Wednesday, 7 September 2016

A Discriminating View of the Doctors' Staffing Crisis in the NHS

We are going through extraordinary times for the NHS, especially so for doctors. From my perspective, this reflects the effect of not getting it right for everyone from the beginning.

The NHS as a care delivery model is fantastic. Tax funded, free at the point of care delivery, delivered at more or less the same standard across the country. It is so special, no doubt about the model/pathway.

The issue comes when it comes to staffing that delivery model. There was simply no staff at any time to deliver this model. So quite simply, as was always done in British history, the UK looked abroad for resources (the detriment to other countries by this policy is till today ignored by the UK). For healthcare the crucial frontline resource - the doctors were simply imported, poached, stolen (you can choose whichever word you want depending on the perspective) from abroad. India being a country which has medical education delivered in English following a British system of medicine was a natural target. For ages, even till today many IMGs end up as GPs in inner city and deprived areas. But it is the hospital medical hierarchy where the glaring disparity hits you.

There was always a surplus of registrar and senior registrar posts compared to the consultant posts (there was a permanent pyramid). Now that may be a problem in itself leaving people without opportunities. What happened from the mid 1970s onward, the demographics of the pyramid shifted. In the registrar and senior registrar grades there were mixed ethnicity with plenty of IMGs but very few of the IMGs went on to become consultants. The locals were in line for progression to a consultant post barring unforeseen circumstances and the IMGs were to remain permanently as registrars and senior registrars barring unforeseen circumstances, till they retired or died. These were later called staff grades and associate specialists. Name change and plenty of warm talk but the intention and roles remained the same. 

In the late 1980s and early 1990s I have heard numerous that local graduates holding registrar and senior registrar posts stated openly, loudly and clearly that they will put up with difficult conditions and low pay because it is only for a relatively short time before they became consultants. Meaning, that locals will progress on to higher pay and the IMGs will remain on the lower pay. This suited a brilliant care delivery model to be delivered at a low cost using a rubbish discriminatory unjust medical staffing model.

Of course, this strategy would have worked except that more consultants were needed and there were not enough local candidates. By late 1990s early 2000s the system woke up to this and created more medical school places and in my view with the hope that this local - IMG differential would continue. Where it went wrong primarily is that they underestimated the impact of women entering medical school, like most men, most women are excellent doctors but firstly they also want a good lifestyle (in contrast to men who in my view were often married to their careers) and more importantly physiology demands that many women choose to have children. So workforce planning went for a six; more IMGs were needed and the flood gates were opened in the early and mid 2000s. 

You see, now, suddenly, the pay for doctors is thought of as high, suddenly evening and weekends are no longer want to be considered as premium pay time. When medicine was overwhelmingly a white, male profession with IMG men manning the lower ranks these were not issues, doctors pay was relatively high compatible with their education and contribution, weekends were precious. The demographics change to equal number of women and a large number of IMGs and the values change.

The next wrong calculation comes from the fact if UK thinks they can import their way out of this mess. I don't know about other countries but many Indian young doctors are very wary of coming to UK; the training opportunities have increased in India, the economic opportunities have increased in India and lifestyle is improving in India - the exchange rate alone is no longer attractive.

To me it seems that the establishment does not want medicine to be an elite profession as it was when it was white male dominated. This makes it distinctively unattractive. There was always discrimination, there still is; the difference now is that there is FOI, there is corporate social responsibility and transparency. In the past we knew IMGs failed exams but we did not know the numbers, we always accepted that we did not reach the necessary standard, we were expected not to reach the standard, we were brought up being told that we could not reach the standard. None of that bullshit anymore. We know the numbers which are spread immediately all around the world by email, whatsapp, fb and twitter. We are asking questions; does the Indian IMG paeds reg trained in UK and taking the exam in UK have a higher failure rate in the UK version of MRCPaed than the Indian paed trainee who takes the exam in India never having worked a day here? Does the MRCGP International AKT MCQ have a longer time to answer their question than MRCGP UK which puts IMGs at risk of failing a 'purely knowledge exam'? We suspect an adverse use of linguistic bias. We know that Scottish, Irish etc need a grade c in English equivalent to IELTS 6.5 but IMGs need an English standard much higher, yet found fault with their language. We know the students in England do not need English A levels to get into med school. The standard for IELTS for IMGs was not set by administering to a group of local FY2s, it was actually set by an equivalent of a large focus group sitting around a table and deciding what was an acceptable standard; what a marvelous way of standard setting (accompanied by truck loads of stats on why that kind of standard setting was valid, the whole lot I found dubious, okay, to put it politely, it was very highly subjective)

The senior doctors including senior IMG doctors seem to have a distinct mentality that is not quite in sync with the younger doctors and their aspirations. The true cost of discrimination against women, discrimination against IMGs is now biting back.

