Saturday, November 15, 2014

Contract games part 2: Think..TEAM

It always makes me bemused when we talk about yet another contract. We fail to actually monitor, adhere to, understand the present contract so to suggest yet another modification will solve it all is steeped in naivety. Most managers I have encountered have not actually gone through a gruelling course or understanding of the Consultant contract -which isn't their fault- so to expect them to monitor and hold people to account is also a bit simplistic, if not fool hardy. The Consultant contract is fundamentally different from say a GP contract or a nurse contract- so to use the same tools to dive efficiency- if that's the new buzzword - not to surprisingly doesn't work

So to some suggestions- not too radical- and indeed have been tried in some places with good effect- whilst also keeping morale high. But it involves help from both sides- not just managers but also Consultants themselves- the billion dollar question,as ever, is are they?

1. Annualise departmental job plans: 

Put all PAs in one pot- maybe tricky in bigger department but not impossible. As a manager, explain to the team that the Trust is paying for X sessions and thus its only fair to monitor whether X are being delivered or not. Give the onus on the department- we talk about working in teams- well then, give the department the ethos of a team. It's THEIR responsibility to deliver- as a group- let them sit as adults and come up with plans- let them sort their team annual leave, study leave out and outline the sessions they will be doing.
As a manager, don't just rock up and say "Its short guv"- give heads up- send the departmental lead quarterly updates where things sit with sessions- a pat on the back if on track- again- to check internally if short- why short, is there a busy month coming up which will cover the shortfall or is it someone within the team not pulling their weight? Let the team sort it out. At the end of the year, its the team which will be responsible for the outcome to the question- "Have you delivered the sessions the Trust has paid you for?" Together you rise, together you fall

2. SPA time- as a team:

Again, SPA is not some mythical beast. If teams are saying they have, lets say, 12 trainees to supervise- no problem- of course check with the postgraduate lead- as to whether they are indeed the supervisors- and have a system of checking even with the trainees whether they are actually being given the supervision? What's the point in having SPA allocated to your time and then not having time for the trainees if most of the time is in DCC? May as well be open about it- again- let the team choose which members of the team are better suited to deliver training, research...I have been involved with education long enough to know many are not interested in teaching or supervising..so why allocate that in their SPA?

3. Outcomes- as a team:

There;s little in job plans to measure outcomes- why not? To suggestion 1...there is little point in doing all your sessions if the outcomes suggest that you are not benefiting patients- who would I rather have as a doctor- a surgeon who does 5 cases in 3 hours but with a higher mortality than someone who does 3 cases but lower one? If its the same case mix, then its the second one for sure. Think broadly- again- let the department be asked what THEY would like to be monitored on- a team effort- and once they agree- that indeed is the monitoring- why indeed not?

4. Transparency of job plans:

Finally, make all job plans, outcomes agreed- sessions being done transparent. At the moment, hospitals are filled with folks who think they work the hardest and by default everyone else is lazy or at least less busy than them. Its like there's an award for being most miserable, downbeat, looking tired...if you smile and say "it's not too bad"...the immediate thought from the other party is "lazy so and so.lets look at their job plans". Let's make it transparent...just because you work in emergency department doesn't make you less busy than if you work in an Endoscopy suite or Rheumatology make job plans open- let the miserable ones review it and come to a more open conclusion- stop the sniping, make teams expand from just departments to have a more divisional feel

Its about treating adults as adults. Discuss, negotiate with them what THEY believe their outcomes should be, don't foist on them. Discuss with them why they can't work as a team- use job plans to create the ethos of camaraderie- get THEM to rise above departmental disputes. Learn from sports- disparate characters get together to make a winning team- Consultants are no different. But once THEY have agreed to be monitored on X, Y and Z, then give managers the tools and understanding to have regular meetings to discuss them.

We in the NHS have a phenomenal capacity to over complicate things and then to change something which we couldn't implement in the first place. It's not really that complicated- it needs strength, tenacity, determination and a strong feeling of mutual respect.

