One policy fits all

Dr Grumble has a Japanese doctor working with him. His name is Ren. The other day he asked Dr Grumble why there are so many parks in London. According to Ren, there are no parks in Tokyo. A quick Google search suggests that this might not quite be true and a look at Google maps seems to show a few patches of green in Tokyo. But a comparison with a map of London suggests that we do have much more green space. Ren asked why. Dr Grumble had to think on his feet. He told Ren it was to do with common land. Ren's face looked blank. Perhaps they don't have such a concept in Japan. Grumble needed a more understandable explanation. Quickly he made up a story about the king needing somewhere to go hunting. Ren nodded. That was something he could grasp.

Recently Dr Grumble went to his local forest to protest. He didn't want to risk the sale of the woods near his home to a private company. A forest is not worth much. Not as a forest anyway. But if you could sell it to be used for something else it would be worth quite a bit more. So, if the local wood were to fall into the hands of a private company, the shareholders would want to make money out of it. You can be sure that they would chip away at any regulations preventing them from doing this. They might not succeed tomorrow or in five years or in ten years but the woods need to be preserved forever. The likelihood is that repeated planning applications would eventually be met with approval for the odd plot of land to be sold off for, say, housing. In this way, bit by bit, over many years the woods would disappear. Once gone they would be gone forever.

A London park which belongs to the community.

Over the years how many people have fought for the green spaces in London? Dr Grumble has no idea. One thing is certain: if it had been left to the market the green spaces in London would have gone long ago. People out to make money have been been prevented from concreting over our parks and commons. That's why Grumble did his bit for posterity and protested in the woods.

And who knows? Maybe our London parks have made us money. Maybe that is partly why Japanese tourists like to visit London. Maybe the quality of life our parks and gardens bring even attracts bankers to London. Perhaps even they realise that there is more to life than money. We cannot know. And it doesn't matter. What matters is that we need these green spaces because we like them and governments have a duty to protect things of value to society especially when, once those things are gone, they are gone forever.

These fundamental principles don't just apply to the parks and gardens that we all cherish. There are other things in England that many of us value. There are others things that will be gone forever if we lose them. There are other things that we need to fight to protect. Just as some of us fought to protect the woodlands.

Here's an article from Sky News, slightly modified, to bring home something else we are about to lose forever:

Ministers have outlined proposals that will allow private owners to manage land hospitals previously owned by the Forestry Commission NHS. Some 15% of the forest NHS estate, worth an estimated £100m billion, is already being sold.

The latest consultation could lead to the sale of the remaining 85% owned by the Commission NHS, totalling 2,500 sq km 250 district general hospitals. Under the new proposals ancient woodland such as the Forest of Dean teaching hospitals such as Guys and St Thomas' could be designated 'heritage forestry' 'National Training Centres' and transferred to be run by a charitable trust.

Campaigners in the Forest of Dean Lambeth have vowed to fight any plans to privatise or restrict access to their woodland local hospital. Rich Daniels Dr Grumble from the Hands Off Our Forest Save Our NHS protest group, told Sky News the proposals raise more questions than they answer.

Commerically valuable forests hospitals will be leased to commercial operators for up to 150 years but under conditions that public benefits of the woods universal healthcare are preserved. Environment Secretary Caroline Spelman Health Secretary Andrew Lansley stressed the plans were not about selling off the forests NHS to the highest bidder. Ms Spelman Mr Lansley said: "State control of forests the NHS dates back to the First World War 1947, when needs were very different. "There's now no reason for the Government to be in the business of timber production healthcare and forest NHS management. "It's time for the Government to step back and allow those who are most involved with England's woodlands healthcare to play a much greater role in their future."

It would seem that the government has essentially one policy for everything. Everything should be privatised or charitised and government should take no responsibility for it. Government is no longer the custodian of things that we value. It is a new concept called the Big Society. What it really means is you are your own. Look after yourself and the things that you value because the government is not going to do it for you.