A fabulous care delivery model designed six decades ago by the local population for the local population in UK did not consider the career prospects of IMGs and did not care that women were not part of the game for a long time are now completely flummoxed when IMGs are waking up and women are demanding a different kind of atmosphere. 

I wait to see if the lessons from past atrocities will be learned, I wait to see if because of the change in demographics medicine will be deliberately made into a lesser profession. I am not optimistic about the people becoming just. Why am I not optimistic? Let us look at the current routes into UK for IMGs - the MTI and the PLAB.

The whole MTI premise is based on getting people into UK to fill in rotas. It would be very difficult to provide any proper training in two or three years; especially when MTI doctors are not deanery numbered trainees for whom there is still to some extent funding for training. When I look around, I find that most new entrants into UK are in rota fodder posts and not in any proper training posts. I am not sure if there are large number of MTI doctors who are undergoing specialised training  (say for instance in pancreatic transplants), I suspect most of them are at SHO and junior registrar levels.

Let us say that a doctor goes back to India after MTI and applies for a job in a corporate hospital in competition with a CCT holder - who will get the job? Let us say an MTI completed doctor applies for a job anywhere else in the world (middle east, australia, etc) what kind of a job will (s)he get on the basis of MTI? Has anyone asked these questions? My personal feeling is that in most of the cases a typical MTI doctor after the completion of the time and leaves UK as per the rules is unlikely to be a strong candidate for any job anywhere in the world (I am sure there will be exceptions to this assumption).

So what is the use of MTI posts? 

The next is PLAB route doctors who more often than not spend years in a variety of non-training posts. My advice to young doctors who come to UK after PLAB process is 'take a formal training post or do not take a post at all in the UK'.

If still doctors from India want to come to UK via MTI or accept a non-training post via PLAB then the only logical reason for that would be to use UK as a temporary staging post to analyse and access opportunities in the rest of the world eg prep for USMLE etc.

UK should stop looking at IMGs as rota fodder. The system should change to provide every doctor who enters UK only formal training posts with the intention of making them a consultant or a GP; there may be some who eventually choose not to practice as a consultant and take up a senior non-consultant post, that would be a matter of personal choice and not a systematic denial of opportunity. This means at junior levels there are only training posts. Well, will this ever happen, I wish it would but I am pretty certain it won't. The system is designed for and habituated to exploitation of the IMGs; that system is unlikely to shock itself by changing even when it faces its own existential crisis.

So unless there is a technological solution there is going to be an ugly muddle impasse in the NHS for a long time to come.


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Friday, 19 August 2016

Seven Day NHS from a 2006 perspective

The seven day NHS debate has been raging for a while now. People die over the weekend, people do not die over the weekend, weekend should become normal time, there are no staff, there is no money; the arguments are plenty.

Interestingly in 2006 I looked at this issue from a flexible working, work-life balance, ‘flexible weekend’ perspective. I did a sample survey of a small number of people and then qualitative interviews of an even smaller number of people.

The quest was to find out if NHS employees had the ability to choose your own two days off in lieu of the traditional Saturday-Sunday weekend off would they go for it?

My own personal view at that time was that employees would love the flexibility and really go for it. That was my mental construct, assumption, bias at that time; though I tried my best for my views not to interfere with my study. Once the study was done, I realised my assumptions were completely wrong.

The findings were fascinating:          

More than 70% felt there would not be enough staff to enable the system to run a routine 7 day NHS service

56% did not prefer to have the ability to choose their own two day weekly break (they would rather stick with the standard Sat-Sun)

66% felt that choosing their own 2 day weekly break/off days (in contrast to the traditional Saturday-Sunday weekly break/off days) will not improve their work-life balance.

61% felt that once this ‘choice’ of being able to choose their own weekly two day off was introduced they may be forced to take specific days off which may not really be of their choice

My views now

These findings from a good representative cross section but small number of NHS employees with a good rate of response to a questionnaire and from a selected representative employees personally interviewed in detail for qualitative analysis.

Firstly, it almost prophetic, that normal NHS employees even in 2006 felt that we would not have enough staff to run a seven day NHS. Those were the days staff numbers were growing and money was not tight; yet they felt that way. It seems even more true now.

Next, the importance of family and social life was based on having the weekly break on days common with family and community. Hence the ‘choice’ of the ability to choose one’s own days off in the week turns out not be a choice at all since it does not suit families and community.

The most alarming was the degree of distrust of the system and the managers – the employees felt that what was offered as a choice now could morph into something that they might be forced to do down the line.

We can see all these magnified big time in the junior doctors’ dispute – shortage of doctors, importance of a family/community oriented work-life balance and huge distrust of the system.

I paste some extracts of the study below to give you a bit more of the flavour.

