The Future of the NHS book 2007

I very much hope that the summary of all the book chapters has sparked interest in the NHS debate and perhaps inspired people to read some chapters in more detail. I am always pleased to hear from anyone who has feedback or just wants to comment about the NHS, please feel free to post a comment or contact me directly on mail@drmichelletempest.com

I wish you all a very successful and happy 2007.

Chapter 35 - The Future of the NHS (The final chapter)

This is a summary of chapter 35 - Funding Expectations. It was written by Jennifer Rankin and Jessica Allen. Dr Jessica Allen is Senior Research Fellow and Head of Health and Social Care at the Institute for Public Policy Research. At IPPR, she is currently working on a project exploring public expectations and a sustainable health system. Prior to joining IPPR, she worked at the Kings Fund and at Unicef. She holds a PhD from the University of London and has lectured at the University of Greenwich and LSE. Ms Jennifer Rankin is a Research Fellow in Health and Social Care at the Institute for Public Policy Research. At IPPR, she is currently working on a project exploring public expectations and a sustainable health system.

They explain in this chapter that rising public expectations are one of the main cost pressures on the NHS.

Since the NHS was founded people’s expectations have risen dramatically. They explain that the political process must bear considerable responsibility for creating excessive expectations and disillusionment. They cites the example that in 1997, Tony Blair came to power with the heady phrase that “we have twenty four hours to save the NHS”. The Government they suggest have subsequently adopted some more realistic language, talking about a process that would take years rather than months. Opposition parties are also guilty of using loose language around the NHS, citing how David Cameron said that the “NHS could no longer ration treatments”. They maintain that in a system where resources are limited and demands are infinite, rationing will remain a necessity - clearly, the NHS has to ration treatments according to need. It has always done and will continue to do so.

They continue with examples of the media fuelling unrealistic expectations. They suggest that politicians and the media are locked in a dialogue of mutual distrust and suggest the need to fashion a new political dialogue about how we value the NHS. Policymakers need to communicate what people are entitled to and how these entitlements can be fairly distributed among the population. The public should have high expectations, but they should also be fair and realistic expectations. Ultimately, a better understanding of health and health services will enable the NHS to pull off the difficult balancing act of maintaining public support, doing more for health and remaining affordable.

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Chapter 34 - The Future of the NHS

This is a summary of chapter 34 - The Case for Pluralism. It was written by Professor Nick Bosanquet and Andrew Haldenby. Professor Nick Bosanquet is a Professor of Health Policy at Imperial College, London and a health economist who first carried out research on NHS funding in the 1980’s for the York Reports sponsored by the British Medical Association, the Royal College of Nursing and the Institute for Health Services Management. He has been Special Adviser on public expenditure to the Commons Health Committee since 2000. He is a non-Executive Director of a Primary Care Trust in London. Mr Andrew Haldenby is the Director of Reform, an independent, non-party think tank whose mission is to set out a better way to deliver public services and economic prosperity.

In this chapter they put the case for a full move towards pluralism. They explain that if the private sector are rewarded for using capacity; markets grow and market expansion raises productivity and prices fall. The public sector currently lacks this dynamic.

They highlight that in the NHS, capacity is used to limit demand, rather than ‘excess’ capacity being used to meet demand and provide more. They believe waiting lists are the consequence. They think that liberalising the supply side will both cause more capacity and improve efficiency. Also effective use of the private sector can be made when it is free to supply in a competitive environment, so that it invests, innovates and responds to consumers. It discusses the need for greater competition to make pluralism work and they list four key elements for effective pluralism:

1) Increasing information about choice.
2) Developing the market for alternative supply.
3) Recognising that reform through supply pluralism will take substantial launch costs.
4) Supply pluralism would be greatly assisted by a wider use of advertising.

They explain that real reform must also extend to demand as well as supply and suggest the NHS requires an environment where there are independent sources of funding. They summarise with the thought that without change in funding of the NHS, any ‘supply side only’ reform is likely to run into new problems of rationing as improvements increase the demand for services.

To comment further on this please do post here, after reading the chapter in the book, or join the debate on www.thefutureofthenhs.com

Chapter 33 - The Future of the NHS

This is the summary of chapter 33. Localism in the NHS: Reducing the Demographic Deficit. It was written by Mr Tim Kevan, a Barrister at 1 Temple Gardens, with expertise in personal injury (including clinical negligence), sports, consumer and general common law. He is the author of nine legal textbooks and edits three legal newsletters. The other author was Mr Daniel Hannan MEP, a leader writer for The Daily Telegraph, author of 6 books and MEP for South East England.

They suggest that guiding principles for reform should be - decisions made as closely as possible to the people they affect; and those people should have as much say in those decisions as possible. They suggested the following:
1) Patient choice should be encouraged.
2) That all structures need to be democtratised. The most significant body within the present structure is the primary care trust (PCT) which commissions the majority of NHS services. They suggested that this should consist of directly elected representatives accountable directly to the people.
3) That structures should be simplified and made more transparent. They suggest that PCTs and other health organisations should be given boundaries that coincide not only with each other, but also with local authorities.
4) They advocated that the powers of 'local bodies' such as PCTs should be increased with greater decision-making discretion.
5) They suggested that doctors and other health care professionals should be brought back into the decision-making process.

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Chapter 32 - The Future of the NHS

This is a summary of chapter 32 - Alternative Funding Models. It was written by Dr Eamonn Butler, Director of the Adam Smith Institute, an influential think-tank which for more than twenty years has designed and promoted practical policies to promote choice and competition in the delivery of essential services. He frequently contributes articles to national magazines and newspapers on subjects such as health policy, economic management, taxation and public spending, transport, pensions, and e-government.

In this chapter he discusses the alternative methods of funding the NHS. Explaining that even after record big budget, the finances remain in a rough state, with many trusts reporting deficits and some being plainly unable to bring their budgets under control. The chapter argues a strong case for looking at alternatives for how the UK healthcare system should be funded. It offers an instructive overview with 16 other alternatives. To learn more about these 16 alternatives I would encourage you to buy the book, it can be bought from most good bookshops or on line at www.thefutureofthenhs.com

Chapter 31 - The Future of the NHS

This is a summary of chapter 31 - Taxation and Insurance. It was written by Professor Alan Maynard, Professor of Health Economics and Director of York Health Policy Group at York University. He has worked as a consultant for the WHO, the World Bank, the European Union and the UK’s Government Department for International Development. He is widely published in many books, specialist journals and the mainstream media. Since 1997 he has been Chairman of the York NHS Trust.

In this chapter he focuses on the debate about financing health care, remembering the objective of the NHS: to improve population health for the least cost. However, instead of focusing on the clinical and cost effectiveness of competing interventions and measuring clinical outcomes, the media and competing politicians propagate the illusion that more and/or different funding will “cure” the system’s often ill-defined problems.

