NEWSLETTER

Editorial – 2

General practice on the brink – 4

Junior doctors: the wider view– 5

Barts merger nightmare – 7

Manslaughter and beyond – 8

AGM and Conference 2015 – 11-21

AGM: Reports – 12

AGM: General practice – 14

AGM: New politics – 16

AGM: Devo-Manc – 17

Git et qui nonAGM: et ommollesFYFV – 18 corempo

AGM: Devolution – 19

AGM: Paul Noone Memorial Lecture – 20

Mental health: What lies ahead – 22

Executive Committee 2015-16 – 24

Page 1 DECEMBER 2015 Page 1 Editorial: Handcarts in convoy

Despite 70 years of continual old- and (as someone else pointed out testament-worthy predictions of when they highlighted the high-risk terminal melt-down, the NHS government strategy of targeting the arrives, join our happy team” – the won’t do that, just as it hasn’t juniors) very definitely neither on usual depressing PR-speak. since 1948. We’d do well not to the golf course nor seeing private Interestingly, many of the trusts were proclaim its demise – a ritual patients. I spoke to a couple of – though you’d never know it looking pronouncement every winter. foundation year doctors. They told at the pictures of happy-clappy But its foundations continue me of their concerns for patient healthcare professionals – in special to be eroded in ways that safety, their insecurity about their measures or otherwise engaged only intermittently make the long-term futures, and the instability with the CQC, so were obeying the headlines. Without seeking out of their organisations. By the time management-consultant mantra of trouble – or even information, for this is in print, they will either have smiling especially broadly when you’re that matter – in the past couple become the 2015 equivalents of in your death throes, and hoping of weeks several of the demons the miners under Mrs Thatcher, or that some people might not notice gave me a good nip. preferably will have ensured that (actually, I’d be interested to know the race to demean professionals how many prospective consultant Juniors on the streets to the status of the lowest currency candidates are properly informed of human capital may have slowed a of the real significance of the CQC On Sunday 15 November, we were little. status of the dying organisation they in a warm and relaxed Birmingham, may be joining for the next 40 years). and spent a few hours in the splendid PFI, PF2 – and counting I spoke to two nicely presented German Market that spills down young people, presumably managers, from Victoria Square all the way Though I no longer do acute or possibly press and comms people, along New Street, and which has medicine, we all need our CPD in front of a lavish scale model become a traditional pre-Christmas notches, and the Acute and General of a new hospital called Midland event. At the station end of New medicine conference at ExCel is Metropolitan. We are encouraged on Street (the station itself has become usually a good two-day update the hospital website (definitely virtual, yet another dreary white shopping for physicians of all generations. as it doesn’t open until 2018) to call centre with a few train platforms The adjoining exhibition is nearly it much more coolly “Midland Met”, attached) in the middle of a very as interesting as the lectures. There which has a laid-back, slightly North large crowd of good-natured beer- were at least 20 trusts displaying American twang to it, presumably drinking and frankfurter-chomping their wares in very smartly appointed fully intended, and of course it will Brummies was a large rally of about stands, all adorned with rural lifestyle be a hospital “Where EVERYONE 200 juniors demonstrating, quite photos. The reasons for these matters”. It will replace a handful undemonstratively, their feelings conspicuous displays of ostentation of large hospitals near Birmingham about the new contract, that nice Mr were frequently less clear than the including Dudley Road, Smethwick Hunt, and other related matters. dreary slogans they displayed, usually and Sandwell. I didn’t spy too many obvious a random mixture of “opportunity, So PFI is alive and well, I suggested. Trots or anarchists. They were nicely innovation, exciting, nice schools, only But this, the young lady told me, is scrubbed and rather well turned out 2 hours from London when HS2 PF2. In what ways does that differ

Page 2 from PF1? Wasn’t quite sure. I over 100 years old in some cases, Commission omission prompted this eager young person and the cost of bringing them with tangential questions like how consistently to basic statutory Finally, the shadowy world of conflicts much the glass-covered cockroachy- standards is over £100m.” of interest in CCGs, widely suspected, looking thing would cost to build and now exposed in the BMJ. Twenty (I suggested the usual “DGH” cost (£100 m for a full refurbishment years of false reassurance about of £350m or thereabouts – they seems like good value, compared the watertight supremacy of the demurred), and more importantly, with the total PF2 cost. The neoliberal quartet of “governance”, the interest rate on the loan (and refurbishment option must always be guidelines, audit and compliance has indeed the term of the loan). Didn’t considered, and is ritually dismissed, led to a morass of just-about-legal know really. But they were up front so presumably the need for clever arrangements that any non-expert that because of new ways of working accountancy is another thing that would immediately spot as fairly stinky and transformative innovation hasn’t changed in PF2.) if they were exposed in banking, but (or it may have been innovatory a few hundred million here or there transformation) they needed fewer Failing the final duty in the NHS doesn’t seem to be the acute beds than the hospitals it was same. replacing. Ah, yes, I said, that was Then, a personal and poignant Actually it’s much worse. The side-bar one of the characteristics of PFI piece in the current 19 November quotes from leading doctors miss the that seems to have been translated issue of the London Review of Books. herd of elephants with their howitzers. unchanged into PF2. Casual question, The novelist Jenni Diski is dying Clare Gerada: “We’ve got to be careful then, by how much would the bed- of lung cancer superimposed on that it’s the patient’s pulse we’re feeling, base be reduced? 10%, 20%? They longstanding pulmonary fibrosis, not the patient’s purse”. were coyly ignorant of all these and is writing a series of articles. She Clare, unusually, seems to have been matters. has been introduced to the hospice. misquoted: we’re ignoring the bulging The Midland Met website has a She felt that she would benefit from purses of some commissioners. Sarah jaunty Q&A section, and the PFI a week’s respite in the hospice, but Wollaston MP, a GP new chair of the question is handled with consummate because of her severe depressive health select committee, and someone mendacity, using exactly the state would have preferred a room who should know better, still seems to arguments DFNHS members have to herself. Promises to fulfil both think that world-class commissioning been hearing for nearly 20 years: these requests were twice given (remember that?) is intrinsically right her, but when she pitched up there and even more strangely, good for “Q. The new hospital will be built was no single room, and she was patients. A little financial irregularity is under PFI – should I be worried? reminded that the hospice doesn’t a price well worth paying for world- do respite. They couldn’t even class care: “The trouble is if you have a A. No. The new hospital will guarantee that she would have a blanket ban on CCGs commissioning be built under Private Finance single room when it came to her from organisations where GPs have an 2. Crucially that means that final admission. interest then you might lose something key services like portering and No clinical negligence, no lack of that gives patients the best care.” cleaning will remain within the communication, nothing that would NHS. The financial model for the register with the CQC. Just non- Four events that I didn’t seek out: new build has been assessed by decent care that is increasingly at commissioning to palliative care, PFI to the trust, the Treasury and the variance with the sloganizing mantras rotting “human resources”. All different Department of Health, as well as of holistic care, mission statements, Rorschach blots. The pendulums have other NHS bodies. It is affordable, and repeated and empty promises swung a long way from unconflicted and the cost proportionate to the to keep the customers happy and care. turnover of the hospital trust is scoring us highly on the Friends and far lower than some PFI schemes Family Test. Many, but sadly not all from the early part of the century. of us, have honourable intentions of David Leavy Of course, new facilities cost. keeping those promises. Editor The existing hospital facilities are [email protected]

Page 2 Page 3 General Practice: On the Brink?

Things are not good in general the funding clearly will have dramatic Workload has rocketed with many practice at the moment. Over effects on the service offered. GPs working 13-14 hour days and recent years we have seen year- Those of us working every day in our dealing with upwards of 60-70 patients on-year systematic reductions in surgeries see the effects of this. GPs a day. This is neither safe nor desirable overall funding to general practice. are burnt out, leaving the profession, from the point of good patient care. This has been a cold, calculated suffering mental illness, having to close What the NHS needs is more tactic and due to political decisions their practices as they can’t recruit funding. It has had flat-line funding rises made at the highest level. Some doctors or nurses and some are going just above inflation since 2009 along say it is being done as ‘punishment’ bankrupt due to all this. with a political drive to save (cut) for what was perceived as an over- General practice is desperate for £30bn from the budget. No health generous contract deal in 2004. more funding to prevent its collapse. economy has ever successfully done In fact Jeremy Hunt even said as this. Why are politicians demanding much at a recent conference [1] – this? Surely they will know it will much to his shame decimate the service, drive doctors Mr Hunt has recently had to handle What the NHS away, diminish patient care and leave the issue that his misguided decisions needs is more the NHS struggling to cope – all things caused: 98% of junior doctors in we see already. England to vote for strike action – funding...it has Many feel it is deliberate in order to unprecedented in more than two diminish the service and push through generations. Yet his actions – driven by had flat-line the sale of more NHS contracts and ideology, not evidence – also threaten services to the private sector. The UK general practice with calamitous funding since is a rich country. We can afford the collapse, to the detriment of the NHS and we can afford to increase profession and the public alike. 2009 its funding dramatically. Politicians have All in the name of “marketising” a decided not do so. system that never needed it, never Why not have a windfall tax on wanted it – and was certainly never We have the perfect storm of falling Google, Amazon or Apple so they voted for. recruitment and retention. Doctors pay adequate tax in the UK? Why not This is not a new problem but is are no longer attracted to a career in hypothecate tax from the tobacco or becoming a critical one. In 2004 general practice given all the negativity sugary food and drinks industry to general practice was in a bad place they read in the press and what they fund the NHS? and needed extra funding. We have hear from colleagues. GPs in their The answers are there – it just needs now slipped back to an even worse fifties are desperate to retire as soon the political will to do it. situation. as they can and often leave many These circumstances have led to At one time funding was over 12% of years earlier than they would have the BMA General Practitioners the NHS budget for general practice done. Very experienced GPs are then Committee (GPC) to call a ‘Special whereas now it is around 7%. To halve lost to the NHS. Conference’ – in effect a crisis

