Cameron's myth number one

Someone in this country is twice as likely to die from a heart attack as someone in France.

David Cameron
Letter to doctors in England

So says Dave. As is so often the case, politicians never tell you where their data comes from - especially if it is a bit suspect. These data are, of course, very suspect. Every doctor knows that there is something odd about data on heart attacks from France. It even has a name: the French paradox. Dave's researchers have obviously trawled about for data that enable our prime minister to slag off our National Health Service in a vain attempt to justify yet another reorganisation. It cuts no ice with doctors because we all know that the country he has chosen to compare us with is a paradox.

But Dr Grumble is also prepared to play this childish game. Let's look at the trends. They are nicely depicted in the graph below.

By next year our heart attack deaths will be lower than those in France. OK. Dr Grumble knows. There is more to this than health care. But this example should never have been used to slag off our NHS. Two can play at this game, Dave.

Oh, Dr Grumble nearly forgot. We have achieved this on less spending on health care than France. According to the latest figures France spent 28% more on health than the UK. Doesn't that bust another of your myths, Dave?


Reference

BMJ 2011;342:d566

Letting the cat out of the bag

Aware of the growing concerns doctors have about yet another tranche of NHS reforms, Andrew Lansley has been desperately trying to get his grim message across as best he can. In recent weeks Dr Grumble has been unable to escape the Health Secretary who seems to be on both radio and TV at every opportunity. Hands-off Dave seems to be so worried that he has been trying to use his clout to bail out the hapless Health Secretary. It does not help that they have not really been honest with us. That creates suspicion.

There are a great many very reasonable concerns about Lansley's plans. Foremost in the minds of many would be why we need yet another reorganisation. We all know that, even if reorganisations work, there is usually a fall-off in performance before any improvement. And a lot of money is wasted on the reorganisation itself.

To create even more suspicion there is the perception that Andrew Lansley has been beavering away largely on his own with his misguided grand plan for the NHS. It certainly does rather seem to have been sprung on us all - including, perhaps, our prime minister. Given this background, it was not unreasonable for a specialist trainee to have asked Mr Lansley the following question:

In such times of financial austerity, why are you ring-fencing several billion pounds for yet more structural reform of the NHS?

To Dr Grumble it seems a perfectly reasonable question. It would have been quite possible for GPs to have been much more involved in commissioning without this level of upheaval. So what is the real purpose of such a costly change? While Dr Grumble does know the real purpose of the reorganisation, Mr Lansley's actual answer was something of a surprise. The interview is available only to doctors so presumably he knows that we, unlike most of the public, know what this is really about.

So here is Lansley's answer to what appears to Grumble to be a perfectly reasonable, innocent question without any side whatsoever:

Yeah, well, I can see where that question is from. It's called public good private bad and, um, you know, it's not quite like that actually....

So there you have it. In response to a question that was not in any way about privatisation but about the costs of the reorganisation, the cat is let out of the bag. Money is being set aside to privatise the NHS.





When it comes to privatisation of the NHS the ConDems, following New Labour's example, talk in riddles. The reason is that they don't actually want the public to know what this is all about. That's why the Lansley plans appear to have come out of the blue. They did not want the electorate to know what they had in mind until they had been elected - which is not very democratic really.

Dr Grumble has been aware of what all the parties have been planning for our NHS for years. At one time nobody believed him. Now it is too late to do anything about it.

Why don't politicians practise what they preach: no decision about us without us?



Reference:

Interview given by Andrew Lansley to dnuk in November 2010

Thanks for the info, Dave

Many thanks to Dr Tom Kirk for this response to the Prime Minister's letter to doctors in England.


Firstly, the patronising "myth-busting" tone used in this letter is disgraceful when addressing professionals. Instead of acknowledging the issues and problems with his rushed plan on a level basis, he seeks to instruct us where we are wrong. As other commentators have pointed out, how his training in PPE prepares him for the largest reorganisation of the world’s third biggest employer is lost on me – but apparently Dave knows it all.

The myths as he puts them are only there because the white paper is as vague as possible - to allow for post implementation changes to suit and woo private investment - such as large scale privatisation and hospital closure.




Response to "Dave's Myths"


Myth 1 – NHS is fine as it is

Dave says change is necessary.

This is a statement of fact, but not an indication of the needed direction of change. To state that change is necessary in health care is stating the blindingly obvious - its probably one of the fastest changing industries there is. However, this is not an excuse to rush through untried ideologically-based ideas.

The phrase "despite spending the European average on health, some of the outcomes are poor in comparison" is particularly odious. Yes, levels reached in spending do hit the enlarged EU average, and yes we are not top of the league table for all outcome data (though we are top, or near top for a fair few).

But here is a list of countries which spend more than the UK (8.7) as a percentage of GDP on health.(1)

France 11.2

Switzerland, Austria, Germany -c 10.2

Belgium, Portugal, Denmark, Greece -c 9.7

Iceland, Netherlands, Spain, Sweden - c 9.1


What's more levels of spending in these countries have been at these levels for a while, and most of the data the Dave is quoting uses 5 year survival data. With time for follow up, gathering a cohort, and analysis the lag is probably in the region of 10 years.