It seems that the normal employee and the powers that be hold contradictory views. In that context if employees feel forced to do disliked activity engagement falls and unhappiness will rise - that cannot be good for patients. If the forced changes remain in place for long, new employees may know no different in the context of their employment but it will have severe impact on families and community - is that a price worth paying?


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READ ON......................................................


‘If it changes week to week, it would help us to get things done during ‘week’ days’

Leisure ‘facilities will be available on two full days and will be less busy’

Will choose Fri and Sat as alternate days off

‘I like having Saturday Sunday off. Husband works 5 days a week. Son at school. Sat-sun only time apart from annual leave that we have quality time as a family’ I will choose Sat-Sun as my preferred days.

‘I would like days off in the week during school holidays to spend more time with son and to cut down on child care expense’

‘It will help me with child care’
‘Friday prayer’
Will choose Thu/Fri.

‘My husband and daughter get week-ends off, so I would like to be at home with them’ I will deliberately choose Sat-Sun.

‘My husband is off work on sat and Sunday, (if I chose this scheme) I would be working when my family is at home’.

‘Working part time I have the flexibility of having two days off in one week as well as being off at weekends. It really makes no difference to me what two days I have off in the week’.

I like to have sat sun at home. My daughter is at an age where I do need to care for her. I do understand the reasons, as when she was younger I worked nights to accommodate her school hours.

To reduce stress I would like to break up my working days. Choose Tuesday and Friday off


‘Other family and friends have their weekends on Sat/sun’

‘Will lose contact with my kids’

‘My activities involve other people up and down the country and everybody may not be free on the same day’

‘Working on Saturday-Sunday can be mentally taxing’
‘Can’t coordinate with friends and family’s off days’

My husband and daughter are not at home Monday to Friday’.

‘My job would not be suitable for me not being here on two days during Mon-Fri. Patients would be unaware of my being here on Sat/Sun and would expect me to be available Mon/Fri’


A large number (20/23, 87%) of respondents worked weekends. This could superficially suggest they were in favour of flexible working or extended working practises. However, the weekends in almost all cases are mandatory contractual conditions being part of the job rather than due to an active choice by the respondent. There are nearly no opting out clauses from weekend work in many circumstances except perhaps on grounds of ill health.

Weekend working which is contractual was not seen by the employees as a form of flexible working practise. They did not mark it as a flexi-practise anywhere in their responses of their awareness and use of flexi-work. In the above contexts, working weekends as a mandatory part of the job could perhaps be construed as an ‘inflexible working practise’

Concerns about flexible working

It emerges that one of the main reasons for being wary about the choice of the concept of this study is that the employees may be forced to ‘take specific alternative days instead of Saturday/Sunday’. This is how it currently works with weekend work by ‘rota’ for doctors and by ‘self-rostering’ for nurses. The opt outs from such rotas are either rare or non-existent. Logically there is a fear that this choice will become an obligation or an enforced choice rather than a true choice with no benefits in return.

In the free hand responses the main theme that emerges is the family. The family was the reason why most respondents would not want any other days other than Saturday/Sunday as their weekly break lest it disturb their current family arrangements. In fact one illuminating response was that the Saturday/Sunday break was a positive ‘preferred choice’ due to the current established social more of mandatory weekly holidays so that the quality of cherished family experience is retained.


Some managers saw immense advantages to their particular family situation. However it could be argued to what extent would or should an organisation match with the employee’s family situation which by logical extension, as seen in the study, to the employee’s spouse’s arrangements. It can be understood how this can cause complex administrative difficulties.

The staff and the managers in this study gave similar reasons of family, work, difficulty in organisation and ability to provide a seven day service as affecting their choice of accepting or rejecting the proposed model, but came to different conclusions with the staff unwilling to accept a personalised weekly off-days and the managers seeming keen about it. The inference here is that the same scheme that suits the manager’s families seems not to suit the staff’s families. Hence suiting individual families seems an issue of primacy.


One manager said, ‘I don’t think a common weekly day off for everyone is that important’.

That statement contradicts the view of the Keep Sunday Special (2006) lobby arguments. The KSS feels that social capital is lost and engaging in community activity is affected by not having a common weekly day off. They quote USDAW poll where 92% of shop workers do not want an extension of the present working and NOP 2005 consumer poll where nearly nine out of ten people said that it is important for family stability and community life to have a common weekly day off. However the facts are that Sunday shopping is present and growing. The availability of online shopping and 24/7 weekday shopping and the argument to treat retail equal with other businesses such as restaurants and hotels makes an argument to treat Sunday different a weak one. Leisure is now commercialised and commodified and could be considered an industry. Hence, the question of communal leisure has to be weighed against individual choice. The difficulty is in understanding whether individual choice is truly available or is constantly overridden by organisational needs.

