Do missed appointments cost money?

There has been a rash of stories about missed appointments costing vast amounts of money:

• The BBC quoted Epsom and St Helier who estimated that missed appointments cost the Trust £5.6m
• The Sunday Express quoted a figure of £800m lost for the whole of the NHS

The question is: do they cost so much money?

Let us look at how these figures are arrived at.  They are arrived at by multiplying the number of missed appointments (DNAs in the jargon - Did Not Attend) by a notional cost of the missed appointment. And the notional cost in these two articles are c. £120 per appointment.

There are two weaknesses to this methodology.  First, the analysis assumes that a missed appointment means that the whole infrastructure of out-patient care (nurses, receptionists, test facilities, and doctors) are just kept waiting looking at their watch, and wasted.  Second, the analysis assumes that the cost of this is the same as PCTs are charged for each appointment (which is roughly £120 when averaged between new attendance and follow-up tariffs).

The first is a ridiculous assumption.  I know of very few clinics that work on the assumed basis.  In reality, most clinics are overbooked, assuming some DNAs.  Moreover, outpatient clinics are very poorly analysed and planned according to some ancient template.  As a result, patients are allotted times that may bear little relation to reality.  How many times have you gone to see a outpatient waiting area that is rammed full?  How often have you as a patient waited for far too long to see a clinician.  The basic point here is that in reality DNAs are a small wrinkle in our imperfect outpatient demand and capacity management; and only a small fraction of the allotted time is actually wasted if any.

The second assumption is just wrong.  It shows a misunderstanding of cost and price.  If you break a pram in John Lewis, the cost to John Lewis (assuming they do not charge it to you) is not the full price of the pram - but the cost to them (what they will pay to have it replaced).  Similarly the price of outpatient consultations is not the same as their cost.  And the marginal cash cost of a consultation will be much lower than the £120 charged to PCTs.

So these losses are just paper losses.

In reality, DNAs impose large costs when clinics are analysed and managed very well.  But hospitals who manage that will also be managing their DNAs to the minimum unavoidable level.  These bald and high-level estimates are just idiotic, and we could do without them.

Most popular Militant Manager posts in 2011

These were the most read stories in 2011, with the number of unique people reading them during that year.  Please note that the number of unique readings are an underestimate of true readers (the majority of viewers go directly to the main Militant Manager blog page - militantmanager.blogspot.com - and cannot be attributed to any one article without detailed analysis.  And as we know NHS Managers are not capable of doing any analysis).


1.  Noble resignation or convenient excuse to focus on greener pastures 279 views
This readership is surprisingly large given the article was only posted on 13 December, and so only had 3 weeks in 2011.


2. Why consultants need more natural predators 270 views
Another post that focused mainly on issues related to doctors.  Interestingly, when I started the blog, my view was that it would be more read by managers.  But it seems that the blog is far more read by doctors . . .


3.  More Del boys will become GPs  124 views
Another issue focused on doctors, and looking at the subtle effect of the health reforms on the composition of GPs.  I must point out that I neither support nor condemn these effects - I am just pointing them out.


4.  The similarities between car design and NHS structures  111 views
The most popular article focused on management issues.  I thought this article deserved greater readership, but it was not to be.  Maybe it will develop a cult following.


5.  The point of Academic Health Science Centres 97 views
On the whole, my more tongue-in-cheek articles (on Clare Gerada, on Bruce Keogh, on Cynthia Bower, David Nicholson, and Richard Smith) did not rouse great interest.  This was the exception.  Probably because Academic Health Science Centres, like Secure Facilities, do not have a point.

Is the Royal College of Physicians really a trade union?

The Royal College of Physicians has published its census results.  And it makes intriguing reading.  But for the full extent of intrigue you have to read between the lines, as well as the lines itself.

It is interesting that the press release makes for really morbid reading.  There is not one bit of good news in it.

I was close to topping myself, and going and buying all my consultants a round of baby-cham (not in that order, you understand, as that would be ridiculous).  But before I did so (either of those things, in the appropriate order), I thought I would actually read the report, and come to my own conclusion.

Here are the three things that struck me:

1. The feminisation of medicine is striking (chart C13b on page 27)
2. Clinicians do not feel that the overall quality of care has changed much over the last 3 years (chart 32d on page 65)
3. Clinicians enjoy their job - over 80% of them enjoy their job always or often (chart 33a on page 66)

Now, you would not have found any of those messages in the press release - which was all about gloom, and more gloom.

Why is that?

