Tom Goodfellow

Tom Goodfellow is a consultant radiologist at University Hospitals Coventry and Warwickshire NHS Trust

After the big game on the safari ward round

By Tom Goodfellow - 29th April 2013 11:42 am

Dawn breaks as watery sunlight struggles to penetrate the dense clinging miasma. “It’s a jungle out there” the intrepid explorer muses to himself as he struggles to shake off the numbing, joint-stiffening chill of the morning.

He consumes a mug of lukewarm, brown, insipid liquid musing ruefully that its sobriquet ‘Costa’ is highly appropriate given the price. Sighing at the prospect of the approaching search he again checks in his rucksack that he has all the equipment he needs to survive.

Map, compass, Thermos of tea, chocolate digestives, stethoscope, supply of biros, fly repellent (those damned flies!). But the worst thing he has to face is the moral-sapping, soul-destroying loneliness of the task. His juniors have long since abandoned him (at the end of their shift) unable to face the rigours of the journey. Medical students? Don’t be ridiculous it is only 9.30am.

Unable to procrastinate any longer he sets off on his post-take safari wondering where his travels might take him as he searches for the elusive, possibly mythical ‘medical outlier’.

Perhaps his journey will take him to the mystical land of the orthopods where its rulers, reputed to be “strong as an ox and twice as clever”, are strangers to modern conveniences like ECG machines, and where drugs are regarded as substances extracted from mushrooms (which explains a lot).

Or he might end up in Neuroland whose savage inhabitants are rumoured to crack open their victim’s heads and suck out their brains.

As he trudges down the first corridor he meditates on the endless, endless ‘black alert’ that has ruled his life for many weeks; the inexorably rising, unstoppable flood of frail, broken humanity pouring through the portals. Detained at the threshold for three hours fifty-nine minutes they then disappear; sucked into the bowels of the jungle sometimes never to be seen again.

At every station and outpost he asks for news of the outlier. “Not here”, “Never heard of him”, “Gone home”, “Died”, “I wasn’t on duty…” are the standard responses. Finally, after a long, frustrating time, he discovers the one he has been searching for in a far, dismal corner of Gynaeland. “Mr Stanley I presume” he states. “And who are you? Dr Bloody Livingston” retorts the miserable old codger in the bed. “Do you know I have been here three days and you are the first human I have seen, not counting that ten-year-old who admitted me!”

The explorer ponders as to the cause of this catastrophic systemic failure. How could this happen? Is this the end of the world as we know it? By chance he notices an old newspaper which is blowing about in the desolate wind. There on the front page in full detail he sees that The Great White Chief himself has pronounced on the matter.

“So that’s all right then,” he concludes before entering the jungle once more to head home.

What was Thatcher’s legacy for the NHS?

By Tom Goodfellow - 10th April 2013 11:37 am

“The NHS is safe in our hands. The elderly are safe in our hands. The sick are safe in our hands. The surgeons are safe in our hands. The nurses are safe in our hands. The doctors are safe in our hands. The dentists are safe in our hands.” - Margaret Thatcher.

As the wall to wall Thatcher coverage continues I have noticed that, so far, there has been little or no mention of her NHS reforms. I think there is a fairly obvious reason for this; simply that she started a process which gathered speed under Tony Blair, and which has now culminated in the Health & Social Care Act which is the biggest and most complex reform of the NHS in its history, and I suspect probably its biggest disaster.

The NHS was (and still is) completely incapable of controlling spending. Thatcher decided that what was needed to sort out these spendthrift doctors was a man with a cool business head. So the grocer’s daughter commissioned a grocer (Roy Griffiths, deputy chairman of Sainsbury) to investigate and report on NHS management. I am old enough the remember it, but to the new generation of doctors this is ancient history.

After a six month consultation period his report (October 1983) came in the form of a letter to the Secretary of State listing the changes he believed were necessary to get the NHS functioning properly. He blamed inefficient management and managerial structures for the financial chaos, and unsurprisingly he came up with a managerial solution to the problem.

His most famous sound bite was, “If Florence Nightingale were (sic) carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge”. As a result so-called Griffiths managers were appointed to run the hospitals and power shifted away from clinicians into the hands of the managers.

The arguments for and against Griffiths rumble on. Most doctors of my generation blame his report for the start of the rot – a process by which doctors became more and more distanced from strategic clinical decision making. To be fair if you read the report it is clear that Griffiths actually wanted quite the opposite, namely that doctors should be increasingly involved in management. However once CEOs were made legally accountable for balancing the hospital finances, control was taken more and more centrally. This became the defining feature of the NHS in the Blair years.

