Tuesday, May 22, 2018

NHS Original: Best Health Care!


Friends moved to France after their retirement and lived in one of the wine growing districts.
 ©2008 Am Ang Zhang
They were extremely pleased with the Health Care they received from their doctor locally. After all, not long ago, French Health Care topped the WHO ranking.

Then our lady friend had some gynaecological condition. She consulted the local doctor who referred her to the regional hospital: a beautiful new hospital with the best in modern equipment. In no time, arrangement was made for her to be admitted and a key-hole procedure performed. The French government paid for 70% and the rest was covered by insurance they took out.

They were thrilled.

We did not see them for a while and then they came to visit us in one of our holiday places in a warm country.

They have moved back to England.

What happened?

Four months after the operation they were back visiting family in England. She was constipated and then developed severe abdominal pain. She was in London so went to A & E (ER) at one of the major teaching hospitals.

“I was seen by a young doctor, a lady doctor who took a detail history and examined me. I thought I was going to be given some laxative, pain killer and sent home.”

“No, she called her consultant and I was admitted straight away.”

To cut the long story short, she had acute abdomen due to gangrenous colon from the previous procedure.

She was saved but she has lost a section of her intestine.

They sold their place in the beautiful wine region and moved back to England.

The best health care in the world. 

Now we know.

Let us keep it that way.


NHS & Private Medicine: Best Health Care & Porsche

Do we judge how good a doctor is by the car he drives? I remember medical school friends preferred to seek advice from Ferrari driving surgeons than from Rover driving psychiatrists.

My friend was amazed that I gave up Private Health Care when my wife retired.

“I know you worked for the NHS but there is no guarantee, is there?”

Well, in life you do have to believe in something. The truth is simpler in that after five years from her retirement, the co-payment is 90%.

He worked for one of the major utility companies and had the top-notch coverage.

“The laser treatment for my cataract was amazing and the surgeon drives a Porsche 911.”

Porsche official Website

He was very happy with the results.

“He has to be good, he drives a Porsche.”

Then he started feeling dizzy and having some strange noise problems in one of his ears.

“I saw a wonderful ENT specialist within a week at the same private hospital whereas I would have to wait much longer in the NHS.”

What could one say! We are losing the funny game.

What does he drive?

A Carrera.

Another Porsche.

We are OK then.

Or are we.

He was not any better. And after eight months of fortnightly appointments, the Carrera doctor suggested a mastoidectomy.

Perhaps you should get a second opinion from an NHS consultant. Perhaps see a neurologist.

“I could not believe you said that, his two children are doctors. And he has private health care!” I was told off by my wife.

He took my advice though and he got an appointment within two weeks at one of the famous neurological units at a teaching hospital.

To cut the long story short, he has DAVF.

I asked my ENT colleague if it was difficult to diagnose DAVF.

“Not these days!”

He had a range of treatments and is now much better.

All in the NHS hospital.

“I don’t know what car he drives, but he is good. One of the procedures took 6 hours.”

Best health care.

I always knew: Porsche or otherwise.


Best Health Care: NHS GP & NHS Specialist


Does having a good hunch make you a good doctor or are we all so tick-box trained that we have lost that art. Why is it then that House MD is so popular when the story line is around the “hunch” of Doctor House?

Fortunately for my friend, her GP (family physician) has managed to keep that ability.

My friend was blessed with good health all her life.  She seldom sees her GP so just before last Christmas she turned up because she has been having this funny headache that the usual OTC pain killers would not shift.

She would not have gone to the doctor except the extended family was going on a skiing holiday.

She managed to get to the surgery before they close. The receptionist told her that the doctor was about to leave. She was about to get an appointment for after Christmas when her doctor came out and was surprised to see my friend.

I have always told my juniors to be on the look out for situations like this. Life is strange. Such last minute situations always seem to bring in surprises. One should always be on the look out for what patient reveal to you as a “perhaps it is not important”.

Also any patient that you have not seen for a long time deserves a thorough examination.

She was seen immediately.

So no quick prescription of a stronger pain killer and no “have a nice holiday” then.

She took a careful history and did a quick examination including a thorough neurological examination.

Nothing.

Then something strange happened. Looking back now, I did wonder if she had spent sometime at a Neurological Unit.

She asked my friend to count backwards from 100.

My friend could not manage at 67.

She was admitted to a regional neurological unit. A scan showed that she had a left parietal glioma. She still remembered being seen by the neurosurgeon after her scan at 11 at night:

“We are taking it out in the morning!”

The skiing was cancelled but what a story.