The only conclusion I can come to is that the RCP is trying to make a political point.  As justification, your honour, I pray leave to submit the following exhibits as evidence:

• The focus on the NHS.  Why would this not be a general survey of how all their members work across potential employers - including NHS, private hospital groups, academic institutions, other commercial institutions.  This is not so much a census of consultants and registrars, as much as it is a data gathering exercise on the experience of members with one particular employer.
• Within the NHS focus, focus on the contracted vs actual hours worked.  I am intrigued that BUPA insurance has kept its private reimbursement limits for consultants fixed for a substantial length of time.  But this gets at nothing like that - all about the NHS and programmed activities.  I spend my life telling managers not to focus on PAs.  Doctors are professionals, and they focus on patients - not on filling a hourly timesheet according to their PAs.  But the RCP seems to be wanting to focus on this.
• Question choice.  So everybody knows that by introducing EWTD one would have expected continuity and training to suffer - that is the logic.  The reason you would do it is because doctors are more alert and fresher to do care for patients when they are actually working.  But it is training and continuity that the survey focuses on (charts C28a, b and c); not on the alertness etc.  And indeed, if one wanted to get to the bottom of this issue, one would also come at it differently - what are the total hours worked by consultants including their other commitments (private, academic, etc).  It is only by looking at this that you can fully evaluate the ETWD.
• Reporting style.  I have also shown the negativeness of the reporting.  But on each question, the glass is always half empty.  For example, in the real world the compliance of a policy with law is always greater than the compliance of working practice with policy.  Only in the perfect world is this not true.  So to report that "29.6% of departments do not work EWTD compliant rotas in practice – despite 94.7% being compliant on paper" without context or comparison is to scare the horses.

So, my advice to consultants is to cancel either your BMA or Royal College subscriptions - as they effectively seem to be doing the same thing.

Response to story about Barts

I have had unprecedented traffic on my story about the resignation at Barts and the London.  Usually, the traffic peaks in the 24 hours after publication.  This time, however, it is still going strong 60 hours afterwards.  And I was also alerted by a concerned colleague that Peter, the CEO, was onto me.

I thought that I would give an insight into why I wrote the story.  After all, my time in the NHS may well be limited.  I can picture it.  A full Trust-wide meeting, and Militant Manager is asked to stand up.  "We know who you are.  We have tracked the IP footprints."  There are only two ways it can go.  There could be a Spartacus moment (thereafter renamed the Militant Manager moment); or I am lead away whimpering like a 6-year old girl.  So given my time with you is limited, I thought I would say something about why I wrote the piece.

It was primarily about balance and scrutiny in the media.  I get irritated by lazy stories - as you can read on this blog entry.  That is how I felt about the resignation story as reported in the press.  My feeling was that people had rushed to the most convenient headline - NHS cuts:

• The Independent: Inquiry launched after leading surgeon resigns over NHS cuts
• The Guardian: Patients physically harmed by NHS cuts and bad management, says surgeon

The stories lack context.  All of us have seen appalling situations in NHS hospitals - even the best of them.  And things go wrong.  It happens.  To get to the bottom of the situation needs more analysis, and context.  It is not always about cuts.

And that is what I was providing.  As you can see, my biggest issue was the stories did not address the agenda of the person involved.   I published what struck me as the potential agenda.  I could well be wrong.  But it made you think, didn't it?

And the rest (including me) is now history.

Noble resignation or convenient excuse to focus on greener pastures

So a Consultant Trauma and Orthopaedic surgeon resigns from his post, blaming management incompetence
in an email [to colleagues?]: cue headlines about NHS cuts harming care.  I am talking about William David Goodier who is set to leave Barts and the London at the end of this year (according to his email).

On the face of it this is a noble act by a doctor who could not in good faith meet the needs of his parents and sacrificed his cherished NHS position.  So thinks fellow alliterative blogger Ferret Fancier.  And Mr Goodier's email is full of detail about the valiant struggle against infernal odds.  If one reads it with violins playing on the gramophone, one can vividly understand what Dr Wilson must have endured on his struggle to the South Pole in the doomed Tera Nova expedition with Scott.

However, Militant Manager is a very cynical sort.  And when a 50 year-old orthopaedic surgeon leaves his NHS practice, Militant Manager's antennae are up and alert.  For I suspect that this has less to do with idealism and struggle; and more to do with filthy lucre.

I have nothing to offer but circumstantial evidence.

