The grinning stupid authoritarian (GSA) phase

…the founder

When privileged-arch-fascist-climate-denier James Delingpole called his 2009 book Welcome to Obamaland: I Have Seen Your Future and It Doesn’t Work , he was onto something.

The UK had unhappily become the template for the next ten years in the polities of the complacent and morally confused West. All thanks to Tony Blair, and I should add, with the benefits of hindsight and his recent return to prominence, the selfish idiocy of John Major. His determination to continue as a dud Tory PM for a couple of years – despite a thriving economy – gave us the horrors that began in 1997.

So, we got Blair, slowly ruining that economy, along with his hated rival Gordon Brown, and visiting quite astonishing amounts of carnage on various foreign countries in the process. He is sort of reviled now, though he obviously finds it hard to take. Brexit has given him the opportunity that he craves to start lecturing us all again***.

In any event, I would say that Britain had begun to recover from his peculiar brand of smoothness, his labelling of opponents as morally bad people, and his oafish certainty. Theresa May’s dismal reign is essentially a hiatus in that recovery, I hope.

That depressing period is becoming a distant memory of course, as we actually got rid of Blair a whole 11 years ago, and whatever his demerits, his successor Brown was not a grinning authoritarian, and nor was Dave, after 2010.


Obama, a master of the amiable rictus, came in after a cunningly stage managed meteoric rise, in 2008, and exemplified the essential features of the GSA: a messianic view of his own powers and beliefs; the support of a mostly invertebrate and adulatory media; a hatred of  ‘old’ (and generally successful) norms in economics, morality, societal structure; a tendency to reward untalented cronies for fawning; an unthinking obsession with climate change; complacency about the electorate; a counterintuitive tendency to violence and the use of physical authority.

There are no doubt lots of other themes, but they’ll do for now.

The final common pathway of all this is the same – failure.

This failure though is one that only affects the public good, including the economy. The corollary of it is that the GSA will always end up personally enriched. That said, they rarely end up happy. This blog began in 2010 with exactly that observation.

Obama’s failures are many, although his extended media fan club hate to admit it. His irrefutable achievement was being the first African American president. The rest of it – not so much. Obamacare is tottering, he was the master of the multi-casualty drone strike, he destroyed his own party as for eight years it was all about him (another typical feature), the economy stagnated with absurd claims made to disguise failure, the church was targeted, terrorists were routinely appeased, and so on and on and on. Par for the course.


Macron has turned into an ongoing car crash (even as I write) at a quite incredible speed****. Clearly more intelligent and widely educated than both Blair and Obama, he nevertheless has proven to be amazingly out of touch and stupid. His de haut en bas style is ruining both him and France. It’s as if he’s making their mistakes at triple speed, just to catch up. What is funny is that he clearly didn’t see it coming – he thought the template worked. The inherent lack of principle is deliciously emphasised by him folding on his daft fuel tax – either climate changes exists and the proposed actions matter or it doesn’t (spoiler – it doesn’t).

…the new boy

The newest GSA is Leo Varadkar. Poor Ireland, generally badly run by a host of chancers since de Valera threw in the towel, its unique identity has been slowly crushed and subsumed by the secular brutality of the EU superstate. Once it sold its soul by giving in to voting twice on the dreadful Lisbon Treaty, it became a perfect seed bed for a GSA – and Varadkar is an exemplar of the breed. Number one priority was sucking up to EU overlords** – there would be no  prospect of dissent. Number two was going to town on legalising abortion – a far more controversial topic to this day than was ever admitted – which inevitably was joined with lots of church bashing. Number three is kicking Theresa May about, which everyone finds easy these days. It plays to the time honoured anti-English gallery in the Republic, itself a form of ‘toxic nationalism’.

There is no happy ending here. These menaces always cause untold avoidable harm. They bask in the approval of  most of the media and the young, until everyone begins to realise that this maybe isn’t so great after all, by which point lives have been lost, economies ruined, society broken further.

At the moment though, we can always eventually throw the bastards out. Far better would be to spot them in advance and never vote them in, in the first place.