Best GP

Best Specialist

NHS

Monday, May 21, 2018

Bipolar Disorder: Lithium-The Cinderella or Aspirin of Psychiatry?

Lithium in Tap Water and Suicide Mortality in Japan.

Abstract: Lithium has been used as a mood-stabilizing drug in people with mood disorders. Previous studies have shown that highest levels of suicide mortality rate in Japan. Lithium levels in the tap water supplies of each municipality were measured using natural levels of lithium in drinking water may protect against suicide. This study evaluated the association between lithium levels in tap water and the suicide standardized mortality ratio (SMR) in 40 municipalities of Aomori prefecture, which has the inductively coupled plasma-mass spectrometry. After adjusting for confounders, a statistical trend toward significance was found for the relationship between lithium levels and the average SMR among females. These findings indicate that natural levels of lithium in drinking water might have a protective effect on the risk of suicide among females. Future research is warranted to confirm this association.
Australian Trilogy:

Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

 

Fremantle: Medical Heresy & Nobel

 


Tasmania & SIDS: The wasted years!


"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium.

Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?

Could it be the fact that 
Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.

Some felt it has to do with how little money is to be made from Lithium.


My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?


Stephen Fry has disclosed that he attempted suicide last year and only survived the “close run thing” when a colleague found him unconscious after he had taken “huge” quantities of pills and vodka.

Fry suffered a nervous breakdown in 1995 while he was appearing in the West End play Cell Mates and disappeared for several days, coming close to suicide.

In 2006 he made a two-part television documentary called Stephen Fry: The Secret Life of the Manic Depressive, in which he spoke to other celebrities including Carrie Fisher and Tony Slattery about their own problems with the illness. In the programme he also disclosed that he had first attempted suicide aged 17 by taking an overdose.

In 2011 he said of his illness: “The fact that I am lucky enough not to have it so seriously doesn’t mean that I won’t one day kill myself, I may well.”

I hope he is on lithium!  
Unless he is doing a Carrle Fisher!

©Am Ang Zhang 2013

Cade, John Frederick Joseph (1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.

And many lives too!

I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here.      It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.

The following is an extract from The Cockroach Catcher:
“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”

“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”

Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.

“Get him admitted and I shall talk to the doctor there.”

He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.

He had one of the worst encephalitis     they had seen in recent times and they were surprised he survived.

Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.

Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.

I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.

Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvard research shows.
Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.
Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.
Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.
Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.
Could Lithium be the Aspirin of Psychiatry? Only time will tell!
Related Posts:


Chile: Salar de Atacama & Bipolar Disorder.


NHS Plot : 5% & Disintegration!


Inspector: Okay. The rules exist because 95% of the time, for 95% of the people, they’re the right thing  to do.


Question: And the other 5%?
Inspector: Have to live by the same rules. Because everybody thinks they’re in that 5%.



©2012 Am Ang Zhang

Most of us who specialise in different specialist medical disciplines do so for the purpose of dealing with 5% of patients.


Yet it is these 5% that central government try their best to not treat. Despite clever attempts, the NHS soup stayed the same: CCGs, FT Hosp., AQPs, OOH, NHS 111. 


Now:

Referral Scrutiny GPs had been put under pressure to refer through their local scheme. One GP partner in England said a local project that started as a 'very useful and helpful referral assessment service' was starting to become a 'referral blocking service'. The scheme amounted to 'arbitrary decisions made by unqualified administrators', said the GP. Others complained the schemes were 'designed to massage waiting list figures'.


Try calling patients clients too! 


Nowhere in the world is health care more disintegrated than in England and there is even pretend integration speak: integration could mean signing away your right to hospital care when you most need it. NHS reorganisation is an attempt to reduce the 5%. Unfortunately some of the 95% tried to gatecrash the 5% hospital party. No, no NHS111 or OOH or even GPs. 


A&Es are still trusted. Why? Because in England the only difference between public and private health is the Cappuccino; the docs are the same. Except perhaps PIP implants.



In one of the episodes of House M.D.

Inspector: Okay. The rules exist because 95% of the time, for 95% of the people, they’re the right thing  to do.
Question: And the other 5%?
Inspector: Have to live by the same rules. Because everybody thinks they’re in that 5%.


In recent days medical tragedies hit the news with regular frequency. What has happened to medical training?

Being brought up in the older medical tradition I have found it engaging to watch the ever so popular House M.D.

It was a relief to hear from my classmates that they too like watching it.

