Tuesday, 31 July 2007

Daily Mail gets the message

Hospital services face chaos tomorrow as an unprecedented 30,000 junior doctors change jobs at once.

Operations will be cancelled or delayed, while casualty and intensive-care departments could be severely undermanned.

Many patients who have been waiting months for routine surgery - such as a hip replacement or hernia repairs - will face the misery of having to rejoin waiting lists all over again.

Doctors and MPs raised fears that patient safety could be put at risk as the hospitals struggle to cope with staff shortages caused by the Government's botched on-line recruitment system.

Junior doctor

An unprecedented 30,000 junior doctors will change jobs on Wednesday

Remedy UK, which represents junior doctors, bluntly warned patients: 'Wednesday is a bad day to go into hospital.' It warned that the knock-on effects will last for weeks.

Junior doctors change jobs every six months to gain experience in different areas of medicine. Even on day one of their new job, they play an essential part in providing health care to patients.

The job transfers used to be staggered throughout the year. But as part of changes to the junior doctor system, 30,000 will start work or change posts on the same day - tomorrow.

Many will have no experience in the areas of medicine in which they are working, will not know their way around the hospital and will be absent from the wards as they attend induction days.

Many hospitals will be overstretched as around 1,000 posts have yet to be filled as a result of delays in processing candidates under the shambolic Medical Training Application Service.

Dr Matt Jameson Evans, from Remedy UK, added that some doctors are being forced to work up to 25 days with only one day off. 'They are deeply worried about how they are going to cope with the exhaustion.'

Ministers were forced to abandon the new recruitment system earlier this year after on-line security lapses. The failures have led to a frantic rush to fill the remaining posts.

Despite this, 16,000 junior doctors have not found new posts and many have been forced to find work abroad.

Dr Jameson Evans said: 'We don't want to alarm patients, but we also don't want to cover up the Government's gaffes.

'We are being contacted by a large number of senior doctors who are very concerned about patient care on August 1 - including those working in intensive care and accident and emergency.

'What is happening is that the doctors who are in place are being forced to cover the shortages. They are going to have to work illegal hours and will be absolutely knackered.

'An already-overstretched service will be pushed to breaking point and that will undoubtedly increase the clinical risk to patients.'

A recent survey of 100 hospital trusts found that nine in ten have already cancelled some operations, while nearly one in five have had to take on expensive locums and temporary staff at extra cost to the taxpayer.

The frantic rush to fill vacant places also means that many junior doctors - including those recruited from abroad - will not be properly security checked before starting work. The Tories have described the lapse as 'disastrous' in the wake of controversy surrounding the alleged attempted car bombings in London and Glasgow by NHS workers.

Michael Summers of the Patients' Association said: 'It is extraordinary`

Monday, 30 July 2007

Botched operation...

...and no one accepts the blame

Botched operation

There is still fury over the junior doctors appointment fiasco. But why? And how did the defective system get passed in the first place?

Sarah Hall
Wednesday July 25, 2007
The Guardian

When Sir Liam Donaldson, the chief medical officer, published his annual report last week, he found himself having to justify not resigning over the bungled junior doctors' appointments system. "The implementation in some respects went wrong," he conceded. "But the responsibility was very widely distributed."

His justification, coupled with an apology, followed widespread denunciation of the system by delegates at the British Medical Association's (BMA) annual conference last month. A motion calling for his resignation was overwhelmingly passed, while the BMA's then acting chairman, Sam Everington, condemned the "scandal" of thousands of doctors contemplating leaving medicine or going abroad.

The sustained level of anger may surprise those outside the profession who thought the medical training application system (Mtas) fiasco was resolved in March, when the then health secretary, Patricia Hewitt, announced that it was being abandoned in its current form and promised every junior doctor an interview in their first-choice area. Mtas had been problematic because the unpiloted computer system, which aimed to appoint junior doctors centrally, was deeply flawed, with problems such as application forms giving too much weight to "creative writing" and too little to academic achievements and clinical experience, and too little consistency to the shortlisting process.

But junior doctors, and their senior colleagues, remain angry and unhappy about the debacle. One in five juniors affected is feeling increasingly suicidal and 94% have felt higher stress levels during the six months covering the application and interview process, according to research published in the British Medical Journal online. Hospitals have been told to be on suicide alert.

