Practice makes perfect…or does it?

The ever thought provoking Javier Benitez (@jvrbntz) had this to say recently

The study in question explores relationships between implicit memory [wikipedia saying Implicit memory is a type of memory in which previous experiences aid in the performance of a task without conscious awareness of these previous experiences] and explicit memory [wiki: Explicit memory is the conscious, intentional recollection of previous experiences and information. People use explicit memory throughout the day, such as remembering the time of an appointment or recollecting an event from years ago]. Essentially in the study the participants where asked to perform a task of pressing one of 4 keys in response to different cues falling down a screen. There were two groups all completing a main task but one group given time to memorise the sequence of the falling cues while the other group just had practice time without realising (or more correctly being told) there was a sequence. In this study sequence learning wasn’t improved by  pre-training memorization of the sequence. The authors hypothesised that explicit and implicit memory may be independent of each other.

In response to an initial question Javier clarified by saying in the context of deliberate practice it may well be worth re-practicing rather than re-reading which was summated as:

At this point yours truly, having not really read the initial paper properly, but enough to notice that the task used in the study was similar to sequencing required in a popular game, waded in with:

Javier pointed out that the tasks needed to be predictable but the overall philosophy was that implicit and explicity are different points of memory.

Now fully acknowledging I had waded into an area in which I am not familiar (and it’s not great practice to pick up “tweetends” without knowing context!) it still got me thinking about how this piece of research was really applicable to post graduate medical practice, and in particular the busy world of emergency medicine. If we take, for example, putting in a interosseus needle the espouced theory may have some merit. Yes an understanding of the theory is needed but actually it’s not really until you have done it in a real patient (or even a dummy) that you can really understand the practicality of it i.e memorise the sequence all you want but you really need to ‘play’ the game to get the hang of it.

However much of what we practice in emergency medicine at a senior level is a complex array of operations of which are not predictable or follow algorithms. So I responded with

At that point I confused poor old Javier a bit and this blog serves as a way of clarifying my thought trail (and conveniently may help me frame an argument in one of the chapters of my Phd on junior doctors perceptions of competence and confidence). Does this implicit/explicit memory split really hold for complex tasks? And how would we test if it does. So an open question to the (#FOAMed) world:

It’s 6pm. The Emergency Department is heaving. Red phone goes off. Nine year old, hit by car at 40mph, thrown off bonnet. Initially agitated now quiet, clear open right femur and obvious trauma to chest.

You are team leader: what memory is going to get you through the next 20 minutes….

The #FOAMed universe – normal laws of evaluation don’t work here

I try and write blogs which can be accessed by anyone, at anytime, with minimal prior knowledge. However in this case you probably do need a understanding of what #FOAM and it would be useful to also read @boringEM‘s thought provoking commentary on methods to evaluate #FOAMed sites. Essentially he proposes a number of metrics to evaluate, and potentially, rank #FOAMed resources. A number of tweets about this got me thinking of a potential conceptual challenge that may inhibit the debate:

I have spent the last three years looking at the evaluation of practice changing interventions, in particular educational ones, as part of my PhD (see summary here). Part of this involved an analysis of the term evaluation, which is different from assessment and effectiveness. One of the things that happens when medics start evaluating things is that they often apply the same measures to a variety of different environments. As soon as discussions started on judging #FOAMed content inevitable comparisons with the process of evaluating academic literature arose (some of my previous comments on this here). The problem with that is:

i) Not only are #FOAM sites, by definition, designed to share learning in an OPEN access fashion but

ii) The methodology of engagement with #FOAMed was always going to be different from that of an academic paper.

To set some context the naysayers and skeptics for #FOAMed have always stated there is no quality control of resources. How do you know if the content holds up to current evidence? What if the authors are not credible or has a conflict of interest? Well – think of the last journal you read? Did you go away and practice immediately what it told you? I am fairly sure you didn’t, probably for a variety of reasons, but ultimately because critical evaluation has been ingrained in most clinicians from early in their training. This criticism  is a particular bug-bear of mine and puts people off receiving information via Social Media (see here for previous thoughts). The lack of peer-review of #FOAM material makes it more vital that the reader is aware of potential error (if I was to change one think it would be a universal alert statement is placed on site highlighting this – this would also act as a very useful #FOAM brand) but the reader can still make their judgement. As an example this paper on Early Warning Scores in Emergency Departments has been a cited on a number of occasions but is neither peer reviewed or commissioned, ultimately it should have no more value than anything else lifeinthefastlane.com or St.Emlyn’s have produced. Why does being in a journal make it have more value?

