Deprecated: Function create_function() is deprecated in /customers/9/b/5/ on line 383 Warning: Cannot modify header information - headers already sent by (output started at /customers/9/b/5/ in /customers/9/b/5/ on line 8 An eclectic mix of political commentary, medical developments and life at Denmark Road Wed, 17 Oct 2018 12:06:16 +0000 en-GB hourly 1 Practice List — temporary closure Wed, 17 Oct 2018 10:16:29 +0000 Read More »]]> I have written previously about the pressures of our ever-increasing list – sadly the time has come when we have reached capacity for our present premises as such we have reluctantly taken the extreme measure of temporarily closing our list.

When I last wrote about our concern our list size was just under 9000 patients. We calculated that we could just about manage another thousand patients – for the average practice to increase their list size by 10% would take about 100 years – ie it would simply reflect the natural growth of the population. However our list size has been gradually increasing, on average by 2-3% per annum over the last 20 years and at that rate it would have taken about 5 years for us to reach tipping the critical point – by which time we would have planned to expand our premises or found some other solution to the problem.

Alas, we hadn’t accounted for the pressures of delivering general practice care in a chronically under-resourced NHS. As a result, all practices in the UK are now feeling the pinch – indeed many have closed or simply been engulfed by larger practices. At the same time, that funding has been cut the pressures on individual GPs and their practices has risen considerably. The NHS may say that it wants practices to work in a blame-free culture and freely admit errors and learn from mistakes – but most NHS employees find that being brutally honest with human error leads to a painful and prolonged investigation followed by your P45 (in the post) or being struck off your professional register or even worse.

Not surprisingly general practice is not top of the list for career options for sixth form students or medical students. The government has also not taken into account that the GPs of 20 years ago worked twice as many hours as GPs qualifying today. In part, because my younger colleagues have a far more balanced view of life in general but also because working 50+ hours in a toxic NHS is utterly exhausting. I imagine most people think the pressures arise from the complexities of modern medicine and the consequences of getting it wrong.

The reality is that doctors’ autonomy to decide what to do and how to do it has been seriously eroded by increasing political pressure. We are now extolled to hit various targets / comply with a huge range of new rules and regulations and are inspected to ensure that we comply. Now you may imagine much of my whingeing is due to sour grapes – but the reality is that we have to ensure we are compliant with regulations primarily aimed at hospitals – such as preventing the spread of legionella.

So most young doctors now like to have a portfolio career whereby they spend some time in practice and sometimes doing something else with their medical skills – such as teaching or working in a hospital or as a medical officer in a local company – doctors in our practice do lots of other things apart from seeing patients.

So the bottom line is that 20 years ago the government should have vastly increased the intake to medical schools rather than the modest increase and then set about ensuring that junior doctors were happy in the NHS – I’m sure many will remember it was only a year ago that the government imposed a very unpopular contract on junior doctors – many of whom are now working elsewhere in the world.

So there are fewer doctors doing more work making general practice even more stressful. Hence the GP recruitment crisis. Most practices have responded to these pressures but simply providing that amount of care that they can manage and no more- I know this sounds obvious but it is a philosophical argument which goes like this – there is a bottomless pit of work in the NHS – so if you double the number of available appointments they will simply all get filled and the practice will do twice as much work for no extra pay (we get paid for the number of patients registered – not for how often they get seen) if we provide worse access then only those patient who really need to go to the doctor will actually contact the surgery – so by providing fewer resources you cut down the practice workload.

Alas to manage the poor access you then have to put in place a layer or two of services to manage irate and frustrated patients who can’t understand why it is so hard to see the doctor. Our philosophical approach has always been the opposite – we start from a different standpoint – firstly we do not believe that there is a bottomless pit of work in the NHS and GP – if you think about this for a second it is patently true. And secondly we feel that the vast majority of our patients would rather be doing a million other things than visiting their GP. Our experience is that excellent access actually reduces the practice’s overall workload, which in turn greatly reduces the stress in the building for patients and for staff.

What we hadn’t accounted for is what happens when access in other local practices becomes so bad that even long-standing patients become disgruntled and decide to change doctors.

As a result instead of our list size increasing by about 10 patients a month it is now over 100 patients a month and our new patients have many problems which need to be sorted out quickly. Not surprisingly the pressure on the practice over the last few months has been considerable.

Now any normal business would simply expand its resources and absorb the new work. Unfortunately funding makes that difficult – as our list size expands we are also having to absorb a 20% cut in our total funding due to the government changing the way practices are funded – at the same time the new patients we take on only attract 90% of the funding of most patients due to the fact they live in the Winton area – which is deemed to be a healthy patient group.