That, I am afraid, isn't something that we have in huge measures in the NHS- sadly we seem to spend more time thinking of new fancy terms to resurrect old power point presentations. This isn't the time for packaging old wine in new bottles- we need a new brewery.

(Next week: Challenging wastage- responsibility of doctors says AoMRC..so are we?)






Saturday, November 8, 2014

Contract Games part 1: The battle

So it's now a Mexican stand off. The senior and junior doctor negotiations have broken down- both parties have walked away. Both parties have accused each other- and its played out publicly - sometimes a bit undignified, sometimes like a school playground- I suppose depends on who you follow on social media. I have been a clinical manager now for nearly 5 and a half years- and I have always particularly taken interest in job planning- which is why the debate fascinates and intrigues me.

On one hand, you will hear the frustration of managers about the inability to pierce through job plans, the multitude of national body recommendations as regards job plans which doesn't always help with delivery of Trust needs while Consultants will also turn and say that if they were held strictly to their job plans, and they decided to walk away when the clock struck "X". the NHS would collapse. The reality is that both sides actually have a point. Did I hear some say "how dare you- have YOU any idea how hard I work?"...well..calm down and read on.

The present Consultant contract is actually a simple one.The last changes moved to a sessional based contract divided into Direct clinical Care along with Supporting Professional Activities. The national contract was that in a 10 session job, 2.5 were recommended and agreed to be SPA. Fact is most trusts or new appointments breach that and as the College advisor asked to review job plans- thats pretty much a standard answer I give to all- the SPA isn't enough as per national contract requirements. Don't quote me on this but as I understand Foundation Trusts are under no obligation to heed that recommendation. Happy to stand corrected by Human Resources teams! Anyway, so this SPA- most managers don't quite like- reason? Well- it actually if rarely generates much revenue for the Trust or helps to deliver clinical care. The flip of that is this..it incorporates time needed for teaching, education, revalidation, audits, clinical governance..all those things which don't get you revenue (No sir, that's not on PbR) but actually means a lot for patient care.

This is where it all gets a bit complicated. Educational bodies recommend that job plans should have 0.25 PA per trainee- 1 hours / week- sounds amazing for the trainee. So if you hold that to the tee- and then factor in the College recommendation as regards time for revalidation (you need that to be a safe doctor) then all you need is 4 trainees to supervise, revalidation time and boom, your SPA is over. What actually happens? The Consultant tries to squeeze in the other relevant bits such as audit, governance in there- the time for training squeezes, juniors feel left out, training standards drop- and the cycle is complete.

What about the Direct Clinical care? Again, areas of greyness- job plans suggest you start clinic at 9- finish at 1230- have 30 minutes for patient letters etc- there you go, 4 hours done- go home. Reality? Ask around- pretty different...don't get me wrong- there are indeed individuals who take the proverbial BUT that's due to poor management or supervision by the clinical managers. A few bad apples don't make the whole barrel rotten. The debate or cycle continues. Then there is the desire to standardise- why does Dr X see 10 patients while Dr Y sees 18 in the same time? From a managerial point of view- why cant both X and Y see 14? Simple really- thats because they run different clinics with patients of different needs. A patient with pituitary pathology will take anything between 15-20 minutes while a patient on an insulin pump may require 30 minutes- 45 minutes. Standardise that...and you fail both groups of patients.

Finally, the area of debate- "normal working hours" as per standard contract is 7 am to 7 pm- the latest contract round wants to make "normal" till 10 pm. An area of amazing greyness mixed with a whole load of politics. Rather than having a proper discussion, most centres around "If you don't agree to this, then you are not patient centred". Lots of folks who actually dish out that advise don't work 7 days themselves but couch themselves in leadership garbs and showcase themselves as inspiring individuals.Always easy to lecture when you don't do it yourself, isnt it? It's a bit like me suggesting Messi should have curved the ball around the wall, rather than going over the top...
Some Consultants also join the camp..check them out- either their kids have grown up and moved out or they don't have much of a family to go to. A few people's evangelism shouldn't burn the dedication of many.I hear plenty say- it is amazing to have a Monday off instead of Sunday- yes perhaps so- but you know what- at that time, my kids are at school- and I want time with them- not be twiddling my thumb on my own at home. Tricky isn't it? Took this job to help, not be a martyr.