It would not surprise anyone to find that House M.D. has made it to Medical Humanities, a BMJ Journal:
Medical paternalism in House M.D.
M R Wicclair Medical Humanities 2008Deborah Kirklin in the editorial of the same issue commented:

"Fear and pity are not emotions that Dr Gregory House, star of the popular television series 'House M.D.', acknowledges or accommodates in either his professional or private life. He is arrogant, rude and considers all patients lying idiots. He will do anything, illegal or otherwise, to ensure that his patients—passive objects of his expert attentions—get the investigations and treatments he knows they need. As Wicclair argues, House disregards his patients’ autonomy whenever he deems it necessary So why, given the apparently widely-shared patient expectation that their wishes be respected, do audiences around the world seem so enamoured of House? Wicclair’s answer raises interesting questions about the extent to which patients trust the motivations of their doctors. Perhaps, he suggests, for the many viewers drawn to this arch paternalist, there is something refreshing about a doctor willing to risk all—job, reputation and legal suits—in order to fulfil his duty of care to his patients: the duty to take care that his actions or inactions do not harm his patients. Because, for good or for bad (your call), once you’re House’s patient there is nothing he won’t do, no inaction he will tolerate, if he believes that by failing to act he will harm you.”

Wicclair stated:“Paternalism is clearly against the norms of mainstream medical ethics. Informed consent—the principle that, except in emergency situations, medical interventions require the voluntary and informed consent of patients or their surrogates—is a core ethical principle in healthcare. A corollary of informed consent is that patients who are able to decide for themselves have a right to refuse treatment recommendations. Another core principle is that when patients lack decision-making capacity, surrogates should make decisions in line with the wishes and values of the patient. Both of these principles reflect a strong opposition to paternalism in contemporary medical ethics.”
Contemporary medical ethics! Except perhaps in Anorexia Nervosa where the Mental Health Act could be used to force feed in a number of countries. The fact that such force feeding did not seem to reduce mortality is a different matter as some deaths are not by direct starvation.
Wicclair asked:
“Yet House repeatedly acts paternalistically without giving it a second (or even first) thought. Is he right, and is the antipaternalism of mainstream medical ethics wrong; or is House mistaken and is a strong moral presumption against medical paternalism justified?"
To prevent House M.D. from becoming God they have to make him out to be rude and full of personal problems and he even rides a motorbike.
Wicclair offered a way out:
“In the world of House M.D., choices typically are life-or-death choices: if a patient doesn’t receive a certain medical intervention, the patient will die.
“However, in the real world, choices are not always so stark. ……If, after careful consideration, a competent patient decides against having the procedure, it would be unwarranted for a physician to insist that the patient needs it.”

You can read it
 here (may require subscription).
Yet my personal view is this, you may be rich, famous or even well educated, but you may not know all that you needed to know to make that judgment.
As Dr Crippen pointed out there are just three medical procedures that can be dramatically live-saving. You might also want to read Dr Grumble’s personal account here.

At the Hudson Plane Crash earlier this year a quick thinking ferry captain 
Brittany Catanzaro came quickly to the rescue of passengers in near freezing water. She was not a doctor.

In Hong Kong a man died outside a medical centre because a nurse receptionist was following guidelines, 
Guideline V to be precise.Kevin M.D. was charitable about Canadian Health Care when he looked at the tragic death ofNatasha Richardson. A number of papers only picked up the fact she turned away the earlier ambulance, but then this happened:
"After picking her up from the hotel, there was a 40-minute drive to the community hospital, the Centre Hospitalier Laurentien. She did have a CT scan there, and the decision was made within 2 hours to transport her to a tertiary care center, another hour away in Montreal." 
And still no burr holes after the CT scan?
Dr. Crippen said that the brave physician would have drilled the burr holes without the benefit of a CT scan:"It would be a career making or career breaking decision. Few American doctors are brave. Defensive medicine is the order of the day. You cannot have a migraine in the USA without someone ordering an MRI scan."
Has modern medical training managed the unthinkable of producing a new generation of doctors and other medical staff forgetting that they should use their brain? Or have they all been “guidelined” out? Has the 5% finally become the 95% too? 
3212009


Where were you when we needed you, Dr House M.D.? 
House M.D. must have the last words:
Question: "Isn’t treating patients why we became doctors?"

House: "No, treating illnesses is why we became doctors."

Granddad: Remember Iceland? Why did you not learn?

Hallgrimur Church, Iceland

 ©2012 Am Ang Zhang

The report comes after The Independent revealed that 51 councils who lost £470m when Iceland's banking system collapsed employed Butlers – an ICAP subsidiary – as their treasury management advisors. ICAP in turn received commission from Icelandic banks for brokering 16 per cent of those investments.