In short, as the practice expands it becomes less profitable. We have now reached a point where the physical limitations of the practice building along with the arcane funding formula mean that taking on any more patients could affect the quality of care we offer to our existing patients. patients.

As such for the next 4 months we are not accepting any new patients unless a member of their family or household is already registered with us.

We are looking at possible ways of expanding the premises – but we are also looking at utilising present resources more effectively and working off-site – we are optimistic that consulting via Skype or emails will enable us to provide more accessible and convenient care.

I must stress that the decision to close our list was not taken lightly – we appreciate that it is a huge decision patients make to change surgeries and that many will be disappointed by our decision – please bear with us.

Thank you. 

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Flu jabs Wed, 17 Oct 2018 10:12:58 +0000 Read More »]]> It is that time of year when we start plugging your flu jabs. Usually I remind everyone just how bad the flu can be and rattle off figures about the Spanish flu which struck the world a century ago and killed far more people than the whole of the first world war and most of those who died were young. This is to try and persuade you that the flu can be a really serious infection.

I then go on to mention that if you’re in at-risk group (over 65 years or chronically ill) then you should get yourself jabbed. I usually have a rant at the boffins at this stage about who they choose to vaccinate – because the NHS has always historically targeted those people who are at most risk should they contract the flu. My feeling is that this is like closing the barn door after the proverbial has bolted.

What we really need to do is to prevent flu taking hold in the community in the first place and as such should target people who are most likely to pass on the disease should they get ill – in short rather than immunising the elderly we should be jabbing anyone working in big institutions such as schools and Universities. I’ve been less on my high horse since the government started targeting the really big bug factories – ie nurseries and infant schools – young children don’t have the same concept of personal space and spread the flu with gay abandon.

So this year my rant is about the government’s heavy-handed attempts to force all healthcare staff to get vaccinated. Years ago we encouraged our staff to get vaccinated and paid for their treatment – so on the surface this sounds like a great initiative – healthcare staff are likely to be exposed and the last thing we want is them going off sick in the middle of a flu epidemic.

Alas the degree of pressure being placed on staff is now bordering on the unethical. It also begs the question what is so special about the NHS that its staff gets preferential treatment – surely council workers and private employees are just as likely to contract the illness and infect others. I appreciate that health care workers have a greater contact with those who are ill but I’m not sure that reason by itself warrants such preferential treatment.
It seems to me that the time has arrived to simply vaccinate everybody.

Incidentally this year’s flu jabs come in 3 flavours – the youngest have to snort theirs, the over 65s have a live attenuated version which is a better way to get their immune system to react to the jab and everyone has the standard jab which this year covers 4 different flu strains.

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Dr Avatar Mon, 17 Sep 2018 17:52:03 +0000 Read More »]]> The NHS is broke. Broke in the sense of being chronically underfunded and broke in the sense of broken.

I know the politicians will tell us about us about how they are protecting funding and investing more in the future – but this smacks of too little too late. Even now when I do see money in the system there are so many strings attached that the funds cannot truly be used effectively.

It has always been thus.

The NHS is publicly funded and as such, the argument goes, every penny must be accounted for. Alas this appalling argument means that failure in the NHS must have consequences – failure in the business world is seen as a stepping stone to greater things, a chance to make changes and modify or to simply look elsewhere. The wisdom of companies like Amazon totally appreciates this economic fact – if they have a success rate of 1 in 50 for new innovative schemes they are happy because at the very least they’ll break even.

In such an environment failure is not seen as a failure but as an opportunity to learn and expand. Employees working within such a system know that being brutally honest about the outcome of their innovation is the best way forward.

Compared this to the NHS where a failure rate of 1 in 50 is likely to have serious consequences to your future employability. Employees in this system have to ensure that success or at the very least ‘not failing’ is the outcome. The NHS and healthcare is so complex that clever employees will always be able to ‘spin’ the statistics to ensure they can continue to pay their mortgage. Brutal honesty is not a viable option. Matthew Syed’s excellent book ‘Black Box Thinking’ looks hard at how the NHS handles errors – he rightly points out that the airline industry has made massive steps forward by introducing a no blame culture which seeks to improve systems when errors occur.

As long as a pilot reports a mistake within a given time frame then he/she is protected from prosecution etc. The industry appreciates the greater good is what’s important, not having a scapegoat. The NHS now proudly boasts that it has a no blame culture – but working within the service it feels very different. For example, I have a duty of candour – this means that if I’m aware of something not being right I must report that fact – if I don’t do so then I will have to account for my inaction to the GMC. This duty extends to my concerns about my colleagues. So if one of my colleagues makes a mistake and I was aware of their failings I will be reported to the GMC (f I fail to report them), interestingly my colleague if he/she simply admits to their shortcomings will be treated more leniently.