Page 4 conference due to the parlous state of the service. Seizing the Pump Handle: The last time a ‘Special Conference’ was called was in 2003 when a new contract was desperately needed to The Meaning of Politics shore up the then failing service. GPC have called this conference for January and GPs from across the UK will come The Junior Doctors’ dispute must together on Saturday 30th January to debate what action is needed to save be seen in a wider context our profession. It may even decide what action GPs are prepared to take We all know the tale. Dr John good just as resolutely as when treating to save our profession. Snow, on linking the outbreak of an individual patient. Acting to reduce Some talk of undated letters of cholera to a contaminated well in health inequalities fits just as strongly resignation, some of resigning from Soho, London, in 1854 persuaded with that as removing pump handles. NHS general practice and some of the authorities to remove the Why is it, then, that our recent actions refusing to comply with the ludicrous pump handle. Heroic genius saves in defending standards of safety and demands and costs of the ever-growing the people. The first example of fairness in the work we do – surely as quango that is CQC. GPs have to fund someone working out how cholera clear an indicator of preventing harm this inspection now and the average was transmitted, and taking steps as you could wish for – have been practice will see fees treble to around to prevent infection. criticised as being “political”, or “too £10,000 soon. That is £10,000 that Except he didn’t. Snow himself political”? could go towards funding another admitted that the outbreak may well I sit on the Junior Doctors’ Committee nurse or member of the admin team have been in decline anyway by the at the BMA. The sheer scale and iron will in a surgery. time the pump of the protests by my There are so many attacks on the was rendered colleagues, sparked NHS across many fronts and the useless. But that The sheer scale by this government’s profession must unite to protect those isn’t what the myth arrogance in who work in the NHS and to protect says; as powerful a and iron will applying a change the service itself. demonstration of to our contract that If politicians continue down the the truism “never of the protests would create unsafe current misguided policy route then ruin a good story sparked by this and unfair practice the NHS as a publicly funded, publicly with the truth” as as the norm, has provided and publicly accountable you could wish for. government’s been inspiring. But service could be a thing of the past. The point was, all too often, at there was a deeper arrogance...has the highest levels Reference principle to Snow’s of the BMA, over actions. That of been inspiring the last year, I have [1] Pulse (2015) [online] available at: acting in the public encountered the http://www.pulsetoday.co.uk/your- practice/practice-topics/pay/gps- good. Something we as doctors have view that we should not be overtly unfairly-punished-on-funding-bma-tells- always done. By demonstrating the politicised and that “we do not seek ddrb/20030248.fullarticle idea (that cholera was transmitted in to change governments but to change water) with concrete actions (removing government policy with equal vigour David Wrigley the handle), the principle was both towards all”. GP, Carnforth, demonstrated and believed in. My attempts to reach out to other Was this a political act? Of course it unions, for example, have been Lancashire was. Removal of handles is not in itself perceived as dangerously political. Any BMA Council member a treatment, and a whole population attempt to clearly describe the fact that Chair, Doctors in Unite (formerly was Snow’s concern. As doctors, our our present junior doctors’ contract Medical Practitioners Union of principles allow us to act in the public dispute is embedded within the politics Unite the Union) Page 4 Page 5 of austerity has also been decried as biggest in the word) and it is one of health workers and public are too political. the biggest branches of Government educated about what is at stake. I would also add that being political in Funding/Financial terms. • For unions, health workers is regularly conflated with being in Given the facts just stated and and campaigning groups to link “party” political alignment. This is not given the need to respond to the together and work in a common the case. global Financial Crisis of 2008 in a defence of the NHS. In my view there is also no escaping certain way; the government has no • To make the reasoned, objective the fact that debates around the NHS choice but to politicise the health argument that it is indeed the more generally have been at the centre service by driving through neoliberal conservative ideology itself of political discourse. This can be seen “reforms”. And the proposed junior which is absolutely devoted to at a number of levels: doctor’s contract is straight out of destroying the very existence of the neoliberal play-book! As was the a safe, efficient, publicly funded, 1. The NHS regularly tops polls Health and Social Care Act 2012. publicly provided NHS. of the public’s view of how The BMA’s reluctance to “get important various political issues too political” is now resulting in the We must cease to be bound by are. impasse which we in the BMA find simple assertions of becoming “too 2. It is at the centre of the debate ourselves. I cannot of course go into political” – in themselves, nearly both between the political parties the detail of that decision publicly always political statements geared to vying for power and at the centre but what I would say is this: the BMA preserve the prevailing political view. of debates within those parties. finds itself in a tough position. Our Only by continuing to engage with 3. The NHS is the cornerstone negotiations with Hunt have been each other and the wider public can of the twentieth-century’s “triple-locked” in my view. And we as we fight the greatest attack on public social democratic consensus. a union and as a movement need to health: the undermining of our NHS. This is the very reason why it is find a way to break through each of under systematic attack. “Social those “locks”. References democracy” as a concept has The first of Hunt’s safety locks is been attacked and undermined the pernicious DDRB report and its [1] Judt, T. (2010) Ill Fares The Land. systematically with the rise modified “November proposal” form London: Allen Lane. Chapter 3. and prominence of neoliberal [2] Kondilis, E., et al. (2011) Privatising the [4]. The second safety lock is the time- Greek health care system. In Europe’s hegemony [2]: the real driver frame of likely imposition. And the Health for Sale (Lister, J, ed.). Faringdon: behind the government’s third safety lock is the “neutral pay Libri. Chapter 2. intentions towards our NHS. envelope” and expansion to a “7 day [3] Peedell, C. (2011) Global 4. For many formerly apolitical NHS” (in the context of cuts to NHS neoliberalism and the consequences for junior docs concerns over a funding)… in a word: austerity. health-care policy in the English NHS. In privatised NHS have come to the Europe’s Health for Sale (Lister, J, ed.). To repeat, we in the BMA have to Faringdon: Libri. Chapter 8. fore during the present contract break through each of those “locks” if [4] Department of Health (2015) dispute. we are to have any chance of achieving Review Body on Doctors’ and Dentists’ 5. Deficiencies in health and health a safe and fair contract. And we won’t Remuneration 43rd Report: 2015 systems both domestically and be able to break through those locks [online] available at: https://www.gov.uk/ globally exist for political reasons alone. To unlock the trap will take government/publications/review-body- (examine the West African Ebola on-doctors-and-dentists-remuneration- overtly political actions with rigorous, 43rd-report-2015 epidemic, the present health ethical principles of the public good crisis in Greece [2] and health driving them. In particular: inequalities in the UK [3]). • For other groups, such as Yannis Gourtsoyannis And we can’t wish all this away. Why? Doctors for the NHS, to keep (Yannis works as a junior doctor Because it is of course natural that this things political: to do and say in a London hospital. His views politicisation should be the case; the that which the BMA cannot expressed in this article are his own NHS is by a wide margin the biggest (or chooses not to!) do, and and do not necessarily represent employer in the country (and fifth to ensure that doctors, other those of the BMA.)

Page 6 to be timid or non-existent for the The Nightmare Merger That’s next 5 years. Because the Trust Development Now Just a Routine Bad Dream Authority (TDA, in charge of non- Foundation Trusts) and Monitor still report separately, it isn’t easy to get a “There are two things that are infinite: human stupidity picture of where things are at present, and the universe – and I’m not sure about the latter” other than the headline projected £2bn deficit announced a while ago. Albert Einstein But 72 of the TDA’s 90 Trusts were Positive note: the disastrous Barts video has had just over 600 views, and in deficit at quarter ending 30 June merger in 2012 that created the it’s well worth another look, but only 2015. Thirty-seven Foundation Trusts largest Trust in the NHS (Barts if you have a cast-iron gastrointestinal are subject to ‘enforcement action’, itself, the Royal London, Newham, constitution. and 8 remain in special measures, now, Whipps Cross and the erstwhile One other luminary deserves a disgracefully, including Cambridge London Chest), at least prevented mention: the Director of ‘Turnaround’ University Hospital – a clear indication an even bigger catastrophe – the at Barts, Donald Muir, whose that the CQC inspection regime and merger of Kings, St Thomas’ and management consultancy earned its battalions of box-tickers are foolish Guys which was being considered £1.4m in about 9 months before he and probably knaves. around the same time. quietly departed in the middle of 2014, To add to the confusion, 29 FTs in The CQC, inspecting Whipps having evidently given a new meaning October were reported to have a Cross towards the end of last year, – and a wholly new direction – to the ‘continuity rating’ of 1 – the most found – hardly surprisingly – that concept of Turnaround. Please let me serious level of risk that the Trust ‘will the loss of some 250 senior nurses know if DFNHS members have any fail to carry on as a going concern’. Oh in the clearout after the merger further sightings of this serial failure – and of course, there’s a ‘governance’ had impaired its functioning, and being employed elsewhere in the rating as well indicating Monitor’s view lipsmackingly placed the whole of Health Service. of their degree of concern about the Barts into special measures. A letter sent during the summer to running of the organisation. Clearly But it was the financial catastrophe, Simon Stevens and signed by 80 Barts this fluid series of arbitrary judgements with a predicted year-end deficit of consultants (a very small proportion will continue, probably intentionally, £140m (up from about £90m in the of the 600 or so employed by the to fuel widespread uncertainty, and Spring), that finally precipitated the Trust), naively requesting the PFI debt blight recruitment, especially to Trusts departure of the finance director, to be cancelled (like the banks, they in special measures. closely followed by that of the CEO, said) would have been better directed Special measures, therefore, are no Peter Morris (salary c.£270,000), towards the Health Select Committee, longer very special, so wielding the the Chief Nurse, Professor Kay Riley, demanding an inquiry into the fiasco. ‘governance’ whip and the ‘financial then the Chair of the Trust, and finally, Unfortunately, the tigger-like Margaret austerity’ cleaver must be delivering Steve Ryan, the Medical Director, all Hodge, Chair of the Public Accounts diminishing returns: if everyone’s in of whom have left to pursue new Committee, has been replaced, and financial meltdown, and breaching careers in areas they, of course, always the Health Select Committee under hitherto line-in-the-sand targets is the really wanted to do, usually education. Conservative MP Dr Sarah Wollaston norm, where can the sanctions lie? It was the medical director, is unlikely to significantly rock the boat But we have been here before, proclaiming his YouTube vision of the (doctors brought into the big tent – and with each crisis our politicians healthy East End from the rooftop of with a very few honourable exceptions become more, not less, wily in their the new Royal London Hospital (total – are well-meaning but politically wet ability to contort language and PFI cost, together with the new Heart behind the ears and usually end up meaning. Centre, around £1.5bn) who claimed as playthings for whichever neoliberal They are also not thick-skinned 3 years ago that the deprived people administration’s in power). enough to pursue evidently politically of East London deserved this merger. Public scrutiny and even rational high-risk strategies like the dismal No they didn’t. Wildly successful, the critique of these cataclysms is likely Barts mega-merger. Surely they can