So, here is what Dave is doing. He is judging the NHS on results 5-10 years old, obtained when levels of spending in the comparator countries was substantially greater than NHS spending.

Even if "Dave’s" analysis wasn't completely flawed, and we aren't ahead in all areas relative to spending - demographical differences (obesity, diet etc) account for most of the apparent health inequalities.

If we go along with Dave for a second time, and say that we do have the same historical spending as the EU average, and the same demographic make up, he offers us no compelling reason to accept his model for future care over any other one.

Repeated non partial analysis of health care systems have found that the most efficient care systems are ones that don’t involve private companies, have a single payer (government), don’t waste money on duplication, and don’t waste time on calculating the exact cost of every ‘health interaction’. (2,3, 4)

Of interest is the prediction (2) in 2008 that a government will come in, use the word “unsustainable” to describe current funding arrangements, and then force through unwanted change on the back of this.

Indeed a recent health committee report entitled “20 years of costly failure” recently asked the question: What benefit has commissioning brought? It is hard to establish what the benefits are, if they exist, and if they outweigh the significant outlay in cost and time that has been put into the commissioning process.

It is all ideologically driven changes - as the son of Thatcher he thinks that anything private is better than anything public.


Myth 2 – Plans out of blue

Dave says: Plans not out of the blue.

All Dave offers here is “I disagree”, followed by comparisons to failed fundholding, and commissioning under the labour government, glossing over the largest ever change to the structure of the NHS, and abolition of most of the management structure.

“Our plans simple build on these advances” – yes in the same that Marxism simple builds on the idea that sharing is good.

How much of this not-out-of-the-blue change was in your plan, Dave?

Myth 3 – That the plans are untested and implemented too fast

Dave says things aren’t untested and too fast.

Dave’s argument here is that its two years in the future – on the assumption that two is clearly enough time to do anything. He glosses over the fact that there are no significant trials of this system that show it works, and that it’s all based on guess work.

In the process he is making a mockery of the carefully built evidence base that has been assembled, and is completely giving up on the noble ideas of evidence-based policy – returning the NHS to a political football.


Myth 4 – GPs will spend all their time on paperwork.

Dave says not true.

GPs will apparently be given extra resources to cover this part of the job. Presumably these extra resources will come from those saved by axing all the PCTs. Oh hang on – wasn’t there an analysis that stated that it will actually cost money to axe the PCTs? The response Walsh published suggested that the cost of reorganisation will cost 2-3 billion, and that even if the savings come in as planned, which is unlikely, we will still be spending more money than saving this parliament.(5) So the money for the extra staff needed for this will come from the clinical budget then.


Myth 5 – That GP’s will be forced to work with Private health sector companies to help them with commissioning.

Dave says nothing could be further from the truth.

I believe him on this. GPs won’t be forced to work with private companies. They won’t have to be forced. With PCTs and SHAs gone, there won’t be anyone else but private companies. No forcing from government is required as the practicalities and the situation they have created will do it for them.

One more thing mentioned in the letter by David Cameron is the repeated use of phrases such as giving the professional “much more freedom to care for patients in the way you decide is best”.

It is clear that this freedom will relate to a small group of influential GPs in each of the consortia who will set local agendas. Already my local consortium is sending various money-saving "tips" to each practice, and the constructing tables and graphs of each practice performance of these.

An example is statin prescribing and the percentage use of simvastatin over all others. The ranking, use of encouraging language and style all give the impression that those practices prescribing the highest percentage of statins as simvastatin are the ones that are succeeding and doing the right thing. This is not true from a patient point of view, with those practices excelling at cholesterol management and prevention of heart attacks likely to appear at the bottom of the list. This extreme budgetary focus will negatively impact patient care, and encourage price control over patient benefit.

I fear that where PCTs were unwilling to interfere with clinical decisions, the leaders of the consortia will not have the same reluctance. Whether this is a good thing or not is debatable. Whether this leads to setting the professional free is not a debate - it will only restrict the abilities of day-to-day GPs and hospital doctors.


Of interest are a number of things NOT mentioned in the letter:

1) What happens when GP consortia fail? This is bound to happen as whichever formulas they use to work out budgets, some area will have a natural deficit. On top of this some areas will inherit deficits that may make budgets unworkable.

a. Answer is – they will be taken over as failing consortia by private health companies


2) What happens to training, when all easy and profitable routine work is contracted out to private companies?

a. Training will worsen, doctors will become under-skilled, patients will lose out.


