Feet first, our NHS is limping towards privatisation

Polly Toynbee in The Guardian

A fish rots from the head, but the NHS may be rotting from the feet. Podiatry is not up there in the headlines, yet what’s going on in that unglamorous zone is an alarming microcosm of the downward path of the health service. This is a story of the NHS in England in retreat and the private sector filling the vacuum.

You know the big picture from the ever-worsening monthly figures: deteriorating A&E, ambulance and operation waiting times, and a steep rise in bed-blocking. As debts pass £2.5bn, the NHS feels the tightening financial tourniquet.

Now look at it through the prism of just one small corner, as seen from the feet up. Every week 135 people have amputations because diabetes has caused their feet to rot: their circulation goes and then the sensation in their feet, so they don’t notice damage done by rubbing shoes, stubbed toes or stepping on nails. Minor injuries turn into ulcers that if left untreated turn gangrenous, and so the toes, then the foot, then the leg are lost – horrific life-changing damage. Numbers are rising fast, with nearly three million diabetics. The scandal is that 80% of these amputations are preventable – if there were the podiatrists to treat the first signs of foot ulcers. But the numbers employed and in training are falling.

In his surgery, the head of podiatry for Solent NHS Trust, Graham Bowen, is unwrapping the foot of a lifelong diabetic to reveal a large missing chunk of heel, a great red hole nearly through to the bone. This man has already had some toes amputated. He has been having treatment with maggots, bandaged into his wound to eat the dead skin and help healing – and he is slowly improving. Everyone Bowen sees now is at similarly high risk. Small ulcers, incipient ulcers, the ones that need to be caught early (and cheaply) no longer get NHS treatment. “On the NHS we’re essentially firefighting the worst cases now,” says Bowen. “We are going through our lists and discharging all the rest of our patients.”

FacebookTwitterPinterest ‘On a 15-minute visit carers can’t check feet.’ Photograph: Andrew Bret Wallis/Getty Images

But not even all these acute patients get the same optimal treatments, due to the vagaries of the 2012 NHS Act. Solent, a community trust that covers mental health and a host of other services, is used by five different clinical commissioning groups (CCGs), including Southampton, Portsmouth and West Hampshire. Each has its own criteria for what it will pay for, and each is toughening those criteria. Depending on their address, some patients get the very best, others only get what their cash-strapped CCG pays for.

You need to know about diabetic feet to understand the difference in treatments: the conventional and cheapest treatment is a dressing and a removable plastic boot, and telling patients to keep their foot up for months. But patients who can’t feel their feet tend to take off the boot and hobble to make a quick cup of tea. “Ten minutes of putting pressure on the ulcer undoes 23 hours of resting it,” Bowen says, so it takes 52 weeks on average to heal ulcers that way. For £500 extra, a new instant fibreglass cast saves any pressure on ulcers and cures them within eight weeks.

Although the National Institute for Health and Care Excellence says this total-contact cast is the gold standard, most of Bowen’s CCGs won’t pay for it. I watched him putting one on a patient in under half an hour: after nine weekly replacements, that ulcer would be completely healed. For every 10 of the new casts, one amputation is prevented – and each amputation costs the NHS £65,000. Such is the madness of NHS fragmentation, divided between multiple commissioners and providers, all in serious financial trouble, that no one spends a bit more now for others to save later, even when the payback is so quick.

This clinic lost four podiatry posts to save money: though diabetic numbers soar, its budget has been static for five years. “Doing more for less,” he says with the same weary sigh you hear echoing through the NHS. As Bowen goes through the clinic’s books removing all but the most acute cases, he turns away diabetics whose problems should be caught early. He turns away others he used to treat: the old and frail who have become immobile due to foot problems; the partially sighted or people with dementia who have poor home care. On a 15-minute visit carers can’t check feet and find out if they are the reason someone doesn’t get out of bed, toes buckled in, leaving them needlessly incapacitated and heading for residential care sooner than necessary.

What happens to those he takes off his books? “They have to go private, if they can afford it. If not, then nothing.” He used to send them to Age UK, but lack of funds shut that service. Only 5% of podiatry is now done by the NHS so Bowen has set up TipToe, a private practice attached to his NHS clinic. It’s not what he wants, but it keeps prices low and all proceeds go to the NHS.

Alarm bells should ring here: how silently the NHS slides into the private sector. Labour leadership contender Owen Smith has flagged up his team’s research showing private practice has doubled since 2010. Now that many CCGs only pay for one cataract, how many go private for the second eye? As the Guardian’s health policy editor, Denis Campbell, has asked, how many more vital treatments will go this way?

Podiatry is the ground floor of the NHS hierarchy. The profession reckons the NHS in England needs 12,000 practitioners but only has about 3,000 – and that’s falling, despite so many high-risk diabetics needing weekly appointments. Next year podiatry trainees, like nurses, will no longer receive state bursaries, so fewer will apply. They tend to be older, with families, unable to take on a £45,000 debt for a job paying around £35,000 per year. Already student places have been cut by nearly a quarter in five years. Most of the 7,000 amputations a year are preventable. A shocking statistic: half of those who undergo amputations will die within two years.

Only in the details of what’s happening on the frontline can we understand the daily reality of Britain’s shrinking state. Step back and ask how it can be that a country still growing richer can afford less quality care than when it was poorer? Is that the country’s choice? As the NHS slides into the private sector, here is yet another public service in retreat.

Legal aid is a national institution like the NHS, so why is it not properly funded?

John Briant in The Guardian


The media jump on high-profile cases of criminals like Ben Butler and Jennie Gray receiving huge amounts in legal aid. The real outrage is successive governments’ policy to limit access to it

 

‘Even if we have done something wrong, or criminal, or stupid, we should still have someone who understands the law fighting on our behalf.’ Photograph: Andrew Cowie/AFP/Getty Images


It is with a mixture of intense frustration and sadness that I read the reports about the amount of legal aid that Ben Butler, convicted of murdering his six-year-old daughter, and his partner Jennie Gray, guilty of child cruelty, received. The figure is quoted at approximately £1.5m over a 15-year period, with £1.2m in civil legal aid.

Legal aid cuts have led to surge in DIY defence, says charity



It’s frustrating for a number of reasons. Of the £1.5m, approximately £300,000 went towards legal aid for criminal proceedings, and accounted for a month-long trial involving complex medical evidence for an original child cruelty and GBH trial, Gray’s case involving perverting the course of justice, and Butler’s murder trial. One would hope that in all of these cases, the legal aid lawyers were working to the best of their ability using the highest quality lawyers willing to conduct work at legal aid rates.

What is also true, is that the lawyers involved will have undertaken an immense amount of work that they weren’t paid for. Had they been privately funded, the fees would have been many multiples higher.

As a criminal practitioner of more than 20 years, I know the workloads that are undertaken daily by legal aid lawyers. In London, the going yearly salary for a duty solicitor is about £30,000 but may reach £40,000 with experience. Barristers’ chambers are paid £50 for sending a barrister to a hearing. This covers travelling time, the two hours waiting to get into court and the actual time spent representing a client in court – and the barristers will only get a cut of that money.

If you attend the police station, the firm is paid £150-£250 per case, which includes the initial attendance, plus any further bails to return to the station on other days – which might include ID parades or second or third interviews. Those who freelance at the police station are paid less than £100 per visit, which can mean a couple of hours travelling as well as up to 12 hours of waiting and advising. Police station advisers’ fees therefore range from an hourly rate of £30 down to £7 – it doesn’t vary with bank holidays or the fact that most of this advising occurs at ungodly hours of the night or weekends.

Legal aid solicitors have similar qualification periods to doctors: after completing a first degree they undergo a year of practical qualifications, then two years of on-the-job training. The qualification for barristers is a year shorter – but the cost of this in London has been estimated by the Bar Council as more than £120,000. Graduate salaries in legal aid firms are usually at the Law Society’s minimum of £18,590 pa for London. Of the respondents surveyed by Young Legal Aid Lawyers(whose membership consists of those within 10 years of qualification), 50% had salaries under £20,000 in 2013.

A well-known London plumbing firm is delighted to share its call-out rates with the public – they are “100% transparent charges and we have a clear, upfront, open and honest pricing system”. These charges range from a weekday daytime rate of £95 per hour at a minimum of one-hour call-out and 15 minute increments after this, to a 12am-7am rate of £200 per hour. Trust me – legal aid firms would kill for these rates.

Legal aid is a national institution, like the NHS. We all hope that we will never need it, that we won’t have unfounded rumours triggering a social services investigation or family proceedings; that we won’t be falsely accused of a crime. Even if we have done something wrong, or criminal or stupid, we should still have someone who understands the law fighting on our behalf to put our side of the story and explain our circumstances. This is part of what has separated us as a “civilised society”, these rights and freedoms and the privilege to be served by those who choose to sacrifice massive incomes to do relatively poorly paid legal aid work.