Page 6 Page 7 see where they are heading: but can we? Perhaps one answer is given by Some More Thoughts on Peter Roderick, colleague of Allyson Pollock, and co-drafter of the NHS Reinstatement Bill. He writes in the Manslaughter and Beyond current, 3 December, issue of the London Review of Books. The excellent conference on The first indication of this to which “This small-print stuff, in this case manslaughter in the context of Dr Adomako responded was 4 from the 2012 Act, is the very medical practice, reported in the minutes later when the Dynamap essence of neoliberal quasi-legalism; June issue of this publication and alarm sounded. He gave atropine but it revolves around a three-year which I also attended, arose from 5 minutes later the patient suffered a agreement between Monitor and the realisation that there was an cardiac arrest and only then did Dr foundation trusts to provide so-called increasing number of criminal Adomako discover the disconnection. ‘Commissioner Requested Services’ prosecutions where previously The court was told he could and (CRS). These are the currently should have noticed that the patient’s provided services commissioned by chest was not moving and, although CCGs, but the requirement to provide its alarms were not switched on, that them expires in April 2016, based “When doctors’ the ventilator’s dials were not moving. on the outcomes of envisioning the Further, he misinterpreted the financial failure of Trusts, who would actions result Dynamap alarm as a malfunction and thereby no longer be in a position to failed to notice a fall in the patient’s provide continuity of these services.“ in death it pulse rate. Presumably through this process, The expert advice to the court which is nearly completely opaque might be from a felt that he should have noticed the to anyone without a law degree, the disconnection of the e-t tube, let alone large number of financially-challenged criminal level of any of its consequences, within about FTs will be able, probably strongly negligence” 15 seconds. Dr Adomako’s negligence encouraged – and possibly forced – by was not in doubt but were his actions Monitor, to ditch current core services, and inactions sufficiently serious to though presumably not – Peter doesn’t warrant a criminal sanction? mention this – emergency care. there may have been only a He undoubtedly owed a duty of care Regardless of whether this comes to coroners’ hearing and possibly a to his patient and this he had failed pass, we can envisage a whole hierarchy related claim in negligence. to discharge but did that amount to of boilerplated processes based on The coroner’s only duty is to a crime. the 2012 Act that can be invoked with investigate who was the deceased Dr Adomako unwittingly set a primary aim of reducing the General and how, when and where they came the standard for gross negligence Hospital to a minimal emergency about their death; but coroners (and manslaughter in the context of care-based institution with patients relatives) can inform the police where medical practice. being despatched to a motley crew they feel that the circumstances He bore the patient no malice and of providers once their acute care is leading to that death may merit a had not intended to kill him but was deemed over (and they have given more detailed investigation. his breach of duty in failing to give a five-star TripAdvisor/Friends and his patient proper, skilled care, and Family Test result to the Costa outlet Dynamap error: Adomoko its consequences serious enough to with a skeletal hospital attached). constitute gross negligence and how Cappuccino rules. In 1995 the unfortunate Dr should that be decided? Should he be David Leavy Adomako took over an anaesthetic judged criminal? from a colleague. Subsequently, during In his summing up Lord MacKay said Editor the course of the procedure the endo- that if undertaking the task in the first [email protected] tracheal tube became disconnected. place he must be expected to exhibit

Page 8 In the jury’s opinion their conduct deference and we all now (rightly) was so bad as to amount to a crime. accept increased scrutiny of what we Some More Thoughts on They appealed on the grounds that do. In medicine there is a huge change, that the nature of the Adomako test not always realistic and some inflated was unfair and denied them a fair trial deliberately, in the expectations of Manslaughter and Beyond but the appeal was turned down but patients and their relatives in what as junior doctors in a system were can and should be achieved. the appropriate level of skill involved they really responsible or was it the In part out of all this has evolved over but “not necessarily the great skill of system? the years, dramatic improvements the great men in Harley Street”, he Ken Woodburn, a vascular surgeon, in consistency and results of both added deferentially. He thought that gives a moving description of his own surgical and medical treatment. The the word “reckless” was helpful in experiences of police investigation actual measurement of some of the reaching this decision. and subsequent prosecution following outcomes is problematic and clearly the death of a patient with leukaemia needs more refinement. It will always Misjudged infection: Sellu after subclavian line insertion. The jury remain easy, and tempting for the took less than an hour to acquit him. uninformed to measure surgical In 2012 Mr David Sellu was asked to outcome as living or dead and this review a patient in a private hospital. is very unsatisfactory, particularly to The patient had recently undergone those practising in the higher risk knee surgery and now had severe “Doctors, with specialties. abdominal pain. Mr Sellu suspected a bowel perforation and plain abdominal some notable Organisations failing radiograph added to his suspicions. A radiologist’s view would have been exceptions, do And how reasonable is all this.? available to him but he arranged Doctors, with some notable CT for the following morning. There not go to work exceptions, do not go to work to was delay in performing the CT and harm their patients. In recent years that combined with Mr Sellu’s other to harm their there has been an increasing focus commitments resulted in delay in on system errors but that does laparotomy till later that evening, patients” not mean that errors cannot be some 24 hours after Mr Sellu first individual. Into which category fall saw the patient. Adomako and Sellu you can decide Mr Sellu could not produce any for yourself. evidence that he wished antibiotics to Ken Woodburn was doing an be given meanwhile and the patient More scrutiny extra case on an extra list with an died following laparotomy. The jury unfamiliar team which he had been felt and the judge agreed, that Where has all this come from? persuaded to do on a Saturday David Sellu’s actions (and inactions) Forty years ago the mishaps related morning. An airline pilot, with which constituted a crime. It would seem above would probably have been industry comparison is often made, likely that, based on the facts as related, dismissed as “the doctors did their would not be expected to work a civil action in negligence would have best” and whilst the immediate, under such conditions or without gone against him. bereaved relatives may have felt proper preparation, in the interests that something could have been of passenger safety. Misra, Srivastra, Woodburn done better, little more would have As the direct result of a shortage of happened. beds into which to transfer a neonate, Junior doctors Misra and Srivastra Then came the motor car and we I was once induced to close a made a serious underestimation of now accept the criminality of death persistent arterial duct on a Saturday the seriousness of a wound infection by dangerous driving but in parallel morning, in another hospital some and the patient subsequently with that much else was changing. 50 miles away, with an anaesthetist succumbed to septicaemia. The professions all noticed a loss of and theatre staff whom I did not

Page 8 Page 9 know, after viewing an investigation The negligence test And where might all this lead us? on very unfamiliar equipment. (For The concept is out there that when my trouble my unfamiliar car was doctors’ actions result in death it might The quality of the test for the clamped for parking in the equally be from a criminal level of negligence. existence of the criminal element unfamiliar consultants’ car park.) What are the risks to patients of the required for gross negligence Mercifully all went well and mercifully proposed, reduced (less rigorous?) manslaughter has received much Ken Woodburn’s jury recognised, training of junior doctors? Is the comment and legal discussion. It is not an individual failure, but a system absence of an on call or even resident agreed that the civil law concepts that had failed and that he was not system for anaesthetists in a private of a demonstrable negligence in the criminal. hospital, a risk that could carry an presence of a breached duty of care is How did Ken Woodburn get there easily foreseeable consequence? the starting point. The civil court not in the first place and where did the As for Alteplase given following a infrequently struggles with this and manslaughter concept for medical stroke, how will one demonstrate adding a criminal investigation may deaths come from? one was not reckless in giving it (or not be the best route to clarity. The police remain relatively not giving it) with a known chance The test is whether the defendant’s inexperienced in the investigation of of either giving or not giving it, behaviour was grossly negligent and medical mishap resulting from the making things worse? How far does thus criminal, a question of fact for the possibility of negligence, normally one continue to struggle against individual case which the jury must sorted out, more or less satisfactorily, reduced staffing, pressure to meet decide. Where does the threshold in or prior to a hearing in a civil targets, knowing that one is running lie? How is the concept of system court. The police are used to dealing a recognisable and recognised risk? inadequacy putting the defendant in a in more black and white terms. And is one’s employer going to jump vulnerable position introduced when There is truth or lies. The concept in and say in your defence that there the media and hence public reaction, that there is the possibility of more is a corporate risk in breaching a demands and knows “that it must be than a single view on management target? Does that generate a greater somebody’s fault”? How often have or interpretation of an investigation or lesser risk to patients than the risk we heard “I know all about system is alien. At a recent such investigation to the patient when working under failure but someone has got to be their feeling was that if there were less than reasonable conditions? The to blame” from those interviewed two declared views of radiological ability to demonstrate that a debate after a disaster of some sort. Have at imaging, one was lying. was held (record keeping again) least some faith, Mr Woodburn’s jury Little room here for here for even if it came, retrospectively, to the got it sorted out and the police now thechance of anything but individual wrong conclusion must be better than have much better guidelines for their responsibility or for the recognition the recklessness of no demonstrable investigations. of a systemic failure leading to debate. an adverse outcome. Further, Reckless? Sadly it is not preposterous that organisations are less than speedy in manslaughter may be considered holding up their hands and saying “it when a patient dies but sorting out The Lord Chancellor introduced the was not poor Dr So-and-so’s fault: where the blame really lies can be idea that the concept of recklessness he or she was doing their best but fraught with difficulty. might be helpful in sorting out really we did not/we should have...”, Labelling an individual as criminal is what is beyond simple negligence. opening them to the possibility of the end of a career. One can only hope Recklessness is an awareness of corporate manslaughter. that organisations will be more willing the possibility of the particular As Ken Woodburn related, he was to admit to their shortcomings and consequences of an action, or inaction unsupported by his organisation and further, admit to the great difficulties or omission, but continuing regardless. although the jury did recognise that they encounter when balancing risks Whilst this concept may be helpful it the failure was not his, the whole against each other, even corporate still remains a matter for the jury to process of investigation and trial, financial against patient safety. decide whether events go beyond a though resulting in acquittal, was a matter of compensation for the victim traumatic event for him and his family. and become a public wrong. Roger Franks