3) What happens to NHS hospitals and departments if they are outbid by private providers?


a. Answer is – they will close, and give a nearly complete local monopoly to the private provider






References

1) http://www.ingentaconnect.com/content/oecd/16080289/2010/00002010/00000021/8110161ec043;jsessionid=1i6jeq11hmqhu.alexandra

2) http://www.bmj.com/content/336/7658/1410.full?rss=1

3) http://www.parliament.uk/business/news/2010/03/20-years-of-costly-failure-mps-verdict-on-nhs-commissioning/

4) http://www.bmj.com/content/342/bmj.d7.full?sid=a3f1af1d-d547-46cb-8495-f908459e1510

5) http://www.bmj.com/content/341/bmj.c3843.full

NHS Cuts

A letter to Dr Grumble from the Prime Minister

OK. The letter is not just to Dr Grumble. It is to all doctors in England. It is good of him to write. Perhaps he is getting a bit desperate. Here it is:

Dear Dr Grumble,

This month, we published the Health and Social Care Bill, which sets out our plans to modernise the NHS to help it deliver truly world-class care for people. Running right through it is a new deal: we want to give you - the professionals - much more freedom to care for patients in the way you decide is best. It's why we're scrapping the targets that interfere too often with your clinical decisions. It's why we're letting GPs - working closely with nurses, consultants and other professionals - take control of commissioning. And it's why we're taking out two whole layers of management infrastructure - freeing up more money for patient care, on top of the NHS funding increases we have already put in place.

But in return for this freedom from central control, we want the system to answer much more strongly to patients. By empowering patient choice, opening up competition and introducing new ways local people can get involved in shaping services, we want to give people, not politicians, the power to shape and improve the NHS.

This marks an important change in the way our NHS is run, so it's of course got a lot of media coverage. But as with any big change, some myths have crept in and people are understandably nervous about what it will mean for them. So I want to address some of these concerns here.

Myth number one is that no change is needed at all. I disagree. Despite the best efforts of staff, the NHS does not consistently deliver the patient-centred, responsive care we all want to see. Too often, the decisions of frontline doctors and nurses are over-ridden by a top-down system which doesn't allow professionals the freedom they need. This is the reason that, despite spending the European average on health, some of the outcomes are poor in comparison. For example, someone in this country is twice as likely to die from a heart attack as someone in France, and our survival rates for cervical, colorectal and breast cancer are amongst the worst in the OECD.

In addition, the NHS faces enormous financial pressures in the years ahead - driven by factors ranging from ageing and obesity, through to the cost of new drugs and technologies. Sticking with the status quo and hoping extra money will meet the challenges is not an option. If we want to deliver better results for patients, we need modernisation. If we just carry on as we are, we would face a big crunch in two or three years' time. Change is needed because we are still behind the rest of Europe. We should aim to be the best.

Myth number two is that our plans have come out of the blue. Again, I disagree. This is not a revolution. It's evolution. GP-led commissioning, patient choice, payment-by-results, Foundation Trusts - they have all existed in one form or another over the past fifteen years. The NHS has always worked with others from the independent sector too, be it social enterprises, charities or private companies. All these changes drew on some simple logic - that clinicians, not managers or politicians, are in the best position to understand the needs of patients. Our plans simply build on those advances.

Myth number three is that the speed of change is too fast; that we expect GPs to do too much, too soon, and we are not allowing time to trial the plans. But it is more than two years before GP consortia take on full responsibility for commissioning and we have put in place a leadership and development programme to help all GPs who want to take a leadership role to gain the skills they need. Many GPs of course, already have those skills, and 141 new GP consortia have already been set up, each varying in size and shape but all eager to take advantage of these freedoms. They now cover half the country and still more are signing up.

Myth number four is that commissioning will mean GPs spend their time on paperwork and negotiations instead of treating patients. Not true. GP consortia will be given the resources they need to secure the support and expertise to perform the extra managerial and administrative functions. And we know that not all GPs will want to play a leading role in commissioning - that's one of the reasons why it's commissioning by consortia rather than individual practices. Our plans simply mean the responsibility for clinical decisions, and for the financial consequences of those decisions, will be brought together. GPs commission care already, and they know best what their patients want, so it makes sense for them to have more control and responsibility.

Myth number five is that GP consortia will be 'forced' to use the private sector to help them commission services for patients. Nothing could be further from the truth. Already, the new GP 'pathfinder' consortia are working with the best staff in Primary Care Trusts and Strategic Health Authorities to ensure their skills and talents are put to use in the new system. But what we also want is for GPs to be free to get help from anyone they decide they need it from. In Cumbria, for example, GPs work alongside local charities to help ensure services are best able to meet the needs of their patients. That is precisely the sort of innovation we want to enable all over the country. GPs will be able to work with anyone they wish from specialists in hospitals to nurses in primary care.

I think people will soon look back at a time when doctors and nurses had to answer to the government machine and think: how was it ever like that? Our plans for modernisation will create an NHS that is more open, more local and more personal. They'll free you to deliver first-class, world-class, services. And they'll help make our National Health Service the envy of the world. That's a rich prize - so together, let's make it happen.

Yours sincerely,

Dave

It's the usual story. The health service is bad so it must be fixed. Governments have been saying this for so long that some people actually believe that it is true. It gives governments carte blanche to do what they want according to their political whim. In the case of the present government this is very much about the government washing its hands of health provision. The plan is to take no responsibility whatsoever for the delivery of health care. This will be handed over lock, stock and barrel to GPs.

