Brexit and the NHS: Just the Facts. Part 4: Show Me The Money

In a multi-part series juniordoctorblog.com looks in-depth at the potential impact a No Deal Brexit will have on the NHS. In Part 1, we looked at the impact on the supply of medicines, in Part 2 we examined the barriers to importing nuclear isotopes and in Part 3 we examined the current NHS staffing crisis through the new lens of a No Deal Brexit.

In this final part, we look in-depth at the NHS books and ask do we have the resources and funding to survive a No Deal scenario?

Before going any further, it’s important to establish a few key facts about NHS funding.

Firstly, as a publicly funded institution the NHS budget is set centrally by government and various affiliated semi-government bodies. In addition several charitable and research organisations donate money and resources for specific NHS services.

Secondly it’s vital to understand that the NHS requires more money each year than the previous, to maintain the same standard of care. There are many reasons for this, the smallest of which is an expanding population. Currency inflation is another. However, the main reason is something called “health inflation” – above currency inflation, this is the concept of the continuous rise in costs in any state of the art healthcare system. This takes into account things like the rising cost of new medicines and new technologies, an ageing population, and more and more people surviving conditions that previously would’ve been fatal, therefore going on to require more complex and advanced healthcare. This has been the case for 70 years. Since the beginning of the NHS activity has increased by roughly 4% every year, and the NHS budget on average has risen by 3-4% every year in step.

So what’s going on right now with NHS funding?

Since 2010 there has been a near funding freeze on the NHS, with the budget rising just 0.9% every year, while demand and activity relentlessly grow. The NHS ran a surplus of £1.5bn 2010/11, it now runs an underlying deficit of up to £5.9bn in 2017/8. Increasing service activity have been paid for by a combination of backroom cuts; selling assets like land and transferring investment budgets into day to day running costs, as well as front line cuts: mental health nurses, closing maternities and A&Es, cutting nursing bursaries. Year on year the NHS in England has had to stretch more and more from the same budget, for 8 years.

Wasn’t this a good thing? More efficiency right?

The NHS was already ranked one of the most “efficient” healthcare systems in the world in 2012- mostly due to primary care triaging, the lack of insurance paperwork and payments bureaucracy and use of generic medications.

There is always room to improve however, especially in an organisation with a budget of £115 billion a year. The Carter report suggested getting rid of unwarranted variation in procurement and practice between hospitals could save as much as £5billion (albeit correcting some of the identified areas would take significant investment itself).

However, there is only so much fat to trim, in what was already a comparatively lean system. Relative to inflation the NHS has already cut pay to its staff for the last 8 years, in some staff groups as high as 25%. The land has already been sold, all the clever accounting cards already played. The deficit is £6bn and the NHS already predicted it needed £30bn by 2020 just to keep the lights on, and has only received £4bn to date.

Everywhere the alarms are suggesting there isn’t much more to give: A&E waits are the longest ever recorded and the target has been scrapped, operation and cancer waiting times are at all time highs and staff morale is at rock bottom.

This was the situation BEFORE Brexit.

How does a No Deal Brexit change any of this?

In addition to the additional costs to import medicines and isotopes across new borders, and the agency fees to fill vacancies we cannot recruit to, No Deal Brexit will hit the NHS in the one area it is threadbare; it’s pocket.

A No Deal scenario effectively removes the U.K. from the free trade area of the EU, an economy worth 22% of global GDP, and the 60+ countries the EU has FTA agreements with: Canada and Japan most recently. Once out of FTA trading these countries would be obligated to charge tariffs on exported goods and supply chains based in the U.K including car manufacturing, farm produce and pharmaceuticals. With loss of the financial ability to “passport” services to the EU the financial services sector, 6.5% of our economy, would be hit very hard. The Department for Brexit’s own figures estimate a No Deal to cost £159bn to the U.K. economy by 2030. That’s the entire NHS England and U.K. schools budget combined.

But can’t the U.K. just make our own trade deals?

Potentially yes, but there are multiple barriers to making that a reality: negotiation time (usually years), the approval of the other WTO states and even potentially the approval of the EU with countries like Canada and Japan as part of their FTA in the first place. Most of the “high profile” trade deals we are courting lately; South Africa, Canada, Japan, are all countries we ALREADY have excellent trade deals. For example, the South Africa-EU FTA allows us tariff free trade on 90% of everything we exchange: a deal that’s already increased bilateral trade by 120%. If we do renegotiate we do so from a weaker position; a much smaller individual economy, with weakened buying power, in a desperate position. Secondly pretending these are deals which will equal the loss of trade between the U.K. and the EU in the event of No Deal doesn’t add up: 50% of foreign trade is done with the EU, our next largest partner is Germany by itself, at just over 10%. The USA is close behind with ~10%. South Africa is <1%. If we lost 20% of trade with the EU we would have to increase trade by 100% with the USA to compensate. Countries we already trade with and many that we have free trade agreements with right now.

So a No Deal Brexit will hit the economy a little, what’s the big deal?

In healthcare money means lives. Less money leads to less resources which in turn causes more harm and more avoidable deaths. An analogous scenario is the 2008 financial crash. Fraudulent banking practices in the US housing market triggered a worldwide recession as major banks that had bet heavily on dodgy mortgage products lost, and went bust in the process. Worldwide in countries where healthcare was linked to employment, there was a spike in cancer deaths, estimated at 500,000 excess deaths that otherwise wouldn’t have occurred.

In the U.K., due to the NHS model, we were insulated from this effect. The decision of the Tory coalition however to impose austerity in response to the financial crash had its own effects. A study in 2015 and a further study in 2017 concluded that as many as 50,000 “excess” deaths occurred between 2010-14 and up to 150,000 by 2020 due to cuts in health and social care. With the lack of staff, lack of resources and general decline in every outcome measure of safety and quality this is no surprise.

We are in the exact same scenario as 2008 once again, except this time the NHS is not in good health going in. Despite all this, the current government seems unwilling to countenance the realities. Theresa May even linked her proposed funding increases for the NHS, £20bn a year extra by 2021, to a Brexit “dividend”. *Sigh*.

Is there a Brexit dividend?

Short answer: No

Long answer:

Each year we pay £13bn into the EU and get around £7bn back as an immediate rebate, and then further subsidies, for example to British farming, leaving £6bn going to the EU each year, or £120m a week, or 26p a day per person.