The principle conclusions to be derived from his discussion of funding health care are that reasons for advocating change may be disguised by ideological and political agenda, but proponents of change have to be challenged. All health care systems, public and private, exhibit gross inefficiencies in terms of variations in practice and failure to deliver, but what the evidence base shows to cost effectiveness? The challenge for all who enter the debate about funding is to be transparent about their ideological concerns. Also, they must recognise that pouring more money into a health care system may not improve the level nor the distribution of population health.

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Chapter 30 - The Future of the NHS

This is a summary of chapter 30 - Financing the NHS: The Current System. It was written by Mr Tony Harrison, a Fellow in Health Policy at the King’s Fund. He has published extensively on the future of hospital care, the private finance initiative, health research policy and waiting list management.

In this chapter he gives an overview of the ways in which the NHS is financed and the historical loop funding seemed to have followed. He believes the decision to finance services almost entirely out of taxation, still leaves a large number of issues to be resolved. The question remains to be considered, is it appropriate to continue to rely upon tax finance? The Government is committed to it: so is the Conservative Opposition. Nevertheless, it may come into question in the very near future.

The Government’s response was to argue that tax finance remained the best option, but that substantially more resources would be needed to provide high standards of health care. The result was the largest sustained increase in NHS spending ever experienced. This rate of increased spending will continue until 2007, but what will happen after that?

He believes, as yet, there is no reason to believe that the level achieved will be regarded as ‘good enough’: the pressure to spend more will continue, due to new technology, the need to continue to raise clinical quality, and from the Government’s own desire to respond to what it perceives as rising public expectations.

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Chapter 29 - The Future of the NHS

This is a summary of chapter 29 - Redressing the compensation culture. It was written by Mr Tim Kevan, a Barrister at 1 Temple Gardens with expertise in personal injury (including clinical negligence), sports, consumer and general common law. He is the author of nine legal textbooks and edits three legal newsletters.

He Suggests that a culture of risk aversion and fear of litigation has gone too far. In order to re-set the balance, he suggests the following:
1) The law of liability for clinical negligence to be reviewed and that certain medical specialties should be immune from litigation.
2) Alternative forms of non-fault compensation to possibly apply.
3) Medical practitioners should generally be immune from discipline subject to certain basic exceptions on condition that they provide full and frank disclosure of their mistakes which would not be able to be used in litigation.
4) Suggestions for spending on legal costs to be reduced.

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Chapter 28 - The Future of the NHS

This is a summary of chapter 28 - Medical Negligence Claims. It was written by Dr Gerard Panting, Director of Policy, Medical Protection Society.

In this chapter he provides a guide to the NHS Redress Bill which is aimed at improving procedures for dealing with clinical negligence claims, both in terms of helping victims and in reducing costs. Ultimately, he believes the success of the Redress Scheme will depend on how individual trusts manage the process at local level, and whether there is counter shift away from attributing blame, towards preventing harm reducing risks and learning from mistakes.

The scheme is to be overseen by the National Health Service Litigation Authority (NHSLA) and he raises questions as to its impartiality, and also whether it will have the resources properly to investigate what the acceptable range of practice was and whether the work came within it.

Ultimately his belief is that the scheme is likely to result in more patients with low value claims coming forward to use the scheme.

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Chapter 27 - The Future of the NHS

This is a summary of chapter 27 - From self-regulation to professionally-led Regulation in Partnership with the Public.

It was written by Dr Joan Trowell a University Lecturer in Medicine and a Consultant Physician at the Oxford Radcliffe Trust. She is a member of the General Medical Council and until recently she was chairman of the GMC’s Fitness to Practise Committee. It was also written by Mr Paul Buckley, the Director of Strategy and Planning at the General Medical Council (GMC).

This chapter examines the changing face of professional regulation. While the focus is largely on the GMC, the trends identify conclusions, intended to apply to the regulation of healthcare professionals more broadly. Many changes have already occurred, but some would advocate yet further change. Given the clear willingness of regulatory bodies to reform radically, further imposed structural change for its own sake, or for the sake of continuing the momentum of change, cannot be the answer. The effect of the recent reforms requires adequate evaluation.
They suggest that the new model of regulation, which is emerging, retains the strengths of professional ownership, but balanced by full public involvement. This is the true meaning of professionally led regulation in partnership with the public.

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Chapter 26 - The Future of the NHS

This is a chapter summary of chapter 26 - The Future for Health Care Management: an Analysis and Some Proposals. It was written by Professor Ewan Ferlie, Director of the Centre for Public Services Organisations and Head of the School of Management, Royal Holloway University of London

In this chapter he argues that 'better management can lead to better health services', via the slogan ‘better management; better health’. He sees a core management task involving active leadership from both general managers alongside clinicians, to inspire and sustain collective service improvement activity rather than ‘form filling’ management, for proliferating audit systems. He suggests the need for more local and long term strategies and fewer top down quick fixes. He believes health care management should be based on a secure evidence base as well as clinical practice. He offers analysis and a 4 point agenda for management in the medium to long term.

1) Stabilising The System: Less haste; More speed.
2) Getting Doctors into Management and Developing Medical Leadership
3) Strategies with Private Sector Providers
4) Developing an evidence based method for NHS management.

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Chapter 25 - The Future of the NHS

This is a summary of chapter 25 - NHS staff. It was written by Dr Chess Denman a Consultant Psychiatrist in psychotherapy at Addenbrookes hospital where she runs the Complex Cases service which specialises in the treatment of personality disordered patients. Dr Denman is the secretary of the Royal College Faculty of Psychotherapy, a member of the Society of Analytical Psychology and a founder member of the Association of Cognitive Analytic Therapists.
Mr Daniel Barnett a leading Barrister in employment law and author of three employment law textbooks, including co-author of the Law Society Handbook on Employment Law. He has advised and defended a number of NHS trusts in unfair dismissal and discrimination claims. He frequently comments in national and specialist press on employment law matters. Also Dr Colin Payton a Consultant Occupational Physician and Clinical Director of Occupational Health and Safety at the Royal United Hospital, Bath.


This chapter describes how the NHS (the fifth largest employer in the world) has reported 36% of their staff have suffered work-related stress. Psychological ill health remains potentially the most serious problem for the health and well-being of NHS staff. What does not emerge from the statistical and survey data are the human stories which surround psychological ill health in hospital staff, many of whom are there caring for others. Doctors take the fewest days off sick but have high rates of suicide. It also seems unfortunate that there are increasing numbers of health care workers with alcohol misuse problems and more recently with other substance misuse problems.

With this in mind this chapter provides some positive suggestions for change in relation to improving the care of the nation’s carers. They fall into two categories. First, improved access to psychological care and second, more employee focused employment procedures.

