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The Impotence of Baffled Malice

Posted by Dr No on 09 September 2011

baffled_malice.jpgOne of the baffling aspects of the Tories’ plan to privatise the NHS is the persistent, mis-representation of facts that has been such a feature of their campaign. The opening case for the reforms – that UK health outcomes are amongst the poorest in Europe – rested on a bed of bent numbers, promptly shown to be misleading. More recently, we have had Mr Cameron saying the ‘the whole health profession’ - the whole health profession? - last time Dr No checked there were several - ‘is on board’, despite clear evidence that the professions, whole or otherwise, had jumped ship some time ago. In April, an overwhelming 99% of RCN Congress nurses voted no confidence in Lansley’s management of the reforms. In March, a special BMA meeting noted widespread concern about the reforms, and called for the Bill to be withdrawn. More recently, an RCGP survey of 500 GPs conducted after the ‘listening exercise’ found only a maverick 4% strongly backed the reforms. Only last week, the BMA wrote to all MPs, warning that the Government’s health reforms presented an ‘unacceptably high risk to the NHS, threatening its ability to operate effectively and equitably, now and in the future’.

Startlingly, given the abundant weight of contrary evidence, only minutes before the Health and Social Care Bill continued (and successfully passed) its third reading in the Commons earlier this week, Mr Cameron produced a corker of a porker – Dr No quotes – at Prime Minister’s Question Time:

we now see the Royal College of General Practitioners, the Royal College of Physicians and the Royal College of Nursing all supporting our health reforms

and this on the very same day that the RCGP, RCN and BMA, amongst others, had a letter in The Times (paywall – unfortunate mistake – but the text can be read here) saying:

Our organisations believe that the Bill could still potentially destabilise the NHS as we know it… Without building in appropriate safeguards, extending choice to any qualified provider risks seriously destabilising existing, mainly NHS, providers and making it much harder to develop the integrated care patients want and need… We share a number of more detailed concerns…

To which Dr No says: if this is evidence of the whole profession being on board, then it is a queer old ship, crewed by phantoms and ghouls.

Whether the defect of veracity is one of deficiency or deviancy is unclear. It may be that the government is surrounded by a court of sycophants, who filter and limit the dope they pass to their leader, but that seems unlikely, and if true, would itself raise questions of competence: what government wilfully misinforms itself? A more likely explanation, it seems to Dr No, is that it is an exercise in Goebblesian – repeated enough, a lie becomes fact – propaganda: an outpouring of lies muttered in the impotence of baffled – and baffling – malice.


Like you, I find it utterly amazing that the Prime Minister said this.

It is a lie of stupendous proportions.

Presumably when the Colleges meet in order to make their views known over a political issue they feel they have to give a comprehensive and intelligent statement.

Unfortunately there are times when less is more. Committees tend not to grasp this. For example, there should have been very little debate over MTAS. The statement should have been "This is utter rubbish" followed by a short list of the reasons why.

In the case of the HSCB, even though HMG protesteth a lot, the key to the whole document lies in the SOS's "duty to provide." A refusal by all the Colleges to discuss any other aspect of the Bill till these words were clearly reinstated would have brought this to the attention of every politician and probably the public too. Unfortunately committees for some reason can't or won't operate in this way and it is up to anonymous medical bloggers to say with clarity what needs to be said.

But where is the politician that will pay attention to anonymous medical bloggers who have just as much experience of the NHS as the Colleges committee members but do not have their constraints?

Dear WD
The College will be discussing this issue at its next council meeting next week
I am not sure that HMG listens to the Colleges - but i agree they might listen more to us that individuals or petitions.
I love your blogs

Dear Clare,

I appreciate that Colleges are not Trade Unions and cannot engage in political discussions, but the HCSC bill has virtually no support even from Tory voting doctors like myself in private practice. It is perfectly proper for the College to express grave concerns about this bill, and point out that it is not endorsed.

Learn lessons from MTAS/MMC before it is too late.


Dr Phil

Dear Dr Phil

As you probably heard last week - the PM has told us all that not is just the profession behind these reforms but so to is the RCGP.

As you know, the College has been fully supportive of the HSCB since the outset. We submitted four consultations giving nothing but praise. We surveyed our members - who even though sent me 900 pages of responses all worrying about the reforms - i chose not to use. I wrote a 22 letter to the PM - laying out how great the reforms were and how much good they will do for our patients, our profession and our country.

