Sunday, August 23, 2015

I don't know

I don't know..I honestly don't know the answer to many a things- and those who are sure they do..are simply either putting on a  face of sheer bravado or..I don't know what they know or believe..but its either not grounded in reality of life and politics..or they are aware of something I am not privy to. I won't say today I have seen enough, won't bore you with all my "achievements" in life, all my exploits..the honest truth? I don't know.
Do you know what I am talking about? Its the NHS and the direction of travel. There is a lot of things I don't know or believe views are too polarised in- all of which stops and continues to obstruct any meaningful discussion

For starters, there is a question whether the NHS needs more money...again..I don't know for sure whats the answer is- I really don't. I look at diabetes care- and I don't even know how much money is where, who is spending it, how the counter productive tariffs are supposed to help..so how can I honestly ask, hand on heart, the public to give more? I look at the lack of finances needed for say, structured education..I also see the sheer wastage that inappropriate treatment of the elderly brings, the vested interest to which many acute Trust works, the Best Practice Tariffs which disappears into bottom lines...and I don't know whether there is enough money. Or not. I don't know but I would someone independent to tell me.

I don't know whether privatisation is the all encompassing evil beast some say it is. Is it because I do private work in my own time? No, its because I also am aware of many a state arenas providing poor care. No- did you say? Maybe so- but again, I don't know - I want someone more clever to make that call..someone independent,someone across political lines- I really don't mind who I work for, where I work for- as long as it serves patients and provides high quality care- thats my position. Blasphemous- did you say- maybe so in the tight chambers of twitter- not so much in the entire world maybe. Again, I maybe wrong, but I don't know- I honestly don't know.

Many dislike the market, would like the return of monopoly. Is that the right thing? I don't know. We have organisations like the CQC because we couldn't do the job what we were supposed to do. Would a monopoly help that? I don't know- I don't have the experience- but I would like someone independent to tell me.
Finally, to the name that seems to make all professionals bristle. Hunt. Do I know whether he is out to destroy the NHS? No- do I think so? I don't know but playing the man, having an angst against one man is no solution when we need to debate the policy as a whole. The point, in my opinion, has been made about what was said regards weekend working- it was aimed at the BMA and misfired..but it is time for us to ask the above questions- and if the answer is only from polarised views, then its time to ask for someone independent. Don't forget many also see the same man as someone who has set a clear agenda for patient safety...you may have a view that it is a politicians smoke screen- me? I don't know

I am tired of polarised views- and that includes those against political views. There is a certain quality about being in the tent in my view. There are many who hate the Tories, hate the fact they are the ruling party- but whether you like it or not, thats who are in the government- for another 4 years- if not longer. If we care for the NHS, then it makes sense to have that dialogue with those that are in the seats of power- a desire to improve /save the NHS should over ride all else. perhaps for some, thats too far a bridge but thats the scenario we have now- but I am more willing to try.  I apologise to all who may find my views offensive, wrong, out of order...but I have spent much time doing many things- and I must put my hand up..I don't know anymore. And I want someone independent to tell me.

Finally, I am a Consultant, reasonably entrepreneurial, street-smart and whether the NHS survives or not, there will always be a way for me. I do however believe in health being a fundamental right of any human beings- and so I would like to...no...not fight..but engage with those who want to discuss it. I don't want to fight- I want to help..I want to try- and to those who want to, I extend my hand. If you want to take the offered hand, then join in.
You know what I am talking  about- its the group I am a part of and very proud of. It has a gathering of a group of individuals with different views and beliefs (and not all of the above views are shared by all either)- but all with a willingness to engage. We will stutter, we will stumble,we are not politically savvy...but we will acknowledge a mistake when we make it. And we will try. Any successful team always brought together a group of individuals with different beliefs...but the key lay in the ultimate goal...the ethos of NHS Survival is no different

In my life, I have never waited for anyone- forged my own way- so if you want to help, then help..you can be of any political leaning, any belief- but if you think an independent opinion is the way  ahead, then do so. If you feel it isn't your forum, I wish you all the best in whatever forum you try and develop the NHS further.