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Chapter 24 - The Future of the NHS

This is a summary of chapter 24 - proposals to improve clinical academic training. It was written by Professor David E Neal and Professor Mark Walport. Professor David E Neal is Professor of Surgical Oncology at the University of Cambridge & Member of PMETB. He is an elected member of the Council of the Royal College of Surgeons of England and a past Chairman of the SAC in Urology. Professor Mark Walport FMedSci, FRCP He is the Director of the Wellcome Trust and Chair of UKCRC & MMC Academic Careers Sub-committee.

In this chapter they address the importance of an academic career including researchers and educators by considering the following issues:
1) Academic medicine as a career had been under threat with warning bells ringing for some time over the perilous state. Several reports highlighted difficulties facing clinical academics, as they attempted to negotiate the hurdles of dual training in clinical and academic skills. Fortunately, an increase to NHS Research and Development funding and the promotion of a partnership approach to strengthen clinical research.
2) The increasing the strength of academic medicine to improve expertise in clinical research and education is of great benefit to the NHS and the wider academic and business community in the UK.
3) Overall, the prospects for academic medicine are improving, and depend upon working with the Colleges, Faculties and Specialties to ensure that new academic programmes are coherent with changes in training. If there continues to be real commitment to improve careers in Clinical Academic Medicine, then they expect prospects to be good and the declining number of academics to be reversed.

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Chapter 23 - The Future of the NHS

This is a summary of chapter 23 - training for a new NHS. It was written by Professor Shelley Heard and Professor Elisabeth Paice. Professor Shelley Heard trained as a medical microbiologist. She has been a chief executive of an acute trust and for the last 10 years has been a postgraduate dean for medicine in London. She is also currently the National Clinical Advisor for the Modernising Medical Careers (MMC) programme. Professor Elisabeth Paice MA FRCP She is Director of Postgraduate Medical and Dental Education for London. She developed the Hospital at Night concept and has published on stress in doctors; doctors in difficulty; workplace bullying; flexible training; and other aspects of medical careers.

They describe how medical education in the UK has an international reputation for excellence, and our own graduates are eagerly sought after by other countries. Nonetheless, there is plenty to improve about the way we train doctors, and there are powerful drivers to do things differently. Whatever else is needed to support the vision of a future better NHS, education must be right up there. It explains the recent changes in medical school training, and the new terminology, such as Modernising Medical Careers (MMC), and the new standards set by the Postgraduate Medical Education and Training Board (PMETB).

They discuss the issue of healthcare being a twenty-four hour business, but that the move to a twenty-four hour society has not produced twenty-four hour people. Night working is intrinsically stressful, error-prone and socially undesirable, and no vision of the future NHS can ignore the damaging effects of night work on its staff. The European Working Time Directive has proved a powerful driver for change to long hours, but in some cases, shortening the hours has simply resulted in excessive work intensity.

Please feel free to comment on this site or to join the debate at www.thefutureofthenhs.com

Chapter 22 - The Future of the NHS

This is a summary of chapter 22 - what do patients want? It was written by Claire Rayner, president of The Patients Association and is the UK’s best known agony aunt. She has a long and successful career as a journalist, broadcaster and writer, but began her working life as a nurse at the Royal Northern Hospital in London.

Claire Rayner makes several strong points in this chapter, which include:

1) We Want to Know the People Who Treat Us:
Patients understandably want to get to know the professionals who are treating them, yet she has found the number of strange faces bewildering. Strangers who know little about you or even why you are there, make patients feel not only lonely but alienated.

2) We Want to Feel Safe
Hospitals now seem a byword for dirt, disorder and hospital acquired infections with horrid accounts of MRSA. Thatcherite thinking to save money was to employ contract cleaning firms; but it seems to have left hospitals disgustingly dirty. The contract company’s employees tend to lack any real incentive to do a good job and they are rarely paid enough for the effort demanded of them.

3) We Want Reliable Day and Home Care
Whatever happened to the idea of convalescence? Now the aim seems to be to get patients out of hospital as quickly as possible, else fear being a ‘Bed Blockers’ - an unpleasant, indeed insultingly, label given by management. To be able to afford care home placements many elderly people have to sell the home, to provide what NHS gurus call Social Care yet many others regard as basic nursing care.

4) We Want the NHS to Continue to Exist
For all its current problems and occasional disasters there is no doubt in my mind that the majority of the people in this country value the NHS highly, and would be deeply dismayed if the current obsession to reduce its costs, takes us back to the bad old days pre 1948.

5) Will the NHS collapse in the future?
I have to say that I very much fear it will. We now have not a National Health Service but a series of Local Health Services, a net that has many large holes through which patients fall with distressing frequency. Add to that the cost debts and the future of the NHS is very bleak indeed. Hence, my fears our descendants be pushed back into the past, to die not only unhonoured and unsung, but uncared for.

To comment on her hard hitting chapter, please comment here or add a comment on www.thefutureofthenhs.com

Chapter 21 - The Future of the NHS

This is a summary of chapter 21 - integrating alternative health. It was written by Dr Mosaraf Ali, who after qualifying as a doctor continued his studies into complementary medicine. With continuous help and encouragement from Prince Charles he established a clinic where both complementary and conventional treatments are integrated. He opened the Integrated Medical Centre in London with a team of fifteen doctors and therapists.

In this chapter he focuses on ‘Integrated Medicine’ – a combination of conventional, complementary and traditional medicines. He sets the basis of integrated medicine as the patients’ participation in creating their own health. He argues that integrated medicine should be incorporated into the NHS and that primary healthcare physicians should be trained in its principles.

He suggests that the NHS should cast aside reservations about integrated health and should embrace it. He also adds that as many diseases could be arrested at the grassroots level this would have the knock on effect of reducing the burdens on the more expensive hospital and specialised treatment.

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Chapter 20 - The Future of the NHS

This is a summary of chapter 20 - the future of nursing. This chapter was written by Jane Naish (a policy adviser at the RCN with a background in nursing, sociology and health policy) and Ms Sylvia Denton, President of the Royal College of Nursing who has recently retired from her post as lead nurse/Senior Clinical Nurse Specialist in breast care. Sylvia was awarded the CBE in the New Years Honours List in 2006 for services to health care.

In this chapter they examine the future for nursing and review the key principles for the development of nursing. They highlight the serious shortages in almost all categories of health care workers and recognise that the low numbers of registered nurses is becoming a significant problem, because of:

· Difficulties regarding nursing recruitment and retention.
· Overall nurse shortages, critically compounded by an ageing nurse population.
· Predictions that more nurses will leave the nursing register than will join in the future.