The unfortunate thing is that it is the abnormal cases like this (which are often the only things that allow a legal aid practice to survive the otherwise dreadful legal aid rates), and the abnormal earnings of barristers with huge experience dealing with the most serious cases and working insane hours, that get reported. Legal aid is not a vote winner; it doesn’t fall into the category of being tough on crime, and it always seems to be paid to people we like to blame – immigrants, good-for-nothings, so-called scroungers. It’s just your money being spent on someone else.

The difficulty comes when that someone else is you. Teacher, doctor, police officer, journalist, city trader, engineer, labourer, English, Scottish, white, black, depressed, addicted, sober: I have represented all of you, without judgment, to the best of my abilities, 24 hours a day for over 20 years.

Ellie Butler's grandfather: 'The devastation is complete and utter'

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What makes me sad is this. Ellie Butler’s grandparents were not entitled to legal aid. Despite spending their life savings and working extra jobs, they could not fight for custody of their grandchild, whom they were concerned may be at risk. They couldn’t afford to pay their private legal fees and had to represent themselves and lost. This is the tragedy: not that £1.5m went on legal aid, but that Neal and Linda Gray didn’t get any help to fight for their granddaughter.

Brexit - An Alternative Narrative

 John Pilger in The Hindu

The majority vote by Britons to leave the European Union was an act of raw democracy. Millions of ordinary people refused to be bullied, intimidated and dismissed with open contempt by their presumed betters in the major parties, the leaders of the business and banking oligarchy and the media.

This was, in great part, a vote by those angered and demoralised by the sheer arrogance of the apologists for the “remain” campaign and the dismemberment of a socially just civil life in Britain. The last bastion of the historic reforms of 1945, the National Health Service, has been so subverted by Tory and Labour-supported privateers it is fighting for its life.


Nothing but blackmail

A forewarning came when the Treasurer, George Osborne, the embodiment of both Britain’s ancien regime and the banking mafia in Europe, threatened to cut £30 billion from public services if people voted the wrong way; it was blackmail on a shocking scale.
 
Immigration was exploited in the campaign with consummate cynicism, not only by populist politicians from the lunar right, but by Labour politicians drawing on their own venerable tradition of promoting and nurturing racism, a symptom of corruption not at the bottom but at the top. The reason millions of refugees have fled the Middle East — first Iraq, now Syria — are the invasions and imperial mayhem of Britain, the United States, France, the European Union and NATO. Before that, there was the wilful destruction of Yugoslavia. Before that, there was the theft of Palestine and the imposition of Israel.

The pith helmets may have long gone, but the blood has never dried. A nineteenth century contempt for countries and peoples, depending on their degree of colonial usefulness, remains a centrepiece of modern “globalisation”, with its perverse socialism for the rich and capitalism for the poor: its freedom for capital and denial of freedom to labour; its perfidious politicians and politicised civil servants. All this has now come home to Europe, enriching the likes of Tony Blair and impoverishing and disempowering millions. On 23 June, the British said no more.

The London class

The most effective propagandists of the “European ideal” have not been the far right, but an insufferably patrician class for whom metropolitan London is the United Kingdom. Its leading members see themselves as liberal, enlightened, cultivated tribunes of the 21st century zeitgeist, even “cool”. What they really are is a bourgeoisie with insatiable consumerist tastes and ancient instincts of their own superiority. In their house paper, the Guardian, they have gloated, day after day, at those who would even consider the EU profoundly undemocratic, a source of social injustice and a virulent extremism known as “neoliberalism”.

The aim of this extremism is to install a permanent, capitalist theocracy that ensures a two-thirds society, with the majority divided and indebted, managed by a corporate class, and a permanent working poor. In Britain today, 63 per cent of poor children grow up in families where one member is working. For them, the trap has closed. More than 600,000 residents of Britain’s second city, Greater Manchester, are, reports a study, “experiencing the effects of extreme poverty” and 1.6 million are slipping into penury.

Little of this social catastrophe is acknowledged in the bourgeois controlled media, notably the Oxbridge dominated BBC. During the referendum campaign, almost no insightful analysis was allowed to intrude upon the clichéd hysteria about “leaving Europe”, as if Britain was about to be towed in hostile currents somewhere north of Iceland.

On the morning after the vote, a BBC radio reporter welcomed politicians to his studio as old chums. “Well,” he said to “Lord” Peter Mandelson, the disgraced architect of Blairism, “why do these people want it so badly?” The “these people” are the majority of Britons.

The wealthy war criminal Tony Blair remains a hero of the Mandelson “European” class, though few will say so these days. The Guardian once described Mr. Blair as “mystical” and has been true to his “project” of rapacious war. The day after the vote, the columnist Martin Kettle offered a Brechtian solution to the misuse of democracy by the masses. “Now surely we can agree referendums are bad for Britain”, said the headline over his full-page piece. The “we” was unexplained but understood — just as “these people” is understood. “The referendum has conferred less legitimacy on politics, not more,” wrote Mr. Kettle. “…the verdict on referendums should be a ruthless one. Never again.”

The kind of ruthlessness Mr. Kettle longs for is found in Greece, a country now airbrushed. There, they had a referendum and the result was ignored. Like the Labour Party in Britain, the leaders of the Syriza government in Athens are the products of an affluent, highly privileged, educated middle class, groomed in the fakery and political treachery of post-modernism. The Greek people courageously used the referendum to demand their government sought “better terms” with a venal status quo in Brussels that was crushing the life out of their country. They were betrayed, as the British would have been betrayed.

Perpetual forgetfulness

On Friday, the Labour Party leader, Jeremy Corbyn, was asked by the BBC if he would pay tribute to the departed Mr. Cameron, his comrade in the “remain” campaign. Mr. Corbyn fulsomely praised Mr. Cameron’s “dignity” and noted his backing for gay marriage and his apology to the Irish families of the dead of Bloody Sunday. He said nothing about Mr. Cameron’s divisiveness, his brutal austerity policies, his lies about “protecting” the Health Service. Neither did he remind people of the war mongering of the Cameron government: the dispatch of British special forces to Libya and British bomb aimers to Saudi Arabia and, above all, the beckoning of world war three.

In the week of the referendum vote, no British politician and, to my knowledge, no journalist referred to Vladimir Putin’s speech in St. Petersburg commemorating the seventy-fifth anniversary of Nazi Germany’s invasion of the Soviet Union on 22 June, 1941. The Soviet victory — at a cost of 27 million Soviet lives and the majority of all German forces — won the Second World War.

Mr. Putin likened the current frenzied build up of NATO troops and war material on Russia’s western borders to the Third Reich’s Operation Barbarossa. NATO’s exercises in Poland were the biggest since the Nazi invasion; Operation Anaconda had simulated an attack on Russia, presumably with nuclear weapons. On the eve of the referendum, the quisling secretary-general of NATO, Jens Stoltenberg, warned Britons they would be endangering “peace and security” if they voted to leave the EU. The millions who ignored him and Mr. Cameron, Mr. Osborne, Mr. Corbyn, Mr. Obama and the man who runs the Bank of England may, just may, have struck a blow for real peace and democracy in Europe.

If "Protest never changes anything"? Look at how TTIP has been derailed

Owen Jones in The Guardian

People power has taken on big business over this transatlantic stitch-up and looks like winning. We should all be inspired.

 

Illustration by Ben Jennings


For those of us who want societies run in the interests of the majority rather than unaccountable corporate interests, this era can be best defined as an uphill struggle. So when victories occur, they should be loudly trumpeted to encourage us in a wider fight against a powerful elite of big businesses, media organisations, politicians, bureaucrats and corporate-funded thinktanks.

Today is one such moment. The Transatlantic Trade Investment Partnership (TTIP) – that notorious proposed trade agreement that hands even more sweeping powers to corporate titans – lies wounded, perhaps fatally. It isn’t dead yet, but TTIP is a tangled wreckage that will be difficult to reassemble.

Doubts rise over TTIP as France threatens to block EU-US deal



Those of us who campaigned against TTIP – not least fellow Guardian columnist George Monbiot – were dismissed as scaremongering. We said that TTIP would lead to a race to the bottom on everything from environmental to consumer protections, forcing us down to the lower level that exists in the United States. We warned that it would undermine our democracy and sovereignty, enabling corporate interests to use secret courts to block policies that they did not like.

Scaremongering, we were told. But hundreds of leaked documents from the negotiations reveal, in some ways, that the reality is worse – and now the French government has been forced to suggest it may block the agreement.