So is the health service really as bad as Mr Cameron makes out? How do we really compare with other countries? It's a simple question. The answer is not so easy but the table below would suggest that we are not actually as far behind as our prime minister is trying to make out.

Carrots and sticks

In the old days consultants had a professional contract. You did whatever you thought was necessary. Now you do what the managers think is necesssary - much of which, of course, is not necessary. Dr Grumble has always been of the view that the taxpayer got a better deal from the old contract. If that seems implausible to you, then watch the video.

Tiger Country

Nina Raine's play is reviewed here. (Scroll through to 18.00.)

Think Tanks and Lobbying

Have you ever wondered why the policies of the three major parties for the NHS are so similar? If this is something that puzzles you, please watch the video.

A GP speaks

Dr Grumble always likes to hear both sides of an argument. One of the greatest mistakes you can make in the management of patients is to get fixated on a particular diagnosis and make the facts fit the diagnosis when what you should be doing is fitting the differential diagnosis to the facts. Making decisions on the facts is not always a natural thing to do. It should be but it isn't. Many people, when it comes to politics, take their view about how things should be and then bend the facts to fit. People buy the Daily Mail to reinforce their view of the world. The lesser number of people who read the Morning Star are doing the same. But to come to the right way forward you really need to read the Daily Mail and the Morning Star and then open your mind.

There has been so much concern about Lansley's reforms that Dr Grumble has not needed to flag up his own concerns. The press and the public are realising, too late, that what Dr Grumble has been warning his readers about for many years is about to happen. The policies of the ConDems are not so very different from those of New Labour. Even Cameron alludes to Blair when he tries, to justify taking the NHS in a direction that he knows the public just doesn't want.

Anyway, in the interests of balance, a video with a more positive view.



Here is a GP whose window on the world is that from his surgery. The most important thing he mentions is a transport issue. You have to have some sympathy. But has he any idea about what commissioning for an organisation the size of the NHS is really about? And was there no easier way of listening and acting upon his frustrations?

Dr Grumble might have embedded a video with a more negative view about Lansley's reforms but the BBC haven't provided the code for any of the less pro-government clips. Isn't that odd?

A new Newspeak word

We are in a post-1984 world. That's hardly surprising - 1984 is now a long time ago. When Dr Grumble first started reading George Orwell, 1984 was still a long way off. Neither Animal Farm nor Nineteen Eighty-Four seemed terribly meaningful books then. Themes of pigs taking over or incessant public mind control seemed fanciful. Others knew better. Lauded though Orwell's books were, he did not come over to the young Grumble as a man with a remarkable prescience. It was all just too unreal for Grumble. The world could never be anything like the fantasies created by Orwell.

But Grumble was young then. Youth lends an inevitable naivety. Some of us can shake this off with age. Some can't. For most, as we near the time we must leave this world, truths we could not see before may begin to dawn. The future matters more to the young than the old but they know less about it that the old. Knowledge of the past gives insight into the future. Perhaps that accounts for a strange paradox: the old, you see, worry about the future more than the young. The young are only interested in the present. That's where their concerns lie.

Blogging is a young person's thing. It's new. The old can be slow to adopt new things that they have never needed in the past. Grumble is not of the Facebook generation. He does not feel the need. But he does feel the need to blog. Most of the medical bloggers with a message are, to put it politely, not young. They all have a substantial mileage behind them. Take a look, in contrast, at the few medical student bloggers. They are preoccupied with the present: exams, boyfriends, a new placement - these are the things that dominate their lives. They have little in the way of a past. Not long ago they were at school. Their limited past makes them unable to see the future. Grumble was once like that.

How has the passage of time altered Grumble's view of Orwell? Does he now realise that the lauding of Orwell was justified? Now that we are living in the future, just how prescient has Nineteen Eighty-Four turned out to be?

Nineteen Eighty-Four was written in 1948 not long before Orwell died. Sadly, he wasn't that old but he was old enough to have some mileage and a considerable insight into the future. It's sad now to read of Orwell's illness and physical decline. If he were to see Dr Grumble as a patient today, he could easily be cured. But in 1948 the treatment of tuberculosis was in its infancy. Streptomycin was not readily available. By the time he received it, it was too late.

Just imagine that world in 1948. Not only was there little in the way of effective treatment for infectious diseases, technology of all sorts was very primitive by the standards of today. There were few televisions, no video cameras. Computers as we know them were non-existent. The internet was beyond anyone's dreams. Yet much of what Dr Grumble considered fanciful when he read Orwell in his youth has come to pass. We live in a world of all pervasive surveillance. Not only do we have cameras on street corners and in shops but there are cameras to recognise your car's number plate and log it on Big Brother's computer. We have no secrets any more. If you are younger than Grumble, you will seek out your sexual partner online on sites built for the purpose. Your drunken antics will be recorded on Facebook. Young doctors, whether they like it or not, have their whole working lives immutably entered into their eportfolios. Few worry about any of this. Not the young anyway.

