1001 things wrong with the #NHS (998): Committees

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Pretty simple, and universally applicable

The Knife has done lots of formal hospital management, though on the principle of ‘quit while you’re ahead’, I voluntarily stepped down quite a while ago. I don’t hate it, usually, but I prefer clinical work by far, and if I leave this earth having done any good, it’ll be in the latter sphere, by a long way. If you step too far away from the clinical stuff, you start to act and think differently, ego takes over and your peer credibility dies.

That’s guaranteed.

That said, it’s an interesting milieu, not least because of the subterfuge, inconsistency and indecision that abounds, usually combined with declarations of ‘caring’. The much hated private sector – which happens to constitute most of the healthcare in the developed world – would never tolerate the crap that goes on. (For the record, I do no private work.)

And today, as it happens, was one of the most gruesome** management meetings that I’ve ever attended – I won’t bore anyone with the details, but it was actually depressing. It was an absurdly large group attempting to share a process that neither needed it, nor was amenable to it.

Where to go for solace, some reassurance that my negative feelings are in fact appropriate?

Well…….

committee1

….the author is talking about restructuring the playing season for American football. The key quote is “committees are what insecure people create in order to put off making hard decisions”. It’s nice to be inclusive, if possible, but it’s no surprise that the phrase ‘design by committee’*** is never used in  complimentary way.

Even worse than that is that such large unwieldy groupings always contain people with nothing to lose, no axe to grind, and indeed no expertise worth having. As any endocrinologist will tell you, a negative feedback loop is an essential regulatory part of a well functioning system. You need people with what Black Swan author and polymath, Nassim Nicholas Taleb calls ‘skin in the game’ (1, 2). I don’t want my clinical practice parameters decided by a committee of people without skin in the game. Nor would they, if it was their area, and nor would my patients want it.

What’s the answer to this?

Well, here is the same author. I agree wholeheartedly with it, not least that it’s coming on the back of a riff about the uselessness of management consultants (who should be barred from the NHS)…

committee2

…for money, read clinical practice.

You can guess the author, I would imagine

 

**if you want to know how gruesome the NHS can be, this vivid account (spoiler: bad language), gives a fair appraisal of a bad spell. I did not write it!

 

***As advertising pioneer and author of Confessions of An Advertising Man, David Ogilvy said: ‘Search your parks in all your cities. You’ll find no statues of committees.’

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The damned statistical lies of the NHS (hip replacement edition)

A quick observation. The ‘top nurse’ in NHS England, Jane Cummings, is quoted in today’s Times as follows:

A million more cataract operations or 250,000 hip replacements could be funded if the NHS did not have to pay for appointments that people failed to attend

Of course this is only the latest in many claims about the NHS which appear shocking, eye catching and as one might expect, either unprovable or simply untrue.

A few facts, assuming that Ms Cummings is primarily referring to missed outpatient appointments. Depending on your specialty, very few operative patients fail to attend:

a. Patients who fail to attend are very often patients who shouldn’t even have had an appointment. Many have got better. Many were given appointments ‘just to check’. There is lots of evidence that the clinical yield from an arbitrarily timed clinic appointment is minimal. Who is benefiting here? Do not assume that these appointments were necessary. The fault may lie with the hospital.
b. It depends if your outpatient clinic template already factors in DNA (Did Not Attend) patients. Mine used to. If your clinic is very busy then these absent patients are actually a great relief. If there is a factored in DNA factor and they all do attend, then it creates a real problem. In other words, it’s not always an administrative disaster, just as it’s not always (or ever) a clinical disaster – see point a.
c.  The claim that these DNA’s mysteriously add up to a quarter of a million hip replacements is a classic piece of pseudo-statistical rubbish. It probably emanates from an NHS head office algorithm built on crazy assumptions, or on the specious views of overrated NHS parasites like the oft-quoted ‘charity’ The Kings Fund. The Times article states:
At an average cost of £120 per slot, this indicates that doctors’ time worth about £950 million was wasted last year.

