5 + 47 + 3 + 17 = 8? Not in the world I work in


How to cut through the Kafkaesque Government smoke and mirrors to get at what is wrong with their flagship policy to improve the NHS by giving patients the ability to choose their GP practice, anywhere in England? This was to have come into effect in October 2014 and is now due to start on 5 January next.

5 + 47 + 3 + 17 = 8: this is one way of getting to the heart of the problem. The politicians, health ministers, the Department of Health, & NHS England will tell you that 5 + 3 = 8. This is true enough. The only problem is that the numbers that need to be added up are 5 + 47 + 3 + 17; in the material world I work in these numbers do not add up to 8.

When I have pointed out to the Department of Health that they have got their sums wrong, they in essence reply by saying 5 + 3 = 8. NHS England have done the same.

Others also behave as if they are unable to do basic arithmetic: the King’s Fund, the Patients Association, health editors at the mainstream news outlets, the BBC, even the Health Services Journal.

In the world I work in you really have to respect the numbers. Ignore the numbers and the building falls over.

Watch this space.

When Government Policy Abuses the Vulnerable….


Over the past 5 years or so, I have frequently had patients with significant mental health problems being deemed fit by the Atos Healthcare administered system of medical examinations for people on sickness benefit. I recently had a patient come to me with heightened distress over this. She felt she was doing well, was seeing a psychologist who was helping her fight her considerable psychological difficulties. Then she received a letter deeming her fit for work, and then an invitation to see a ‘Personal Adviser’ at a Jobcentre Plus office about 2 miles away (she has trouble travelling out of the neighbourhood).

I told my patient (let’s call her H.; this is not her name) about the work of Franz Kafka, about vulnerable people getting caught up in a bureaucratic nightmare. I printed out a few paragraphs from Wikipedia on ‘kafkaesque’. She was comforted by this, knowing that someone had described this situation, that she was not entirely on her own in this.

I told her I would provide her with a letter to take to her interview with the ‘Personal Adviser’ the following week. I asked her permission to write this up on this blog. She consented, provided she remained anonymous. I asked her to write a few words about it felt to be on the receiving end of these letters and injunctions.

Here is my letter to the ‘Personal Adviser’:

Sharon(not her name), Jobcentre Plus

Dear Sharon,

I understand that H. is due to meet with you this week.

I think it is important that you be aware that H. suffers from quite significant mental illness in the form of bipolar affective disorder (she was hospitalised two years ago for some time) which at times has psychotic features. She also has chronic depression and anxiety, and panic attacks. She has a sleep disorder, with regular nightmares of abuse she suffered as a child. She is under the care of local psychiatric services, on an ‘Enhanced Care Programme’. She sees her keyworker monthly. She takes antipsychotic medication, mood stabilisers, and antidepressants. She has just finished a course of psychology treatment which she has found very helpful. She also has chronic fatigue syndrome. She struggles to hold things together on a daily basis.

H. has a 22-year-old son with autism. She is his carer. He has high dependency needs.

The DWP seems incapable of assessing people with mental illness intelligently. As a result, a number of patients of mine with significant mental illness are forced to jump through quite inappropriate hoops in order to hang on to their benefits. This system is in itself abusive and worsens their mental health.

I am aware that you are merely doing your job and you have nothing to do with the development of this policy. Please let your superiors know that this lady is struggling to survive and that if you attempt to force her into one of your pigeonholes you risk making her worse.

If you wish to discuss this any further, I can be reached on  Tel……

Yours faithfully,


Last night I saw H. again in surgery. She said the Personal Adviser said it was nothing to do with her; she did not make the decisions; she advised H. to appeal; and gave her some documentation and an ‘invitation’ to see someone at A4e, the next hurdle in the thoughtless endurance trek she has to undertake.

She had brought something she had written at my request, about how it felt to be on the receiving end of all this. She said she had difficulty writing it down, so she wrote a poem, she hoped that was ok. She gave me permission to publish her poem, provided she remained anonymous.