If instead of whistleblowing, I choose to take up my concerns directly with the individual this can be, in some cases, seen as breaching the duty of candour!! This is hardly a no blame culture – there is no get out clause for doctors admitting errors early on as there is in the airline industry. When you admit an error, every NHS employee knows they are putting their head in the noose. I realise I’m taking an extreme view because changes do occur and organisations do learn from their errors – we have certainly done our best to develop a no blame culture at Denmark Road – but when complaints are investigated externally I despair at the heavy-handed search for a scapegoat or, strangely an almost zealous belief that when a sad clinical outcome occurs then something MUST be learned from the event – the concept that ‘sometimes sh*t happens’ is simply ignored. I’m also appalled that clinicians can be criticised for making less than perfect decisions in a rushed 2-minute telephone consultation by external experts who spends months pouring over records looking for mistakes.

The latest government initiative to make the NHS more open and to reduce its toxicity made me smile and groan at the same time.

The government is concerned about bullying in the NHS, apparently, it’s a serious problem. I would beg to differ, but who am I, I’ve only worked in the organisation for 30 years – when I started bullying was so endemic it wasn’t even recognised. The Lancelot Spratts ruled the profession and the NHS. And they ruled by the power of will and bullying – there was a strict hierarchy.

My training was scattered by numerous episodes of being publicly humiliated. If I were to complain then I knew that my career opportunities would be dramatically reduced because I wouldn’t have possessed the backbone to survive the training and beyond. Even my interview to go to medical school was designed to ensure I was robust enough for the profession. It is daunting waiting to be interviewed when the two preceding candidates have both departed in floods of tears.

Such behaviour in today’s NHS would not be tolerated at all – 30 years ago it was so the norm. But, like all big organisations, which are under stress bullying will occur. Invariably, now, the bullies aren’t all powerful consultants but worried middle managers fearful for the sack looking to control their environment and either deliberately or inadvertently making life hell for one of their colleagues. Now an enlightened organisation would be looking at the working environment and asking themselves whether bullying behaviour is a natural consequence of how they work and if so what can be done to reduce that risk.

Well, you don’t need an economics in health degree to know that most of the toxicity in the NHS comes from 1. lack of autonomy (most initiatives start in Whitehall and filter down) 2. lack of money and 3. targets. Whenever any new initiative comes along you can be sure of two things, the NHS accountants will want you to measure something and that something must then hit a target!

So, if by any chance the new secretary of State for Health and Social Care, Matt Hancock is reading my rantings here is the simple message – properly devolve power from Whitehall – this means making health locally funded with a separate tax and taking politics completely out of the equation. Pump more money into the NHS – via a separate tax (so important needs stating twice). Stop this obsession with targets – hopefully when the NHS truly becomes local then targets will automatically disappear anyway.

So there you have it a proper, respectful way to stamp out bullying in the NHS – which simply addresses the underlying problem.

I admit that my simple solution may take a little while and a lot of effort but I still prefer it to the government’s strategy which has only one thing going for it – it is simple.

Which makes me feel like I’ve come back to the beginning of my article ie a simple ambiguous statement where both ambiguities are true. The government’s strategy is simple in that it can be described in a single sentence and simple as in half-witted, ill thought out simplistic.

So here it is. The governments master plan to eradicate bullying is to sack managers who fail to stamp out bullying in their organisation. Or to put it differently, the government plans to stamp out bullying by bullying managers. And hey ho, we’re back to the NHS of 30 years ago where bullying was so endemic that no one realised they were the bullies. But I guess bullying is endemic within politics so it’s hardly surprising.

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Teenage Madness Mon, 17 Sep 2018 17:45:11 +0000 Read More »]]> When I first started as a GP 30 years ago it was unusual for me to see any children (oops sorry young people) with mental health problems. When they did present they were often very ill with the beginnings of a serious mental illness such as schizophrenia. The support services were excellent and would see everybody really quickly.

Over the years there has been a steady increase in the number of teenagers I’ve seen with utterly disabling anxiety, depression, and suicidal thoughts. What was a rarity a decade ago is now commonplace – to such an extent that specialist services are no longer able to cope. Just feeling suicidal no longer gives you a ticket to getting expert help and support – you have to have made a significant attempt on your life to warrant an expert opinion.
Alas whilst this tsunami of adolescent angst has been growing funding to vital services has been neglected or even cut. We’re now left in this perfect storm of rising demand and diminishing resources.

As GPs we feel overrun but we only see a small tip of a huge iceberg. Two of our children decided that teaching maths to the next generation would be a great career to follow, but now both have left the teaching profession due to the stress that frontline teachers face with rebellious stressed out pupils. Once again our political masters have only introduced measures which make the situation much worse and do not address the underlying problems.
And what are those underlying problems?