Will it work? I don't know. But it most certainly is worth a try..and if not anything else, would have made some good friends for life. To those who are my friends, those who know me, know about what I stand for...help if you can..if you believe in me. If you can't, thank you for considering.


Friday, August 14, 2015

Fine balance

Recently something happened...without going too much into details, I saw a bright young healthcare professional upset...and I mean genuinely upset. There had been a post on social media- directly against the care given...and I saw it...caustic, bitter,angry. Patient confidentiality stops anything else but I knew it wasn't accurate...and yes, I know enough about social media to know everything isn't accurate and in someone who lives with a chronic disease, its isn't right to judge either- as quite rightly those who don't have it, do not live their lives, do not live their frustrations.

But what about the carer? Compassion is a 2 way street too- and the number of amazing examples of healthcare always far outweigh the minority of poor care. Indeed there are some examples which can never be condoned. professionals who don't care enough but that minority is no different to any group of individuals- a mixture of extremes makes us all the human race we are. So I asked the question on twitter whether there were any blogs which actually spent time appreciating the care they receive. I always see blogs which suggest what could improve, I also read highly critical blogs..there also seems to be a dissociation of the reality the NHS finds itself in. Any carer in the NHS will tell you one thing- the expectation, the pressure is high but more importantly the financial numbers are simply not adding up. Under pressure,under constant squeeze of time, compassion gets eroded - one step at a time....someone said compassion needs nothing extra...wrong..compassion and caring needs one thing we don't have nowadays- time.

If I am honest, locally, we have our own Ninjabetic whose previous blogs have been of constructive criticism as wells laced with appreciation (examples: here , here and here)where it has been due..however I have been keen not to highlight those- as it once again goes back to what I myself have been guilty of..."Look at us, aren't we amazing?" Time has taught me it does tend to rub people up the wrong way- and its perhaps time to share- but with more care, more humility and less bravado. 

So I asked for examples beyond our local patch- and I must admit to being very pleasantly humbled at not only the beautiful tweets I received but also the sparkly examples of what they care they felt they had received. 

Want to read? Have a go here and here and here and here . Beyond diabetes, a great read sits here It does make you feel nice and warm.

I have never done guest blogs but via twitter someone kindly said she would put down a few thoughts...have a read below..from Emma Stahly ..in her own words...



My daughter was born at 36 weeks gestation, weighing 5lb 5oz. Against the odds, my induction had been successful and 8 hours after my waters were broken I gave birth. I felt on top of the world, empowered, proud - and grateful.

As soon as I called my diabetes specialist nurse (DSN) when I got a positive pregnancy test, I was booked straight into the diabetic antenatal clinic for a scan, blood tests and a chat with my consultant about my blood sugars. From then on I saw my team every other week, and e-mailed my consultant almost every other day. I did all the hard work, but I never felt alone doing it. I felt listened to, and that I was working on my diabetes in partnership with my healthcare team. My control was excellent, and I believe it was in part because I was so well supported.

Towards the end I started to suffer more hypos and the expected insulin resistance didn't happen. My obstetric consultant became concerned about placental failure. I was booked into the maternity ward every other day for cardiotocography (CTG) monitoring. Each time I sat there with my belly strapped up, clicking every time I felt a kick, my consultant endocrinologist showed up to have a look at my blood glucose diary and see how I was doing. Finally she became concerned enough to call the obstetrician, who arrived at the ward immediately. He decided to admit me to receive steroid injections to help the baby's lungs, and that I'd be induced 48 hours later.

My daughter was small for her gestation, and I was told my placenta was too. I believe had I been allowed to carry much further my baby would have been at significant risk. I am certain that my consultant team spotted the danger and made the call at just the right time to deliver early. They are paid to see patients and make these decisions daily - but the pay in itself would by no means guarantee positive outcomes. They are committed to their patients, to healthcare, and to making lives better. They may well have saved my daughter's life, and I will forever be in their debt.

