It’s 15 years to the day that I did one of my better operations. On the first day of the millennium I cut off a man’s arm, because of gangrene. It saved his life. When I thought about it, it became obvious to me that two of the best operations that we do today – amputation and draining of abscesses – are probably the earliest two operations ever, that actually worked. War, over many centuries, has confirmed their benefits, however destructive the procedures might seem. I still do them, every month, for one reason or another.
Which raises the question: what constitutes a ‘good’ operation?
When the NHS began, 66 years ago, the choice was limited. In various specialties there was an explosion of seemingly innovative and effective new procedures in the 70’s and 80’s, and the new operations just keep coming. There are three broad groups – whatever the specialty – emergency procedures for life or limb threatening conditions; cancer surgery, usually cutting stuff out, and hopefully with an element of reconstruction; the third group is the bane of many surgeons’ lives in the NHS, elective (scheduled) procedures for other conditions. This is the group most subject to political, arbitrary, waiting list targets.
Everyone knows that the NHS is a massively funded, but finite resource. It may seem free ‘at the point of source’, but it is of course, anything but free. Its enormous costs are essentially unconstrained by market forces in many areas, which means that a ton of money is wasted every day. So what we shouldn’t be doing, as surgeons, are ineffective procedures, procedures for which we don’t really know the likely outcomes, procedures with marginal value at best, procedures to make us feel better (as opposed to the patients).
One of my colleagues asked all the candidates at a consultant job interview the same question: what makes a good surgeon? Everyone improvised and burbled about personal qualities, hard work etc. The answer he was after was “a good surgeon knows his or her own results”. He was right, though nobody came up with the answer. For a lot of operations in the OPCS code book, however technically good you are, the results will be at best equivocal. So why would the NHS offer such services, from its limited pot of money?
The answer lies in the frankly remarkable trust that it has traditionally placed in the consultant body. Once you got the job, you could often do what you like. There are checks and balances, to an extent, but if you decide that your patient should have a two hour endoscopic procedure for a sore shoulder, then they can have it. And you will be judged by whether you did the operation within the target time, not by whether or not it helped the patient.
Over the years numerous procedures have declined and fallen out of fashion, for various reasons, only some of them (eg peptic ulcer surgery) because of medical advances elsewhere. Hysterectomy, tonsillectomy, and surgery for low back pain have all come and gone to a large extent. The latter is actually a brilliant example, because new and relatively untried techniques are constantly being introduced, so the rates go up and down. The condition is so common that there’s no shortage of potential subjects, whatever the clinical outcomes. The NHS has the advantage that you don’t (usually) get paid extra for operating, so the financial incentive which distorts the decision making in other countries isn’t there. Nevertheless, we should only be doing operations that we know are likely to help, and the NHS’s attempts at providing outcomes data are rudimentary at best.
Having criticised the fact that consultants can seem to do what they want, to a large extent, I have to say that I think the answer to such profligacy lies within that professional group, rather than more rules and ‘guidelines’. I would say that, perhaps, because I am one. All of which brings me to the point of this blog post.
The status/position/respect/power of the consultant is being eroded, and no good can come of this in the long run.
There are plenty of examples. The GMC, which actually does a fine job with respect to many of its duties, such as fitness to practice, had far too much wrangling over whether there should be a lay majority sitting in judgement on doctors – the implication being that medics can’t be trusted with self regulation. Likewise there has been a real controversy over whether accused doctors are able to receive a presumption of innocence. This hard hitting document from the Civitas think tank makes a lot of these points well. These issues don’t inspire confidence in the working clinician.
Whistleblowing is regarded as laudable, and the Bristol heart scandal backs that up. However, not every whistleblower is a well motivated, knowledgeable judge of practice, and a Stasi-like culture is on the horizon. You don’t like that doctor – make an allegation about patient safety. They all have to be investigated with the misery that causes to everyone. Frankness is not however necessarily appreciated, nor is an adherence to the principles of freedom of speech. Only this last year the brilliant sarcoma surgeon at the Royal Marsden, J Meirion Thomas – a man who has truly delivered for the NHS and countless patients over the years – has been seriously attacked for speaking his highly experienced mind. The NHS won’t improve if thoughtful, experienced critiques are suppressed to avoid ‘offence’. The public sector won’t improve if the genuine bedrock principle of freedom of speech is flouted. Not all of Meirion Thomas’ concerns are fair or evidenced, the Royal college of Surgeons’ superb president, Clare Marx skillfully rebutted his comments on female doctors. The point here is freedom of speech, and valuing real experience, the risk is losing a healthy, challenging autonomy.
The background to this has been rehearsed on many occasions, and if you’re a Marxist, Antonio Gramsci’s ‘long march through the institutions’ rings true here:
A war of position is one in which one first identifies “switch-points of social power” and then one seeks to peacefully take control of those switch-points. The switch-points all relate to the field of cultural values – in particular, the arts and education. The most important switch-points of power are positions like school principal, university professor, government policy maker, education department bureaucrat and journalist.
In 1967, Rudi Dutschke, a German student leader, reformulated Antonio Gramsci’s philosophy of cultural hegemony with the phrase, “The long march through the institutions.” Instead of a long military march, such as the one undertaken by the Chinese Marxist Maoist Tse-Tung, in the highly developed western countries the long march would be through the most culturally significant of our social institutions – that is, through schools, universities, courts, parliaments and through the media, through newspapers and television.
To which add medicine, as a key component of the NHS.
I don’t claim this is original thinking, the Spectator ran a prescient piece on it back in 1998, spelling out how various parts of the British cultural world – including medicine and the churches – were falling prey to this Gramscian sneakiness. No-one would call Tony Blair a Marxist, but that’s when it began.
Here’s where the real old fart stuff begins. I reckon that I have experienced the best of the NHS as it’s currently configured. The almost monstrous rise of bureaucracy, feeding upon itself and the taxpayer, the obsession with guidelines which inadequately address the issues of value and effectiveness outlined above, the desire to control individuals of great intellect, motivation and talent and to suppress individuality, the obsession with arbitrary rules and targets with no clinical foundation, and many other developments, genuinely make me fear for the future of the institution. It is certainly nothing like its original conception, back in 1948, and I am not referring to the stupendous advances in clinical medicine since then.
The Knife has many extremely talented colleagues, men and women, who are entering, or about to enter, consultant practice. There are also many of a new kind of doctor, who would not recognise the old model. This last week I’ve had to point out to two different juniors that when I ask them to see a patient (because I genuinely want their clinical opinion), that means turning up at the bedside and speaking to the individual. They both decided to argue the toss with me. These doctors, who are also talented and clever in many ways, are the direct product of the deconstruction of the old ways of doing things. They have been badly let down by politicians and by their union, who have combined in radically limiting their access to patient experience, through the depredations of the punitive working hours regulations and the juniors’ contract. The best ones recognise this. They are up against a crushing system though.
It’s not all about the hours regulations. No-one wants to return to the days of 72 hours straight on call, though many consultants still do 48 hours or more without a break, it’s the cultural problem of the NHS.
Carl Honore, the Edinburgh educated author of In Praise of Slowness, describes one facet of this:
We live in a culture that’s been hijacked by the management consultant ethos. We want everything boiled down to a Power Point slide. We want metrics and ‘show me the numbers.’ That runs counter to the immensely complex nature of so many social, economic and political problems. You cannot devise an algorithm to fix them.
and William Osler was right, as usual, when he delivered this timeless advice:
Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.
..and right now, the culture across large swathes of the NHS is a disincentive to this.