But I suppose I digress slightly, what is different about the evaluation? Well academic literature is spread by publication in journals, promoted by citations and only recently  encouraged by social media. #FOAM has always been essentially reliant on word-of-mouth. The route to #FOAM is rarely discussed. Think of the last #FOAMed site you went to – why did you go there? Did you just find it? I suspect (and please comment and say I have got this wrong) it’s because it is from a source you already follow or someone has directed you there. And who was that person? My guess it is someone  you trust,  follow or is a leader in #FOAM. Not really sure how you define a leader in #FOAM but I stake trust in the sites that key #FOAM supporters recommend. So if @sandnsurf@emmanchester, @_nmay, @predordialthump, @boringem, @jvrbntz or @tessardavis mention a site I take a look. Others may have a completely different list – but it probably doesn’t matter who they are. There is a different form of peer review in process here – that of trusted followership.

Could there be mistakes in the process – well yes there could. But the process of academia and publication has not been risk free . So when it comes to evaluation the metric is at stake is the spread of information. The more recommendations leading to website hits being a proxy measure of word of mouth assessment of the perceived quality of site. Problems still exist if you want to be pedantic- hits to sites can be manipulated (but this can be controlled for) and the “quality”, in terms of readability and evidence, if you are determined to measure this as well has still not formally been assessed. But if you are evaluating  the primary purpose of FOAM then it is metrics like hits which have value. How this reflects the sharing ability of some of the FOAM leaders is open to question? This also prompts the question about what is the ultimate aim of #FOAM and whether it wishes to be constrained by old paradigms of evaluation or maybe create new ones.

Friday Follow #ff: Functional or Frivolous?

I have previously written about the notion of followership on twitter (distinct from the leadership concept which is equally as important!) and would like to ‘follow’ it up with a muse on #ff. A quick guide to what #ff actually means can be found here.

Those on Twitter will know as Friday morning comes around some people go to great lengths to include as many of their twitter colleagues in #ff lists. I always feel a little awkward about watching people list either:

i) the same people each and every week or

ii) fill as many people as possible behind or in front of the #ff as they can.

I feel awkward not because it really bothers me what they are doing but because I actually secretly enjoy getting a #ff but never really have the inclination to do #ff spamming myself. There is also something unsettling about what to do when you have received an #ff – do you have to #ff back? do you even have to acknowledge it at all?

I have #ff a number of people but I do try to choose people that I think others really should follow i.e not selecting close friends who have only tweeted 3 times in their entire life. But I often ponder if I am just being a miserly kill joy. There is something quite warming about a collection of people simply being nice to each other in a very public way. In fact there are few things, other than a ‘like’ on Facebook, which are as easy to publicly demonstrate your support, friendship or commoradie with others.

Currently healthcare is taking a bit of beating in the media, is under constant reform and moral is particularly low. Those who use social media to unwind or refresh from the constant pressure of clinical activity could easily be forgiven for celebrating a bit of shared good feeling. So maybe a random #ff , which actually may not be hugely beneficial for your followers, may actually be very beneficial for the recipient. Furthermore given the fact the art of simply smiling at work is clearly something health care professionals would like to see more of (NHS Change Day Interim report) a simple #ff is maybe what everyone needs.

Top 14 (couldn’t fit in 10!) Tweets from #Quality2013

Would be interested in people’s thoughts on this list – please do comment!

Submission to “Shape of Training” Review

The Shape of Training Review is looking at potential reforms in the structure of Medical Education in the UK. As I was not part of any organisation, or acting in a representative capacity, my response is a more personal reflection on the key issues in post graduate medical education in the UK at present (and hence the reason for adding it to my blog!)

My key recommendations were as follows (followed by responses to each of the questions)

1) The training of Doctors is not seen in isolation of the potential large upheavals needed in acute and community care. Any significant changes in training pathways must be future proofed to be able to flexible to changing patient demographics and service requirements.

2) HEE and the (National Commissioning Board/ NHS England) should agree a joint strategy and policy for proportion of care delivered by health care professionals in training.

3) The AoMRC should produce a joint statement on watershed roles between specialties in relation to service delivery and education. This would inform the specialty/generalist debate started by the RCGP.

4) If this review is to alter the CCT (certificate of completion of training) as an endpoint the views of trainees and newly qualified consultants must be heard during oral evidence.