A London hospital which belongs to the community.

Why is the Labour Party not protesting? The answer is pretty obvious but if you can't work it out you may need the help of a Black Cat.

Forest plots and pitch-rolling

Why did so many people get out into their local woods to protest about the sell-off of our forests? Plainly it took our government by surprise. Even Dr Grumble was impressed by the number of people protesting in his local wood.

But some protests are not a surprise. When Grumble's local hospital was under threat even more people were on the streets. Just as in the case of the woods, these were just ordinary people with very limited resources organising themselves to protest. Whenever this sort of thing happens people power prevails - especially if the hospital is in a marginal constituency. The NHS is so important to the electorate that it has even resulted in the election of a single-issue MP. That should surely sends signals to our government that meddling with the NHS is dangerous.

The trouble with the public getting involved in these issues is that sometimes there can be more heat than light. Passion can impede progress. Sometimes it is the right thing to close smaller hospitals. Certainly the NHS estate needs rationalisation. In theory a centrally-managed government-owned service should do this well. The reality is that successive governments have signally failed to even take on the problem.

Every single hospital (and there have been scores) Dr Grumble has worked in has been in need of some form of rationalisation. London is held up by those in charge as being the place with the biggest problems. The problems have been there for a very considerable time. Sometimes governments have made them worse. Westminster Hospital used to be across the bridge from St Thomas'. Despite opposition, it was closed. But then soaring property prices and a hospital sale enabled a triumphant Mrs Thatcher to create Chelsea and Westminster Hospital only a short walk from Charing Cross Hospital in Hammersmith itself not very far from, yes, Hammersmith Hospital. The reasons why hospitals fail to be closed when closure is necessary are political. Sometimes unnecessary hospitals or polyclinics are built for the same reason. What all this shows is just how important the NHS is to politics in this country.

Politicians may be prepared to send young people to die in unnecessary wars but difficult decisions about the NHS seem beyond them. It is this underlying problem that has led governments to the bizarre conclusion that they can deal with their own failings by privatisation or quasi-privatisation. The idea is that hospitals are made to fail in the market. Planning, which has failed to close hospitals, will be replaced by cut-throat competition. Some hospitals will just wither on the vine. There is a blind faith that the market will get right what politicians have not.

But none of this has been thought through. Do politicians really believe that when a local hospital closes because of market forces the local populace is going to accept that? Do politicians really believe that local GPs are going to be able to persuade their patients that their local hospital is no longer needed? Do they really think really think that the electorate will blame GPs for what happens rather than their local MP?

The woods and the NHS are more similar than some might think. We love our woods much as we love our NHS. Why didn't the public want the woods sold? It was because the woods are part of England. They are a part of England which belongs to us all. We want to be able to use them without incurring exorbitant charges. They should not be sold off. They are inviolable.

What does the public think of the NHS? They love their NHS. It is a part of Britain which belongs to us all. We want to be able to use the NHS without incurring exorbitant charges. It should not be sold off. It is inviolable.

Pitch-rolling.

So why don't we see the public outside their local hospital with placards? It is because of the soft focus on what is about to take place combined with lots of obfuscation and the ConDem's secret weapon: pitch-rolling. Since this article is so Anglocentric, it is unlikely that any North American readers have got this far. Lest they have, Dr Grumble needs to explain "pitch-rolling". If you have been to a great English public school, as have both the Prime Minister and Deputy Prime Minister, you will know that on Wednesday afternoons in the summer you play cricket. You may have heard of the playing fields of Eton. That's what we are talking about. (There were playing fields in the state schools but they were sold-off for development.) But if you are wealthy you will still have access to a green field and a cricket pitch. Now a cricket pitch needs rolling. It's a backbreaking job but at Eton they have a flunky or two who go out before matches to roll the pitch. The longer you roll it the better it is. They have been rolling the pitch at Eton for nearly 600 years which is why it looks so good. If you don't roll it the ball will bounce all over the place and the boys will get restive.