I continue to never express any concerns - even though every day my members ask me to.

Dear Phil

I agree with you 100% - all the above is in jest of course- and you know that. I became Chair 20th November 2010 - on 19th November 2010 the article in the Guardian came out - which reflected the Colleges and my view of these reforms. I am worried and spend every day researching, consulting and so on.

If you have any suggestions I would gladly receive them


Dear Clare

Please see this Populus poll showing that 63% of those who took part are very concerned re gas and electricity prices whereas only 34% are very concerned about The State of the NHS.

I would think it fair to state the ?majority of the general public are ignorant of the ramifications of the HSCB.

Get political. Create posters to adorn the walls of GP practices. Educate the patients (‘flyers’ even?) and encourage them to adopt a lord.

Anna :o]

Well, call me a cynical bastard if you want to, but I fear the doctors first loyalty will be to the doctors rather than the NHS - and we can't expect any political action from the bovine nurses, they have a long and proud tradition of being ignored.

No wonder so many scrambling for pole position in Lansley's exciting new health market.

I absolutely agree with posts above that Cameron's claim that we all support the Bill is the most monstrous, blatant and deliberate lie.

How can he get away with this? This, and the way the Bill has been rushed through with so little discussion is no way to run a democracy.

Clare is doing brilliantly and is being heard, at least by those prepared to listen,but really ALL the Colleges, unions and other representative bodies need to get together in a joint assault on the Bill.The NHS Consultants' Association has written to the Presidents of all the Colleges, in a letter signed by a large number of their Members and Fellows.

Responses are awaited!

"How can he get away with this?" - because the powerful business lobby that stands to gain so much from these reforms exert far greater influence over our here today gone tomorrow politicians than doctor committees, nursing unions and certainly the great unwashed (aka the general public).

The likes of Milburn & Hewitt must be misty eyed at the thought of the tories, sorry coalition, finally giving birth to their unpopular health baby?

Dear Clare,

As a Hospital Doctor I would not presume to tell a GP what to do ;-)

I have made my own views clear via the HCSA and my own College, but am rather defeatist on the issue. The House of Commons has passed it, it would be an affront to hold it up in the Lords.

I know that just because an idea is a stupid one, it does not mean it won't be implemented. I have found it better over the years to battern down the hatches, wait for the idea to flop, and see what will replace it.

Good luck with your meeting, I hope that your College has as good as wine cellar as my own!

Dr Phil

The Guardian today reports on the letter I think Adrea Franks refers to above. Not clear if the words are the The Guardian's interpretation rather than what was actually said in the letter.

"The bill, the letter says, cannot pass without the medical profession's support."

I think this is true. However in recent years a lot of things have "gone through" within the NHS, not necessarily because of support by the medical profession but because of their unintended complicity or lack of interest. How could the Bill possibly go through without the support of the medical profession?Should we assume therefore if the Bill goes through it is the fault of the medical profession? I think we should.

Most doctors, including witch doctors have always been against taking industrial reaction. Nevertheless, there is surely some action that could be taken that is not in the least "industrial" and could fire a shot to the government while protecting patients. The ridiculous hijacking of the professional referral system springs to mind - where a GP can no longer refer a patient directly to a consultant of their choice after discussion with the patient. The colleges could easily get together and en masse boycott this system. Then governments might begin to take their disapproval seriously instead of lying in such a way that it will be recorded in Hansard for posterity.

This seems to be the letter referred to in The Guardian. Not the same one referred to by Andrea Franks above.

Over the twenty five plus years that Dr No has been a doctor, he has seen a steady relentless and most unwelcome decline in the character of both the medical profession, and those who are part of it. Where once there were robust eccentrics with hearts of gold, he now sees empty suits, placemen, apparatchicks and villains. This debasement of the profession extends from the top - MMC and MTAS, and the ongoing betrayal of junior doctors, for example - to the mundane. Recently, Dr No's GP ordered - or should that be requested in today's world? - an x-ray. The radiologist declined, saying it was 'out of protocol'. The patient, who knew the NHS, took exception, and the patient's GP, now temporarily a darling locum of tender years, got involved - and said she couldn't possibly argue against 'the protocol'. It took the patient's gentle mutterings about guts for garters if serious pathology was missed because an x-ray was declined because it was 'out of protocol' to make the light, or rather the x-rays, shine (and yes there was a shadow, and a subsequent urgent CT and biopsy, but thankfully the histology was benign).