Here is the poem:

I need the Lord my saviour,
but you make me feel a failure.
I need love and tenderness,
but all you give me is stress.
I am made to feel like a criminal,
but your knowledge of me is minimal.
I am innocent and free,
but you make me feel guilty.
I try to be good with all my might,
but you think me a parasite.
I need salvation,
but you give me aggravation.
How would you feel, if you were me,
made to feel worthless and lazy.

Choice of named consultant-led team: another moronic policy from Lansley & DoH


I was aware of this proposal, as it had been listed in the White Paper, in the same list as the right to choose your GP practice, no matter where you lived. At the time I thought it was a mad idea, and I still think it is mad. How mad? If the KGB had infiltrated the DoH and parliament with operatives whose mission it was to make various services within the NHS malfunction, then this would make sense. It is as moronic as asking a GP practice to register anyone wishing to register with them, irrespective of capacity. The same dynamic is operating here, the same muddled thinking. If a first year GCSE student handed this proposal in as part of his or her course work, one might reasonably expect it to be handed back for further amendment.

Essentially, the problem is this: as GPs we refer patients, when appropriate, to a hospital specialty service (say gastroenterology). Several years ago, we wrote letters to named consultants (usually, but not always, in a local hospital); or we would address it to ‘Consultant Gastroenterologist’, Local Hospital, Main Street. For a few years we have been referring through an online system called Choose and Book: this is, with rare exceptions, a referral to an unnamed consultant within a named hospital. This new development proposes to have the consultants named on Choose and Book so that patients can choose who to refer to. This is a perfectly welcome development because as a GP I often have a preference myself which I would suggest to the patient. However, we run up against the problem of capacity. If too many people request to be sent to Dr Popular’s team, then that team will not be able to continue the same quality of service. The quality will fall. The waiting times will lengthen; because there are maximum permitted waiting times, locums will have to be drafted in. And let me tell you, the quality of doctors you will obtain in this way is patchy: they might be excellent, they are more likely to be be mediocre. I have outlined this problem in more detail in a previous post, if you are interested.

On Wednesday October 12, 2011 I read the following brief article in the Independent (the online version has it at the end of another article, link below if interested):

NHS patients will be able to pick consultant

NHS patients needing specialist treatment will for the first time be able
to choose the consultant to whom they are referred, Andrew Lansley announced

In a significant extension of patient choice, hospitals will be required to
accept all “clinically appropriate referrals to named hospital
consultant-led teams”.

Patients will be able to travel to any part of the country to see the
consultant of their choice and hospitals would be required to publish
individual “success rates” for their specialists to help patients
choose, the Department of Health said.

The announcement, timed to bolster public support for the Health and Social
Care Bill during its Second Reading in the Lords, brings NHS patients into line
with private patients who already have the right to choose a named consultant.

But it marks a divergence from past policy which prohibited named
consultant referrals to keep down waiting lists.

Rating individual doctors’ performance has also been rejected in the past
on the grounds that modern medicine is a team activity and individual
performance measures would be misleading.

Sir David Nicholson, chief executive of the NHS, interviewed in 2008, said:
“It’s the team that makes the difference, not the individual. The days of
the heroic surgeon, like Sir Lancelot Spratt, are long gone.”


I can only assume that the text of this article is more or less listed verbatim from the DoH press release. Now I know as a referrer that this policy will simply not work, that it is moronic. But what made me shake my head was this idea that the announcement of the policy was “timed to bolster public support for the Health and Social Care Bill during its Second Reading in the Lords”. Now if the Lords were to be swayed by this news, then they too must be pretty moronic. The article is filled with very odd statements which don’t really make sense. For example,  the policy “brings NHS patients into line with private patients who already have the right to choose a named consultant.” Of course they have a choice, it is a private arrangement and they are able to see the consultant of their choice provided their insurer has that consultant on their list. But what the press release fails to say is that in the private sector there is no requirement whatsoever for that private consultant to see all patients within a certain amount of time. There are consultants in the private sector who have long waiting times; people will wait because they want to see that consultant, or they will go to another consultant. And they will see that consultant personally, not some junior member of his or her team.


I had planned to email a consultant at my local hospital just to check with him whether I was missing something, whether there was new efficiency technology or ‘new physics’ which made this policy possible. I would have promised not to reveal his identity. But then I met had a conversation yesterday with a colleague on one of the London CCGs who told me that he had been told by a manager at one of the London hospital trusts that they were awaiting guidance as to how to implement this policy, who felt it was just not possible, that it was Kafkaesque.