First, let us take Mr Goodier's age - just at the inflection point where there aren't sufficient years of practice to justify additional investment in training and education .  So further experience in the NHS is no longer necessary - and all the skills needed to fleece private patients have already been gained.

Secondly, let us look at his (extensive) private practice:

• London Sportscare - a sports and musculo-skeletal chambers run by BMI London Independent (as part of the subsidised support many private hospitals offer to their practising doctors).  Under this guise, he has two weekly clinics, and a weekly operating list.
• London Limb Reconstruction - another chambers, this time run by HCA's hospitals, and based mainly at the Princess Grace.   In this case, Mr Goodier can only do patients on an ad-hoc basis (presumably because his NHS practice timetable does not allow him to make more persistent commitments)
• Medico Legal practice - providing personal injury and medical negligence reports for both plaintiffs and defendants

 Third, let us look once again at that resignation letter.  It is a bit of a rant.  But certain clues can be gleaned:

• Flexible working request.  The letter suggests that he made this last year.  Aaaahhhh, right.  Now, let me see.  Would that allow the aforementioned Mr Goodier to be able to make a stronger commitment to Princess Grace?  Conveniently so!
• The "Non" Issue.  So one of the precipitating issues was the lack of movement in appointing the "second pelvic surgeon." But this post was approved and appointed well within a year.  Most of us (admittedly those of us older than 7) would see that as a pretty reasonable (if not rapid) time frame in the NHS - especially if we had been exposed to the NHS for 30 years, 15 as consultant.
• Demand/ capacity issues.  Mr Goodier writes "Unfortunately, there has been a relentless increase in the workload . . ."  Yes, David.  That is right.  That is one of the underlying problems in the NHS.  And 1m others are putting up with, and rejoicing in it.  But I agree with you David, the NHS would be far better if we did not have patients (wait, let me read that again).
• "Are we there yet?"  Mr Goodier complains that a further 2 consultants have not been finalised.  But wait - it is being worked on right?  And you have clinical leaders in Michael Walsh and Constantio Pitzalis also supporting this right?  And you are older than 7 right?  So can you recognise that it will take time, but we will get there.
• Lack of organisation.  Mr Goodier is unhappy with the organisation of theatres, beds, etc etc.  Is that also not your problem Mr Goodier?  As a consultant there for 15 years, do you not share both the blame, and the responsibility to put it right.  Or are you going to take your ball and go home?  Wait, I forgot that I was using a child under 7 as the metaphor: "Are you going to throw your toys out of the pram?"
• Unprofessionalism.  When somebody does not have the skills to lead a solution, or the emotional intelligence to identify and follow an appropriate leader, they resign; and when doing so, they send a long diatribe that damages the organisation, their colleagues and themselves.

I think this is pretty strong circumstantial evidence.  Overall, my conclusion is that Mr Goodier is not so much driven by ideals as much as by money.

There is nothing wrong in moving to earn more money.  But I do object to somebody who does not have the maturity to distinguish what is a noble struggle, and what is blatant unprofessionalism.  I just wish he had had the decency to thank his NHS colleagues for the years of training and support, and wished them luck in dealing with the challenging needs of inner-city East London.  Mr Goodier, however, lacks such class.

Maternity's flaw is not midwives or quality, but economics

Maternity care is much in the news.  Many of MM's readers would have followed the BBC Panorama report on London's maternity care.  The programme concludes that 17 deaths could have been "avoided" in London in 2009.   Yet, this is not new.  There have been stories about the difficulties faced in and by maternity departments for a long time.  The question is why so much attention and is it deserved?  Is there something underlying that is at work and needs fixing, or can it not be avoided?

It could be because of a number of unavoidable reasons.  It could be related to the primordial nature of maternity.  It is when a new life emerges into the world; where our urge to procreate bears fruit.  The attention could be a result of the scale of loss when obstetrics goes wrong.  After all, nobody is “ill.”  And both mother and baby are relatively young.  If these were the reasons why maternity gets so much attention, then there is not much you can do to avoid it.

But MM thinks there is an avoidable problem that underlies these issues.  It is not easily seen, but lies there and manifests itself in poor staffing ratios; lack of doctors on the ward; high rates of vacancy and agency; poor infrastructure and so on.  All of these issues then give rise to problems and incidents.  This fundamental problem is economics; money; lucre - whatever you term it.  Maternity care does not pay for itself in the NHS. 