The documents imply that even craven European leaders believe the US demands go too far. As War on Want puts it, they show that TTIP would “open the door” to products currently banned in the EU “for public health and environmental reasons”.

As the documents reveal, there are now “irreconcilable” differences between the European Union’s and America’s positions. According to Greenpeace, “the EU position is very bad, and the US position is terrible”.

The documents show that the US is actively trying to dilute EU regulations on consumer and environmental protections. In future, for the EU to be even able to pass a regulation, it could be forced to involve both US authorities and US corporations, giving big businesses across the Atlantic the same input as those based in Europe.

With these damning revelations, the embattled French authorities have been forced to say they reject TTIP “at this stage”. President Hollande says France would refuse “the undermining of the essential principles of our agriculture, our culture, of mutual access to public markets”. And with the country’s trade representative saying that “there cannot be an agreement without France and much less against France”, TTIP currently has a bleak future indeed.

There are a number of things we learn from this, all of which should lift hopes. First, people power pays off. European politicians and bureaucrats, quite rightly, would never have imagined that a trade agreement would inspire any interest, let alone mass protests. Symptomatic of their contempt for the people they supposedly exist to serve, the negotiations over the most important aspects of the treaty were conducted in secret. Easy, then, to accuse anti-TTIP activists of “scaremongering” while revealing little of the reality publicly.

But rather than give up, activists across the continent organised. They toxified TTIP, forcing its designers on the defensive. Germany – the very heart of the European project – witnessed mass demonstrations with up to 250,000 people participating.

From London to Warsaw, from Prague to Madrid, the anti-TTIP cause has marched. Members of the European parliament have been subjected to passionate lobbying by angry citizens. Without this popular pressure, TTIP would have received little scrutiny and would surely have passed – with disastrous consequences.

Second, this is a real embarrassment to the British government. Back in 2011, David Cameron vetoed an EU treaty to supposedly defend the national interest: in fact, he was worried that it threatened Britain’s financial sector. The City of London and Britain are clearly not the same thing. But Cameron has been among the staunchest champions of TTIP. He is more than happy to undermine British sovereignty and democracy, as long as it is corporate interests who are the beneficiaries.

And so we end in the perverse situation where it is the French government, rather than our own administration, protecting our sovereignty.

And third, this has real consequences for the EU referendum debate. Rather cynically, Ukip have co-opted the TTIP argument. They have rightly argued that TTIP threatens our National Health Service – but given that their leader, Nigel Farage, has suggested abolishing the NHS in favour of private health insurance, this is the height of chutzpah.

Ukip have mocked those on the left, such as me, who back a critical remain position in the Brexit referendum over this issue. But if we were to leave the EU, not only would the social chapter and various workers’ rights be abandoned – and not replaced by our rightwing government – but Britain would end up negotiating a series of TTIP agreements. We would end up living with the consequences of TTIP, but without the remaining progressive elements of the EU.
Instead, we have seen what happens when ordinary Europeans put aside cultural and language barriers and unite. Their collective strength can achieve results. This should surely be a launchpad for a movement to build a democratic, accountable, transparent Europe governed in the interests of its citizens, not corporations. It will mean reaching across the Atlantic too.

For all President Obama’s hope-change rhetoric, his administration – which zealously promoted TTIP – has all too often championed corporate interests. However, though Bernie Sanders is unlikely to become the Democratic nominee, the incredible movement behind him shows – particularly among younger Americans – a growing desire for a different sort of US.

In the coming months, those Europeans who have campaigned against TTIP should surely reach out to their American counterparts. Even if TTIP is defeated, we still live in a world in which major corporations often have greater power than nation states: only organised movements that cross borders can have any hope of challenging this unaccountable dominance.

From tax justice to climate change, the “protest never achieves anything” brigade have been proved wrong. Here’s a potential victory to relish, and build on.

Jeremy Hunt doesn’t understand junior doctors. He co-wrote a book on how to dismantle the NHS

Frankie Boyle in The Guardian


The health secretary’s name is so redolent of upper-class brutality he belongs in a Martin Amis book where working-class people are called Dave Rubbish

 

Jeremy Hunt: overtly ridiculous. Photograph: Mark Thomas/Rex Shutterstock




One of the worst things for doctors must be that, after seven years of study and then another decade of continuing professional exams, patients come in telling them they’re wrong after spending 20 minutes on Google. So imagine how doctors must feel about Jeremy Hunt, who hasn’t even had the decency to go on the internet.

Consider how desperate these doctors are: so desperate that they want to talk to Jeremy Hunt. Surely even Hunt’s wife would rather spend a sleepless 72 hours gazing into a cracked open ribcage than talk to him. Hunt won’t speak to the doctors, even though doctors are the people who know how hospitals work. Hunt’s only other job was founding Hotcourses magazine: his areas of expertise are how to bulletpoint a list and make dog grooming look like a viable career change.

Of course, the strikers are saying this is about safety, not pay, as expecting to be paid a decent wage for a difficult and highly skilled job is now considered selfish. Surely expecting someone to work for free while people all around them are dying of cancer is only appropriate for the early stages of The X Factor. Sadly, Tories don’t understand why someone would stay in a job for decency and love when their mother was never around long enough to find out what language the nanny spoke.

The fact that Hunt co-wrote a book about how to dismantle the NHS makes him feel like a broad stroke in a heavy-handed satire. Even the name Jeremy Hunt is so redolent of upper-class brutality that it feels like he belongs in one of those Martin Amis books where working-class people are called things like Dave Rubbish and Billy Darts (No shade, Martin – I’m just a joke writer: I envy real writers, their metaphors and similes taking off into the imagination sky like big birds or something). Indeed, Jeremy Hunt is so overtly ridiculous that he might be best thought of as a sort of rodeo clown, put there simply there to distract the enraged public.

I sympathise a little with Hunt – he was born into military aristocracy, a cousin of the Queen, went to Charterhouse, then Oxford, then into PR: trying to get him to understand the life of an overworked student nurse is like trying to get an Amazonian tree frog to understand the plot of Blade Runner. Hunt doesn’t understand the need to pay doctors – he’s part of a ruling class that doesn’t understand that the desire to cut someone open and rearrange their internal organs can come from a desire to help others, and not just because of insanity caused by hereditary syphilis.

The government believes that death rates are going up because doctors are lazy, rather than because we’ve started making disabled people work on building sites. Indeed, death rates in the NHS are going up, albeit largely among doctors. From the steel mines where child slaves gather surgical steel, all the way up to senior doctors working 36 hours on no sleep, the most healthy people in the NHS are actually the patients. This is before we get to plans for bursaries to be withdrawn from student nurses, so that we’re now essentially asking them to pay to work. Student nurses are essential; not only are they a vital part of staffing hospitals, they’re usually the only people there able to smile at a dying patient without screaming: “TAKE ME WITH YOU!”

The real reason more people die at weekends is that British people have to be really sick to stay in hospital at the weekend, as hospitals tend not to have a bar. We have a fairly low proportion of people who are doctors, don’t plan to invest in training any more, and are too racist to import them. So we’re shuffling around the doctors we do have to the weekend, when not a lot of people are admitted, from the week, when it’s busy. This is part of a conscious strategy to run the service down to a point where privatisation can be sold to the public as a way of improving things.

Naturally, things won’t actually be improved; they’ll be sold to something like Virgin Health. Virgin can’t get the toilets to work on a train from Glasgow to London, so it’s time we encouraged it to branch out into something less challenging like transplant surgery. With the rate the NHS is being privatised, it won’t be long before consultations will be done via Skype with a doctor in Bangalore. Thank God we’re raising a generation who are so comfortable getting naked online. “I’m afraid it looks like you’ve had a stroke. No, my mistake – you’re just buffering.”

When I was little, I was in hospital for a few days. The boy in the next bed was an officious little guy who took me on a tour of the ward. He’d sort of appointed himself as an auxiliary nurse and would help out around the place, tidying up the toys in the playroom, and giving all the nurses a very formal “Good Morning”, which always made me laugh. I got jelly and ice-cream one evening (I’d had my tonsils out) and they brought him some, too. Afterwards, he threw his spoon triumphantly into his plate and laughed till there were tears in his eyes. Then he tidied up and took our plates back to the trolley. What he meant by all this (we’d sit up at night talking and waiting for trains to go by in the distance) is that this was the first place he’d known any real kindness and he wished to return it. For most of us it will be the last place we know kindness. How sad that we have allowed it to fall into the hands of dreadful people who know no compassion at all, not even for themselves.