For that amount we have access to 27 Free trade countries worth £350bn a year to the U.K. in trade, as well as 60+ further countries via EU agreements. The CBI estimates this is worth £3000/year per household, or £2 a day per person, eight times what it costs.

In the event of leaving the EU, we gain the balance contribution, but the trade we lose has to then be factored in, the corresponding hit to the economy and the subsidies we would then have to pay ourselves to our own industries. The OBR already estimated we have lost £15bn in economic activity due to the Brexit vote, and even if that were not the case and there were really was a Brexit dividend the government has already promised to spend it several times over.

Specific post-Brexit spending has been promised to: a U.K. satellite system (£100m), a new customs solution and border infrastructure (up to £20bn), storing 6 weeks of medicines (£2bn), a “divorce bill” (est. at least £18bn by 2028), several thousand more civil servants and customs officers, new staff for an expanded civil aviation authority, a new border solution in Northen Ireland, an entirely new authority for food and animal trading and new lorry waiting parks to mention but a few.

On top of that the missed opportunity of firms taking a look at the chaos and uncertainty and deciding to contract elsewhere. Whatever tiny amount we get back from the EU is going to be lost in a deluge of direct and indirect losses.

What does that have to do with the NHS?

Despite promises of another “£20bn” for the NHS, budget after budget will have black holes that need filling, and the chance of any new money, let alone current funding, becomes more and more remote.

Meanwhile, demand will continue to rise. There will be 3,000,000 more over 80s in the U.K. by 2037, a group of patients that costs an average around £7000 a year in healthcare. Increased survival, technology, wage inflation and likely higher currency inflation will all continue to increase the cost of the service we currently have.

Are you done now?

Nearly.

To be very clear, the crisis state of the NHS is not the fault of Brexiteers and voting Leave was not a vote for this. Be that as it may, a No Deal Brexit reality will throw up new barriers to importing medicines and isotopes for cancer diagnostics, push existing EU staff away and stop new staff from coming, and throttle any hope of new funding. Worse, when we should’ve spent two years debating about how to fund the health and social care system we have, how to staff it and supply it, we’ve been talking about Brexit. All other political issues have also been put on hold; teachers, policing, welfare. Brexit isn’t the root cause of the NHS’ problems, far from it, but it may prove to be the straw that broke the camel’s back, a No Deal scenario even more so.

Informed consent is the absolute bedrock of medicine. It’s my job as a professional to fully inform you of the options and you then make a decision knowing every risk and benefit. I’ve never heard a position on Brexit that involved Euratom, the EMA or EU nursing applications. Who knew this stuff? I have to admit, I didn’t. Find me someone who voted Leave that did. I haven’t so far. We can now see the shape of Brexit, for the NHS at least, you are now properly informed. Democracy requires everyone has the same set of facts before they make their opinion. Here are the facts.

The question is what are you going to do about it?

Juniordoctorblog.com

References

https://en.m.wikipedia.org/wiki/List_of_the_largest_trading_partners_of_United_Kingdom

https://www.google.com/amp/s/www.bbc.co.uk/news/amp/uk-politics-42559845

https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/nhs-budget

https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/how-nhs-funded

http://www.pharmatimes.com/news/nhs_bodies_delivered_1.5_billion_surplus_in_201011_980543

https://www.nuffieldtrust.org.uk/research/the-bottom-line-understanding-the-nhs-deficit-and-why-it-won-t-go-away

https://www.google.com/amp/s/www.telegraph.co.uk/news/2016/05/25/financial-crisis-caused-500000-extra-cancer-death-according-to-l/amp/

https://www.bbc.co.uk/news/uk-24831941

https://www.google.com/amp/s/amp.theguardian.com/society/2016/feb/01/ageing-britain-two-fifths-nhs-budget-spent-over-65s

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Brexit and the NHS: Just the Facts. Part 3: We, The People

In a multi-part series juniordoctorblog.com looks in-depth at the potential impact a No Deal Brexit will have on the NHS. In Part 1, we looked at the potential disruption to the supply of vital medicines, and in Part 2 we examined the barriers to importing nuclear isotopes essential in many treatments including cancer.

In this part we look closely at the largest and arguably most important resource the NHS has, the staff.

What’s going on with NHS staffing in 2018?

The NHS is the world’s fifth largest organisation, in England alone it employs 1.2million people. Since 2010 staff numbers across multiple areas have fallen, leaving large gaps. To maintain current services we need 40,000 more nurses, 10,000 more GPs, 11,000 more hospital doctors and 7000 more mental health nurses.

What has the government done about this so far?

Short answer: A lot of words and little else.

Long answer: During the coalition years the government cut nursing training numbers and nursing staff posts in hospitals, as well as cutting 6000 mental health nurse positions. Meanwhile demand and activity in the NHS relentlessly grew every year by ~3%, increasing the pressure on the remaining staff and creating a situation where more staff are leaving than joining.

Despite promises of “5000 more GPs by 2020”, the number of GPs have actually fallen by over a thousand. Growth in nursing numbers is equally negative, as more leave the NHS than join. Despite proposing 15,000 more nursing places to train “homegrown” staff, so far those extra places have not been filled. Funding for places may have increased but bodies have not followed; applications fell by ~10,000 in England last year, meaning the number of nurses in training actually dropped. This is due to the government cutting nursing bursaries and charging full tuition fees from 2016. Similarly, the government has announced an expansion of doctor training places by 1500 per year from 2020, but these new doctors won’t be on the shop floor until 2025, and won’t be new GPs until 2030 or new hospital consultants until 2033.

What has that got to do with Brexit?

We have a worsening staff crisis coupled with a failure to train our own staff to deal with it. We are therefore 100% reliant on recruiting trained staff from abroad to fill the gaps, in recent years from the EU especially. Of the NHS 1.2 million staff, approximately 5% are currently from the EU, 10% of doctors and 7% of nurses.

How have things changed since the Brexit vote?

The official number of self-reported EEA staff has actually risen slightly from 58,698 to 61,974 between 2016 – 2017. This is partly because 10,000 “unknown” nationality staff members in 2016 became “known” in 2017. In specific groups, such as nursing, there has been an 89% drop in the number of new EU nurses, and a 67% rise in those leaving.

Are EU staff leaving?

Short answer: Yes

Long answer:

Staff in the NHS come and go as with any very large organisation, it’s the relative balance that is important. The total percentage of EU staff leaving has increased, and the percentage of EU staff joining has decreased. 10,000 EU staff left the NHS last year, an increase of 42% on the year before.