It makes me smile when I see lots of folks quote Gandhi- how he dedicated his life to making India free...can I suggest you check his life story too? There are reams written on his lack of family life, his destroyed relations with his children. History has an odd way of suppressing the faults of those we believe so much in- read a bit more- you will find plenty of interest. Let me be honest- I don't want to be like Gandhi- I would just like to be Partha Kar- with my flaws- trying the best I can do at work- and then going home, enjoying my life with friends and family.

However, there is actually a way around all this as regards contracts- or at least in my opinion. It involves both sides - clinicians and HR/managers working together, being adults and open about solutions, a bit of give and take on both sides... the question is are both sides actually ready for that?

(To be Continued in Part 2)

Friday, October 31, 2014

From the heart..Thank You

Pride is good, isn't it? When you get something right, you have to be proud, isn't it? Today when I see our local model of care being recognised either by Diabetes UK or the Kings Fund, I don't make any bones about how proud it makes me. No one- and I repeat- no one has seen the long evenings, the extended negotiations, the charm offensive, the time with the family sacrificed to do only with one thing in mind...the model of care needs to change..patients deserve better, much better.
Yes, the NHS is cash strapped, yes, we belong in silos, yes, we all like to believe we are doing a fantastic job and yes, we baulk at the thought that the NHS may not be delivering great care sometimes...but there are many and many folks out there crying out for better care. And I have tried..in my own inimitable style..tried to change years of working, years of obstinence, lack of mutual respect between primary and specialst care..and 4 years later? Excuse me for taking a moment to look back..and say " We got there...ladies and gentlemen, we got there".

This blog isn't about explaining the model - there are now enough literature on it- it works on 2 simple principles...Firstly, diabetes care sits in primary care- so support them, help them- on THEIR terms, not ours. Secondly, the changing role of a specialist...moving away from just being a specialist to being also a support, a friend in need, a helping hand and an educator...plus a realisation that for primary care diabetes is only a fraction of what they do..so support, help...don't criticise, help..be there when needed. Honestly,its not that complicated- never was. No this blog today is about taking off the veneer of arrogance and saying thank you...saying ladies and gentlemen..without you, it simply wouldn't have happened. I have been the public face of it, the spokesperson, the person to showcase it..little else..the credit for this belongs to many others.

Firstly my amazing colleagues..for years my Consultants...then folks who believed in my vision, never unhappy with me taking the spotlight, allowing me to show boat, drive the changes and keeping implicit faith. Darryl, Mike and Iain..its has and is been nothing but a privilege...my colleagues, my mates, folks I intrinsically trust with anything...gentlemen..thank you.
Then what about our nurses? What can I say...I can't repeat myself enough..they ARE the lynchpins of what we do...amazing women who do a job I can only stand back and admire...ladies, a group hug from me..you all have been just simply ..wow...folks who have shown it can be done.
I must acknowledge my primary care colleagues who have received us with open arms- across 83 GP surgeries. everyday has been a learning experience..simply being stunned by the workload...and silently making a note the care being provided. Thank you guys...it has and is fun...great to work with you indeed  :-)

At this point, I must say I tire of the managerial bashing I continuously hear. Let me make this crystal clear..without some good managers to work with me, none of this would have happened. Firstly Melissa Way, then Sarah Malcolm..if you want to ever know why we need managers, go and see what they have done for us. Local CCG leads have been great...people always ask how we have done what we have..well..without such forward thinking ones like Jim Hogan, Andy Douglas, Paul Howden et al,..it would have stayed confined to a powerpoint presentation - for sure

Finally, our patients...I have observed, learnt, taken feedback, accepted the challenges thrown and been my driver to implement what we have done. We haven't solved everything but are always open to being challenged, always open to change and improving things further. The above may indeed read like an Oscar acceptance speech but I don't know of any other forum to thank you so many who have made all this come true.