In the real world, in the unlikely event that your clinic finishes early, then you probably do one of the following valuable things: speak to colleagues (including non-medical ones), have lunch, conduct a ward round, review investigations, write to GP’s, make necessary phone calls, answer emails, complete training dashboards online, speak to management and much much more. All necessary parts of the job. What this unexpected ‘spare’ time does not, and cannot equate to is knocking off a quick hip replacement.

Oddly enough it might, if in a parallel universe the NHS had spent a bit more of its already colossal budget on meaningful infrastructure, like operating theatres. There is no shortage of patients who can come in at short notice, and NHS admin staff are now often superbly responsive at  getting hold of patients in a hurry. That is the sort of NHS of which Nye Bevan and William Beveridge would approve. The NHS desperately needs to factor in some free space in both its physical and administrative infrastructures, if it wants that kind of flexibility. I think it should.

Ms Cummings is describing a made up situation that is misleading at best. It appears to be part of a national drive. Some Scottish health boards, for example, are claiming that these DNA’s cost an unlikely £4 million a year, based on back of an envelope calculations.

If, however, you want to save millions of actual cash payouts for work not done, generally speaking, try rescinding the increasingly absurd and profligate New Deal contract.

There’s a suggestion for 2018.

surgery day
….it’s actually a bit more complex than this

The SNP: decline and fall (16)

As 2017 ends, this long running saga is drawing to a close. It’s been 3 months since the last episode, and in truth, not much has happened. Not much in Scotland, that is, although events elsewhere have conspired to put a further dampener on the whole SNP raison d’etre (unless you cynically believe that such a thing is in fact the mere fact of clinging to power and the associated trappings, with independence merely a Scottish avatar). So….

51. Ozymandias Salmond

Although Shelley’s paean to fallen grandeur and the passage of time had a certain romantic majesty, it’s difficult to claim as much for the fate of Alex Salmond. Not only does he seem to think that a gruesome chat show on the amusingly barefaced bias of Russia Today is some sort of positive career move, he’s in trouble for blatantly lying in his opening episode, so short was he of ‘material’.  In keeping with no. 49 in this series, there’s a bit of unhappiness between Eck and Ms Sturgeon on this one, which is strange given they’re one big happy family. Talking of which, the ubiquitous Tas has been both getting exposed to Eck’s undoubted sartorial flair (see pic), and being punted (by Eck) as a fashion guru herself to deal with the…um…shortcomings of middle class legend SNP MP Mhairi Black. To quote Ms Black:

He then said that the last time he’d had this conversation it was with a young woman called Nicola Sturgeon.

“I thought, ‘oh, very good’ and I just left the awkward silence hanging when he asked me if I wanted him to arrange it with Taz. I’m like, ‘I am never going to be told how to dress, especially by a man.’

Still, the good news is that Eck’s flagging TV career may only last as long as his overpaid yet now apparently defunct journalistic one.

Look on my works, ye Mighty, and despair!

Alex-Salmond RT kilt
“Is anything worn under the kilt, Alex?” (I’ll stop there)

 

52. Catalonia is still part of Spain

No need to reprise the whole Catalonia secession thing. Suffice to say that despite the ignorant and rather pathetic urgings of various SNP lackeys, neither the glorified opinion poll of  October 2017, nor the actual national elections of last month, lead to anything like independence, nor is there any hard evidence that it would be popular.

In fact the Spanish have lead the way on this by issuing various arrest warrants, such that the floppy haired Salmond manqué (and talk show guest) Puigdemont, ran away from the heat and is now in exile.

Oh, and the SNP’s beloved EU backed Spain to the hilt on this. As any sane observer would expect them to.

53. Tax the ‘rich’

The SNP, having avoided using their tax raising powers for a long time (with good reason), have now caved in, and courtesy of the ‘limited’ Delboy Mackay, their Finance Minister, have decided to punish the middle classes.

It may please the zoomer base, but as a general observation, these things never end well. Interestingly, it coincides with Trump’s bold application of Laffer Curve principles in the USA. We’ll see how that works out as the year unfolds.