**This terrific Brendan O’Neill piece on Varadkar’s poison came out a couple of days after this blog post. Essential reading

***and Dominic Lawson rips into Blair’s outrageous solipsistic posturing. He refuses to go away, naturally

****here’s Gavin Mortimer on Macron’s extremely rapid fall from grace

Where did it all go wrong? (AKA politics today)

That faintly nauseous feeling engendered by numerous politicians of various tribes, with the high points exemplified by the twin peaks of Blair and Obama in their hubristic primes. Yup, it’s got a name now, which I hadn’t quite twigged before.


It’s one of those bland words/phrases – think liberalism, neconservatism, social justice – which gets knocked about in the media and the political arena, often without people pausing to consider what it means.

Well here’s the ideal definition:

Progressivism was imported from Europe and would result in a radical break from America’s heritage. In fact it is best described as an elitist-driven counterrevolution to the American Revolution, in which the sovereignty of the individual, natural law, natural rights, and the civil society — built on a foundation of thousands of years of enlightened thinking and human experience — would be drastically altered and even abandoned for an ideological agenda broadly characterized as “historical progress.”

Progressivism is the idea of the inevitability of historical progress and the perfectibility of man — and his self-realization — through the national community or collective… progressivism’s emphasis on material egalitarianism and societal engineering, and its insistence on concentrated, centralized administrative rule, lead inescapably to varying degrees of autocratic governance.

Yup, we can all recognise that, whether we like it or not. I’m a ‘not’. It’s the opposite of true democracy, subsidiarity, respect for others, charitable endeavour etc. A surefire way of stifling altruism and enterprise, of crushing freedom of thought and speech. It’s neither specifically Left nor Right. It is a horrible amorphous blob of state control. It has ravaged the UK (especially Scotland), parts of Europe and is trying to take over the USA.

The author of the above is populist (and popular) Jewish intellectual, Mark Levin.

There is a lot of bullshit about when it comes to describing ideologies, political philosophy, the roles of the state and the individual, all that stuff – but I reckon the above description is a keeper. It always helps to know your enemy.

Stalin poses ad demagod WW2 Propaganda Poster
Raise your hand if you support progressivism!




Blair: batten down the hatches

My thanks to the wonderful @smithsky1979 for her #blairroll

The spectacle of Tony Blair as an apparently sincere penitent – albeit one still laden with his predictable list of hubristic justifications –  doesn’t surprise me at all, at this stage. The very first post on this blog, back in 2010 was about Blair’s apparent search for atonement in the truest sense. At that time I was confidently expecting Chilcot to report within the next year. It does surprise even me though, that Blair has ended up in quite such an abject state, when seen from the perspective of 1997.

A little context. Back in the time of  John Major’s government in the early 90’s, the UK was doing quite well. After Major’s appallingly selfish and ideological pursuit of the deutschmark (a folly which doubled my mortgage briefly, in 48 hours, not that JM cared about such things), the economy was booming, relatively. It was to be a golden inheritance for Labour, the exact opposite of the scorched earth bequeathed by Brown in 2010.

In about 1993 I began to notice Blair as an unctuous and slightly cocky Shadow Home Secretary, popping up on the TV. I’d seen Gordon Brown in action at the Commons as Shadow Chancellor under John Smith, and for all his faults, he seemed then a far more substantial figure than the glib Blair. After Smith’s death it became rapidly apparent that, under the youthful Blair, Labour were going to win the next election, irrespective of the economy.  I remember on election day in 1997 sitting in the operating theatre coffee room saying that Blair appeared to me to be a flighty and unserious chancer, albeit an ambitious one. The uniform response was “you can’t possibly want the Tories back in”. Nobody except me seemed to have any concerns about Blair**.

That election night I stayed up till two watching it unfold,  and by then the enormity of Blair’s majority was already apparent. He would clearly be in power for years. The phrase that kept going through my head was “batten down the hatches, this will take a long time to get through”. The next day at work everyone was delighted that the groovy young Tony was in and everything would be fine.

My concerns, which were pretty much completely borne out, related to the very clear message that this administration would intentionally change the social, cultural and moral fabric of the country, and eventually, through the timeless expedient of spending money they didn’t have, they would wreck the economy too.