Ladies and gentlemen, genuinely, from the heart...for once taking off the aura of arrogance, letting the ego rest for a bit...just wanted to say thank you to all. I wouldn't have even dreamt of getting where we are when I started my job in 2008..and wouldn't have without you all. Partha Kar...today....says thank you. From the heart. xx


Thursday, October 23, 2014

The Fantastic Four

Sometimes it's worth taking a pause in the hustle bustle of life, politics, work to perhaps stand back and simply say..thank you. This blog certainly aims to do that...thank you to four special ladies with whom I have had or continue to have the utmost privilege of working with. Why am I writing about them? Simply because they are the unsung heroes similar to the thousands within the NHS who are self effacing, humble, absolute super- professionals but never recognised in the fast modern world of self aggrandisation and publicity. I have said this publicly, in forums as well as blogs...I have one specific task..it isn't job planned but I do it. It's publicising the work of the department of Diabetes & Endocrinology of Portsmouth.Love it or hate it, call it the marmite effect, whether it be via blogs, twitter, public campaigns or articles, I do indeed try my best to highlight the stupendous work some of my colleagues do...sometimes it's branded as my ego, to some it's cockiness..to me, it's giving these individuals the rightful place they deserve when they don't have the time or inclination to self publicise like so many do on public forums ( but feign mock horror when someone suggest so!) or social media. Looking after our team is my job too..and yes, it does involve going out and showcasing some amazing work that happens day in and day out.

So lets start with Sharon Allard. I have known her for nearly 12 years now- and recently we went out and celebrated her 25 years of being a part of the diabetes department. Always humble, always the quiet one, she has been a pillar of strength for anyone who has done research within our department. An amazing individual, her patient focus has been second to none and indeed someone who patients love unequivocally...there is something special about Sharon...if you know her,it is impossible to have not been touched by her kindness. An archetype nurse specialist..someone who embodies what nursing should be about..and tongue in cheek? She has been doing the 6 Cs much much before it became a hashtag campaign.

Next is Jane Cansfield..another nurse specialist who celebrated her 25 years with us..again someone who I have known for more than 10 years. One thing about Jane? She knows someone who knows someone...master organiser, lynchpin of social events within the centre..everyone within our department loves Jane..without Jane, there never has been any organisation of travelling together to conferences. Her knowledge about retinal screening puts many a specialist to shame..hang on..let me change that..actually, I know very few specialists who know more about retinal changes than her. Jane' s our go-to person..always helping, always accommodating..someone who has and is always there whenever there is a problem.
Testament to how much both these ladies are appreciated? We organised a 25 year party..bar a couple, we had a full house turn out including legendary figures of the Portsmouth team from the past such as Ken Shaw and Sue Craddock.

Next up is Jean Munday...and I cannot describe in words what Jean means for our department. Jean breathed the word "retirement in another 5-7 years"..and the sheer look of panic amongst all of us said it all. Without Jean, our endocrine service doesn't exist anymore..it collapses. A legendary figure in our department..someone who commands respect and admiration from all irrespective of their status or grade, Jean is someone I would encourage any nurse to learn from and try and perhaps achieve even 25% of what she has achieved. It is our pride that she has been shortlisted for Nurse of the Year..whether she wins or not, if we had an award along those lines in our department, Jean would have walked away with it perhaps every year.Her intrinsic knowledge about endocrinology will put most to shame but more than that, her calmness, friendly manner has made her so special...best of luck at the awards, Jean!

Finally, a mention about Gwen Hall. I have known Gwen personally for about an year or more but have known of her for a number of years due to her national profile and work in diabetes education. A strong character, we head hunted her to helm the Portsmouth community team fully aware that she would step down after 1 year or so but boy hasn't that been a recruitment master stroke. She has helped put down the basics for primary care leading on education and support for our local GP surgeries and I suspect the Portsmouth of the future will always thank her for her time, efforts and undisputed passion to improve diabetes care. On behalf of the team and the wider community, thank you Gwen for your time and help to develop diabetes services in Pompey.