They warn that any future nursing strategy needs to recognise that registered nurses will not be able to personally deliver all the nursing care needed and will have to rely on teamwork, and to extend their expertise to others in the caring profession. They discuss that nursing and nursing teams will have to become far more integrated across the different care settings span both community and hospital settings.

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Chapter 19 - The Future of the NHS

This is a summary of chapter 19 - the future of mental health provision. It was written by Mr Derek Draper, a former political adviser and author of “Blair’s 100 Days” (Faber). He is a psychotherapist in private practice in Marylebone, London and during his training worked as the development director of a community counselling centre in northern California. He is a member of the British Association for Counselling and Psychotherapy (MBACP). He writes monthly columns in the magazines “Psychologies” and “Therapy Today”.

This chapter Derek concentrates on “sub-clinical” problems; conditions that don’t quite meet the diagnostic criteria for any particular mental disorder, but that nonetheless involve a great deal of psychological or emotional unease. He explores:
1) The changes that would be necessary to make the current system deliver on its existing standards.
2) Reviews the recent proposals for expansion of therapy services, arguing that whilst such changes are welcome, they remain fundamentally inadequate to deal with the scale and depth of the problem.
3) Proposes a new and radical solution of therapeutic volunteers – coining the term “para-counsellors”.

He concludes that current demand is so great that without the new voluntary “para-counsellors”, millions of Britons in need of mental health treatment, will sadly never receive it.

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Chapter 18 - The Future of the NHS

This is a summary of chapter 18 - the future of psychiatric services in the NHS. It was written by Professor Peter Tyrer, Professor of Community Psychiatry, Imperial College, London in the Department of Neurosciences and Mental Health Medicine.

In this chapter he considers how mental health services have been regarded as a 'Cinderella service' scrabbling for resources; yet mental illness incurs a heavy burden on populations and it is very unwise to ignore this burden.

He discusses the attempts to integrate mental health and social services, yet warns of the remaining yawning gap. He suggests that these systems should integrate and work together to allocate patients to appropriate care.

He warns that although there are increasing services for care in the community there is still a long way to go. Currently there are too few outlets for patients to be discharged from hospital into community settings, meaning they remain in hospital. This has the knock on net effect of there being a shortage of acute psychiatric beds.

The chapter adds a plea ‘please, oh please, do not introduce changes in policy until they have been shown to be evidence-based’.

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Chapter 17 - The Future of the NHS

This is a summary if chapter 17, Plastic, Reconstructive and Aesthetic Surgery by Mr Peter Butler. He is a Consultant Plastic Surgeon and Honorary Senior Lecturer at the Royal Free and University College Hospitals, London and a Consultant in Plastic Surgery at the Massachusetts General Hospital, Boston, USA. He is a council member of the British Association of Plastic Surgeons (BAPS). He is also frequently seen on television discussing face transplants.

In this chapter he explains that plastic surgery specialty is adapting to the ever-changing healthcare environment. However, he discusses the concern over the lack of provision of adequate manpower. This has caused other surgical specialities to have to pick up this capacity shortfall, adopting plastic surgery techniques with variable standards and achieving mixed results. The inadequate numbers of plastic surgeons is in the face of an increasing demand for plastic surgery provision. This is in part related to medical advancements making plastic surgery possible, that previously would have been deemed untreatable. Demand is also compounded by an ageing population and increasing numbers needing plastic. Added to this is the demand for surgery for normalisation and improvement of appearance, partly related to increased patient demand and increased awareness due to television programmes such as ‘Extreme Makeover’. Increasingly, GPs refer patients to plastic surgery units for this type of surgery.

He believes that currently the provision of cosmetic surgery is not driven by evidence-based medicine but by subjective opinion.

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Chapter 16 - The Future of the NHS

This is a summary of chapter 16 - The Future of Public Health, written by Professor Griffiths. He was the regional director of public health for the West Midlands Regional Health Authority until his retirement in May 2004 and is currently the President of the Faculty of Public Health. He was awarded the CBE in 2000.

In this chapter he discusses the three aspects of public health.
1) Health promotion.
He Comments on the recent parliamentary vote in England to ban smoking in all enclosed public places as a landmark decision. He hails it as a success for public health but warns that there is still more work to be done towards health promotion.
2) Health protection
He explains that health protection involves surveillance of infectious disease, environmental hazards and interventions intended to control outbreaks and incidents. Controlling an outbreak of infectious disease requires public health workers to be part of multidisciplinary teams, understanding ststatistics, epidemiology, social sciences and the arts. The diversity of workers from a variety of backgrounds in public health has enriched the specialty enormously. It is also necessary to remember the importance of international collaboration. This has been highlighted recently by avian influenza (bird flu), where WHO collaboration around the world identifing new infectious agents in a matter of weeks and greatly continues to assist in controlling measures.
3) Service improvement
He warns that the required close relationship with statutory organisations makes public health vulnerable to politicians reorganising the system. He highlights that NHS reorganisation can disrupt the important work of public health leading to a net loss of capacity.

He hopes that in the future there will be a more stable pattern of authorities retained for a longer period, to let the public health workers get on with their jobs.

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Chapter 15 - The Future of the NHS

This is a summary of chapter 15 - the crystal ball of cancer care, written by Professor Karol Sikora. He is Dean of Britain’s first independent Medical School at the Universities of Brunel and Buckingham. He is an editor of the standard UK postgraduate textbook Treatment of Cancer which this year goes to its 5th edition. He was Professor of Cancer Medicine and honorary Consultant Oncologist at Imperial College School of Medicine, Hammersmith Hospital, London where he was Clinical Director of Cancer Services for 12 years. He was seconded as Chief of the WHO Cancer Programme in 1997.

In this chapter he worryingly highlights that the global incidence of cancer will increase by 100% over the next twenty years. The public, understandably, is more frightened of cancer than any other illness, but warns that it is difficult to present balanced views, as everyone has a vested interest and calm analysis is not front-page stuff.

He believes that the NHS has unfortunately not anticipated the dramatically increasing costs associated with high quality cancer care. Even though politicians are keen to improve cancer care, the existing system just can’t cope, despite the massive amounts of taxpayers’ money thrown at it. He warns that the NHS in its current format will simply not be able to meet the surge in demand for innovative cancer care.

He proposes that it is time to get the independent sector to drive the cancer delivery agenda. Moving the NHS away from the Stalinist era, towards the consumer age, where people can vote with their feet. He explains how the delivery of care could be done in the future, giving a template to rollout a network of outpatient ‘cancer hotels’. He believes that the NHS needs a revolution, demolishing the icons of the past – waiting times, targets, restrictions to access, propaganda and mindless bureaucracy - cracking them apart like the statues of Lenin around Eastern Europe. When they fall, the new Phoenix of a consumer led healthcare system will emerge. Britain could then lead the world in cancer care.

