The SNP: decline and fall (4)

15. Objective evidence that the SNP are very bad at grown up government things.

I should have put this in yesterday’s batch of Nat failure and cock ups, but perhaps it deserves a post of its own. All governments work within a necessary system of checks and balances, without which the SNP dream of a tartan totalitarian dictatorship would quickly emerge. Many of them are beneath the radar – advice from government lawyers, things like that. In terms of public display though, the latest NHS round up from the sort-of-independent Audit Scotland, from the end of October, contains some depressing gems. I can do no better than quote from the Lib Dems (something I never thought I’d write):

Last week, the First Minister told us that she wants to be judged on her record. This week, Audit Scotland published a damning report on her government’s record on the NHS. The SNP claim to have protected investment in our NHS. Audit Scotland say that funding has been cut in real terms by nearly 1% over the last 7 years. Two health boards have been forced to take out loans from the Scottish Government just to break even. The SNP claim that things are getting better in our health service. Audit Scotland say that national performance against key targets and standards is getting worse. Waiting times targets have been missed and missed again. Health boards have experienced huge problems in recruiting and retaining qualified staff. Territorial health boards spent £284 million in 2014/15 for temporary workers, an increase of 15% from the previous year.

Quite. As the Auditor General for Scotland pointed out:  “The Scottish government has had a policy to shift the balance of care for over a decade but, despite multiple strategies for reform, NHS funding has not changed course. Before that shift can occur, there needs to be a clear and detailed plan for change, setting out what the future of the NHS looks like, what it will cost to deliver and the workforce numbers and skills needed to make it a reality.” That’s more than 10 years of talking crap about change, which is always just around the corner. In fact the much heralded Integration of Health and Social Care Act – wholly owned by the SNP – came into reality in April, and no-one’s noticed any difference yet.

It’s not actually the current health minister’s fault – she is just the latest incumbent of the office in an arrogant administration of people who are cocky, but not…competent. And it’s not just in health either. So demented is the obsession with money in Scotland’s taxpayer-subsidised universities, Scottish students are being blatantly disadvantaged in favour of lucrative fees from elsewhere, one third of places go to non-Scots, and it’s getting worse.

The Scottish NHS is fixated on arbitrary targets, well beyond the sensible ones relating to emergency care and cancer treatment. It’s missed them all, with one happy exception, the ‘drug and alcohol treatment is being delivered on time’.

Just as well really

 

rab
I’ve no complaints

 

 

You may appeal to my authority

There are plenty of people making hay over credit agency Moody’s declaration that the UK economic outlook has turned ‘negative’. This may or may not be correct. The rider that there will be  “a prolonged period of uncertainty” doesn’t look like a particularly insightful comment, whatever their data sources. It’s not that long ago – February 2013 in fact – since Osborne’s economic approach was hammered using (Moody’s) removal of its Triple A credit rating. This was because “the government’s debt reduction programme faced significant “challenges” ahead”.

Well, something must have happened that was unanticipated by the agencies if  Moody’s rival, Standard & Poor only yesterday, after Brexit, decided they would remove the Triple A status, apparently joined by Moody’s, as well as  Fitch (the third big agency). One suspects that Moody’s original claim had been rather overdone (and possibly this one too). Had they in fact restored their Triple A rating in the interim? It looks like it.

My point in all this is that these agencies are big businesses in themselves, with their own agendas. When they get it wrong it gets less publicity. Even uber-liberal cat loving Nobel economic guru Paul Krugman thinks it’s overdone :

“…right now all the talk is about financial repercussions – plunging markets, recession in Britain and maybe around the world, and so on. I still don’t see it. It’s true that the pound has fallen by a lot compared with normal daily fluctuations. But for those of us who cut our teeth on emerging-market crises, the fall isn’t that big – in fact, it’s not that big compared with British historical episodes. The pound fell by a third during the 70s crisis; it fell by a quarter during Britain’s exit from the Exchange Rate Mechanism in 1992; it’s down about 8 percent as I write this….This is not a world-class shock”

These appeals to authority, in this case credit ratings agencies, are an omnipresent feature of modern life, hugely abetted by the intrinsically unreflective nature of much of the internet and its social media. That is not to suggest that all such pontifications embody the fallacious appeal to authority – but clearly some/many of them do. Nearly all of the EU referendum campaign was built on unreliable speculation on both sides (which is why this was the single best argument I read on the topic).

I call it the Formula 1 argument. F1 as we know and (possibly) love it, is a suitably important sounding name for the fastest level of motor racing. It is overseen by FIA (Fédération Internationale de l’Automobile) otherwise known as the Association Internationale des Automobile Clubs Reconnus,  where the last word means ‘recognised’. Recognised by whom?  In other words, although FIA has historical precedent, it is essentially a self-appointed authority. There is nothing to stop the entire set of F1 teams decamping to a brand new tournament calling itself whatever it wants. Boxing has already recognised this, which is why there are currently four ‘world’ authorities – the WBC, WBO, WBA and the IBF. Big bucks all round with their many different titles to fight for.