All in all, it has been nothing but a privilege and an honour to work with such amazing individuals. There are many such more with whom I work within our department but at this moment of time, these fabulous four and their contribution to making our department stronger and improving patient care must be applauded and recognised. I have always maintained that there perhaps are better departments than Portsmouth but I doubt there are better places to work in...it has always been and continues to be individuals such as the fantastic four who have made it so.

So ladies and gentlemen a moment to pause and say thank you to our Fantastic Four. a moment perhaps for the wider community to also look at where you work and go tomorrow and say thank you to those who are the unsung heroes.
Such individuals exist in every department in the NHS and it is time we have them their just due.Go find them,make them perhaps a cuppa and just say "thank you"

Tuesday, October 7, 2014

Wrong tack?

So shall I dip my toe into this water? Challenge the RCGP and thereby the GPs..or are they a separate entity?  Let me set my stall out at the very outset..don't know about politics but amongst the mates I have grown up with, those who are GPs, I see less of, they arrive late for the football games, look a bit more knackered, so this isn't a debate about who works hardest. Let me be perfectly honest, most GPs, I know work harder than me and unlikely to have as good a work-life or as Mark Cheetham likes..work-family balance.Thats not a condescending sop to balance for what I write below, but as I see it day in, day out.

Nope this isn't about that...this is more about the pathway or tack adapted by the RCGP akaThe Royal College of General Practitioners... it's made me wonder...is the RCGP more of a collegiate institution or a trade union? I say so without prejudice but mostly from point of view of my own college which has tended to adapt a "hands off" approach to political changes,for good or bad..though in all fairness, their engagement as regards the future hospital has been laudable to say the least.

But the RCGP in recent times has slightly baffled me as quote unquote one of my GP colleagues "it just says more GPs". Which in itself is an interesting position in my book, as the ethos behind that seems to believe that more GPs will solve the problem while on the ground, if given a choice,for right or wrong,I would probably have more practice nurses, more community DSNs...whatever be the case, certainly more primary care staff, not necessarily "just GPs"

It is at this point I can already hear murmurs saying what qualifies me to speak about such an issue? The answer is probably not much but am giving a perception, from the outside if you may, that the position sounds too siloed. Put patients first...absolutely 100% with you....But not by saying lets just have more GPs. Not by saying "give money from hospitals"...believe you me, hospitals aren't running in rosy balance sheets either. I appreciate I offer perhaps a narrow siloed view but diabetes care isn't going to be resolved or improved with more GPs...more primary care staff...absolutely 100%.
As an analogy, you will never find me go out and say we should have more and more diabetes consultants...not certainly when we still haven't evolved enough to work differently and learn to help primary care more, rather than do our clinics in the traditional way,still ducking behind the spectre of information governance and shying way from patient access.More on that chestnut later.

Which brings me to the next point...on one hand, the clamour is for more GPs..on the other hand, posts can't be filled, people are leaving,social media is abuzz with burnouts, GPs themselves encouraging others to leave,tough working life..all this publicly played out...impact? I teach medical students and the proportion of folks considering becoming a GP continues to dwindle. Recently I asked on twitter what makes a GPs job attractive and there were some wonderful stuff,absolutely inspiring..heck...if I had my time again, may have gone for it myself. So why the lack of balance? Yes jobs are busier but to say working conditions haven't improved from say, 20 years ago, isn't right either, is it? You can't attract generation next by being negative...careful you don't end up being the reason why no one wants to do primary  care anymore. Those who work with me know that without being condescending, I am very public and open about my admiration for GPs but a bit of balance is needed.