This debate emerges in this study as well in the form of staff being wary of being forced to opt for a ‘choice’ that they do not prefer and with the managers being enthusiastic about the study subject whether organisational priority would hijack individual choice.

Perhaps the average employees experience and perceptions have been shaped by the origin and difficulties faced by the ‘work-life balance issue’ with women having had to go part time, difficulty in returning to full-time work, gender based pay differences, the economic pressures on employees especially on women and single income families, increasing stress, decreasing satisfaction and the employer profitability orientation of the general debate. This could have played a part on our respondents being wary of new initiatives on ‘work-life balance’.

The evidence suggests that larger organisations offer flexible working practises including a wider range of the modes of flexi-work. Our institution being an NHS Trust hospital therefore fits in the profile of a large organisation and the proposed extension could be offered to increase the range of flex-work programmes.

The findings in this study is compatible with the evidence in the literature that shows that managerial, highly educated and high-income workers are more likely to take up flexible working since it is thought that they are more likely to benefit from organisational changes (Nisar). However in this study we also find that doctors as a group though fit into the profile who according to the literature are likely to embrace flexible working rejected the concept. This could be due to the specific situation of doctors whose terms and conditions are in general nationally agreed and set. Further since they already working shifts, weekends, on-calls etc they feel any further expansion of flexi-work as proposed could be manipulated to impinge on working styles, training and personal time.

There is a history of compensation for adverse working conditions. Weekend working is hence compensated with premium rates. The proposal under question offers choice but the findings could be interpreted as the loss of the opportunity to earn premium rates in the guise of offering an increased choice.

It has been argued that flexi-work arrangements are one of the many strategies such as flat hierarchies, horizontal networking, multilevel skills, team and employee involvement in operational decision making, to implement a decentralised organisation. But the evidence of this in practise is very limited (Nisar). It could therefore be surmised that in the absence of a package to effect truly decentralised organisation, the offer of flexi-work or its extensions may not have much takers.

In Senge’s view: “the fundamental flaw in most innovators’ strategies is that they focus on their innovation . . . rather than understanding how the larger culture will react to their efforts.”


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Tuesday, 12 July 2016

Evidence, guidelines and possible solutions

I was looking at the guidelines on the management of community acquired pneumonia (CAP) in adults: This got me interested into looking at the BTS guidelines update 2009 ( ).

Here are some observations and thoughts on it.

The 2009 British guidelines for pneumonia in adults:

Has 12 Authors W S Lim, S V Baudouin, R C George, A T Hill, C Jamieson, I Le Jeune, J T Macfarlane, R C Read, H J Roberts, M L Levy, M Wani, M A Woodhead

Endorsed by 10 major clinical professional societies British Thoracic Society Standards of Care Committee in collaboration with and endorsed by the Royal College of Physicians of London, Royal College of General Practitioners, College of Emergency Medicine, British Geriatrics Society, British Infection Society, British Society for Antimicrobial Chemotherapy, General Practice Airways Group, Health Protection Agency, Intensive Care Society and Society for Acute Medicine

502 references

45 pages of guidelines, 6 pages for the synopsis of the guidelines

Giving us 137 specific guidelines for management of CAP in adults.

Very extensive and formidable work. Would not have been easy to do and
must have consumed a lot of time and other resources.

The evidence was classified as ABCD. You know all about it but I detail
here for the purpose of my own clarity.

A+ A good recent systematic review of studies designed to answer the
question of interest

A - One or more rigorous studies designed to answer the question, but
not formally combined

B+ One or more prospective clinical studies which illuminate, but do not
rigorously answer, the question

B - One or more retrospective clinical studies which illuminate, but do
not rigorously answer, the question

C Formal combination of expert views

D Other information

BTS guidelines' recommendations are based on the following evidence levels:

4 A+ evidence recommendations (3%)
8 A- recommendations (5%)
19 B+ recommendations (17 + 2 : some recommendations have some
sub-sections with different levels of evidence) (13%)
6 B - recommendations (4 + 2 : some recommendations have some
sub-sections with different levels of evidence) (4%)
19 C recommendations (13%)
91 level D recommendations (62%)

147 evidence points resulting in 137 recommendations

My commentary

It looks like an overwhelming majority of recommendations are based on level C and D evidence which in my mind translates basically as 'individuals' opinions'. To put it radically, level C and D 'evidence' is mere opinion masquerading as evidence just because it comes in a list where the level A is properly scientific.

Whom would I trust for my own care, if I had pneumonia? I would trust our own local clinicians' opinions more as it will have local and personal context than someone who has published (guidelines comprising of 75% opinion) but has no bearing on who we are and what we do. Even the 25% level B recommendations are according to the definition 'do not rigorously answer the question'. If I had CAP why would I want my clinical treatment based on recommendations that do not rigorously
answer the question combined with the opinion of non-local physicians?