In 1989 and 1990 Thatcher introduced two more Acts which had profound effects on the NHS. These allowed the setting up if the “internal market” and created the purchaser provider split. Health authorities ceased to run hospitals but were able to “purchase” healthcare from hospitals. It also allowed the setting up of GP Fund Holding and hospitals to become “trusts” to encourage open competition in health care provision.

The Labour Party opposed all the changes until they got into power. Then, other than abolishing GP Fund Holding, they embraced the new order like a hungry python with a pie. Blair took competition to heights undreamed of by the Tories, involving the independent sector and wasting £millions on inefficient contracts.

But to return to the start of it all, I am fairly neutral about Griffiths. The NHS needs to be managed properly and in many cases I think we are under rather than over managed. My own radiology department is a highly complex £20 million p.a. business yet we run on just a handful of fairly junior managers.

My colleagues and I know exactly what to do in order to transform our business into a modern thriving service delivering high quality timely clinical imaging and intervention. But our managers and clinical director have neither the ability nor the authority to make the necessary strategic decisions to initiate change which is what Griffiths wanted. All we can do is stand at the edge of the playing field, waving our arms and shouting “please listen to us”, but fairly confident that no body will! I emphasise that this is not a critique of our trust executive who are as much strangled by system as we are.

So now Thatcher’s vision reaches its conclusion in the Health & Social Care Act. Already our local CCGs are contracting with the independent sector to provide some primary care based imaging with no reference to us, and the Act has barely got going. If a sizable chunk of primary care imaging is outsourced our income will plummet and our ability to deliver will become even more constrained. I would not mind so much if I had any confidence in the CCGs ability to commission imaging or the independent sector’s ability to provide it – but I haven’t! My experience so far is that GP commissioners have little understanding of what constitutes a good imaging service or of the essential interaction between clinicians and radiologists.

So Mrs Thatcher rest in peace. But the NHS “safe in your hands” – I think not!

Undemocratic reaction to Leveson Inquiry

By Tom Goodfellow - 26th March 2013 11:15 am

Last year my youngest daughter, who is waitressing her way through a law course, served Ian Hislop at a well known Oxford restaurant. While chatting with him she remarked that her father (me) was a lifelong fan of HIGNFY and that I regarded it as the pinnacle of my career when I once got a mention in Private Eye.

“Goodness gracious; what had he done?” retorted Hislop. She was able to reassure him that I was not a sinner, but that comments I had made on the most recent collapse of an independent company providing diagnostic (or rather non-diagnostic in this case) imaging had been quoted.

This came to mind recently as I settled into my chair for the fifty minute journey to London on Mr Branson’s Virgin train. On such trips I always treat myself to a copy of Private Eye and opened immediately to Medicine Balls, penned by the redoubtable Dr Phil Hammond.

Several years ago I had the pleasure of sitting next to Dr Phil at a posh dinner where he was the after-dinner speaker (and very funny he was too!). I have always enjoyed reading his columns which are generally both pithy, informative and to the point. The Eye has about 700,000 regular readers including, I am sure, many doctors. The investigative journalistic style of the Eye is, in my opinion, one of the great bastions of freedom in our society as they probe and reveal the shenanigans of public and political life. However I am now deeply concerned that this may now be under serious threat.

My reason for this is the recently cobbled together agreement by the politicians for the regulation of the press following on from the Leveson inquiry. I note the statement of the Prime Minister to Parliament, “Let me be clear: this is not by any stretch statutory regulation of the press.” But let us just take a few steps back.

There was undoubtedly some very bad behaviour some years ago by certain sections of the press. As a result people have been prosecuted and imprisoned, large fines paid and a well-known newspaper has closed with many job losses. The actions of some were criminal and they have paid the price. However in response to vociferous pressure groups such as Hacked Off the decision was made to set up the Leveson enquiry. This recommended the setting up of a new press regulator, underpinned by new law, a rather unsurprising conclusion if the chairman of the enquiry is a lawyer!

However fearful of making an enemy of the press two years before a General Election David Cameron decided to back-pedal on his previous commitment to implement Leveson in full. Instead he opted for a regulator to be set up by Royal Charter with a little new underpinning law.

So now rather than a full and open parliamentary debate what we have is a decision on this most crucial issue, the freedom of the press, taken by a small group of politicians in a late night meeting behind closed doors. The only people present were the representatives of the three main political parties and Hacked Off crusaders. There were no representatives of the media to lend some balance to the discussion. To me it seems deeply disturbing that crucial policy should be framed, it would seem, to appease a vociferous campaigning group.

The Royal Charter will be overseen by the Privy Council. This is an unelected, secretive and unaccountable body, controlled completely by Downing Street. This has nothing to do with democracy as we know it.