We are a nation which has become obsessed with measuring stuff and then complaining that standards are not being met and our children are the ones who have been most affected.

School should be a relaxed place where your curiosity of the amazing world we live in should be encouraged, nurtured and developed. We’ve known for years that the best ways for children to achieve their potential is to be rewarded for their curiosity and effort. Yet we have a system which seeks to make everyone conform to a stereotype and pass exams – we do not reward effort we only celebrate success. And success in the modern age is increasingly being seen as your score at passing tests. We have developed an educational system, stating at 3 years which is constantly trying to measure stuff in an attempt to improve it – the irony is that by so doing so we force out curiosity which is the vital spark to creativity and innovation.

We should be doing everything we can to encourage diversity of thinking, we should celebrate those individuals who think differently for they could be our future. But our educational system is hell-bent on getting our young curious minds to conform to the norm. Sadly that norm is now increasingly being set by social media.

The government may be obsessed with targets but our children are increasingly becoming obsessed about their Facebook profile. Not surprisingly these profiles have become a poor representation of the real world, but it is one our teenagers now have to aspire to – but the reality is that life is not perfect. As an adult, you appreciate that life’s rich tapestry is what makes life so rich, without the downs you cannot fully appreciate the highs. These are lessons we learn from our childhood experiences but these experiences are being warped by social media. Now our teenagers can be forgiven for believing that if you are not living life in a permanent state of fulfillment then you are a failure.

So the CCGs initiative to fund Kooth an online resource for 11-18 year old is a great idea. I would encourage anyone teenager who is suffering emotionally to visit their website –

The only drawback is that the first patient I recommended to access the site was ineligible because they were too young – amazingly the fastest growing suicidal age group in the practice is our under 10-year-olds. It is almost unbelievable that children under 10 in well-supported families express thoughts to their loving parents that they would be better off dead. Hopefully, Facebook will wake up soon to this catastrophe that they have unleashed on the planet, but in the meantime, could excellent organisations such as kooth develop a platform for junior and preschool children as well.

Alternatively, our beloved government should completely overhaul their obsession with targets, but sadly there’s as much chance of that happening as them cutting targets in the NHS.

In the meantime, if you are (or know) a teenager who is suffering then please make sure they are aware of the excellent support and help which is available online through

As it is a new service (for Dorset) I would be grateful if patients could share their experience of the service.

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Parkrun Practice Wed, 01 Aug 2018 10:57:34 +0000 Read More »]]> Regular readers will know that I have extolled the benefits of exercise for a long time. If exercise were a drug it would be unethical not to add it to tap water. Roughly speaking regular exercise, 30 mins x5 per week sufficient to make you feel short of breath, halves your risk of heart disease, stroke, diabetes, hypertension, cancer (almost certainly all forms of cancer) and you feel better with less anxiety and depression. Wow.

So anything which encourages people to exercise gets our backing – for purely selfish reasons the more you exercise, the less work we have to do!! Regular readers will also be aware of Parkrun – a brilliant initiative started about 15 years ago at Bushy Park in London. Every Saturday morning at a variety of venues in the UK and around the world runners, joggers and walkers all come together to run, jog or walk 5km. The aim of the run is to simply enjoy a run, invariably the person finishing last gets more plaudits than the one coming first.

The Royal College of General Practitioners has now also acknowledged the important work Parkrun has done for the nation and is encouraging all General Practices to become Parkrun Practices. As more than half of our staff already regularly Parkrun we are keen to embrace the initiative – effectively all practices have to do is to encourage staff and patients to take part in a local Parkrun.

I think we are officially linked up with Bournemouth Parkrun which meets at Kings Park and starts just opposite the athletics stadium. Many of our staff (and patients) live in Poole, in which case you might want to take part in the Poole Parkrun at Poole Park – you can’t miss it – 800 people regularly run here.

Finally, there are 2 other local runs – Upton Country Park – which I haven’t yet run but sounds really interesting and my favourite Moors Valley Parkrun – it is quite a hike out of Bournemouth but it is the most beautiful of the local courses.

Good luck. 


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Vets and Pets Lessons for us all Wed, 01 Aug 2018 10:52:06 +0000 Read More »]]> As regular readers know now that our kids have well and truly left home we’ve replaced them with surrogates namely Mitsi and Milly our cockerpoo and caverpoo respectively.

Pets have the most amazing ability to enhance human well-being. The genius who isolates the gene in dogs which controls their default mood mode ie ecstatic happiness, will simultaneously become a billionaire and put the pharmaceutical antidepressant industry into bankruptcy. Wouldn’t it be wonderful if humans had that same fantastic love of life? For dogs, the glass is never just half full it’s always brimming over.