I  usually date the completed initial phase of the first of these malign objectives to the release of the worst film ever made, Love Actually ( I’m serious), in 2003, which was basically a New Labour 90’s zeitgeist epic of the worst kind. The second objective was apparent by the financial crisis of 2008. It took them 11 years to destroy a booming economy, but they managed it. In case anyone is still spinning the line that it was all secondary to American subprime mortgage lending (Brown’s favourite excuse), then I would direct you to a prophetic book by two British hacks – the esteemed Larry Elliot and Dan Atkinson – called Fantasy Island, which was published in 2007. If you don’t believe me, read the synopses (1, 2 and 3). Truly the Blair/Brown government was a disaster on a huge scale, despite their aggressive and largely successful debasement of the government spin apparatus under the enduringly loathsome Alastair Campbell, which subjugated an already enthralled media.

So I wasn’t remotely surprised by all this, it was obvious to me when I first set eyes on Blair, and I took a lot of shit for it. The endless supply of people all willing to slag Blair off now, and over the last few years, are mainly the people who voted for him in three general election victories, a point made eloquently by James Kirkup. What a bunch of hypocrites.

That said, I never thought he’d become the crazy and infantile warmonger, which role has now, finally, skewered him.

Which is why I have to laugh at the endless bleatings (eg: 1, 2, 3) from Guardian writers and others now, post-Chilcot, who spent the period from 1997 to 2008 drooling over Blair and Brown. I don’t remember too much genuine opposition from them to the Iraq debacle back then. Jeremy Corbyn, Ming Campbell, the late Charlie Kennedy and Robin Cook all take credit for their stance at the time. A special mention goes to the routinely reviled George Galloway (see below), the only person who predicted in detail the aftermath of the Iraq invasion. Their  reasons for opposition varied, but they have the moral high ground today.

Max Hastings neatly outlines the stage on which Blair played out his monumental and ego driven disaster: “What took place was only possible because in 2002-3 Blair was an immensely popular Prime Minister with a personal dominance that enabled him to persuade or conscript the rest of Westminster and Whitehall to support an Iraqi adventure overwhelmingly driven by his own hubris and moral fervour.”

I doubt that there will be any article written in the aftermath of Chilcot that expresses the tortuous hypocrisy  of the British public and media in all this, than Brendan O’Neill’s, in Spiked. As he rightly puts it:

The important, humane task of understanding the history and politics of that calamity in 2003 has been sacrificed at the altar of allowing a needy elite the space in which to say: ‘Blair is evil, and I am good.’

I can already sense a neat dividing line developing when considering Blair’s legacy: Iraq bad/all else good. For the purpose of clarity – and going back to where I began this post – I would refine that to: Iraq bad (Blair sort of penitent)/most of his other stuff also bad (Blair unrepentant).

The criticism rightly heaped on him for Iraq, and on his many, many aiders and abetters  should be spread around on most of his other endeavours too. A messiah complex unburdened by caution and intelligent reflection is unlikely to come good at any point. This was a truly awful government, lead by a figure who since then has become more and more unhinged.

I should leave the last word to the hated yet prescient George Galloway, confirming what Chilcot meant when he pointedly said “We do not agree that hindsight is required.


** as Stephen Glover puts it ” Only a hard core of widely disbelieved critics saw him as an untrustworthy fraud”

Why do you want to be a doctor?


A few months ago I was talking to a friend who is a gifted surgeon, urbane, humorous, well published, popular with staff and patients and has plenty of outside interests. With us was a similarly accomplished colleague, with stacks of quality publications and a recent presidency of one of the main surgical bodies, a man at ease with politicians, journalists, difficult clinical problems – in short, a very admirable doctor. We had just agreed, in all sincerity, that none of us would get into medical school these days.

In fact, the whole rigmarole of medical school entry in the UK is one of my pet hates. It is absurdly popular, and quite possibly for the wrong reasons. A different colleague holds the view that one reason why so many GP’s seem pissed off is that they spent the first 25 years of their existence being told – with some justification – that they were the intellectual elite of the nation. Their adult day to day tasks frequently fail to meet the expectations that this raises, made ten times worse by the now discredited GP contract rewarding all the least fun and professionally dissatisfying aspects of the job.