The business empire of the Conservative Party treasurer and chief fundraiser Michael Spencer should be investigated over the propriety of its dealings with local councils and other public bodies, MPs say today.

The Communities Select Committee say in a scathing report that the Financial Services Agency (FSA) should investigate whether it is appropriate for one part of Mr Spencer's ICAP empire to assist council finance officers with council investments while another part receives fees for brokering the deals. This could give rise to "actual or perceived conflicts of interest", it said. The FSA said it would consider the request.

Of the 116 local authorities who lost money, 51 received advice from Butlers. 


Granddad: Why? 

I went to school and they told us all about doing good and preserving our oceans and our planet. Your minister insisted that instead of abandoning nuclear power as it was the most expensive failure he would embrace it. Did not sound like learning anything at all:

The climate change secretary, Chris Huhne, has described the UK's nuclear policy as the "most expensive failure of postwar British policy-making" in a "crowded and highly-contested field".

…..Speaking at the Royal Society on Thursday, Huhne said: "If we are to retain public support for nuclear as a key part of our future energy mix then we have to show that we have learned the lessons from our past mistakes."

…..Huhne noted the UK has enough high-level nuclear waste to fill "three Olympic-sized swimming pools, and enough intermediate waste to fill a supertanker". Because of the errors of the past, his department was spending £2bn a year "cleaning up" the "mess" of nuclear waste which he said would rise two thirds next year.

"Nuclear energy has risks, but we face the greater risk of accelerating climate change if we do not embark on another generation of nuclear power. Time is running out. Nuclear can be a vital and affordable means of providing low carbon electricity," he said.

I thought you might have learnt after Andy CoulsonRiotsMurdoch and Liam Fox, you might choose to listen to some decent advice.

Granddad: Why? 

The nuclear power failure may turn out to be the 2nd most expensive failure: The NHS failure is turning out to be many times more.

You should have listened to Baroness Kennedy of The Shaws  who neatly summarise what many bloggers and doctors were saying for months:

Care, not money:
My Lords, I make a declaration that I am a fellow of three royal colleges, too, like the noble Baroness, Lady Cumberlege. I should also say that I am married to a surgeon who has spent his life in the National Health Service. He is from a dynasty of doctors. His grandfather was a doctor, his mother a doctor, his aunt a doctor and now our daughter is entering medical school. They all entered medicine not because they are interested in making money but because they want to care for people. It is the idea of being at the service of others that draws most health carers into medicine. They do not want to run businesses; they do not see their patients as consumers or themselves as providers. They do not see their relationship as commercial and they do not want to be part of anything other than a publicly funded and provided National Health Service.

Private Providers and Secrecy:
Health professionals also feel proud, as all of my husband's colleagues do, that Britain is the only country in the industrialised world where wealth does not in some measure determine access to healthcare. They are saddened that the National Health Service is now facing the prospect of becoming a competitive market of private providers funded by the taxpayer. When we hear talk of accountability, they point out that nothing in the Bill requires the boards of NHS-funded bodies to meet in public, so there will be a lack of transparency. That will be complicated by the fact that private providers are not subject to the Freedom of Information Act, so they can cite commercial sensitivity to cover their activities.

Insurance-based model by stealth:
Others have spoken of the removal of the duty on the Secretary of State to provide healthcare services and pointed out that that duty is now to be with unelected commissioning consortia accountable to a quango, the national Commissioning Board. The Bill does not state that comprehensive services must be provided, so there may well be large gaps in service provision in parts of the country, with no Secretary of State answerable. Providers will be able to close local services without reference of the decision to the Secretary of State. Although the Government say that the treatment will be free at the point of delivery-we hear the calm reassurances-the power to charge is to be given to consortia. That paves the way for top-up charging and could lead eventually to an insurance-based model.

Monitor & family silver:
Monitor, the regulator, is to have the duty to sniff out and eliminate anti-competitive behaviour-and, of course, to promote competition. According to the Explanatory Notes to the original Bill, Monitor is modelled on
"precedents from the utilities, rail and telecoms industries".
How is that for reassurance to the general public? If anything should be a warning that this spells catastrophe, it should be that this is another step in the disastrous selling-off of the family silver to the private sector, with the public eventually being held to ransom and quality becoming second to profitability.