Much of this fury is due to the mismatch between training posts and applicants, and the uncertainty this is causing. Department of Health (DH) figures reveal that doctors are chasing 18,391 training posts - with 29,193 applying for 15,600 in England. A total of 2,320 posts will be on offer in a second round of applications, but at least 12,000 eligible junior doctors will remain without posts and will instead have to seek work abroad, leave medicine, or remain in staff-grade jobs, which will not allow them to become consultants and are often seen as career dead-ends.

The problem is most intense for the more senior doctors in the most competitive areas of surgery: figures released by the DH earlier this month show that 713 orthopaedic surgeons, 885 general surgeons, and 206 plastic surgeons were without training posts at the end of round one. For would-be surgeons, the chances of getting a training post are as slim as one in five for general surgery, or one in six for orthopaedics.

Doctors are also angry that, with most jobs supposed to start on August 1, they face a scramble to apply for the remaining training posts available in round two, or for vacant non-career jobs.

The second round of interviews has been extended to the end of October, and every junior doctor still applying is supposed to be guaranteed employment until that deadline. But there are no promises that this will be in their existing hospital, or even in their existing trust.

Huge uncertainty has surrounded even those who have received jobs, with successful applicants only recently being told in which hospitals they would start. With deaneries such as London covering all of Greater London, Kent, Surrey and Sussex, and the East of England deanery covering Essex, Suffolk, Cambridgeshire and Norfolk, huge logistical problems have been arisen in terms of arranging accommodation and childcare.

Childcare problems

The profession wants to retain women, who now account for 60% of those entering the profession, but they are being forced to abandon their careers to keep their families together or because of childcare problems.

Andrea Siggers, a GP with a one-year-old son, has had to give up her job because her husband was unable to gain a training post in emergency medicine in Wessex, but gained one in the south-west. And Katharine Augustine is having to move to Southampton, with her 19-month-old son, to pursue a training post in radiology, while her husband takes up his cardiology post in Bristol. With a second baby due in January, she says: "There are no other job options, and I need to be in continuous employment to get maternity pay. This process is forcing apart many families."

Crucially, the ongoing fiasco will affect not just junior doctors but also patients. Morris Brown, professor of clinical pharmacology at Cambridge University, says it is unlikely hospitals will become "chaotic" at the start of August, but warns that clinics and elective surgery will be cancelled - with an obvious impact on waiting lists.

Brown, a leading critic of Mtas, is more concerned about the long-term impact on the quality of medical care and clinical research. A poll he is conducting suggests that the system, which gives the same weight to a PhD and to a two-day course that can be attended by paramedics, disadvantages the most academically able.

The relative absence of posts for the more senior junior doctors also means the experienced will be shunted into non-career posts, while inexperienced colleagues entering at a lower level will become the consultants of the future. That is compounded by the shortened training offered under modernising medical careers (MMC), the new system to which Mtas relates - and by the European working time directive, which, from 2009, will reduce junior doctors' hours to 48 a week.

Then there is the long-term impact on the NHS of a demoralised group of doctors, stuck in dead-end jobs, and no longer feeling a strong sense of vocation.

So how did this catastrophe in workforce planning happen? In part, because, with all applications for training under the old system drying up last autumn, an unprecedented number of doctors applied under Mtas. As Donaldson, the original architect of MMC, admits in his report: "The number of doctors ... was larger than anticipated."

The number of junior doctors had burgeoned since the NHS Plan enabled a rapid expansion to allow the NHS to meet new targets. But, with NHS deficits being felt from 2005, hospital trusts then began to cut back jobs and training posts.

Andrew Rowland, of the BMA's junior doctors committee, says that, when it came to MMC and Mtas, there was a lack of engagement between the bodies involved in workforce planning - individual trusts, deaneries, regions and individual specialities on a national level.

Richard Marks, programme director in anaesthetics for north-central London, says programme directors - the people with experience of the actual numbers needed for each region - were left out of the loop. "The hierarchy seemed to be that Lord [Norman] Warner [the health minister, who retired in December] wrote to the deaneries for numbers required, the deaneries asked the trusts, and trusts then told the programme directors - without anyone asking the departments what was needed." Strategists were planning 10 years ahead, but were not sufficiently engaged with the number of doctors currently in the system, he adds.

Meanwhile, it is these doctors, and their future patients, who will suffer.

· Sarah Hall, a Guardian senior reporter, is married to a junior doctor who is applying for jobs under round two of Mtas

At a hospital near you

Hospitals braced for chaos

Jul 30 2007

By Emma Brady, Health Correspondent

Patients at Midland hospitals could get "nothing more than a basic service" as a result of a shake-up in medical training this week.