My sympathy with the striking junior doctors is limited, for which I tend to take some stick. One of the most bizarre aspects of it to me is that I was walking on air when I graduated as I was a doctor. I now had intrinisic special skills. I could in theory work usefully anywhere in the world. There was a certain status that came with the title – something the current juniors would be wise not to take for granted. 30 years later I still feel that way, the ‘special feeling’ has barely diminished. None of us was that bothered by, or interested in the details of the rather brutal contractual obligations. We had money in our pockets, and much of the work was its own reward.

By that way of thinking the current strike is crazy. It’s already morphing into a leftie hatefest of the worst kind, which won’t end well. The juniors’ terms and conditions are infinitely better than they were even 20 years ago. Are they really saying that after a colossal input from the rest of us – as taxpayers and willing subjects for their education – they will withhold their services for emergencies because a small part of the particular terms and conditions of their work with the monopoly employer in the UK displeases them? Do none of the strikers feel that ‘doctor vibe’ I mentioned earlier? Are they now all the serfs that the New Labour mob in cahoots with the General Medical Council of the early Noughties intended the doctors to become?

Perhaps they are.

Which brings me back to why they wanted to do medicine in the first place, as a sense of vocation is possibly dropping down the list, and to how the UK medical schools select them. The majority of juniors are indeed talented and committed individuals, but something has changed. Here is an excerpt from the great Theodore Dalrymple, writing in Spectator Health, on the decline of informal recommendations and selection in medicine:

This kind of selection by boastfulness now affects even the choice of medical students. It is not that their intellectual quality has gone down: on the contrary, it has probably gone up. But what is now required of them to gain entry to medical school is morally repellent, much worse than any possible defect that existed before. They now have to make a ‘personal statement’ about why they should be admitted, and this, of course, results in the most odious conformism; a kind of psychological cloning, as well as an invitation to untruth.

The son of a friend of mine applied to medical school and was turned down. He was told that, though he was academically qualified and admirable in many ways, his personal statement was not impressive enough. So he went a tutor who told him how to write his personal statement when he re-applied to the same medical school the following year. (In the world of spivvery that we have created, there is an allegedly private-sector opportunity in every procedural requirement.)

Having made his ‘personal statement’ more impressive with the paid help of his tutor in this dark art, he was admitted to the school that had refused him the year before. Needless to say, he had not changed in any way other than being a year older: but in a world in which the virtual is more real than the real, self-presentation has replaced theology as the queen of the sciences.

My solution would include adopting the perfectly good North American model (which includes Canada), and make all medical school entry postgraduate. Dalrymple’s precise phrase “odious conformism; a kind of psychological cloning” is part of the current problem.


Celebrity death match: the Queen v Blair

The Queen has done us another unexpected favour, via journalist Iain Martin at CapX. He has provided in one paragraph a neat summary of the unique awfulness of the Blair years’ cultural mood (traces of which remain). I would normally use the joint worst film ever made, Love Actually, to provide the necessary snapshot of the era, but here is the paragraph. You probably had to be there to fully appreciate how awful it all was:

For all that the Queen has provided continuity, she has been extremely canny in the manner in which she has adapted to change. In the last quarter of a century, no British institution or profession has been untainted by scandal. Parliament, the press, the police, the BBC, the armed forces, the City, bankers and sporting stars have all been badly burned at various points, as that decline of deference turned into full-blown disaffection with the behaviour of elites. In the scandal stakes, the monarchy got there first in the 1990s, from the events surrounding the divorce of the Prince of Wales to the death of Princess Diana, when even some of the monarchy’s supporters accused the Queen of hard-heartedness and inflexibility. But in a tight spot, the monarchy executed a pivot rather brilliantly while looking slow-moving and reliant on others. The masters of spin and marketing descended to “rescue” the Queen following the death of Diana. Afterwards, the Blairites swaggered about. They had prevented a potential revolution when public feeling spilled over into outright mania. They had saved the stuffy old Queen (who during the madness was doing the best thing possible of caring for her bereaved grandsons in the tranquility of the Scottish Highlands). Under pressure, she was forced back to London by the mob and politicians responding to the mob. And the two boys, just young boys, were paraded in front of the mob outside Kensington Palace, where there was a mountain of flowers, so that the mob – which had so fetishised emoting on demand and “caring” that it could not see the cruelty in what it was demanding – could gawp. This was all done in the name of modernity, but 18 years later the Queen is still reigning, magnificently. Where are the bright, modern Blairites and their hero now? In the dustbin of history.