Newspeak is all around us. For 'plurality' read 'privatisation'. For 'contestability' read 'commercial'. For 'polyclinic' read 'private provider". The NHS is riddled with examples. What could be worse than not saying what you mean? Is it lying or concealing the truth? Do they intend to deceive? Does it matter?

The world has moved on to technical levels undreamed of by Orwell. Google's computers essentially know how you think. Employers log every web page you have ever looked at. Your service provider may do the same. Emails are scanned by the people in Cheltenham for subversive words. The workings of your mind are known. Whether anyone cares or not is another matter. The important point is that the technology to see into your mind is there.

If you own a Kindle your reading habits will be known. If Amazon were to decide that you should no longer be reading Nineteen Eight-Four, they can just delete it without your permission. Of course you might think that they never would. But don't forget that Nineteen Eight-Four has been banned as intellectually dangerous to the public. Anything could happen. In fact it already has. Amazon has already seen fit to delete Nineteen Eighty-Four from your Kindle. The reasons were not actually too sinister but the incident does reveal the frightening control Amazon now has over our your personal virtual library. They don't need your permission they just delete your books. It's just like Big Brother.

Grumble could go on. If we do not already live in an Orwellian world, today's technology certainly makes it more possible than ever.

But let us be thankful that we still have control of our own minds. We are free to express our views in blogs like this. There is no way the ruling class can touch our minds, is there? In any case why should anybody want to? We all agree that we should be free to think and do as we please.

OK. Grumble is bamboozling you. No government, democratic or otherwise, has ever wanted us to think or do as we please. You might think you are free but you are not.

Dr Grumble has some sceptical readers who by now will think that he is well and truly off his trolley. There is obviously no way that there is anybody close to government working on controlling your mind. That is just ridiculous.

But, dear reader, you might just be wrong. There might already be an institute for government working on how to control your thinking and your behaviour? They might even have hired a surgeon to help them. Which can only mean one thing. Brain surgery. OK. That last bit cannot be true. Or is the world even more Orwellian than we realise?

By the way, there is another Newspeak word that Grumble has just come across. It is Mindspace. What do you think that really means? It couldn't be Newspeak for mind control could it? Brain washing even? And could there be a surgeon involved? Surely not.

A Letter from a Reader

For some reason this comment didn't get published. Perhaps it was too long. Fortunately it reached Dr Grumble's in box because it merits a post all to itself. It says it all. I hope that any Liberal Democrat MP reading it will feel very ashamed.

Dear Dr Grumble,

Just a little food for thought on what somebody starting medicine on the £9k fees system can expect: I don't believe I have previously written about this although I have often been sorely tempted when reading about funding. I find it astonishing that the state still considers me the responsibility of my parents in my mid-20s and determines my loans on this basis. I want to contrast the situation of someone who graduated in your year with someone in mine. These are very crude, unadjusted figures and I have not been too specific, for fear of revealing myself, but give an idea of the economic problem coming soon.

I am a medical student in London, towards to end of my degree and thankfully only paying £1300/year in fees. I am able to borrow this off the student loan company.

I am also able to borrow slightly more than £4000 a year to live off. The NHS bursary of approximately £1300 for the final 2 years is of some use, although it reduces the loan available. Unfortunately, my parents work, so my funding ends there. All additional money has to be begged off them: since they graduated many decades ago, this grates on them.

I rent a tiny room in a former council house, which houses 5 students. My rent for this is £6000 per year: the cheapest I could find. My medical school is not situated in a cheap city. The costs of everything else are more variable and harder to calculate, so I will ignore them for the moment. The cost of being able to turn up to my course in the morning is, over my 6 year course, of the order of £7800 fees, £36000 rent but with £2600 bursary leading to a total of approximately £41,200 (I have not allowed for the fact that the interest is compounded). I cannot borrow this of course, as it is clear that my rent is more than my annual loan, so my parents must find £2000 a year simply for me to be able to live anywhere near the institution. For the first few years its possible to work in the summer and I saved several thousand pounds doing this, but afterwards medical students do not have the summer off.

This is before consumption of baked beans has even been contemplated. I wonder how much most people spend on gas, electric, internet, landline, food, clothes, shoes, computers (for everything is electronic these days) and so on over 6 years?

This is the situation of many on my course. However, let us consider 2 other groups: those whose parents don't work, and those whose parents are very rich.

For the rich, the equation is simple. Many of my fellow-students have had flats bought by their parents near the medical school, which they have sublet to others. With rising property prices, this has even earned them a profit measured in the tens of thousands. They have £0 debt at the end of the course, as well as a flat which they will probably continue to rent out to their colleagues upon graduation. A very desirable situation, which I wish I could arrange for myself!

For those whose parents don't work: they receive such large loans and bursaries that they are financially independent from their parents and often live in much better accommodation than I can afford. However they have even more debt than I do upon graduation - I lived with someone who could borrow over £8k/year for maintenance alone, but bursaries come into play here and this person was getting a similar amount to keep. Frightening.