But hang on a minute! A couple of years ago many of our politicians were crucified by the press over the ‘expenses’ issue, and huge damage was done to their reputation by the associated revelations. It is hardly surprising that, in consequence, they have a deeply ingrained hostility to the media and an obsessive desire to enforce external control.

So what has this to do with Private Eye? Well the little bit of law behind the charter allows courts to impose “exemplary” (i.e. massive) damages on any publication which does not sign up to the charter. Ian Hislop has stated publicly that he will not sign just as he refused to be subject to the Press Complaints Commission. Despite its reputation The Eye has a surprisingly good record of getting it right and quickly apologising if wrong.

There is, in my view, a high risk that this disastrous bit of political manipulation will be used by an angry victim of The Eye to wreak revenge with possibly the most serious consequences for Hislop and his team.

They are prepared to take the risk, but I am sure that the challenge will come sooner rather than later. I would be very sorry indeed if the publication was to be brought down in this way.

Time to stop spreading further suspicion

By Tom Goodfellow - 19th February 2013 11:05 am

“The truth is rarely pure and never simple” (Oscar Wilde, The Importance of Being Ernest).

One of my favourite films is Starship Troopers. On the surface it is simply a traditional sci-fi shoot-em-up with lots of clever special effects. But there is a subversive sub-plot which satirises the way in which society demonises those who are different or challenging in any way. The goodies in the film are beautiful, clever and sexy while the baddies are hideous monsters (bugs) who simply want to kill humans and suck their brains (literally).

This comes to mind as I read and listen to the coverage devoted to Mr Gary Walker, former United Lincolnshire Hospitals Trust chief executive, who stated on the Radio4 Today programme that he was required to sign a gagging clause as part of a settlement following his dismissal. He states that he was sacked after raising concerns over patient safety when excessive demand for emergency beds forced him to abandon official government targets for non-urgent patients. This brought him into conflict with his bosses.

He is being hailed as a hero for fearlessly standing up to the culture of bullying and cover-up which, we are being told, is endemic in the NHS. Indeed the Secretary of State himself has intervened by writing to all trusts informing them that such gagging clauses are to cease and indeed whistleblowing is to be encouraged to expose bad and dangerous practice in the NHS. Transparency is now the buzz word of the moment.

All well and good; indeed my own views on target chasing are clear.

So why am I uneasy? Well it is just that I don’t actually know the full truth of the matter because I have only heard one side of the story! I am sure that Mr Walker is upright and honourable and I have no reason to question his veracity. But in this present post-Francis climate anyone who claims to be a whistleblower is going to be believed whatever their motivation; the good guys versus the brain-sucking monster managers.

Some whistleblowers will act from the very best motives, but to assume that all do so is completely naive. People who are in conflict with their employers will bring their own issues to the table and it is all too easy to develop a victim mentality.

In my career I have known both types. For example I have huge respect for one individual who, at great personal cost, spoke out against a management policy which was clearly wrong and potentially damaging to patient care (the particular issue has long since passed). I also know of others who have waved the victimisation flag when the reality was completely different. Such individuals can often garner considerable public and media support by claiming they are acting in the interest of patients, and in consequence do great undeserved damage to the reputation of a hospital. It is often impossible for trusts to challenge this, and anyway in the current climate of suspicion the bug-eyed managers will automatically be disbelieved.

However at the heart of the matter is a question of trust. We must be able to trust our institutions or they cannot function. Because there has been a significant and damaging breakdown of trust in one organisation this does not mean necessarily that all organisations are untrustworthy or that all persons must be treated with suspicion.

Unfortunately this is exactly what the Secretary of State has achieved by his statement endorsing whistleblowing. He has given the message to all that no one is to be believed or trusted and has turned the entire population into NHS vigilantes ready to speak out fearlessly when they detect a whiff of wrongdoing. I realise that in these days of instant news politicians must give immediate responses to the current issues, but in this case I think a little more thought would have been wise. If you input distrust into an organisation people will become more distrustful of it, and that is not healthy.

But we now have a whistleblowers charter and I suspect that any disaffected NHS employee or patient will have a willing and ready audience to allow them to vent their spleen without challenge or question. The facts will rarely be allowed to get in the way of a good story and through the web it will be around the world in seconds, preserved in digital aspic for all time.

The sad thing is that I believe in the long run this will actually do harm to openness and transparency. A frenzied hostile culture of ‘outing’ will simply encourage more deception and cover-up; it always does! My advice to the Secretary of State would be that if he wants to improve things he should stop spreading further suspicion. Better ways must be found to improve both trust and trustworthiness in the NHS.