54. Reflections on the Revolution in Scotland

(misquoting Edmund Burke).

The Knife has continued to be impressed by the resemblance (1, 2) of the intolerant zealots of the SNP to their French predecessors, the Jacobins of the French Revolution. In keeping with their bizarre attempts to take over the rearing of the nation’s children, and to impose a monoculture on debate within their masses, I was struck by the similar mood music of the Law of Suspects, which the National Convention of 1793 passed in France:

“1. Immediately after the publication of the present decree, all suspects within the territory of the Republic and still at large, shall be placed in custody.

2. The following are deemed suspects:

i. those who, by their conduct, associations, comments, or writings have shown themselves partisans of tyranny or federalism and enemies of liberty;

ii. those who are unable to justify, in the manner prescribed by the decree of March 21st, their means of existence and the performance of their civic duties;

iii. those to whom certificates of patriotism have been refused

…and there’s more. I’m not saying it’s going to happen, although a stroll round SNP Twitter might persuade you otherwise, it’s just that there’s a certain doctrinaire flavour that keeps cropping up…

eck2
…wishing the voting age was even lower

 

To close, over to a better and more measured writer than me, Euan McColm, with his New Year observations:

Nationalists now growing impatient with the First Minister over her hesitancy will, I think, be further disappointed in the year ahead.

Sturgeon is understandably keen to maintain the myth that she is in control of when another referendum takes place but the power to make this decision lies with Westminster and, after the general election showed a majority of votes for unionist parties, the UK government would have no hesitation in rejecting the First Minister’s proposal. This, I suppose, might play into the SNP narrative about a Scotland forced to bend the knee by the Westminsters (which is what we must now call the English) but no matter the grievance dividend, it will not get Sturgeon the referendum she says she wants.

The challenge for the First Minister in the months ahead is to keep her hardcore supporters happy with just enough constitutional meat while winning back the trust of unionist Scots who were previously happy to back the SNP in Holyrood elections but who are now weary of and frustrated by the nationalists’ obsession with another referendum.

Quite.

 

 

The new semantics of the public square

From Sky News, who are slowly drifting into sloppy PC reporting, on the tragic murder by stabbing in an Aldi store, the details of which remain obscure:

North Yorkshire Police said it was neither terror-related nor a hate crime.

Terrorism I get (see below), but is ‘hate crime’ a thing in the public mind these days to be placed on a par with terrorism when considering each violent death? If so, it has a pretty warped definition. Murder is a crime, and it seems inevitable that hatred was involved in some way. Yet this wasn’t ‘hate crime’. What a relief.

On the other topic, it’s hard to beat the weaselly syntax of the Australian police, no doubt under a certain amount of pressure:

Acting Chief Commissioner Shane Patton said police had found no evidence Noori planned his horrific actions or that they were terror-related.

Which as the numerous news reports (1, 2. 3) indicate, is not really true.  There are lots of ethical and practical problems with this intentional deception, not least is that it’s an appalling slur on people with mental health problems to clearly suggest that this kind of rampage is the sort of thing we can expect from them.

Frederick William, The Great Elector of Brandenburg-Prussia who dealt with the devastating aftermath of the Thirty Years War,  wrote eloquently about this in his Political Testament, exactly 350 years ago – some things never change:

“One thing is sure. If you stand still and think that the fire is still far from your borders, then your lands will become the stage upon which the tragedy is performed”

Non-politicians will draw their own conclusions.

melb
*

 

 

Multipurpose soundbite (1): apply as necessary

From Jonah Goldberg’s brief precis of Trump’s plan to actually move the US embassy in Israel to Jerusalem:

The only people who bought the idea that the Middle East conflict began and ended with Israel were those guys in the control booth describing the wrong game — i.e., Western experts and activists deeply invested in the “peace process.”  In a sense that’s understandable. If you’ve dedicated your entire professional life to a moveable feast that covers your airfare and lodging in Paris or Geneva while you discuss grave matters, it’s probably hard not to cling to fictions.