So if there are any hospital consultants out there (or, indeed, a DoH operative) with a comment on this issue, this would be most welcome. I promise to maintain your anonymity, as I understand that those working for a trust may feel there are pressures not to speak out freely, honestly. But without an honest look at the policies, without a sensible methodology, we are doomed to failure. If the emperor is wearing no clothes, what are we to do?


Link to:

Independent article

Contract implementation guidance: Choice of named consultant-led team

An early morning email to Lib Dem MPs


It’s me again, I’m afraid. I thought I better warn you about what almost certainly lies ahead with respect to the issue of GP practice boundaries.

I have never felt that this added up: from a practical point of view, it just does not make sense at all. I thought these politicians and DoH planners were just grotesquely stupid.

The reality is almost certainly one of deceipt and corruption, with the rest of politicians either complicit or just naïve.

A member of the public left a comment on my blog yesterday; he had joined up the dots, and at the end he mentioned the ‘virgin assura system of connected health centres across the UK’. I was unaware that such a thing existed. I had hypothesised that such a thing would exist in the future and that this was why they wanted to abolish GP proactice boundaries. But I woke this morning at 4am and thought I would just check, and, lo and behold, I found this.

I suggest you have a look at the leaflet that the DoH and New Labour produced  to accompany the so-called ‘Consultation’ on the question of GP boundaries in March 2010. Notice that nowhere in the leaflet, and nowhere in the larger consultation documentation, do they say: ‘and you could join the Virgin Assura system of connected health centres’, but this is in effect what the abolishing of GP practice boundaries will do. That is why they want to do it, otherwise it just does not make sense. All this talk of ‘patient choice’ is just camouflage. Just have a look at Virgin’s website, and then look at the DoH leaflet. The leaflet is a promotion of what Virgin is offering. And note that the proponents of this policy use the results of the ‘Consultation’ as evidence that the English public want this. But the ‘Consultation’ was pitched in such a way so as to produce this result, the questions are skewed in this direction.

There is really a lot more to this, and it will come out in the open in due course, I am sure. Because the media (who up to now have been crap about this issue, completely uninterested) is going to wake up soon and start shining a light on this.

Why am I writing to you at 4am? Because you people are heading off to your conference and you have been told by your leader that you cannot mention the NHS. And yet, shouldn’t you be talking about this?? Nick Clegg may have some sort of future as a Tory MP, but the Lib Dem party will have had it entirely when it becomes clear that you have been duped and used, along with the English public, as the NHS is swallowed up the the piranhas. Once they pass the law, there will be no going back.

I just thought I had better warn you.

And now I’ll have some breakfast, and then go to the surgery and see some patients, all of whom live local to the practice.

Best wishes,


Are the politicians and health planners very stupid or clever in a devious and corrupt way?



For about two years I have been waking most mornings about an hour earlier than I need to with the thought, ‘How can they be so stupid?’ ‘They’ being the Wankers at the Top (WATTs) at the Department of Health (always anonymous) and their political masters. My particular reason for thinking this thought (2 years ago) was that we were being expected to implement a policy that meant self-destruction for us as a GP practice and the undermining of the quality of the service we provide, all in the name of patient ‘choice’. We solved our particular problem by simply refusing to implement this policy any further, quite openly, pointing out to the PCT the inherent flaw in the design of the policy. Then the focus of my concern became a far worse policy which takes the first policy and magnifies it 100 times: the policy of allowing people to register with the GP practice of their choice anywhere in England. Now perhaps the lay person can be forgiven for thinking this sounds like a good idea: choice has got to be better than limited choice. But for anyone who has worked as a GP for long would see that this was quite unworkable and quite mad. Hence my waking in the morning: ‘How can they be so stupid?’

In an attempt to resist this madness I started this blog, and have been laboriously emailing MPs, journalists, think tanks and anyone else I can think of to alert them to the stupidity of this idea. Everyone else has been caught up with other aspects of the Andrew Lansley’s health ‘reforms’, I have been (unhappily) focused on this one issue because it is the one that presents itself to me on almost a daily basis in everyday work.