All of this was bought to my mind recently when a patient complained that for all the good we were doing him he might as well see the vet who undoubtedly looks after his pet better than we can look after him. I have a degree of sympathy for this view.

One of our dogs recently had a bout of diarrhoea, we treated her with some magic probiotic paste and within a few hours she was better. I was tempted just to squirt some on my toast, but the smell is pretty off-putting and I can’t help but think that the bugs in Milly’s intestines are probably quite a bit different for the ones in mine. The reason that dogs can eat raw meat and not get ill is that they have genes which help them to break down all sorts of nasty things. Humans lost those genes when we started cooking our food almost 2 million years ago,  I say lost them they were actually diverted into many other purposes instead.

I’ve also felt for a long time that we are much better able to manage suffering in our pets. If you allow a pet to suffer it is immoral and illegal. Sadly humans are not treated with the same respect. Now I know many of you will be shaking your heads in disbelief how can an experienced GP say such things about how society treats some of us; surely I, more than most, should know how to reduce suffering.

Sadly there are many times when I see suffering and I am impotent to help. Such as some patients with advanced dementia whose brains have failed but their bodies are still going strong. Or patients in a persistent vegetative state who are being kept alive by artificial means.

Science has long proven that we are our brains. Brain injury can profoundly affect who we are and when our brain has failed there is very little left of what was you. Our dogs would not have to endure any suffering, one compassionate injection and they are released from their torment. I welcome the fact that patients in a persistent vegetative state can now be allowed to end their lives without recourse to the Court of Protection. However, it seems inhuman that we then allow those individuals to simply starve to death, a process which will probably take days and make take weeks.

I have felt for a long time that assisted dying/euthanasia is the most compassionate way forward. Alas this flies against the philosophy of certain religious groups and is opposed by many people on the grounds that it is the first step on a very slippery path. Their argument goes along the line of where do we draw the line – it is one thing to end the life of someone who is effectively already brain dead but it is another to end the life of someone who wants to avoid their children losing their inheritance to nursing home fees.

I couldn’t agree more. But they are missing the point, once you appreciate that there is one instance in which it is compassionate to end someone life in a dignified way prematurely then you have accepted that the premise of euthanasia / assisted dying is appropriate for at least one individual. Then the only other decision to be made is where you draw the line of what constitutes a compassionate act and what is murder. This is obviously a very challenging line which will be highly contentious, but just because it is difficult does not mean that we should simply shy away from making a decision – which sadly Parliament has repeatedly done.

The greatest shame is that the only option very ill patients with conditions such as motor neurone disease and dementia have at present is to go abroad. But to be able to get on a plane and visit a clinic in an industrial site miles away from home, inevitably means you will end your life many months sooner than if that same service were available in the comfort of your own home.

When will we treat patients as compassionately as we treat our pets?

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Form Rejection Form – The Antidote to Ridiculous Bureaucracy Wed, 01 Aug 2018 10:47:36 +0000 Read More »]]> I had a most interesting discussion with a senior colleague recently. We were discussing the frustration of working within a broken system and what we could do to make life easier for us and our colleagues. He has come up with the ingenious idea of a form rejection form.

The NHS is in complete meltdown. Waiting times are going up. Hospitals are blowing their budgets. New systems are simply introduced to manage systems which are failing – rarely is patient care at the forefront of these ventures.

We now have to cope with referrals being bounced back to us for a variety of falsely constructed reasons eg

  • We’ve filled out the wrong form (because its recently been changed) – 20 years ago the forms didn’t exist but if they had the hospital department would have had the flexibility to accept referrals in any format.
  • Or the patient failed to complete a form sent on to them – this is a favourite of the pain clinic.
  • Or the referral hasn’t followed the correct procedure – ie they should have been referred onto something first – the new musculoskeletal service is a major culprit – almost every referral is bounced back because we haven’t tried physio first – usually there are two reasons for this, one is that we simply know physio isn’t going to help and the second is that NHS physio is also broken, there is a 6 month wait for routine appointments.
  • Or the problem simply doesn’t meet the threshold of what’s required – for example, unless your adolescent child with mental health problems is floridly psychotic or suicidal they are not ill enough to warrant a specialist opinion. Adult mental health services are similarly overrun.
  • Or …well you get the idea.

General practice does not have the same luxury of being able to bat the problems back in the same way – until now. Following my discussion above we are in the process of developing our own ‘form rejection form’. In future, we will not accept that our referrals have been bounced back to us until our colleagues in hospital complete our form rejection form.

We are taking a few tips from various government departments and are aiming to ensure that our form rejection form can only be completed by senior doctors or chief executives of local trusts – the simple form will only be 50 pages long and should take no longer than 2 hours to complete. If, of course, there are any errors then the form rejection form will be rejected – with no indication as to why it’s been rejected. #

Most importantly we will ensure that the ticking clock which is set the moment we refer on – this is the same clock that Tony Blair’s government installed and is linked to financial penalties on hospitals, will be not be stopped when the original referral was rejected.

