The Twunt's Comms Masterclass 1: Shafting a Whistleblower. David Drew - A Case Study.

Definition. Whistleblower.(ˈwɪsəlˌbloə(r) ) "A man or woman who is unable to control their ability to shut the fuck up" (Jeremy Twunt's NHS Dictionary)

There have been some high profile comms failures since The Twunt took up the hot seat.  As the resident comms genius in Richmond House, I am issuing this note as part of a potential series of comms masterclasses. I want to deal with the whistleblowing phenomenon that has been in the papers like stink on shit since the beginning of the year. Ive flagged several of the most high profile of these fuckers already. If you have one of these characters crapping on your patch you need a strategy to deal with them before you completely lose control of your comms.

It can be an utter pain in the arse to have someone on your team who doesn't buy in to your corporate strategy on reputational management. You know the kind. They raise awkward awkward questions about patient safety  (just because you don't sort out any minor problems straight away) and embarrassing questions about the competency of their colleagues.

THERE IS NO I IN TEAM PEOPLE!! YOU NEED THESE FUCKERS OUT. They are a serious threat to your organisations' reputation and by extension, your tenure as CEO. For this note I am going to use some examples from the case study of Dr David Drew (@NHSWhistleblower on Twitter). Now (sadly), you will know that it is illegal to sack idiots like Drew under PIDA legislation so you are going to have to get creative. Following these 5 simple steps you may just get a result. Drew is proof that this works. His appeal against the Employment Tribunal which backed his sacking by Walsall Manor Trust failed last week.

1) Try some of the standard tried and tested techniques. Make life as difficult for them as possible. Querying their mental health with some well placed people often does the trick. If that doesn't work you could try this sort of thing.

2) You'll also need to trawl for dirt on the idiot in question. Doesn't matter how old it is. But it needs to be effective. Here is a good example.

3) Naturally you will be challenged by your target so you may need an 'independent' review team to come in and take him or her down. This wont be easy so here's what has to happen. Firstly, under no circumstances must the review address the whistleblowers claims. The panel will identify leadership weaknesses and recommend the removal of a key manager. This position (lets say, for the sake of argument its a Clinical Director post) could then be offered to the chair of the panel recommending the change (on an interim basis...and it would have to be a good career stepping stone for him of course).  As you know,  conflicts of interest don't matter as long as they are declared. I know this for a fact....because I said it. Now, I'm sure there is a technical name for this kind of thing but it has momentarily escaped me....

4) The new incumbent then has to usher the whistleblower snitch out. I recommend bribes first and if that fails then make some ridiculous demands like not using religious language in work. This is pretty reasonable, its not like you haven't gone the extra mile with your previous inducements. And you are not making this guy a scapegoat for a department with serious problems

5) Now if any of this ever got out you would clearly be in deep shit. To that end I would recommend that you get all members of the panel to sign a gag. As you know, I have had to say that I will ban the gagging of whistleblowers. However, I've never said a thing about it being wrong to gag the people investigating snitches....so, y'know...carry on.

Of course, once you have finally got rid of this moron you may have to weather a little local media turbulence as a window of opportunity opens up to allow them to mouth off. But take confidence in the rock solid fact that they will not get an iota of support from their former colleagues who will have seen through their crap. And that their patients are glad that they have gone......really glad.

All of this will help you keep your ship on course.....there may be a few casualties along the way but you have to think its for a greater cause. Now I'm going to let you in on a secret. Follow these simple  steps and you will buy yourself some peace....but you dont have to worry about getting caught out. The big secret is that no one who can intervene and hold you to account really gives a fuck. I'm not going to kick up a stink and have said that there is no need for an inquiry into whistleblowing in the NHS. The Health Select Committee and Comrade Nicholson have taken the same view.

Post Script :- It appears that David Drew is about to publish a book which may blow the lid on what went on at Walsall (its such a pity that the recent heart attack he had didn't finish him off). The Twunt predicts that it will sink like a stone BUT if by some lucky chance it goes big I WILL FUCKING SACK ANYONE I CATCH WITH A COPY. No questions, no second chances. Got it? Good.

What do you do with a problem like Kay Sheldon?