When it comes to the NHS there has been an awful lot of pitch-rolling. New Labour were masters at it. It has taken an amazing number of forms. Knocking GPs has been one. Who do you think feeds the misleading headlines? Faux consultations have been another. Anybody who filled in the latest forestry consultation will understand. Motherhood-and-apple-pie questions with only one answer cannot be called consultation. And there have been questionnaires about NHS services. When people are happy it goes unreported. Problems, on the other hand, get highlighted - even tiny problems. At one time Grumble found this very odd. Why should government be knocking the very service it was responsible for? The answer is that it is all part of a very prolonged pitch-rolling exercise. It is designed to create dissatisfaction with the NHS and the conclusion that something must be done - usually fed to the public as "no change is not an option".

This pitch-rolling is very powerful. It is a euphemism. If you say something often enough people may believe it. But they are not always taken in. They weren't taken in over the sale of our woodlands. But then there wasn't any propaganda pitch-rolling. Fortunately the electorate are not as daft as our contemptuous politicians like to think.

The Virgin delivery

Lest anybody was wondering Dr Grumble's prize of splendid Virgin wine has arrived. So thanks once again to Clinic Compare and all the readers who took the trouble to vote for Dr Grumble.

Dr Grumble has never actually drunk Virgin wine before and it set him wondering about the Virgin empire and the man in charge, Richard Branson. Sir Richard has had the odd mention before on the Grumble blog. He is somebody you need to keep an eye on when it comes to the future of healthcare.

The older you get the smaller the world seems to be. Amazing as it may seem, Dr Grumble has actually met Sir Richard. The first time was some decades ago when Sir Richard threw a party for a mutual friend and Grumble, being well connected, got invited. The whole Branson family was there. Dr Grumble sat next to Sir Richard's father. Holly Branson spent the whole evening running about along with her brother, Sam. She was something of a tomboy then. That's how long ago it was. Dr Grumble chatted to Richard's father on what attributes you need to become a multimillionaire. He never did quite find out.

Sir Richard comes over as a nice guy. One of Dr Grumble's readers warned him against being taken in by this. Her message was that you cannot be as successful as Sir Richard without being tough, perhaps even cut-throat. But you have to be tough to survive as a doctor too.

A little incident made Dr Grumble think that maybe Sir Richard is actually quite a good egg. Dr Grumble was on his way back from a meeting in Cannes and in Nice airport stopped off at a rather dismal restaurant where he sat down to eat a rather unappetizing sandwich. To Grumble's surprise, Sir Richard then came in and sat at the very next table and began eating an equally unappetizing sandwich out of the wrapper. Even the extremely wealthy have to rough it sometimes and, as all doctors know, they even have to go to the loo like the rest of us. Dr Grumble immediately recognised Sir Richard but he did not think it was appropriate to introduce himself. Then a rather glamorous black girl came in. She spotted Sir Richard, went up to him and asked if she could have her photograph taken with him. He was fine about it. He happily abandoned his sandwich and had the black girl sit on his knee while her boyfriend snapped away. It was a nice thing to have done. On that rather limited evidence, Grumble thinks that Sir Richard is probably OK.

Dignity and crap

The other day Dr Grumble exchanged emails with an American colleague. Healthcare in the US is claimed to be fantastic but they have their problems too. Dr Grumble was bemoaning the fact that the hospital managers now want Grumble to focus on money-making activity. You can understand why. The hospital needs money. And these days, now that we are in a market, there is no point in doing work that doesn't generate much of an income. Since this new system Grumble has become something of a blue-eyed boy. A new department was built. Agency staff were hired at great expense. It all paid for itself. More tests meant more money. But Grumble is also responsible for elderly patients whose main need is to be looked after well and with dignity. That doesn't pay for itself. The more you do of it the more it costs the hospital. It is not work our managers seem to want and because it is so very expensive to supply this sort of care great efforts go into paring down the staffing levels to an absolute minimum.