Jeremy Hunt is a hero for standing up to the BMA bullies

Leo McKinstry in The Telegraph

Today, junior doctors are staging the first ever all-out strike in the history of the NHS. Never can a stoppage have been less justified than this one. In their irresponsible greed and puerile militancy, the strikers are making a complete mockery of the Hippocratic Oath to do no harm. 

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With spectacular double standards, they claim that they oppose the new contract because it is “unsafe for patients”, yet their own selfish industrial action is putting the lives of vulnerable people at risk. They profess their devotion to the publicly funded NHS, then threaten to work in the private sector overseas if the Government refuses their pay demands.
Their sense of entitlement is repugnant. They enjoy salaries, pensions and job security far beyond the dreams of most professionals, while they have been offered an excellent new deal in return for the removal of outdated weekend practices. Yet, suffused with victimhood, they act like oppressed members of the proletariat.

They are only able to get away with this hypocrisy because of their exploitation of public sentimentality towards the NHS. The former Chancellor Nigel Lawson once famously said that the health service is “the nearest thing the English have to a religion.” By cynically posing as the keepers of the holy faith and presenting every attempt at reform as wicked heresy, they have been able to protect their privileges and ruthlessly advance their own interests.

But now they have met a stumbling block in the form of Health Secretary Jeremy Hunt. With his air of reasonableness and quiet, almost deferential manner, Hunt may seem an unlikely figure to challenge union blackmail. But his willingness to take on the reactionary bullies of the BMA shows that he has an inner steel similar to that displayed by Margaret Thatcher when she took on the unions in the 1980s.

In the process, Hunt has taken a tremendous amount of increasingly hysterical abuse. He has been vilified as the enemy of the NHS, a Right-wing extremist, a Nazi and a potential killer. But alongside these savage personal insults, there has also been the persistent complaint that he has somehow “mishandled” the dispute. It is a refrain that is heard not just from Labour politicians and Left-wing commentators, but even, privately, from some of his own MPs and fellow Ministers.

Yet the charge is absurd, for Hunt has shown remarkable patience in his negotiations with the unions. The term “mishandled” is really code for his refusal to surrender to the unions. Effectively, his critics are arguing that he should have caved in at the first sign of trouble from the BMA. That is how most of his predecessors have acted, always desperate to avoid confrontation. So the NHS remains hopelessly unreformed, a gigantic bureaucratic monolith operating more for the convenience of its staff than the real needs of its patients.

No one elected the BMA to decide how the NHS should be run. That should be the job of our democratic politicians. Hunt has a clear mandate from the Conservative victory in 2015 to introduce a proper 7-day-a-week health service, which can only be done through a new contract. If the NHS is to improve, the privileged, picket-line poseurs have to be defeated. Hunt should be praised, not demonised, for taking his heroic stand in this battle. Even if they dislike him now, the British public will ultimately benefit from his courage.

The final offer made to junior doctors was too generous – they should stop striking and get on with it

Mary Dejevsky in The Independent

You know things have reached a pretty pass in any dispute when the combatants start to invoke the spirit of deceased politicians. But when two men who have reached the top of their political trees also start invoking their own mothers – as Jeremy Corbyn and David Cameron did at Prime Minister’s Questions – well, the possibility of any agreement looks remote indeed.

Yes, after a merciful, but all too brief, period of remission, we are back in the heat of the junior doctors’ dispute. The Labour leader accused the Government of showing bad faith and “misrepresenting” statistics (about hospital deaths at weekends); the Prime Minister returned to his mantra about people not getting sick only on weekdays. Whatever else the Government may be ready to compromise on, it appears not to be a “seven-day NHS”.

And quite right, too.

“Our” NHS is not run for the benefit of the staff, however long they have spent in training, however mountainous their student loans, however arduous and responsible their work. A great many people would probably like to work only Monday to Friday, 9 to 5, especially if highly-paid overtime for additional hours comes virtually guaranteed. But this is not the reality for most people, and there is no reason, when so much in this country now functions 24/7 – with the staff on rotas and little, if any, overtime paid – why it should still be such a struggle to get the emergency services to do the same. Yet it is here the overtime culture has proved most resilient.

There will be those – and I admit to being among them – who saw the final offer to the junior doctors as too generous. By preserving a system of overtime, for Saturdays after 5pm and all Sundays, it leaves in place the idea that doctors can expect to work something like traditional office or factory hours with additional rewards for anything else. Those expectations need to be scotched.

Junior doctors, and their many vocal supporters, have tried to turn the contested statistics about weekend fatalities to their advantage, suggesting that a “cut-price” seven-day NHS would simply raise death rates around the week. Anyone who visits hospitals on weekdays and at weekends, however, will be familiar with the glaring disparity in staffing – at every level, and what sometimes appears to be a surfeit of employees, especially in the least skilled jobs, during standard working hours. There is surely money to be saved here, that could offset the cost of more staff at weekends.

Nor can the junior doctors’ dispute be seen in isolation. Their new contract is just one part – if a large part – of reform of the NHS that is yet to come. If next in line are to be the consultants, for whom the junior doctors are often deputising at nights and weekends, you can understand why the Government might be keen to hold the line.

What occasioned the latest sword-crossing in the Commons was the announcement by the British Medical Association earlier this week that the junior doctors would hold three more days of strikes, and would fight the Health Secretary’s imposition of the new contract through the courts. In the first instance, this means seeking a judicial review.

On precisely what legal grounds the BMA intends to fight is not yet clear. For all the perception that the English judiciary has become more politically engaged in recent years, it is hard to see a judge ruling that an elected government is not within its rights to set the terms of a contract for public sector employees, particular when in line with a manifesto commitment. Going to court is only going to inject more poison into this already toxic dispute.

It is beyond time that the BMA called it a day and recognised that the junior doctors have won as much as they are going to – more than they could have expected at the outset and more, indeed, than may be wise for the future health of the NHS. The BMA’s continued insistence a “safe” seven-day NHS is somehow beyond the country’s means is defeatism of the first order, and really not junior doctors’ call to make. It is the stated policy of an elected government.

That said, the extent to which this dispute has become politicised has made it infinitely harder to resolve. Jeremy Hunt has not just been defending his government’s policy of a seven-day NHS, he has been engaged directly in negotiating the small print of a new contract. This has enabled junior doctors, and the BMA on their behalf, to cast the project as a heartless Tory plot.

The most senior non-politicians – the chief executive of NHS England, Simon Stevens, and the medical director, Sir Bruce Keogh – have both been conspicuously absent from the fray. This may be because, if heads had to roll, the Health Secretary is deemed more dispensable than either of them. But here, perhaps, also lies the key to change. For 10 years or more – most recently in the Conservatives’ 2010 election manifesto – proposals have been mooted to separate the NHS from politics by placing it under an independent board. Policy, such as the creation of seven-day service, and the overall NHS budget would be set by central government, leaving the rest to professionals. Each time, however, a consensus evolved to the effect that the NHS was so integral a part of national life and the sums of money allocated so vast, that there had to be direct political accountability. The scandal at Mid-Staffs augmented that view.

But the downside of the argument is again before us. Junior doctors and a Conservative government at loggerheads; there is talk of relations blighted for a generation. One solution might be for the Government to return to its election manifesto of 2010 and divest itself of managerial responsibility for the NHS. If junior doctors can cast that as a victory, so be it. But there is no reason why the sort of hands-off arrangement that is considered good for the BBC and – increasingly – for schools should not be good for the NHS, too.

Our adoration is killing the NHS. It needs tough love

Simon Jenkins in The Guardian

Archaic demarcations between GPs, consultants and nurses are wasting billions. These have to go
 

Protestors demonstrate during a doctors strike in Oxford. ‘The sheer scale of past NHS mismanagement has been staggering.’ Photograph: Dylan Martinez/Reuters


John Reid, then the Labour government’s health secretary, in 2004 offered GPs a deal that ended weekend and home visits. They could hardly believe it. He also leveraged their average pay to £100,000 a year. People said it would send thousands rushing to accident and emergency. The British Medical Association called the deal “a bit of a laugh”, and the King’s Fund later calculated it added £30bn in costs to the NHS with no appreciable benefit. But no one blamed the NHS. Everyone loved the NHS.

The attempt by Jeremy Hunt, today’s health secretary, to remedy part of Reid’s disastrous reform enjoys no such popularity. There is two-thirds support for the junior hospital doctors in their strike against weekend restructuring.

People may dislike other public services. They see the police as dodgy, train drivers as bolshy, utilities as run by crooks. But the NHS “saved my mum’s life”. So leave the doctors and nurses alone. Just give them money. Give everyone money.

