Category: NHS Administration

NHS England: undifferentiated GPs, and revalidation. When policy starts masquerading as regulation

The Problem

GPs are being split into differentiated and undifferentiated camps by NHSE.

NHS England (NHSE) is using its funding of English GP appraisals to lever the GMC appraisal and revalidation process for its own ends. There is no legal framework for the NHSE policy of insiting that GPs remain “undifferentiated”

Many GPs are now going to be labelled low volume workers even when they are working full time, simply because their work is deemed differentiated. Not as NHSE wants, which is for GPs to remain as newly qualified undifferentiated general practictioner, as found working in English street practice.

According to NHSE, GPs can only remain undifferentiated if they do at least 40 sessions in an English general practice as a generalist every year. I wondered if this policy is designed to ease GP shortage should 1000’s of specialising doctors be forced to work back in street practice for their 40 sessions.

NHSE and GMC functions are being mixed up by NHSE, and then is presenting that muddle as if mandated by law or by the GMC.  Policy and guidance is masquerading as regulation.

The terms at the heart of the problem

NHSE has introduced (or at least put in operation) the term undifferentiated GP in a way that carries consequences inside appraisal conversations and splits the profession. A differentiated is no longer a proper GP. My GMC R.O. says this has been mandated for many years but I met it for the first time this year (2026). I see that NHS guidance is of 2018 vintage.

In correspondence and discussions, the working definition presented to me is broadly:

  • Undifferentiated: an English general practice generalist doing at least 40 sessions/year of normal non-specialised GP work.
  • Differentiated: a GP working in defined-scope settings (for example, prison GP work, GPwSI/portfolio work, or British Territory work) where NHSE says the work does not count as undifferentiated.
  • Low volume: now used by NHSE in a way that can apply even to full-time doctors if their work is deemed differentiated.

That is an extraordinary shift. Low volume meant low volume. Now it can mean high volume, wrong type.

NHSE argues that all GPs should remain as trained, as generalists in case they return to normal practice. Once on the performers’ list a GP can do anything, including return to street practice without much ado. NHSE considers that a risk. But the same risk applies to specialists changing their scope of work. If we plan to, or change our scope of work we change our CPD accordingly. Nobody need keep up skills they were never need to use. But NHSE insists on it for GPs, and only GPs.

My situation: the new-to-us policy that does not fit with reality

My working pattern has not changed in 15 years. Yet for the first time I have been labelled a low-volume worker. I work part time as an APMS GP in prisons and I also do remote location work. The latter is deliberate as it is one of the few ways left to retain genuinely generalist skills that modern English practice rarely uses (e.g. minor surgery and maternity exposure). In this appraisal year I worked around 135 sessions in prisons and another 45 sessions as undifferentiated-plus GP work in the Falklands, where GMC registration is mandatory, plus a few sessions at my old NHSE practice grouping.   

GMC accepts overseas evidence when a small part of appraisal and 100% where GMC registration is mandatory (Gibraltar and beyond).   NHSE does not accept it, only accepting English time as evidence.

Under the NHSE thinking my work was to be treated as low volume because most of the work was considered differentiated prison work.  The rest was not undertaken in England so would not be counted (despite GMC accepting that evidence).

NHSE seeks that we demonstrate maintenance of skills that are outside our real scope of practice, or else do remedial work listed in our appraisal documentation to become undifferentiated.

Using appraisal and revalidation to enforce local objectives

In communications about this issue, the message was that if a GP does not comply with NHSE undifferentiated expectations the Responsible Officer may find it difficult to recommend revalidation. I cannot see how that can be the case as thr GMC’s core revalidation principle is scope-based: you must be up to date and fit to practise within your scope of practice. It is not a requirement to demonstrate competence in skills you do not do, cannot do, and will not do.  Ii is not a GMC requirement to be undifferentiated. The GMC R.O. could not ‘find it difficult’ when the GP is fulfilling all GMC requirements.

Appraisal is not the place to force doctors to remain undifferentiated. If a commissioner or employer wants a particular service profile, that is a contractual and workforce-planning issue, not something to be smuggled into revalidation.

What the law actually says (England)

1) The performers List law gives NHSE some leverage, but not for this

My R.O. stated that as NHSE is paying for my appraisal it is entitled to make adjustments in line with its policies.