Last night a consultant urologist - based at City Hospital in Winson Green, Birmingham - branded the reforms as "completely chaotic".

Thousands of junior doctors across the country will take up new posts on Wednesday, a move which has led hospitals to postpone elective surgery.

Staff at one Birmingham hospital trust have been warned the number of anaesthetists has fallen by 30 per cent, as a result of the reforms.

And appointments at consultant-led clinics have even been reduced, as registrars are offered jobs as far away as Scotland leaving vacancies which are proving difficult to fill.

Sunday, 29 July 2007

What a surprise

SENIOR executives at the Environment Agency face new controversy after it emerged last night that they received five-figure “performance bonuses” shortly before the recent floods hit Britain.

Baroness Young, the quango’s chief executive, got a bonus of about £24,000 on top of her £163,000 salary. A further eight executives, including the director of water management, shared in the bonus handout last month. The average paid to each executive was equivalent to 10% of their salaries, although Young received 15%.

Details of the bonuses were to be revealed in the agency’s annual report, which was expected to be released last week but publication has been delayed due to the floods.

Board minutes also show that the agency’s top executives privately expressed strong concerns last September about the country’s preparedness for serious floods.

Baroness Young is a Labour peeress. So once again, they are looking after their chums and everyone else can go hang.

Thursday, 26 July 2007

Not black and white

Brown – it’s not quite black and white

Over the past twelve months I have been one of the foremost critics of the government’s management of the NHS. Patricia Hewitt, before she embarked on a career in politics, was a management consultant, and she vigorously applied the techniques of that background to the NHS with the consequences with which we are all too familiar. Performance management and targets have been developed with an enthusiasm that has not always been shared by staff, and almost unimaginable sums have been spent on IT systems and management whiz-kids. So how should critics such as myself react to there being a new Prime Minister and a new Secretary of State for Health?

After ten years as Chancellor of the Exchequer, Gordon Brown knows better than anyone that the extra money which he made available for health has been spent, and that not always to best effect. Last year, £500 million was spent by the NHS on management consultants, and the ambitious NHS IT scheme CfH is already billions of pounds over budget and years behind schedule; PFI is a financial millstone which will burden some hospitals for the next thirty years. He cannot be best pleased that after all the extra financial resources, the NHS remains the government’s most obvious Achilles heel ; no wonder that it was very early in his recent national tour of meetings of Labour supporters that he announced that the NHS was to be his number one domestic priority, although in his first bruising week in office it already had to give way to floods, a postal strike and a security crisis.

The mere fact that he has recognized that the NHS is in such a precarious position, with many Trusts facing financial pressures, a collapse in morale of junior doctors created by the MTAS fiasco, and a general exhaustion from meddling, reorganization and the chasing of arbitrary and often irrelevant targets, must be a positive. Relieving us of Mrs Hewitt, and replacing her with Alan Johnson must also be a move in the right direction; Johnson is not the sort of politician who is going to set the world alight, but a bit of dull efficiency might be just what the doctor ordered. Indeed his first statement to parliament (Hansard, 4th July) was as close to an apology for the mayhem as we are likely to get. Furthermore, Independent Treatment Centres, which carry the real risk of cherry picking the easy cases for the private sector and leaving the NHS to bear the burden of care of the rest, seem to be being quietly dropped.

The appointment of Professor Sir Ara Darzi, a practicing surgeon, to a junior ministerial post is also clearly intended to send out appeasing signals; I cannot find a precedent for a government minister taking on his duties part-time, whilst continuing his previous job. However Darzi is said to be a enthusiastic proponent of super hospitals, with a downgrading of the traditional DGH to the status of cottage hospitals; how compatible this is with patient choice is difficult to imagine.

So far so good, but there are some ominous signals. Brown, in one of his last acts as Chancellor cut NHS spending on equipment and building in England by 25% in the current financial year, in order to have money available to bale out trusts in deficit. He also, in the same speech (11th May) in which he said that he wanted to listen to those in the front line, stated that he was looking for an expansion of NHS Direct and of Drop-in centres for primary care , ideas which few of use would regard as a wise use of resources. He also called for an extension of GP opening hours, which is scarcely likely to endear him to doctors whose work has been even more target driven than their hospital colleagues, and which even if achievable is likely to be enormously expensive.