That may be a bald statement to make, but can be backed up by a detailed review of the economics of maternity.  Militant Manager has built an economic model of a maternity department to illustrate this economic problem (available on request).  At 4,000 births, the model concludes a Trustwill lose c. £2.8m pa, and £3.7m at 6,000 births.

The model was built using publicly available staffing and productivity guidelines.  Many of these are from the Royal College of Midwives (RCM) and the Royal College of Obstetricians and Gynaecologists (RCOG).

Some of you may be thinking that the sums do not work because MM has taken the guidelines from those with a vested interest.  The Royal Colleges are hardly going to suggest meagre staffing.

MM would, however, disagree that this is a fundamental problem – partly because some of the numbers makes broad sense; and partly because the producers also have interests which moderate the financial call.  For example, the RCOG guidelines suggest that units with 4,000 births should have a consultant on the labour ward for at least 40 hours per week and those with 6,000 should have one for 60 hours.  This is ludicrous.  Firstly, it shows an attempt at reflecting the economics, and moderating the call for the number of consultants by paying attention to activity.  If such an attempt was made, then they should have gone the whole and way, and modelled it out.  They would then have realised the parlous state of maternity finances. 

Secondly, and more importantly, each birth is a birth. Should the RCOG not focus on the care given to each birth, and treat it equally?  Why should some babies have a better chance of obstetrician cover?  It is a bit like when a job applicant answers the question “why should we hire you?” with an answer that talks about what they can get out of the job, and how they will enjoy it.  To be frank, that is not very relevant to the company doing the hiring.  The question is how will the company benefit - and in this case, the baby.

Lastly, and most importantly, how can a clinical (not managerial, efficiency or productivity) standard be any different from either zero or 168 hours cover a week?  Births do not follow time patterns, so if a clinically safe birth can happen without an obstetrician on the labour ward, then it is safe that all births happen that way.  Conversely, if a clinically safe birth cannot happen without an obstetrician on the ward, then no births should happen without that.  There is no space for a fudge. 

MM believes that the issue is that people like the RCOG try and solve the fundamental problem of economics in other ways.   The economics does not support great consultant cover; but rather than recognise this fundamental fact, these bodies try and nudge up standards a little at a time, and put the pressure on Trusts to solve it.  Other attempts act in a similar way: for example, the CQC’s publication "Towards Better Births" which aimed to show the distribution of maternity provision, and nudge up standards.  And another is the BBC's Panorama survey.

Fundamentally, however, the issue is that the economics do not add up.  No private provider is working hard to become an elective or AQP provider of maternity care - they are for orthopaedics and other areas.  No Foundation Trust is building spanking new maternity wings - they are building Cancer Centres.  Lots of Trusts are rationing care, and closing their list to non-local geographies.  The numbers do not work.

When the economics do not add up, Trusts do not invest in staff and resources to give good care.  As all good economists know, economics drives our behaviour - even when we do not realise it.  Trusts do not mean to do it; but they do it subconsciously.  The end result is that care suffers, and we get headlines.

The best solution would be to drive up tariffs. 

NHS Medical Director seems to have stopped taking his prescription drugs

At least, that is the best reason I can find for the stream of inane and ridiculous comments that Sir Bruce Keogh made at the launch of the Government's campaign to publish data.  As reported in the Telegraph, here are some of his comments [with Militant Manager's commentary in square brackets]:

1. He could envisage an NHS that was "available 24-7". [Isn't the NHS already 24-7, with NHS Direct and A&E?  Maybe he was talking about the date 24/7, coming as it does at the beginning of the school holidays.  Those days are always quite hard to staff.]
2. High-speed broadband could allow people to consult international experts or to take advantage of out-of-hours care provided by overseas doctors in another time zone. [Rather than copper wires allowing foreign doctors to provide out-of-hours GP services from another town zone.]
3. Such technology would lessen the need for a "geographical connection" between GPs and their patients, while it would also enable doctors to conduct what he called "virtual ward rounds". [He is much mistaken.  It is the advent of reviews, listening exercises, quangos, and other pass-times that have allowed GPs such as Steve Field, Charles Alessi, Clare Gerada etc to lessen their geographical connection with their patients; and I know of lots of consultants who already do virtual ward rounds - or is it ghost ward rounds?]
4. He said the NHS had to adapt because “young people won’t put up with having to travel to a doctor and wait 20 minutes when they can just use the web to talk directly to a doctor”. [What!  20 minute wait?????? From the same processes that calls all morning day surgeries in first thing in the morning - so that some wait 3 hours!  Aaagh, if only a 20 minute wait was the norm].
5. Sir Bruce acknowledged that the NHS had yet to lay out a “national vision” for digital access, but he said that it would happen in the future. [Just what we need.  Another grand IT vision.  OOOhhhh, let me volunteer for that one]

The similarities between car design and NHS structures

Car companies have a sophisticated strategy for their cars over time.  Their initial authority is over a particular segment.  But over time, they want to play in different segments.  And they do this by slowly invading that space with a model that consumers are familiar with, and taking their authority and consumers with them.  At the same time, they introduce a different model to fill a space customers already trust the marque with.