Beautiful, isn't it? I will be honest- i don't want false praise- a sentiment which will be echoed by thousands of professionals everywhere. But I don't want to be told off always either..I took this job to help- and in the circumstances, I am trying the best I possibly can. Patients and professionals have to work together- there should be no "you" and "us"- if the system is such that this decide is created, then we must- I repeat, must join hands together to ask whether the system is sustainable, ask ALL political parties to accept a review of where we are heading. The NHS is struggling and this is not the time to have divisions- this is the time for the public and the professionals to unite for better,safer care.

Shine a light where needed..but with care...just as the professional doesn't know what you are going through with your needs...similarly you, perhaps don't know what the professional is going through every day in their work. Let's have that balance- it indeed is a fine balance- but one we must work together to keep.

To the professionals, read some of the links too...its not all bad either. In the heat..it perhaps feels so but it isn't the case always. The fact is..we all need to look out for each other a bit more.

Tuesday, August 11, 2015

Soft touch; hard evidence


Much has been said about the role of the Care Quality Commission in recent times- a murmur has gathered pace with the Professional Standards authority questioning the role of regulation. 211 million pounds is the figure mentioned spent behind CQC and maybe its time for some sense checks, as well as for the CQC to consider the next phase of its development.

For starters, let’s be honest- nobody likes to be examined or regulated. We, hopefully, all go to work believing to be able to do the best for our patients- so any external regulation raises the question whether we are or not. Sadly, past events have suggested there probably is a need for this- and the question is whether CQC needed to exist whether all Trusts and staff had done enough with their internal processes. That’s what, perhaps, CQC needs to tackle..a step away from the criticism and be more of a guide. Shine a light but also make robust suggestions, share examples from their travels where its better. There is little point in saying “you are not good” if you can’t be a support to improve or indeed give suggestions as to how to do so within present financial constraints.
Interrogate success, not failure- that possibly needs to be how CQC functions

Secondly, I have seen CQC appear in a few Trusts- and to be fair, it has opened doors to fight the corner of patients in some cases. The name CQC has made managers sit up and listen when previous business cases, please, data has failed to do so, failed against the wall of financial imbalance. One may say that’s a culture of fear but it’s a sad indictment of internal processes where the name CQC is needed to make changes. In an irony, perhaps it makes the case more for its existence. To many, the message thus is..sort your own internal bits out..if you do, then the CQC doesn’t need to exist

Thirdly, the money involved. 211 million sounds a lot but its also about context- especially when you think that the whole NHS budget is about 110 billion. Our local 3 CCGs has a combined budget of about 800 million- so in a national context, that money released would be about 1 million/ CCG..something that would be swallowed by CIP budgets in a blink of an eye

Finally, its also about CQC learning from experience. More soft touch, less marching in. But most importantly? The need for data. Quite rightly the return of investment is asked for- as with every sector of the NHS and this is where CQC has floundered. Let me give you a simple example- CQC has examined X number of steps- as a diabetes specialist, I would like to know what diabetes specific changes have happened in hospitals to keep patients safe? Gillian Astbury was one of the deaths due to lack of insulin in Midstaffs. Has CQC inspection improved that? Anecdotally, the answer is No. Prove the doubters wrong- show that insulin prescription has improved, show that errors are less, never events are less..think of metrics, markers, maybe even simply checking whether the recommendations given in Trust Z has been implemented or not.

Indeed, there are many arm length bodies that can be amalgamated and role looked at in times of financial strife- but on balance, the CQC probably still has a role as I am yet to be convinced that internal processes are robust enough and protects patients enough. But for that CQC also needs to adapt and be ready to answer critics with data- not with simple emotions. The need to improve care sits with all of us- the trick is to move away from the emotiveness and base it on data. Let’s see whether the powers that be are ready for that.