In a separate cinematic reference, the kind of milking the public that Martin describes is reminiscent of the quote from Gracchus, in Gladiator:

I think he knows what Rome is. Rome is the mob. Conjure magic for them and they’ll be distracted. Take away their freedom and still they’ll roar. The beating heart of Rome is not the marble of the senate, it’s the sand of the coliseum. He’ll bring them death – and they will love him for it.

Possibly a link with the utterly daft invasion of Iraq there. If Labour hadn’t got the push in 2010, God knows what mob-friendly schemes they might have come up with, though I reckon the incompetent crowd pleasers of the SNP may yet show us.

The Queen, out for a stroll
The Queen, out for a stroll

Labour’s glorious 13 years in power: an appreciation

Right then, what should we wreck first?
Right then, what should we wreck first?

Labour were in power for 13 years: 1997 to 2010, mostly under Tone, of course.

I used to argue with friends on the topic: what genuinely good things did Labour actually achieve, with the massive power to be wielded after their landslide? Bear in mind we can agree on most of the bad things, Iraq being no 1, and we probably can, however grudgingly, agree on what Maggie achieved in many key areas, as a handy comparison.

Happily, Labour Uncut, in the course of considering a Corbyn leadership, have offered their own carefully considered list. Remember, they all voted for Blair etc, and they still keep the Labour flame burning. Here is their list, with my comments. I’m pretty sure they haven’t missed any opportunities to big up the New Labour legacy:

…all the time Jeremy has been in parliament he has had a Labour party that either was in government or acted like it wanted to be in government. So his, and other constituents benefited from the minimum wage, 78,000 more nurses, devolved power in Scotland, a Welsh assembly, the overseas aid budget doubled, 30,000 more teachers, winter fuel payments to pensioners, halved waiting times in the NHS, free school milk and fruit, the Disability Rights Commission, free entry to museums and galleries, the Good Friday agreement, paternity leave, civil partnerships, to name but a few.

Hmm. Is that it?

the minimum wage

OK, not bad in principle, as a safety net. But it does distort market forces, which can be very damaging. Already Osborne has been fiddling with it, to his peril. as the FT says “As for working people, many will thank the chancellor as their wages rise. Others will become unaffordable and will lose their jobs”.  A mixed blessing, at best.

78,000 more nurses

Well, as a full time NHS worker, I would say firstly, it’s not that many, and secondly, putting nurses in non-jobs, which is a lot of it, is of no use. The problem, if there is one with hospital nursing, is attitudinal, and the changed nature of the job.

devolved power in Scotland

Tam Dalyell would have been proven right, if the oil price (and industry) hadn’t started collapsing. Basically a short term bit of meddling with terrible consequences. The only plus point is that despite the extremely low calibre of Holyrood MSP’s, the devolved chamber means that public spending is protected in Scotland by a nervy Westminster, whatever the Nat morons claim to the contrary. See Chokkablog on all this.

a Welsh assembly

What can I say? The Welsh NHS?

the overseas aid budget doubled

Like the minimum wage, in theory it’s a humane approach. The reality is a bit different, and being in government really shouldn’t be primarily gesture politics. It’s also spending money we don’t have.