The BMA surveyed 1700 EEA doctors this year- 50% were considering relocating, and 20% had already made concrete plans to leave. Although this is bad, the major issue is recruitment.

Since 2016 EU recruitment has flatlined, for nurses especially. In addition to new language tests, new EU nurses also face a falling exchange rate, dropping the effective starting salary by 12%, and prolonged uncertainty about their working conditions and residential status. Applications for EU entrants into nursing have dropped 96% since Brexit began. Where 6400 new EU nurses joined in 2016, only 800 joined in 2017, a loss of 5400 nurses we sorely needed. The number of doctors also joining the register from the EU declined by 1000 between 2016-8.

Overall since 2009 there has been a steady rise in nursing and medical staff from the EU, a rise which levelled off after the EU referendum and hasn’t resumed. The balance of recruitment to resignations has shifted dramatically, so as a source of manpower to solve our staffing crisis the EU has dried up.

Why is this a big deal? What’s a few less nurses?

Statistically there is a direct correlation between staff numbers to patient ratios and the chance of survival. For example, the higher the number of nurses per patient the more likely stroke patients are to survive. Less staff = more deaths and more patient harm. The NHS recruits in large drives to plug these gaps from the EU; Spain, Portugal and Ireland in particular, but no longer. That shortfall will undoubtedly lead to patient harm.

How does No Deal change any of this?

The No Deal Brexit papers specifically do not mention EU citizens status in the event of No Deal. Whether a tactical omission or a political misstep, the lack of concrete reassurances for EU staff is deeply troubling. Bear in mind many of our EU NHS staff have lived here for years, have children in schools, support dependent relatives and have long-term careers. The looming threat of uprooting and even deporting, however distant or vague, should not be underestimated. If you were in the same position of uncertainty, unsure if you might have to pack up your whole life in six months time, would you buy a house? Would you move to a new job? It seems unlikely you’d come to a country that was so unsettled currently.

The additional predicted further drop in the value of the pound, the uncertainty over basics like pensions and healthcare access in the event of No Deal, will only compound that. As a father with a young family I certainly would not move here if I were in that position, and I can’t say I wouldn’t be thinking of leaving myself. Would you?

Is the government doing anything about this?

Dominic Raab, the current Brexit Secretary, has “reassured” EU residents no one will be “turfed out” in the event of No Deal. However, as already mentioned, they haven’t published anything tangible on this as yet.

There is a pilot programme in the North West for up to 4000 EU students and NHS staff to apply for Settled Status, initially for those in 12 NHS trusts. Although a digital process this pilot will require a face to face Home Office appointment. The Home Office has already stated it does not have sufficient staff currently to process 3,000,000 applications, and the initial launch of the “app” in June did not function on half of smartphones, so it remains to be seen how the remaining 60,000 NHS staff will be settled in this way. Whether these terms will change in the event of No Deal is another question hanging over everything.

What about future EU recruitment for the NHS?

The drop in recruitment due to Brexit is creating a worsening shortfall in key departments, increasing the pressure on existing staff and exacerbating increased numbers from all groups leaving the profession or retiring early.

In a No Deal Brexit the U.K. remains a less attractive destination: relatively less pay, new barriers to the immigration process including visa caps as a third country and uncertain settled status.

So in summary the NHS is already in an understaffing crisis, created by under-resourcing and poor workforce planning, exacerbated by cuts to posts and bursaries for recruitment, meaning hopes of new “homegrown” staff to plug the gaps are a decade away. EU staff have been invaluable to maintaining a functioning service but since the Brexit referendum recruitment has dropped off a cliff. A No Deal scenario will only compound the haemorrhaging of staff, in a system where staff numbers are a literal matter of life and death.

With a shortage of medicines, diagnostic isotopes and vital staff, we will require a massive influx of resources and funding to keep the service going.

Resources and funding we do not currently have. If you’re still with us, read on to Brexit and the NHS: Just the Facts. Part 4: Show Me the Money. (coming soon).

Juniordoctorblog.com

References

http://www.pulsetoday.co.uk/home/finance-and-practice-life-news/at-least-12000-new-gps-needed-by-2020-new-workforce-data-reveal/20032973.article

https://improvement.nhs.uk/documents/2471/Performance_of_the_NHS_provider_sector_for_the_month_ended_31_December.pdf

https://fullfact.org/economy/pound-fallen-since-brexit/

https://www.nursingtimes.net/news/workforce/nurse-patient-ratio-found-to-be-key-to-stroke-survival/7012974.article

https://www.bma.org.uk/news/media-centre/press-releases/2017/november/almost-a-fifth-of-eu-doctors-have-made-plans-to-leave-uk-following-brexit-vote

https://researchbriefings.parliament.uk/ResearchBriefing/Summary/CBP-7783

https://fullfact.org/health/eu-nurses/

https://www.health.org.uk/chart-large-drop-number-new-nurses-coming-eu-work-uk

https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/influence/europe/effect-on-the-nhs-of-the-uk-leaving-the-eu.pdf?la=en

https://www.bloomberg.com/news/articles/2018-02-15/european-doctors-are-giving-up-on-the-u-k

https://www.careappointments.co.uk/care-news/england/item/44896-nursing-in-managed-decline-as-new-figures-show-further-drop-in-student-numbers

Brexit and the NHS: Just the Facts. Part 1: Medicine

In a multi-part series juniordoctorblog.com looks at the No Deal Brexit scenario and its direct and indirect impact on the National Health Service.

Informed consent is the bedrock of medical ethics. It means I cannot legally do anything to you without your express permission, and for anything you do allow, or “consent to”, you have to know why you need it, the risks, benefits and all the alternatives. Such are the legal ramifications of this, if I were to perform a procedure without properly informed consent I could be jailed for the crime of battery.

The absolute irony of the EU referendum, arguably the most important vote in a generation, was the completely backward approach to the decision. The further from the time of “consent” the more informed the conversation has become. In this first part juniordoctorblog.com asks, how will a No Deal scenario affect our supply of drugs and medicines?

Will we still be able to import medicine?

Short answer: Yes, but costs will likely rise, and some supply chains will be threatened or may breakdown entirely.

Long answer:

Currently there are no tariffs or border checks within the EU for medicines. Tariffs are additional duties charged at the border for moving medicines between countries.