Wednesday, August 5, 2015

Ask the question

We must be able to do what we preach. No- really, we must. How many courses, events, conferences have we all attended where we talk about importance of being transparent? We must be able to- shouldn't we? We have an issue of patient safety- and quite rightly, it is top of the agenda. The CQC- for whom I actually don't possess negative feelings - (as frankly, seen enough occasions where the "fear" of CQC has worked far better than any data, any debate, any business cases to get appropriate staffing) - quite rightly tries to flag areas of poor care; poor staffing and asks the question of Trusts- and Trusts have to respond to that. 

What sticks in the throat of then Monitor turning around and saying- well.. actually staff appropriately. So we come back to a question. There actually isn't one question only. I know many want the question to be simply - where's the money- whether that be due to personal experience, whether that be due to political leanings, belief- so for many- that indeed could be the question. The efficiency evangelists say - there can't be more- which is also fair- in which case the question could be "Ok- so what isn't essential?" 
We could talk about value based interventions- but the interpretation of that is individual- who's bold enough to say "We think safe staffing on wards is most important, so we will stop providing pumps to type 1 patients"? Sorry- did that offend you? Is it by chance that you are someone or know someone with type 1 diabetes or does that not matter to you- as you are don't interact with people with type 1 diabetes? Ok- don't get angry- I will keep it- shall we then take away community rehab for heart failure? Outrageous did you say?

So what's the question? Well it could be many- the problem? All believers, evangelists are tainted by their own experiences, their own confirmation bias. I would like to ensure psychology services are available to all- that's because of my interaction with patients who would need that...would it matter to a Gastroenterologist..or a Radiologist? Maybe it would- but would it matter above their latest tech or whatever that would "improve patient care"? 
Let's take patient safety- the loudest supporters are the ones who have gone through pain personally or been at hearings listening to harrowing tales..their drive and passion is understandable but they didn't ask the question. They didn't ask one simple thing: Can we afford it? Or if we can't, what else is going to be sacrificed? Does it mean they care less about say the need for a pump in a type 1 patient? I don't think so- but question is would they rather sacrifice it to get better patient safety or improve patients they see everyday? 

It's tough, isn't it? I have been on the other side of the NHS  a few times  too- and before #hellomynameis became a movement, I never even felt the need for something like that. Why? Because every GP, Consultant, junior I met was polite , introduced themselves- and no, they didn't know I was a doctor. Kate's experience shaped her views but it still has been her views- which resonated with many...the difference? She knew the how...it didn't need the basic question answering- what else gives. This was a simple human interaction- nothing else had to give.

So we are now here. I do not know what is non essential staff. From my experience,a manager isn't, a dietitian isn't, an admin person isn't...so I don't know who is. But I would like to ask the question- Who is? I would like some to ask the question- what gives? I would like some to ask: How? If it isn't about money, what do you want me to stop?

If we are in a state where we can't do everything- maybe its time to do a few things of highest quality- and maybe top of the tree is nurse staffing. Then lets be adult and say we will stop other things. I am ready to have that conversation in the world of diabetes- with patients. Let me finish with a question...
Are you?

Thursday, July 30, 2015

Harsh reality?

Florida. Atlanta. New York. 3 cities with a difference..3 cities where 2 weeks whizzed by..away from the hustle and bustle of work. Not quite away from the NHS though...Twitter provided a harsh reminder of the emotions and issues always there at the tip of the fingers. The last few weeks have witnessed a storm of opinions, thoughts, blogs, open letters...the views of the medical profession has been there for many to see. Angry, hurt, disappointed...some say out of touch with the public, to some that bit being immaterial.

Taking a pause, how actually does it affect Consultants if the NHS ceases to exist or moves to a 2 tier system.a system let's say which say has an NHS Plus..an NHS you can access only via co-payments or top ups. The very concept makes many froth at the mouth, their heart churn but anyone worth their salt, deep in their hearts knows, financially at the very least, we are in a situation which is nearly irrecoverable. The money doesn't stack up anymore. Yes, you may not agree with that but there is also the minor issue of the electorate mandate.