I fully support Mr Walker’s right to speak about what he believes to be true, but I remain completely unclear as to his motivation and, although it seems to be Goodfellow contra mundum, I strongly doubt that his revelations will ultimately achieve anything positive.

Who is to blame for cataclysmic Mid Staffs?

By Tom Goodfellow - 11th February 2013 1:26 pm

“O would some power the giftie gie us to see ourselves as others see us” (Burns, To a Louse).

This quotation comes to mind as I read the Francis report on the Mid Staffs tragedy. Following its publication the media have been falling over themselves to find the right language of outrage and horror to describe what happened. Indeed the level of vituperation seems to escalate hour by hour.

“Catastrophic” seems to be the final judgement - I don’t think it is possible to get any worse than that other than possibly “cataclysmic”.

Like many of us who are committed to caring for our patients I have listened to and read all this with a mixture of emotions including anger, frustration, sadness, shame and a tinge of disbelief. Surely it cannot have been that bad?

Unfortunately it seems that it was!

What is worse is that it seems very likely that this is not an isolated incident in the NHS. Already five other trusts are under investigation for mortality figures which are higher than expected in similar trusts and if we are honest I doubt that any of us would claim that our own hospitals are entirely without fault. While my own inpatient stay two years ago was almost blameless, relatives and friends have had mixed experiences, and colleagues regularly inform me of situations for patients which are disturbing to say the least.

There are the inevitable, and perhaps understandable, calls that heads should role and people be sacked including Sir David Nicholson. Even the Prime Minister has queried why no one has been disciplined despite the fact that 42 doctors have been investigated by the GMC and four will shortly be examined at a public hearing.

But two things are glaringly obvious from the Francis report. The first is that the Mid Staffs Trust Board was focused on achieving financial and clinical targets in order to obtain foundation status, irrespective of clinical priorities. The second is the abject failure of the full array of regulatory bodies to identify and deal with the deficiencies.

To be frank I have been banging on about both these issues for some years in this blog and elsewhere. I have long believed that the top-down, command and control, target-driven, name-blame-and-shame culture, initiated by Tony Blair, was pernicious. The Francis report has now confirmed that it was, in fact, destructive. I accept that a target might seem superficially attractive; no one wants to wait for hours on a casualty trolley. But it is the culture which is wrong. Target-driven performance has been demonstrated not to work in industry; as one quote suggests: “In every single system studied, it was discovered that targets drove dysfunction into the service and led to unintended consequences for services users.”

It also does not work in healthcare. Let me give a simple example from my own specialty (radiology). The department has a finite capacity and a very tightly limited budget. There are strict targets for scanning OP and GP referrals, and the booking staff are required to ensure that no patient breaches or they get into trouble. Consequently all the appointment slots are filled although this leaves no room, on a daily basis, for the non-urgent in-patient requests. So a patient will sit in a bed, sometimes for several days, waiting for a scan. All will agree that this is utterly stupid, but it is a result of the target culture.

Target-chasing by managers distorted clinical priorities and resulted in doctors being disempowered and ultimately disengaged from serving the needs of patients. This is not an excuse, but it is an explanation, and I believe that the politicians carry a heavy burden of responsibility for this.

Many of us have also been deeply sceptical about the plethora of regulatory bodies with unbelievable top-heavy bureaucratic processes, the Care Quality Commission being a classic behemoth. To quote Onora O’Neill from her Reith Lecture, 2002: “Many of you will have looked into the vast database of documents on the Department of Health website with a mixture of despair and disbelief. Central planning may have failed in the former Soviet Union but it is alive and well in Britain today.” (Lecture 3, Called to Account)

“Despair and disbelief”! Look guys, wake up and smell the coffee! Externally imposed, centrally driven punitive regulation does not work; Francis has confirmed this. Better systems need to be developed to ensure that patient care is the central focus of a hospital. But I am deeply fearful that the political response to Francis will be yet another layer of regulation and accountability which will still fail. Perhaps the politicians should listen to the profession for a change.

The media and the pressure groups are baying for the blood of the doctors and nurses who disastrously failed their loved ones. But I believe that the politicians and regulators share an equal degree of blame. And while we are all trying to work out how to respond to Francis’s 280 recommendations the NHS is in the middle of the most complicated and convoluted re-organisation in its history with increasing use of the independent sector which also has a very questionable track record.

Thank God I will be fully retiring in the next year or so.

Will the royal colleges change or perish?

By Tom Goodfellow - 23rd January 2013 11:44 am

In 1974, as a fresh-faced houseplant at The London Hospital (not Royal in those days) I was attached for six months to the firm of Mr Alan Guyatt Parks, a name well known in the annals of proctology. I believe (although I may be wrong) that it was he who coined the aphorism: “There are two sorts of people in this world: those with piles; all the rest are liars”. But he certainly pushed forward the surgical frontiers of the rear end, if you get my meaning.