Many have argued that the renumeration is worth the training. This is no longer the case. Even as a student many are paying interest at a rate of £160/month whilst still a student: this is at a time of historically low interest rates. What will happen if they go up to a reasonable 5%, or 10%, or even 15%? At what point will the interest on my student loan out-strip my wage? Will it ever be payed off?

Many cite the example of consultants and GPs. However, their tuition fees were £0, their loans were £0 and their grants were extremely significant. Most, certainly outside london, emerged with no debt whatsoever. Furthermore, a mortgage of 2.5 times their annual salary was considered a lot: now the average property price in London is in excess of 9 times the wages of an F1. And we start work 3 years behind other graduates. Some of my friends, having failed medicine, converted to other subjects went into banking and now own cars and flats. Was passing the exams the right career move?

Many have suggested that students should bear the burden of this expense themselves - this is a fallacy if we are to work as doctors in the UK. The NHS is a state-owned monopoly employer, so if the cost is going to be met whether by grants or wages the taxpayer will be meeting it. Is healthcare worth it? The politicians and NHS managers don't seem to think so, but I would dearly love to see a taxpayer vote on the subject.

If not, doctors will leave the NHS in droves (or never even join) for other avenues of employment. Not because they don't like patients, or because they have no social conscience, but because we owe £30-40,000 each and would like to, one day, buy a house. How many of those debating the rights and wrongs of this matter have no hope of ever owning a house? Getting married? Raising children?

So many commentators treat the suggestions that the debt is unsustainable lightly, but let me ask - how many reading this post managed to save £40,000 within the first few years of graduation whilst getting a mortgage on 10x their annual salary? How many can save that even when at the peak of their earning potential? The numbers simply do not add up.

Now let us consider those with £9k/year fees. A rough estimate would seem to be £90,000 for fees + rent at today's prices, without compounding. So their monthly interest, at today's low rate, will be astronomical. They must of course eat and so on as well: I would be fascinated to hear what is a reasonable figure for this. I think it is quite likely that they will be charged more interest than their salary for a large part of their career without a massive rise in wages.

It is no coincidence that many of my friends - of wildly differing social, political and religious backgrounds - are reading the USMLE books (the exam that is the gateway to america and many other countries) and wondering if its worth spending the money on the exam. I think I will be investing.



P.S. To those critical of anonymous posts - my situation is not improved if I am disciplined or not employed for not towing the party line.

The Middle of the Road View

Dr Grumble prefers to write about what he knows about. Sometimes he strays into the realm of general politics goaded, in the case of the previous post, by a politician's gaff. When this happens many do not agree with the Grumble view which, these days though not in the past, is regarded as left-wing, socialist even. It just shows how right-wing general thinking has become. As Grumble has said before right-wing views are very seductive. Dr Grumble has himself been seduced.

One of the good things about a blog is that if you get something factually wrong readers can immediately point out your mistake. We all make mistakes and Dr Grumble welcomes corrections. On matters of opinion the comments column can become lively. Here there are no rights and wrongs.

Following Grumble's last post he was accused of "breathtaking naivety". Grumble is a sensitive individual but he decided at first to leave others to come to his defence. And they did. Thank you.

The accusation of breathtaking naivety came from Middle of the Road Moderate. The comment is well written and makes many good points. As Grumble has said, there are no rights and wrongs. The world is shades of grey. But the comment deserves a reply and since the size of the replies is limited Dr Grumble is going to reply here as a new post. Unusually Grumble will write in the first person.

So here is Middle of the Road moderate's first broadside:

This post, and most of the comments, have an underlying thread of naivety that, frankly, is breathtaking. The country is in debt. Huge, society-threatening debt. Someone had to stop the spending. Someone has to start paying the bill. All over the country, members of each sectional interest are moaning and saying, “Yes, yes, the bill must be paid but our group cannot be expected to cut spending for we are too important”.

And now Grumble's reply:

I would very much agree that New Labour spent money wastefully. Quite often money was spent on window-dressing designed more to create good headlines for Tony Blair than good governance. Wrong though that was, it was not the cause of the huge society-threatening debt. This was a consequence of unfettered markets driven by people who could make big bonuses but could never make a loss – one way tickets to success (and, for the taxpayer, disaster). Even the organisations were bomb-proof as the taxpayer has found out to his cost. Banks cannot be allowed to fail. Yet, despite this risk to the taxpayer, nobody in government really knew what the people in the world of money were up to. They didn’t even know themselves. The financial set-ups had become so complicated, complex and convoluted that the banks themselves didn’t know what had happened to their own assets. Regulation was inadequate because the market was seen as sacrosanct (and bankers were being wooed to London). There was scarcely a single siren voice warning what was to come. The Conservatives goaded New Labour on as they deregulated the financial systems freeing them to head lemming-like to catastrophe.

The bill that has broken the taxpayer’s own bank came not from the NHS or the students or the libraries or whatever your favourite good cause is. It came from the people who to this day are still not feeling any pain.