I would encourage you to comment on this chapter further after reading his hard hitting view about the future of cancer care. Please feel free to comment here or log onto www.thefutureofthenhs.com

Chapter 14 - The Future of the NHS

This is a summary of chapter 14 - the future of cardiology within the NHS by Dr David Stone, a consultant Cardiologist and Director of Education at Papworth and Associate Dean at the Faculty of Clinical Medicine.

In this chapter he warns that cardiological development is fraught with uncertainty, because the discipline crosses many borders and is associated with technological development in very rapidly changing fields. He addresses the question: what will we be doing and where will we be doing it?

He strongly warns against the short term-ism in working within a system, at least somewhat dependent on an electoral system, with a (maximum of) 5-year cycle. The consequences are then imposed upon a financially based health service that is also undergoing major changes in training and reimbursement. He believs it is little wonder that the future is uncertain and that there is a retreat into a defensive position. He sums up by warning against letting the future of the NHS be sacrificed for our present.

To comment further on this chapter, please leave a comment or join the debate on the forum on www.thefutureofthenhs.com

Chapter 13 - The Future of the NHS

This is a summary of chapter 13 - the future of ophthalmology (eye specialty). It was written by Dr Nick Astbury, President of the Royal College of Ophthalmologists and is a Consultant Ophthalmic Surgeon at the Norfolk and Norwich University Hospital NHS Trust.

He belives that the debate about plurality of providers is particularly relevant in ophthalmology, as cataract surgery is the most commonly performed elective procedure in the UK. The specialty has been a leading innovation with a highly successful initiative conceived by the College in partnership with the government. NHS staff, by embracing new technology have dramatically reduced waiting times. But he warns that the future does not lie with commercially driven independent sector treatment centres staffed by overseas doctors on working vacation, who to date, have carried out just 2.5% of the cataract throughput, at considerably greater cost. Experience has revealed that we should be investing in our own hospital departments that are more than capable of delivering an excellent, innovative and local service.

He believes that the future rests in all of our hands, to a greater or lesser extent. What we do today directly affects our patients and those around us; we can set a good example to others or lead them astray. But there will always be events over which we have no control and governments that impose change for changes’ sake rather than building on existing good practice.

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Chapter 12 - The Future of the NHS

This is a summary of chapter 12 - the future of anaesthetics. It was written by Dr Peter Simpson, President of the Royal College of Anaesthetists with special interests in training, examinations, assessment and accreditation of doctors and anaesthetists. He is President of the European Society of Anaesthesiology

In this chapter he discusses the importance of anaesthetics, highlighting that with this speciality is involved in 65% of all hospital admissions!

He focuses on how to plan ahead for the future and the requirement of having enough trained staff. He discusses the difficulties in projecting workforce requirements, in terms of gender, nationality or indeed the way in which they wish to work is challenging. Despite the increased intake into UK medical schools, which will take time to percolate through the system, the 70+% female intake will undoubtedly influence things. Also, the 50% overseas graduates currently in anaesthetic training are extremely welcome, but this needs to be considered in the diversity of workforce planning.

To comment further on this chapter - please feel free to post a comment.

Chapter 11 - The Future of the NHS

This is a summary of chapter 11, the Organisation of NHS maternity care, by Professor Jim Thornton. He is a Professor at the Academic Division of Obstetrics & Gynaecology and Child Health, City Hospital, Nottingham.

He descibes three organisational features which distinguish NHS maternity care from that of most other West European countries.
1. Britain has the most centralised system. Not only do we have a low rate of home births, typical of most other countries, but we also have the lowest proportion of small delivery units <1000,>5,000 deliveries.
2. Doctors, and in particular senior doctors, are relatively uninvolved in labour and delivery. It is difficult to overemphasise the importance of close consultant involvement in labour. Although maternal and perinatal deaths are now both uncommon, the day of delivery remains the most dangerous in most individuals’ entire lifespan. Yet normal deliveries are left largely to midwives and senior doctors leave complicated deliveries, forceps and caesareans, to doctors in training.
3. Probably as a consequence, Britain is unique in having the majority of normal births conducted by midwives. However, midwives are expanding their role outside labour and the required number of midwifes has not kept pace with these new developments leading to a possible overall shortage of midwifes.
4. The potential medico-legal claims arising from alleged negligent care in labour causing brain damage, now dwarf all other medical claims from any other NHS specialty. The chapter reviews evidence of the NHS having the highest rate of sub-optimal care in Europe and suggests ways to improve the service.

To dicuss further about some of his more chilling insights, then please e mail me direct or post a comment.

Chapter 10 - The Future of the NHS

This is a summary of chapter 10 on the future of health services for children. It was written by Professor Alan Craft, a Professor of Child Health and a Consultant Paediatrician. He is National President of Royal College of Paediatrics and Child Health and Chairman of Academy of Medical Royal Colleges and Dr Simon Lenton, Vice President at the Royal College of Paediatrics and Child Health. He works in Bath as a consultant paediatrician with a special interest in community child health.

They describe how superficially children themselves have never appeared to be healthier, but what about the health systems to support children and families, do we really have a first-class service or can we do better? It suggests some key ways of progressing child health services:

1) Increasing training for GPs to develop specialist skills in community child health.
2) They suggeat that it is no longer possible to continue to provide inpatient care on every hospital sites. Therefore, services will have to be redesigning. However, they warn against advancement attempts being thwarted at the last moment by politicians, concerned about losing votes.
3) Encourage “pathway thinking” as a logical way of providing information and lists the many good reasons for developing care pathways. They warn that the big challenge in developing better services for children, through managed networks, is difficult due to the fragmentation of commissioning. They site the example that for any child’s NHS “journey” there could be up to 7 different commissioning bodies (across health education social care and the community/voluntary sector) responsible for purchasing “bits” of a journey. The principles of commissioning have great potential for improving services if a way can be found to commission whole pathways across organisations, rather than contracts with individual organisations. Children’s health and well-being is dependent on multi-agency services, the outcome of which is only as good as the weakest link in the child’s journey.

Everyone has thoughts on the health and well-being of children in need and to comment further, post a comment here or log on to: www.thefutureofthenhs.com

Chapter 9 - The Future of the NHS

This chapter is a summary of Chapter 9 - The future of geriatric medicine. It was written by ,Professor Peter Crome, Professor of Geriatric Medicine and Deputy Head of Keele University Medical School as well as President-Elect, British Geriatrics Society. He is a Consultant Geriatrician with a special interest in the evaluation of health services for older people and the treatment of common disorders of later life, including stroke and dementia

In this chapter Professor Crome discusses the impact of the increase in life expectancy that has been a triumph for humankind, but brings with it great challenges for the NHS.