The great man operated on a Monday; consequently all his patients were admitted over the weekend which meant, in effect, that I had no time off for the six month duration. Of course this would be illegal these days but it seems to me we were made of sterner stuff forty years ago.

It was the responsibility of the houseplant to telephone ‘Sir’ on a Sunday afternoon in order to inform him of the admissions for the following week. There is a story, possibly apocryphal, of a courageous doctor who telephoned him from a coin-operated box - no fancy technology in those days - in an underground station in central London. While giving a summary of the patients the background noise suddenly increased in intensity as a tube train pulled in. Mr Parks commented: “Doctor, you are in the hospital aren’t you?”

The unfortunate doc, sensing immanent doom, immediately jumped on the nearest train and made it back to Whitechapel just in time to greet his boss as he arrived to do an unannounced ward round.

Mr Parks was formally knighted in 1977 for services to the rectum. But like all great men he lived on another plane and, kindly as he was (and a deeply committed Christian), my existence barely registered with him. Indeed I remember one day while I was humbly holding a retractor for him in theatre (a minor anal procedure so the more important members of the team were elsewhere) the ward sister came to the theatre door with a query about another patient. “Get the houseman to sort it out, where’s the houseman?” he retorted in a rather belligerent manner.

Rather shamefacedly I admitted that it was indeed I, the missing houseman, who was standing next to him. “Oh, oh” he muttered, “Well, err…” That was the end of the matter and I think he was genuinely mortified.

My other abiding, but affectionate, memory of him was a post ward round tea break with all the team in Sister’s office. He dunked his Rich Tea biscuit overlong and as he removed it from the cup the soggy mess fell onto his smart RCS tie. All those present then spent the next ten minutes trying desperately not to disintegrate into uncontrollable hysteria. Happy days!

He was elected president of the Royal College of Surgeons in 1980 but tragically suffered a major myocardial infarction in 1982 at the age of 62. Despite emergency cardiac surgery in St. Bartholomew’s Hospital he died on November 3rd. I was a cardiothoracic registrar on the unit at that time although I was not involved in his case. His premature death was a tragic loss to both his family and the profession at large.

To be president of a noble royal college was, in those days, a very great honour and the incumbents were generally held in very great respect. As a junior doctor they seemed to me like distant gods inhabiting celestial regions and pondering the mysteries of the universe while we mere mortals scuttled around doing the donkey work. How things have changed!

They are now mostly my near contemporaries and fellow coal-face workers who, by luck or judgement, have ascended slightly higher up the greasy pole than me. I am certainly on first name terms with the current president of my own royal college (RCR), and although we have an excellent relationship I am certainly not in awe of her (much to her relief I suspect).

But things seem to have changed in the way in which college presidents are viewed by large chunks of the profession, and it is definitely a more hostile climate. Time-serving, gong-seeking toadies are some of the more moderate descriptions I have read. Indeed many are now asking of royal colleges the Willie Hamilton MP question about Princess Margaret, “What is she for?”. Many view the traditional ceremonies, gowns and gongs as irrelevant and unnecessarily expensive in these financially stringent days.

Much of the disillusion was triggered by the MTAS and MMC debacle when many juniors believed that the colleges had not challenged the government over the disastrous implementation of these schemes. More recently some were demanding that the colleges take a much more political stand over the Health & Social Care Bill. With some exceptions they were accused of passivity and complicity with the government while the legislation leading to the destruction of the NHS as we know it was formulated. There are increasingly strident voices demanding that colleges be made more accountable to the views of their members and fellows and that they become more proactive in the formulation of health policy.

The world is changing and it seems to me that the colleges must change with it or perish. My own college is shortly to have an election for its next president. Through the grapevine I have learned of at least two candidates and both have an excellent, although quite different, record of service to the college and the specialty. But while I am trying to decide who to vote for I keep wondering why they would want the job. Look what it did to Sir Alan Parks!

The hills are alive with radiology competition

By Tom Goodfellow - 2nd January 2013 4:12 pm

As the new year commences the media pundits are reminiscing on the last 12 months and framing their predictions for 2013. Obviously the main past issues are the Olympics, Obama and omni-shambles with a bit of royalty thrown in.

Oh yes and rain!

Interestingly the other week I did see a man building a very large boat in his back garden. I wonder if he knows something we don’t?

But one matter has been conspicuous by its absence from the pundit’s deliberations and that has been the infamous Health & Social Care Bill which received the Royal Assent on March 27th.

And when you gaze long into an abyss the abyss also gazes into you.