It's the same in the US. My American friend told me how much the interventional radiologists are now earning. It's a staggering sum. But if you look after the elderly it is quite another matter. That's the market for you. Worse, Grumble's friend told him not to bother with the elderly. Just focus on the things that make you money was his advice. That's what we do here, he wrote.

The elderly care ward certainly doesn't pay for itself. Agency staff are shunned. If you are a bit short staffed the tendency is to get by somehow. Nor are the wards as they might be. We are told that patients like to be treated with dignity. Now isn't that a surprise? So what do we do? We have red pegs on the curtains. Meanwhile elderly patients are required to crap into an equally elderly commode. The ward stinks. The commode is trundled to the sluice with faeces spilling on the way. It is no way to treat people. In the US even condemned prisoners have a loo next to their bed. And is it any wonder we have outbreaks of C diff?

Whatever system you run the elderly are always going to put a drain on resources and their care is always going to be expensive but with this new market stark differences between their care and the care of the young have been highlighted. The worried well now get their endoscopies in double-quick time because with the test comes money. If there are not enough staff the managers will offer more and more money to get those staff. If better facilities are needed they will be built. But it is not like that on the general medical ward.

Forest protest

The last time Dr Grumble went on a protest march it was over MMC/MTAS. Before then it was way back in the 60s. Dr Grumble does not often feel the need to take to the streets. But yesterday Dr Grumble felt the need to take, not to the streets, but to the paths through his local woods. Once again it was an interesting experience. Dr Grumble took a look around at the protesters. Many, perhaps the majority, might best be termed middle-class old farts. They were very peaceful and rather too quiet. They are not the sort of people who know how to protest. What brought all these people out?

Even children were carrying placards. For them it will matter most.

Dr Grumble thinks that these middle class old farts have rumbled the coalition government. The electorate are not quite as daft as politicians like to think. We the people have realised that Cameron's Big Society is something of a con. It is not really about less top-down government. It is more about look after yourself. The government is not going to do anything. You are going to be left to your own devices. The woods may well need looking after and preserving for future generations but that's not the job of government. The call from Cameron is for the locals to get their act together and sort out the maintenance of their woods themselves. If they haven't got the money to buy them, then somehow they have got to raise it. If they can't then the woods will simply have to be sold to the super-rich. There's no discussion because we are in a financial crisis. It has simply got to be done. That anyway is their line. It's a similar thing with the NHS. It's performance is awful. There's no choice. Something has got to be done. But is any of this true?

According to Mark Steel, in 2007 a report by the Ministry of Defence on future threats to national security stated that the growing gap between the middle class and the super-rich could lead to the middle classes becoming a revolutionary class taking the role envisaged for the proletariat by Marx. Could that be what was happening in the Grumble woods? Have we become aware of the enormous divide between us and the local super-rich Charterhouse-educated MP? How many people on the march were lowly-paid government servants who are already giving much of their time to society? How many were teachers who stay late? How many were doctors or nurses doing much more than they are paid for? Who amongst these has the time to raise the money to buy the woods we already own?

One of many yellow-ribboned trees in the Grumble wood.

Dr Grumble thinks that it is these things that brought out the crowds and not just concern about the welfare of our forest. The woods matter but so do all the others things this government doesn't want to take any responsibility for. Everywhere you look you see the pernicious effects of this Big Society nonsense. As others have joked, society is going need to be big to have all the volunteers needed to take on all this extra work. No. It's not just the woods. The government doesn't want the Royal Mail. It doesn't want the NHS. And it wants parents to run the schools. We the electorate have not signed up to this, Mr Cameron. We elect governments to look after things. Things like libraries. And universities. And students. And, yes, our woods.