I can only offer tips from history...recruitment in our specialty a few years back was low, with poor job prospects...there is a session at the Annual conference in diabetes UK called the Consultant/SpR session which happens every year. And year after year, as an SpR, I went there and heard people just moan, talk about how life was bad, negative..and a bunch of us sat in the audience and vowed to change that. The SpRs had a 10 minute slot and we decided to showcase the positives in front of everyone...give it a bit of balance and energetic people like Emma Coull, Pratik Choudhury, Marc Atkin went up on stage and said "No" to the negativity..and people started walking way from that session feeling all was not lost, positives were the too. It's our job to inspire generation next, not to push them away. Yes, of course realism, not shying away from the toughness but a bit more balance too, right? It's great to say we will "make" people do more generalists, "make" more GPs....one fundamental flaw? You can't make anyone do anything they don't want.


The NHS will struggle to exist, not because of political restructuring or any other reason, but simply will collapse if we don't have a robust primary care. The wizards have only a few spells in their magic box....if the gatekeepers stop to exist, the facade of sorcery may well be under threat. A campaign designed in the right spirit hopefully will not end up alienating the rest of the workforce...let alone the next generation. Politics is a part of what we all do...but in that game, hopefully the campaign doesn't t do more damage to the future of primary care. Have a think.

Saturday, October 4, 2014

Up to YOU

One of my colleagues recently mentioned that I had strayed away a bit from diabetes in my blogs...looking back, perhaps she does have a point...so let's get back to it this week- shall we? After all, politics and the NHS along with its challenges will always be there. Let's be honest and keep aside our political leanings for a moment...or if you are overtly optimistic, you may actually believe that the 8000 extra GPs that one party has promised from Narnia will help to provide the 7 day GP service the other party promises. Maybe they are actually working together, right? The elusive hunt for that wardrobe to Narnia is going to go on for a bit- so enough time to get back to that...for this week, let's get back to diabetes, shall we?

The National Diabetes Audit just got published -I am not going through the data - have a read….makes for sobering reading doesn't it? Yes, there are flaws with data, yes-there hasn't been enough data submitted...but cut it any way- if you had diabetes, you would be pretty worried 

Let's take the first one...we are talking about BASICS here. Nothing too complicated, nothing about evidence based medicine, nothing about evil Pharma promoting their drugs….these are basic checks that anyone with diabetes should have- as simple as that- and the national data around it is astoundingly poor. So what shall we say- primary care is poor? Let's take a reality check- shall we? Due to the evangelism of a few who are in committees, below is what primary care has now been asked to do regard diabetes care:

Screening / Diagnosis / Education / Early Intervention / Looking after co-morbidities / Seeing patient in home environment / Intensification /Complication Screening / Counseling / Appropriate referral / Keeping them out of hospital

Extrapolate that across all other disease areas- and the one thing that is crunched is...yes…..you guessed it….time. How much extra resource has moved to accommodate that sea-shift….very little to be honest. So you would have thought a golden opportunity for all national bodies to get together and look at working together- wouldn't you? Or do specialists take this an opportunity to suggest that they need more specialists....patients should never have been sent to the community? Do GPs say that they need more GPs and it would be fine? I will let you be the judge of that.

Let me be as honest as possible- Diabetes care in this country is in the hands of practice nurses- and if we want to improve care, then we need more educated and supported PNs, NOT GPs, NOT specialists. You don't need specialists to see everyone in hospital but need them to be as educators, guides to making sure the basic check is happening. Not that complicated, is it? It is however when national organizations work in silos, in isolation- all asking for more of their own. The National diabetes Audit has been running for a few years- responses from the national bodies such as ABCD (Association of British Clinical Diabetologists) have been tired, lazy, siloed…I predict a report as to how there is a plan to improve things…how long do you need to actually do so? The NDA hasn't shown much improvement over last few years....so what next? Another report? Where’s the public lobbying, where’s the setting up of educational events looking at addressing this basic issue? Why isn't this primary aim?