The form will only be available on an obscure tab on our website and must be completed online.

All I now have to do is to persuade all the other practices in the UK to adopt our new form!!

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NHS – A political football Sun, 01 Jul 2018 10:43:01 +0000 Read More »]]> I have complained ad nausem about the NHS being used as a political football, kicked around every so often for this or that party to get elected or unelected.

The metaphor works pretty well. The NHS always seems to bounce back no matter how much it’s kicked around. Most politicians seem unaware which side they’re on and which way to kick the ball, most often scoring an own goal

The football bounces around in the middle goes this way and then back again but rarely making any progress. When I think of the NHS I think of the really old leather footballs which weighed heavily and sadly caused premature dementia for a number of professionals who headed the ball too frequently.

In other words, a nostalgic feeling that this is a great institution which has been around for a very long time and although it is undoubtedly to be admired mainly because of the selfless people it employs its primary triumph is that it provides a reasonable standard of care on the cheap. Many of us feel it is what makes the UK great but surely if that were really the case wouldn’t other countries around the world be reinventing their own NHSs’.

We all know that the NHS needs to change but my concern is that the present team in charge seems more concerned about changing the rules than playing the game better.

Maybe we having something to learn from another institution we invented, football itself.

I write this newsletter just after England triumphed against Sweden to find themselves, somewhat unexpectedly in the world cup semifinals. Throughout their campaign, I have been impressed with the quiet way their modest manager has gone about his business.

Football managers of the past have relied on egos and bullying to get the best out of their young charges. Such tactics work well until something unexpected happens on the pitch, such as Iceland scoring against us in the European Championship. In this situation, you need the players to be able to think for themselves, but if the manager has bashed that out of them then there is no flexibility or second plan. Gareth Southgate really does understand people management. He knows that to get the best out of his team, each individual needs to feels autonomous and feel an identity to the team. In his England, the sum of the whole really is much greater than the sum of the parts.

The team has no superstar, all of the squad are reasonably good professionals but there is no stand out individual who personally carries the responsibility of the whole nation on his shoulders. The media and the public have got so used to England teams underperforming,  so much so that public expectation was subzero, which has in turn reduced the pressures on the team.  Couple this to the fact that we have been unbelievably fortunate with the draw, now everyone is dreaming that the team could go even further!!

You may ask what this has to do with general practice, the NHS and so on. For years we have underperformed as a football nation because we have failed to understand the system in which we played. Germany has won so many tournaments because they’ve understood these underlying principles for years. Alas our management of the NHS is still stuck in the days of Fabio Capello, a domineering system which is convinced it knows best.

We need Gareth Southgate’s team to go even further, to show that great man (person) management can achieve more than the most talented of individuals and that such systems should be introduced across all areas of Government but most especially health and education.

Allowing our really talented professions to achieve what they are really capable of, means giving them greater control and autonomy just as Southgate has done with the England team.

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Dr Avatar Sun, 01 Jul 2018 10:37:06 +0000 Read More »]]> I don’t know about you but 50% of the calls I receive requests to help me with my recent accident or PPI insurance or whatever.

The latest conversation went something like this;

Hello it’s Dr Cowley


Hello it’s doc-tor cow-ley.

Its strange but when I think the person on the other end of the phone is struggling with my accent / attitude / or whatever I tend to speak slower and louder. I guess the usual Englishman abroad sort of speech.

Hello we’re just phoning about your recent accident, we should be able to help you.

Ahh I think you’re cold calling me and even though you sound human I’m not sure that you are.


I’m going to give you a test, if you get the answer right then I’ll continue talking to you. Can you tell me what the weather is like outside?

OK, can we help you with a possible PPI claim instead.

At which point I thought this is just like talking to someone from the 111 services but instead of a teenager on minimum wage following a rigid script they’ve gone for an even cheaper alternative of, well, just a talking algorithm.

But what was really impressive was that her voice sounded completely authentic. I have no doubt that the majority of people would think they really are talking to a real person. I’m sure if my default wasn’t just to be rude and antagonistic I would have been merrily talking about my last car accident about a decade ago.

Which got me thinking about the future of health and social care. We already know that witnesses who are interviewed by an avatar rather than an experienced police officer actually have 40% better recall of the event. It transpires that we humans do our best to please or impress other humans and have a habit of making things up – which is ok in the work environment when you’re discussing the enormous trout you landed at the weekend, but isn’t ok when you’ve just given an inaccurate description of a murderer.