Good article, but it’s the second half of the quote that is so handy:

If you’ve dedicated your entire professional life to a moveable feast that covers your airfare and lodging in Paris or Geneva while you discuss grave matters, it’s probably hard not to cling to fictions.

It’s possibly the best explanation for nearly all climate change activity, numerous medical ‘conferences’, the EU, various peace processes (see above), the G7, the G20 and much much more. Nobody holds these boondoggles in Detroit or Dundee.

I wouldn’t care except when I end up paying for all this nonsense, directly or indirectly.

Here’s the reliable Lou Donaldson to celebrate what’s actually going on:

We have to talk about nationalists, AKA Bigger Than Brexit

tibidabo2
On Tibidabo, gazing down on the chaos..

As someone with an intimate knowledge of secessionist lunatics and the trouble they cause – with complete indifference to its effects and an utter disregard of those who might demur from their obsessive worldview – I have watched the Catalonia situation with a mix of deja vu and disgust.

In retrospect, lancing the SNP boil by giving them their referendum might have been David Cameron’s signature achievement. Scotland, despite the SNP hype, is not ruefully regretting the majority rejection of the SNP raison d’etre.

And also, as someone with a pretty good knowledge of Spain, including Catalonia, over many years, I can observe that Puigdemont’s mob, in common with the SNP, don’t really have anything tangible in the way of active grievances. Their gripes are historical, though in Spain I would concede, some of the bad stuff still lies within living memory. Not so Scotland, I would suggest.

Other things they have in common are a failure of serious planning – currency, defence, capital flight, all that stuff – and the thinnest of veneers when it comes to respecting democracy. It was almost inevitable that the floppy haired egomaniac Puigdemont would turn out to be an unelected demagogue, in that no Catalan actually voted for him to become president. That would be too risky. Here’s Wikipedia:

On 10 January 2016, he was invested as the 130th President of the Generalitat of Catalonia by the Parliament of Catalonia. This followed an agreement carried out the day before between Together for Yes and the CUP, in which it was announced that he would replace Artur Mas as president of the Generalitat in exchange for a guarantee of parliamentary stability for his Government

Nice deal guys

However, enjoyable sneering aside (the SNP similarities keep coming), there is a very serious aspect to all this, or aspects. Spain’s tumultuous history comes to the fore, from the epic of Covadonga in 722, through the Reconquista of 1492 to the civil war of the 1930’s. For the last 5 years and more there have been clear signs that Catalonian separatism was encouraging an Islamist enclave to form, in part as a further divide with the rest of Spain. The recent horrific terrorist attacks, conveniently airbrushed now, combined with any casual observation in Barcelona and environs, will tell you that it has changed immensely. This is in part hardcore Salafist Islam, a problem for everyone, including the vain and solipsistic Puigdemont.

By contrast, the beleaguered Mariano Rajoy has shown a decisiveness and maturity so far, that it provides a little ray of hope.

The best summary of all this right now, with hard hitting criticism of all parties,  is  from Iain Martin, a man who knows a mad secessionist when he sees one, over at Reaction (which is worth its tiny subscription fee). I feel compelled to quote it at length:

One of the more obscure aspects of the latest, tragic events in Catalonia is the way in which the constitutional emergency has brought together under one banner some unlikely allies in Britain. Not only are the separatists in Barcelona being cheered on by activists from the Scottish, Welsh and Northern Ireland nationalist parties, as should be expected.

They all support the potential break up of Spain for the obvious reason that separatists love separatism, and, because they want to break up countries on principle, they enjoy the spectacle of it happening elsewhere, probably because they expect the impulse to spread beyond the borders of Spain.

But alongside the SNP et al, the Catalans also have the support of the Faragists, that collection of tin-pot populists clustered around the former leader of UKIP, Nigel Farage. In that faction, judging by their comments today, the delight at the declaration by the Catalan parliament of independence from Spain is rooted instead in the potential for the Catalan business to damage the European Union, which they despise and want to fall apart. In this way the Catalans are cast as the latest exponents of the Trumpian impulse – breaking norms, smashing up the system, as though it is all a great laugh, Carry on Up the Sagrada Familia.