In England, the performers list framework is statutory. The enabling power is in the National Health Service Act 2006, section 91. The current implementing instrument is The National Health Service (Performers Lists) (England) Regulations 2013 (SI 2013/335).

Those regulations require that performers list practitioners participate in an appraisal system established by the Board (NHSE):

That is the legitimate place where NHSE can set process expectations for performers list governance.

2) The Responsible Officer framework

The where you do most work rule sits in the Responsible Officer Regulations, not in GMC registration rules and not in performers list entry rules. See The Medical Profession (Responsible Officers) Regulations 2010, regulation 10 (prescribed connection).

3) Revalidation is anchored in the Medical Act, and the GMC can set guidance, not NHSE

Revalidation is a statutory process under the Medical Act 1983. The GMC may publish guidance on information/evidence required for revalidation under section 29G. The GMC’s 2012 regulations that implement the licence/revalidation machinery are The General Medical Council (Licence to Practise and Revalidation) Regulations 2012 (SI 2012/2685).

In other words: NHSE can create policies for its governance systems. The GMC sets revalidation requirements through its statutory framework and its guidance.

What the GMC itself says about local requirements vs revalidation

This is where the clearest support comes from. Two GMC publications provided to me contain explicit statements that should stop local objectives being imported into revalidation decisions.

GMC, 2017: Update on implementation of Taking Revalidation Forward recommendations

Source: Strategy and Policy Board meeting, 9 February 2017, Agenda item 7. Original GMC link:

https://www.gmc-uk.org/cdn/documents/07—update-on-implementation-of-taking-revalidation-forward-recommendations_pdf-69414753.pdf

‘We are also concerned that there can be confusion between revalidation criteria and local job-related requirements, particularly around mandatory training. We do not consider it acceptable for employers to add management objectives to the evidence required for revalidation. Everyone needs to be clear on what is required for revalidation and what is not’ (page 7).

‘distinguish local initiatives and employment obligations from revalidation requirements in the appraisal process so it is clear to doctors what is necessary for the purposes of revalidation and what is not;’ (page 9)

GMC, 2018: Taking revalidation forward, Working with others to improve revalidation

Source: November 2018. Original GMC link:

https://www.gmc-uk.org/cdn/documents/rev—-taking-revalidation-forward—working-with-others-to-improve-revalidation—dc11687_-76860097.pdf

‘We have made the distinction between GMC requirements and local requirements clearer and emphasised that failure to meet local requirements eg completion of health and safety training shouldn’t influence the revalidation recommendation made about a doctor. (page 7)

These are not my blog opinions. They are explicit statements about the boundary between revalidation requirements and employer or local requirements.

The NHSE reply 

In an NHSE reply to my questions (with my annotations), NHSE accepts some principles in words but then applies a different test in practice. For example:

  • Appraisal should cover the full scope of practice, yes, but NHSE implies that to remain on the performers list the Responsible Officer must be assured the doctor is up to date ‘to work in general practice’, regardless of the doctor’s actual scope.
  • NHSE indicates that if supporting information is primarily overseas, the RO is unlikely to consider it satisfactory, while simultaneously acknowledging exceptions where a UK licence is legally required (which is relevant to various British Overseas Territories)
  • NHSE asserts that the old low volume guidance has been replaced by PLAN 32, If Plan 32 is now the basis, it should be cited clearly and explained.

The most concerning line is the recurring warning that ROs ‘may find it challenging’ to recommend revalidation based on minimal NHS GP work. That looks like using revalidation as an enforcement mechanism for NHSE workforce objectives, even though the GMC’s own published statements warn against precisely that.

Why would we expect a GP to prove competence in unused skills, remain undifferentiated. A breast surgeon is on the GMC register as a general surgeon,, but nobody expects them to demonstrate in their appraisal that they can perform procedures outside their scope pr practice, for example, inserting a renal stent or forming a colostomy when  those are not part of their actual work. The requirement is to be up to date and safe within scope.

NHSE’s undifferentiated status targets GPs, and only GPs  towards a different standard, retain broad skills irrespective of scope, or be treated as low-volume even when working full time.