So I suspect our doctors, nurses and telephone support services of the future are more likely to be friendly avatars rather than the real thing because not only are they a lot cheaper they also do the job better. I have always warned training doctors about the downside of videoing your consultations – the positive is obvious you get an opportunity to eavesdrop on your consultation as a third person. The negative is just as obvious, you get an opportunity to eavesdrop on your consultation as a third person!!

When I first saw myself on tape (yes we used tape back then) I was a complete wreck for a couple of days afterwards. In my mind’s eye I was a heady mix and Clerk Kent, Sherlock Holmes and Dr Kildare, however, the reality was a not so heady mix of Mickey Mouse, Donald Duck and Goofy. It took a couple of days for my subconscious to rewrite the story so I could return to the fantasy of my superhuman self who could manage any problem that presented to me.

The difference was that I spent a little less time putting my finger in my nose and impatiently looking at my watch!! I mention this because although I may think that I’m still that heady mix of Superman, Supersleuth and Superdoc your personal doctor avatar really will be that good. In this new world, fantasy becomes reality and delusioned dinosaurs, like myself, will, by comparison, be second rate.

This is not the first time that my expertise has been usurped by a computer. A long time ago I used to be a reasonably ok chess player, several years ago I realised that even though I thought I was good, I really wasn’t going to cut it in the real world of chess grandmasters because a cheap computer program had just thrashed me. A few years after that a much more powerful program, IBMs Deep Blue, beat the world champion Gary Kasparov.

In some ways, this should have marked the end for professional chess players, but surprisingly chess is just as popular and active now as ever. Man and machine have formed a synthesis – the computers get better and better, but so do human players who are better able to understand deeper complexities in chess because of their more powerful chess computers. The present world champion, Magnus Carlson, is the highest rated human of all time. I suspect that the future for medicine will involve exactly the same synthesis of carbon and silicon-based brains for the benefit of all.

So perhaps for most of us, the future of medicine is actually in good hands, even if those hands are more virtual than physical. The only patients who are likely to be worse off are the stroppy ones who after a couple of minutes decide that their new physician really needs to pass the Turing test before they’re going to divulge such intimate details as the colour of their poo.

So a few retired and stroppy GPs asking what the weather is like outside will probably not be too impressed with tomorrow’s health service.

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Lancing A Painful Boil Fri, 01 Jun 2018 10:27:26 +0000 Read More »]]> When I first started writing a few years ago I remember being cautious about saying anything controversial for fear that someone might take offence and I’d be shopped to the GMC.

Over the years as the consequences of being struck off have diminished (children left home etc) I have felt freer to let rip – indeed I now realise that being uncontroversial and not voicing your opinions is, from a writing perspective, boring. And being boring simply means I won’t enjoy writing and the few regular readers of the Denmark Doctor will diminish further. There are times, however, when I think might have strayed beyond the edge of controversial and this month’s newsletter is one of them.

It boils down to the fact that I don’t write for you, I write for me. This newsletter is quite simply a cheap way to get psychoanalysed. Rather than forking out £50/hr  lying on a couch and chatting about what it felt like to be breastfed to some Freudian shrink, I blurt out my frustrations in print instead. Just putting down your thoughts on paper is remarkably therapeutic. Firstly you have to get them into some order for them to make sense and secondly having put proverbial pen to paper it’s like having a boil lanced, the emotional pain you were suffering is eased. And working in the NHS in the 21st century you need to lance a lot of boils to stay sane. This month a particularly painful boil which has been growing for a long time needed lancing.

I have become increasingly angered by the actions of our government over the last decade – it is as though the desire to hurt and punish by some right-wing ministers was unleashed by the 2008 economic crisis and the decade of austerity which has ensued.

Life was different back in 2008. Primary care or general practice was better funded, the NHS was better funded. I was a Conservative councillor. There was a lot more money sloshing around society. Then the sub-prime bubble burst. The overstretched banks finally had to admit that the economic emperor wasn’t dressed in magnificent finery but was completely and utterly starkers. The banks had known this for years but with easy profits to be made by selling ever expensive clothes to the emperor, who in their right mind would point out that his new suit was just a figment of the imagination.

This economic disaster will still have far-reaching consequences to come, it has already affected the lives of billions, many have suffered enormous hardships and yet the perpetrators of the disaster have walked free without punishment and indeed many were paid off. In the UK taxpayers forked out billions to save banks which were too big to fail.

In the States their economy recovered more quickly because President Obama injected a series of measures which stimulated their economy. Although in the UK we did print money (quantitative easing) to stimulate the economy we also embarked on an unprecedented program of austerity measures based on the flawed hypotheses of a now discredited PhD economics paper.