He explains the benefits of the key standards in the National Service Framework for Older People (NSFOP) but warns against a “tick-box” approach to the improvement of services. He tackles the difficult questions such as, residential and nursing homes, rehabilitation and chronic disease management and warns of the paucity of information about the effectiveness of medications for common conditions in those aged 80 and over.

Optimising the health of older people is no small task and requires investment and co-ordination at all levels. He suggests requirements over the next decade:
· greater emphasis on health promotion by education
· greater involvement of older people themselves in health decisions
· suggests developing tailored therapeutic elderly services to tackle the growing problems of the misuse of drugs and alcohol within this age group
· proposes developing GPs with a Specialist Interest in elderly care
· highlights the need to treat older patients as individual people, to respect their rights, opinions and feelings and to treat them with dignity and humanity however ill and seemingly incapacitated.

To comment on this chapter, please post a comment here and/or on the discussion forum at www.thefutureofthenhs.com

Chapter 8 - The Future of the NHS

This is a summary of Chapter 8 by Mr Jim Wardrope, President of the College of Emergency Medicine and a consultant at the Northern General Hospital, Sheffield and Dr Alastair McGowan, Immediate Past President of the Faculty of Accident and Emergency Medicine and consultant at St James's University Hospital, Yorkshire.

This chapter deals with Emergency Medicine - the sharp end of NHS care. In England, a staggering 13 million patients will visit an Emergency Department this year, equivalent to almost one quarter of the total population. They highlight that major changes in the delivery of primary care has had a knock-on effect, to increase the number of patients attending the Emergency Department.

Over the past 4 years the NHS has seen real growth in resources and successes in reducing Emergency Department waiting times. But they warn that the outlook for the next 5 years is less certain. Already there is evidence that demands are outstripping capacity and resources. The current level of success in emergency care is fragile and hospitals are operating at or near maximum capacity. They discuss that there will have to be greater availability of experienced doctors, and that other professional staff will have to expand their training and expertise to asses and treat patients who would have traditionally been seen by doctors.

To discuss this chapter further, please feel free to post a comment or go to the discussion forum at www.thefutureofthenhs.com

Chapter 7 - The Future of NHS

This is a summary of chapter 7, written by Dr Mayur Lakani, Chairman of the Royal College of General Practitioners, Visiting Professor in the Department of Health Sciences, University of Leicester School of Medicine.

In this chapter he discusses primary care, and mainly concentrates on the role of GPs. He explains how primary care is expanding and is imperative to the running of the NHS. He tackles some common concerns, such as the inability to book GP appointments in advance, not being able to access GPs out of hours, and the new GP contract.

He also explains the significance of the Government White Paper on 'Care in the Community', which is aimed at reshaping the NHS, by transferring services from hospitals, into the community. He sums up by considering some suggestions for the future development of primary care:
· Longer and flexible consultation times with patients (say 15 minutes)
· Focusing more on prevention and well being, including mental health
· Focusing on earlier diagnosis
· Making patients the key holders for deciding on their treatment
· Integrating primary health care teams
· Improving communication between hospitals and GP practices
· Providing more tests and procedures, and services in primary care
· Improving primary care access, particularly for urgent problems
· Developing stronger GP services in deprived areas
· Increase the sexual health services in primary care settings
· Offer patients a choice of seeing a named GP and the choice to register with their preferred practice.
· Let the GP be the navigator rather than the gatekeeper

· Improve management of co-morbidity which is found more in deprived communities.

To offer comments on his chapter please feel free to comment on this blog, or add to the forum debate on www.thefutureofthenhs.com/forum

Chapter 6 - The Future of the NHS

This is a summary of chapter 6 - The Future of Surgery. It was written by Professor Peter J Friend, Professor of Transplantation at the University of Oxford, Director of the Oxford Transplant Centre and a Consultant Surgeon specialising in Transplant and Hepatobiliary surgery at the Oxford Radcliffe NHS Trust.

Professor Peter Friend describes that the medical world is on the cusp of radical change and if properly implemented, will provide a better, safer service for patients and a more cost-effective service for the provider. He considers several possible areas of change for the surgical specialties, and a few of those are mentioned below.

1) The changing face of surgery
The surgeon, used to direct the progress of a patient often single-handedly, but notes the surgeon is now part of a ‘committee’ that determines how the patient should be treated. However, the multi-disciplinary team will now be the key to the way the health service of tomorrow will look.

2) Surgery as a technology-driven specialty
He believes the future of minimally invasive surgery will involve robotic procedures under video-imaging, carrying out the entire operation using robotic arms controlled remotely by the surgeon. He notes that this technology is hugely expensive to buy and operate. Therefore, it will be a challenge to deliver new technology and cost-effectiveness.

3) Surgery and training
He explains how the traditional system of apprenticeship surgical training is becoming replaced with a more active training process to enable a surgeon to achieve competence with less than half the clinical contact time of his/her predecessor. [There is nothing more important than investing in the future of training.]

4) Surgery and regulation
He describes how a surgeon's future will include a closely scrutinised performance record. In fact hospitals are subjected to ‘league table’ comparisons. He argues that although transparency is clearly a good principle, the use of such simplistic measure of outcome, such as crude death rates, could be extremely misleading. One surgeon may be the best in the country but if the most difficult and highest risk cases are referred, then the mortality may still be high. If crude mortality becomes the marker by which surgeons are judged, then there will be a natural tendency to refuse to take on high-risk or complex cases and warns this would be very much to the disadvantage of patients. He highlights the need for this to be considered.

To comment on this please post a comment, e mail me direct at mail@drmichelletempest.com or join in the discussion forum on www.thefutureofthenhs.com

Chapter 5 - The Future of the NHS

This is a summary of Chapter 5 - The Future of Medicine. It was written by Dr Robert Winter, a consultant physician and Medical Director, Cambridge University Hospitals NHS Foundation Trust.

He explains the Paradox that although the scope of modern medicine is immeasurably greater than it was, the optimism generated by its advances seems to have evaporated. In short, ‘medicine is doing better, but feeling worse’. The future of the NHS is a scenario where the elderly are living longer yet in less good health towards the end of life, the young with more ill-health related to lifestyle all demand access to high cost, high technology drugs and resources. This scenario is undesirable and unsustainable.

Perhaps the challenge for the future NHS will be to develop a more holistic, integrated approach with an emphasis on keeping people well and a service that better reflects high, but reframed, consumer expectations. He believes this will provide a more balanced and therefore a more hopeful future – the basis of a new kind of modern NHS. If this can be achieved then he thinks this would be the cusp of a new enlightenment.