Nothing dents this love. Day after day, the headlines scream of NHS woe. Last month half of all doctors said they offered a worsening service. Eleven thousand heart patients “die because of poor care”. The NHS wastes £12bn on a computer system that “does not work”. One in four hospital staff feels “harassed and bullied”. Three-quarters of them tell care quality commissioners that “patient safety is now at risk”. If the NHS is to the British, as former chancellor Lord Lawson said, “not a service but a religion”, the religion must be juju.

The sheer scale of past NHS mismanagement – of private finance and of procurement – has been staggering. It makes the Ministry of Defence seem a paragon of efficiency. When David Cameron at the 2010 election promised “no more tiresome, meddling top-down restructuring” and then did just that, I realised the NHS was more powerful than him. The beast had to keep reorganising or, like a shark, it would die.

The NHS’s carapace of love has to be its biggest danger. On Wednesday it was revealed that, despite last year’s Francis report on whistleblowing, not a single sacked NHS whistleblower has been re-employed or manager reprimanded. Instead doctors are eulogised for the “daily miracle of saving lives”. This is despite the OECD reporting that they save fewer lives per head than insurance-based health services in Germany, Switzerland and the Netherlands. Britain’s record on tracing cancer is dreadful.

Doctors are in the business of saving lives. It is their job. Firefighters are not “miracle workers” for putting out fires, or teachers for getting pupils through exams. Healthcare may benefit from fear of death and disease, and we are rightly appreciative of those who relieve it. But when other professionals such as social workers or carers of the elderly fail, they are publicly excoriated. Why is the NHS immune?

I have intermittently experienced medicine at home and abroad, in public and private sectors. I admit I feel strangely secure in the familiar NHS surgery, with its tired magazines and admonitory notices. It has a wartime air, like a Dad’s Army set, rendering it unpatriotic to complain.

But this is no joke when a friend dies of MRSA, or when a mentally disturbed child is left untended, or when, in my own case, the labyrinthine “referral” system between GPs and hospitals leads to dangerously delayed cancer diagnosis. When I challenged the consultant, he said the opinion of my GP on a particular test was “of absolutely no concern to me”.

Lax professional practices are bad enough in the law, but in medicine they can be fatal. Simple blood tests and check-ups which, in the NHS, take three visits and a month of waiting for results, in the private sector take one visit and 24 hours. A heart scan can take half a day off work in the NHS (and goodness knows what fee to the commissioning practice), but £295 and half an hour at Lifescan.

In the age of the internet and computerised testing, archaic demarcations between GPs, consultants, nurses, pharmacists and technicians make no sense. This is not a matter of ideology, but of restrictive practice. It must cost billions.

Britons love to swap horror stories about the foreign health systems. American care for the uninsured was, at least before President Obama, dire. But the American best puts the NHS to shame, as does care across most of Europe’s insurance or pay-and-reclaim systems. Insurance is not always a cost-effective basis for care, but the private sector delivers so many services more efficiently than the NHS.

Doctors' strike turnout much lower than last time, says Jeremy Hunt



People love to defend the NHS – and attack private provision – through those deadly twins, prejudice and anecdote. The state’s anonymous hospitals and complex staffing systems can be glorious, but they are equally wasteful and demoralising. It is not just Hunt that is driving NHS staff at all levels into the arms of agency contractors, and costing the taxpayer a fortune.

I have never understood why so many self-inflicted “health needs”, such as sports injuries, drunkenness and overeating, should be charged to the state. Some fire brigades are charging for careless callouts. Mountain and lifeboat rescues often request “contributions”. Free at the point of delivery has long been a proud boast of the NHS. But that is policy, not papal doctrine.

The drug companies always made sure “free” did not apply to NHS prescriptions. With demand rising exponentially, supply of care must be rationed by something: if not by some form of payment and insurance, it will be by queueing and quality.Last year it emerged that more than 300,000 patients waited in ambulances for more than half an hour just to get into A&E.

Something is clearly snapping. One day, charging will assuredly come. The maddening thing at present is that it is unnecessary. It is not the NHS that needs reform but the concept of “seeing a doctor” or just getting care. The NHS may not be very good, but it is cheap to the nation. If it got tough with its labour practices and demarcations it could be even cheaper – and far better.

There is nothing wrong with loving the NHS, but it needs to be tough love.

Declare a No Ball when a batsman attempts an early run

Girish Menon from CamKerala CC

David Hopps in his piece, 'Is the game going to the dogs' suggests that Stuart Broad in the forthcoming World T20 should without warning 'mankad' Kohli and Raina off successive balls. This is his way of reminding us of the role of convention and civilised behaviour in cricket and he implies that in its absence anarchy would prevail.

So, I decided to look up the meaning of convention on the omniscient Google and found that one of the meanings of convention is 'a way in which something is done'. I think it is this definition of convention that Hopps uses to criticise Keemo Paul for mankading Richard Ngarava in the U19 World Cup.

----Other pieces by the author

Sreesanth - Another modern day Valmiki?

To Beef or not to Beef - A Personal View on the Beef Crisis in India

On Walking - Advice for a Fifteen Year Old

----

I then asked myself what would be at the other end of the spectrum of convention and I felt the term 'creativity' would fit the bill. Google defines creativity as ' the use of imagination or original ideas to create something'.  When Keemo's act is examined from this perspective it is a creative act, not illegal, and an imaginative way to reach the objectives of his task.

In the history of the world, not just cricket, whenever any creative solution is implemented, affected governments would debate and proscribe such activity if it was not in the 'public' interest. In the case of 'mankading' such an inquiry has been conducted by the ICC and the act has still been deemed legal, hence the furore baffles me.

Hopps felt that it was newcomers who failed fail to honour cricket's conventions. So I asked myself, two questions:

'Is it newcomers to cricket who disrespect its conventions'?

and

 'Are conventions in the best interests of all participants?'

In the case of Keemo Paul, yes he is definitely a newcomer to cricket, so probably was the original sinner Vinoo Mankad and the other mankaders in between. I suppose these guys may have read about the laws of cricket and how the umpire's decision should not be questioned. As they plotted to get the opposing batsmen out, a difficult task at the best of times, they may have noticed this anomaly between the law and its actual practice. Being young and innocent they may have focussed on their objectives and failed to realise the opprobrium that will befall them if they challenged cricket's archaic anomalies.

So who makes conventions? A historical examination of societies will reveal that conventions and practices evolve out of the systems devised by the powerful. A history of cricket also reveals that it's rules and conventions were determined by upper class batsmen epitomised by the roguish W G Grace. The bowlers were the proverbial servants meant to exist for the pleasure of batsmen. It is these servants, like the erstwhile British colonies, who now challenge the prevalent conventions albeit legally in the case of the mankaders.

Hopps then gives an example of queue jumping to illustrate the catastrophe that will befall mankind if any convention is broken. Yes, the effects of queue jumping has created havoc in India and probably other erstwhile British colonies. Yet, as any economics student will tell you the problem with a queue is that it does not ration a scarce resource based on greatest need. If the A&E departments of NHS hospitals worked on the convention of queues then a Friday night over-reveller would have priority over a critical patient and an ambulance would be perennially stuck in traffic.



© PA Photos

Returning to mankading, I believe that cricket's current convention enable non striking batsmen to cheat wilfully throughout an innings and it is time for conventions keep in tandem with the laws of the game? I actually even have a solution for the mankading problem. Declare a no ball* and penalise the batting side every time a non striker steps out of the crease illegally. This could be done by the third umpire while the on field umpire focuses on the bowler's actions.



* This no ball means a one run penalty and a ball reduced from the batting side's quota.

This NHS crisis is not economic. It's political

Aditya Chakrabortty in The Guardian


As the health services endures its biggest squeeze, talk of it being unviable is wide of the mark. We cannot afford to do without it

 

Patients wait for spaces in A&E at Royal Stoke university hospital in Stoke-on-Trent. A&E waiting time targets have been watered down in recent years. Photograph: Alicia Canter for the Guardian


How many times have you read that the NHS is bust? No need for answers on a postcard: I can tell you.

Over 2015, the number of national newspaper headlines featuring “NHS” alongside the words bust, deficit, meltdown or financial crisis came to a grand total of 80. Call this the NHS panic index – a measure of public anxiety over the viability of our health service. Using a database of all national newspapers, our librarians added up the number of such headlines for each year. The index shows that panic over the sustainability of our healthcare isn’t just on the rise ­– it has begun to soar.


During the whole of 2009, just two pieces appeared warning of financial crisis in the NHS. By 2012 that had nudged up a bit, to 12. Then came liftoff: the bust headlines more than doubled to 30 in 2013, before nearly tripling to 82 in 2014. Newspapers such as this one now regularly carry warnings that our entire system of healthcare could go bankrupt – unless, that is, radical change ­are made. For David Prior, the then chair of the health watchdog the Care Quality Commission - and now health minister, that means giving more of the system to private companies.