5) A core group of Stakeholders including but not restricted to the FMLM, Academy of Medical Sciences, Academy of Medical Educators and  Health Policy Groups should meet to plan a strategy for expanding the Walport scheme beyond academic training.

1. Over the next 30 years, how do you think the way patients are cared for will change?

 It is unlikely that despite advances in technology (heart surgery, prosthetics, drug delivery etc.) the fundamental nature of health care professional interaction with their patients will alter. There will always be a need for face-to-face contact, communication skills demonstrating empathy, examination skills that elucidate key findings and an ability to make decisions based on clinical, social and ethical factors.  Regardless of the state of finances, political systems or even the construct of the NHS training doctors in good patient interaction, history taking, examination and technical intervention will be no less needed than it is now.   It is likely that more practice will happen via teleconference, closer to patients home or by non-medically trained practitioners. This does not diminish the need for well trained medical staff with core skills in history, examination and management.

2. What will this mean for the kinds of doctors that will be needed in primary care? In secondary care? In other kinds of care?

What is almost certain is that doctors will work in different ways and with different medical devices. Therefore as well as maintaining high standards of care doctors will also need to be able to respond to a rapidly changing technological arena.   The changing demographic of the population will mean a breaking down of divisions between primary and secondary care and re-thinking of this arbitrary divide. The concept of a community specialist or a hospital acute generalist are likely to become increasingly common. It is vital that the Royal Colleges are flexible and engaged with workforce needs to avoid ‘silo’ roles developing and there being inflexibility in career pathways.

3.  What do you think will be the specific role of general practitioners (GPs) in all of this?

The fundamental right to see a health care professional regarding a range of health issues, at a local level, who has a skill set to manage minor illness but be simultaneously cognisant of serious and rare disease is unlikely ever to be allowed to diminish by the general public and profession alike. Regardless of the changes made to delivery of care to patients requiring ‘admission’ GPs will need to retain a breadth of experience and expertise. This will be the only way to ensure quality care is received in the most relevant location for patients.

4. If the balance between general practitioners, generalists and specialists will be different in the future, how should doctors’ training (including GP training) change to meet these needs?  

The foundation curriculum has helped to some extent but we are still not entirely clear on the attributes we would like all doctors to have. We are also tied to a system that means everyone has experience of acute medical care. It is right and proper that this is the case but it has meant hospitals have always had their basic service commitments fulfilled by an excess of doctors at a junior level (but who often only perform very basic tasks or tasks beyond their competence – Collins Report)   If the balance of doctors is to change; the environment in which doctors can learn the requisite skills to move from having knowledge (medical student) to applying practice (foundation doctors) to delivering care (specialty trainees) will need to change as well. This does not just involve curriculum alteration but will require a system wide evaluation of the deployment of foundation doctors in the acute care system.

5. How can the need for clinical academics and researchers best be accommodated within such changes?  

I contributed to this question on behalf of the Academy of Royal Colleges Trainee Doctors Group. Please see their response as well.

It is important to differentiate between the need to train the whole medical workforce in the core principles of research, related ethics and good clinical practice (GCP) and those who will become established academics with a full or partial whole time equivalent research brief. It should not be the case that there is a clear divide between the two but ignoring the needs of either group risks jeopardizing both the strong UK academic standing in medicine and ultimately patient care. Currently there remains an artificial, and sometimes stereotypical, divide between those with a clear research interest and those without. This is not aided by poor awareness of where to seek advice on academia and research. A recent survey of paediatric trainees revealed only a third were able to identify who their local regional academic advisor was and other surveys of specialties suggest similar results.

The creation of the Walport training scheme has transformed the ability of a core group of potential academics to learn and develop research skills. However, as with all pathways, there is the potential to reduce opportunities to those uncertain about careers choices in their early clinical years. Any system of developing a future academic workforce needs to be cogniscent of the fact that research interests develop over time, that certain specialties have optimal and suboptimal periods of undertaking substantial research endeavors and that for many pursuing a long term academic career is not viable or desired.