According to the twisted populist reading, the EU is trampling on the will of the Catalan people. That is nonsense. It is not clear there is anything like a majority for a split from Spain. Unlike the Brexit referendum in the UK in 2016, held legally in a nation state, the recent Catalan referendum was illegal, and the EU’s refusal to recognise the unilateral split is perfectly fair and sensible. National governments elsewhere across Europe are taking the same position, not because the EU told them to, but for the perfectly understandable reason that it is rooted in truth and respect for law. In the fantasy ultra-Brexiteer version of diplomacy, this is supposed to be cast aside, sanctioning the end of Spain when there is simply no majority for it.

There has always been a brainless, reckless strand at the Faragist end of the Brexit side of the argument, which operates on the assumption that anything bad for the EU, or Europe more broadly, is good fun and good for Brexit, as though this is a zero sum game and as though we are not all living in the same continent, in the shared space that is Europe. The temptation to mix the two up – Europe and the EU – must always be resisted. Europe is an old civilisation and an enduring concept. The EU is a relatively new political experiment.

In that context, what is happening in Spain is not a cause for celebration. It is a European catastrophe. After a difficult 20th century – and a return to democracy in the mid-1970s following the death of Franco in 1975 – Spain has re-emerged as a confident country with distinct economic strengths (in finance in particular) and restored pride. Catalonia is a disproportionately productive part of that success story. With only 16% of Spain’s population it nonetheless generates 20% of Spanish GDP and a quarter of national exports. It is, for now, a magnet for foreign inward investment.

Catalonia is, or was, doing well, and Spain is, or was, recovering strongly – with growth running just above 3%. The considerable difficulties that Spain encountered stemmed from joining the euro. They are being overcome after a robust programme of reforms.

Now, this weekend, the unity and economic health of that major European democracy is in peril. Direct rule will be imposed. Civil unrest seems certain and violence highly likely. In simple human terms, once the celebrations in Barcelona are matched by counter-demonstrations, a lot of people are at risk of being hurt.

There is another important and overlooked reason for non-Spaniards to fear the break up of Spain. It is on the European front-line against the Islamist war on Western civilisation. Islamic State talks of retaking the Iberian peninsula, and it was from radicalised communities in the Pyrenees that the cells emerged to perpetrate recent attacks. Spain falling apart in the face of such violence would signal to the enemies of European civilisation that great countries are disintegrating and the West is weakening.

Some things, you see, are bigger than Brexit. All Europeans – in or out of the EU – should be extremely concerned by the crisis in Catalonia and should hope for some statesmanship and compromise.

It is indeed a catastrophe, and no-one knows how it will end.

Science: it’s not rocket science (and climate change is not science)

Here’s a quote from the column that runs down the right side of this blog:

One of the great commandments of science is, “Mistrust arguments from authority.” … Too many such arguments have proved too painfully wrong. Authorities must prove their contentions like everybody else

The author is noted populariser of science – but also a real scientist – Carl Sagan.

What can he possibly be getting at? Let’s try another famous scientist: Einstein. In 1905 he’d proposed his Theory of Relativity, and worked on it until 1916 (the year of the Somme, which made communications tricky), and it immediately had a huge impact, with British scientists, notably Eddington, who publicised it through the Physical Society in London.

Here’s where the key point is. Despite the acclaim he was receiving, Einstein refused to accept it until the theory had been verified by empirical observation. Which makes sense, no? Here is the extract from Paul Johnson’s essential history of the 2Oth century, Modern Times:

einstein3
*

einstein1919Which is where Eddington came in, setting off to the coast of West Africa to photograph a solar eclipse, with all the vagaries of the weather. It worked. He proved two of the three tests were correct, and the third, related to the phenomenon of red shift, was confirmed in 1923 by the astronomers of Mount Wilson observatory. Four years earlier though, Einstein had received a huge amount of publicity following Eddington’s trip, which he disavowed, until all of the empirical observations had been made and had proven his theory.

So what’s my point?