Meanwhile PFI, Choose and Book, performance management, CfH and expensive management gurus still seem flavour of the month. I am happy to give our new Prime Minister every encouragement and I have already written to Alan Johnson offering him an olive branch, but I fear that the battle is not yet won. At least the NHS is at the very centre of the political agenda.

Wednesday, 25 July 2007

Choose and Book...the truth at last

Choose and Book is a tool being used by the Department of Health to limit choice and reduce the number of referrals to hospital specialists (see previous posts).

Today's board meeting of the East of England Strategic Health Authority received a report on the implementation of C and B. In the East of England, usage was now only 22% in May (20% in April) against a national target of 80%, and a figure of 29% last year when GPs were being paid extra if they used the system!

The report revealed that there had been "little progress" in recent months,notwithstanding a massive programme of management action to address the issue. There was a telling comment at the end of the report: "Choice and Choose and Book are central to performance management arrangements".

So there you are, C and B is vital to government plans, but it has been resoundingly rejected by those who use the service - the doctors and patients.

Tuesday, 24 July 2007

A true story

The government are keen to reduce waiting lists by preventing (or discouraging) referrals.

This is a true story.

A lady went to her GP with a lesion on her face which had grown over the course of a year. The GP said that it was a mole, and that it could not be removed because it was cosmetic. She went away but went back to the surgery to say that it had grown and bled. The GP wrote to a plastic surgeon, who said that he could not see her as he was not allowed to see benign moles.

The patient was still concerned so the GP wrote to the PCT exceptional cases committee asking permission for her to see a specialist. The PCT said that she could only be referred if she was sent to a clinical psychologist who was to determine whether the lesion was causing her distress. She saw a psychologist, who asked all sorts of personal and embarrassing questions and finally recommended specialist referral; so six months after she was originally seen by the GP she was sent to me for my opinion.

On examination the lesion was not a benign mole, it was not a simple cosmetic problem, it was a large skin cancer, which I shall excise.as a matter of some urgency.

It's enough to make you weep.

Monday, 23 July 2007

Wet, wet,wet

This is from another web site:

"When I was a kid, I used to go newt collecting in my home town in a place called “Flood Meadows”. When I went back a few years ago, I was amazed to see that they’ve built a housing estate on it now.

If you build houses on a place calld “Flood Meadows”, you’re an idiot.

If you buy a house in a place called “Flood Meadows”, you’re an idiot.

If you now live in a place called “Flood Meadows” and you’re now under 4ft of water, don’t blame God; don’t blame global warming; don’t even blame the government. You only have yourself to blame."

Being flooded must be ghastly, but something has gone very wrong with the planning process.

Friday, 20 July 2007

Fishy business?

I am grateful to Guido Fawkes' website (see links) for this piece of evidence based politics:

The correlation between making large donations to the Labour Party and receiving an honour is extraordinary. Statistical analysis shows that 58.54% of all donors giving more than £50,000 to the Labour Party receive an honour. This compares to just 0.035% of non-donors. Large Labour Party donors are 1,657 times more likely to receive an honour than a non-donor and 6,969 times more likely to receive a peerage. It is almost impossible to avoid the conclusion that the Labour Party has been selling honours, including places in the House of Lords. An analysis of all donations over £50,000 since 2001 reveals that Honour certainly has its price. We publish below the average amount donated by the recipients of various honours – an “Honours Price List”. Those receiving a Peerage have given £1.07 million on average, and a Knighthood £747,000...

I am happy to reassure you that the Save Bedford Hospital party will not make any recommendations for honours (not that anyone would take the slightest notice if we did!)

On the ball

This week the Chief Executive of Bedford Hospital received an instruction from the East of England Strategic Health Authority to make sure that the hospital's contingency plans for a heatwave were in place.

Reassuring that they are getting their priorities right.

Thursday, 19 July 2007

A health warning

Don't be ill on the 1st August, and preferably not in August as a whole.

The first week of August is always a chaotic time in hospitals, as newly qualified doctors start their first jobs; there is obviously a learning curve- what number do I dial in an emergency, where's the cardiac arrest trolley, how does the bleep system work, where's the accident department, how do I get to the wards at night when doors are locked, and so on.

This year, thanks to the fiasco of MTAS and MMC the chaos is going to be bigger and better than ever. Virtually every junior doctor in the country is going to be starting a new job. In many cases they are only finding out now (or haven't yet found out) where they will be working. Many haven't fixed accommodation, and thousands are awaiting their occupational health and CRB checks, without which they can't start. Many are going to jobs that they don't actually want to do, or are working in hospitals that they have never visited.