To comment on this chapter please feel free to leave a comment here, or on the discussion forum www.thefutureofthenhs.com

Chapter 4 - The Future of the NHS

This is a summary of chapter 4, written by Professor Steve Webb MP, Shadow Secretary of State for Health (Lib Dem)

Professor Webb argues that the debate surrounding the NHS is unhelpfully polarised, and that an observer would be forgiven for concluding that there are only two possible positions.

Pole One: The market-driven approach:
This has merit of simplicity and argues that competitive markets usually deliver lower prices, higher quality and greater. If this works for supermarkets, the argument runs, it should also work in public services. [But is the NHS like a supermarket?]

Pole Two: The “do nothing” approach:

This is believing there is nothing much wrong with the NHS that can’t be solved by pouring in yet more money.

He believes the reality is that neither of these extreme positions stand up to rigorous scrutiny.
He discusses there must a third way. He goes onto discuss accountability, decentralisation, creating a pattern of local health services, determined locally and accountable locally. Finally, he suggests that prevention is better than cure and we need more emphasis on public health and encourages people to live healthier lives.

He also offers the metaphor that watching the current state of the NHS is like watching the NHS is being subjected to amputation with a rusty hacksaw.

To comment on this chapter please don't hesitate to contact me direct, or post comments on the discussion forum www.thefutureofthenhs.com

Chapter 3 - The Future of the NHS

This is a summary of chapter 3 written by Andrew Lansley CBE MP, Shadow Secretary of State for Health (Conservative)

In this chapter Andrew Lansley raises the concerns that the NHS has all the complexities and bureaucracy of a huge organisation, yet lacks any of benefits of scale and consistency being delivered in practice. He discusses :

1) Public Health

He believes there is a distinction between the NHS and the health of the public at large; the NHS should treat the patient, whilst the government should treat society. Therefore, the first element in his future NHS, is to deliver improved public health.

2) Return the NHS service to its staff
He believes that in an NHS which is professionally-led and patient-centred. The professionals (doctors, nurses and managers) should be trusted to deliver the NHS service, free from day-to-day political interference.

3) Increase plurality – using competition to increase efficiency.
He believes that by using a plurality of providers, this would increase competition (a tide that can lift every boat) and in turn greater efficiency would ensue.

4) Finite resources versus insatiable demand
He believes that commissioning bodies will have to reconcile the tough decisions involved in finite resources with insatiable demand.

He believes the future of the NHS must be secured by a clear consistent strategic approach. This can not be achieved without the skill, care and leadership given by the staff of the NHS- managers free to manage; doctors able to offer clinical and professional leadership; nurses able to focus on the needs and care of patients; and all the staff of the NHS able to realise the potential of their service. He looks forward to an NHS in which patients put themselves in the hands of empowered professionals.

To read this chapter in full, please buy the book 'The Future of the NHS' - which is available from amazon, good bookshops or buy on-line www.thefutureofthenhs.com

Chapter 2 - The Future of the NHS

This is a summary of Chapter 2, written by the Rt. Hon. Patricia Hewitt MP, Secretary of State for Health.

Ask people what makes them proud to be British and most will name the NHS. In this chapter Patricia Hewitt explains the nature of necessary change and describes what a reformed NHS will look like. She first tackles why we need more change and then explains the four strands of reform:

1) More choice and a stronger voice for patients
She wanta to create a self-improving health service that designs its services around patients, rather than making patients fit in around the service.

2) Money following patient.
She beleives as patients exercise more choice, as different hospitals challenge each other to provide the best quality, as payment by results exposes differences in practice and therefore in cost, every clinician, every manager and every organisation will have an inbuilt incentive to compare themselves with the best, to innovate and improve, to give patients the best possible care – and taxpayers the best possible value for money.

3) Create more diverse providers
In her new NHS, there will be an element of competition. As that drives the less good hospitals to improve – or sees their services replaced by better providers.

4) A new framework of regulation and decision-making that guarantees quality, fairness, equity and value for money
She believes this will ensure proper stewardship of public funds.

She concludes that now is the only opportunity we will have in our lifetime to secure a health service that is true to its founding values, but fit for modern demands.

If people want to comment on this chapter, then please log onto www.thefutureofthenhs.com or send me a comment direct.

The Start of the Book Summary

Introduction - Chapter 1 The Future of the NHS, written by Dr Michelle Tempest.

The book aims to assist the reader, to penetrate the fog of confusion, about how to make future plans for the NHS. It brings eminent experts together from centrally relevant disciplines with a wide range of perspectives, to set out views clearly and readably; to enable the general reader (whether professional or lay person) to better understand the cardinal questions involved in this NHS debate. Early chapters express views from main political parties, Labour, Conservative and Liberal Democrats. Then chapters continue from top NHS professionals, experts at the forefront of their specialty, who collectively bring Centuries of experience. Their wealth of knowledge is unrivalled, admired and invaluable; they are the leading authorities across a broad range of specialties. The discussion continues about how the NHS is managed, trained, regulated and funded, and considers alternative and innovative methods of tackling complex financial issues.

It is imperative for every person to be involved in the debate, as it is not just for the ‘experts’ in the disciplines concerned, but for everyone - doctors, nurses and patients, lawyers and clients, legislators and voters, young and old, - because the debate crosses every age group and every social divide. Each one of us has a right to contribute to the debate, not least because, how we as a society answer the questions raised about the NHS, will ineluctably have a profound effect on the very nature of society as we know it. This book allows views regarding the NHS debate, to be informed rather than ignorant, rational rather than emotional, and to evaluate competing arguments and various ideas. ‘The Future of the NHS’ book enables the reader to take the first step into the most exciting debate of our times.

2006 is an important year for the NHS marking 60 years since the implementation of the National Health Service Act 1946. Therefore, it is an ideal time to start planning for the future of the service and to ensure '60th birthday celebrations' are not a sign of retirement. It is hoped that by gathering together some of the most eminent and respected health care professionals, policy makers and opinion formers, this book could go some way to pooling their collective wisdom into one volume and help start what might be the great health debate in this country.

So, where do we start with this process, to acquire long-term strategies for successful rehabilitation? In medicine, when a patient presents, the doctor starts by taking a history and then examining the systems. This book also takes this approach by asking the most involved and knowledgeable people from many walks of the NHS for their thoughts and ideas.

Each day for the next 34 days will include a very brief chapter summary of all the 35 book chapters.

An NHS Independent Board

Our health service has been founded on the principle that healthcare should be freely available to all from cradle to grave, and that provision should be based on need rather than ability to pay. These noble aims and ideals have been translated within the NHS to create what is frequently described as a ‘beacon to the rest of the world’.

This weekend Gordon Brown released his plan for the NHS: to devolve power away from politicians and create an NHS independent board. Basically, repeating his trick with the Bank of England by taking decisions away from ministers. This seems to be in tune with a recent YouGov poll carried out following the book ‘The Future of the NHS’ which found a two-to-one majority favouring the government withdrawing from day-to-day running of the NHS.