Judging by the profession’s reaction to the Bill there is clearly a fair amount of Nietzsche-like abyss-gazing taking place. The most hackneyed word in the lexicon, when applied to the NHS, is “privatisation” and this accusation is being bandied about like a kipper in a fish market. The demise of the NHS as we know it has clearly been set in motion.

We know that a group of doctors take the matter so seriously they have formed a new political party dedicated to fighting the next election on the slogan of “Save our health service”. Good luck to them, but I fear the issue has already slipped off Joe Public’s radar and they will struggle to keep it alive. Let me give you a practical example of what is happening to make my point.

My department delivers a high quality ultrasound service, supervised by yours truly, with first class staff and six shiny new top-range scanners with lots of additional bells and whistles (one of the few advantages of a PFI contract). We have a good reputation among the GPs and our success is evidenced by steadily rising referrals. When patients reach the department the service is efficient and most are seen at their appointment time or with only minimal waiting. Reporting is ‘hot’ and the GPs have almost immediate on-line access to the results.

However after the referral is made, the patient will wait up to five weeks for the appointment (which is the maximum time are allowed to make them wait) and we struggle to achieve that, frequently having to persuade staff to take on extra lists.

In addition, as a consequence of John Prescott’s ‘integrated travel policy’, there is totally inadequate access to the new hospital site and too few parking places. So at peak times punters may spend 30 minutes queuing to get on site and a further 30 minutes to find a parking space. The PFI car park company then charges them an arm-and-a-leg for the privilege.

But now the new age has begun. We are aware that Scans-R-Us have already opened shop in the city centre with easy access, no parking charges and a guaranteed eight day turnaround from request to report. Undoubtedly more companies will follow. If demand rises they will simply take the obvious business decision of increasing capacity and recruiting more staff (probably ours). So why would any GP not wish to take advantage of this service? And the benefits for the patients are obvious.

We may argue as much as we like over the ‘added value’ of an immediately available experienced radiologist’s opinion, but I doubt the customers will care much as long as they get their scan with minimal fuss and free at the point of delivery.

The obvious challenge for my department is that we might lose a very significant chunk of income. So in response (and at my suggestion) the trust managers have agreed to site our own scanner in a city centre location, covered by our own staff and linked into our PACS. This seems like a sensible way forward, although having closed the old city centre hospital six years ago you begin to wonder why we bothered!

However, although I know we can match and even exceed the independent sector in terms of quality and governance, I doubt that we will be able to match them on price. While we have little option but to come in at full tariff (we have fixed costs and need to pay the huge PFI mortgage), they will take the obvious business decision and reduce the price. We will soon have the equivalent of BOGOF and super sales reductions, “all scans must go”. In other words, a full price war which our competitors will be in a much better place to win.

Now obviously this is only one minuscule example in the whole complexity of healthcare provision in England as a result of the Bill, but it makes the point.

Are we gazing into the abyss or has the abyss has got inside us? No doubt time will tell. Meantime I must go and contemplate the Abbess - ‘yes’ the girls have decided to watch The Sound of Music again.

Just as well, as I have almost forgotten the words. Happy New Year everyone.

State licensing of the press is a mistake

By Tom Goodfellow - 4th December 2012 10:41 am

SENIOR DOCTOR ADMITS TO HOT TRAMP IN THE HILLS

Dr Bob Bury, a recently retired consultant, candidly admitted today that he regularly enjoys a hot and steamy tramp in the hills. “There is nothing to be ashamed of,” he stated to the crowd of journalists and photographers clustered outside his garden gate, “It’s just a bit of fun in the great outdoors”. However the authorities may take a different view.

MEDICAL JOURNALIST CONFESSES TO DOCTOR ROMP

Well-known medical journalist Mike Broad today confirmed rumours that he regularly sleeps with a doctor. “There is no law against it,” he retorted when challenged. However representatives of the medical profession have expressed outrage at this revelation. “This relationship is too close,” stated one angry doctor. “How can he objectively report on medical matters under such circumstances? Who knows what they discuss when they are alone? All such relationships should be transparent and above board”.

WHO ATE ALL THE PIES?

Angry catering staff at the Middle-Bit-of-England Trust have revealed that an entire delivery of pies - intended to nourish needy NHS patients - has been stolen. The police have been looking into the matter and it is understood that the culprit has been identified although they will not reveal his name. However I have it on excellent authority that the prime suspect is none other than Mr Jerry Nelson, a surgeon at the trust, and currently on “gardening leave” (although he lives in a flat). When approached for a comment today he uttered only one word - a profanity.

I expect you get the drift of this by now. I have obviously deliberately libelled and slandered three completely upright blameless individuals (well definitely two). And this in the week after Lord Justice Leveson’s report into media culture and ethics has been published.