In the event of No Deal we would leave the EU and become an individual state within the World Trade Organisation, an internationally agreed baseline for trading.

The WTO has its own issues:

1. Although we are currently members our membership is within the EU bloc. We don’t have individual membership yet.

2. The WTO court for settling disputes is currently non-functioning due to a dispute with the USA. If any aspect of our joining or terms is disputed, there isn’t currently a way to settle it within the WTO.

Specifically in regards to moving medicines back and forth between the EU from the WTO, the EU is signed up to the Pharmaceutical Tariff Elimination Agreement, an Agreement to eliminate tariffs on a set list of medications with other WTO countries. We could continue to import tariff free medicines on this list from the EU under this agreement. However, this list hasn’t been updated since 2010- the US are again disputing it and holding up a revision. This leaves many new medicines off, meaning we would have to pay new tariffs on importing those from the EU. Which is a lot. We import 37 million packets of medicines every MONTH from the EU worth £18.3billion. The EU are our largest source of medicines (73% of all our imports), likely due to the frictionless movement and lack of tariffs. Estimated WTO tariff rates would add 5-6% of cost to these medicines. We also leave all the EU-WTO countries Free Trade Agreements we also had access to, e.g Japan, and any agreed medicines tariff reductions included in them.

Worse, UK based companies produce medicines in supply chains that often cross borders multiple times – each import potentially adding an additional tariff without an agreement. This will add significantly to the current £16bn medicines bill for the NHS.

That’s just the additional taxes. The costs and practicalities of physically moving medicines across customs borders will be a huge barrier to importing medicines, so-called “non-tariff barriers”. These govern how medicine is checked, regulated and transported – essentially guaranteeing the drug that’s injected to you has for example been refrigerated across the entire supply chain so it remains safe. Or is actually the drug on the bottle and not a knock-off imported elsewhere.

If we leave with No Deal we also leave the Customs Union, meaning we will require infrastructure at our border and at every exporting countries border to facilitate movement of medicines between our countries.

Not only will this disrupt and delay the import of finished medicines to our hospitals, it will also disrupt our ability to make medicine in U.K. based pharmaceutical companies like AstraZeneca and GSK. Many of these supply chains are time and temperature sensitive. Delays at borders may break the chain entirely and strategies to circumvent these issues, such as building additional storage space, additional supply routes or moving manufacturers, will only add to the final cost of the medicines passed on to the NHS.

Many drugs we also can’t stockpile for very long to prepare for a No Deal scenario. Insulin is a good example. We only make 1-2000 patients worth of insulin in the U.K. each year, while the national need for the medicine is 400,000 patients, the vast majority imported from Europe. We can’t stockpile insulin for very long, and it requires refrigeration and very careful regulated transport.

So, back to our short answer, availability of medicines will be reduced due to customs delays and supply chain issues, while the cost of these new barriers will be added to the medicines alongside any new tariffs for medicines off the list of WTO traded drugs. If this adds even a conservative 8% to the cost of medicines, that means an additional cost to the U.K. of £1.4bn every year.

What about importing future medicines?

Short answer: Leaving the European Medicines Agency will add to the cost of introducing new medicines to the U.K., deprioritising the U.K. for new drugs and delaying the introduction of state of the art therapies, such as in cancer.

Long answer:

Even if we can secure the supply line for our existing medication, in the short to mid-term we will face difficulties bringing new medications to the U.K. We were previously a key member of the European Medicines Agency, an organisation governed by the European Court of Justice. This Government decided Brexit should include leaving the EMA as it’s under the jurisdiction of the ECJ, although passed a motion this summer to include negotiating to stay in the EMA as a non-member. Obviously in the event of No Deal we are out of this entirely.

Why does this matter?

The process to develop new drugs and medicines is unbelievably expensive and time consuming. New medicines have to first be synthesised, tested on cells, then animal models and then a dose and formulation needs to decided upon. That process alone can take a decade and often doesn’t go anywhere at all. Once a drug is stable and theoretically beneficial to humans it has to go through several phases of trials before it can be approved for routine use by any doctor for a patient. Firstly it’s tested for safety in healthy people- unforeseen severe side effects in humans sometimes occur, for example see the “Elephant Man” trial at Northwick Park Hospital in 2006, where six healthy adults took an experimental drug at this phase of testing and all become critically unwell. Once it passes this safety benchmark the drug is then tested in a small group of people who actually have the disease. This is to demonstrate benefit and look at side effects- again, in the real world this may not work at all. If it passes this stage a much larger trial is organised, usually testing the drug against a placebo or the current best treatment in the strictest conditions possible to avoid any possible corruption of the results. These large trials take years to organise and perform and then publish, cost millions of pounds and again, often don’t go anywhere at all. Even once a drug is in the market we have a phase 4, where data is continuously collected from reported side effects. Sometimes it takes two or more of these trials to prove something actually works.

You can see already what a time-consuming and data-heavy undertaking this is. The EMA’s job is essentially to check every stage of this process, to take into consideration of practicalities like how the drug is given and how much it costs, and then to approve and regulate the medicine for use in EU patients.

Without this function there would be no checks on the drug development process, a process already hugely driven by the need for pharmaceuticals to recoup the money they’ve spent on development.

The EMA streamlines this process for the U.K. by allowing a single member state to undertake the approvals process and then applying that approval to all other members. So a drug approved in France is then licensed for the U.K.

Our subdivision, the Medicines and Healthcare products Regulatory Agency, was a leading part of the EMA. EMA HQ was formerly in London, and employed 900 people, but has already moved away post-Brexit vote. Once we are out of the EMA we will have to approve and license every new drug ourselves. As a much smaller market for drug companies than the EU we will be deprioritised for new drug launches. State of the art developments for conditions like cancer will take longer to come here. This might seem a trivial concern; what possible difference could a year or two make for a single drug?

In the 1960s an accidental discovery created an entirely new cancer drug called Cisplatin. Based on platinum, Cisplatin was found to be revolutionary for the treatment of testicular cancer, a condition that was once fatal in nearly all patients, but is now cured in 90%.

Imagine you have been given a terminal diagnosis, perhaps a year to live, when a new game-changing medicine like Cisplatin is discovered. Those few years delay will make the difference between life or death for you. That’s the reality of the unforeseen consequences of such a colossal decision; the knock-on effects domino everywhere, and real people may actually die as a result.