We are not taken in by assurances that the 'royal' will still be in Royal Mail. Or that the queen's head will still be on the stamps. That is just a Condem con. There might (or might not) be a case for privatising the post but please don't play these tricks with Dr Grumble. We need a proper case for these changes and not patronising platitudes.

And another thing, Mr Cameron. We are not taken in by those consultations. We had enough of this from the previous government. We know that government pollsters will ask ludicrous motherhood-and-apple-pie questions designed so that you get the answer you want. That's not democracy.

Working for nothing

Yesterday afternoon Dr Grumble settled down to do some work with one of his scientific colleagues. She mentioned to Dr Grumble that she is being worked very hard. She is. She even gets called about problems in the night. She does not get paid for this. She does not get paid for all the overtime she works. It's always been like that in the NHS. That's why the new consultant contract cost the trusts more not less. Managers from outside did not realise that there is a long tradition in the NHS of doing what is required rather than working set hours for money. With the new contract, for the first time, there was pressure to pay consultants for what they did. Now, with the cuts, there is unseen pressure to go back to the old ways. The hours staff are being paid are being cut back. The work that needs to be done remains the same.

Honorary physicians and surgeons have a long history.

Of course people cannot necessarily go on like this. The Grumble hospital is in an area of very expensive housing. The influence of bankers and other industries more lucrative than healthcare has seen to that. The consequence is that not only do the staff in the Grumble hospital work hard they also have to travel long distances to work and this is both exhausting and expensive.

At the end of the afternoon Dr Grumble went to his office to upload his letters to his typist in India. Grumble's letters are typed by the cheapest transcribers in the world. That's NHS efficiency. Quality secretaries are difficult to recruit to the Grumble hospital. Lawyers and bankers pay more than the NHS. Fortunately some secretaries like to work for the NHS. They like the idea that they are contributing to the care of patients.

Just as Grumble was about to leave work the phone rang. It was a consultant colleague, a lady called Dr Werkard. Dr Grumble is not sure he has ever met her. It is like that in the Grumble hospital. In the old days consultants knew all their colleagues. Now, in hospitals the size of the Grumble hospital, they know very few. There are various reasons for this. Quite a lot revolves around meals. We used to have a thing called the lunch hour. These days, in common with the rest of society, lunchtime sustenance has become a hurried sandwich while catching up with the emails. Colleagues our masters would have chatted to over a leisurely lunch are now just names on a circulation list. It is not the same. And it is not conducive to good medicine. Meeting your colleagues over lunch is a good way of finding out who they are and what they do. That's good for patient care. These days it would be called networking. Our masters called it lunch.

Dr Werkard seemed really pleased to hear Dr Grumble's voice. Human contact is important to us all. We have shared the care of several patients. Our patients know both Dr Werkard and Dr Grumble but we have never met each other. There is something wrong with that. Dr Werkard told Dr Grumble that she had been very pleased with the assessments her patients were being given. This, of course, is a wonderful compliment to Dr Grumble. He was very pleased. You actually see things like this in the records from time to time when a consultant will thank a GP for a helpful details in a letter. It is a way of saying that you think your colleague is a good doctor and has done a good job. It is about the only praise you will ever get. But with the bouquets come brickbats. Only this week Grumble has received a letter of complaint from a GP. Complaints from GPs are unusual and usually revolve around poor communication. Quite often they show scant understanding of the difficulties we are working under. Reading between the lines you can detect an underlying anger. Without the anger, they wouldn't have bothered. To be fair, they are angry for their patients.

Dr Grumble wondered why he had never once met Dr Werkard and she told him that mostly she works at the Western Hospital but she spends three days a week at Grumble Hospital. Maths is not Grumble's strongest point but there seemed something wrong with this. Dr Werkard explained that she only works part time. She is only paid for one day at Grumble Hospital but she works three. Two days a week she works for nothing. That's the NHS for you. Perhaps her husband is a banker. Dr Grumble didn't ask.