In developing a new training structure the following should be considered:

i. It should be the responsibility of LETBs (in England), Deaneries (elsewhere in the UK) and Colleges, in collaboration, to establish fail safe mechanisms for trainees to access individuals and resources to advise on research and academic careers.

ii. Mechanisms for advancing and assisting those with potential and a clear interest must exist at all levels of training e.g. Medical School MB-PhDs, Foundation Year Academic Programmes and Academic Clinical Fellow/Lecturer posts.

iii. It should always be possible, but not necessarily an individual guarantee, to be able to undertake research activity within a training programme even if an accredited research pathway is not being undertaken.

iv. The concept of OOPE should be expanded to be able to undertake small research projects, as well as QI initiatives and education fellowships. These should be considered distinct from OOPR which should be reserved for those on research degree programmes. LETBs should ensure that work force planning and service needs allow for a number of OOPEs to be always available across specialties for those with an interest in research, but without funding, to undertake activity which may lead to a higher degree but also allows for return to clinical work without prejudice.

6. How would a more flexible approach to postgraduate training look in relation to: 6a.  Doctors in training as employees?

Doctors have traditionally been employed by their trust. Employing doctors at a regional (or even national level) would enable great flexibility in rotations and remove issues with multiple CRB checks and some parts of induction.

6b. The service and workforce planning?

 The fundamental problem with developing a flexible and dynamic training programme is that it is designed around service needs rather than vice-versa. It is clearly not simple to suggest that trainees are placed into training posts once the service needs have been met. But it would be possible over the next decade to start thinking about the need to make this change. It will not be possible to allow a flexible training programme if for example only one OOPE is available at any given time.  A debate on “extra-curricular” training i.e. skills in education, research, leadership and policy development must be had. One to determine why it is current training is felt to be inadequate to develop these skills (as evidenced by the high number of requests to undertake such activity) and secondly to understand how important they are in sustaining a high quality medical workforce in the future.

6c. The outcome of training; the kinds and functions of doctors?

 Is this question asking whether it is possible to have an endpoint of training that doesn’t produce an independent practitioner (whether GP or Consultant)?  Decisions made by junior doctors to apply to specialty or VTS training is made on the basis of reaching the consultant or GP end-point. Ensuring flexibility in training must always bear this in mind, and while some trainees, wish to undertake SASG roles there is no convincing evidence that this is their primary intention (further research is clearly needed in this area). The public also have a clear understanding of what a consultant or GP is. Therefore a flexible approach to training would still need to maintain a clear standard to achieve at its completion. The definition of a independent, unsupervised practitioner is a standard that is clear to all who aspire to do it and regulate its attainment.

6d. The current postgraduate medical education and training structure itself (including clinical academic structures)?

6d and 6b are integrally linked. There already exists a huge flexibility in the system from anaesthetics trainees being supernumerary in the first few months, to the cohort of medical director clinical fellows and also the integration of academia as evidenced by the Walport scheme. The ACCS programme has demonstrated, as will hopefully the broad based training pathway, how rigidity can be taken out of current training programmes to the benefit of trainees.   Perhaps no new flexibility is needed just an increased opportunity for trainees to partake in the experiences on offer. This is entirely dependant on service need and its potential reconfiguration.

7. How should the way doctors train and work change in order to meet their patients’ needs over the next 30 years?  

There have been few fundamental reforms of medical education since the Flexner report at the beginning of the last century. Of course nominology has altered, the training time frame has been adjusted and curriculums have been completely revised. But the core nature of medical training has stuck to some fundamental principles: At medical school a framework of basic science and key skill sets in each of the specialties learned. In the early years doctors clerk new patients and perform routine day to day care.  As they progress skills widen with experiences in clinics and theatres while greater responsibility is placed on leading juniors and making decisions.   Both the Temple and Collins reports highlighted current issues with this approach.

1) The need to provide a constant 24/7 general acute service was reducing learning opportunities once the core skills sets of dealing with acutely unwell patients had been learnt.

2) Supervision from supervisors was inadequate.

Neither report mentioned another issue with current education policy: “one size does not fit all in medical education”. Although generic skills are vital it cannot be the case that the training of a surgeon should match that of a psychiatrist. The current debate on working hours has always been flawed in its approach that everyone needs 56+ hours or that all patients are potentially unsafe unless we are rigid with 48 hours.   A surgeon may get rest at night and have their learning enhanced by operating on the patient they saw the night before whereas it would be catastrophic for a neonatal SpR who will have had little rest on a night shift in a tertiary NICU to have to continue onto an out patient clinic.   It should not be for this review to determine the individual needs of each specialty and I don’t think it intends to. However recommendations on training pathways must be flexible to individual specialty needs and in keeping with current workforce policy and regulations.

8. Are there ways that we can clarify for patients the different roles and responsibilities of doctors at different points in their training and career and does this matter? 

This does matter but requires national co-ordinated action. If each LETB/Trust etc. choose a different method it would cause confusion.