Summary

  • Appraisal cannot be used or modified to ensure a GP stays on the performer’s list.  NHSE can run a performers list governance system as it does for major complaints.  But otherwise unless a GP fails to work in an area or is not having appraisals, there is no easy mechanism to remove a GP from the performers’ list.  G.P.s cannot be removed for failure to be undifferentiated.
  • The GMC sets revalidation requirements not the NHSE.
  • Appraisal evidence should reflect actual scope of practice.
  • Local requirements must be separated from revalidation requirements, and failure to meet local requirements cannnot, by itself, drive revalidation recommendations. The GMC has said this explicitly.

If NHSE believes it can require undifferentiated work as a condition of remaining on the performers list, then it should cite the precise statutory basis and define the term in a way that is coherent, fair, and challengeable. If it cannot cite the statutory basis, it should stop presenting policy as if it is law or GMC mandate.

 NHSE does have powers as funds and sets the appraisal format. The critical distinction is that GMC revalidation and NHS England Performers List inclusion are not the same legal test. Revalidation concerns fitness to practise and maintenance of the GMC licence. Performers List inclusion concerns suitability and fitness for purpose to provide NHS primary care services in England. NHSE powers are limited in that regard.

Short answer: NHSE cannot simply turn appraisal into a pass/fail exam on whether a GP accepts being undifferentiated.

They can require participation in an appraisal system. They can also expect the appraisal to cover the doctor’s full scope of practice. But the sanctionable issue is not whether the doctor agrees with NHSE’s terminology. The real legal questions would be:

1. Has the doctor engaged with appraisal/revalidation?
2. Has he provided adequate supporting information across his actual scope of work?
3. Is there evidence that his continued inclusion on the performers list is unsafe, unsuitable, fraudulent, or prejudicial to service efficiency?
4. Has he failed to perform relevant performers-list services for 12 months?

If the doctor says:

I dispute the term ‘differentiated’. My scope is prison GP/remote GP/defined-scope generalist work. I maintain competence, CPD, QI, SEA review, feedback and reflection within that actual scope. I do not accept that revalidation requires me to plan to practise outside my current scope.

That is not, by itself, a disciplinary failure.

The possible NHSE levers are these:

Appraisal outcome: the appraiser may record concerns or unresolved issues, but appraisal itself should not be a pass/fail process.
Responsible Officer recommendation: the RO might try and claim, or be trold by NHSE there is insufficient information and seek deferral. That is the practical pressure point that NHSE is attempting to use.
Performers list conditions: NHSE could try to impose conditions, but only on proper statutory grounds, mainly efficiency/fraud prevention, with notice, reasons, representations and appeal rights.
Removal from performers list: possible only under statutory grounds, such as unsuitability, efficiency case, fraud, loss of registration/licence/GP register status, or failure to demonstrate relevant services in the previous 12 months. It is not lawful simply because the doctor refuses to adopt NHSE’s preferred workforce ideology.
Suspension: only where necessary for patient/public protection or public interest, usually pending investigation/removal/conditions. A mere disagreement about “differentiated” status would be a weak basis.

So the key distinction is:

NHSE may ask the doctor to reflect on scope.
NHSE may not lawfully require false reflection or compel a plan to practise outside actual scope as a condition of revalidation, unless it can identify a clear legal basis.

The safest wording for the doctor is not “I refuse to engage”, but:

I have engaged fully. I have reflected on the issue. I dispute the label ‘differentiated’ as being imprecise and potentially misleading. My professional duty is to remain competent, up to date and safe within my actual scope of practice. I do not consider it appropriate, safe, or consistent with GMC scope-based revalidation principles to create a development plan aimed at practising beyond my current scope unless and until I intend to undertake such work.

That preserves engagement while refusing the trap.

All I got the RCGP team so far is ‘The RCGP supports GPs to continue to work as GPs, whether that is providing core general practice services, or GPs with extended roles or other portfolios, and we shall continue to do so’

 

Here is the NHSE reply to my Qs in black NHSE response in blue and my secondary comment in green.  “SRT” is the RCGP designed form low-volume worker 40 sessions or less in total form. “NPL”: National Performers List.
 