I think it’s best made by a youthful Karl Popper, then at Vienna University, who ended up knighted and a doyen of British academia at the LSE and elsewhere, only dying in 1994. He knew Einstein personally. Here he is:

einstein1
*

None of this is remotely controversial. It demonstrates well two key requirements of real scientific endeavour:

  1. The role of observable, verifiable data in proving – or disproving – a theory
  2. Humility

Of course, point 1 is routinely abused with a cornucopia of computer modelling (the most easily abused of all the techniques), surrogate endpoints and allowing one’s politics, emotions and beliefs to play with whatever data you’ve got.

Point 2 is a rare quality in humans (me included).

In medicine there are quite a few examples. For instance, death from a pulmonary embolus after a hip replacement is self-evidently a bad outcome. it’s also very rare, despite the huge number of joint replacements performed. It is ‘prevented’ by the routine use of chemical agents which reduce the body’s capacity to clot blood. As you might imagine, an undesirable consequence of this is bleeding – from the wound, the gut etc – which can lead to all sorts of problems. The ‘cure’ might lead to other serious complications. It does, in practice, to a degree.

So why do we use these drugs? Well, they actually don’t reduce the risk of fatal pulmonary embolus. They may not even reduce the risk of a symptomatic deep vein thrombosis. They do, in relatively small studies, reduce the risk of clots in the leg visible on some sort of sophisticated imaging. That is the basis of the ‘big pharma’ marketing that everyone buys into, for fear of being sued. Yes, fear and loathing stalk the NHS too.

A surrogate endpoint like that (a leg clot visible on an ultrasound scan, whether or not it’s symptomatic), with no definite link to fatal pulmonary embolus, is bad science, yet it’s out there.

None of us is immune to such dodgy data. Einstein’s ‘purity’ is getting rarer in medicine, and it’s very rare in another area of Big Science: climatology as it relates to ‘anthropogenic global warming’ (AGW).

I won’t rehearse all the very justified arguments as to why #climatechange is chock full of bad science and histrionics, I’d rather show good scientific papers, which helpfully debunk a lot of the propaganda.  So here you are, courtesy of the much-attacked James Delingpole. These are from the recent literature, and the usual climate change mob are not enamoured of them:

  1. The alleged ‘pause’ in AGW that the computer models mysteriously allow for is actually more than a pause. The warmists tend to ignore the well recognised El Nino phenomenon. Astronomical influences and empirical observations tend to point away from the AGW claims. Read it here.cc3
  2. Flooding in the USA and Europe is a random event with no relation to alleged        AGW/’extreme weather’ etc etc. Or as they put it “The number of significant trends was about the number expected due to chance alone”. Read it here.cc1
  3. The confident predictions of a global 1.5 degrees C temperature rise by 2022, upon which most of the hype, whining, government virtue signalling and overreaction is predicated, cannot possibly happen by all the postulated mechanisms. It’s really not going to happen. And these researchers are far from being AGW sceptics. Read it here. And if it seems a bit abstruse, here’s Delingpole’s very neat summary.cc2

…and if that wasn’t enough, despite the utterly pathetic attention seeking underwater cabinet meeting by the Maldives government in 2009, sea levels are dropping, much to NASA’s disappointment. Of course, if the Maldives’ dismal excuses for politicians meant what they said, they wouldn’t be building 5 new airports, to add to the 11 they already have.

Ibrahim Didi
Sad!

I won’t even mention the news that the much maligned Great Barrier Reef is in fact doing just fine, despite predictions of doom. Or that the now disappearing Independent newspaper’s famous  news story from the year 2000, that snow would ‘soon be a thing of the past’, has been quietly erased from their website – but not from others (read it here). Who’dathunkit?

Note that the above references that I have provided are refutations of the AGW hysteria and associated hype, not mere denials. The Warmists’ favoured meme of Deniers v Scientists just took a big hit.

It’s all a scam. I could live with the propaganda, it’s the abuse of  the scientific process that I can’t stomach (plus the outrageous expense). I’ve written on this before. The wise doctor and writer Michael Crichton had these guys sussed.