9. How should the rise of multi professional teams to provide care affect the way doctors are trained?

Currently there is little work done on assessing health care professional interaction and learning in a post graduate medical education context. Simply encouraging engagement will have little training benefit unless some core competencies can be defined. The rise of MPT in more integrated services will mean this area must be explored.

10. Are the doctors coming out of training now able to step into consultant level jobs as we currently understand them? 

Yes they are – there is little evidence of serious harm although it is clear the support given by colleagues is much improved from a decade ago.   The problem for this review of post graduate medical education is that it depends on the concept of a consultant/GP remaining static otherwise the end product will not meet the current health system requirements.

11. Is the current length and end point of training right?

Interesting question as the length of training is substantially different between specialties. Despite not feeling confident many trainees do feel competent to be consultants (anecdote I’m afraid!) although this maybe biased because they have deliberately extended their training. Qualitative and Quantitative research in the patient and personal outcomes of specialty trainees who have completed training entirely according to the pathway i.e. ST1-6 with no breaks and are no consultants is needed.

12. If training is made more general, how should the meaning of the CCT change and what are the implications for doctors subsequent CPD? 

This is an interesting question as it implies training may be made more general. What if the question were if training became more specialist?   As stated previously a CCT should remain as the benchmark to reach when you can be an independent practitioner. If less specialty accreditation was on offer the meaning of the CCT should remain unchanged. It would be possible post CCT to pursue education in more specialist areas but this would not devalue the important or relevance of CCT.

13. How do we make sure doctors in training get the right breadth and quality of learning experiences and time to reflect on these experiences?

HEE and the Commissioning Board must meet and re-appraise the core duties of junior doctors in providing acute care. Although it is not necessary in all specialties and environments it is quite clear that Emergency Medicine is suffering from trainees having little time to do anything other than constantly see patients. Although this is clearly a fundamental part of their training, only reflection and mentoring can avoid poor habits becoming ingrained and learning from mistakes turned into a positive experience.

14. What needs to be done to improve the transitions as doctors move between the different stages of their training and then into independent practice? 

The introduction of accreditation of educational supervisors will be instrumental in improving mentoring of doctors and providing better and more comprehensive cover of their transitions. It is vital that the GMC are robust in their processes to ensure that standards remain high.

15. Have we currently got the right balance between trainees delivering service and having opportunities to learn through experience?  

 No (The Temple and other reports demonstrate this)   Confusion has been created by the belief that trainees either deliver service or they don”t. In order to learn doctors must see patients in a supervised manner. However currently some patients are dependant on trainees for the care they receive i.e the medical assessment unit staffed overnight by an ST4 and two ST2s. It is entirely reasonable for learning experiences to take place in this setting. Unfortunately pressures on acute services will mean those doctors will see patients in a way that ensure throughput rather than learning opportunity. The same unit with additional SASGs, nurse practioners and consultants takes the pressure off, especially junior staff, meeting trust targets as well as meet the needs of their curriculum.  As stated previously changes in population demographics mean the Health Service must examine who is providing patient care and what is a sustainable way of delivering education. The two are intertwined but should not be dependant.

16. Are there other ways trainees can work and train within the service? Should the service be dependent on delivery by trainees at all?

See question above. Service entirely independent of trainees would be a tough financial and workforce ask. The review of Emergency Medicine by the Department of Health is a good example of work that could be performed in all specialties to review the delivery of acute (and community) care.

17. What is good in the current system and should not be lost in any changes? 

Clear steps from Novice (Foundation) to Expert (Consultant)  A defined end point  The ability to undertake OOPE and OOPT.

18. Are there other changes needed to the organisation of medical education and training to make sure it remains fit for purpose in 30 years time that we have not touched on so far in this written call for evidence?

The Walport system has transformed academic training. Although there are still some bugs to be ironed out the inception of protected out of clinical time is clearly beneficial. This principle should and could be applied to Medical Education, Leadership and Management and Health Policy.  Leadership and Management, especially in the light of Francis, have been neglected for decades in the training of junior doctors. It is vital if we are too develop a generation of consultants and GPS who can transform services and deliver high quality care that this is remedied. The FMLM response to shape of training has clear recommendations in this regard.

Simultaneous Safety: Purposeful Physiological Detection

The Million Pound Challenge was a new event at the International Forum of Quality and Safety in Healthcare #Quality2013. Judges included Donald M. Berwick, Fiona Moss, Helen Bevan, ‘e-patient’ Dave deBronkart and JoInge Myhre.