Page 10 AGM and Conference 2015: York

“Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens...have access, when ill, to the best that medical skill can provide. ...If the job is to be done, the state must accept financial responsibility.” – Aneurin Bevan, In Place of Fear [1]

This year’s Annual General Meeeting and Conference was held in York, at Bedern Hall, a short walk from the Miinster (pictured) and within earshot of its bells, on Saturday 3 October. The following pages contain abridged transcripts of the principal speeches as well as the main points of business.

[1] Bevan, A. (1951; reprinted 2015) In Place of Fear. . New York: Kessinger. p.79

Page 10 Page 11 AGM Reports Opening address: taken over by Alan. The introduction of lifetime subscription had resulted Eric Watts, Chair in some additional money, but at the expense of slightly reduced year-on- Eric reported on the very successful year income. Membership had remained launch of the newly renamed Doctors static. for the NHS in March at Portcullis House Current assets as of 9 November: in London, which had resulted in a page £11,421 (interest-bearing account; see being devoted to DFNHS in the BMJ Figure 1) plus £3,500 (current account). and an increasing number of requests for Expenditure was currently on the NHS related to England, but he accepted media comments. Keep Our NHS Public campaign Philippa’s point. He said he had been busy building (£8,000 pa), and £3,000 to the NHS After some detailed discussion, the alliances with other organisations, and Support Federation. This all meant that meeting felt that DFNHS should also urged those present to start using at the moment DFNHS was paying out examine the size of its contribution to social media, especially Twitter, as a £4-5,000 pa more than its income. This KONP, especially in light of DFNHS’s way of reaching younger members of is unsustainable. change of emphasis and its decision to the profession. The ways of countering Options were to increase subscriptions invest substantially in its own continuing attacks on the NHS deserved careful or to reduce income. The subscription campaigning activity. [The EC meeting in thought, and DNHS members could baseline for membership had remained November considered this in depth and offer an invaluable perspective based on fairly constant, with income from decided to pay the next instalment of their years of experience. numbers of new members approximately £2,000 due at the end of this year but matching memberships ceasing. Peter to review further instalments after that Treasurer’s report: favoured reducing current outgoings to date, probably reducing these to £1,000 Peter Trewby, Treasurer KONP and the NHS Support Federation quarterly.] as a solution. He put the accounts to the Peter told the meeting that subscriptions meeting as a correct and full version. Communication Manager’s yielded approximately £25,000 pa, and There had been a few resignations report: Alan Taman that this year the organisation had raised over the past year, for various reasons, additional funds with an appeal which but none could be said to be because of Alan reported that since the publicity had covered the costs of setting up the DFNHS’s principles. surrounding the launch his principal task website, launch, marketing, and publicity The question of holding meetings and had been to change the communications banners. Alan Taman’s appointment as events in Scotland as a way of increasing channels and resources to reflect DFNHS’s Communications Manager, part time, recruitment was raised for consideration changed emphasis. This included building had resulted in a considerable amount of by MP and DFNHS member Philippa up and changing the website, developing the work previously undertaken by Peter Whitford. Peter Fisher pointed out that social media (especially Twitter), some Fisher in producing the newsletter being most of the pressing issues affecting the printed resources, and consolidation of DFNHS’s e-mail database. Press liaison was ongoing but Alan cautioned that since the election national media had shown less interest in NHS campaigning groups generally. But DFNHS had a unique “selling point” in being a very strong peer group with a powerful voice. The rise of the junior doctors’ dispute and the politicisation this was undoubtedly causing amongst doctors in training gave DFNHS a good opportunity to use its more coordinated communications and Figure 1 Deposit account balance 2009-15 (excluding one-off appeal donation 2015) recruit more members, as well as get

Page 12 AGM and Conference 2015

its aims across, especially by focusing on group’s website as formal notice and put local campaigns. Specific trusts were now this to the meeting to be adopted. This Alliances with other groups: being targeted with that in mind. was accepted. Eric Watts This new magazine was also an example of the kind of change undertaken since Recuitment: Eric outlined the development of a Alan came into post, aiming to be a Peter Fisher, President new coordinating organisation, Health more “up-market” and outward facing Campaigns Together, which would serve communications resource. This would Peter reported that each trust in the to coordinate the actions of the NHS continue to be developed with more UK is targeted roughly every 5 years, with campaigning groups as well as organise new features over future issues, while each consultant in that trust being sent several major conferences to be held remaining loyal to DFNHS’s aims and a letter inviting them to join. Targeted in the winter of 2016. DFNHS was membership. letters were also sent to individuals represented on this group. Alan concluded by saying that likely to be sympathetic from comments Ron Singer’s MPU group had also communications would continue to be made the medical press or from word organised a conference to draw like- developed and were now in a much of mouth via existing members. minded medical professionals and other stronger position to enable DFNHS to NHS campaigners together, which Eric recruit more members and express would attend. its aims to a wider audience, based “The essence of 38 Degrees had also been approached on its unique and powerful nature as by Eric on a national level but there was “the doctor’s voice” amongst NHS a satisfactory some reservation about this group’s campaigning groups. commitment to the same aims of DFNHS, An interesting point was made during health service and its preferred way of engaging with the discussion, that members of the the public on a wide range of issues, not public were generally convinced that the is that the rich just the NHS. However, the meeting did NHS was a “wonderful service” and did acknowledge that 38 Degrees had a not appreciate the nature of the threat and the poor are great deal of strength in organising local facing is. Presenting the dangers in an groups and that DFNHS could engage informed way that was not alarmist was treated alike” with them successfully in this way. the key. Alan pointed out that this was how propaganda worked, and that there – Anuerin Bevan Election of Executive was a credibility problem that groups Committee: Eric Watts needed to address through constant This had yielded a gradual rise in explanation and exploitation of particular membership historically but a noticeable Several of the current members were problems as they emerged, while avoiding “trough” in recruitment was apparent prepared to stand for election, and needlessly “gloomy” messages about how since the last election. Since expanding there were several vacancies (see page dire things were getting. to become DFNHS 200-300 GPs had 00 for full list of current EC members). been contacted and invited to join, with David Wrigley was appointed as a new Support motion for the no result to date. Recruitment is vital EC member by the meeting. Junior Doctors to continuing success and the group has to come up with new methods Keep Our NHS Public report The meeting decided to pass a motion of recruitment. Different methods are in support of the junior doctors: needed to be developed to attract This was submitted to the meeting. junior doctors, and the campaign to Alan Taman reported that KONP “Doctors for the NHS offer its target trust in special measures was had undertaken a major upgrade and support to UK junior doctors in already underway. restructuring of its website which undertaking any and all lawful action The point was repeated that postal had been launched on the day of the that seeks to secure a fair and safe methods of recruitment were unlikely meeting (www.keepournhspublic.com) contract for junior doctors.“ to be successful for junior doctors. Social media engagement was likely to be the NHS Support Federation DFHNS Constitution best way of reaching them. [The website is now being changed to facilitate online This was submitted to the meeting. Eric Watts reported that the updated joining and be more coordinated with The Federation continued to produce constitution had been placed on the Twitter, to reflect this.] highly useful reports on the NHS.