Let me state at the outset that, like all people of sense, I deplore the actions of some journalists whose behaviour was seriously out of order. I have huge sympathy for those whose lives were shattered by the untruths published against them. However those who broke the law in these matters have or are being prosecuted, and the newspapers concerned have had to make large payments in damages.

I am reminded of Sir Humphrey in Yes Minister whose advice was that you should never set up an inquiry unless you were sure of the outcome. I suspect that David Cameron has not got what he wanted and within minutes of the report being published the whole thing has degenerated into a political dog fight. But was the Leveson inquiry really necessary and am I happy with the outcome? Well frankly no!

The idea that the entire press in this country is out of control and running wild is on a level with the idea that the entire NHS is a filthy, MRSA-ridden cesspit where patients die from neglect or are actively killed to free up beds for more victims (at least in the view of the Daily Wail). In fact most of our patients get good or excellent treatment and most journalists are ethical and thorough.

I feel very uncomfortable with Leveson’s conclusions which, in effect, is simply a return to state licensing of the press. Our ancestors saw the importance of a free press and licensing was ended in 1694 and we throw this away at our peril. I am not suggesting that we are heading for a North Korea type of rigid media control, I think the danger is more insidious. What we will get is a tame, dull, sanitised press which is anxious not to offend.

But my other objection is more fundamental. With respect to Leveson I think he has misunderstood the basic issues. These were brilliantly outlined in a series of Reith Lectures delivered by the philosopher Onora (now Lady) O’Neill in 2002. The whole series of five talks was entitled, “A Question of Trust” in which she addressed the apparent crisis of trust affecting all aspects of public and professional life including the media and the medical profession.

A quote from her first lecture: “The common ground from which I begin is that we cannot have guarantees that everyone will keep trust. Elaborate measures to ensure that people keep agreements and do not betray trust must, in the end, be backed by - trust. At some point we just have to trust. There is, I think, no complete answer to the old question: who will guard the guardians?” (Lecture “Spreading Suspicion”)

In the series she forensically analyses the whole issue which has so absorbed Leveson and large chunks of the media for the last year. Indeed in my view if they had bothered to review what she said there would have been little reason to hold the inquiry in the first place other than to give various celebrities a chance for their day in the limelight.

She makes the point that the response of the government to such situations seems to be an inquiry which in turn generates a call for stricter regulation and accountability. The medical profession has been subjected to this to our cost (Dame Janet Smith), and the letters giving the dates for our revalidation are currently hitting the doormats although many of us still find it difficult to understand exactly what will be achieved by the whole process.

O’Neill again: “For those of us in the public sector the new accountability takes the form of detailed control. An unending stream of new legislation and regulation, memoranda and instructions, guidance and advice floods into public sector institutions. Many of you will have looked into the vast database of documents on the Department of Health website, with a mixture of despair and disbelief. Central planning may have failed in the former Soviet Union but it is alive and well in Britain today. The new accountability culture aims at ever more perfect administrative control of institutional and professional life.”

In my view her conclusions and suggested actions are much more balanced that Leveson’s and I wish politicians would take note of her. She will be speaking on the subject of trust at 8.50am on Radio 4 next Sunday. I for one will be listening.

I won’t be watching Children in Need tonight

By Tom Goodfellow - 16th November 2012 9:44 am

Many years ago when I was just a lad of about 11 years my best friend was Jonny W. For several summers we had played happily together, usually in his garden because his Dad was well off and they owned a significant property in a smart area of North London.

However Jonny proved to be a fickle friend. One day when I turned up to play as usual the big boy from next door was there too. His Dad owned a large toy shop in the neighbourhood and he went to a private school. The taunting began immediately and Jonny decided to side with his new best friend.

Then the big boy decided that they were going to remove my trousers and pants. They tried but did not succeed because I fought back and finally escaped on my bike with hot tears streaming down my cheeks and their triumphant laughter ringing in my ears. The sense of betrayal was overwhelming and I was far too embarrassed to tell my parents about what would probably now be regarded as attempted sexual abuse, and anyway we didn’t speak of such things in those days.

But what doesn’t kill you makes you stronger, and I learned an important childhood lesson that we are not defined by the way unkind or cruel people treat us. I had loving parents and other friends so I soon recovered. At the end of the summer Jonny and I went off to different secondary schools and I never saw him again although I heard in later years that he had “gone off the rails”.

You may think that this is a pretty trivial event as compared to some of the horrific accounts we are hearing these days of childhood abuse, and you would be right. However, the fact that I still recall all the details and the raw emotion after more than fifty years shows that such incidents do imprint themselves deeply in the minds of children.