30,000 more teachers

Another numbers game. What did the OECD find when it assessed Labour’s legacy on this? Try visiting any country in Europe, even crisis hit Spain and Greece, they seem pretty well educated and mostly fluent in English.

winter fuel payments to pensioners

Another blunt instrument, does it actually work in practice?

halved waiting times in the NHS

Ah yes, waiting times. I am part of this one. Fine concept for cancer, good for A&E, but very difficult in that service due to Labour’s destruction of GP out of hours services. However, the politicians are obsessed with waiting times for non-urgent elective surgery, over almost anything else. This distorts NHS provision, damages staff, wastes money and creates unmeetable expectations. There is no evidence that it gains votes, and all this when huge swathes of elective surgical practice are, embarrassingly, of uncertain value and unknown outcomes. Not everything is as good as a cataract op or a hip replacement.

free school milk and fruit

It’s not ‘free’. Do they actually consume it?

the Disability Rights Commission

OK as far as it went, now unfortunately swallowed up in the potentially tyrannical megabureaucracy of the Equality and Human Rights Commission, a classic politicised quango

free entry to museums and galleries

Gold star, we can all agree on this one

the Good Friday agreement

Well, I have to admit that peace in Northern Ireland – for the most part – is better than the bad old days. I’m of the view however, that letting unrepetentant thugs like Adams and McGuinness swan around in government and being lauded has its down side. A lot of crimes have now gone unpunished, a lot of people feel very bitter, but powerless. A genuinely tricky one. Read this

paternity leave

Otherwise known as extended annual leave. A nightmare for small businesses and running essential public sector services. Of no proven advantage, as compared to the old days, when we just took annual leave. Actually, a pathetic development in the true sense of that word.

civil partnerships

Fair enough. Not to be confused with ‘gay marriage’.

I note that they didn’t include banning fox hunting. Is this a secret pleasure for the Labour Uncut staff? In any event, does the thin gruel outlined above even come close to outweighing the Iraq War, the institutionalisation of lying to voters, the destruction of the economy, the issues with immigration, the bizarre relationship with the worst of the EU, the explosion in unaffordable freebies by abusing Bevan’s concept of the welfare state, the subtle and not so subtle attacks on the teachers, the doctors and religion, the witless nurturing of violent Islamism in the UK?

I think the answer is no. And remember, the above is the Labour supporters‘ list of achievements, not mine. Also, bear in mind their indirect responsibility for the worst film ever made, Love Actually.

No wonder they are, happily, self-destructing.

The Blair legacy: a snapshot

Great geopolitical thinking in action
Great geopolitical thinking in action

The Knife has complained in the past about people whose words or actions proclaim that they’re ‘strategic not operational’, particularly as it pertains to the NHS. Operational is tough, strategic can mean almost anything. It’s usually bullshit.

So it comes as no surprise to read that  Tony Blair suffers from this malaise. In a perceptive piece in the Mail, these paragraphs stand out:

However, there is little doubt that his predecessor in the job, James Wolfensohn, former head of the World Bank, spent much more time in the region. He told us that to do any good for the peace process, you have to put in a lot of time. ‘It is a full-time job and you cannot do that on a timetable of two or three days. You cannot do anything in a rushed manner in the Arab world.’

Those in the know say Wolfensohn was in non-stop negotiations between the Israelis and Palestinians, shuttling between Gaza, Jerusalem and Ramallah. He got involved in nitty-gritty issues, such as organising openings at road crossings so there could be free movement of buses for the Arab population and goods between the West Bank and Gaza.

Blair, on the other hand, with his once-over-lightly, butterfly approach to diplomacy, prefers great geopolitical thinking and high-flown rhetoric rather than detailed on-the-ground negotiations.

The considered view is that in one of the most turbulent times for the Middle East, he has done little or nothing to bring Israel and Palestine together through economic and security co-operation, apart from occasionally turning up at the region’s most exotic hotel and consulting with a few local leaders and journalists.

I don’t begrudge Blair a few quid and a nice retirement, it’s just the need to pretend that he’s doing something noble and selfless, tinged with the wisdom of Solomon, that gets me.

The ascent of the ‘strategic’ NHS manager, and numerous gruesome self-appointed health experts like the pompously named Kings Fund neatly parallels the rise of Blair, and his relentless dilution of substance with superficial style. The surprise is how permanent is the damage done to institutions by that once-over-lightly, butterfly approach‘.


The NHS: the best of times, the worst of times

The consultants had it good back then……………(it’s a joke, honest. Artwork by the great Robert McGinnis)

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.