Page 12 Page 13 Major Issues Facing the NHS General Practice Where we were: could have a big list, do nothing and earn seen to be too controversial so it was more than somebody who was working shelved. But as usual, under a Conservative Paul Hobday quite hard. administration the service was starved of Despite a big pay rise in 1952, which funds. The headlines in the 1980s were The NHS didn’t quite make its 65 kept GPs quiet for a while, the unrest all about waiting lists being longer and years; it ended in England on March in the early sixties was really beginning longer. Thatcher announced a review of 2013. to take over. In 1965 all 14,000 GPs the health service. The terms of service I started as a GP in 1983 and I had submitted their undated resignations of that review were never revealed, the best period, in the eighties, before the BMA to blackmail Roberts, the but it was influenced by Professor Alan purchaser-provider splits were brought in. Labour Minister for Health. This results Eindhoven’s work describing the internal This was after the GP Charter and before in the 1966 Family Doctors’ Charter, market, with input form Redwood and the disastrous Ken Clarke’s attempts to which revolutionised general practice. It Willetts, who are still getting their way. interfere. It was a good period because included staff reimbursement at 70%, a Blair decided to go along with all this we were allowed to get on with the job. group practice allowance to encourage in the end, and produced the death of The main way of travel was positive and GPs to get together, and other fees.This the NHS by a thousand cuts. First of all, it was gradually improving little by little. was encompassed in the “red Book” the Fundholding experiment, with the In the 1980s there were 150 good which was our bible from 1966 to 2004. two-tier service, the different types of applicants for most jobs. Now we can But then the rot set in with Ken Clarke’s GP contracts, the out of hours changes have none. purchaser-provider split. Where did that in general practice and the splitting off In 1948, the BMA was 9:1 against the come from? The right wing have always of out of hours so it could be easily establishment of the NHS, and produced hated the NHS. privatised, the abolition of boundaries, some bad propaganda. But Bevan pushed The Tory cabinet in 1957 had a full the walk-in centres which didn’t do the Act through, of course. He wrote discussion on turning the NHS into a fully anything to help continuity of care, and this about GPs: “I have a warm spot contributory system and this was drawn the dismantling of primary healthcare for the general practitioner despite his up in great detail in Whitehall in 1959- teams. The PCT micro-managing us. Then tempestuousness. The family doctor is in 60. This was blocked by the Minister for the 2004 contract came along offering many ways the most important person Health, Enoch Powell! Enoch Powell “enhanced services” which were a way in the service. He comes into the most saved the NHS at that point. of taking work away from us and put immediate and continuous touch with But the plots in the background them out to tender. Choose and Book: members of the community. He is also remained. In 1968 the co-founder of a greater way of getting in the private the gateway to all the other branches of the Institute of Economic Affairs, one sector, and making us do generic referrals the service.” of Thatcher’s heroes, Arthur Seldon, instead of to specific consultants. Nurse In 1951 he wrote In Place of Fear [1] produced After the NHS [2] which was specialists appearing in general practice. – the chapter on healthcare is amazing. about how to introduce an insurance- And now, tying us into federations on the The warnings about how the NHS could based system to replace the NHS. The journey to multi-speciality community potentially be destroyed are as though Tories came back into power in 1970. providers; and the Health and Social the right wing have taken them as a Keith Joseph invited McKinsey to advise Care Act turning us as GPs into ration blueprint. on the organisation which was put in givers. All of these were part of the jig- Bevan wanted a graduated system of place in 1974. saw, parts of the big picture. capitation payments to discourage big In 1974 Barbara Castle tried to push There is one final point that proves this lists, which obviously would have been everything back. The BMA opposed is ideology, and that is the cost of GP a good idea but again the BMA blocked her and when Wilson was replaced by practice per patient per year at £72. You this. For the following 10 years GPs were Callaghan, Callaghan sacked her. can’t insure your cat or your car for that. at war with each other because the By 1982 the Tory cabinet were The only reason they are doing this is more patients they had on their books presented with a Tory think-tank paper, because of ideology. the more they earned. Basically you on an insurance-based system, which was

Page 14 AGM and Conference 2015 Major Issues Facing the NHS

Where we are now: the UK; in 2013 it was 8.5%. That increase people. In a hospital that means closing came because of what happened during wards down. In primary care it means David Wrigley Tony Blair’s time. There were lots of new referring fewer patients. facilities. Lots of them were under the This is often dressed up as “improving I think general practice is in a very disastrous PFI arrangements but it did quality of care”. Data will be collected, dark place. I am not one to use such iimprove healthcare. GPs will be shown what their referral language. I think general practice My patients in 1997 died on the waiting rates are, and will be told “drop that is on its knees now. I fear for the list waiting for heart bypass. In 2000 they by 5% and we will give you £20,000’. I survival of my profession. were getting them done in 14-16 weeks. think that is completely abhorrent. The Who would have thought, some years Yes, the private sector was used but there potential for destruction of the doctor ago, that we would see GP surgeries was an improvement. But if you look –patient relationship is immense. Once closing down? It is an absolute travesty. at 8.5% now and compare with other that is gone, it is gone for ever. That is a Primary care in this country was seen countries, Germany is 11%, Japan 10.2%, very dangerous route to go down. as an amazing system. It’s all going down France 10.9%, Spain 8.9%, Australia 8.8% Lansley and the Tory-led reforms are the drain. It’s absolutely vital we fight for - we are right at the bottom of this list. very clever. They put GPs inside CCGs this. One of our biggest concerns is that In 2010 we had the highest ever so GPs get all the responsibility but very we will end up with a dentists’ model satisfaction times and the lowest ever little influence. We get all the blame. of healthcare. It only takes a group of waiting times in the NHS. But with the Because of the disastrous Health and practices to say “we can’t continue like this, homoeopathic increases in funding Social Care Act. we are going to open our lists to private since 2010 there has been a decrease in Regarding Federations, GPs are patients” which will attract people to pay funding after inflation. The GP share of sometimes doing that just to save the for insurance. Just like with dentistry you the NHS budget has plummeted. Once services they offer because they are will have a mixture of provision and then over 10%, it is now 6.2%. No wonder under such funding pressures. So some of it will be de-funded and we will end up primary care is in such a state. the federations should not be dismissed with an over-run primary care service. This is a clear de-funding of primary out of hand. There ore other ones coming I sit on the BMA council, which care which I take as a conspiracy. As with together as limited companies – those represents the whole profession, and also the railways in the eighties and nineties we do need to be concerned about. the GP Committee. The GP Committee we saw a defunded service worsened, it’s One solution is to write to your MP undertook a massive survey. Half the GPs the same with the NHS: the media roll and get your friends and family to do so. responded. It is quite shocking. One-third out the stories and the NHS just gets a Write to your local press. People listen if of GPs are considering retiring in the worsening reputation and then we will they see a letter about the NHS in their next 5 years. One in five GP trainees are hear “we will have to bring in the private local paper, which have a large readership. considering going abroad; 9 out of 10 GPs sector, it’s the only way to save the NHS”. Alan Taman will help with any wording have said heavy workload has negatively Only this week I saw more headlines ([email protected]). I would also impacted on the quality of patient care. about GPs, “GPs being paid to refer encourage you to look at NHS For Sale These are shocking statistics, all because fewer patients”. This has been going [3], which I co-authored. It talks about of what is happening in the NHS. The on for a number of years and has only the myths that are undermining our NHS junior contract is just one part of it. I am just been picked up. It’s because of and offers facts to de-bunk them with. firmly behind the juniors. If they beat the new contract, the decision of the the juniors, the next will be the nurses, commissioning groups who are in fact References the next will be the other healthcare an arm of the Department of Health. workers. They are already trying to split The funding is inadequate. How do you [1] Bevan, A. (1952) In Place of Fear. the consultants by divide and rule. The reduce the spend? Because if the CCGs (Reprinted 2010. London: Kessinger) juniors deserve our support. don’t balance their budget they get called [2] Seldon, A. (1968) After the NHS. London: Funding of healthcare is a political choice. to Whitehall and their jobs are on the Institute of Economic Affairs. The politicians decide. The share of the [3] Davis, J., Lister, J. and Wrigley, D. (2015) line. They have to bring in savings. How NHS For Sale. London: Merlin. GDP on healthcare, in 2000 was 6.3% in do you do that? Well, you treat fewer

Page 14 Page 15 New Politics, New Opportunities

Philippa Whitford, MP I had to leap in and say no, that it is Our interest in it in Scotland is that we much cheaper to gather in whatever tax don’t get to control our own finances. for Central Ayrshire, SNP you can and if you are meant to deliver That is what the referendum was all health spokesperson that healthcare with public money the about: we control our public services, we cheapest way is just to get on with it and do not control our own money. If the The NHS is very much what has deliver it. It really shocked me that the NHS in England is destroyed or moves to landed me doing this, as an MP. message that what makes the NHS the an insurance-based system, that will take I was an active member of the ‘Yes NHS is through the purchaser-provider almost a third of our funding away in Scotland” group. A “Better Together” split has reached a place like Addis Ababa. Scotland, which is what we spend on the leaflet caught my eye. This claimed that We are often accused of being the NHS. That will therefore destroy ours, so if we became independent we would doom-sayer, saying how the NHS is in we see a vested interest in helping you. no longer have an NHS. That incensed crisis. I believe you should be completely I raised the issue of the NHS Bill with me. The Scottish NHS has existed since the opposite. The NHS is amazing. The Nicola Sturgeon and her response was 1948; the Highland and Island Medical media are already telling people the NHS to put that in our election campaign. We Service, its predecessor, has existed is awful. We should not get on board that will be throwing down the gauntlet to since 1913. So this is something Scottish waggon. What we need to say to people see what the new Labour party decides people really value. I was looking on in is that the basic principle of a public NHS to do about it. disbelief from 2011 when the coalition is the cheapest, most straightforward, We have talked a lot about what you government started to say what it was highest quality and most egalitarian way can do. It’s absolutely important that you going to do. I realised people in Scotland to deliver health care. are who you are: Doctors for the NHS had not heard of this at all and I felt it was We must not attack the NHS, destroy carries a lot of weight with the public. my job to speak out. how people value it. That is not our Keep Our NHS Public do the local groups, At the end of the referendum people message. Our message is that the NHS the public involvement, the leafleting. You started saying I should stand for is incredibly cost effective and worked need to be the voice of authority that Westminster. I’ve been a breast surgeon really well but it is on a trajectory to be says “we do understand the NHS” and for over 30 years and a consultant broken up. we can see the road that we’re on and for 19 years; I’d never had the slightest We must not be on the same platform that’s not the road that want to be on. wish to be a politician. A Women for or we are reinforcing the message which But you therefore need to recruit all the Independence rally finally persuaded me, will build up to the point where they people, the GPs, the junior doctors, and if because I realised “if not me, who?”. The peel off the NHS logo and display this you can fix them up in some way when first month in Parliament was a case of wonderful shiny, clever private plan. they are students that is important. “What have I done, how bad can a by- Our message has to be about the You need to become a much more of a election be?”. trajectory that it is on. The privatisation mass movement. Because last year, when But now I am the health spokesperson in the English system is only around 7% my video went viral, what we saw was for the SNP. I spent the last week visiting at the moment but if you look at the that the nurses, the porters, the cleaners, Ethiopia, looking at the health system bids, more than half of them are going the dinner ladies, they were all voting there. It is impressive. They have health to the private sector, because they have “yes” to independence. centres like we have, and below that bid teams, corporate lawyers, they will Who we didn’t convince were the they have what are called “health posts”, font-load the system, they will loss-lead consultants, who were saying we should which are staffed by locally employed, to win that contract. Then they start not rock the boat, and we need to be young women who work at educating changing terms and conditions, they start aware of that, but by word of mouth you their population in public health. cutting corners. That is what we need to are talking of accessing the biggest single We finished with a more official be saying. employer in the UK, so you can convert meeting. I was utterly shocked to hear You will find it harder if you are working staff. I think you should also see the NHS that although they think the idea of in a broken up, unintegrated system. To as an organisation that can help itself by free treatment at the time of need is me the biggest loss would be this loss taking this road. marvellous, they plan to encourage the of collaboration. This loss of working Where can I fit in? As the front bench set-up of providers and they will purchase together. I think that that is something spokesperson I do get to speak in every health from them! that we all have a vested interest in. health debate. I don’t need people to