"The world is a dangerous place, not because of those who do evil, but because of those who look on and do nothing." -Albert Einstein

OK coasters, The Twunt has got a problem. On the 13th of May I have a meeting with a non-executive director of the Care Quality Commission. Her appointment is up for renewal and she wants to stay on. Her name is Kay Sheldon (@KayFSheldon on Twitter) and she has got A FUCKING CHEEK!!!

If you've never heard of her before then you may not know that Sheldon has been in this position before. She blew the whistle on the CQC's catastrophic leadership during the Midstaffs clusterfuck as part of a ridiculous grandstanding gesture at the Midstaffs public inquiry. This unfortunately ended up with the then CEO of the CQC (Cynthia Bower) resigning. This pissed off the Chair of the CQC (Dame Jo Williams) so much that she did this and then wrote to Andrew Lansley asking him to give Sheldon the boot. Lansley refused. Dear Readers. I know Andrew Lansley, I've shaken Andrew Lansley's hand and looked into those cold dead eyes. Let me tell you now...I am no Andrew Lansley. Sheldon is getting the boot.

All this kept Sheldon in the firing line at the CQC As can be seen in this car-crash grilling of Jo Williams by the Health Select Committee here (starting from 11.29 and really hotting up at 11.47). Williams exposes Sheldon as the nut job which she undoubtedly is (before being embarrassingly called out by Valerie Vaz and inviting this complimentary comment from the respected health commentator Andy Cowper -@HPIAndyCowper). 

Now you'd think that given the clear out of the CQC's executive team last week Sheldon would be in the clear. However, the current incumbent of the chairs position (Former Tory MP David Prior) has told me that he thinks that given her position she should resign as a NED. Which is why I referred to her relation ship with the board as having a "long history of acrimony." (Answer to Q533)

Well what makes a good non executive director? That's a big question but it can be succinctly answered in three words. The Nolan Principles.

The Nolan Principles were created as part of the first report by the Committee on standards in public Life (itself created by John Major in 1994 as his government became mired in allegations of sleaze). There are 7 of them and as they form part of the ministerial code they apply to me as much as they do to Sheldon. Her problem is not that she didn't follow the ones that apply to her to the letter...but that she took them way too fucking seriously:

• Selflessness Holders of public office should act solely in terms of the public interest. They should not do so in order to gain financial or other benefits for themselves, their family or their friends. - To be honest...this one is an utter mystery to me. I can't think of one member of this cabinet who this applies to. Sheldon on the other hand has just gone off at the deep end with this selflessness shit. She just carries on doing her job despite every banana skin put in her way.

• Integrity Holders of public office should not place themselves under any financial or other obligation to outside individuals or organisations that might seek to influence them in the performance of their official duties. WELL this is all well and good but The Twunt suggests an additional consideration. People shouldn't have TOO MUCH integrity  Sheldon obviously does.  She  was only allowed to stay on the exec team after intervention Andrew Lansley once he had been prodded by Sheldon about his own policies towards whistleblowers

• Objectivity In carrying out public business, including making public appointments, awarding contracts, or recommending individuals for rewards and benefits, holders of public office should make choices on merit. - Hahahahahahaaaaa! Suffice to say Ill be ignoring this one on Monday.

• Accountability Holders of public office are accountable for their decisions and actions to the public and must submit themselves to whatever scrutiny is appropriate to their office. Oh....I think Sheldon is going to be held accountable. I'll see to it...

• Openness Holders of public office should be as open as possible about all the decisions and actions that they take. They should give reasons for their decisions and restrict information only when the wider public interest clearly demands it. Sheldon is BIIIG on this one...JUST READ THIS SHIT FOR GODS SAKE!!!

• Honesty Holders of public office have a duty to declare any private interests relating to their public duties and to take steps to resolve any conflicts arising in a way that protects the public interest. Jeezus....I dont even know what to say about this. You can be too honest you know...Sheldon was

• Leadership Holders of public office should promote and support these principles by leadership and example. - Ahem......

So, ask yourself.,,,do you really want to see someone like Sheldon working at the CQC? Now, I see that the word has gotten out about this meeting and I'm starting to get tweets off dickheads like this....

This does not please me. I don't want to see anything else like this again. OK? Sheldon is going down. End of.

The Tory Blues

Tory Blues

Stop all the protesters, cut off their mobile telephones
Prevent them all from whinging. Confiscate their eggs and stones.
Fire up the Daily Mail and with muffled drum
Bring out her coffin, let the mourners come.