We see exactly the same weak and feeble conduct by the profession today in response to the HSCB. We spend much time arguing about the language and tone of the profession's response. We get diverted by tiresome twittering pen-pushers quoting out-of-date nonsense. We have tree-huggers trousering funds and lining the pockets of lawyers in the pursuit of pointless 'expert legal opinions' (a typical 'third sector' nice work if you can get it scam, if you ask Dr No - you don't need a learned friend to tell you the bleeding obvious).

All of this is stuff and nonsense. So too is the delusion that the Lib-Dems will make a jot of difference. Even the peers are probably a lost cause. Dr Death is still in the crypt, and Dame Shirls - by far and away the most 'outspoken' - has minced her words - the Bill merely threatens, not will destroy, the NHS (as well as getting her knickers caught in a Lib-Dem love-in).

The WD is right: the only people who can stop this Bill are doctors, notably GPs, who could stop it in an instant. Dr Gerada is to be congratulated on her brave and consistent opposition to the Bill, even if, one suspects, even she is fettered at times by weak and feeble counsel from her colleagues - last week's letter to The Times (itself an unfortunate choice since it placed the letter behind a paywall) was nowhere near as firm or resolute as it might have been - not to mention the many colleges who were conspicuous by their absence.

It may be that Cameron's lie supposedly rests on the observation that GPs have signed up to commissioning. This argument has all the strength of the one that says the public supported the Poll Tax (which Dr No mentions for the obvious reason) because they paid it. We know (from RCGP surveys) that in fact the majority of GPs do not support the Bill, and only a four percent lunatic fringe strongly support it.

The RCGP council, we are told, will discuss 'this issue' sometime this week. They know the facts - majority opposition, and only four percent 'strong support' amongst GPs, the very doctors who will be called upon to implement the Bill. This is as clear a mandate as could be imagined for strong action. Let us hope that the weak and feeble character of recent times is cast aside, and the donkeys once again become lions.

Nope. It seems there is only one letter!

Here is the list of the co-signaturies

Re Dr No's previous comment. There is no great divide between patients and doctors. Doctors are also patients as are those close to them. They have the advantage of seeing the NHS from both sides of the fence and know how the system works or fails to work. If a doctor who is aware of the differential diagnosis finds it difficult to obtain an important diagnostic investigation for himself, then what hope is there for non - medical patients? A and E charge nurse - your fear that doctors' first loyalty will be to doctors hopefully will be ill founded in the context of the HSCB if only because of the fact that doctors and their families are also patients, but hopefully their lack of support for the Bill will also be less selfish than that.

"your fear that doctors' first loyalty will be to doctors hopefully will be ill founded in the context of the HSCB if only because of the fact that doctors and their families are also patients" - that's true WD but I think other factors come into play?

First of all I think there is genuine frustration amongst clinical staff about the general direction the NHS has been forced to take - I do not see this as tantamount to support for the HSCB but there might be an undercurrent that the NHS has finally had it's day?

Secondly doctors and their children will not necessarily do badly in a system driven by markets.
As a rule of thumb those with income well above the median wage will be able to avail themselves of more robust insurance policies (or privatisation of funding, as Dr No correctly identifies as the next piece of jigsaw) - I am not accusing anybody of elitism here just stating an obvious political reality.

Thirdly doctors have no meaningful culture of political activism - MTAS/MMC demonstrated that self survival nearly always trumps the wider needs of the profession when the chips are down.
The medical hierarchy did little to fight these unpopular changes while the poor old medical students were left scrambling for the last lifeboat on the titanic.

Now I'm not dissing doctors here, especially given the lamentable performance of the nursing workforce when it comes to opposition to the bill - the likes of the RCN have done little to protect nurses or patients in hellish places like Mid-Staff or Maidstone and Tunbridge Wells (either by omission or design)

By the way, I think your "less is more" comment are absolutely spot on ;o)

"If a doctor who is aware of the differential diagnosis finds it difficult to obtain an important diagnostic investigation for himself, then what hope is there for non - medical patients?"