By a strange quirk, where this post began, with Einstein insisting on observational proof of his Theory of Relativity, has been repeated in this last couple of weeks, about 100 years later. The news was rightly full of the observation of gravitational waves – predicted by Einstein – following the remote collision of two neutron stars.  Hard observational data, not a computer simulation.

As Lord Rutherford, splitter of the atom said, with some truth: if your experiment needs statistics**, you should have done a better experiment.   

cc5.jpg
I feel fine, thanks

 

**to update this, I would add ‘and computer simulation’

 

Most people are normal (AKA politics today)

Harvey Weinstein Hosts a Private Dinner and Screening of "Bobby" for Senators Obama and SchumerGiven numerous news ledes, most recently Theresa May’s ludicrous claims about racism – which indicate she leads a pretty closeted existence  – here is a nice summary of what it is to be a normal citizen in the UK today:

        chancers4  To be a normal  UK citizen is to constantly be scolded, to be lectured, to be treated as a morally bankrupt simpleton in need of the guidance and direction provided by an urban elite ruling class notable for its empty academic credentials, its track record of incompetence, and its idolization of people who erotically abuse the foliage.

chancers3If we are to have betters, is it so wrong for us to demand that they actually be better? Superiors should be distinguished by their superiority – if you presume to take charge shouldn’t you demonstrate tactical, technical, and moral mastery? So what has our ruling class mastered lately? What is the skill set that sets the smart set apart?

chancers1
…still a classic

As you may have twigged from the foliage reference, this otherwise accurate take is actually from the US, by the impeccably grounded Kurt Schlichter.

What did we do to deserve these people? As Kurt correctly goes on to point out:

Where are the elite’s achievements? Our betters have been running things and yet they are the ones crying loudest about how awful things are. It’s another scam, of course. Things are awful, but not for them

Thank God things are slowly changing.

The SNP: decline and fall (15 and a half)

I  think this should wait till the Nats’  less than enticing conference in Glasgow is finished, next week. There’s a bit to talk about, not least their ahistorical and opportunistic alliance with the reckless and mad Puigdemont (and the more reasonable Catalan separatists).

They’re still on the way down though. Read Stephen Daisley in the meantime, here.

salmstur
…we were happy once

Surgery will always be a matter of life and death

I’ve nothing against him personally, but when I’m urged to read Atul Gawande’s books about aspects of surgical practice, particularly outwith the technical skills, I wonder what makes him such an expert. Here’s the evidence:

Qualified in Medicine at Harvard in 1995 aged 30

Master of Public Health degree in 1999, then 6 years of residency training in surgery – ie. junior doctor acquiring experience – till 2003.

He spent quite a bit of time from the late 80’s involved in writing magazine articles and working in Democratic politics.

His first book, Complications: A Surgeon’s Notes on an Imperfect Science, came out in 2002, when he was still a junior doctor in training, far from the finished product. The next one Better: A Surgeon’s Notes on Performance, was released 5 years later. I assume he’d been busy in clinical practice for this time, with possibly some of the previously noted extracurricular activities getting in the way occasionally.

w-eugene-smith-dr-ernest-ceriani-following-the-loss-of-a-mother-and-child-during-childbirth-1948
…still a role model

An NHS consultant surgeon, 5 years in, working in a busy hospital is, in my view still very much on the learning curve. ‘Surgical maturity’, I would say, is at least 10 years in. Some people never get there.

Gawande’s Wiki entry implies that from about 2009 onwards he was doing more and more non-surgical things, fair enough, he seems an interested and accomplished fellow, but I feel very strongly that the way you get better in medicine is, I’m afraid, long hours, year in year out, in the wards, the theatres and the clinics. It’s a lifelong thing, even if – as I do – one has plenty of other interests.

One of the classic scenarios in the NHS is the consultant who having got to the top – as it was perceived in the old days – realises that he or she wants to get out. Often ‘management’ and ‘governance’ are the dubious beneficiaries of their career move, which amazingly usually involves telling working clinicians what to do. Not that I’m accusing Gawande of that, but some individuals closer to home, certainly.