This can be seen clearly with Volkswagen's hatchback strategy.  So today's Volkswagen Golf (which is in its 6th iteration, i.e. Mk6) is 50% larger than the original Golf Mk1 introduced in 1975.  It is in effect an offering for an entirely different customer segment.

But on average cars do not get bigger.  And that is because as one model migrates away from its entry configuration, the marque introduces a new model to fill the space it leaves behind.  In Volkswagen's case, as its first family hatchback (the Golf) grew in size, it first introduced the Polo and, as that also grew in parallel with the Golf, it introduced the Lupo/ Fox.

The size changes of Volkswagen's hatchbacks since 1975 can be seen in the chart below.  Size in this instance is calculated as the floor area of the car (length x width) in square metres.

Plus ca change, plus c'est la meme chose.  Even though each model gets bigger, the overall market still looks similar.  So you can see that Volkswagen had an offering in the size range of 5.5 to 6.0 sqm from 1975 to today.  And ever since the early 1980s, it has had a model in the size range of 6.0 to 7.0 sqm.  So though things look like they are changing, they are not.  My child has illustrated this paradox with a drawing of her own.  It is meant to show that each column and each row has a car of each size (small, medium and large) even though it all looks different (at least that is what it is meant to show; please cut her some slack, she is only in the 4-6 bracket).

What does this have to do with the NHS.  The similarities are uncanny.  The thing that changes here are the commissioning bodies.  As a proxy for size, Militant Manager has used the number of bodies that cover England.  So if 5 bodies of a certain level cover England, they would cover a much larger population each than if 50 bodies did the same job.

The similarities between the NHS and car design can be shown by the size changes of NHS commissioning bodies since 1990 - as illustrated in the chart below.

This shows that new bodies are introduced at a small size; and over time they grow in size with each restructure.  Over time bodies grow and die; but new ones are introduced.  So 500 PCGs have now made way for 50 PCT Clusters; 100+ Health Authorities will make way for 4 SHA Clusters by 2012.

It's deja vu all over again.  Despite these changes, nothing really changes.  So as you can see there has always been a body at the 300-500 size level since 1997.  And there has also been a regional structure between the Department of Health and this 300-500 level. 

These are incontrovertible facts; but each generation of politicians and officials think they can do something new.  And like those amongst our organisations who feel there is a technical fix to everything; there are those that think there are structural fixes to everything.

I fear that this may all be caused by the management consultants.  Who has not heard of the consultancy who gets called into a decentralised firm, and insists it should be centralised; and goes into a centralised firm, and calls for decentralisation?  This also sounds like the product of a series of structural reviews by consultants - who understand the problems with current situations; but cannot optimise overall; and cannot place their solutions in greater historic context.

But there isn't a structural fix for everything.  Somebody has already thought of it 20 years ago; and we are all tired of structural fixes.  After a series of these changes, we are exactly where we started.  And a lot of effort, time and money has gone into navel gazing.  The NHS structure is not a consumer problem like car design.

So what are the other lessons for the NHS:

1.  NHS structures change too quickly.  If car companies take 6-7 years to introduce a new model because it takes that long for consumers to adapt and factories to settle down and then be retooled; why would you think that organisational structures (which require much greater familiarity and comfort) can be turned on its head every 3-5 years (as seems to be the current average in the NHS).

2.  The NHS introduces too many names.  After any restructure, there is no need to call it different.  So District Health Authorities need not have been called Health Authorities and then Strategic Health Authorities.  The NHS could have built 20 years of brand equity in the simple, all-season name of "Health Authority."  In fact, while we are on the topic of ridiculous arguments, the NHS' names are too boring.  Why cannot SHAs be called the "Kalahari" or "Focus."  We should be more imaginative.

3.  There is no beauty in symmetry.  So though Volkswagen cover the small family segment via three equally spaced hatchbacks, other marques do it differently.  And there is no "Department for Cars" that mandates a symmetrical approach in every company.  Similarly, the NHS should be able to develop its structures differently in different areas.