The way forward would be groups of local clinicians agreeing on local delivery protocols based on their personal local knowledge, context and resources. Once agreed, the outcomes of the delivery can be tracked and the protocols continuously improved. We know this approach reaches us a better place than externally mandated approaches.

This blog site has outlined some ideas on this approaches which can be found at:

There are significant unresolved issues on the question of evidence based practice. They need to be dealt with by the Quality Improvement approaches. Let us do it.


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Saturday, 21 May 2016

Spiritual Healing

Spiritual Healing 
A guest blog by Dr Amudha Anand, Singapore

This topic is very abstract and need to be experienced to understand. Being an initiated and practicing spiritual healer I will try to share relevant information in a simple manner.

Health is defined by World Health Organisation as a state of complete physical, mental and social well being and not merely an absence of disease. Science of healing is helping an individual restore his health through the cosmic energy (paramatma) that activates its extension (the jeevatama) that resides in every individual.

Different systems of healing act through different existential sheaths of our lives (phenomena called koshas). Current western medical systems acts through annamaya kosha or physical body. Pranayama  and pranic healing systems work through pranamaya kosha; this would be the vital force or energy that pervades the physical body. Manomaya kosha based healing is understanding and using one’s mind to heal (this is not just psychology, for instance religion and spirituality uses manomaya kosha for healing; some say that homeopathy is the better understanding of the mind after which is thought to enable healing through homeopathy). Vigynanamaya kosha is the sheath of intellect that we have, understanding and using this phenomenon is the basis of vignyanamaya healing; some say Ayurveda uses vignyanamaya principles. Most spiritual healing happens through anandamaya kosha; anandamaya is a state of inherent eternal bliss, a disturbance of this can and will affect all the koshas and hence the whole person. Healing with knowledge of the annamaya kosha heals the spirit – that would be the meaning of spiritual healing.

Being a human with an open mind is the only requirement to be a healer or be healed. I had hypertension longstanding vertigo and irritable bowel syndrome all of which got cured by spiritual healing after a two day chakra cleansing course by a great spiritual master.

One of the most useful methods used in spiritual healing is clearing the chakras.

There are seven chakras in our body

Each of these chakras have specific functions; their blockages have specific adverse effects and cleansing them has specific positive effects – a full detailing of these are beyond the scope of this short write up. As a mini illustration, the Sahasrara or crown chakra flowers when we live in gratitude. Getting to that point is a journey with defined pathways. But the effect of reaching that point is a life that is lived in gratitude, living in gratitude for all that we possess shifts your consciousness to higher plane.

(There are many references and links available, this is just one easy one to become aware of the chakras and their relevance in healing )

The innate intelligent energy that resides within us which is called Kundalini energy gets activated by cleansing the chakras. The full activation of the Kundalini is when it rises from the Muladhara (base) to the Sahasrara (at the crown of our head) and results in oneness with the absolute eternal. Regular practice of yoga, pranayama and dhyana can activate this energy when done over many years. Same can be awakened by a spiritual master in a word, touch or glance. This healing from a master happens for a short while but we can continue to remain healed by following the above mentioned practices on a regular basis.

A healthy satvic diet (yogic, stable, pure, clean, moderate diet) helps in acceleration of healing process making our body a good conductor to receive such energy.

The very first experience of this inner energy spreading within self gives one intense bliss the memory of which keeps one go deeper into seeking. The first sign is well being for oneself which when pursued with essential Vedic practices and initiation leads to healing of self and those around.

Somewhere along this path one is able to experience the vast difference between maya (illusion) and the TRUTH. As you go deeper into the pursuit of truth healing happens as a continuous process and our mind that was constantly looking for pleasures outside turns inward. The journey inward gives us the realization of the supreme purpose of human birth. 

All diseases, mishappenings, trauma and unhappiness is deemed to be the play of the macrocosm (paramatma), for the microcosm (jeevatma) to unite with its higher self. Once the being identifies with source and pursues techniques to be in constant communion with the source, major barriers that is knowledge, maya and ego melts unfolding higher powers in the form of siddhis and then we know that spiritual healing is one small yet important effect in this journey.

This science was thought to be part of each being in ancient times which was maintained by the culture of the day nourished by systems such as the gurukul. Now the same knowledge is being renamed, repackaged and taught to us in modified and edited versions.

We should aim to tap into the benefit of these ancient systems by tapping into the positive aspects of transcendent knowledge based spiritual practices; these are not the rituals of religion which are different from spiritual practices. This when acquired under guidance of authentic Guru will lead us from darkness to light, bondage to freedom and sickness to health.