And now here an accusation of champagne socialism:

I love coming here for my glass of Grumble-style champagne socialism. Grumble-socialism may be naïve but it is a refreshing change from, for example, the uber-right wing Wat Tyler. Sadly, though, Grumble-economics does not add up, for Grumble-socialists do not acknowledge that we are facing a financial catastrophe.

Grumble seems a bit stung by that:

If I haven’t acknowledged that there is a financial crisis, it must be because it seems to me to be self-evident.

Now Middle of the Road moderate goes on about successive Labour governments destroying the education system:

The education system has been destroyed by successive Labour governments. The Grumblers extol the virtue of state education and well they might for, as good champagne socialists, they live in leafy-laned suburbia and congregate around good comprehensives. Comprehensives that can attract keep good staff. How many of you live in Tower Hamlets? All well and good for medical Anthony Wedgewood Benn clones to enthuse about schools such as Holland Park comprehensive or St Olaves. (http://en.wikipedia.org/wiki/Emily_Benn) As well paid middle-class professionals you have the dosh to live close to these schools. Comprehensive? Bollocks. Not from the pool they serve. And you guys complain about post-code lotteries! Diane Abbott was less hypocritical.

He does make some good points. Good state education is heavily dependent on where you live. What this shows is that it is as much dependent on the local people as the schools. It will help if society recognised this. Grumble does not really know about schools but he does know a bit about health. The nonsense that Darzi used to spout about life expectancy falling by a year for every stop on the Jubilee line as you travel from Westminster to Canning Town is just that: nonsense. OK, the fact is true but the nonsense is that doctors are to blame for not providing better healthcare to the poor. Health and wealth are closely related and lack of provision of health services to the poor is not the reason. Grumble suspects that there are parallels with education. Anyway here is his riposte:

Do you really think that if you were to transplant a fully-funded Charterhouse to Tower Hamlets the problems would be solved? One of my neighbours, a doctor, worked outside the NHS for a private company and, earning much more than Grumble, was able to send his children to a public school. One of them ran into difficulties and they asked him to leave. It is very much easier to run a good school which selects children only from the very rich and leaves the state to take on kids they cannot handle. Private schools like private hospitals cherry pick and immediately dump what they cannot handle.

Now something about pallid skinheads waiting on Matthew Paris (actually Grumble had very similar thoughts when he was at Oxbridge):

The question of funding university students is challenging. Easy for you to slag off the Coalition/ It’s always easy to criticise the status quo. But you don’t offer an alternative. Some one has to pay. Who should that someone be? Why not just pay for students out of general taxation? Matthew Paris wrote recently about how, when dining at his Cambridge College as a student he felt uncomfortable being waited upon by a pallid skinhead, moonlighting to increase his income out of which he was paying taxes to support Paris et al at Cambridge. Something wrong there. You can make arguments for the taxpayer putting the Grumble medical students through University, but please don’t ask the taxpayer to underwrite crap like a joint honours degree in "football and society" as offered by the University of Central Lancashire. And there’s lots of stuff like that around.



Grumble's reply points out that there are still two ways of doing things:

My point about paying for students is that borrowing money and paying it back is one way of funding university and paying it back as a taxpayer is another way. The two are not so different. Either way you pay back the money eventually. One way you pay it back as a loan, the other way as a taxpayer. Actually a large proportion of the students will never pay back their loans so the two are not so different as they appear. It’s mostly a question of which book the debt appears on. My view is that it is not a particularly good idea to sell to people who come into this world with nothing the idea that they should start their adult lives with a substantial debt – especially since it is debt that has caused the problem we are in now.

Actually I think the previous government, goaded by educationalists who do not live in the real world, made a mistake in thinking that so many should go to university. Learning is important but many do not learn well in the lecture theatre. What was wrong with traditional forms of learning such as apprenticeships? It's no wonder we ran out of plumbers and others who work skilfully with their hands given some of our education policies. And the same has happened with medicine. We are told that lack of experience can be remedied with a day's training on a simulator when what doctors really need is more supervised on-the-job training at the bedside.

And now Grumble is giving the last word to Middle of the Road moderate who has posted a comment yet again as Grumble was typing. In this comment he gets to the fundamental issue that is driving a lot of what we are seeing which is that we need the bankers and their roulette wheels and that if we do not woo them they will earn money for someone else. Unfortunately he is right.

Ah! We got there. The bankers. They are, even as we speak, eyeing up their January bonuses. Of course it's obscene. But, once again, the champagne- socialist ethic prevails. Lots of criticism but no solutions. If you tax bonuses to extinction, the bankers will disappear. And there are lots of countries who will welcome them with open arms. Switzerland and the BRIC countries for starters. Don't forget what percentage contribution these bankers make to our GDP. There are other approaches that would help the public. Stop the investment scams. Did we really use to buy endowments? Stop the pension fund rip-offs. Pay the obscene bonuses but only to bankers who have been demonstrably successful. Much could be done without destroying the city as a source of income. And don't forget it was your very own Gordon Brown, now hiding somewhere on a witness protection programme, who was so anxious to cosy up to the bankers that he removed all effective financial regulation.