So, leaving the EMA will add to our own development costs and time requirements to approve medicines and delay state of the art treatment in conditions like cancer, where time can make all the difference.

What about future medicines?

Short answer: We are pulling out of research funding and EU-wide scientific collaborations on health and medicine products, which may hamper potentially life saving medical advances.

The long answer:

In the mid to long term, threatening to pull out of the EU with No Deal has already dropped many U.K. applicants from the EU research fund, Horizon 2020. A half a billion pound fund backing health science and technology, we may never know what good that could’ve done, what avoidable harm will now happen as a result.

So a No Deal scenario will have far reaching and damaging effects across nearly every aspect of current and future medicines in the NHS?

Short answer: Yes

Long answer: Very much so. But it only get worse. See Brexit and the NHS Part 2: Going nuclear.

Juniordoctorblog.com

References:

https://www.cancer.gov/research/progress/discovery/cisplatin

http://www.pharmatimes.com/news/nhs_managers_warn_no-deal_brexit_risks_drug_shortages_1249697?utm_source=dlvr.it&utm_medium=twitter

http://www.pharmatimes.com/news/mps_vote_for_uk_to_remain_part_of_ema_1244680

https://publications.parliament.uk/pa/cm201719/cmselect/cmbeis/382/382.pdf

http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2018/08/news_detail_003005.jsp&mid=WC0b01ac058004d5c1

https://www.channel4.com/news/factcheck/factcheck-are-insulin-supplies-really-at-risk-from-a-no-deal-brexit

https://www.google.com/amp/s/www.bbc.co.uk/news/amp/magazine-35766627

The ambulance never came.

Indisputably, life is complicated. However we are increasingly ill-prepared to receive and process complex ideas and problems. The challenges facing the NHS are multifaceted, intricate and blown up to a national scale. The campaign to raise awareness of the damage being down to the health service is often waylaid by an inability to crystallise our concerns into a single message that can penetrate through the spin and lies. Worse, the constant back and forth of statistics and numbers both fatigues the general public and dehumanises the subject matter.

The past few weeks have seen the NHS at a level of crisis like no other in its history. Colleagues across the country are reporting conditions no developed industrial country should ever tolerate in their hospitals.

At this point I would normally bring forth statistics illustrating this disaster: waiting times, trolley waits, operations cancelled, ambulance queues. We’ve all tried that. It’s not working.

So, for a moment, let me simply tell you a story.

You are busy back at work after the New Year, trudging through the piled paperwork eclipsing your desk, when you get a phone call.

It’s your grandmother- she doesn’t feel well. She tells you she has chest pains. Concerned you tell her to call an ambulance straight away. It takes some convincing, but she eventually agrees.

She’s a tough elderly lady, never one to complain. She hangs up the phone and duly dials the ambulance.

You wait a few minutes and then phone her back. She tells you she called and they are on their way. Relieved you tell her to take the mobile you left her, and make sure it’s switched on. You make arrangements to leave work early to get out and see her.

An hour passes. Not hearing anything you phone back on the mobile. It bounces to voicemail. Concerned, you call back the landline. Your grandmother picks up: she’s still at home, waiting. The pain is still there. Maybe a bit more than a twinge. She feels a little sick, couldn’t manage lunch at all. You start to panic a bit, trying to see if there is anyone who can get there to take her directly sooner. You are two hours away. You hang up and dial her GP, not really sure what to do. You end up on hold waiting for a receptionist who eventually tells you to call 999. You try to call 999 but they can only tell you an ambulance is on the way. You hang up and dial again, tell her you’re on your way. She tells you not to fuss but you’re already in the taxi heading to the train station.

You try her landline again before you get on the tube: it’s been nearly two hours now and still no ambulance. You tell her to call 999 again. She says okay. She sounds weak.

The tube journey is the longest and worst of your life. Every extra delay is torture.

You get to the overground station and try her mobile again. No answer. The landline rings and rings. You dial and re dial frantically. There’s no answer. It’s been nearly 3 hours since her call. Sick with worry you bundle onto the train, desperately dialling 999, the police, an old neighbour, anyone you can think will be able to get there sooner. No one can. The train sweeps into the country wrenching your soul as you will it to go faster.

You jump in a taxi at the other end, stuff a twenty into the drivers hand and tell them to get you there as fast as humanly possible. There’s no answer on any line. The taxi driver weaves through traffic and bus lanes and jumps an orange light, screeching to a halt outside your grandmother’s house, just as an ambulance pulls up. It’s been three hours 46 minutes exactly.

Frustrated and driven mad with worry you shout and scream at the crew, who look exhausted and defeated but run up to the door and knock frantically. In the end the door is kicked in by the police. But it’s too late. You find your grandmother sitting on her favourite chair, slumped, ashen, and far too still.

It’s too late.

I work in a heart attack centre. We have strict national targets for patients having acute heart attacks- 90 minutes from arrival to a life-saving procedure to open a blocked heart vessel. We do this because we know every precious minute we wait means more damage to the heart, more risk of heart failure and death. We often get in there a lot sooner- from the moment a patient arrives at the front door a whole cardiac team is waiting for them: doctor, specialist heart nurse, radiographer and specialist cardiac physiologist. While we hear the handover we ultrasound scan the heart, take electrical tracings, blood tests, give blood thinning medication and tubes for giving fluid, examine and explain the procedure and consent the patient. At a clip this whole process takes just five minutes. We then whip the patient into our procedure room, prep the instruments and special tubes we use to access the heart, sterilise the area, hook the patient up to a monitor and blood pressure cuff, give specialist medications and then insert a needle into their wrist, then a sheath then a tube which we thread all the way into the three arteries around the heart. We take x-rays to see where we are going as we inject dye. We then thread a balloon down the tube and inflate it inside the blockage. We put a stent in to keep it open and then we relax.

On good days the patient feels better, the chest pain is gone, the artery is open. A life is saved. The clock says just 50 minutes have passed. We get them a cup of tea.

We do this several times a day, every day, day and night. The system works and it works well. It just needs the resources to run it.

For Marie Norris, the 81-year old lady who died this week 3 hours 46 minutes after calling an ambulance with chest pains we were too late. For her and dozens more, the ambulance never came.

This has been the worst winter in NHS history and we aren’t even at the halfway point yet. It comes at a time when the NHS has never had less resources for its population, never been more understaffed. If the stats and figures and endless spin don’t connect with you, think of this happening to your own grandmother. To you. Is that the country you want? Is that a government you would vote for?