This means that the press and political classes are now discussing a theoretical impossibility. Think about it for a moment, and you realise the NHS can’t go broke. It’s not an endowment with a set pot of cash, but a giant service with a yearly budget. Unlike a business, it doesn’t need to raise money from sales – as taxpayers and voters, we have the final say over how much funding it gets. This panic isn’t economic at all, but politically created.

The balance to be struck with the NHS, as with all public services, is between how much cash we sink into it and how much we expect in return. Give the NHS less money, get less healthcare. Give it more, and the opposite happens. As Rowena Crawford at the Institute for Fiscal Studies says: “Financial stability just requires that healthcare demand and expectations are constrained to match the available funding.”

And that right there is the rub. Because the NHS is enduring the sharpest and most prolonged spending squeeze in its history – even while the government pretends no such thing is happening and the public expect the same service. Our health service is where all the paradoxes of austerity come home to roost.

This may seem an odd thing to say. Isn’t the NHS one of the very few parts of the public realm to be sheltered from this decade’s cuts? Didn’t David Cameron promise before the last general election to “protect the NHS budget and continue to invest more”?

  David Cameron addresses the Tory conference in October 2014. Photograph: Facundo Arrizabalaga/EPA

The figures suggest otherwise. True, the NHS is seeing a rise in its funding. Between 2010 and 2014, health spending went up 0.8% each year, adjusting for inflation. A plus sign in front, granted, but a teeny-tiny one – since its creation in 1948, the health service has never had it so bad. Over this decade as a whole, that allocation will amount to 1.2% a year, which is way down on the average 3.7% that health spending grew each year between 1949 and 1979. And, coming after the 6.7% extra that Gordon Brown was shovelling in annually by the time of the banking crash, it feels like a recession.

So on the one hand, you have a healthcare system that can cause even the most secular of Brits to get religion, that can drive Telegraph-reading colonels to channel their inner Nye Bevan – hell, that even beats Justin Bieber to a Christmas No 1. And on the other you have a Tory prime minister who wants to cut public spending but knows that harming the NHS will be electoral poison.

Put the two together and what do you get? A dangerous muddle of overspending, frontline service cuts and political self-denial.

Cameron pretends the NHS isn’t on austerity rations and expects it to do the same work to pretty much the same targets. The various parts of the NHS try to do just that with a budget smaller than they need, with the result that they begin missing targets and making cuts even while breaking their budgets.

Take the A&E waiting times. Under Labour, the old rule was that 98% of patients must be seen within four hours. Soon after Cameron moved into Downing Street in 2010, the target was watered down to 95% of patients – even so it is now routinely missed. The number of patients stuck on trolleys in A&E, while staff try to find them beds is now at levels that “no civilised society should tolerate”, according to the Royal College of Emergency Medicine .

Even while falling short, arm after arm of the NHS is now in the red: 95% of hospital and other acute care providers in England plunged into deficit in the first half of the financial year starting in April, joining 80% of ambulance providers and 46% of those in mental health.

Demoralised staff can resign, go on an agency book, pick their shifts and earn more

You might treat all this as argument for NHS staff to be more productive. Except that, as John Appleby of the King’s Fund thinktank argues, they are. He calculates that, had NHS activity only gone up in line with government money, between 2010 and 2015 it would have treated 3.7 million fewer outpatients and 4.5 million fewer A&E patients than actually got seen.

This is productivity as doing more with less, which is almost always unsustainable. A real increase in productivity would come from doing things differently. There’s certainly scope to do that – by doing more phone consultations with GPs, perhaps, or upgrading technology. One joke among NHS professionals runs that, in all of China, there’s but one factory left still making fax machines, and that its only client is the NHS. But this sort of change is never going to come in an organisation now in a frenzy of cost-cutting.

One example of NHS austerity’s screwy logic is its sudden reliance on expensive agency staff. This, says Anita Charlesworth of the Health Foundation charity, is a direct result of staff pay freezes and overwork: “If you’re a permanent member of staff and you’ve had no pay rise and you’re demoralised and disengaged you can resign from the NHS, you can go on an agency book, you can pick your shifts, you can pick your wards and you earn more.”

The result is that agency staff costs are rising at over 25% a year.


Meanwhile, NHS England pretends it can cap hospital deficits for the year at £2.2bn – even though in the first six months alone that had already hit £1.6bn . Some of Britain’s biggest and most renowned hospitals are now actively planning on ending the year in the red. And Appleby points out that everything from patient time with doctors and nurses to repairs of your local hospital’s roof is being sacrificed in order to do the same work with less money.

“I can see another Jennifer’s ear coming,” Appleby says, referring to the five-year-old with glue ear who waited a year for a simple operation and ended up being used by Neil Kinnock to attack John Major on health spending. “Only this time it probably won’t be something as innocuous as glue ear. It might be a child who dies of cancer because their medical care has been so drastically cut.”

As societies get richer and older, they spend more on healthcare. Compared with nearly everyone else in western Europe, the UK spends much less of its national income on health. By the end of this decade, we will be even further behind. Meanwhile, pundits will continue to claim the entire system is unaffordably expensive, even while the public still want and need doctors and nurses, their medicines and operations.

This is the paradox of austerity: pretending that you can scrap and scrimp on the services and institutions that make you a civilised country, without making your country less civilised.

The age of deference to doctors and elites is over. Good riddance

Mary Dejevsky in The Independent

There was something about the story of five-year-old Ashya King that went beyond the plight of this one small, sick child, wrapped up in his blanket and connected to a drip. It was not just the public relations savvy of his family: the elaborate preparations for their flight, recorded and posted on the internet that drew such all-consuming public interest. Nor was it only the drama of the police chase across Europe, and the nights spent in a Spanish prison. It was much more.

There was a profound clash of principles here at a junction of extremes: a child with a terminal brain tumour, a fixed medical consensus, and parents who hoped, believed, there could be another way.

You probably remember – I certainly do – how forcefully Ashya’s father, Brett, argued his case. He had, he said, set about learning all he could about treatment possibilities for his son’s condition on the internet and in medical journals and concluded that a particular form of therapy was superior to the one being offered by the NHS.

Now, 18 months on, Ashya King’s story has a sequel beyond the so-far happy ending of his recovery announced last March. The sequel is that the treatment his family fought for so hard has indeed been found to be superior to that generally offered by the NHS, and in precisely the ways that the Kings had argued. A study published in The Lancet Oncology – an offshoot of The Lancet – concluded that the proton beam therapy, such as Ashya eventually obtained in Prague, was as effective as conventional radiotherapy, but less likely to cause damage to hearing, brain function and vital organs, especially in children. 

In one way, that should perhaps come as no surprise, given King’s claim to have scoured the literature. There is also room for caution. This was a relatively small study conducted in the US. There was no control group – with children, this is deemed (rightly) to be unethical – and harmful side-effects were reduced, not eliminated. But such is the nature of medical research, and the treatment decisions based on it. Things are rarely cut and dried; it is more a balance of probability.

This may be one reason why the Lancet findings had less resonance than might have been expected, given the original hue and cry about Ashya’s case. But my cynical bet is that if the study had shown there was essentially no difference between the two treatments, or that proton beams were a quack therapy potentially hyped for commercial advantage, sections of the NHS establishment would have been out there day and night, warning parents who might be tempted to follow the Kings’ path how wrong-headed they were, and stressing how the doctors had been vindicated.

Instead, there were low-key interviews with select specialists, who noted that three NHS centres providing the therapy would be open by April 2018. Until then, those (few) children assessed as suitable for proton beam treatment would continue to go to the United States at public expense. (Why the US, rather than Prague or elsewhere in Europe, is not explained.)

It may just be my imagination, but I sensed an attempt to avoid reigniting the passions that had flared over Ashya’s treatment at the time, and especially not to raise other parents’ expectations. But I don’t think the controversy should be allowed to rest so easily. The King family’s experience raised serious questions about the practice of medicine in the UK and the attitudes of the professionals to their patients. And these latest research findings on proton therapy mean that it still does.

When Brett King presented his arguments, he did so not just with understandable emotion, but with enviable lucidity. He patently understood what he was talking about. This treatment was there; he wanted to give it a go, and he was prepared to raise the funds to pay for it. To the medics, he may well have come across as difficult, and there were those who genuinely felt that he was acting against the best interests of his son. In that case, the arguments should have gone to court – as they had done with eight-year-old Neon Roberts and his contested cancer treatment half a year before. That the Kings are Jehovah’s Witnesses may also have cued particular caution.