Looking back it feels as though these austerity programs have been instituted by a group of politicians who feel that all individuals should primarily be able to look after themselves and not need to turn to the state for support. They have sought, over the last decade, to weed out benefit fraud, send back immigrants who are solely in the UK to fleece taxpayers and so on. As a result, the UK of 2018 is a very different place – we have given 2 fingers to Europe because of …. basically David Cameron trying to cozy up to his xenophobic backbenchers and here are a few other changes

Education – 40% of teachers leave the profession after a couple of years. I have a son and daughter both of whom taught maths in secondary school and left after 2 years. They had been sold a romantic dream of inspiring the next generation. The reality was having to follow a national agenda, largely driven by Michael Gove, and managing an overly bureaucratic system.

Far from inspiring kids, oops, young people (to use the latest PC term), they spent most of their time simply trying to control them. I am now starting to realise that the epidemic of teenage anxiety which is rife in the UK is not just due to the perfection pressures of social media but is a direct consequence of the UK austerity measures. The simple fact is that the group which is most affected by the government’s policies over the last decade is the poorest. The children of these families are most affected and their dissatisfaction is spilling over into school. This disaffected generation will have an impact in society for decades to come.

It is a worrying fact that the real reason violent crime in New York city has declined over the last 2-3decades is not that New York was tough on crime but because they eased their abortion laws in 1973 – as a result there were simply fewer young, disaffected and angry men to commit crime.

Over the last decade, we have produced a series of measures to create a lot of disaffected young men. It is no surprise that violent knife crimes are on the increase amongst teenagers. We now have laws that fine parents of children that do not attend school – even though that non-attendance may be the result of severe poverty or disease. The government knows that its measures have these possibly unforeseen consequences yet chooses to do nothing about it.

Benefits – Ian Duncan Smith, no doubt, will claim that the benefits system has been changed to be fairer, so those who are sick will get the support that is their due. Alas as a practitioner on the coal face this is not my experience. I may be naïve but I don’t really know any benefit scroungers.

Almost everyone on benefits would rather not accept a hand out from the government, especially this government, but they have little choice. Alas many of them now find it really difficult to make ends meet. Their assessments are almost bordering on the comical, I have an image of Monty Python’s black knight fronting up without arms and legs and being found totally fit to work any job. The assessments seem to completely ignore that patients with mental health problems can be severely disabled. The whole system is geared up to be imposing and demoralising.

Can there be any doubt that the increase in suicides over the last decade is related to this toughening of the benefits system? 80% of our patients who appeal their initial assessments have them turned over – the cost to the individual and the taxpayer is enormous. This is a system which costs a fortune, saves nothing and delivers misery. Charities have been complaining for years, the government knows what is going on and yet still does nothing.

Heath – regular readers know what a complete mess up has been made over the last decade. Only now when the NHS is on the brink of collapse and the government is realising what a complete calamity it will be,  come the next election, are they listening. I can’t help but feel that their intervention will be too little too late.

Immigration – ok I get it. We live on a little Island and there is only so many people we can support. But the question is how many people can we support? The naysayers argue that we can’t support our present numbers, but actually, technology will deliver ever better ways to feed, care for and manage our population. Most of the UK is green land – ie we have not run out of area.

The reality is that we could easily support a much larger population. But our present immigration rules are bizarre especially when trying to attract highly skilled workers to the UK for jobs which cannot be filled by UK graduates. Our hospitals desperately need doctors from abroad to help fill empty posts. These hospitals have gone the extra mile to fill the posts – often with ethically driven goals ‘come to work for us for a couple of years, you get great training which will benefit your own country, we get doctors who treat our patients for a couple of years – these are win win schemes which the NHS supports.

Alas the Home Office is tough on immigration. So there is a cap on skilled professionals who are allowed into the country without any consideration other than an arbitrary number. Theresa May was the architect of the barmy policy when she was home secretary – its sole benefit is to provide a good headline for the conservative party conference. Its disadvantages are legion – asks the health service, the universities, business and so on.

The government has been told for years that this policy is crippling the country, but they cannot listen for fear of being perceived weak on immigration in the popular press. I sometimes wonder who is leading our country? Theresa May or right wing tory backbenchers or Paul Dacre from the Daily Mail?

I’m sure you can all cite just as many areas where the government is failing us. In part, it is due to a broken political system where we all feel disempowered and psychopaths are the only people who can make it to the top. As present as bad as the incumbents are there doesn’t seem to be a viable alternative – but I’m fast coming to believe that anything may be better than what we have.

I have previously judged governments against the wart test – put simply the gold standard for treating warts is doing nothing – in the fullness of time they get better by themselves. The secret is to resist the temptation to treat. Good government is just the same – if a government can leave the country is as good a state as when they arrived that is a success. Alas, the desire to do things often has the exact opposite effect. This government fails the wart test.

What good government understands is that society will make progress of its own accord.

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