The evangelism of a few, however right at the present, will ironically, perhaps supply the ammunition to break the back of the NHS finances...how will history judge them? Time will tell. Today's patient safety advocates have opted to go for the issues of patient safety first, ask for resources later. Todays news as regards NICE U turn should come as no surprise- the money simply doesnt stack up.
Tomorrows ones - hopefully- will be at least bolder - at least raise the issue of prioritization and resources first. Only then maybe, just maybe, we would avoid the issue of better-staffed wards but financial balances in the red. Did you say money shouldn't matter when patient safety is at hand? Ah but it does...ask any Trust or CCGS finance directors. To fund X, they have to cut Y. To YOU patient safety maybe paramount, to someone else, having psychology support for their diabetes maybe of a higher priority. In footballing terms, to aspire to win the Champions league is laudable- maybe you need to have the resources (and talent) like Barcelona to do it. Pure talent or will rarely cuts it- in any sphere of life.

So how would it affect those recent pantomime villains called the doctors? In a business called health, in a world where we are worried about our future, worried about dying, worried about growing old....I will allow you to make your own conclusion to that. Free from the "trappings" of a public funded structure or the "dreaded efficiency", only one thing suffers...healthcare for all irrespective of ability to pay. Thus, it is with a incredible dose of irony one notes doctors trying to resist the slide of the NHS..spun today as the pantomime villains trying to protect their salaries and perks...it could also be about the strongest force trying to raise a united voice against the inexorable slide at hand.

The doctors with their entrepreneurial sides will flourish.as in fact, most of them already do...in an open market, their skills or whatever you want to call it, will be unbounded, unfettered...would you bother about who was suffering due to inability to pay or would you worry about how much you can earn? If that sounds like blasphemy, do pay a visit to other countries where concept of "free health" is met with raised eyebrows and genuine surprise. Some will struggle in isolation, opting to stay true to their ethos of "help others at all costs" while the majority will fall in line with the 2 tier NHS...that's called life, that's called making sure your own family is provided for, that's called reality. Sounds harsh? Maybe YOU wont do itbelieve memany will. Do patients needs come before your own families needs? Think about that

That's exactly what has happened or is happening in other countries...UK will be no different. I also do appreciate many believing that morally it would be wrong - however when I did raise that argument to Mexican chap a few days back, his response was curt, waspish but perhaps true too."A country which has spent centuries plundering other countries maybe shouldn't lecture others on morality". All about your viewpoint, isnt it?

So why do I write this particular blog? Simply to ask one more time for some semblance of unity- amongst doctors for starters. Too many divisions exists- on lines of what we do, what CEA awards we have, whether we do private practice or not...maybe it's time to try and get a united voice. Then it's a bigger gathering of like minded voices...and that's everyone who firmly wants the NHS to survive as it is.

Let your passion to improve the present not destroy the future, let your own prejudices towards your colleagues not hamper a united voice...for tomorrow if the system changes, it's not the doctors who will suffer...it will be many more who will.folks not born with the fortune or luck fate has provided them with. It's a very simple question really...do you believe enough in it? And if so, are you willing to forget your differences?


Choose well.

Thursday, July 23, 2015

Opt in; Opt out

Before I proceed with this blog, let me lay down a few cards, especially regarding what gives me at least some mileage to pass an opinion. 

I am a Consultant in Diabetes who has so far:
Been a Consultant in an acute Trust contributing to diabetes and general medicine
Been a Consultant working within 2 community Trusts 
Been a clinical manager for an acute Trust as well as a community Trust
Work on a CCG Board
Work/involved with think tank such as the Kings Fund
Worked with quangoes eg:NHS Institute of Innovation& Improvement- renamed as NHSIQ later

Happy with that? Ok then...here goes.

It's time now for this 7/7 debate to have some pure facts...facts based on experience of working within different formats/organisations, facts away from the raw emotions understandably generated recently. So let's get to the nub.