...we worked hard, but it was rewarding...
…we worked hard, but it was rewarding…

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. had outsourced brain surgery again.. had outsourced brain surgery again..





Pinochet, Blair and the usual hypocrisy

That's what a dictator should look like
That’s what a dictator should look like

In a typically mad article in today’s Guardian, child of privilege Seamus Milne rants on about Blair’s dud and pointless role in the Middle East. I agree that Blair should drop it, but those of us who never bought the whole Tony schtick never expected it to be anything other than a bit of fake gravitas and earning opportunities for the ageing fraud. We don’t have Seamus’ outraged disappointment.

However, in the middle of his cliche-fest was the phrase:

The Egyptian regime isn’t just autocratic. Its president overthrew an elected government Pinochet-style, with a bloodletting of Chilean proportions.

Of course! Pinochet, possibly the ultimate bogeyman for well fed British liberal prats, which culminated in a lengthy and futile period of house arrest under Tony’s government, at the instigation of a now disgraced excitable self publicist, the dodgy Spanish magistrate Baltasar Garzon, now a chum of the ludicrous Julian Assange.  How the UK lefties enjoyed that slice of gesture politics.

Eventually Jack Straw (as Home Secretary) let him go, and Pinochet was never extradited to Spain. He never committed any offences there anyway.  Jack now inevitably claims he was ‘deceived’ into releasing him. Of course you were Jack.

Anyway, the point in all this is what Pinochet actually did that was unique, and for which he never gets the credit. He voluntarily gave up his authoritarian dictatorship to democratic government. Unheard of in the annals of dictators of any political hue, though Franco in Spain came close with his arrangements for after his death.  The reasons for Pinochet doing this are often speculated upon, but no-one seems to know for sure.

In 1988 the Pinochet regime instigated a national referendum on whether he should continue in power. It seems to have been conducted pretty much impartially, and he lost (56%:44%). By the next year the democratically elected Patricio Aylwin was in power, and Chile has, more or less, never looked back. It’s one of the few economically successful democracies in Latin America.

None of this is to exonerate Pinochet and his regime of the very many brutal crimes that their government committed. He continued to be

From the early years of the Blair Terror
From the early years of the Blair Terror

followed by this legacy in the new democracy, and was not immune from attack. Clearly, he was one of the bad guys.

But….is there another example anywhere of such a remarkable – and successful – voluntary relinquishing of power, by a dictator with such a reputation? In particular, Seumas Milne’s billionaire murderous lefty heroes like Stalin, Castro, Mao….Brown etc etc?

I think not. It remains one of the least remarked and unusual episodes in international politics. Every time a trite jibe at Pinochet crops up in the Guardian etc (3,520 search results, and counting), ask yourself  how many of the current crop of madmen, warlords and friends of Tony are likely to follow suit, giving up power and installing democracy without outside interference?

I think we can all guess the correct answer.



Tony Blair: “Quem deus vult perdere, dementat prius”

I would never have voted for him...
I would never have voted for him…

Most bloggers and Tweeters like to claim that they were right all along, and have the solipsistic habit of linking to their previous pearls of wisdom. I’m no different.

Here is my first ever post, written at the tail end of the Blair/Brown Terror, more than four years ago. I quote:

Blair is a man carrying heavy  baggage,  and it’s beginning to show. His conversion to Catholicism is well known, the timing seemed almost cowardly, but there’s no rules to these things, and nobody does it lightly. It’s not possible for it to take place on the spur of the moment. All those  churlish catholics who questioned the move do so at their peril – it’s between Blair, God and his confessor.

I think he is genuinely seeking atonement. What else can he realistically do to make amends for his colossal hubris and misjudgement in the Iraq war, as well as numerous other nightmares, not least his role, however peripheral in David Kelly’s death?  He’s not going to ‘fess up on Oprah, start squealing to Chilcot or write an honest memoir, not at this stage.

He can however start to make things right within himself. Perhaps his ludicrous role as an utterly ineffective mini-Kissinger in the Middle East is the acceptable public face of this attempt to do the right thing, but the real action is taking place inside him.