The challenge: Junior health care staff to pitch an idea for what they would do with One Million Pounds to transform healthcare. Four finalists were shortlisted for presentation. The video of my presentation is here:

I was very humbled to be not only shortlisted but win the award with my idea for a multi-purpose saturation probe. In  summary the technology exists to not only calculate oxygen saturations and heart rate, but also temperature and respiratory rate from the same device. These four measurements together, adjusted by an internal microcomputer for a designated age range, could be used to simply display a green, amber or red light to given an impression of the patients health. This would NOT replace clinicians judgement but would support health care professionals and potentially those without significant medical training to make decisions on patient care. The probe would be powered by a small solar panel enabling its use in the developed and the developing world.

My presentation is attached. I am not a big fan of bullet points but the general sense is there.

A picture of my mock of what the device would look like is below (click on it to expand):

Annotated Picture of Monitor

So what turned out to be a ‘back of packet’ scribbling seems to have caught peoples attention. Could this really be taken forward?

To do this I need the help of the world-wide health community.

Do you work in medical technology industry?

Do you have a friend who is expert in solar panels?

Can you program algorithms into motherboards?

Would you like to just simply help!

Please get in touch by commenting on this blog. This is a real opportunity to change the world. Don’t just believe me. Donald Berwick said so….

I’m in the business of medicine, but do I really want medicine to be a business?

Today is the beginning of a new era in the NHS. For supporters of the Health and Social Care Act it represents the implementation of a necessary shift to cope with rising demand and cost:

“[6] The main aims of the Act are to change how NHS care is commissioned through the greater involvement of clinicians and a new NHS Commissioning Board; to improve accountability and patient voice; to give NHS providers new freedoms to improve quality of care; and to establish a provider regulator to promote economic, efficient and effective provision.” [explanatory notes for Health and Social Care Act]

For its detractors, it is popularly described as the end of the NHS and an entire political party has arisen as a result. The debate has often been extremely heated but generally confined to those already in touch with medical “politics”. Anecdotally  (I have no supporting evidence for this) wondering around the corridors of a random english hospital may not find you many staff with a clear knowledge of the details of what has happened on 1st April 2013.  It is this lack of knowledge that may explain, despite some of the vitriol, why contributions by members voting on the Royal Colleges support for and against the bill last year were not that impressive.

College Total Voting Members Number of Respondents Votes against the Bill Response Rate
RCPL [1] 25,417 8,878 6,092 (69%) 35%
RCPCH [2] 10,289 1,492 1,184 (79.36%) 14.5%
RCGP [3] 33,837 in England nearly 2,600 completed responses 90% support withdrawal of Bill 7.7%

Independents have attempted to explain the detail (this summary from fullfact.org is good). There is also a visual timeline of events via the Kings Fund.

A great many commentators have put their hats into the ring about what will happen in the future. I am neither experienced or wise enough to do this. As a trainee, albeit a relatively senior one, I have been disappointed about the level of information given to the future workforce about the changes. It is is a complex area, the Health Act is a huge piece of legislation with arguments of recent terminology on the section 75 amendment making the area even more confusing.

What is without doubt is new ability to widen opportunity for any “provider” to deliver services for patients. I don’t think I am naive about healthcare as a business. The NHS has always run to accounts, tendered and has paid private companies to deliver operations it was falling behind on. But I am old enough to remember a day when there was one National Rail Service. I don’t know if it was true that ‘nationalisation’ was not providing effecient, cost effective services but rail is now clearly a competitive business, even though the trains are often not competing for the same track. However, as a regular train traveller, I know my experiences between the companies are often very different, that even if they do run on time it is at a cost or comfort detriment and I certainly don’t know who best embodies the rail service.

I ask myself is this really how I want to see the NHS?

References

1. Results of RCP Health and Social Care Bill Survey.

http://www.rcplondon.ac.uk/press-releases/results-rcp-health-and-social-care-bill-survey (last accessed 1st April 2013)

2. RCPCH votes for Government to withdraw the Health and Social Care Bill.

http://www.rcpch.ac.uk/news/rcpch-votes-government-withdraw-health-and-social-care-bill (last accessed 1st April 2013)

3. RCGP members support withdrawal of the Bill, says RCGP survey.

http://www.rcgp.org.uk/news/2012/january/rcgp-members-support-withdrawal-of-the-bill-says-rcgp-survey.aspx (last accessed 1st April 2013)

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