I am not against any system of medicine. Whichever system is necessary and suitable for any given disease condition must be used to cure our illnesses; however when we aim for a certain kind of complete cure that goes above and beyond any presenting illness in question, in my personal view, it would only be possible by dealing with our person (body, mind and spirit) holistically that promotes healing from within.

May your health and healing include the healing of your spirit.

Dr Amudha Anand
Paediatrician, Singapore

(with editorial assistance by M Hemadri)


Note by M HEMADRI – Success in Healthcare, which is the name and the purpose of this blog recognizes that there are many modes by which success can be achieved in healthcare – Spiritual Healing by the vedic method is one of the ancient and profound methods. Amudha’s short writing is a welcome addition to this blogsite; my sincerest thanks to her.


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Friday, 15 April 2016

Honoring the Mothers of Gynecology

Honouring the Mothers of Gynecology

This blog was written after hearing Shankar Vendantam’s excellent podcast from the NPR Hidden Brain series on the mothers of gynecology.

The history of healthcare, the history of the noble profession, doctors, nurses, scientists and others has an underbelly of unethicality and double standards. This is often justified by the rationale that the practices were compatible with the ‘standards of the time’. That is one of the fundamental issues, the wrong question is whether it was compatible with the standards of the time, a possibly right question would be whether it was compatible with some of the eternal principles of medical practice. We will find again and again that actions of many of our predecessors in modern healthcare were not compatible with eternal ethical principles of healthcare.

An infamous example of an individual was the American physician J Marion Sims, who acquired black women slaves for the purpose of experimental surgery to resolve vesico-vaginal fistula. He operated on them without anaesthesia when anaesthesia was available and he operated on white women with the same condition only when he had completed his experimental surgery on black slave women after his technique was perfected on these black women. Who were these black women? It seems there were 14 of them; we do not even know their names except three of them. Anarcha, Betsy and Lucy.

In the NPR podcast historian Vanessa Gamble alludes to some potential motives. The women with vesico-vaginal (abnormal connections between urinary bladder and vagina) and recto-vaginal (abnormal connections between rectum and vagina) fistulas that happened after traumatic childbirth, meant that these enslaved women could not work for their ‘masters’ and could not reproduce creating more enslaved people to benefit their ‘owners’. So, it seems that it might not have simply been the desire to progress the frontiers of surgical science that was the primary motivator for Sims to have acted unethically. The view that he might have acted unethically is not just from retrospection, he was challenged about it even within his time.

Vanessa Gamble and Bettina Judd (a poet) talk in the NPR podcast about how these women whose life, living and bodies were used without consent could be recognised; there is some talk on statues along with the one that exists for Sims. Recognising and honouring these women is not tokenism, it is a fundamental for progress of humanity. Statues will act as symbols but they will have the constraints of geography and history whereas Sims will continue to have universality.

The mothers of gynecology should have universality (while Sims would become a lesser part of history). With that in mind I propose the following:

1)      Anarcha should be referred to as the mother of gynecology.

2)      The vaginal speculum currently known as Sims and its variants should from now be known as the Betsy speculum

3)      The surgical procedure to repair vesico-vaginal fistula should be called the Lucy’s repair.

While these three are important, it is also important to stop referring to Sims as the father of gynecology.

These suggestions stem from the principle where an immoral or unethical person is disassociated from any glory that is derived from the outcome of such person’s activity. The new world demands a new kind of approach, the sins, crimes and injustices of the past will remain – the benefits from those should not. The ignominy suffered by these women must be honoured by making them the main story; Sims of course needs a place on the page which he will have as an incidental footnote in the history of gynecology. Success in Healthcare demands these actions, we cannot allow healthcare to fail by not giving the mothers of gynecology their rightful place.

Organisations and persons working for equality and justice should lobby the gynaecological profession to adopt these changes so that they become the norm.


PS: I started writing a blog called ‘What are the nasties in healthcare we may regret in the future?’ and intended to use the mothers of gynecology as an example. Once I started writing it I realised that it will be yet another injustice if the mothers of gynecology did not have their own place in these blog pages.


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Saturday, 9 April 2016

A View of the NHS from the private sector health care

A View of the NHS from the private sector health care - A Personal Perspective:
Joe Karthikappallil

Whenever there are more than one solution to solve one problem  its safe to assume that  none works satisfactorily .

Healthcare for all free at the point of delivery is a commendable dogma which has made the UK a privileged population.  The staff including doctors who are appointed to the NHS enjoy reliable employment with a decent pension provision and great  perks with no pressure, obligation, or motivation to a  target orientated work ethic or to eliminate the waiting list of patients - apart from their goodwill.  