Medical students do already get some mitigation of fees in their final year. As earners they will be in the top 1% of the population and will have the privilege of pursuing a vocational career with rewards in terms of status and personal satisfaction far greater than many others. Why should they not pay more than, say, a school teacher or a social worker.

So there you have it. The final word from Middle of the Road Moderate.

Thank you, Middle of the Road Moderate, for commenting. And thank you Dr Aust, Julie and Sam for generating the debate. Forgive me for not including your contributions here but this post is getting rather long and I have doubts about whether it will work as it is.

Let them eat cake

You may think that curmudgeonly Dr Grumble celebrated the New Year by staying at home with Mrs Grumble and drinking a cup of hot cocoa. But no. Dr Grumble has actually got a few friends and he went for a New Year's Eve supper with Mr and Mrs Short who live across the road. They are both teachers. Both are scientists: one a chemist, the other a physicist. One of their children, state educated, is a medical student at Cambridge. Dr Grumble likes the Shorts. They are nice hard-working people who have no airs or graces. One of them was born on an estate - a council estate.

Teachers are a bit like doctors. Like most doctors most teachers work in the state system. And, like doctors, through their work, they engage with all strata of society. They know what life is about and their politics tend to reflect this. In short they have a better feel for the world that many of today's politicians.

When the Grumbles visit the Shorts inevitably the conversation eventually drifts towards politics. Last night was no different. The Shorts are well informed. They know about the NHS and what threatens it and they know about state schools and what threatens them. Like the Grumbles they didn't much like New Labour and like the Grumbles their suspicions of the ConDems are growing. The Shorts pointed out that:

• the economic crisis is being exploited to make it appear that when it comes to unpalatable policies the ConDems have no choice
  
  
• that the Lib Dems had reneged on their tuition fees promises
  
  
• that the Cons had promised no more top down reorganisation of the NHS and that Andrew Lansley was coming over as a lone loose cannon.

Things seem to be going wrong quite quickly for the ConDems who are beginning to look like a folie à deux.

There's trouble at Mrs Shorts' work. They are trying to charitise part of the service. This is, of course, a ConDem policy but it was around with New Labour and the Witch Doctor's and her Black Cat have been warning for some time of its creeping progress. The details of the changes at Mrs Shorts' work are interesting because Grumble has heard it all before. The managers think that they do not need teachers to do the work. Somebody less than a teacher will do. Mrs Short is quite sure that the work is so difficult that this is definitely not the case and the plans are inevitably doomed. But nobody listens. In any case the charitisation process will distance the misguided managers from the consequences of their decisions. Distancing government from the delivery of services was a New Labour aim as well. Modern governments don't want to have to take responsibility for services. They just want to dole out our tax money to independent organisations and blame them if things aren't right. Better still they will get the public to pay for the services directly. We are all to give our small change to charities to bolster the public services we will no longer get. It's not very British. We don't give much to charity compared with other countries. It is not because we are not nice. It is because we want the vulnerable in our population to be looked after by the state and we want to pay for this fairly with our taxes.

Changes are afoot. Perhaps this is what Cameron's Big Society is about. But, as Dr Jest's friend has quipped, the difference between the Big Society and the Big Issue is that nobody buys the Big Society. With jokes like this circulating, the honeymoon may be over for the ConDems. Certainly they are beginning to cause annoyance in the Grumble household where these are the questions being asked:

• Just who are these people in charge who think that the common man has enough money to give away to well-meaning amateurs and faith groups for them to plug the gaps in services that should be provided by government?
  
  
• Just who are these people who think that the only option is for students to pay their own university fees?
  
  
• Just who are these people who, with no public discussion, think that virtually the whole of the NHS can be run from GPs' surgeries?

Unfortunately very few of them live in the real world, few of them have had real lives outside politics and few are acquainted with the problems of the common man. The debating society at Eton may have taught Dave to talk confidently without notes but can anybody remember anything meaningful he has ever said? And neither Nick or Gideon with their top public school credentials are quite your average man next door. These people may have been born on estates but they were certainly not council estates.

But Grumble is going to reserve his teacher friends' vitriol for the Culture Secretary, Jeremy Hunt. He too, in case you haven't already guessed, went to a top public school: Charterhouse no less where he was head boy. Now Grumble doesn't particularly object to that. But what he does object to is Jeremy Hunt's views on state schools. This is what he said in an email to a constituent:

Michael Gove's vision is for state schools to have the same ethos as independent schools where the children are proud of what they do.

Now remember that Grumble's children were entirely educated in the state system and are now all doctors or medical students. And the Shorts children were also state educated and have done well with one at Cambridge. Our children were proud of what they did. And we are proud of what they did. How out of touch do you have to be to have such an unsavoury view of state schooling?

According to this clip, making Jeremy Hunt Culture Secretary was reckless in the extreme. Dr Grumble is inclined to agree.