However, what many, especially in the medical establishment, seem reluctant to recognise is that change is afoot in relations between the professional elite and the rest – and not only because the so-called “age of deference” is dead.

Increasingly, it seems, we lay people are invited to make choices, only to be censured, or worse, for making the “wrong” one. Lawyers, for instance, will repeatedly tell you that they offer only advice; it is up to us to act on it, or not. So it is, increasingly, in the NHS. 

In theory, you can choose your GP, your hospital, your consultant – and, within reason, your treatment. In practice, it is more complicated. You may live too far away, the professionals may try to protect their patch, and the actual consultant is not there.

In the crucial matter of information, however, things have been evening up. The internet-nerd who turns up at the GP surgery convinced he is mortally ill may be a time-consuming nuisance, but such self-interested diligence can also help to point a time-strapped GP in the right direction. Not all are hypochondriacs. Patients may have more time and motive to research new treatments than their doctor. We old-fashioned scribes may have misgivings about the rise of citizen-journalism. But not all challenges to professional expertise are ignorant – or wrong.

In the case of Ashya King, everyone behaved questionably, even as they genuinely believed they were acting in the child’s very best interests.

But the days when the professionals – for all their years of training – had the field to themselves are gone. In medicine, we lay people are getting used to that. Are they?

By the end of my first year as a doctor, I was ready to kill myself

An Anonymous junior doctor in The Guardian


On my morning drives to the hospital, the tears fell like rain. The prospect of the next 14 hours – 8am to 10pm with not a second’s respite from the nurses’ bleeps, or the overwhelming needs of too many sick patients – was almost too much to bear. But on the late-night trips back home, I’d feel nothing at all. Deadbeat, punch-drunk, it was utter indifference that nearly killed me. Every night, on an empty dual carriageway, I had to fight with myself to keep my hands on the steering wheel. The temptation to let go – of the wheel, the patients, my miserable life – was almost irresistible. Then I’d never have to haul myself through another unfeasible day at the hospital.


By the time I neared the end of my first year as a doctor, I’d chosen the spot where I intended to kill myself. I’d bought everything I needed to do it. All my youthful enthusiasm for healing, big dreams of saving lives and of making a difference, had soured and I felt an astronomic emptiness. Made monumentally selfish by depression, I’d ceased even to care what my husband would think of me, or that my little boy would grow up without his mother.


Doctor suicide is the medical profession’s grubby little secret. Female doctors aretwice as likely as the general population to take our own lives. A US study shows our suicide rate appears higher than that of other professional groups, with young doctors at the beginning of their training being particularly vulnerable. As I wrestled silently with the urge to kill myself, another house officer in my trust went right on and did it. To me, that monstrous waste of young life seemed entirely logical. The constant, haunting fear of hurting my patients, coupled with relentless rotas at work, had rendered me incapable of reason.


Though we know large numbers of doctors kill themselves, what is less clear are the reasons why, when dedicated to preserving human life, some doctors silently plot their own deaths. A 2006 study at the University of Pennsylvania identified that during their first year as doctors, young physicians experienced skyrocketing rates of burnout, with symptoms of emotional exhaustion, depersonalisation, and reduced sense of personal accomplishment soaring from 4% to 55%.


For me, the explanation ran deeper. I was entrenched in a hospital system that brutalised young doctors. Working on my hospital’s surgical emergency unit, there were simply too few of us to cope with the daily onslaught of patients. Officially eight or 10-hour days ran routinely into 13, 14 or 15 hours as we house officers worked at fever pitch to provide what was, at best, a mediocre service for our patients. Run ragged, we fought to keep our patients safe, but their numbers outstripped ours 20 or 30 to one, and the efforts this took were superhuman. The nurses knew, the consultants knew, even the hospital management knew, yet no one seemed to give a damn.

It wasn’t just exhaustion that drove me into depression. Plenty of jobs are busy. But there is something uniquely traumatic about being responsible for patients’ lives, while being crushed under a workload so punitive it gives neither the time nor space for safe assessment of those patients. Days were bad enough, but nights on call were terrifying. I remember running from the bed of one patient, still haemorrhaging blood from her surgical wound, to another whose heart rate had plummeted to 20, perilously close to a cardiac arrest. Two stricken patients, but only one doctor, wracked with the knowledge that if something went wrong, the guilt would be hers alone.


I was lucky. I was pushed by the colleague in whom I finally confided into seeking professional help. It took anti-depressants, therapy and a narrowly-avoided psychiatric inpatient admission to bring me back to the land of the living.




 Now, on the cusp of junior doctors’ first national strike in 40 years, I’m astounded the health secretary persists in ignoring unanimous condemnation of his new contract from juniors and medical leaders alike. If he gets his way, Jeremy Hunt will make it easier for hospitals to abuse their juniors, by stripping away the safeguards that stop hospitals overworking us, fining those that do. Under his new contract, our hours will become even longer, even more antisocial – at a time when we simply have nothing more to give. And as we are pushed to treat more and more patients, faster and faster, fatigue and psychological distress will dull our competence: your lives will be less safe in our hands. And our own? Take it from someone who’s been there. Watch the suicide rate climb.

What is TTIP? The controversial trade deal proposal explained

Julia Kollewe in The Guardian

The EU claims it will create millions of jobs and bring down the cost of living – but others say it is a threat to public services such as the NHS
 

An anti-TTIP banner is held aloft at a rally before the G7 summit in Munich in June. Photograph: Wolfgang Rattay/Reuters



If you are not yet familiar with the acronym TTIP it is likely you soon will be. TheTransatlantic Trade and Investment Partnership is a proposed trade agreement and the subject of an ongoing series of negotiations between the EU and US aimed at creating the world’s biggest free trade zone spanning the north Atlantic.

It would dwarf all past free trade deals: the European commission reckons it could boost the size of the EU economy by €120bn (£85bn) – equal to 0.5% of GDP – and the US economy by €95bn – 0.4% of GDP.

It would create several million jobs dependent on exports, Brussels says, while consumers would enjoy cheaper products and services. The average European household of four would be around €500 a year better off as a result of wage increases and price reductions, according to the study commissioned from the Centre for Economic Policy Research in 2013.

The plan is to cut tariff barriers – levies imposed to control cross-border trade – to zero and other non-tariff barriers by 25-50%. The study insists this is a realistic prospect. The business sectors that would benefit most include industries based around metal products, processed food and chemicals, and especially the motor industry.

In the UK (and elsewhere), the main beneficiaries would be big businesses, as smaller firms are less likely to trade outside Britain. The UK could benefit to the tune of £10bn, which means the average household would be £400 a year better off.

The main aim of TTIP is to reduce regulatory barriers to trade, in areas ranging from food safety law to environmental rules and banking regulations. Opponents argue it will water down important EU regulations.

Food safety has become a major stumbling block in the negotiations as both sides prepare for the latest round – the 10th – which takes place from 13 to 17 July in Brussels.

The talks have been conducted largely in secret, but opposition to TTIP is growing on the ground. More than 2 million people in Europe have signed an online petition against the proposed deal. Campaigners have been outspoken about TTIP’s potential dangers and have painted it as a threat to European democracy.
In Britain, MPs on the all-party business, innovations and skills committee havedenounced the government’s firm support for TTIP amid fears for the NHS and other public services.

Concerns are mounting that TTIP could lead to more privatisation, with the prospect of US corporations providing vital UK public services such as transport, education, water and health.

As highlighted in this Guardian video, another major concern is whether standards will drop. For example, the EU bans cosmetics tested on animals but the US does not. Another question is what happens if EU countries want some protection, for instance Italy for its Parma ham, and the UK for its pork pies.
One of the most controversial elements of the trade proposal is the Investor State Dispute Settlement (ISDS) provision. ISDS provisions have been included in many trade deals since the 1980s, to encourage overseas investment in poorer countries. It means private investors can ask a tribunal of international arbitratorsto judge if a government has treated them unfairly – and can get compensation.

Over the past decade some big, mainly American companies, such as tobacco conglomerate Philip Morris, have used ISDS to claim rights. The provision would in theory allow private investors to sue governments for the loss of future profits due to decisions made by national parliaments. Critics say it could be used to attack the UK’s NHS by making privatisations of specific services harder to reverse.



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TTIP: the key to freer trade, or corporate greed?

Some say the US/EU trade deal that could be agreed this year will open up markets and promote UK growth. Others fear it will drive down wages and promote privatisation

Philip Inman in The Guardian


Cheap American olive oil could, in a few years’ time, be sitting on supermarket shelves next to the Tuscan single estate varieties loved by British foodies. At present a prohibitive tariff on US imports effectively prices them out of contention.