Page 16 AGM and Conference 2015 New Politics, New Opportunities Devo-Manc

write speeches. But I need facts. The Report by Eric Watts the standards set out in national guidance principles. These are things I can use in and will continue to meet statutory parliamentary questions, I can use them requirements and duties, including those A bravura presentation from JS in debates and can get them aired. of the NHS Constitution and Mandate Bamrah, Medical Director of the In Scotland our population now with and those that underpin the delivery of Mental Health and Social Care Trust Parliament Live TV, they put it on Twitter,. social care and public health services. in Manchester and Chair of the NW What this organisation needs to be The planned timetable is April 2016: Region of the BMA, who described doing is to try to get that happening full devolution of agreed budgets, with his involvement in the scheme as around the NHS. We know it is the preferred governance arrangements “someone who would rather be thing that is most values by everyone in and underpinning GM and locality S75 in the tent looking out than the Britain, in the UK. We need to get them agreements in place. reverse.” all talking about it. No attacking it, not The scope will include: He commented there was no public moaning about it, but realising it’s exactly vote for the scheme and that many as we said before, the reason you get • Acute care (including specialised are against it, partly because of the good is through good people. We have services). long secret negotiations carried out to support those people and we have to • Primary care (including management between Osborne and Bernstein of the keep it public. of GP contracts), who will continue Manchester City Council described in Some of what the Conservatives are with their independent contractor Simon Jenkins article in the Guardian [1]. talking about is not targeted at people status. Key points are that it will: who are ill but so that they can create • Community services. this ‘”Tesco’s”; they keep going on about • Mental health services. • Continue to deliver the NHS Tesco’s: you can pop in 24/7 and get • Social care. Constitution and Mandate your shopping. Well you’re not getting a • Public health. requirements and expectations. fish-monger, the bakery is shut and the • Health education. • Commit to the production, during butcher is shut. on a Sunday. So even • Research and development. 2015-16, of a comprehensive they do not provide everything 24/7. Greater Manchester (GM) We need to be clear that is your This much was easy to follow but I Strategic Sustainability Plan for message, what is your voice? I think you was not alone in thinking that the vision health and social care. have to get the entire profession speaking of the benefits will be hard to realise, • Seek to play a leading role in that message among themselves, among the planners have said that their plans, designing and delivering innovative staff and to the public. Because that is involving closures, cutting numbers of new models of care as set out in the what we need to do. We need to get health and social work staff will result in FYFV. It will use the opportunities such a welling up of a wish to protect improvements. resulting from its GM-widescale the NHS that it is something that they Gasps of incredulity were followed by and integration to create ground- have to listen to. All of us can contribute ribald laughter as the predictions were breaking innovation in areas to that. read out: of mutual GM/NHSE strategic If I can contribute in any way by just “By 2020 there will be: focus to be agreed, and to be an getting those going out to my Twitter exemplar for the national whole followers or into the Chamber or into • 4,000 fewer children and 60,000 system efficiency initiative. Hansard then obviously I would be fewer adults with chronic, long term • Ensure clear accountability, happy to do that. I think we have a huge conditions;. exemplary governance and job of work to do and I am really glad we • 6,000 fewer people will have cancer. excellent value for money in relation have changed how we see ourselves and • There will be a 10% reduction in to the health funds delegated or can take that forward. visits for urgent care. devolved to it. • Around 18,000 children will be

Follow Phillipa onTwitter: better supported by local services He reported that the publicity has stated @Dr_PhilippaW to live in stable, caring homes. that the underlying principles are GM will • Nearly 70,000 extra people with still remain part of the National Health chronic conditions will be provided Service and social care system, uphold

Page 16 Page 17 FYFV: The Devil in Disguise

Anna Athow substitutes doing doctors’ work, etc. They want completely new models of staffing: many hospitals they do not want to have The Five Year Forward View is a surgeons at all. They want “generalists” and plan to privatise the provision what they call “hospitalists”. They want and commissioning of clinical to end the current national contracts services in the NHS within 5 of doctors for “service redesign”, and years. It proposes a gigantic Agenda for Change for other staff. They reorganisation of the provision want to shorten medical training. They with community help. of clinical services. want an army of volunteers which is • Reduction of elective hospital The name being given to this largely about bringing in volunteers to do services by 15%. reorganisation is “transformation”. There skilled work on the wards. • 25,000 people with severe and are many references throughout the They want “7-day services”. This long-term mental illness will benefit document to a shift of care outside is important. They want to set up from proactive community care. hospitals. A number of new models of accountable care organisations, which is • Involvement with urgent services care are listed. modelled on US healthcare. In essence will be reduced by 30%. “ What it does not say is as important as this is a type of health maintenance what it does say. It says “outdated models organisation. This, the advocates suggest, will be of delivery have to go”. These will be big: 30-50,000 patients achieved in spite of the budgets being What this means is that District General each or more. They will be doing primary reduced so that they cannot deal with the Hospitals have to go and GP surgeries care, mental health care, social care, consequences of many severely deprived have to go. Another key point is a “modern preventative care, out of hours care, areas with the highest UK suicide rate work force”. By deduction there is to be public health care, and they want the outside Glasgow. a new workforce, and we have already capitated funding for all these services. Not only are the needy set to suffer but started to see the decision to smash The Vanguard services are essentially at least one centre of excellence is to be current national contracts. Implantation these ACOs, for which bids have to be excluded from the grand plan. is about commissioner dictatorship by submitted. In my view they are being The consultants at Withenshawe – a various means, which is top down. £22 prepared for private providers. leading centre of cardiothoracic research billion of cuts in the next 5 years. They Urgent and acute care networks: they – are so inflamed they are on course to want £8 billion to carry out the “double are proposing that half of our type 1 launch a Judicial Review, which could stop whammy” of a transformation and push A&Es go. This means people will have to the whole process. it through. travel an awful long way to get acute care. He concluded with an expectation The result will be a cheapening of Foundation trusts are now being aligned that there would be steady flow of provision by bringing in the new care into hospital chains, which are clearly embarrassing headlines as the story models and the new work force, pay modelled on US and German-type unveils. freezes, new staff contracts, and selling off private hospital chains. These could be NHS property. satellite services or placed with a multi- Reference Stevens has said that he hoped they speciality community provider (MSCP) would sell £7.5 billion on NHS assets. The but they would not be run by consultant- led teams but by “hospitalists” and the [1] Jenkins, S. (2015) ‘The secret aim of all this is “productive investment”. people in the MSCPs would run them. negotiations to restore Manchester to What is “productive investment”? It is greatnesss’. Guardian, 12 Feb [onlline] profits for private companies. There is no Dumbed-down DGHs. available at: http://www.theguardian. mention of privatisation – but then they Specialised care: they want, for example, com/uk-news/2015/feb/12/secret- can’t do that – but that is what productive cancer care and orthopaedic care to negotiations-restore-manchester- investment means. They think that on the be called “specialised care”. I see no greatness back of these changes there will be scope reason for stripping these out of DGHs for profits to private companies. and putting them into huge private This is aimed at an American-style contractors, but this is what they want. system based on health insurance. The demand for Saturday services is They want skill-mix change. Doctor- the government’s way of pretending they