While the BBC is busy self-flagellating, and grossly overpaid managers are fretting over their futures it is too easy to forget the real victims of childhood abuse. There is one very obvious reason for this. Many never recover psychologically and grow into deeply troubled teenagers and adults, some manifesting extreme antisocial behaviours. And, to be blunt, society would rather not be bothered with them.

I am a trustee of a small mental health charity dealing with psychological trauma, including children. This year we were contacted by the head of a local primary school in a deprived area of town. She was asking for help with about ten of her pupils, children from very troubled and abusive backgrounds. If they turn up to school at all they are smelly and neglected, often hungry and all very disturbed and disruptive. They all probably should have been taken into care, but social services are broke and do all they can to avoid this.

To fund the therapy (including family therapy) we decided to approach Children in Need for a grant. However having completed the complex application process we were subsequently informed that they did not fund any project which took place within school hours because it was wrong for children to be kept from their schooling! Despite explaining that it was almost impossible to keep these kids in the classroom let alone “school” them, and that it was the school itself seeking help they were adamant. I should point out that this exclusion is not stated explicitly anywhere on the their grant application website.

So there we have it! Tonight we will see TV and pop stars strutting their stuff aiming to bring in £millions for Children in Need. This money will be used to fund nice clean shiny projects like after-school clubs and playgrounds. It will support childhood cancer research projects (despite the fact that most cancer charities are awash with cash), and no doubt will contribute to hospitals such as GOSH who already have massive legacies, and support from Lord Sugar.

It will give many opportunities for celebrities to be photographed surrounded by happy smiling children. But the profoundly neediest children, victims of the current media obsession, will get nothing because mental health issues and psychological trauma are things that society would rather avoid. Most of these kids will end up costing the taxpayer dear in the long run. Many of the boys will end up in prison.

To say that I am a bit cross about this is somewhat of an understatement. I, for one, will not be watching tonight.

Obama or Romney - does it matter which?

By Tom Goodfellow - 6th November 2012 3:25 pm

Today millions of Americans will be voting for their choice of President, and I, like the rest of the world, will be heartily glad to see the end of it whatever the result. Although finely balanced the probable outcome is that, after all the $billions spent, the rather weak incumbent will be re-elected with a poor mandate, a hostile Congress and a virulent Republican backlash. In other words no change!

What has astounded me over the last year has been the visceral hatred expressed by many right-wing Republicans towards Obama and the complete descent of politics from vigorous rational debate to utter vilification of political opponents and all they stand for. Politics in the UK may not be perfect and many (but not all) politicians are idiots. But I don’t hate them, even if I strongly disagree with some of them.

My wife has been highly entertained by surfing the right-wing Republican Christian blogs where Obama is not just vilified he is frankly demonised, and denounced as utterly evil and depraved, largely because he refuses to ban abortion and is in favour of gay marriage. The followers of the religion whose founder taught his disciples to “love your enemies” rather seem to have missed out on that one. It is also astounding that the Mormon faith of Romney, originally defined as a ‘cult’ by no less than the Billy Graham Association, has been transmogrified into merely another Christian ‘denomination’ for the duration of the election. Religion and politics make strange bedfellows indeed!

One of the most puzzling things of the debate has been the visceral detestation of Obamacare, the President’s attempt to bring a little sanity into the appalling US healthcare system. Four years ago, while on a US visit, I was discussing this with a very pleasant family of strong Republican persuasion. When I briefly described my work in the NHS the atmosphere became noticeably frigid. It seemed that the concept of ’socialised medicine’ was an unmentionable horror, on a par with Nazi death camps (which is how the marvellous Sarah Palin termed it).

Yet I remember vividly how, while on a team visit to an eminent cancer hospital in New York, the director informed us that chemotherapy was always administered IV rather than oral whenever possible. He admitted, with mild embarrassment, that this was for “remunerative” reasons rather than clinical necessity.

I also remember on early Cancer Peer Reviews watching senior clinicians, used to being in charge, struggling with the concept of shared care. Yet MDM working when done well, especially in cancer care, delivers excellent treatment for patients. But this is largely unknown in much US healthcare because no physician or oncologist wants to share patients (and the associated income) with another doctor. The result is significantly poorer outcomes. But despite this the Republicans continue to defend their dreadful system as a God-given right for all decent Americans (excepting, of course, the poor and chronically sick).

I don’t care who wins today, I doubt that it will make any difference to the slow climb out of economic recession. But, much as I admire much that America has to offer, I am fed up with their self-belief that they are the greatest nation on earth. They are still a very powerful nation and have done some great things in past times. But their dysfunctional version of democracy frankly sucks and I am unsurprised that much of the world wants nothing to do with it.