Consultant opt outs part 1:  Let's be crystal clear on this..emergency work has no opt outs. The NHS needs 7/7 emergency cover and that's something any manager worth his or her salt, with backing from clinical leaders, should and must deliver. There is NO contract obstruction to that. the question thus is...of people are struggling to implement what is already IN the contract, what good will a contract change actually achieve? Get better skilled managers, clinical or otherwise, not contract changes.

Opt outs part 2: There indeed are opt outs in Consultant contracts. They are for elective work. So let's see why many want to have this removed. 

The one for all principle: if no one else has it, why should Consultants? A fair point. No one is special indeed...but let's look at those who have no opt outs. Specialist Nurses, podiatrists...how many elective clinics are run by them? Very few..some due to lack of resource, some due to lack of need, some due to lack of will. So..if we can't even implement elective work for those who have the opt in..what good would a contract change do without the investment? 

Financial: weekend elective work is indeed done- at a cost. Consultants and others involved are thus paid higher rates, as negotiated locally. This costs more and thus is an issue. But it's an issue because the Trusts are running out of money and need more elective work, thereby money..while they get beaten over a rack when the targets get missed. Why are targets getting missed? Because the surgical beds are filled with medical patients who can't go home due to lack of funding in social services etc. Cue last minute surgical lists cancelled, cue targets being missed, cue waiting list initiatives. How vicious do you want a cycle to be?

Political: negotiation tactics always involves decrying the other side( especially when it's tough) and painting Consultants as the pantomime villains plays to the classic view of decrying the higher paid individual. I have no issues with that but that's slightly underestimating the faith and belief other colleagues within the NHS have towards Consultants too. Anyway, it's politics to try and force the other side to the table..weakened by public pressure...the problem is you need the Consultant to deliver the services..by force or contract battles, you can achieve only so much. An engaged Consultant or for that matter anyone will deliver far more productivity..and accusing medics of not doing something they have been doing for years, has somehow brought many warring factions together.
 
I am also aware that there are patients who fall between emergency and elective. That indeed is the case..and that is about access, about using resources differently..and no, you don't need contract changes for that. Example? Let's say neurology. Does everywhere have a 7/7 service? No..as the responsibility for that falls on the physician on call. Sometimes it care beyond their expertise..but rather than input resources into 1 specific specialty, that's where networks come into play...for that you need organisations to think beyond their silos, think beyond their own bottom lines...that's got little to do with contracts.

Finally, to the BMA...apart from the message from last week ( I repeat, do NOT put the next generation on the line and protect the present) here's something to mull over.."You will not get what you deserve, you will get what you negotiate". Is there money already in the overall contract? Is there a place to consider the Clinical Excellence awards and making them ALL time bound? is there a place to reconsider automatic increments? Is there money there to help fund elective work where it is needed and make the savings needed which is otherwise being burnt via WLIs?

As Consultants, we have always taken pride in leading change in our services and for once, it is good to show unity. Here lies a perfect opportunity once the angst has died down and the point is made..to make some suggestions and overtures....if not to do something which many have  struggled so far..to turn this debate into one simple issue of "Show me the money, we are here to do what is needed". Politicians come with a mandate and are sometimes also let down by advisors, advisors who have left the coal face long ago, high on the ambition and intention scale, low on keeping pace with developments at the grassroots  Don't also forget this will also compete with safe nursing staffing as well as primary care investment. 

Finally? If indeed there is no or limited money...then we talk about prioritisation. If safe staffing on wards is indeed of the highest priority, then maybe elective work on weekends isn't. In which case, the debate about "opt outs" is just a fallacy, nothing more..and nothing less. Or shiver me timbers..are we talking about electives on weekends which a public taxation can't afford at present funding...are we now heading towards asking the public to pay for an upgraded service? 

We shall indeed see. Now THAT would be a whole different debate regards opt in and opt out.