To give any possible future NHS independence board some idea of the mammoth task ahead, it’s worth noting that the NHS is the fifth largest employer in the world with 1.33 million people, behind only the Chinese army, the Indian Railways, Wal-Mart and the US department of defence. At any one time the total NHS population equals around the size of a small African country, such as Botswana. Thinking of the NHS as a country, and of this magnitude, really brings home some of the difficulties faced in how to manage an organisation with a vast number of patients, an unstable economy, an ageing infrastructure and an organisation that does not produce saleable goods.

On the face of it, an independent NHS board may look like a welcome reform, removing the temptation of politicians to meddle for short-term political gain. So why has the British Medical Association warned that the new proposals do not help address NHS problems? Perhaps, the reality is that by creating an independent board, it hands over an important part of our political system to an unelected group, and takes the decision-making process yet one step further away from the people it directly affects. After all, we already live in a society with 882 such quango bodies costing a total of £124 billion.

Next year sees the end of the increased level of spending pledged to the NHS and what will remains are some extremely difficult policy decisions to be made. The question then seems to become, is this new level of bureaucracy a method of passing the buck on political decisions?

Stick-thin obsession must end

This was published in The London Paper, 18/9/06

To celebrate London Fashion Week, try the following exercise. Count the number of times your brain registers an image of a thin woman between getting up and going to work.

Check your cereal box, your newspaper, your morning TV, posters on the Tube. When I did this recently, I was staggered to count 63 models who appeared underweight in less than an hour. Almost every minute, my brain was being subjected to an unhealthy image. Society now seems to accept that junk food is an unhealthy input into our mouths, yet it still seems unconcerned that junk information is unhealthy food for the brain. We get a choice of different foods on offer, so why don’t we have a choice of what stimuli our brains are bombarded with?

Eating disorders including anorexia nervosa, bulimia nervosa and binge-eating disorder, affect a staggering 12 per cent of the population with milder forms being more prevalent. The common factor among all eating disorders is dissatisfaction with body shape and consequent dietary restrictions. Although these disorders are multifactorial, few would dispute the social pressure to be thin, especially for women.

The sad fact for anorexia nervosa sufferers is that as many as 20 per cent may die – some during their quest to imitate underweight role models. What must be done?

Few people would argue with the general proposition that weight in itself is a matter of personal choice. Further, that press freedom is crucial to a democratic society. However, with freedom comes responsibility and this is where the problem lies. By turning a blind eye to the effects it is having on society, the media is simply abusing its freedom at the expense of us all.

One solution may be to add provisions into the constitutions of the media’s regulatory bodies, such as the Press Complaints Commission, to try to avoid portraying the symptoms of eating disorders as glamorous. Or, as we celebrate the start of London Fashion Week, a lead might be taken from a recent show in Madrid to ban models with a Body Mass Index below 18 and urge them to go see a doctor rather than go down a catwalk.

Why Society is Part of a Big Family

Tory leader David Cameron said his party must do more to keep families together, after a report suggested that parental splits are creating an underclass.

Indeed, it is known that behaviour is learnt after spending years imitating parents, siblings, friends and society. Many people like to blame their parents for their maladaptive coping strategies, and this may, in part, be true. However, this also leads onto the good news – if behaviour is plastic then it can also be modelled, so new behaviours can be learnt changed and modified. After accepting that behaviours can be learnt from others at any age, the door is opened to breaking the cycle of maladaptive coping mechanisms, by modelling new behaviour on different adaptive coping mechanisms.

Whilst the report highlights the role of parents, we forget at our peril, the societal social responsibilty.

The Master

“the metaphor is perhaps one of man’s most fruitful potentialities. Its efficacy verges on magic, and it seems a tool for creation which God forgot inside one of His creatures when He made him.”
Jose Ortega y gasset

The master of metaphor Winston Churchill understood that to make something understandable, the message had to be given to the receivers’ brain in a way the brain can create a picture with it; after all, a picture can incorporate a thousand words. Nearly everyone finds it easier to understand in terms of metaphors. For example, “struggling to keep my head above water”, is a cry many people howl when they have taken on too much work.

It is interesting to consider the power of metaphors within our own internal questioning. Can internal stress be increased by saying you're “struggling to keep your head above water” rather than “climbing the ladder of success”? If working is seen in a similar light as “pulling teeth”, will it make the task much more arduous than if it was seen as “playing a game”? When a metaphor is given, it’s important to remember the framework it’s sending your internal mind. It is far easier supporting the mind, than informing it about the possibility of drowning or having teeth removed.

The power of metaphors is dicussed futher in the new book (due start 2007) 'Why Lawyers Should Surf' by myself and Mr Tim Kevan

Psychiatry and Surfing at the Beach

Next time you are at the beach, spare some time to observe the waves. Many will have heard life advice ‘go with the flow’, but is this really the answer? If you take the journey of life to be analogous to surfing the sea waves then there are several things to consider.

Just as in life, ground work must be undertaken. The way the sea, wind, shore, tides, and moon interact must be learnt about. Knowledge must be attained about the equipment, boards and the safety procedures. Dangers and consequences must be considered with reference to respecting what's around you and the environment's possible limitations. Inevitably there will be obstacles along the way and some waves will throw the surfer off the wave resulting in the full weight of the water above, crashing down upon them. Each situation has to be dealt with individually; but the important thing is never to loose the love for trying, otherwise that would be paramount to lacking the zest for life. Instead the surfer must get straight back on the surf board and rise up to the next challenge. Surfers can expect to get thrown off some waves, but rather than seeing these ‘wipe outs’ as failures and giving up, surfers seize them as learning opportunities. Mistakes and ‘wipe outs’ are experiences to learn from and it’s never too late to learn from failures and share knowledge with others. Buckminster Fuller once wrote “Whatever humans have learned had to be learned as a consequence of trial and error experience. Humans have learned through mistakes.”

Surfers need to carefully consider which wave to catch and which direction they must point their board in order to gain the most awesome ride. Surfers quickly learn to consider their direction of travel, as not only do they have to be able to avoid dangerous sea bed rocks but also their wave position makes the difference between riding a wave and falling off it. This is analogous to planning life’s journey, as forgetting to consider the direction of travel would be like trying to fit together a jigsaw puzzle without having seen the bigger picture. Life does not and can not stand still, deciding upon the wave to follow, prevents just ‘going with the flow’ of water and being washed up somewhere you had not anticipated to be. Instead, surfers learn to steer their own course and ultimately their own destiny.

These thoughts will be included in a new self-help book entitled 'Why Lawyers Should Surf' (xpl publishing), which will be available in bookshops from 2007.