But a groundbreaking trade deal could lower the $1,680-a-tonne tariff on US olive oil to match the $34 a tonne the US charges on imports from the EU. Or the tariffs could disappear altogether. Either way, Greek, Spanish and Italian olive farmers must fear the Transatlantic Trade and Investment Partnership (TTIP), a deal that aims to create a level playing field between them and massive US agri-businesses.

Trade deals were once seen as a panacea for global poverty. In the 1990s, the World Trade Organisation was formed to harmonise cross-border regulations on everything from cars to pharmaceuticals and cut tariffs in order to promote the free flow of goods and services around the world.

There was always a fear that, far from being a winning formula for all, lower tariffs would favour the rich and powerful and crucify small producers, who would struggle to compete in an unprotected environment.

The effects of the North American Free Trade Agreement (Nafta), signed by the US, Mexico and Canada in 1993, appeared to justify that fear: it became in later years a cause celebre for anti-poverty campaigners, angered by the plight of Mexican workers. Not only were they subjected to low wages and poor working conditions by newly relocated US corporations – and, as consumers, to the relentless marketing power of Walmart, Coca Cola and the rest – but the major fringe benefit of cutting corruption remained illusory.

This year the US hopes to sign what many believe will be Nafta’s direct successor – TTIP. Should it get the green light from Congress and the EU commission, the agreement will be a bilateral treaty between Europe and the US, and, just like Nafta before it, outside the ambit of a gridlocked WTO.

Supporters say it will be an improvement on its predecessor because the main proponents are a liberal US president and a European commission that considers itself concerned with workers and consumers. Why, the commission asks, would 28 relatively affluent member states with concerns about high unemployment, stagnant wages, welfare provision and climate change agree to a charter that undermines workers’ rights, attacks public services or reduces environmental regulations?

TTIP is also billed as an agreement between equals that allows both sides to promote trade: it is claimed that the UK’s national income could be raised by £4bn-£10bn annually, or up to £100bn over 10 years. That amounts to a 0.3 percentage point boost to GDP, which would have pushed this year’s expected 2.4% growth to 2.7%.

  An anti-TTIP demonstration in Berlin this year. Photograph: Wolfram Steinberg/EPA

But it strikes fear into the hearts of many, who believe it to be a Trojan horse for rapacious corporations. These corporations, hellbent on driving down costs to enhance shareholder value, spell the end for Europe’s cosy welfare states and their ability to shield fledgling or, in the case of steel and coal, declining industries from the harsh realities of open competition.

TTIP has been compared to the 1846 Corn Law abolition, which either swept away protectionist tariffs that impoverished millions of workers, or protected a vital source of food and led Karl Marx to ask: “What is free trade under the present condition of society?” His answer was: “It is the freedom which capital has to crush the worker.” Is that the case with TTIP? Here are five key factors to consider.

Health and public services

From the moment TTIP became part of President Barack Obama’s growth strategy, critics have feared that he little realised the expansionary intentions of US healthcare companies or was too distracted to care. The concern relates to the prospect of EU countries, under pressure from rising healthcare costs, handing over major parts of healthcare provision to the private sector. Once services are in private hands, say critics, TTIP rules will prevent them being taken back into state control.

Since these fears were voiced, trade negotiators have excluded provisions that would have allowed firms to sue governments for the loss of health and public services contracts once they expired. This allows the UK’s rail franchise system and the contracting-out of health services to continue under time-limited contracts.

But the US private health industry, which is the largest in the world, views a Europe struggling with the needs of an ageing baby-boomer generation as ripe for the picking. For this reason alone, contracting out the distribution of drugs, the supply of medical devices and the provision of vital services could prove irresistible.

Dispute resolution

A little known facet of every trade deal is a separate form of arbitration for the businesses covered by the agreement, allowing them to avoid the civil courts. As such, the investor-state dispute resolution (ISDS) gives foreign investors the power to sue a government for introducing legislation that harms their investment.

Famously, it was used by big tobacco to sue the Australian government when it introduced plain cigarette packaging. Before and after the scandal, other governments have come under legal challenge from corporations concerned that public policymaking is denying them revenues.

In spring 2014, UN official and human rights lawyer Alfred de Zayas called for a moratorium on TTIP negotiations until ISDS was excluded. He warned that the secret court tribunals held to settle trade disputes were undemocratic. Their reliance on a small group of specialist lawyers also meant that arbitrators sitting in judgment were the ones who at other times represented corporate clients.

De Zayas feared that smaller states would find themselves in the same position as many governments in trade disputes, suffering huge legal bills and long delays to public policy reforms. He was joined in his mission by NGOs and, most importantly, by MEPs in Strasbourg.

As a first concession, the US side agreed to prohibit “brass-plate” firms – those that exist only by name in a county, without any employees or activity – from suing a government. This aimed to prevent a repeat of the Australia incident when the Ukrainian arm of tobacco firm Philip Morris, effectively a brass-plate entity, spearheaded the attack on plain packaging.

  European commissioner Cecilia Malmström has proposed an international court of arbitration to settle investor disputes. Photograph: Emmanuel Dunand/Getty

Many EU politicians said this concession was too easy to circumvent, leaving corporations in a powerful position. So Europe’s chief negotiator, Swedish commissioner Cecilia Malmström, hatched a scheme for an international court of arbitration – an open public forum instead of the private court system. Even her critics said it was a bold move, and unlikely to be accepted by the Americans.

Washington has countered with proposals for a more transparent ISDS court, with live-streamed meetings and the publication of all documents. Not enough, says de Zayas, who wrote recently: “Alas, countless ISDS awards have shown a business bias that shocks the conscience. To the extent that the procedures are not transparent, the arbitrators are not always independent and the annulment procedure is nearly useless, ISDS should be abolished as incompatible with article 14(1) of the ICCPR [International Covenant on Civil and Political Rights] which requires that all suits at law be decided by independent and competent tribunals under the rule of law.”

The two sides have yet to formally discuss either proposal: under deals between the US and Japan and the EU and Canada the issue was barely mentioned, but it is now expected to be among the most contentious.

Regulations

Michael Froman, the US chief negotiator, described the task of harmonising regulations as follows: “For years the US and EU have accepted each other’s inspection of aeroplanes because it was obvious they would not be able to check all the planes landing in their jurisdiction. We seek to expand this practice to other areas.”

So how would Froman apply this to the fact that American cars will still be left-hand drive, restricting their use on British roads? He argues that the cost of imported cars, research and development and testing can still benefit from the harmonisation of regulations on either side of the Atlantic.

Yet there is nothing US food regulators would like less than to accept processed foods tested by EU officials who failed to spot the horsemeat scandal.

And EU regulators are duty bound to reject GM foods, after sustained protests by Europe’s consumers in direct conflict with US farmers. Washington claims it will accept the science when it applies to regulations, which supports GM foods being accepted by the EU as part of TTIP, just as it is part of the WTO agreement.

Tariffs

Dispensing with tariffs seems like a straightforward process compared with tackling complex regulations. Under TTIP, tariffs on goods and services should disappear, though it is expected that some will only be reduced, and others may take years to go the way of history.

Under the Trans Pacific Partnership (TPP) recently agreed, but not yet implemented, between the US, Japan, Australia, Vietnam and other East Asian countries, all goods, from pork to cars, are covered.

A good example of how long it can take for tariffs to come down is found in the case of the 2.5% rate slapped on Japanese car imports to the US: this will start to be incrementally lowered 15 years after the agreement takes effect, halved in 20 years and eliminated in 25 years. In return, Japan will, among other things, lower its tariff on imported beef from 38.5% to 9% over 16 years. A similar programme could be possible under TTIP, with olive oil tariffs lowered over 25 years.

Labour standards and workers’ rights


Japanese trade unions supported the TPP deal, and unions in Europe are expected to follow suit with TTIP. They accept that labour protection rules lie outside the scope of a deal, and that their governments can therefore continue to implement minimum wage legislation and other supportive measures without being sanctioned.

But unions, where they exist, tend to represent workers in successful industries, which naturally welcome access to wider markets. Workers in weaker areas of the economy could find their jobs coming under pressure from harmonised regulations, lower tariffs, or even just exposure to a US rival with a work ethic that denies most employees more than two weeks’ holiday a year.

TTIP is important to the UK government because the US is our biggest market for goods and services outside the EU. It’s seen as especially important for small and medium-sized businesses, which appreciate the lack of language barrier. Britain also has a trade surplus with the US: we export more than we import, which helps counterbalance the country’s huge trade deficit.

Such is the momentum behind the talks that a deal could be agreed by the end of the year, and go before Congress and EU parliaments in 2017. Both sides claim to be making good progress. But the dispute over ISDS and protests from farmers could yet quash Obama’s hopes for US olive oil sales.