The liberal leftwing media keep moaning in our heads
Scribbling on their front pages the message
Ding Dong the wicked old witch is Dead,
While the rest of the country dies a death from 1000 cuts
Pour out 10 million for her funeral..lets have no 'ifs' or 'buts'..

She was our Tory North, our South, our East and West,
Our working week and our Sunday rest,
Our noon, our midnight, our talk, our song,
Till we stabbed her in the back and now she is gone

The miners are not wanted now, get rid of every one;
Pack up the Eurozone but never dismantle The Sun;
Pour away the unions and soak up Orgreaves blood.
And let’s have a massive barney over whether she was bad or good.

                                 

                                 

NHS Whistleblowers as heroes? The Twunt thinks not!!

OK...Richmond House we have got a big fucking problem. It has come to my attention that 
there is a concerted campaign to get two NHS whistleblowers installed as winners of the  NHS Heroes Competition. I have got to take a line on this. Here it is.

OVER THE DEAD BODY OF JEREMY FUCKING TWUNT!!!

This is a CODE RED situation. Repeat this is not a fucking rehearsal. The DoH Hit Squad has been alerted. These two fuckwits need to be neutralized

Target 1: Gary Walker (a.k.a @ModernLeader). Former CEO of United Lincolnshire HospitalsTrust. 

If you haven't heard of this baby-faced snitch before, here is a potted history which was added to this month when he appeared before the Health Select Committee and pretended that he had been forced out for challenging the target culture that David Nicholson is charged with presiding over because he was (and here is the unbelievable bit) "concerned about its implications on patient safety. I mean, is this guy for real?! His boss at the time,  Barbara Hakin told Walker to meet his target  'Whatever the demand'. I PROPOSE BARBARA HAKIN AS A REAL NHS HERO!! She is just the sort of person should should be leading the NHS. (Which is probably why David Nicholson chose her as his Deputy). 

Of course, his old trust and strategic health authority hotly contest that Walker is a whistleblower (on the rock solid grounds that a court hadn't declared him one). When he appeared before the Health select Committee Select Committee its a bloody good thing that no one was interested in asking why the SHA were willing to pay him off £500K rather than take their chances with an employment tribunal if he had such a good case, or why his payment was agreed by an unusual process called 'judicial mediation' in an apparent attempt to obscure those payments from gazing eyes at the treasury...and elsewhere. Of course,this may be due to my deployment of Team Twunt 1st Team star player Stephen Dorrell who gave Walker a good doing over with some surprising support from Rosie Cooper

Let me list the reasons why this shit bird Walker cannot be allowed to win

1) This fucker represents the most direct challenge to the NHS  hierarchy I have experienced in my tenure of this awful post

2) Walker has already seriously fucking embarrassed David Nicholson by making him lie to the Health Select Committee

3) But most importantly. Utterly fucking vitally...Walker is a symbol for the cultural revolution that Robert Francis called for in his report for the Midstaffs Public Inquiry. I cannot stress what a clusterfuck it would turn out to be if it ever came to pass that Walker won the NHS Hero competition. We cannot have CEOs or anyone else openly challenging the whims of the NHS leadership in the name of patient safety...especially if that leadership is me or people I support...or kind of support.

Look at this arsehole!! Just look at him and tell me is an NHS Hero for fucks sake...seriously ..Just look at this jumped up little bean counting shit strut his stuff.....




ACTION POINTS

i) Under no circumstances should anyone vote for this wanker in the NHS Heroes competition
ii) Efforts should be made to discourage others from doing so.
iii) Do not fill in this form for the NHS Hero Competition outlining any of the spurious reasons some people might be lured into using to vote for him

NB. Hopefully people will be put off from voting for Walker since as he rightly got the boot he doesn't work for the NHS anymore



Target 2: Helene Donnelly. Nurse. Formerly Midstaffs Hospital

People not voting for Walker may be tempted to vote for Donnelly. This preening fantasist was forced out of Midstaffs Hospital after blowing the whistle on nurses fraudulently altering the 4 hour target admissions data in A&E.

She represents the front line who have to bring about the Health and Social Care Act. They might have to deal with the stress of that and I'm sorry but shit rolls down hill and we cant have them challenging their managers every time a rule is bent or broken even if it means patient safety taking a hit.