Page 18 AGM and Conference 2015

care about public services, but in reality it is a way of changing the workforce. They Devolution: cannot achieve a change to the working pattern unless they change the working The Hidden Agenda for Public- terms and conditions, the doctors’ contracts. Service Destruction Jeremy Hunt has claimed “around 6,000 people lose their lives every year because we do not have a proper 7 day service Deborah Harrington, of health which lie in the remit of the in hospitals.” He is trying to pretend that local authority which cast light on how National Health Action the NHS might faire under devolution. I this so-called excess deaths at weekends Party is something to do with the consultant would like to illustrate how the existing contract, whereas as emergency cover is structures of local government might Everybody seems to think this is impact on the transfer of responsibilities not affected – this is provided 24/7 and absolutely the thing to do – much of always have been. and to look at a case study to highlight the agreement is cross-party. Whlle I the gap between the rhetoric and the This is being done because commercial absolutely agree with the principles companies want to take over the running reality of localism. of democratic decision making being Devolution is about the devolution of of the NHS. They can’t make money unless devolved to the lowest level possible, they get people to do Saturday, Sunday a budget from central government to the I can see no evidence that this is what local authority. It happened in 2012. The and evenings doing electives, outpatients is entailed in the current discussions. lists and endoscopy lists so they can have government legislated for local authority The rhetoric of devolution fails to a big throughout of elective cases. housing to be self-financing for the first match the reality. Also, government Also, the new “super-hospitals” must time. This was an absolute revolution in commitments today can be undone cover acute care, and they need a massive moving money out of central government by commitments tomorrow, with amount of elective care to cover this. down to local government, who would threatening consequences. What they need to do this is sweated then be able to use the money for what The immediate context to devolution labour: medical staff in there evenings, they wanted. This sounds like perfect includes unprecedented cuts to public Saturdays and Sundays doing the elective devolution. But this year a second funding of services and social support, work. legislative round gave a shock to local escalating housing prices, massive The main feature of the junior doctors housing authority managers. This was changes to the NHS, and a fundamental contract is the increase in plain time two fold. First, the government made an change in the ethos driving public sector working form 60 to 90 hours a week: 7 am “intervention” unprecedented on rent provision away from the basis of our to 10 pm Monday to Saturday. That is what levels. Tenants who earned more than combined service solidarity towards has to change: they want cheap labour in £40,000 combined household income the management of public expectations the evenings, Saturdays and Sundays from would have to pay affordable rents rather within a framework of private provision. junior doctors. They want to get rid of the than council rents. Affordable rents are The latter is one of the greatest risks compensation juinor doctors used to get set at 80% of market rent. All the other for devolution, if you believe as I do for unsocial hours working, banding. They tenants would have a rent reduction of that public service is best when it stays also have safeguards to make sure they 1% per year for the next 4 years with no public in ownership, delivery, funding and weren’t working excessive hours, but this allowance for inflation – a huge decrease accountability. removes the monitoring of that. in total rents collected. The scale of the funding cuts has Consultants contract: same plain time The second part was even more a direct impact on devolution. Since working changes as the junior doctors. shocking. A percentage of council 2010 local councils have suffered an Imposition of elective work at evenings properties deemed to be of high value almost 40% budget reduction in real and weekends. Private companies need must be sold off as soon as they are terms. Like the NHS, they have had to this otherwise they can’t get the new vacated. It has been estimated that every make efficiency savings, by cutting staff models in. single council property in Westminster, and selling property, to make good This government is also pushing through Kensington & Chelsea, Wandsworth the gaps but many services have been anti-trade union legislation which target and the riverside area of Southwark severely depleted. The effect this might the NHS workforce. will have to be sold. The viability of the have on the NHS is clearly the issue of All these things are to replace our NHS. housing stock will collapse. The income paramount importance here but in the But we do have a lot of our NHS left. from housing stock will not cover the broader context those elements that are necessary outgoings. referred to as the social determinants This has reverberations echo through

Page 18 Page 19 everything: you are told you are going how demographics themselves will be to be given the money to do everything, mapped. The localising of budgets and Paul Noone Memorial Lecture 2015 : Who Holds The Power? then the money is taken away. Housing provision, especially in our critically is, as Bevan knew and every health under-funded local authorities. Risks Rachael Maskell, MP for York Central (report by Geoffrey Mitchell) professional in the country knows, a perpetuating those conditions of pre- major social determinant of health. 1948 inequality. Rather than producing Being able to pay for your home with good, appropriate local provision Rachael’s background or without help is an important security. responsive to real need. Those people The combination of social security and from my local area who will shortly be 20 years as an NHS physiotherapist, social housing changes is primarily having displaced from their council homes will trade union official, Labour MP since a negative impact on people who are join the 50,000 already scattered across May 2015 with over a 6,000 majority not well enough mentally or physically the country by the social cleansing , supporter of Andy Burnham in the to sustain of obtain employment. This is programmes that put property values Labour leadership campaign, recent particularly marked in those with mental before human need and view being Health Select Committee member, health needs, who are also struggling to supported by social security as an innate local campaigner for protection of York access support as our NHS services moral failure. mental health services and current collapse. With funding levels as they are, What is to me the final poison that shadow defence spokesperson under we have been able to employ another infects the body of local politics is Maria Eagle. housing officer to support these people: privatisation. Local authorities are already housing officers are having to give well-established outsourcers. The new Power, its use and abuse support to those who are mentally ill local authority model will be a fully and vulnerable. This is in jeopardy. This is commissioning council, a council that has Rachael began her lecture with the situation into which it is proposed virtually no employees, its own version a clear message of intent: that she to merge major responsibilities including of a CCG. Local authorities have already planned to persuade us, a key group of health under the devolution funds. privatised many if not all their care homes. health professionals, that we have the The NHS - and yourselves – are aware Charges are in place, means tested for knowledge, the collective power, the of the extent of the disparity between social care. Merging these projects within public support and a duty of care to promise and practice of legalisation. the means –tested and privatised remit take on the politicians such that their Public health budgets are facing a £200 for local authorities opens the clear political objectives are overturned and million budget cut this month. CCGs pathway for charging for health services. replaced by vital clinical outcomes for have failed utterly to be accountable CCGs have a responsibility for making an NHS under threat. or transparent. The NHS was created further efficiency savings form next year. She warned how it is so easy for because local authority provision There will be a reduced core menu of individuals, acting alone, to lapse into a was not capable of coping with the NHS services being funded and anything state of accepting and conforming to dreadful health inequalities across the outside that core is a target to be a agendas set by politicians and others country and there was no universal or mean-testable service. As local authority who take control of communities, as comprehensive health care. departments find themselves providing a survival mechanism for coping with Devolution decisions are being rushed core for services in crisis and for which energy sapping feelings of powerlessness, into without considering whether they are not properly trained, the dangers hopelessness and despair. regional differences can be properly lie in limiting the national character of the As an illustration of this process and accounted for under such a system. NHS - that we will end up providing as a message of how change can be NHS England is talking of withholding a service of last resort for the poorest, achieved she described what happened budgets if specific criteria are not met. losing the universal can comprehensive in the Chicago slums in the 1940s and Local councils may feel they know their service completely and to grasp charging 1950s under the inspiring influence of constituency better than any national as the only recourse and last resort. a Russian-Jewish immigrant Saul Aliskey, government but will they have the whose book Rules for Radicals. written power to argue for budget increases I hope you will agree with me, that no just before his death in 1972 is according to match the fluctuating demographics matter what the rhetoric and promise of to Rachael a” must” to understand how that a national service can currently take devolution, it’s reality and practice is to power transfer is at the heart of political account of? This is set not only against bring to an end the NHS. change. Saul took under his wing a a background of cuts but also a growth group of African Americans living a life agenda which relies on local authorities of serfdom and mafia exploitation and being able to generate extra business helped them form community groups income. There is very little clarity about to begin to challenge their exploiters.

Page 20 AGM and Conference 2015 Paul Noone Memorial Lecture 2015 : Who Holds The Power? Rachael Maskell, MP for York Central (report by Geoffrey Mitchell) He taught them about power and how quality mental health care inspected and parties, trade unions, campaign groups, those controlling their community only declared unsafe and requiring structural communities, academics, journalists, had their power because of a too ready modifications to admission areas in writers ,media personalities We have acceptance of and submission to it, of particular, last year by CQC, who found to take on an educational role with the how it was possible to remove power on a recent revisit that the mandated collective as Saul Aliskey did in Chicago by refusing to accept it, not so much by maintainance work and other safety with Doctors having to realise that they individual action but by using collective changes had not been carried out cannot afford to go it alone, that they power built on trust and confidence and ordered closure of the hospital. have to use parliamentary opportunities within the group. The Vale of York CCG has since then to ask questions, to influence local MPs Turning to politics and specifically the transferred patients, some as far away and attend meetings with Ministers. politics of the NHS Rachael explained as Middlesborough under completely We must hold on to the substantial that holding power and collectivising new clinical teams with major impact on power we have, not be to complicit, power is the basic principle of politics patients rehabilitation programmes and challenge head-on funding shortages, and the basis on which political stress and inconvenience to relatives shaving of budgets, downgrading of staff movements, trade unions and campaign and carers. and be prepared to refuse to accept groups are organised. The lack of coordinated responsibility unreasonable unpaid overtime. We by the different bodies working within should recognise that in our collective The hidden agenda the complex framework of the H&Social objective it is better be” for” something Care Act lies at the root of the closure rather than against --”vote yes” is With the current NHS crisis ,the first with patient care and safety hardly a stronger than “vote No”. Agreeing the task is to define who is setting the priority. issue is the hardest thing but essential . agenda and then to uncover how they In current government-speak, pay Collective action should be smart are achieving it. Rachael has a clear restraint measures are justified as a action. Short of strike behaviour is vision of what is happening:. means of protecting jobs, and job sometimes better than actual strike Jeremy Hunt, Health Secretary, has losses have impact upon patient safety, action. Rachael gave as illustration how a covert agenda of privatisation and is strikes are reckless and accepting that a dispute over night time provision of ruthlessly exploiting patient safety as his staff are needed to work at weekends emergency pathology tests in North repeated manipulating message to the necessitates making changes to terms Wales was resolved by an insistence public, starting with the first message to and conditions -----these are just some that the lab manager would require to be learned from the mid-staffs enquiry, of the devious arguments being used to be telephoned over every emergency namely that the labour Party cannot be achieve the covert goal of privatisation request. The lab manager soon settled trusted with the NHS as the problem ,with outsourcing and running down the dispute! arose under their watch. services through mergers, closures, Rachael concluded: He has calculated that he can expect service reorganisation being justified in “We have done the marches, the public to cling to the memories of public on safety grounds in preparation the protests, the strikes, but the the reported deficiencies in patient for a message to the public that the NHS is rapidly imploding. You have care with safety as a central issue such NHS is failing and that the solution to a duty of care to your patients that no one can argue against whatever provision of safe health care rests with You will put patient safety above measures are being proposed around Virgin care or care UK for example. every consideration. You have the patient safety, whether they be changes understanding to hold your power to clinical service or medical contract. Collective power and not conform or give in. You have Only two months ago he was noted to the transactional agreement to share make 12 references to Mid-staffs with Rachael argued that as Key healthcare your power. You have the evidence, the Health Select Committee. professionals we have to use Jeremy the knowledge, the public support, The charade of prioritising patient Hunt’s case for patient safety against him the1.4m working in the NHS. Jeremy safety has been all too evident locally in utilising an evidence base and a vision Hunt doesn’t have a clue what he is York with Bootham Park mental hospital to challenge these deceptions and an talking about. Who’s National Health a grade 1 listed building with a long identification of and close working Service is it? Organise – and you will distinguished history of provision of high with allies whether they be political win!”