A and E Charge Nurse, I realising I am now "outing" myself slightly here. It is likely that The Witch Doctor's family over the past decade would have bankrupted themselves if they had had all lived in USA even if they all had medical insurance. When it comes to major illness, taking into account the interventions that are now possible, many, possibly the majority of doctors, would find themselves unable to afford the care necessary in spite of their privileges. This revisits the question: how can we afford all the expensive interventions that are available when we are truly vulnerable patients rather than "clients?"

Rationing however in “healthspeak” is still a profanity. The Witch Doctor has been known, tongue in cheek, to use the R word from time to time in committees. They were never amused.

Agree with you completely over MMC/MTAS.

Dear Dr No,

I think militant opposition by the profession is not possible. Historically most idiocies in the NHS that I have encountered over the last quarter century have been stopped with passive resistance. It is fairly easy to nod and smile, then do bugger all to implement a policy. Don't like the commisioning groups? Do the bare minimum and let them collapse through apathy, Don't like revalidation? Then ask as one of my colleagues did at our college AGM to much amusement "what is the bare minimum that I need to do in order to remain licensed?" Don't like choose and book? Then abandon it now that there are no more financial incentives (I note that I am getting many more letters and far fewer c and b patients since April, so this is seemingly a widespread view).

Overt resistance is likely to end in tears, the way forward is the approach of "the good soldier Svejk" , the funniest and most subversive book in my collection. This approach works less well than the MTAS/MMC debacle, which was driven by our own side, and was the logical sequel to the precedents set by Foundation programmes and "Tommorows Doctors".

The destruction of the old undergraduate curriculum led to the inevitable metastasis to postgraduate training. MTAS/MMC had it's roots there, in the heart of our own profession. It wasn't politicians that forced it on us, it was our own professions lack of respect for the accumulated experience of generations. After hubris comes nemesis.

Dr Phil

"Historically most idiocies in the NHS that I have encountered over the last quarter century have been stopped with passive resistance" - this type of approach makes sense so long as there is an NHS to employ such a strategy, the HSBC is the mechanism to virtually guarantee that there won't be.

Once the penny drops all of us will be more preoccupied with scrambling for a role in the semi-privatised system, rather than fighting a retrospective battle for a model of health care that our political masters (of all stripes) are determined to consign to the rubbish bin.

I am not clear where the other medical leaders stand - RCS were in press this week saying they support the changes -and others are "fearful" of speaking out in case they will be sidelined for decades. Others want to see "what happens" and others still think they can join at the end - and help implement rather than shape the reforms. I disagree with all these views - and I fear that many of the other leaders do not realise the implications of this Bill - though at the moment it is such a mess that
i suspect no one is clear as to what they can and can not do - so we might as well just continue to do what is right for our patients and get on regardless and ignore the proposals (just a thought).

Looks like Cameron and Lansley could not wait or cannot be bother to. Circle is likely to take over another hospital.

Would there be support if Private Providers are totally banned. The arithmetic is simple: private providers do it for profit and that means less money for actual health care.

What about non-profit: well it happens in the US and they only pay big salaries to the CEOs.

Money corrupts.

Private management is better and more efficient according to Circle: what happens with RBS, Metronet, Southern Cross, great Eastern Rail and Lehman.

All very sad!

Dr Phil,

Like you I think passive resistance can work extremely well within the NHS as a mechanism to help scupper some of the deranged, often expensive activities we are asked to participate in. But this is a slow burnout tactic that is no use at all for the HSCB.

I also agree militant opposition by the profession is not possible – the key word being “militant.” Very strong opposition IS possible though and seems to be me to be necessary regarding the HSCB. This is because nothing else will work. We are dealing with a complete and fast change in the law which, if passed, will be irreversible because there will be so many vested interests involving those more powerful than either the medical profession or politicians themselves.

In my view, in spite of government denials, the scene is being set for the NHS to soon become a ruthless market-place not just in the accoutrements of health care like bedpans, scanners, swabs and drugs, but in patients themselves. The NHS logo will only be retained to comfort those who cannot or don’t want to understand what is going on.

The MPs have spelt it out to us. They have allowed the Bill to go through the Commons. They have been well and truly whipped. The public can no longer depend on those they have voted for to represent them on matters relating to the NHS. It is now up to the medical profession. The Bill cannot become an Act without us. If it does, it is because we cannot get our own “Act” together. We will be the ones to blame.


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