The consultants for whom they will be working have almost certainly not met their new juniors and have no way of knowing what they can and can't do. In many parts of the country (and the East of England seems to be the worst here) not all the jobs have been filled.

Hospitals have been asked to draw up contingency plans. In some cases consultants have been asked to cancel holidays. But no one really knows what will happen.

Will it be another Millennium bug false alarm? I wouldn't bet on it. But I'm going to be on holiday!

Wednesday, 18 July 2007

"Insane" - allegedly

From the BBC news website:

The Conservatives are fighting a claim that a businessman did not know what he was doing when he left the party £8.3m in his will.

London's High Court heard Branislav Kostic was "deluded and insane" when he willed his money in the 1980s.

As I have said many times, why do political parties need such absurd amounts on money.The Save Bedford Hospital party gets its message out loud and clear without any great expenditure.

Best year ever?

NHS trust announces 600 job cuts
A North Yorkshire NHS trust is to axe 600 jobs - a third of its workforce - to try to save £10m, staff have heard.

Managers from the Scarborough and North East Yorkshire NHS Trust gave the news to staff on Wednesday.

Unison regional officer Ray Gray said the redundancies were a "disaster" for health services in the area.

Tuesday, 17 July 2007

So much for the GMC

The General Medical Council is the body which by statute regulates the medical profession in the UK. Any member of the public may check whether someone purporting to be a doctor is qualified by checking their registration on-line on www.gmc-uk.org

So how accurate is the register? I today checked the registration of a doctor who died in April 2006 - fifteen months ago. Amazingly, he is still listed.

It was Fredrick Forsyth in Day of the Jackal who exposed the scam of getting a passport in the name of someone who had died. But it appears that the GMC still hasn't got round to closing the same loophole for fake doctors.

Sunday, 15 July 2007

From the Daily Telegraph

It's nice to be quoted:

Thanks to those of you who pointed this out from James Le Fanu's column in the Daily Telegraph on 2nd July-

Patricia Hewitt was a terrible Health Secretary - and her exit last week was more than welcomed by the thousands who campaigned to save their local hospitals.

"I can't pretend I'm sorry to see her go," commented Dr Barry Monk of the Save Bedford Hospital party. "Her period in office has been a catastrophe for staff and patients." Quite so.

But will her successor, Alan Johnson, do any better? It all depends on the company he keeps. I would advise him to put in a call to Sir Roy Calne, our most eminent surgeon.

Sir Roy's comments on the Letters page last week, on the need to "pull the standards and pride of the health service back to where they once were" touches on a fundamental truth: "The health service was immeasurably better run 20 or 30 years ago than it is now."

Mr Johnson needs only to find out why and to act on it.

Thanks, James

More money down the drain

This appeared recently in the Northern Echo

HEALTH officials last night defended a decision to send a North-East delegation on an £84,000 mission to Japan - to find new ways of "increasing efficiency".

Families of patients denied drugs on the NHS, as well as two GPs, have criticised the trip to study Toyota's "lean management" techniques at a time when cash-strapped health authorities are trying to cut costs.

But the North-East Strategic Health Authority stood by the decision last night, insisting that the lessons learnt would save money and make the NHS more efficient.

Last month's visit cost £84,000 to fly a 14-strong team to Japan. Officials said the cash came from "central training funds".

If they want to be efficient, why sent fourteen?
Efficiency is sending one with a notepad and pencil

Thursday, 12 July 2007


The Chief Executive of Bedford Hospital NHS Trust, Jean O'Callaghan, and the Medical Director, Ed Neale have spent a large slice of the last six months drawing up "Draft Guidelines for Trust Employees who are Prospective Parliamentary Candidates". I wonder who those guidelines are intended for.

Personally, I think that they would be far better off spending their time on the running of the hospital than worrying about Dr Monk, but perhaps I should be flattered that they spend so much time thinking about me. Unfortunately I understand that Mrs O'Callaghan, by virtue of not being a British national, will not be able to vote for me.

Choose and Book

Choose and book is the deranged hospital appointment booking system which GPs hate, patients don't understand and which drives hospital consultants to despair. It is expensive, doesn't give choice, and disrupts adequate communication from GPs to hospitals. It has been largely rejected; in the East of England it is only used for 23% of hospital referrals, compared to a target of 80%.

Tomorrow one of our hospital managers is coming to see me to ask me to agree to only accept referrals on Choose and Book (in preference to the tried and tested, quick, cheap and efficient system of a "Dear Doctor Monk" letter). I'll let you know how the discussion goes.