Saturday, July 18, 2015

Its all a bit odd

Florida. A wet, muggy afternoon. Am on holidays in Disneyland...sitting by the pool as I write this. Don't worry, I am relaxed..enjoying my time off..but while the rest of the family takes an afternoon nap after yet another scorching day at the Park, this seemed like a perfect moment to pen some thoughts.

It's been amusing to see the #IaminJeremy take wings on social media...and it's always the humorous ones which make you chuckle the most..and enough already has been said about whether Consultants work 7 days or not, so won't waste my breath on it.The hard fact is that Consultants, in the main, do emergency weekend work, the contract doesn't allow you to duck out of it. Non emergency however isn't. The debate of course is what constitutes what and whether Consultants should have the right to do so or not.

As a clinician, and as a manager, this has left me scratching my head a bit. Beyond the humour and the daily mail headlines, it's all a bit weird. As a manager, take this catch 22. Hospitals are jammed to the gills, social services are bust, departments are judged based on how many discharges have happened per day..so understandably with all hands on deck, elective procedures get cancelled. The waiting lists bulge and to ease that target, with Consultants  having power to opt out, the only way to bring back parity, waiting list initiatives come into play- and whether we like it or not, it's a headache for many in management, not to mention the financial consequence. So if only, that leverage could be broken, then it's another way forward or simply put, another part of the system creaking..another finger in the dam.

Let's take it as a clinician..let me give you an example of my specialty. Foot clinic...a requirement via NICE is any new diabetes foot ulcers should be referred within 24 hours. Most hospitals don't have even a 5 day service, let alone a 7 day service. Now if someone asks me should I do a Saturday foot clinic..the answer is "Yes..with a but". The 2 buts, at least in my case, what else do you want me to stop doing? I work on a 1:7 weekend helping to evidence patients on wards as well as ensure a 7 day urgent diabetes service is in place. Do I drop that...or would there be investment? Even if we get past that hassle, to run a foot clinic, there needs to be a podiatrist, not to mention urgent access to vascular, orthopaedics, radiology...ergo everything running like a Tuesday. Do-able? If you say yes, come to the table, I say.

What baffles me however is the stance. Politicians are rarely someone who take steps without advice and the key of negotiations are always simple...keep something up your sleeves to make sure the other party never walks away. The tone of war/battle makes it all sound very heroic but at the end of the day, the people you need are the ones you are trying to alienate. Healthcare is an oddity in the sense that without the personnel engaged, you simply can't deliver. To say in 1 hand, the days of the god-like Consultant is over and then also say that it's due to absence of a Consultant,mortality can go up is all a bit odd.

A bit of honesty from both parties..yes, the BMA would be welcome too.Or let me rephrase..perhaps a bit of better clarity. From the politicians point of view, it would, perhaps sound, much better if there was acceptance the majority of Consultants do work emergency services BUT there is now a need to discuss elective work on weekends..as its all now tied in with how the non elective side works. From the BMA side, perhaps a bit more honesty too...who are you standing up for? All the Consultants or is this just about the new ones? Or is this again about sacrificing the incoming ones to keep individual bits ok? It honestly gets a bit Pythonseque when you see a Professor lecture about 7 day working, when as a junior, you have seen them appear 1-2 times a week on the wards, leaving everything else for the juniors...

So perhaps, just perhaps, all the posturing needs to ease off. It's pretty pointless to be honest- as without the finances this won't stack up. As someone who enjoys negotiations, I also understand classic negotiation posturing on both sides and the end point, as we all know, will be somewhere in the middle. To politicians, let us do our jobs..we aren't too bad at it..as most statistics will say. Yes, there are things to improve..and to be honest, if we didn't we would be living in utopia. To the BMA, for sake of us all, negotiate and negotiate with some chutzpah and panache, not like petulant kids. ..and whatever you do don't sacrifice the incoming ones at the altar of bargaining.

Best of luck and have fun...for me? It's time for me to meet Buzz Lightyear. To infinity..and beyond!