1. GPs working in prisons are providing primary care. These sessions should be counted as such; they are APMS performers’ list work – We request completion of the SRT to assess how you keep your skills up to date, as prison work is not considered undifferentiated GP work. (They ignore Shetland or Falklands, but GMC does not)  
2.      For revalidation, GPs must demonstrate they are safe and up to date within their scope of work. There is no GMC requirement to maintain all undifferentiated skills. – As you are on the NPL, the RO must be assured that you remain up to date to work in the general practice. (What is NPL got to do with GMC appraisal?  Once appraised you cannot be removed from the performers list)
3.      The GMC does not require NHS-only work; a GP may work entirely in private practice and still revalidate. – To maintain your position on the NPL, you must continue to work in General Practice. (That is a bit vague, the RO told me it has to be English street NHS general practice)
4.  Non-NHS work is not excluded from appraisal. – Your appraisal should cover the full scope of your practice. (Quite: appraisal is about SCOPE of practice, not more)
5.      Overseas work is not excluded from appraisal evidence, provided it does not form the substantive part of that evidence. –  Overseas work may be included in your appraisal evidence, provided it does not constitute the substantive portion of that evidence. If your supporting information is primarily from overseas practice, the RO is unlikely to consider it satisfactory appraisal. Supporting information should be from UK practice, except in exceptional circumstances, such as a legislative requirement to hold a UK licence in another country (e.g., Gibraltar). that means all British Overseas territories, Isle of Man, to Falklands.  But yet NHSE won’t accept these hours worked calling them “undifferentiated”)

6.       Low-volume worker guidance applies when a GP undertakes 40 sessions or fewer within their scope of work. – This has now been replaced with PLAN 32. Anyone undertaking only one session cannot be removed from the NPL administratively. However, ROs may find it challenging to make a revalidation recommendation based on minimal NHS GP work. Hence, our appraisers continue to request completion of the SRT if fewer than 40 sessions have been undertaken, and we will advise doctors accordingly based on the provided information. (I could not find any reference to all this in Plan 32)
7.The definition of low volume is not based on the scope of primary care practice undertaken. – please see above.
 
You see in (6) “Anyone undertaking only one session cannot be removed from the NPL administratively”   So there is no mechanism for NHSE to remove someone if they do one day’s work in England (and have an appraisal anywhere; appraisal is UK wide).  I could work in England one day, have an appraisal privately or in Scotland (I am on the list there as well) and NHS could not remove me from the performer’s list, so the stipulation that a doctor must remain undifferentiated cannot be enforced.
  
PS.  As it happens, I am not keen on GPs specialising.  I think it frustrates patients and it creates the need for multiple appointments.  Appraisal is NOT the place to attempt to force GPs to remain “undifferentiated”.  That is a contractual issue.  Yet we all drift into a defined scope of practice. We differentiate ourselves.  
    
Pps: NHSE dissolution will not help on jot.  NHS reorganisations are a game of musical chairs and names changes; functions do not change, and we get to see a nice new logo.
 
 
 
 

 

 

References (key links)

Abuse of NHS Doctor’s Appraisal System

There are individuals within the NHS who view GP appraisals as a reference system, using them to assess a doctor’s suitability for particular roles by requesting GPs to submit their appraisal output data or a “copy of their appraisal.” Additionally, some administrators aim to utilise doctors’ appraisals as a management tool for audit and performance, aligning with appraisal systems in other work sectors.

Doctors should firmly refuse any requests to share a copy of their appraisal or appraisal summary with employers. Many doctors are already cautious about including reflections in their appraisals, especially after the Dr Hadiza Bawa-Garba case. Using appraisals as a reference tool would exacerbate these concerns significantly.

In March 2021, I discovered that the GMC appeared to support this new stance from employers. A statement on the GMC website read: “Appraisal documentation is confidential. When requested, doctors should share summary appraisal outcomes with the organisations where they work (in addition to their designated body) but should not be expected to share their full appraisal portfolios on a routine basis.” However, the GMC later acknowledged that this wording was incorrect and replaced it with a fuller document, available here: GMC Information Sharing.

After representation to the GMC by the RCGP Revalidation team, I have been reassured that doctors are only required to provide evidence that they have had an appraisal. This can be done through the appraisal statement, which consists of a few tick-box lines with no detailed data. It merely confirms that an appraisal has taken place. This statement is entirely different from the appraisal summary, which contains the detailed content of the appraisal. The appraisal summary should not be shared, nor should any other part of the appraisal documentation.

If appraisals are used as references by NHS Trusts, other employers, or GP practices, this will undermine the appraisal process and potentially jeopardise revalidation. Doctors will avoid addressing challenges and will be unable to reflect in confidence. A salaried GP, for instance, would be highly reluctant to share their appraisal with their workplace or practice manager if workplace issues were involved. Appraisers may also begin tailoring their appraisal outputs to fit this new role as a reference for third parties, rather than as they are currently designed: confidential, reflective learning documents and private professional development plans.