Think about that.

We appreciate your thanks and support, but what NHS staff really want is to be able to do our jobs, to not have to face families who’ve been let down by the system. To not have to explain their loved one died because we couldn’t do enough, because we didn’t have the time or funds or staff. Don’t give us your thoughts and prayers, give us your action, your vote, your demonstrations. Whatever it takes.

Give us, and give yourselves, a chance. A chance more than Marie had.

Juniordoctorblog.com

 

Dear (brand new) Doctor…

To all the new doctors,
First and foremost, I think I speak for our profession, junior and senior, when I say, Welcome.
Tomorrow will be your first day as a doctor. A day you have probably thought about for a decade or more, but perhaps could never quite imagine. 

From Hippocrates to Osler, Galen to Gawande, every medic of every age had a “first day”. Be careful with the advice you listen to, there are as many ways to be a doctor as there are doctors. This is my advice, please feel free to take it or leave it.
1.Looking after humans is a messy business, literally and figuratively. Know where the scrubs are kept. Don’t wear shoes you can’t afford to throw away.

2. There’s always time for lunch. Your stomach won’t thank you for ignoring it, but worse, your patients won’t either. Irritable doctors make crappy decisions. 

3. Look after your back. Sit down to cannulate or bring the bed up so you don’t have to. Your fifty year old self will thank you.

4. Be nice to your fellow F1s. They will be the closest colleagues and friends you will make in your career. You will go to their weddings and hold their newborn babies. Like soldiers on the battlefield you will be bonded for life. 

 5. Be nice to everyone else too- even when others don’t reciprocate. You never know when you’ll need their help. Successful medicine is sometimes about who you know as much as what you know. Learn to know when you should bite your tongue.

 6. And when not to. Ultimately the patient is your only priority. If you need to voice a concern, do so, loudly, coherently and without anger, to whoever, however high up, that you need to. 

 7. Don’t drink too much, if you do. It’s easy to let one glass become two, become three. Don’t drink your stress, find better ways to deal with it. 

 8. Learning from your own mistakes is mandatory. The price of a mistake is high, you must do everything you can to recoup that cost. Better still, learn everything you can about other doctor’s mistakes, so you don’t repeat them.

 9. Find what you’re scared of, and run towards it. I was terrified of cardiac arrests so I used to run to every single one. Now I’m a cardiology registrar. Life is funny like that.

10. If you’re not sure about a drug dose, look it up.

11. Look up anything else too. Google diagnoses when you’re not sure. Don’t be dismayed, your seniors do this all the time, probably more than you. Knowing what you’re talking about is much more important than merely looking like you do.

12. Find a toilet that no one else uses. Trust me on this.

13. Take all your leave. Go on holiday. 

14. Recognise you made a choice to be a doctor, take pride in and be empowered by that choice.

15. But also recognise when you see a patient they didn’t get a choice, and they didn’t choose you as their doctor. You have a responsibility to be the best doctor you can be in that moment, because that patient doesn’t get to choose anyone else.

16. Keep your moving boxes- you’ll need them again.

17. Understand you work at a nexus point in a patient’s life. Patients come in going one way in life, but oft-times leave going somewhere completely different. Sometimes, sadly, nowhere at all. That enormity of exposure to Life can take it’s toll.

18. Talk about it. Cry about it. Commiserate with your colleagues, support and celebrate with them too. Deal with your emotions fully, or they will overwhelm you.

19. Try your best, always.

Feel free to heed or ignore any of the above. Add your own pearls as you find them.
Tomorrow is your first day, doctors, and truly the first day of the rest of your life.

It is genuinely the most wonderful job.

Good luck. You will be brilliant.
Juniordoctorblog.com

“Your Life In My Hands” by Rachel Clarke. A juniordoctorblog.com review

“The unexamined life is not worth living”
Socrates

 

There’s an inextricable link between medicine and books. To a medical student books are both stepping stones and obstacles, huge tomes to surmount as much to absorb. Later, they become totems, a copy of the ubiquitous Oxford Handbook of Medicine, colloquially known as the “Cheese and Onion”, jammed into a scrub back pocket to ward off disaster and protect us from our own insecurities and our patients from our inexperience. Later still, books become mirrors, reflections that let us examine our own careers and lives.

Reading the rather wonderful “Your Life In My Hands” by Dr Rachel Clarke leads to it’s own examination. Dr Clarke writes with a prose that is both immediate and personable, dumping you straight behind the eyes of an NHS junior doctor, bursting bladders, blood-soaked scrubs, desperate tears and all. This book is a portal into our hospitals, coming at a time when it’s never been more important to be able to share the actual reality of the NHS frontline.

Full disclosure: I’ve met Rachel Clarke. We swam in similar circles during the junior doctor contract dispute. When she and Dr Dagan Lonsdale kicked off the 24-hour protest TimeToTalkJeremy, outside the Department of Health, I was working just up the road and went down to show solidarity. Unflappable, sincere, ever-smiling; she was hugely inspiring and extremely nice. A few days later I was sitting in the same chair.

Before this book landed on my doormat, I knew Dr Clarke was a great writer and a shining example of our profession. It was the parts that I didn’t know that made this book so surprisingly brilliant. Besides doctoring, her semi auto-biography takes the reader through her past life as a TV journalist, dodging bullets in the Congo, filming experimental deep-freeze neurosurgery in the US, casually bantering with Alastair Campbell and Prime Ministers. Weaved throughout this rich tapestry of past and present, Dr Clarke paints the powerful and undeniable picture of an NHS being failed through short-sighted politicking and chronic underfunding.

For me, reading this book forced me to re-examine my own career. Her descriptions are achingly accurate: of the crash-calls, the dark quiet moments with a dying patient’s family, the highs of a shot-in-the-dark diagnosis or a surprise success where it seemed impossible and the lows of the true tragedies, dealing with the pieces left behind. I have been there in every one. We all have. And now you have too.

And that is the true beauty of “Your Life In My Hands” – it brings to life with dazzling perspicuity, not a unique experience, but a ubiquitous one. This is a junior doctor’s life, as damn near as you can get without living it yourself. And even if you have, it’s worth reading for the mirror it holds back. I left medicine after the burnout of the junior doctors contract dispute, and then, like Dr Clarke, rediscovered my love for it again. Reading this book made me remember exactly why.