Check her out swanning around the TV studios demanding that people whistleblow when they see poor care ....JUST WHO THE FUCK DOES SHE THINK SHE IS?!! Eh?!!  Does this prima donna deserves an accolade? I dont think so...I think she deserved to be bullied threatened and told she would lose her job. Just read her statement to the Francis Inquiry where she recounts not feeling able to walk safely to the car park after her shifts. Those 'bullies' are the enforcers of the NHS. We owe them a debt of gratitude!!

Why should she be rewarded for doing the right thing? Its utterly ridiculous! Ok, she took alot of shit for just doing her job properly but honestly you should see what I have to put up with on Twitter
.
If you had to explain to someone thinking of voting for Donnelly just ask them these four simple questions (I have provided some easy to understand answers in case they don't know them.

i) Did she go beyond the call of duty? NO! Its just that she was the only person stupid enough to.
ii) Did she suffer because of what she did? NO! She got on TV because of it FFS!
iii) Did she really have to be brave to do what she did? NO..She had to be really fucking stupid.DO WE REALLY WANT STUPID NURSES IN THE NHS??
iv) Does she represent any kind of example of the cultural change that Francis had in mind for indiciduals in the future NHS? If every nurse who could did what she did the whole NHS Shit House would go tits up. End of.

ACTION POINTS

i) Do not fill in this form for the NHS Hero Competition outlining any of the spurious reasons to vote for Donnelly  mentioned above.

ii) Efforts should be made to discourage others from doing so

Our comrade the King is a dead man walking. Who is the King?

I've got to tell you, I'm at a bit of a loss. Comrade Nicholson is up shit creek with a thousand NHS whistleblowers from hell on his case. WHAT THE FUCK AM I SUPPOSED TO DO? I dont want to give him the old heave-ho, no one has more intimate or labyrinthine knowledge of how the NHS works. AND he has always delivered. What? What was that? Oh, I know I cant sack him... I'm not really in charge of the NHS anymore. That would be down to the NHS Commissioning Board...I think.  But seriously, between us I'm not sure how long he can hold out. The big beast is wounded and it's beginning to look mortal.

So ..I wouldn't be doing my job if I didn't begin to start to think about the succession. Now if you were me who would you choose? Someone who believes in the founding principles of the NHS? Someone who believes the NHS should be free at the point of use? Decisions decisions. Well I was looking over the line up of candidates the other day and I've got to say one has really caught my eye. Oh...you want to know who? Well, get an eyeful of this guy

Now you may not think he looks the part but let me tell you why I'm so impressed. This guy is a fully paid up member of Team Twunt. His name is Mark Britnell.

1) Britnell left the NHS to work for KPMG just before the coalition took over. This man knows when to jump ship.

2) Britnell has aligned himself with the philosophy of  Team Twunt. He is on the record as saying that the NHS will become a form of state insurance and private providers will help you all get better when you are sick. So he's cool with the Health & Socal Care Act....He also predicted that the NHS will be "shown no mercy" in the first few years after the Health & Social Care Act were passed. The man is a prophet!!

3) The guy talks my language. He wants the NHS to be "entrepeneurial". 

4) He is very careful to make sure he praises the NHS while pointing out its faults and constantly makes the case for co-payments.

5) In case you thought that he was enjoying the benefits of the private sector too much to return the the open sore of the NHS, he has promised to come back.This man knows when to jump back on the ship. (When the captain has just been made to walk the plank)

So, you see what I mean? My kind of guy. It would be a shame if Comrade Nicholson had to go but....every cloud.....I think I'll just give him a ring.....

Credit to the NHS (A memo for members of Team Twunt)

***FOR TEAM TWUNT EYES ONLY***

You may have noticed this recent report regarding Standard & Poor's shot across the bows to G20 countries that they risk credit rating downgrades if they don't 'reform (1)' their healthcare costs. Now given Gidiot's dogged like attachment to the argument that austerity was in part to maintain the UK credit rating this represents an opportunity. OK ...he may have ballsed-up his execution but that's not the point. We should increasingly be using this threat of a credit downgrade as an argument for NHS spending cuts....especially in the run up to the next election. Positive reports that the NHS is among the best and cheapest healthcare systems in the world should be suppressed or ignored. This should not be too hard in the post-Francis era. We have to get this message on repeat NOW to soften up the public for the post 2015 cuts. And keep the 'The NHS is safe in our hands!" message on repeat...