Why consultants need more natural predators

Without natural predators, growth in consultant numbers is uncontrolled.  This is the conclusion you reach when you look at the training numbers of doctors through an "ecological" prism: where doctors are the fertile mothers, and registrars in training are the juveniles who will grow to become future doctors.

Replacement fertility measures "the total fertility rate at which newborn girls would have an average of exactly one daughter over their lifetimes" who would go onto have further children. In more familiar terms, women have just enough babies to replace themselves.  It is a bit sexist to define this in terms of women alone, but as 50% female, Militant Manager does not mind.

In a stable ecology, replacement fertility is determined by a number of factors.  First is annual survival rates - the chance that you may die each year (predators, lack of food, disease etc).  Second is the age at maturation (the age at which a female can have children).  The lower the rates of survival each year, and the greater the age at maturation, the greater the replacement fertility.  And this equilibrium is stable because if numbers increased, then survival rates would drop as the population became easier to hunt, or they exhausted their food supplies.  A picture of a cow with an element of its replacement fertility is included for completeness below.

  

On this basis the replacement fertility for hospital consultants is 1 - i.e. consultants only need to have one registrar in their career.  And given 30 years of consultancy (which may increase if retirement is pushed back), and 6 years of training, the stable ratio of consultants to juveniles is 5 (this is 30 years of fertility in the consultant, divided by 6 years of maturation in the registrar).  The child bearing years are so long, the maturation age is so early, and the survivorship is so good, that in a stable population there would be 5 consultants per registrar.

And what ratio do we have today?  We have 5 times what we need, as illustrated in this spreadsheet, and summarised in the table below. 

Of course, the model needs to be adjusted for the more complicated reality.  People retire early, or change career.  There are some who go part-time (often the case for women); and others who go "private" entirely or in part.  There are even some who go to the dark side and become managers.

But these complexities only change things at the margin.  The replacement fertility ratio in humans is higher than the theoretical 2 (the theoretical figure).  This replacement fertility ratio ranges from 2.1 to 3.4 depending on country.  And similarly - though Militant Manager has not seen such an analysis - the stable ratio of consultants to registrars may be around 3 to 5:1.

Yet, we have a ratio of 1:1.  My spreadsheet is based on numbers published by the Information Centre.  This shows how the numbers have deteriorated over the last few years.  One can also see that vacancies for consultants are at negligible levels - the levels at which changes in recruitment practices in Trust will affect the numbers.

The more astute amongst the readers will be pointing out that I have not considered the growth that would be required.  That is by design.  The reality is that in a stable advanced economy, one cannot increase the workforce engaged in a sector without also saying in the same breath that that sector will also account for an increased share of GDP.  The UK already spends 8-9% of GDP on healthcare, and I do not see a groundswell to increase this further.  In fact, national policy is to reduce the share of GDP healthcare absorbs by keeping public spending on it constant as GDP grows.  So there are no grounds to independently plan for rapid growth in doctor numbers.

So what does this all mean.  I have four main thoughts:

1.  NHS Workforce leads should be sacked.  Not only have they allowed this to arise, they are asking the wrong questions.  Militant Manager has searched for years for strategic analysis of training numbers - what numbers do we need; and what drives the replacement ratio.

2.  There is going to be a lot of pain for trainees.  There was - not so long ago - a role for "senior registrars."  They were effectively registrars who had all the requirements for consultancy, but had to do "their time" waiting for a job to come up.  It was not unusual to be in such a stage for 5 years.  Those days are coming back.  And the 5 years will be used to erode, demoralise and reduce the registrar base.  Many will leave the profession, and lots of others will seek other ways to burnish their CVs to distinguish themselves in an the increasingly competitive process of becoming a consultant.

3.  We need a better plan.  Juniors now do a lot of activity in hospitals; and many rotas require them.  So in some respects there is a requirement for this number of registrar level doctors.  But we do not need those numbers "training" and aspiring to consultancy - an aspiration we cannot meet.  That will require a reduction in training throughput, and a change in the stable workforce mix in hospitals - away from "training" posts.  This is a task that will have to be picked up by the new HR directors who replace the sacked ones.

4.  We need more natural predators for consultants. Ideas include taking consultants and leaving them in the serengeti; encouraging more to go camping in Siberia; and introducing diving in the shark infested waters of South Africa as a training requirement.  

Readers will have better ideas, and I would welcome those.