The NHS is consistently the number two top issue of concern in UK opinion polls. A “political football” to some, often those campaigning for it are accused of “weaponizing” the subject. The true power behind this book is Dr Clarke’s ability to humanise it. The irony of “Your Life In My Hands” is in it’s title, because once you’ve bought this book, you are holding a life in your hands. Once you’ve read it and experienced it, you will see the NHS one hopes, as we see it. And then, as Dr Clarke masterfully surmises, you will realise that the future of the NHS is not in our hands, but yours.

juniordoctorblog.com

Your Life In My Hands by Rachel Clarke is out now.

 

Dear Other Normal Human Beings

I am writing to you, because, like myself, you are a normal human being.

You, like me, wake up in the morning and sleep at night, eat meals, sometimes with loved ones, sometimes alone. We are alike in our requirement for other people, for happiness, for security, for food, for warmth, for shelter.

You may have children, you may have brothers or sisters. You have, or had, parents, and perhaps were lucky enough to know your grandparents.

You may have noticed that many health professionals were becoming uncharacteristically vocal, leading up to the General Election. You may have thought them self-serving, morally bankrupt individuals, upset over their own pay packets.

I would like to explain to you, from one normal human being to another, what is going on.

I am a doctor. I decided to be a doctor before I really knew what decisions were, and can never remember wanting to do anything else. Once I knew how, I found the path, and worked my arse off. Six years, in secondary school, studying. Two years, in college, studying. I took four A-levels, I had 25% less free time than my friends, and when they were out, doing whatever they wanted, I was not. I was studying. Another six years at medical school, studying, and sometimes working to pay for the studying. The last three years of medical school I worked harder than I ever had, and the same hours as a full-time professional, sometimes way more. It even made me sick- in my final year I developed acute gastrointestinal bleeding. But, becoming a doctor was all that meant anything to me. So, I took my top grades and turned them in, in return I got fourteen years hard graft, and £50,000 worth of debt. [2]

Why is this important? Because, from the very beginning, I knew about sacrifices. As thousands of my colleagues have, as millions before me have, and millions will. I knew about sacrifice when I worked for a year before university, so I could afford the rent, when I missed my first family Christmas to work as a warden in student halls, so I could afford to stay at medical school. I knew about sacrifice when I missed nearly every other Christmas since, working, or sometimes studying. I knew about sacrifice when I’ve missed my friends weddings, my nieces and nephews birthdays, when everyone I knew was travelling, and I was studying, or working. Being a doctor, and it’s inherent position in society and in the hearts of the public, is irrevocably tied to sacrifice- it’s the dedication it takes to become, and to stay, a doctor, that by definition requires sacrifices to time, to personal satisfaction. All over the country right now, doctors and nurses, physiotherapists and occupational therapists, radiographers and ward clerks and all the other medical professionals are sacrificing their lives, minute by minute, to try to give you or your loved ones minutes, hours, days or years more. So, when, as a normal person, someone tells you doctors don’t understand ‘vocation’, you know now- it is beat into us before we even get through the door.

But, as a normal person, of course you understand why doctors would defend the NHS, would fight to protect it, and so vociferously attack it’s detractors. They have a vested interest, they want to keep their cushy salaries and great jobs, and the NHS is great for that.

Let me tell you straight: if I didn’t care about you, or my patients, I would be out there campaigning to close the NHS right now. I would make more money in the private sector in a  day than I would in two weeks of NHS work. I could also take my UK Medical degree, one of the most respected qualifications anywhere in the world, and go and earn 50-200% more in the US, Australia, New Zealand [3]. In the private sector, if I stayed after 5pm to look after you, the next thing you see after my smiling face as you exit the hospital, will be the bill on the doormat; ‘overtime’, ‘time in lieu’, ‘additional hours rates’ aplenty.

But, I, like you, have a family. I went to state school, and worked and grafted to pay for my six years at University. Without the NHS my grandmother would have gone blind, my father would have had several heart attacks, my mother would have died. I might have died. A private system would’ve bankrupted them, ended their hopes for a better future in order to pay to survive. I, like you, would do anything for the ones I love, and that is why I campaign to protect and improve the NHS. And that is why, when 5pm comes and goes, as does 6pm, 7pm and all the other hours in between, I, and every colleague I have ever worked with, stays for their sick patient. Because, one day, somewhere, for someone else, that patient will be their mum, or dad, wife or husband, son or daughter.

We have had, and always have had, the extraordinary privilege of one the greatest healthcare systems, pound-for-pound, in the world. The reasons for it’s great outcomes and low cost are debatable. But there are some reasons we never mention. This country has a medical school system of international renown, whose doctors, for the most part, qualify and stay exclusively working within the NHS. The staff of the NHS gives untold free hours to the profession; when I was a first-year junior doctor, I calculated I worked one day at work for £4.10 an hour. I used to get paid more at Tescos. But a very sick patient needed a lot of complex care, and so I stayed, and helped, and he survived: as millions of patients have since 1948. [4]

The moves of the current government against the medical profession are calculated: to deride working conditions, salaries, hours and deplete hospital resources, until a normal person, like myself, buckles under the social, financial and emotional cost. At that point, a sea-change of new, private hospitals will open, and we will go and work there. And our lives will be pretty much the same- different bosses, the same bureaucracy and probably better pay. But our lives, as normal people, will not. You will still pay taxes, a stripped-down NHS will persist, for no frills, emergency care only, but not for all the other healthcare needs of a 21st century population: you will need private healthcare. And that healthcare insurance will cost you hundreds of pounds a year, if not a month. And if you don’t have insurance, you will spend thousands of pounds on the simplest, quickest procedure [5]. And the NHS won’t be there for my family, or the families of normal people across the country.

So, I want this to reach as many normal people as it can. If you don’t act now, it will be too late. It might already be too late.

We care deeply because we can see the great good the NHS does, every single day. And I care because, like you, I care about the ones I love.

Where can you start?

June the 8th, 2017

At the polling booth,

Yours sincerely,

juniordoctorblog.com

[PART 2: A Factual Appendix]

-What normal people appreciate, are hard, solid, unflinching, facts. So here they are.

[2] Medical students studying now can now expect to pay £9000 pay a year as of 2015 for six years for most courses: that is £54,000. Most will require a student loan to pay living expenses for a full time course, at a further £5000 a year that totals £79,000 for six years study. Maintenance grants for the poorest students have been scrapped, adding an additional £10,000 debt as a minimum.