Yours
The Twunt

(1) 'Cut'

The C word. The coming culture shock in the NHS

"If you want to change the culture, you will have to start by changing the organization." Mary Douglas (1921-2007)

OK I'm going to try out this blogging thing out, yah? Marvelous. And the thing I want to talk about first is **CULTURE in the NHS**. Now clearly, there are few people better to talk about this than The Twunt having been both Secretary of State for Culture and now Health (don't be convinced otherwise by this bogus survey on the right suggesting I was a shit culture secretary). My supporters (well, Camoron) don't let a little thing like that undermine their (his) ROCK solid belief in me. Yes, I'm talking about the culture of the NHS. If you don’t have the misfortune to live in the unbearably tedious world of health policy then let me tell you why this is important. 

Apparently, in the next few weeks some guy called Robert Francis is going to give me his final report of the MidStaffs Public Inquiry. Whats that? That’s the question I asked when I was told about it last week. You've never heard of it either? Well, the national media were pretty much absent throughout the proceedings and a fucking good thing they were too. It’s a nasty story. Read about it here. Anyway, Health Policy World is going nuts because it thinks that Francis is going to say that there is a problem with 'the culture' of some hospitals that ends up with horrors like MidStaffs. That’s why, in an attempt to preempt this issue I've cunningly started talking about culture in the national press and how we should sort it out and start assessing it. 

So…I can hear you thinking "What…the fuck…is hospital culture?". Good question.  I don’t bloody know but it sounds like something useful to put the blame on for all the shithouse problems in the good ship NHS. It's also a fantastic stick to beat managers, doctors, nurses and every other poor fucker who has to scrub the decks.


Let me give you an example of how people use the word when they talk about the NHS in a way that's relevant to Midstaffs. Last week, a clever SpAd (I had to sack him) sent me a recent article from the BMJ by some nobody called Brian Jarman entitled ‘When Managers Rule’. It's utterly tedious so let me use my genius comms skills to distill it down for you. Since the early 1980's there has been a change in the NHS to a situation where managers have developed more power than patients and clinicians. Now, the only reason I paid it any attention was because it cited three reports by private consultants (which obviously have much more weight given their origin) that contained statements like this

“The NHS has developed a widespread culture more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement.” It also said “Virtually everyone in the system is looking up (to satisfy an inspector or manager) rather than looking out (to satisfy patients and families)” and “managers ‘look up, not out.’”

Now, this is exactly the kind of thing that people are saying was the root cause of what went on at Midstaffs. The kind of thing that I'm supposed to sort out for fucks sake! Imagine if you will, someone suggesting trying to change the culture of England? What makes anyone think changing the culture of the monolithic NHS would be more achievable?! Incidentally, the fact that these reports had to be wrung out of the DoH using Freedom of Information requests tells you something about what might be driving the 'culture' they mentioned.

So, I need to work out what culture is. That clever SpAd once told me that the word "culture" has a classical origin based on a term used by Cicero. He wrote of a cultivation of the soul "cultura animi" using an agricultural metaphor to describe the development of a philosophical soul, the highest possible ideal for human development. You see why I HAD to sack that SpAd?…bloody useless! Try measuring the development of the philosophical soul of a Hospital CEO with a C-diff outbreak trailing him round the wards, mortality stats going north and an annual PFI bill the size of Gidiots offshore assets.

The Oxford English Dictionary has Culture down as “The ideas, customs, and social behavior of a particular people or society.” Now that might be a bit more useful, but can it really help us come up with something we can assess? Try assessing that CEO's ideas or behavior directly where it matters. Its bloody difficult. Doing it for a WHOLE FUCKING HOSPITAL? Good fucking luck with that. 

If culture is something to do with our ideas and social behavior, what is 'the culture of the NHS'? Well there's been a cottage industry in academia looking at this for the last 10-15 years. Its proponents seem to think culture in the NHS is either attributes the NHS has, which it might be possible to change, or something the NHS is in which case changing its culture (on purpose at least) is probably fucking impossible. Can the culture of the NHS be changed? It does change, apparently (see refs below) but it is not at all clear that it will do our bidding.