My experiences in the NHS are limited to ophthalmology and it would be reasonable to limit my comments to this speciality. Others may be able to comment on their speciality.  Lengthy waiting lists in Ophthalmology in the 90s and 00   were the result of a healthcare monopoly. Lack of competition and assured employment caused the incumbent surgeons to become inefficient. The result, lack of essential healthcare for the needy. 

Monopoly kills competition and stifles viable alternatives. Lack of competition causes creeping inefficiencies. Choice is important to maintain efficiency and keep costs down. Capitalistic market forces are not ideal but it delivers results. Private healthcare had to be roped in to reduce the massive waiting times in a fully funded NHS. How this could be achieved was a lesson that the NHS needed to learn.

The private sector quickly realised that efficient use of surgeons who are an expensive and scarce resource is key – something the NHS has still not taken any notice of. Five days a week and sometimes more - surgeons were utilised to perform surgical operations.

All other activity involved in the patient pathway could be serviced by staff who were trained e.g. preoperative assessment, biometry preparing the patient for operation, consenting and all postoperative care. This was a concept which the NHS was resistant to. Doctors were involved in organising all the above activity.

It was customary for all cataract surgeries to be performed under GA in the NHS whereas surgeons elsewhere were performing the same surgeries under topical anaesthesia. Compared to an average NHS list of 4 to 5 patient who required inpatient care due to GA, the private sector could treat 25 cataracts without anaesthesia cover as outpatient procedure. These efficiencies were lacking in the NHS due to the lack of competition.

A huge outcry was raised by the incumbent surgeons pointing out safety and cherry picking of patients. But evidence based medicine and audit of the outcomes paid put to these baseless allegations.  Kicking and screaming, efficiency in the NHS was improved.

Today the constant threat of funding following the patient compels the NHS to find efficiencies and failing surgeons and departments are shut or amalgamated.

The NHS is a monolith as far as procurement is concerned. Huge efficiency can be achieved if standardisation of use of capex products. In Ophthalmology departments the number of high tech equipments purchased and serviced runs in to billions of pounds.

The private sector buys standard equipments in large orders and thus drive prices down form suppliers. For instance the lenses and surgical instruments used in cataract surgeries, eye drops used can be standardised and prices can be a fraction of the current price if all orders are generated centrally. Similarly servicing charges for equipments are enormous and could be mitigated by  a dedicated NHS team of service engineers  - the private sectors do this currently.

These are just a few ways efficiencies of scale can be achieved. To the trained eye the NHS seems to be riddled with inefficiencies and in this age of technology, where there is a will, a way can easily be found. This is a relentless everyday process of discovering and upgrading efficiency.

In various other fields of British life, partnership between the private sector and the public sector is acceptable. The famous nuclear deterrent of the cold war was built on private public partnership.
There are build and operate private and public enterprise in constructing  hospitals  but not  healthcare delivery systems.

Not long ago NICE came along with recommendations regarding laser vision correction that made a mockery of available evidence base. All it achieved was a loss of credibility and a diminished its status as an institute of excellence. To lay out clear guidelines to the effect that although there is clear evidence to suggest that laser vision correction for myopia and hyperopia which is safe and effective there is no case for this to be available on the NHS would have been an elegant  stance to take. 

Such procedures  are performed and the public who have done their research are availing of such services but the animosity that this generates between the  surgeon community each trying to  undermine the other is unbecoming of an  erudite community of health professionals.

Aneurin Bevan in 1946 conceived and dedicated to the nation the NHS on the premise that services were provided free at the point of use. Advances in technology, extension of life expectancy, changes in the nation’s demographics and the longest recession in living memory are some of the forces testing the resolve of the British Isles - it is a challenge if such a health service or any health service conceived on the premise of free delivery at the point of care can endure any longer.

The people of the nation, if not the politicians are determined, that the NHS, the envy of the rest of the world shall endure. Take care of the pennies the pound will take care of itself. You shall find efficiency or efficiency shall be thrust upon you. A strong resolve alone is not sufficient to ensure that this generation and many generations to come shall continue to benefit from the high ideals of our fore-fathers.

Author of this post:
Joe Karthikappallil, FRCS Ophthal, is a consultant ophthalmologist in the private sector working in the northwest of England. The views expressed are his personal views and does not represent the views of any organisation, individual, associates, businesses, etc. 

I thank Joe for his contribution to this blogsite. 


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Saturday, 13 February 2016

Should a UK postgraduate medical qualification be awarded to someone who has not worked in the UK?

UK medical postgraduate qualifications can be obtained outside UK(1,2) without any work experience in UK. This is common knowledge among the medical profession around the world. This also a rather unique system since most postgraduate medical degrees and diplomas offered by institutions in many other countries require a period of training within their own countries. We were curious to know if the members of the public were aware of the ways by which UK postgraduate medical qualifications could be obtained and if it made any difference to their choice of a doctor to treat them.

A PubMed search did not reveal any such study about the public perception of doctor’s qualifications and its impact on consumer/patient’s decision making.

Our objective was to find out:
1)  If the public knew that UK postgraduate medical qualifications could be obtained outside UK
2)  If the public knew that UK postgraduate medical qualifications could be obtained without any work experience in the UK
3)  If the public knew that UK postgraduate medical qualifications could be obtained outside UK and without any UK work experience would it make any difference in their choice of a doctor if they needed medical care.

150 members of public in Kuwait from a similar social class and educational background were given questionnaires in either English or in Arabic. Questions were designed in sequence as per the objectives defined.

We found:
53% were not aware of the terminology of UK qualifications such as FRCS/MRCP etc
75% were aware that doctors with UK qualifications were practising in their city
72% would prefer to see a doctor with UK qualifications if they had a choice
50% thought that a doctor with a UK qualification would have a higher level of knowledge
45% thought that a doctor with UK qualification would have higher skills
85% said that if they were consulting a doctor holding UK qualifications they expected to benefit from the doctors UK experience
54% expected a doctor holding a UK medical qualification to have worked in the UK
67% did not know that a UK postgraduate medical qualification can be obtained without ever working in the UK
79% said that if they were seeing a doctor with UK qualification and they had the choice they would prefer to see one who has UK experience as well
84% said that if they had a major problem that needs a specialist consultation they would prefer to see a UK qualified doctor who also has UK work experience.


About half the respondents were not aware of the terminology of UK postgraduate medical qualifications, but three fourths knew that doctors with such qualifications were practicing in their city. The majority also said that they preferred to see a doctor who held UK postgraduate qualifications. Therefore we feel that it is in the interest of the medical fraternity in the UK to promote an increased awareness of the terminology of the UK medical postgraduate qualifications so as to enable patients to make a better informed choice in selecting a specialist medical practitioner.

However, half of our respondents did not expect a doctor holding UK postgraduate medical qualifications to have a higher level of knowledge or skills. But, interestingly we note that a majority would like to consult a doctor with UK qualifications. This suggests that there must be other intangible factors at work, perhaps ‘trust’, ‘glamour’, an ability to induce patient confidence and so forth which are inherent or implied.

An overwhelming majority said that when they consulted a doctor holding UK qualifications they expected to benefit from that doctor’s UK work experience. Two thirds of the patients did not know that a UK postgraduate medical qualification could be obtained without UK work experience. This suggests that patient’s expectations could be let down due to a lack of information and awareness of the way in which such qualifications are awarded. Perhaps, more seriously it is possible to speculate that some patients have the mistaken impression that doctors who hold UK qualifications have worked in the UK when that is not actually the factual situation.

An overwhelming majority of our respondents said that if they had a problem that needed specialist consultation they would prefer to see a doctor who had UK postgraduate medical qualification and UK work experience. We infer that lack of information prevents patients from making the choice that they would like to make. Our respondents were all from a more or less similar social background of an educated and middle class nature. It may be possible to assume that in the general population or in a population segment with lesser education, the awareness of such matters is likely to be much less while the expectations may be similar and hence prevents them even more from making a proper informed choice; sometimes, possibly a wrong choice.

In summary, our survey shows that in Kuwait some patients thought that when they consulted a doctor with UK postgraduate qualifications the doctor also had UK experience. Many patients did not know that UK postgraduate medical qualifications could be obtained without ever setting foot in the UK. Patients preferred to consult a doctor who has a UK qualification and UK experience. We conclude, that some of the patient’s expectations are not being met due to the way in which the award of UK postgraduate medical qualifications are made. We also feel that some patients could be misleading themselves into thinking that when they consult a doctor holding UK qualifications the doctor also had UK work experience when in actual fact that may not necessarily be the case.

One of our recommendations would be that UK postgraduate medical qualifications be awarded only to persons with UK work experience. Alternatively separate nomenclature could be used to indicate that the UK qualification was obtained without UK experience and/or training; the Royal College of Surgeons of Edinburgh has already started some movement towards such a practise by the award of SMRCS,(3) etc. Perhaps doctors holding UK qualifications could be obliged to divulge their training information as a part of enhanced ethical disclosure, say in their reception or waiting areas of their office. The institutions awarding such qualifications could have information campaigns that inform the patient hence empowering them with the ability to make an informed choice.

The Americans do not seem to confer their clinical postgraduate qualifications to doctors who have not actually worked in the USA.

The survey was conducted in the year 2000, we are not aware if there have been any changes in the public perceptions and understanding on this matter since.


Note: The above material is extracted from the following poster presentation:
A postgraduate medical qualification from the UK. What does it mean to the public in Kuwait? M. Hemadri and M. Purva. Hull York Medical School First Research Conference, Hull. 11th February 2004.


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