[3] Starting pay for any consultant in the UK : £75, 249. In the US: £111,799.80 for internal medicine, £183,152.91 for a radiologist. ($/GBP rate correct at time of writing). In Australia: a basic salary of £78,000 for internal medicine consultants, BUT this is for a 38 hour working week. Average overtime and up-scale pay between £92,526.97- £244,366.10.  Same with New Zealand for a 40-hour week, after average overtime and up-scale up to £128,039.69.

UK data: http://bma.org.uk/practical-support-at-work/pay-fees-allowances/pay-scales/consultants-england
US data: http://www.payscale.com/research/US/People_with_Jobs_as_Physicians_%2F_Doctors/Salary.
Australian data: http://www.imrmedical.com/australia-salaries-tax
New Zealand data: http://www.imrmedical.com/new-zealand-salaries-tax

[4] The NHS opened it’s doors, metaphorically, July 5th 1948. It’s first patient was a 12-year old girl with a liver condition. http://www.legislation.gov.uk/ukpga/Geo6/11-12/29

[5] This is incredibly interesting reading, although it is for claims, it is still very reflective of the actual cost. https://www.freedomhealthinsurance.co.uk/downloads/your-choice-procedure-payment-guide

Is being a doctor just a job?

You hear this phrase a lot; being a doctor is “just a job”, but funnily enough in widely different contexts. On the one hand, the “higher calling” of medicine is derided by some, who insist it’s “just a job” like any other. On the other, doctors under extreme pressure need to know sometimes that their work is “a job”, it should stay compartmentalised and allow them a life outside the hospital or surgery, to balance their own mental health against their working lives. 

Which is it?
I don’t think anyone who has working in any emergency setting with human beings would accept the derogatory label of “just a job”, whether that job is doctor, nurse, physiotherapist, pharmacist, fireman, policeman, or paramedic. The normal course of a human life is long periods of normality and stability, punctuated by “Life” with a capital L; births, deaths, marriages, divorces, comedy and tragedy. There’s only so much of that a human mind can take, few of us can stand constant turmoil and upheaval. That’s why the mental health of those in extreme situations suffers: refugees, long-term domestic abuse, and homelessness amongst others. 

Being in an emergency job such as medicine means you are party to a constant stream of Life events: births, deaths, monumental illnesses. All the things that intrude into our bubble of stability to rudely remind us of what we already know but wilfully forget: life is random, and hard, and cruel, and important, and wonderful. 

So medicine isn’t “just a job” in that sense: it’s an enormous privilege to bear witness and to help human beings through the hardest and most real times in their lives. 

But if you let that tragedy in too much, you expose too much of yourself to that constant stream of suffering, you run the risk of your own mental health, exceeding your mind’s capacity to process capital L Life events.

That’s why it’s important to know in a positive sense that medicine is “just a job” too.

Knowing it’s “just a job” means you know you can walk away, which validates and empowers that unconscious choice to walk back in again. 

We all chose to do something important with our lives, but we should all recognise that that was a “choice”, and take heart in that. 

We should always recognise that we chose to help others, and that no one has an infinite individual capacity to do so; that’s why we work in teams, that’s why we do go home, that’s why we should remember to look after ourselves so we can look after others properly.

So yes, medicine is “just a job”; you have the freedom to walk away at any time, and, I hope, be empowered to choose to come back again. It’s a job, yes, but it’s a job like few others; it’s an enormous privilege and it is honestly one of the best jobs in the world.
juniordoctorblog.com

The NHS underfunding is a choice. And people are dying. [video]

It’s really hard to capture and keep even the most interested and motivated persons attention long enough to explain how and why the NHS is being underfunded and the truly catastrophic impact of this.

This rather excellent video series does this perfectly. 

Share and RT, write to your MP. It’s your choice too; stand by and let the NHS die, or do something about it. 

This is everything wrong with Jeremy Hunt’s tenure as Health Secretary

Yesterday in the Mail Hunt made at least two completely bogus claims;
1. He ‘won’ the judicial review into imposition and gained High Court backing for the junior contract

2. Post Brexit he is going to remove foreign doctors and replace them with ‘homegrown’ trainees 

There’s been enough of heated opinion lately- so let’s just serve cold hard facts.
1. The Justice 4 Health team took Hunt to court on three premises- that a) he does not have power to impose the contract b) that he acted without clarity and transparency and c) he acted irrationally. Despite a lot of press spin saying Hunt won, he actually just dodged the issue, by claiming that he never imposed and ‘no junior doctor’ thought that he was. As in last week’s blog here is the many instances that Hunt said he was. 

The case pushed Hunt to clarify in law that he isn’t imposing the contract, simply passing the buck to local hospitals. The judge also found he could’ve acted with less ambiguity but found it hard to demonstrate the high legal threshold for irrationality.

So far from ‘winning the case’, Hunt was forced back from claiming falsely he was imposing leaving local negotiations with hospitals now a real possibility.

Secondly, Hunt’s plan to replace foreign doctors with ‘homegrown’ talent is as laughable as it is xenophobic.
We are already in the midst of a workforce crisis- applications to medical school dropped 13.5% in the last 5 years, and increasing numbers of junior doctors are leaving training and the country. On top of this, the existing doctor workforce increasingly cover the work of two or more doctors- 7 in 10 doctors work in departments where at least one doctor is missing, 2/5 of consultant posts are unfilled, and 96% of doctors work in wards with nurse shortages. 
To add insult to injury, health education England, the body that funds training of so-called ‘homegrown’ talent, has had its budget slashed by £1 billion next year– all on Hunt’s watch.

Now around 25% of the doctor workforce are non-UK, and 10-15% of all NHS staff. 

We are well below the European average in hospital beds per person and doctors per person in the NHS as we are- yet Jeremy Hunt plans to push away up to a quarter of the workforce, cut the training budget to train less doctors who are already doing two or more doctors work, and make no plans to actually address the drop in ‘homegrown’ talent already, a direct repercussion of Hunt’s own morale plummeting war against the profession. 
Those are the facts. Unfortunately if you read the Mail comments you will see why Hunt would ignore them; there’s a segment of the populace that laps up this anti-immigrant posturing, even if it’s completely insane as an actual plan. 

This is everything wrong with Hunts tenure as Health Secretary- politics before policy before patients. The NHS will only continue to suffer if it goes unchallenged. 
Juniordoctorblog.com