Anyway, this preamble is to praise the benefits of long, hard won clinical experience, especially of the surgical kind. There is a significant difference between prescribing a drug – which could do harm – and opening someone up with a knife, which is intrinsically harmful before it gets better, even if everything goes well.

Is there a plausible alternative to working the hours? I think not. Don’t get me started on the world of ‘simulated surgery‘.

All of which brings me to a fascinating interview with both Stephen Westaby (69), heart surgeon and Henry Marsh (67), neurosurgeon. Both have a public profile, both have performed thousands and thousands of challenging high end operations, for the NHS. With respect to the aforementioned competition, these are the guys that I want to hear from. They’ve also written books for the general public, as it happens.

There are numerous gems in the interview, here’s some tasters:

HM:  We have this very complex relationship with patients. It’s not one of straightforward altruism at all; it’s a very difficult relationship. You have to be both hard and soft at the same time. You certainly don’t want to be empathetic. If empathy means you actually feel what your patients are going through, actually . . . you can’t do it.

…the problem is you could spend the entire national income on healthcare and everybody still dies — there is 100 per cent mortality — so you have to decide somehow where to set your artificial floor on that bottomless pit.

…[When he was PM] David Cameron made this speech about we must have “zero harm” in the NHS, which struck me as the most incredibly stupid thing to say because it suggests that when anything goes wrong, therefore somebody’s to blame. The whole point about medicine is it often goes wrong. The decision whether to operate or not, to recommend an operation or not, is all about probabilities, and these are very subjective, difficult judgments. Everything we do is in the face of uncertainty and a lot of the time patients come to harm. It doesn’t necessarily mean that anybody’s at fault. So I thought that was a very, very naive and rather silly thing to say.

SW:  The job is difficult enough without having the press and everybody else on your back. A British heart surgeon had the idea when he became the medical director of the NHS that surgeons’ death rates should be published and available for the newspapers. Let me ask you: which surgeons would have the highest death rates, the worst ones or the best ones? The best surgeons attract the worst patients like a magnet. So if you want to make your best surgeons defensive, you start counting the bodies and putting it into the public arena. My particular branch of the profession is now risk-averse. Fewer heart surgeons want to come to Britain to do heart surgery and the British especially don’t want to do heart surgery. They’re long operations, you can end up operating all night, every day of the week, and it’s taxing and it’s rotten when people die. It’s totally rotten to have to go out of an operating theatre and tell a couple of young parents that their baby’s just died on the operating table. It’s misery. None of us lose patients because we’re careless or don’t care. So I’ve seen my profession wrecked, I’m afraid.

HM:  Forty years ago, the power structure in hospitals in this country was very simple. There was a senior doctor, a senior nurse and one manager, and basically the hospitals are run more or less by the senior doctors, for better or for worse. Now you have a whole series of competing pyramids. The management, the doctors, the nurses — more or less autonomous now — the other paramedics and physios and people like that, so there’s a real sense of nobody being in charge. I would go to work in the morning and I wouldn’t know what I was going to do that day because it all depends. Is there a bed? Is there an intensive-care unit bed? Is there a bed on the high-dependency unit? You have to negotiate with each of these individual power structures, it’s deeply chaotic

…Another example is that, after the Stafford scandal [over nursing care] and the Francis inquiry [into it], the General Medical Council wrote to all the doctors saying that when a mistake is made you must apologise and then it said that this is usually the duty of the senior clinician; in other words, whoever makes the mistake, muggins here has to go and say sorry. And then thirdly it added that for an apology to be meaningful, it must be genuine. If the GMC can’t see there’s a problem here — if an apology is compulsory, how can you force it to be genuine? Well, the answer is that it is genuine if the senior doctors have a sense of authority, if they feel they’re trusted and then they do feel responsible for what happens in their department.

Just superb, and not calculated or self-serving, simply real world experience of something very important. Westaby’s line “The best surgeons attract the worst patients like a magnet” is very very true.

I’ll give him the final word: