About a better NHS

I am Jonathon Tomlinson. I am an NHS GP working in Hackney, London. I originally set up this blog to inform people about the great scandal going on with the NHS, which is its conversion into a pre-1948 (start of the NHS) market economy as a result of steady lobbying from UK and US private health insurers and a prevailing neoliberal political ideology. For more about neoliberal politics and healthcare reform please see Dr Clive Peedell’s blog. I believe, like Virchow that,

“Medicine is a social science and politics is nothing else but medicine on a large scale. Medicine as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution; the politician, the practical anthropologist, must find the means for their actual solution”.

Most of my posts are about the relationships between GPs and patients and how health policy impacts on that. I am also a NIHR (National Institute for Health Research) In Practice Research Fellow studying moral development in medical education and clinical practice and I use the blog to test my ideas which will be used to inform my research. My main interest is in the use of narrative to illuminate patient and professional values. Ed Piele on Value Based Medicine and Havi Carel on Epistemic Justice are good starting points.

As well as criticising present reforms I’ll be adding suggestions for alternative reforms, which are most definitely needed to improve the quality, efficiency and humanity of care in the NHS.

I’ve been most recently inspired by US Surgeon and writer Atul Gawande, Dutch Philosopher Anne-Marie Mol, British GP and writer Julian Tudor Hart, Academics Colin Leys and Allyson Pollock and British campaigner and retired doctor Wendy Savage.

Conflicts of Interest.

I belong to Keep Our NHS Public and I was a member of their steering committee, but resigned when my young children needed more of my time. I joined them in 2009 and I still give them £50 a month. They need every penny they can get. I also donate £50 a month to the Centre for Health and the Public Interest who publish papers and blogs about health policy. I belong to the British Medical Association and I pay them a membership fee every year. I belong to the Green party because they stand for social justice above and beyond any of the other parties.  I also belong to MEDACT who campaign for global justice for health.

Everything on here I have written without payment of any kind, in my spare time. Usually at night when my family are asleep. I have never received any money from any individual or organisation for campaigning for the NHS.

In June 2011 the London Review of Books paid me for writing an article for them. It is available to subscribers here. It is the only payment of any kind I’ve had for trying to keep the NHS public.

In the last year, the topic of my posts has changed to explore the nature of the doctor-patient relationship, which I believe to be precious and under particular threat.

Top pages:

Medical Advocacy Doctors are the natural advocates of the poor, but have little training about advocacy. This needs to change

Kindness in healthcare Kindness in healthcare is in grave danger of being lost. This blog examines the culture of healthcare and suggests how we can bring kindness back.

A Perfect Storm: Welfare meets healthcare Poverty, illiteracy and isolation are at least as great a threat to health as what we consider to be diseases

Loneliness. How doe lonely patients present to medical professionals and how does loneliness impact on care?

Shame. Why do patients and doctors feel ashamed? How does it affect care and relationships between patients and medical professionals?

What’s in a name? Patients, Clients and Consumers Why are we looking for new names for patients?

Love, Hate and Commitment. Why are these things such an enduring and important part of medical care?

Narrative, Forgiveness and Listening. What can the forgiveness teach us about how to listen to the stories our patients tell?

Confessions: Hearing our patients’ stories When we fail to hear the stories our patients are trying to tell us we may miss the diagnosis

Do the justifications for NHS reform stand up to scrutiny? Is there any evidence for the government’s justifications for the Health Bill?

Competition in Healthcare, the risks What are the dangers of increasing competition in the NHS?

Conflicts of Interest and NHS reform In whose interests are the NHS reforms?

What is the point of patient choice? Why is patient choice so controversial? Are doctors really against patient choice?

The cost of chronic disease and the lack of NHS reform Why is healthcare so expensive and why does the Health bill do nothing about it?

Who is the NHS for? Not me! Why are we so divided in our love/ hate relationship with the NHS?

Henry Sigerist and NHS reform What is the history of healthcare reform?

A better NHS. What do we need to do to improve the NHS?

Contact: echothx at gmail dot com

37 responses to “About a better NHS

  1. There is a deliberate bias towards moral questions here because contemporary political debates are won and lost on moral rather than factual grounds (see ‘Is socialised medicine evil?‘)I would prefer a greater political appreciation of empirical facts though I’ve come to realise they get scant respect. The continued efforts of Ben Goldacre to raise awareness of the political abuse of scientific facts is a noble fight. Other than my medical qualifications I have a MA in Human Values and Contemporary Global Ethics from King’s College London. This, combined with my experience of training doctors in rural Nepal and Afghanistan and working in Hackney, East London leads to my particular interest in the moral implications of healthcare provision.

  2. keep up the good work!
    but how can we get something done? my MP (conservative) tells me it would be possible to get the regulations discussed by asking for a prayer to annul. he hasn’t yet responded to my asking when would be the best time for it though…
    will there be a more concerted protest soon? the current protests do not seem to be getting on fast enough

    • From Wikipedia:

      ‘A motion to annul a Statutory Instrument [i.e. a Bill or bit of legislation] is known as a ‘prayer’ and uses the following wording:
      “That an humble address be presented to Her Majesty praying that the [name of Statutory Instrument] be annulled.”
      ‘Any member of either House can put down a motion that an Instrument should be annulled, although in the Commons unless the motion is signed by a large number of Members, or is moved by the official Opposition, it is unlikely to be debated, and in the Lords they are seldom actually voted upon.
      ‘If a resolution to annul an Instrument is passed, it [the Instrument] will be revoked by the Queen through an Order-in-Council. Between the date of the resolution to annul and the date when the Order-in-Council is made, the Instrument remains law but ineffective. Anything done under the Instrument whilst it was in force remains valid, and the Government is free to make a new Statutory Instrument.[12]
      ‘The last occasion on which a Statutory Instrument was annulled was when, on 22 February 2000, the House of Lords passed a motion to annul the Greater London Authority Elections Rules 2000 (SI 2000/208). The last time the House of Commons annulled a Statutory Instrument was in 1979 when it rejected the Paraffin (Maximum Retail Prices) (Revocation) Order 1979 (SI 1979/797).[13]…
      [13] House of Commons factsheet L7, page 4’
      Doesn’t exist any more – takes you to a page with these on:

  3. Hi there
    Please see the email below I have received from the DH and my earlier email to A ndrew Lansley:
    “Dear Ms Ackroyd,
    Thank you for your further email to Andrew Lansley about GP commissioning. I have been asked to reply on Mr Lansely’s behalf.

    I note your concerns but must reiterate that the Government does not believe that its proposals will undermine professional ethics. GP practice income will be entirely separate from GP consortia commissioning budgets. GPs will not have a financial stake in the clinical decisions they make on behalf of their patients.

    All GPs commit NHS resources by referring patients or prescribing medicines. Ministers believe it makes sense for GPs to have more control and responsibility for organising NHS services and resources.

    As you know, the Government proposes to set out in legislation the duties of the NHS Board and commissioners to act transparently and non-discriminatorily in all commissioning activities, and to prohibit agreements or other actions to restrict competition against patients’ and taxpayers’ interests. The Government expects that this will include managing conflicts of interest. The new economic regulator, Monitor, will have powers to investigate and remedy complaints regarding commissioners’ conduct.

    I hope this reply is helpful.

    Yours sincerely,

    Adam Butler
    Customer Service Centre
    Department of Health”

    “Dear Dr Lansley

    Thank you for the responses I have had from the DH and Earl Howe. However, although there are the best intentions, I am sorry to have to come back and say I have not been fully reassured so far. Some of what is being said and done cannot be other than naïve or gung ho and I urge you to seek greater advice from all those you can call upon. I wish to make the following points:

    It is the incumbent responsibility of Parliament to legislate in order to set standards and impose requirements, which are to be followed for the benefit of all. In this regard legislation is necessary for the NHS providers. There should be legal obligations on the new commissioners and providers so that they can be sued for negligence. All these and associated other professionals should be subject to stringent laws to protect the public.

    GPs actually having direct contact with patients should not be allowed to commission the services. They could have sabbaticals from frontline practice or the services could be separated in some other way; separation of interests should be prescribed legally.

    Devolving responsibilities to consortia and councils is not per se a bad idea in view of the remote status of PCTs but historically councils have not been strong professional institutions and it is not clear they are sufficiently competent to cope and the consortia are totally new. It will take years to properly put this into practice and a legal framework with guidance in statutory instruments should be drawn up as for anything else.

    If these entities have insufficient legal responsibilities there will be inadequate control and redress. Government should be ultimately responsible. Otherwise, the social contract is being changed and without the support of the people.

    Hospital consultants could be involved with the consortia because they are the true experts in their fields. We need more communication between consultants and GPs in this country. The principle of taking commissioning nearer to the patient is a good idea but the framework should be clarified in advance. Too much localism will just end up being a cop-out and the Government, if it is not so planned, should have supervisory responsibility in law.

    I hope you will reassure the public by consulting experts in the respective fields and introducing suitable safeguards, rather than leaving these crucial questions to be sorted out over the next twenty years. Getting it right in advance would help everyone. As they say ”Act in haste, repent at leisure”.”

  4. and my response,
    “Mr Lansley
    Thank you for Mr Butler’s response, which includes some encouragement. It is the moral separation of interests I am worried about.
    In my view it would not be right for GPs on the frontline to in effect ration treatment or medicine according to a budget. I can see the sense in GPs near the frontline to be involved with commissioning according to a budget, which is different.
    I very much hope that the Government will ensure that measures are included to manage and indeed avoid conflicts of interest.”


  5. Thankyou for this very useful blog. It would help you to get readers if you set up a RSS [Really Simple Syndication] feed so that readers like me who rely on an aggregator like Google Reader http://www.google.co.uk/reader/view/?hl=en&tab=fy to organise their blog reading would get your posts automatically.

    Not all of us are twitterers yet or likely ever to be!

  6. Thanks: the RSS link works as it should.

  7. You seems to be an expert in this field, Great articles and keep up the good work, my friend recommended me it.

    My blog:
    Meilleur taux puis Rachat de credit surendettement

  8. sorry could not find the piece on efficiency you referred me to

    hope your family are well


  9. Hi there,
    Do you have an email that you can be reached on? I work for the Guardian’s healthcare network and we’re always looking for contributors. You can email me at jessica.fuhl@guardian.co.uk. Many thanks.

  10. You can email me on echothx@gmail.com

  11. Dear Better NHS readers

    Hackney Keep Our NHS Public have been working to secure a demo outside Parlaiment to register public opposition to the Bill. We now have permission for this. Please help us by attending and promoting this weekday demo – which continues until 8.30 p.m. The sooner we start promoting the demo the better. We have heard that others may soon announce plans to demonstrate and we hope that is the case and will support them.

    The details of which are on the flyer attached. It is widely predicted that the 8th of February will be the day the Bill moves to the Report stage and we could not arrange anything any sooner. This is a formal demo for which we have Metropolitan Police Approval.

    Where: Wed 8th Feb. Old Palace Yard Westminster SW1P. Opposite The Lords
    When: 2.30 – 8.30 p.m. Bring banners and placards and everyone you know!

    Andrew McCabe

    HackneyKONP.org E Mail us: HackneyKONP8thFebDemo@gmail.com

  12. what are the alternative recommendations given that public finances cant sustain the NHS’ growing costs?

  13. Hello!

    I am a freelance journalist, currently working on a feature on how the NHS bill might influence people with disabilities and carers.

    I came across over your blog while doing my research and was wondering if you would be available for a short interview? I would really like to hear your thoughts.

    You can contact me at sarah_leo@ymail.com

    Thanks a lot and I’m looking forward to hearing from you!

    Sarah Leo

    • Hi Sarah,
      You can email me on echothx at gmail dot com, or call on 07880953148. Leave a message, as I’ll probably be seeing patients,

  14. Dear Jonathon
    Some time ago you said you had the need of some resources to help you support a 15 year old girl with Type1 . my daughter who also has type 1 would be willing to help and she now lives in hackney . We are concerned about the imbalance between the huge technical interest in Type 1 and the lack of interestein the existential challenge in teenage girls and their families

    She has a GP in oxford but is considering a change but she said she would be willing to see you even if your list is packed, as i am sure it is


  15. Dear Jonathon –

    I’ve just come across your excellent blog, and I thought you might be interested in Dr Hairy – http://drhairy.org – a series of comic puppet-videos about a fictional GP. There’s also a short animation about NHS reform called “The Problem of Healthcare”, which might be of particular interest, and which can be seen at http://youtu.be/k-heGn8QzGg .

    Keep up the good work.

    – Edward Picot

  16. Keep up the good work, Jonathon and colleagues! Everyone would be very welcome at the next Defend Our NHS public meeting in Wirral. You can find details on Facebook https://www.facebook.com/groups/defendournhs/

  17. Hi Jonathan,
    It’s brilliant to see a GP taking the ‘right’ view. Since my dad had a stroke 2 yrs ago I have seen first hand how the NHS take money from the tax payer to ‘meet targets’ and completely ignore the patient who had the timerity to stay alive . This is not what it was designed for.

    If I may, I would like to invite your readers to sign this epetition http://t.co/Lt2GAYBJ , as Nicholson is one of the main architects of what we have today, and should have resigned himself….but feels he doesn’t have to,
    Feel free to remove this if you feel it is inappropriate here.

    Good luck with your endeavours

    Peter Colclough

  18. “Rather than criticise this from any political motive, …..”. Why not have a political motive? Aren’t you doing this for people? Don’t they need good housing, good education and jobs? Isn’t that what politics is about? You undermine your case by concentrating on a single issue and claiming to be apolitical.

  19. Listened to you on radio 3, tonight. It’s seems the BBChave not spent much time on researching the details of the changes being implemented, when the BBC eventually realise the enormity of the changes, coverage on the channels will hopefully increase.

  20. An interesting website, I too work in the NHS and am concerned that the latest bill to pass in the House of Lords will be the end of the NHS.
    Do you not think that it is now too late to save the NHS, and that we will just have to put up with the private companies,that are about to takeover everything?

  21. A patient who endorses your aims and would like to help in some way.

  22. I have just posted a new blog entry about the NHS reforms and I am concerned because it is slowly, surely being turned into a private institution. Not overnight – that would cause an outcry – but the ‘Nasty Party’ are doing it in a far more subtle way. You can read my blog http://eighthsinner.blogspot.co.uk/ to find out more. What worries me most though, as an ordinary citizen with no knowledge of NHS management structures, let alone medical procedures, is how almost every medical professional such as yourself is against THIS KIND OF (not any) reform – and yet still the changes go through.

  23. Pingback: Introduction to Spoken/Unspoken: hidden mechanics of the patient-doctor relationship | Illusions of Autonomy

  24. I’d just like to say that, in huge swathes of this country, society isn’t on the verge of breaking down, it has already broken down. There’s chronic unemployment that has now lasted for 3 – 4 generations, given that some people see their way out as having children when they are teenagers, the old work ethic that drove the country from the Industrial Revolution through 2 World Wars has gone. We are a nation of two tribes, those who have, and those who do not. The twain do not meet. There’s patchy provision of voluntarily agencies who try to help, but successive governments shy away from dealing with the underlying causes.
    I lived in London 30 years ago, I was a news reporter then. The social issues that existed then are unchanged, even worse, today. The rich become richer, the poor stay the same, or get worse. Now I live in the countryside, I would never live in London again.
    I don’t know how you can hope with dealing with the flotsam and jetsam that winds up in your surgery. You can listen, organise help, medicate, but you cannot cure the widespread social evils that I believe cause a lot of physical and emotional illnesses.
    Only some sort of peaceful social revolution could do that. Society needs to become whole again, not a melange of entities of self interest and greed. The education system is failing our children. The economic system is impossible to access for some. Benefits are not the solution, but a part of the problem. The welfare state doesn’t really exist any more, except in a conceptual sense. In parts of the country, the NHS is a total, complete mess, but, on the other hand, a huge opportunity for entrepreneurs to make easy money, as is the benefits system, etc..
    I give up. I’m going to live in the Middle East or Indonesia, where I know a real society still exists, in certain places. I am of Scottish/Irish origin, but I no longer feel the UK is my home.

  25. Loved that you mentioned Virchow. I did as well in a blog post I wrote a while ago; his philosophy still inspires me.

  26. Pingback: Re-humanising healthcare | Even stars explode

  27. This is heart rending and all the more so because you are a devoted NHS employee trying to care for others . You need to be very strong to be ill, and so do your family. My best wishes to you all during this ordeal. Carol Roy

  28. I just found this blog traveling from the London Review of Books. I am delighted to see it – and hope to learn more from you

  29. Pingback: The Changing Face of Primary Care in England – romneyhouseppg

  30. Hi Jonathan, I am a big fan if your blog, your trauma-informed, empathic approach & evocative writing style. I am a PhD student in Cork, Ireland and research the prison system and impact of post-release supervision of long sentence male prisoners. I will be passing through London in a few weeks and would love to do an interview with you for the Law and Justice radio show/podcast in conjunction with UCC Law Department and UCC 98.3fm. Would you be up for it? If so, the morning Friday the 23rd is the day I’ll be around. It would be great if we could swing a meeting. In any evebt, keep up your important work.

  31. Continuing thanks and in solidarity from @DefendOurNHS #DefendOurNHS https://www.facebook.com/groups/defendournhs/?ref=bookmarks

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