The woods today

If you go down to the woods today, you're sure of a big surprise. Well, perhaps not. Dr Grumble did go down to his local woods today and he wasn't too surprised to see For Sale notices up. They are not real For Sale notices. They are notices posted by concerned local groups worried about the sale of our woodlands.

Dr Grumble's local wood is part of a forest that has been there for at least 7000 years. Wood has been taken from it to meet the needs of shipbuilders and for buildings. The rape of the forest has at times left it without much timber but its importance was recognised by the king and hundreds of years ago it was replanted following which it flourished unmolested for a century or more. Sadly, the exigencies of the Napoleonic Wars resulted in the forest becoming denuded yet again.

Much of the land that forms the Grumble wood was once common land. Locals could graze their livestock and harvest wood for much needed fuel. But, in 1812, land that had been for the use of commoners was enclosed under the Inclosures Act and along with this the red deer that had lived there for perhaps 11000 years were eradicated never to return. By this process rich people acquired the land and very poor people lost the use of what had once essentially belonged to them and been recognised as a common resource.

In the 1920s the Forestry Commission took over the Grumble woodlands. The reason for this would be very familiar with any doctor brought up with the Babcock Sentence:

One thing a nation must have to be rich and great is a large, secure supply of wood.

Babcock, H. (1930) Arch. Psychol., N.Y. No. 117

Indeed the original purpose of the Forestry Commission was to look after the interests of the state by ensuring a large and secure supply of wood. But today the Forestry Commission manages the Grumble woods for people. By a wonderful turn of fate, these are the common people who lost the use of the very same common land when it was taken away from them in 1812 so that the rich people could become even richer.

A notice stapled to a tree in the Grumble wood.

It is a very odd thing that just as the Forestry Commission is restoring the Grumble woods to their former glory so that the common people can use them again, the ConDem government is hell-bent on taking the woods away from the common people and giving them to rich people so that they can become even richer. Isn't it strange how history repeats itself?

Dr Grumble wins

What a surprise! Dr Grumble has apparently been voted Britain's best health blog - the first time Grumble has won a competition he didn't even enter. So a very big thank you to all those readers who took the trouble to vote and to the sponsors, the Clinic Compare Editorial Team. Dr Grumble is very touched. To absolutely frank, he is not at all sure he deserves this award but he is very pleased all the same. And he is looking forward to the prize - a crate of Virgin wine!

Get thee glass eyes

For the first time in his life Dr Grumble is beginning to get into Shakespeare. Last night, in common with others both in the UK and abroad, Grumble watched King Lear live. The performance was interrupted by a satellite failure. You might have thought that this would have marred the experience but it was actually quite interesting to see the actors faultlessly repeat part of the scene again.

The more Shakespeare you listen to the more you begin to realise the profound influence he has had on our language. Another thing you realise is that human nature doesn't change and that quite a lot of people are greedy, just out for themselves and, frankly, not very nice. And that includes the fair sex.

Now, for those that are unfamiliar with King Lear, there is a rather gruesome scene when the unfortunate Gloucester gets his eyes torn out. Last night's gouging was not actually quite as bad as Grumble's previous experience of theatrical eye-gougings. Mrs Grumble thinks they deliberately downplayed it. Lots of agonising screams during eye-gouging on stage is a bit cheap. The production was about more than that. But Grumble takes the view that Shakespeare himself would have wanted lots of screaming and hollering. Why else would bloody eyeballs be rolling across the stage for stamping upon?

What is the relevance of King Lear to Dr Grumble's mission to save the NHS? Well it was the effort to rehabilitate the blind Gloucester that Grumble wanted to tell you about. In particular when King Lear says:

Get thee glass eyes, and like a scurvy politician, seem to see the things thou dost not.

Which caused Grumble to think of this picture of a well-known politician.



And this man who claimed to be able to see the future of polyclinics.



And the other thing of relevance is that there are still a lot of greedy people about who really don't care what damage they do as long as they themselves get rich. Which Dr Grumble finds very sad.