Well, maybe I was wrong, because his latest weird self-exculpatory message suggests that he thinks he was right, though I still doubt that he really thinks that.

Here is Boris Johnson in today’s Telegraph:

I have come to the conclusion that Tony Blair has finally gone mad. He wrote an essay on his website on Sunday  that struck me as unhinged in its refusal to face facts. In discussing the disaster of modern Iraq he made assertions that are so jaw-droppingly and breathtakingly at variance with reality that he surely needs professional psychiatric help.

He said that the allied invasion of 2003 was in no way responsible for the present nightmare – in which al-Qaeda has taken control of a huge chunk of the country and is beheading and torturing Shias, women, Christians and anyone else who falls foul of its ghastly medieval agenda. Tony Blair now believes that all this was “always, repeat always” going to happen.

He tells us that Saddam was inevitably going to be toppled in a revolution, to be followed by a protracted and vicious religious civil war, and that therefore we (and more especially he) do not need to blame ourselves for our role in the catastrophe. As an attempt to rewrite history, this is frankly emetic….

He (not Blair, but a CIA man who Boris met in Iraq) was hoping to find someone to carry on the business of government – law and order, infrastructure, tax collection, that kind of thing. The days were passing; the city was being looted; no one was showing up for work. We had utterly blitzed the power centres of Iraq with no credible plan for the next stage – and frankly, yes, I do blame Bush and Blair for their unbelievable arrogance in thinking it would work……

The Iraq war was a tragic mistake; and by refusing to accept this, Blair is now undermining the very cause he advocates – the possibility of serious and effective intervention. Blair’s argument (if that is the word for his chain of bonkers assertions) is that we were right in 2003, and that we would be right to intervene again…

Somebody needs to get on to Tony Blair and tell him to put a sock in it – or at least to accept the reality of the disaster he helped to engender. Then he might be worth hearing. The truth shall set you free, Tony.

Well, perhaps he is in need of the psychiatrist’s couch.  Ian Birrell, in a very fine piece in the Independent is less kind:

Please forgive me. I know we should ignore his latest attention-seeking outburst, like a kind parent might turn their back on a child prone to temper tantrums. But it is hard when he pops up to pollute the airwaves and defile acres of newsprint with silly statements. So, once again, we must focus on our former prime minister Tony Blair, who has moved far beyond the point of parody with his latest attempt to absolve himself of guilt over the terrifying events in Iraq.

As a group that even al-Qa’ida thinks too violent runs rampage through Iraq, exploiting the region’s chaos in its drive to recreate a repressive medieval caliphate, Blair pens a 2,848-word essay, claiming it is “bizarre” to blame the crisis on his 2003 invasion. Incredibly, he still argues that Saddam Hussein might have used weapons of mass destruction, despite the crushing evidence he had given up such devices. As Blair blames everyone but himself for the current carnage and bloodshed, he even claims to speak “with humility”.

These are the delusional and self-serving ravings of a man who just a year ago bragged that Iraq was a better place for the removal of Saddam. As he flits around the world giving speeches on democracy, while receiving huge cheques from despots, the former Labour leader seems to have lost touch with reality. No doubt, he sees himself as some kind of Churchillian figure whom history will prove right, yet experts and former diplomats were not short of evidence yesterday as they tore apart his arguments….

Never an apology. Never any sign of awareness, trapped on his self-harming journey to wealth and global vilification. Never any reflection on the blood spilled, nor the struggle of those really fighting for human rights. Blair is a messiah in his own mind, reviled by most others.

Perhaps it would be kinder if the media did ignore his strange desire to shred the little that is left of his reputation

General Sir Michael Rose very effectively ‘fisks’  Blair’s oddball essay in the Mail, concluding with:

“But Blair, all to clearly, cannot face this brutal truth. He once said that war is an imperfect instrument for righting human distress. He should pay more heed to his own words”.

Well, the latin title of this post, often attributed to Euripides,  is (of course) translated as Whom the gods would destroy they first make mad.

Even better is Sophocles’ variant:

evil sometimes seems good
to a man whose mind
a god leads to destruction. neither
…me neither