the new US president's book.

What does Jeremy know about Gordon?

BBC World wide is the commercial arm of the BBC, which makes Top Gear, whose presenter, Jeremy Clarkson has called Gordon Brown a "one-eyed Scottish idiot". How much does the BBC pay for the programme? What nothing from the mole inside the TV show? Not much of a mole.

Clinicians and finance

There is evidence that disengagement can have a detrimental effect on NHS organisations. Statement from Academy of Medical Royal Colleges, Audit Commission, DH, Royal College of Nursing, NHS Institute for Innovation and Improvement, and the Healthcare Financial Management Association. They say "Clinicians should be encouraged to take financial responsibility for their service with the freedom to make changes and use the funds available to improve services". Are we going full circle to consensus management and medical superintendant?

Summary of a Prescription for Partnership. "Clinical engagement depends on effective communication and good working relationships." As I said in relation to the Ian Kennedy interview "[C]reating a manageralism that fails to provide the organisational infrastructure to support doctors in the exercise of their responsibilities is not the way forward." Eminent bodies seem to be agreeing with me.

BMJ publishes five commentaries on Doctors, patients and the drug industry

Origins of the present mass protest

Good description by Andrew Rawnsley of the fear, resentment and anger.

Fear for your job if you still have one and fear that you may not see work again if you are already unemployed.

Resentment that the agony is not being evenly shared and that some will profit from the miseries of others.

Anger with the unapologetic financiers who made billions from their follies and left less affluent folk to pick up the bill.

If Henry Porter was 20 years younger he would take to the streets.

My perspective on the economic crisis

I was in a lot of debt when the credit crunch happened. Now I'm better off and I'm supposed to spend to get you out of recession. Is this right?

Rare "feel-good" movie that actually makes you feel good?

Ok, so love triumphs in Slumdog Millionaire when we didn't expect it to, but that doesn't innoculate us against the violence. Same point made by Alice Miles.

Ian Kennedy really does think that Health Care Commission has improved quality of health care

Interview with Ian Kennedy in BMJ in which he defends use of health indicators. Measurement of quality is not easy and failure to recognise how indicators can create perverse incentives is not helpful. In fact, focus on indicators can paradoxically make quality worse.

For example, I've just looked at the first core standard in the safety domain in the Annual Health Check for mental health trusts. This is that trusts self certify that they have a system for learning from patient incidents. It doesn't matter how well the Trusts do this - just that they have a system. In fact, undertaking a root cause analysis is extremely difficult, often mistakes and misinterpretations are made leading to recommendations which are never fulfilled, even if they were appropriate.

People forget Kennedy upset the medical establishment when he gave the Reith lectures in 1980 "Unmasking medicine". He answered his critics. Medicine does need to be more patient centred. But creating a manageralism that fails to provide the organisational infrastructure to support doctors in the exercise of their responsibilities is not the way forward.

Baby P

The Ofsted Joint Area Review of Haringay Children's Services is light on detail about the findings. We need more information to be clear about the basis on which they made their judgements.