Sunday 8 May I woke at about 5:45am; as per usual the thought appeared: ‘How can they be so stupid?’ Sometimes I am able to switch this thought off by concentrating on my breath and thinking of the sea, and I get back to sleep. Sunday morning, however, a plausible explanation came to me as to what the WATTs are up to, what the ‘direction of travel’ is in their minds. And I knew I was not going to get back. So I got up and wrote this post.


A few weeks ago I learned about an about to be published book called The Plot Against the NHS. I read the transcript of a lecture by one of the authors which introduced the book.

I ordered the book. One week ago, while on holiday, I finished reading the book. Chilling stuff, and every citizen (and even politicians) ought to read a copy, book clubs should be formed to discuss it. But the authors did not mention this issue of registering with the GP of your choice: how did this particular policy fit into The Plot? I am trying to contact the authors to ask them.

Yesterday I spent some time at the library looking at material related to this blog: I was writing a detailed analysis of an email which the Department of Health had sent me in response to my email to the Health Ministers about 5 months ago. I re-read portions of the Department of Health’s response to the so-called consultation Choose Your GP Practice. My mind began to turn to jelly. I stopped for lunch. I went back to library, packed up my stuff, and went home. We were having people for supper. I spent the remaining time typing some excerpts from The Plot Against the NHS (to include on this blog). Then I stopped.

The human brain/mind is a mysterious and wonderful thing. One example is the way it works on stuff overnight: I go to bed feeling a bit confused or jumbled about something, and often wake the next morning with clarity and a sense of perspective. So overnight my brain/mind worked on the stuff I had looked the day before and presented me with a provisional answer this morning to the question: ‘How can they be so stupid?’

The answer is this: if they were trying to improve general practice as we know it, as it functions when it is working well, then they are quite stupid. But if they have in mind quite a different model, but one they cannot be open about because then the majority of the population would pillory them, then you would have to say they are clever enough, much like the brains behind the banking crisis (the Credit Default Swaps, CDOs, subprime mortgages) and government lobbying that made it all possible were ‘clever’. Then it makes quite a lot of sense, even if it is chilling.

So in a nutshell what my mind presented me on Sunday morning was this: taking into account the thesis presented in The Plot Against the NHS (in essence the privatisation of health care provision in England, essentially on the United States model, carried out by a number of people at the Department of Health, health think tanks, and government–all covertly over the past 10 years or so), the reason the abolishment of practice boundaries is necessary is that it then opens up primary care to large multinationals to bid for and win contracts to provide general practice services the same way that McDonalds provides hamburgers. Let me explain: let us say that Virgin want to provide general practice services. At present they have to bid for individual practices when they become vacant. In addition, these practices serve a local community, within a specified limited boundary (there are perfectly good reasons for this, practice boundaries serve a real purpose, they are not ‘anachronistic’ or outmoded or old fashioned as the Government and Department of Health say). But this is quite limiting if you are thinking of a quite different model. The model might be this: ‘Virgin Health’, a ‘willing provider’, sets up a number of primary care centres around the country (much like Virgin Active has their ‘Health Clubs’, aka gyms), at locations they feel would best suit their business model. Because you are not constrained by practice areas, anyone living inEngland can join any ‘Virgin Health Centre’ inEngland. Indeed, the ‘Virgin Health’ model might mean they have an integrated IT system so your medical record is accessible to any ‘Virgin Health’ healthcare professional at any centre inEngland. So if you are in Swindon on business, just drop into theSwindon ‘Virgin Health Club’ at lunchtime and get your blood pressure checked, and why not step into the adjoining gym while you are at it?

This model would be quite attractive to the mobile youngish person, and might provide a reasonable service for some self-limiting conditions, but it would not do what good quality British general practice does. It would not look after people who have significant health problems, and it would not look after people when they actually get sick and cannot travel to the Health Club for assessment. Not only would it not do what quality British general practice does, it would also be far more expensive. But it would of course make a lot of money for some entrepreneurs.

This, I fear, might be, the ‘direction of travel’.