Below is the letter that initially raised my concerns. It followed several months of working via an agency. I had worked in the area since 1993 and appraised locally. I was both licensed and revalidated:

 

“Hertfordshire Community NHS Trust   1st  August 2018                                                  Dear Dr Bulger   Re: Appraisal Output request for Gerard Bulger  As you will be aware the Responsible Officer regulations came into force in 2012. As the Deputy Responsible Officer for the Designated Body Hertfordshire Community NHS Trust (HCT), I am accountable for seeking regular assurance that Doctors who work for HCT in any capacity are up to date and fit to practice across their whole scope of work.  As such and in accordance with the HCT process Non Designated Body Doctors’ Governance Process’ approved in January 2017 by the Workforce and OD Committee, I kindly ask that you provide your last appraisal output form no later than 8th August 2018.As you will be aware the Responsible Officer regulations came into force in 2012. As the Deputy Responsible Officer for the Designated Body Hertfordshire Community NHS Trust (HCT), I am accountable for seeking regular assurance that Doctors who work for HCT in any capacity are up to date and fit to practice across their whole scope of work.”  

In March 2021 I got another request, a CQC inspired compliance list from another employer which included a demand for “copy of my appraisal”, as if standard and matter of fact.  My reply to both reply was no.  The employers can check references, my place on performers’ list (so therefore appraised) and can check I am licensed and revalidated on line.  The Trust or any other employer have no right to demand to see my appraisal output and data (which, as it happens is suitably glowing, so I should show it off); the  principle is that that appraisals are also private reflections.

West Herts Trust, frustrated by my refusal then tried to apply to NHS England for the appraisal data as if I was changing my GMC Responsible Officer (R.O), that is moving area using the  RO to RO form (MPIT). NHS England’s response was robust and the request refused.  The data cannot be used by anyone other than the doctor’s one and ONLY responsible officer.  NHS England’s Programme Manager replied to me in 2018:” We would not consider sharing your appraisal documentation with any employer and it should not be used in the manner in which your organisation is suggesting. I am happy to write to them on behalf of your RO to confirm your fitness to practice and that you are fully engaged with the appraisal programme.  That is all..”

These requests are a nasty extension of the use of the appraisal system output as a reference and a management tool.  This is not appraisal’s purpose, which is about probity, reflection, developing a personal development plan for licensing and revalidation.  No doctor should volunteer to send their appraisal output to anyone outside their own Responsible Officer’s team.

West Herts implied in the letter that in effect a doctors could have more than one GMC responsible officer, so each Trust could view appraisals outputs. 

BMA: Responsible Officers (ROs) are the individuals within designated bodies who have overall responsibility for helping you with revalidation. A designated body is the organisation (likely to be your main employer) that will support you with your appraisal and revalidation.  You only have one designated body and one Responsible Officer irrespective of how many organisations you are contracted with or employed by. Only UK organisations can be designated bodies, because the legal rules that determine this – the Responsible Officer regulations – only cover the UK.

GMC: Taking Revalidation Forward  the GMC has the following statement in Sir Kieth Pearsons recommendations (Appendix B)
9 Responsible officers should make sure that the revalidation process for individual doctors is not used to achieve local objectives that are not part of the requirements specified by the GMC. 

LMC: “believes this is a gross misuse of the appraisal process and that there are no such requirements for outputs to go to new employers”

GPC: An employee should not be requesting this information and you do not need (nor should you) share it. All they need to know is that you are on the performers list (which you can only do it you are keeping up with appraisals and revalidation. 

During my time as an appraiser I assured my doctors that the appraisal process was confidential, and that the only person who may see it would be their one and only responsible officer and their appraiser.  A doctor has one, and only one GMC Responsible Officer, no matter how many employers he or she has.

We have understood that appraisal remains a formative and reflective process. The output has no pass or fail unless there are clinical risks found or the doctor is not engaging.  The purpose of appraisal is to demonstrate continued probity, learning and reflection to keep a license.  The doctor’s one R.O. can approve for revalidation after five years.