PS if you don't know about Choose and Book, you really ought to; it would be funny if it wasn't so serious. Please look at other postings on the topic, or at the Dr Rant website (see links)

Sunday, 8 July 2007

Election success

I am pleased to advise readers of this blog that I have been elected!

I have been elected to be President of the Section of Dermatology of the Royal Society of Medicine for the year 2007-8. To be chosen by one's peers is an enormous honour, and I feel very privileged.

Campaign update

It's been a busy (and useful) week:

1. Have just completed an article that I have been commissioned to write for Hospital Doctor magazine.

2. Have been invited to speak to a meeting at a hospital in London on my campaign.

3. Have been discussing a television programme about the NHS with the producers.

It's all go.

Friday, 6 July 2007


This was written by a consultant colleague, about the first faltering, slightly apologetic steps by the new Secretary of State for Health, Alan Johnson:

"Standard first steps in this weary, dreary, repetitive little dance.

Make reassuring noises and assure the shell shocked troops that this time it's really, really going to be better.

Shuffle paper for 9 or so months.

Pick up a coterie of meddlesome wannabees (recycled, if it's Roy Lillee).

Implement their harebrained, self serving schemes.

Repeat perseveratively the mantra 'the welfare of patients is paramount'.

Resign/get sacked/get moved. Watch the next Health Secretary go to Step 1 above.

Bloody great.....I can't wait."

More money down the drain

An NHS manager was given a payoff of £480,000 because he could not find another job after a government-ordered reorganisation.

The settlement awarded to Chris Town, the former chief executive of Greater Peterborough Primary Care Trust, was described as “scandalous” by a local MP, but Mr Town defended it as “not unreasonable”.

The payoff – four times his £120,000 salary – was made last December when the trust was reorganised, Health Service Journal reports. Mr Town had been seconded to act as interim chief executive at the neighbouring Cambridgeshire trust, but was paid off after he did not get the permanent job there or at the revamped Peterborough trust.

The package was underwritten by NHS East of England, which was £152 million in debt last year and has given warning of staff cuts. Stewart Jackson, Conservative MP for Peterborough, said: “It’s scandalous that funds are being spent in that way. It shows the true cost of reconfiguration to the taxpayer.”

Wednesday, 4 July 2007

Who are you?

Gordon Brown has today announced, in the context of recent security alerts, a review of the vetting procedure for NHS staff from overseas.

I will therefore tell you a cautionary tale.

However I will preface my story by saying that for the past 50 years the NHS has be sustained by doctors trained overseas. These doctors have in many cases filled posts in unfashionable parts of the country, or in less popular specialties; they have been disproportionately represented for example in inner-city general practice, in psychiatry an in geriatric medicine. Many of my colleagues in Bedford trained overseas; they are excellent committed doctors and many are personal friends, and they are as horrified as everyone else by recent events.

Until a few years ago, most overseas doctors came to the UK from a very small number of countries, and within those countries they came from a very small number of medical schools.
At Bedford, one department had a regular flow of juniors from one medical school in India; we knew exactly what training they had had there, and they were without exception just the sort of doctors, and just the sort of people, that we needed.

In the past five years or so, the geographical spread of medical graduates has expanded remarkably; anyone who has had to look through CVs presented by intending candidates for junior medical posts will need an atlas to identify where they are coming from, and it has been almost impossible to evaluate what their medical experience equated to.

When this trend first became apparent to me I telephoned the General Medical Council, the body which by statute regulates whether foreign medical graduates can get on to the Medical Register, and thereby practice medicine in the UK, to ask for clarification.

"Suppose", I asked, presenting an entirely hypothetical scenario "someone came to them from, say Outer Mongolia, and presented himself as a graduate of the Ulan Bator Medical College - if there is such a place- and provided certificates showing that he had passed his exams with a first class degree, that he had won the gold medal for neurology, and first prize in orthopoedics, how would they actually know that the certificates were genuine rather than something that he had created on his home computer?"

"Did they" I asked, naively" keep a selection of genuine certificates to compare?"

The answer I was given, was that they did not.

The regulatory authorities for nursing in the UK have in the past unmasked a number of individuals who have claimed overseas nursing qualifications which have turned out to be entirely bogus. Yet remarkably, the GMC, the guardians of medical standards in the UK, appear to have to have a system of regulation that is as watertight as a sieve.