Monitor: Competition or integration.
The regulator, Monitor, will have the power to fine hospital trusts 10 per cent of their income for anti-competitive behaviour. Any decent doctor will tell you that for seamless, efficient care for patients, integration is key to improving quality of life and patient experience. The question is whether competition and integration can co-exist. Evidence from the Netherlands is that they cannot. There, market-style health reforms designed to promote competitive behaviour have meant that healthcare providers have been prevented from entering into agreements that restrict competition, so networks involving GPs, geriatricians, nursing homes and social care providers have been ruled anti-competitive. There is a fear that care pathways, integrated services and equitable access to care in this country will be lost when placed second to market interests.

Delusion of patient choice: Cherry Picking
Under the delusion of greater patient choice, people are to be given a personal health budget. I am interested to hear what happens if it runs out halfway through the year. Private hospitals will enter the fray as treatment providers and, as in other arenas, they will undoubtedly, as others have said, cherry-pick and offer treatment for cases where they can treat a high number of low-risk patients and make a profit-for example, hip and knee replacement, cataracts, ENT and gynae procedures.

NHS Hospitals: Undermined!
It is essential in an acute teaching hospital to retain the case mix, though, so it will be the teaching hospitals that will also provide the loss-making services such as accident and emergency and intensive care and deal with chronic illness and the diseases of the poor, such as obesity-we can name them all. These are essential services but they are also very costly. An ordinary hospital cannot provide them if it does not have the quick throughput cases as well to maintain a financial balance. If relatively easy procedures go to private providers, the loss of revenue to the trusts will eventually lead to them being unable to provide the costly essential services. It will mean that doctors trained in these places are not exposed to all aspects of patient care. Private companies cherry-picking services undermines and destabilises the ability of the NHS to deliver essential services like, as I have mentioned, intensive care units, accident and emergency, teaching, training and research.

Asset Stripping: as Southern Cross
Clause 294 allows for the transferring of NHS assets, including land, to third parties, and the selling off of assets. Clause 160 allows for the raising of loans by trusts, so hospitals taken over by the private sector could be asset-stripped and then sold on, as happened with Southern Cross homes.

Practice Boundaries:
The removal of practice boundaries and primary care trust boundaries will mean that commissioning groups will not be coterminous with social services in local authorities, so vulnerable people are more likely to fall through the gaps between GP practices. GPs will also be able to cherry-pick by excluding patients who cost more money and can lead to overspend.

Lawyer-multimillion-pound executive salaries, dividends and fraud:
Then there is the issue of the cost of market-based healthcare. Advertising, billing, legal disputes-I say this as a lawyer-multimillion-pound executive salaries, dividends and fraud could end up consuming a huge amount of the pot that can be spent on front-line services. We will end up, as in America, with that extra stuff taking up 20 per cent of the health budget. The downward spiral of ethics, the increase in dishonesty and the conflicts of interest become huge, and you see the destruction of the public service ethos.

Overdiagnoses, overtreats and overtests.
I want to scream to the public, "Don't let them do it"-and in fact the public are responding by saying in turn, "Don't let them do it". Market competition in healthcare does not improve outcomes. The US has the highest spending in the world and the outcomes are mediocre. The US overdiagnoses, overtreats and overtests. Why? Because that increases revenue. You change the nature of the relationship between doctors and their patients. You get more lawsuits and doctors therefore practise defensive medicine. You ruin your system.
I say this particularly to colleagues on the Liberal Democrat Benches. They may be being encouraged to think that voting against the Bill may bring down the coalition, but all I can say is that the electorate is watching. If people feel failed by the party on this, I am afraid that it will pay a terrible price.

McKinsey et al: 25 year plot:
This has been a 25-year project, done by stealth. It started with the internal market and is now moving to the external market. It was not thought up by mere politicians but by the money men, the private healthcare companies and the consultancies like McKinsey-the people, in fact, who in many ways brought us the banking crisis. They have funded pro-market think tanks and achieved deep penetration into the Department of Health, into many of our health organisations and right into some of the senior levels of my party as well as those on the other Benches.

The NHS is totemic. It is about a pool of altruism and it speaks to who we are as a nation. It is the mortar that binds us in the way that the American constitution does the American people. For us, it is about this system. It really is the place where we are "all in it together"-one of the few places, it would seem at the moment. Doctors get 88 per cent trust ratings with the public, while politicians get 14 per cent. The vast majority of doctors are saying to us, "Withdraw this Bill". We should be listening.

Granddad, I have read most of these behind your back via Twitter and many Blogs. You should have listened. Now we are paying dearly.


Hansard source (Citation: HL Deb, 11 October 2011, c1551