A Trust can check that a GP had had a recent appraisal, that he is licensed, revalidated and on the GP performer’s list.  Should a Trust need to know that a doctor is suitable for a particular job this is achieved by references and interview.  The appraisal data would be a poor way to do this.  To provide appraisal data to third parties is an extension of the appraisal and revalidation system beyond its scope and purpose.

GPs must refuse to send appraisal output demanded by employers. They have no right nor reason to see it. 

Gerry  Bulger

https//bulger.co.uk/message.htm

Covid: Bureaucracy blocked Clinicians working

Time to rage against most of the NHS? 10/01/2021

At the height of the second wave I was waiting for the call up to help in the overwhelmed hospitals or for the vaccination campaigns.    Not a word, not a single email.

Meanwhile my inbox was full of requests from Australian agencies offering up to $2,700 a day for Covid related work, in a country where, so far, Covid is pretty much under control.  I also remain on the Australian register, but I cannot get there unless I self-isolate at my expense in special hotels, and I would need a new visa.

Here in UK I did the in-house training for NHS Nightingale and its on-line modules, got the lanyard, ID card, staff number and T-shirt, but thankfully never needed.  I also other modules and the NHS “credentiality” checks for 111 primary care work. All that extra training is imposed on doctors as if they are not already in practice. It was designed for those coming out of retirement, and the rigid rules set place could not be changed for those already working and appraised.   A list of some of the stuff is here:  https://www.bbc.co.uk/news/uk-55516277

Most of so-called mandatory training modules such as anti-radicalisation are not even mandatory at all. Apart from some internal health and safety rules, there is no legislative or GMC requirement for the training modules. The “mandatory” aspect is an NHS urban myth that keeps many in employment.  Doctors must be professional and keep up to date.  We undergo annual appraisal and then revalidation to prove it. That alone is our training duty.  The NHS as invented the rest.  It may seem sensible that module to recognise allergic reactions.  But if any doctor does not know how to recognise or deal with that then we need to look seriously at the 10 years+ of medical training.  I very much doubt the Health Secretary’s vow to reduce this will have a lasting effect, as the culture to require this nonsense it too imbedded. https://www.bmj.com/content/372/bmj.n13

Did anybody in NHS other than Casualty and ITU staff in the NHS know there was a war on?   Could they not slash these requirements and call up trained doctors to help?

I was shocked and aghast attending “Pinnacle” and Covid Vaccine roll out on-line NHS Team Meeting seminar at the start of the vaccination programme.  Even the GPs leading it have got wrapped up in the bureaucracy of it and believed in it.  They should be in a rage.  Instead, their energy seemed to be directed to worrying about £10.00 fee for nursing home jabs.  Vaccinations centres as in GP hubs are being loaded with computers, printers and scanners and specialised software.  We all have computers in our pockets which can scan bar codes of all sorts, surely there is app for that would make that pile of kit redundant.   Less is more.

During that Team meeting it was clear that the hoops expected by the software and NHS minions were no longer necessary.  Previous anaphylaxis is not a contraindication, and no need to watch the patients for 15 minutes.

Sir John Bell has it bang on. “NHS could vaccinate UK against Covid in five days, says Oxford professor: Bureaucrats are blocking a rollout that could prevent many more deaths, according to Sir John Bell  https://www.theguardian.com/world/2021/jan/09/nhs-vaccinate-uk-covid-five-days-oxford-professor

Those working in Casualty and in ITU manage despite of the system. They pull in levers in Government and nothing happens, as the NHS system blocks and delays.  Time to rage against most of the NHS, not clap it. 

I carried on working elsewhere in the NHS part-time.

Dr Gerard Bulger BSc MBBS DCH FRCGP FRACGP CCFP

https://bulger.co.uk/message.htm

More of the pointless NHS Administration

Most of the boxes are NHS related 1993-2008

I have added back an archive of NHS Commissioning documents based in Hertfordshire, 1999-2008.

Perhaps someone will copy and paste some of the old documents for yet another new project, as all has been done before under different names.  Family health Authorities, Regional Health Authorities, Area Health Authorities. Primary Care Trusts. Practice Based Commissioning Groups, and now Clinical Commissioning Groups.  It’s pointless.

All NHS reforms do is play musical chairs.  No reform dares start on the basis that these functions are simply not needed. They are moved to different named bodies.

I have worked in Australia where these layers of NHS administration simply do not exist, despite the fact that Australia is considered to be over governed.

https://bulger.co.uk/dacorumhealth

Part of the Achive