Excellent Debunking of Government Lies by Ben Goldacre



Courtesy of a Tweet I saw this morning, I have just read a piece by Ben Goldacre on his Bad Science blog. It concerns a government leaflet Working Together for a Stronger NHS, published on the Department of Health’s website (on the home page!). (You can get all the links on the Bad Science blog, or the article published by The Guardian.)

I wish Ben would apply his skills to a debunking of The Department‘s document Your choice of GP Practice published a year ago. I plan on doing this but have limited time. 

Quite shameful stuff. I am having to add a new category to the posts on this blog: Government Bullshit.

Oh, I almost forgot: to understand why they are using all these distortions and corrupting our language, see The Plot Against the NHS, and buy the book, just published.

Reform as sabotage



When I went to a meeting at the PCT in November 2009 to voice my complaint about the patient registration policy, I said that if the KGB had infiltrated the Department of Health and Parliament with the intent of undermining British general practice, this is the sort of policy they would design and implement.

A succession of New Labour health ministers introduced policies which eroded and undermined quality in general practice and called them ‘reforms’. To me, a ‘reform’ is a change you introduce which makes something better. Some (not all) of New Labour’s ‘reforms’, in primary care and in secondary care, made things worse. Can we therefore, please, not call them ‘reforms’?

The following is the first sentence in the current Wikipedia entry for ‘sabotage’:

Sabotage is a deliberate action aimed at weakening another entity through subversion, obstruction, disruption, or destruction. In a workplace setting, sabotage is the conscious withdrawal of efficiency generally directed at causing some change in workplace conditions. One who engages in sabotage is a saboteur.

Andrew Lansley’s plans for primary care (and here I am thinking mainly of the plan for people to register with the GP practice of their choice anywhere in England, but it certainly applies to the other ambitions as well) will weaken and undermine the quality and efficiency of primary care. I don’t think he is deliberately setting out to destroy general practice, but were he consciously and deliberately setting out to do so he would not really have to change much. In that sense, he is an unconscious saboteur, and the workers at the Department of Health are unconscious accomplices.

On the Kafkaesque



Kafkaesque: you may be familiar with this term. Not everyone is. I sometimes say to a patient who has brought me a particular type of problem, ‘Do you know the meaning of Kafkaesque?’ Many do not. I then explain that it is a situation where a person feels in a nightmarish situation: they are standing in a queue for hours; then are told that they are in the wrong queue, that they need to go to Section 7 and wait for further instructions; they go to Section 7 and wait; nobody comes for them. They ask for guidance and are told they should not be in Section 7, how silly of them to come to Section 7, they need to be in Section 9a; they go to Section 9a and find a sign which says: ‘Section 9a is closed for refurbishment, please go to Section 7 and await further instructions’. And so on; you get the picture. Patients are usually helped by being aware of this term and its meaning: at least someone has described this, recognised this; they are not alone.

Like the patient who has quite severe, enduring depression; he has seen psychiatrists, is on medication, but feels dreadful, hopeless. He feels physically exhausted and spends a lot of time in bed. He feels ashamed of his inability to get going. He goes to the DWP medical examination (with great effort), and is told, in a letter that arrives a week or two later, that based on the examination (one test was to see if he could fold a piece of paper and put it in an envelope) he has been deemed fit for work, and that his benefit (including his housing benefit which is paying his rent) has been stopped. This is a true story, incidentally, and occurred recently. This is Kafkaesque. The patient appealed the decision; then waited several months (benefits cut off); when he went to the Tribunal they apologised and re-instated his benefit. (In a truly Kafkaesque situation, they would have turned down the appeal….)

The writer Borges said this: ‘Kafka’s most striking talent was for inventing intolerable situations.’

Yes, intolerable situations. Our situation with having to register all patients was Kafkaesque.

The policy of registering with whatever GP you would like, anywhere in England, is Kafkaesque.

That nobody is discussing this policy is, in itself, also Kafkaesque. When I asked about this at a GP meeting a few months ago, I was told, ‘Yes, it is a crazy thing but all 3 parties are in favour of it so there’s nothing we can do.’ They are all worrying about how we are going to form Consortia, grapple with a limited budget, and so on.