A brief Google search will find you a shitload of business gurus and commentators (or 'legends' as I like to call them) telling us how to change the culture of an organisation. But you will notice they rarely define it and (however much they bang on about values and behaviours) the things they describe are changes in the procedures or operations or structures of their organisations. I'm not knocking what they achieved, it just doesn't seem to me like they changed culture, just how their employees 'did stuff'. Look at this example from the World Bank. And really, I think that's what people mean when they talk about culture in the NHS. How we do stuff. As Paul Corrigan puts it;  Culture - "The way we do things around here"  Read like that, a culture of compliance means too many people are too compliant when they should speak up. A culture of fear means a lot of people are afraid of ...speaking out when they should, losing their jobs, being bullied etc. Are these things, in themselves, culture, or are they are single outcomes of the wider, deeper and richer thing that culture is: what we are as people? More directly, they are outcomes of how institutions like the NHS are organised and managed. And that is where we come to Mary Douglas (see top) She is exactly the kind of person I wont be consulting in the push to change the NHS 'culture' because she was an anthropologist who studied culture her whole life and understood it deeply (and admittedly, partly because she is dead now). Just look at that quote of hers at the top. I don't think I'm going to get away with telling people the NHS needs more (dis/re)organization after the Health & Social Care Act clusterfuck, do you? Much easier to bang on about changing the culture than the organisation, and then change the organisation anyway..


This is all pretty complicated stuff isn't it?  Lets look at an example of the kind of thing that needs to get sorted out. Nurses now routinely accused of working in an uncompassionate culture in the NHS? Why? Is it because of 

a) Their culture?
b) They have too much work to do in too little time because of chronic under staffing?
c) They know that complaining about staffing levels and organisation will get them blackballed? (That incidentally is exactly what happened to the one nurse whistleblower we know of at Midstaffs) 
d) b+c ?
e) Something else e.g Hospital CEOs and boards have much harsher penalties for not meeting financial targets than for ensuring the quality of patient care that nurses give is good. 

How could the Winterborne View horror show be allowed to happen? Because of  the culture of the carers or as a natural outcome of the way care of this group has been neglected from the top down for years?

Take your pick. It really is complicated isn't it? The profession has launched its own preemptive moves to the Francis MIdstaffs report with the publication of 'Compassion in Practice' which outlines a three year plan for promoting a culture of compassion. At no point do its authors even attempt to define what culture is. That's the kind of deep thinking I'll be encouraging more of on my watch. 

There's one final point I would like to make. Whether you call it culture or not, whatever you call it, I'll bet you my detachable bell-end that the way people behave and the values they abide by in institutions is largely set by the way the people at the top behave themselves, and organize that institution. The NHS is nothing if not a fine institution full of large numbers of institutionalized people. So now, you see my problem? If the behavior of NHS workers is set from the top do you think someone like me is going to improve it, or change it? You may have read previous accounts of my business leadership. And look at the BSkyB balls up. Did I take an iota of responsibility for my team's behavior, or behave in in open and accountable way myself? Oh yes, Adam Smith could tell you some stories about the culture I promoted. But of course, I forgot! I don't lead the NHS, do I!? Who is in charge? Step forward Sir David Nicholson! Unfortunately SuhDave stands accused of presiding over the instigation of the very 'culture' of bullying which has been fingered as part of the problem at Midstaffs. Take a step down to CEO level in the NHS...read this. You see! NHS 'culture' isn't so different from the rest of Britain, and like I said, no one is going to be changing that in a hurry. Much easier to label the problem as culture and use it as a big stick to whack the NHS with before I pimp it out to Branson and Serco et al. 

So, workers of the NHS. Loyal subjects. Culture is probably something you are going to be hearing a lot more about over the next year or so. I urge you not to think about it too deeply. Just accept the word of The Twunt and your other over lords. We have the situation in hand. You need to change. We can help you do it.

My next blog will be about subcultures in the NHS. .................That's a joke by the way....

Further Reading 


Scott et al. (2002) Implementing culture change in health care: theory and practice. Int J Quality HealthCare 15(2). 111-118

Abbasi (2009) Your hospital was a ‘clan’, now it’s ‘rational’ J Roy Soc Med 102. 307

Mannion et al (2009) From cultural cohesion to rules and competition: the trajectory of senior management culture in English NHS hospitals, 2001–2008. J Roy Soc Med vol 102 8332-336