Page 20 Page 21 The Next Few Years – What Should Lie Ahead for Mental Health Services?

The important themes which will 2. Number of psychiatric beds. affect mental health in the next 3. Splitting up of integrated 5 years are those affecting other multidisciplinary teams. largely incomprehensible to anyone medical services: marketisation, other than the person who filled privatisation and fragmentation 1. Management in the form, and which didn’t give of care. sufficient information about any of Section 75 of the Health and Social Mental health services were the numerous items on the list. Care Act requires commissioners to subjected to management The laboriously compiled CPA put all clinical services out to tender interference in medical, nursing documentation was hardly ever unless the NHS is the only possible and social work practice long read by anyone. Every item has to provider. Private contractors win before other specialities. The Care be completed for every patient. It these tenders in competition with Programme Approach (CPA) was was as though if one was shooting doctors, many of whom have never introduced in England in 1991, having an arrow at a target, one would seen a notice of tender. Care UK, been imported from the USA. shoot off arrows in all directions, just Virgin Care and others cherry-pick In the USA the closure of to be on the safe side. Community easy and profitable services such as state psychiatric hospitals was psychiatric nurses spend a substantial diagnostics, routine elective surgery accompanied by the appointment part of each working day at and simple treatments – leaving of largely untrained individuals called computer screens filling in forms of behind A&E and anything that is case managers who were given a little use and of unproven reliability unpredictably expensive. budget to place individuals in the and validity. This is at the expense In July 2015 the NHS Support community. of face-to-face contact with their Federation reported that in the Because of their lack of training, patients. previous year the private sector elaborate paperwork was required Despite research showing that has won £3.5 billion of NHS clinical to check on what they were doing risk assessments make no useful contracts. This total is five times and unfortunately this process contribution towards predicting the amount they won in the first was exported to the UK. Initially it untoward events, when an adverse year of the NHS changes, from was intended for use with forensic event such as a suicide does occur, April 2013-14. Private companies psychiatric services, but by 1996 it the first response of management is have consistently won the majority had become a key component of to ask to see the risk assessment. of tendered NHS contracts. Unless the entire mental health system in Of course what counts is the quality Caroline Lucas’s NHS Bill is passed England. of the service, which is subject to by parliament, there really is nothing With each scandal in the community repeated cuts. positive left to say about the NHS’s that occurred, the paperwork, We need is to get non-professional future. particularly risk assessments, became micro-management out of our hair, What has happened to mental more elaborate. Thus where I we need a lightening up of current health services? This is about three worked there was a listing of risk documentation requirements and problems and their solutions: factors for suicide, homicide and we need a restoration of reliance self-neglect covering over two pages on clinical skill and professional 1. Management interference in of yes/no answers which took far judgement. Arrows should be shot clinical practice. too long to complete, which was directly at the target and not all over

Page 22 the place, supposedly to be on the the problems and a greatly increased inpatient teams and so a patient safe side. use of private sector beds mutiplying seen in the community who required the cost of these admissions. admission would be looked after 2. Psychiatric bed numbers The situation is worse for child and on an inpatient ward and followed adolescent psychiatry: some counties up after discharge by the same In the 1970s there were studies and boroughs have no beds at all for psychiatric team. No more. No from Sydney in Australia, Wisconsin this group. The Five Year Forward View one knows the NHS source of the in the USA and elsewhere showing speaks of investment in new beds for idea to fragment the community that community interventions could young people with the most intensive and inpatient services. I suspect the reduce the number of admissions to needs in order to prevent their being plan was to break up the whole into psychiatric hospital beds. In response admitted far away from where they packages which could be sold off. there was a reduction in bed live or onto adult wards, or what is The split of the integrated service was numbers in the UK, but the reduction not mentioned, their ending up in proposed and speedily implemented. was pursued over decades with police cells. But the Five Year Forward Obviously it is disadvantageous for a untoward zeal by hospital managers View does not indicate from where person in a disturbed mental state to a degree way beyond anything the funding for these beds will come. not to have the same personnel relevant to the research literature. involved in their in-patient care. The fewer the number of psychiatric Not only is it a question of totally beds, the lower the cost and the more “With each different faces on admission, but the Brownie points managers earned. detailed psychiatric history given to Beds became a four letter word not scandal in the the community clinician has to be to be mentioned in polite company. relayed, or repeated, to the inpatient The OECD figures for psychiatric community clinician. In the real world, a lot of beds per 100,000 population for the important information is lost. After year 2011 are as follows: Belgium that occurred, discharge it takes a week or two, 180, Netherlands 170, Norway 130, usually two, for a discharge summary Germany 120, France 90, the OECD the paperwork to be produced, so that following average (which includes countries became more discharge patients arrive in a fragile such as the Slovenia, Poland, Estonia state at the outpatient service where and Hungary) 70 and the United elaborate” the clinician is largely in the dark as to Kingdom 50. what happened on the ward. Where I worked at the Bethlem The suicide rate for any given Royal Hospital, bed numbers were This shortage of psychiatric beds period of time is highest immediately cut to three admission wards serving mirrors the shortage of all-speciality following a psychiatric inpatient a population of 330,000. We had bed hospital beds, so that in 2012 England discharge, so this is entirely the occupancies up to 120%, patients had 51% of the EU average of 27 wrong time to have discontinuity of were asked to move from their countries. France and Germany had care. The re-integration of the two beds late at night and there were far more than the EU average. services would be a goal for the considerable problems in finding Despite the financial shortfall for future. beds for emergency admissions. clinical services, annual NHS spending Unbelievably in that context the on management consultants doubled managers put the case for closing from £313m to £640m between Morris Bernadt one of the three wards. Some of the 2010 and 2014 according to a money saved by closing the ward was Freedom of Information request by to fund the creation of a community David Oliver. [This article is based on a talk given psychotherapeutic resource which by the author at a Keep Our NHS was supposed to prevent admissions, 3. Teams split up Public conference in July 2015 at but which had no prospect of doing Queen Mary University of London, this. The closure went ahead with Previously there had been ‘The next few years – key campaigning predictable results: a worsening of integration of community and themes’.]

Page 22 Page 23 EXECUTIVE COMMITTEE : Elected at AGM 2015 Contact information is provided so that members can if they wish make contact with a Committee member in their area or working in the same specialty.

Mrs A. Athow Dr P.W. Fisher Dr M. O’Leary General Surgery, London Gen.eral Medicine, Banbury Psychiatry, Sheffield 28 Gales Gardens, Pott Road, Hill House, Great Bourton, 185 Chipping House Road, London E2 0EJ Banbury, Oxon OX17 1QH Sheffield S7 1DQ 0207 739 1908 01295 750407 [email protected] 07715028216 [email protected] [email protected] Dr H.J. Pieper Dr A.R. Franks General Practice, Ayr Dr M. Bernadt Dermatology, Chester 53 Ottoline Drive, Troon, General Adult Psychiatry, London (Countess of Chester Hospital) Ayrshire KA10 7AN 8 Alleyn Road, Dulwich, 9a Fulwood Park, Liverpool L17 5AA [email protected] London SE21 8AL 0151 728 7303 (H) 020 8670 7305 01244 366431 (W) Dr P.N. Trewby 07510 317 039 [email protected] General Medicine/Gastroenterology [email protected] [email protected] 24 Hurgill Road, Richmond, North Yorks DL10 4BL Dr C.A. Birt Dr P.J. Hobday 01748 824468 Public Health Medicine, Liverpool General Practice [email protected] 01422-378880 Rose Cottage, Churn Lane, 07768-267863 Horsmonden, Kent TN12 8HN Dr E.J. Watts [email protected] [email protected] Haematology, Brentwood, Essex 01277 211128 Dr C.J. Burns-Cox Mr C.H. Hutchinson 07876240529 General Medicine, Bristol Ophthalmology, Halifax [email protected] Southend Farm, 11, Heath Villas, Halifax HX3 0BB Wotton-under-Edge, 01422 366293 Dr C.P. White Glos. GL12 7PB [email protected] Paediatric Neurology, 01453 842243 Swansea (Morriston Hospital) [email protected] Dr D.A. Lee [email protected] Paediatrics, Whitehaven Dr J.R. Dare The Rectory, Grove Road, Dr D.G. Wrigley Child Psychiatry, London Egremont, Cumbria CA22 2LU General Practice, Carnforth 16 Brookway, Blackheath, 01946 820268 31, Croftland Gardens, London SE3 9BJ [email protected] Bolton-le –Sands 0208 297 2747 Carnforth LA5 8FB [email protected] Dr D.G. Lewis [email protected] Cardiac Anaesthesia, Leicester Dr J.C. Davis Strangford House, 3 Shirley Road Dr P. M. Zinkin Radiology, London Leicester LE2 3LL Paediatrics, London (Whittington Hospital) 0116-270-5889 45 Anson Road, 27 Patshull Road, London NW5 2JX [email protected] London N7 0AR 0780 17218182 02076091005 [email protected] Dr M. R. Noone [email protected] Microbiology, Darlington 41 Cleveland Terrace, Dr M.G. Dunnigan Darlington DL3 7HD General Medicine, Glasgow 01325 483453 Communications Manager (paid staff) 104 Beechwood Road, [email protected] Mr Alan Taman Broomhill, Glasgow G11 7HH 19 Northolt Grove, Great Barr, 0141 339 6479 Dr S.A. Olczak Birmingham B42 2JH [email protected] General Medicine, Boston, Lincs 07870 757309 45 Pilleys Lane, Boston PE21 9RA [email protected] [email protected] [email protected]

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