So to those who do diabetes as a speciality, let me say so clearly..it is YOUR responsibility to make it better- not anyone else. If you are waiting for national bodies to do it, you have waited, we have waited, I have waited…it’s not coming ..or if its coming, its not coming fast enough for the people who matter. YOU are the advocate for patients with diabetes, so engage with the Trust, work with colleagues, learn from others, go visit other places, find out what they do- and make the change that’s needed. YOU are the one who can work with patient organizations like Diabetes UK to help drive up basic care in the community, work with the practice nurses, build bridges with GPs, say you are there to help, not to judge. 

In the words of Martin Luther King.." Change does not roll in on the wheels of inevitability, but comes through continuous struggle". It's upto YOU as someone who does diabetes as a job to decide whether you want to lead that..or there is little point in doing audits, is there?


Saturday, September 27, 2014

Life without the NHS

So what exactly would happen if there was no NHS? And by that I don't mean the badge or the name because I suspect THAT will always stay..its the principle of "free at the point of access irrespective of social background etc etc". What would actually happen? Social media, newsprint is abuzz with the theories, primarily because it's becoming a battleground for the politicians and with elections coming closer, the noise has just got a bit more shriller.

And everyone has an opinion. People who have never worked anywhere else have an opinion, people have an opinion with wild fantasy laden, anecdote based remarks, people use study which suits them to make a point..and as ever, a practical based debate is impossible. Recently on twitter an event was held called "Without the NHS" and some of the tweets were quite interesting, fuelled with passion, laced with political beliefs, a few laced in reality but majority by those who believe it should stay as it is.

So, let me give you a perspective - having worked in a country where there is no such socialised medicine. Let's get some basic facts straight. The principle that because the NHS is free thereby ts the best medicine ever is frankly odd. The reason the care is such high quality is because of the staff and the care they provide. When folks say their relatives were saved because the NHS is here...believe you me, folks are saved by caring healthcare professionals all over the world, every day, with high quality care..irrespective of what the system is. So what would happen if the NHS became insurance based or the principle of free for all went? I will tell you what will happen. Overall care will not suffer..it will simply become 2 tiered. Consultants, GPs..their families will continue to get high quality care because they will be able to AFFORD the insurance. For a significant number, it will, simply put, become a care system where they will pay and recieve care to the extent they can afford.

Hurts doesn't it? Tugs at your ethos of socialism? Let's flip this then...how do you feel when the UK to continue provide high quality care raids other countries in desperate need of nurses and doctors to fill up their own stocks..simply with the promise of a better life? Fair? Or does the principle of socialism stop at the UK boundaries? Or does the responsibility end with donating to Children In Need or something equivalent? Tough isnt it? I have worked in a system where I have seen people sell their utensils to buy medications, take huge loans to fund an MRI, get sucked into a world of corruption where the ones who could afford did and still does afford the best treatment money can buy..and though this may sound harsh...sometimes, even better care than what the NHS can sometimes provide.

I have seen the darker side of what "healthcare based on your worth" looks like and I cannot, simply CANNOT stress enough the importance of keeping the principle of the NHS intact...not the NHS, but the principle. Today its a political battleground and promises being made will only stop the slippery slope for a bit, not halt it. Primary care is crumbling, hospital Trusts are struggling...its decision time folks...NHS..free for need or free for want? And Life without the NHS or the principle? There are many and many on twitter and rest who will be fine without it...but there will be many out there who will struggle...big time. I will not regale you with my tales of working in an Emergency department in Calcutta...you won't want to know it, trust me. But when you have 2 folks gasping for breath, no nebulisers around you, 1 oxygen tank- and then you also work somewhere where most people are worried about the 4 hour target rather than a tubing of oxygen...let me tell you this...you don't want to lose the principle.

The NHS will always stay...but the slope has started..some procedures already banned, some products already being pushed by companies to "buy as its amazing"...been there, done that..and it wasn't nice wearing that T shirt either. Fight for the principle- its worth it.

In simple plain terms? You have no idea what you have got- or what you are heading towards. As a professional, I will always try to provide the best care- whoever employs me...but as regards the rest? Crunch time is here.