Football is the same. Let’s dump FIFA and invite all the countries to play every four years in a new tournament, preferably in somewhere with an appropriate climate (not Qatar). We can call it the Mundial. Who decided a bunch of corrupt phonies like FIFA should still get the prize? The main reason of course is that like Formula 1, like boxing, there is a very healthy living to be made from the many lucrative sidelines., and it’s worth clinging on to.

And you get it in medicine, all the time. The phrase ‘top doctors’ is regularly trotted out, and is frequently associated with the most paternalistic self-important drivel. One of my favourites is when the grandly named King’s Fund pronounces. They self describe as a “health charity that shapes health and social care policy and practice”. Perhaps they do produce the odd good idea that no-one in the NHS would come up with, but in reality, they are a private body with plenty of well paid staff, some of whom may have a sketchy knowledge of actual health care delivery. An acquaintance of mine went for a job there, and it was very revealing. The key thing is the brand name, which relates to a long lost charitable fund named after King Edward VII (died 1910). Somehow, if it was just called ‘private NHS advisory think tank’ – a more accurate description – I feel its authority may appear diminished.

And on that note, what about the ‘Royal’ colleges of medicine, surgery etc? The presidency of these bodies is undoubtedly a classic bully pulpit, but what are they for? The answer is that they organise the odd educational event, they run (very good and necessary) postgraduate exams, and they produce not very good journals. None of this comes cheap. They also, however, choose to proclaim on NHS issues where they may or may not have any real insight. Naturally they tend to get a media hearing, and sometimes a governmental one. This lapses rapidly into ex cathedra nonsense in many cases, and gets the NHS nowhere.  An academic colleague of mine, who is extremely competent, distinguished and sensible and did himself hold high office in such a college, wearily confessed to me recently how disillusioned he was by the institution “I’m not sure what it’s for these days”. Like most clinicians, he now favours his own specialty organisation when it comes to practical issues, and for very good reasons.

What makes an ‘expert’ and thus an ‘authority’ has been debated and often healthily derided in the EU referendum, one of its more beneficial side effects. As is often the case, Thomas Sowell provides the necessary wisdom.  On balance, Eddie Izzard probably doesn’t make the cut.

So Moody’s, FIFA, numerous ‘royal’ institutions and many, many more, maybe your time is running out. It’s long overdue.

heath_rob_pp
This is what a real expert looks like

 

 

 

 

 

Medicine – beauty amidst chaos

The work of medicine can be grim. Death, pain, madness, addiction, mutilation, indignity are all around you at times. How one copes with it as the objective medical practitioner is hard to define**. I personally feel that the ancient rite of passage of the dissection room in first year had considerable merit in this regard. Its abandonment in most UK medical schools means that current and future generations may be missing out on something other than knowing anatomy. Likewise, the cosseted world of the junior doctors’ contract and hours regulations means that the fruitful maxim, ‘they can always hit you harder’, becomes less true by the year.

Doctors, then, are changing. Their work by and large stays the same in its broad themes. You have to be able to cope with the dark side, which includes a significant attrition rate amongst our own – illness, fatigue, family crises, scandal etc.

Some of our coping mechanism comes from our personality and our background, some is learnt. Some relates to personal beliefs, often religious.  Either way, you have to acquire it in order to function. Here is a vignette from Lermontov’s A Hero of Our Time, a mini masterpiece of selfish young man nihilism, written long before trite pale imitations like American Psycho. The hero, Pechorin, is preparing for a duel in the Caucasus mountains, seconded by his worried doctor friend, Werner:

“Why so sad, doctor?” I said to him. “Haven’t you seen people off to the next world a hundred times with the greatest indifference? Imagine that I have a bilious fever, and that I have equal chances of recovering or succumbing. Both outcomes are in the order of things. Try to regard me as a patient stricken with a disease you have not yet diagnosed–that will stimulate your curiosity to the utmost. You may now make some important physiological observations on me . . . Isn’t expectation of death by violence a real illness in itself?”

This thought struck the doctor, and he cheered up.

A true and shrewd observation, which most medics will recognise: the awfulness of illness and death is mostly genuinely fascinating, and can be its own reward, in a strange way.

cauc4
Pechorin country – the Gergeti Trinity Church in the Caucasus mountains

.

**As an afterword there is a good quote from Russian/Armenian/American author Vera Nazarian, the parentheses are my own contributions:

“If you are faced with a mountain, you have several options.
You can climb it and cross to the other side (doctors who can do the job, but who get out into management etc ASAP).
You can go around it.
You can dig under it.
You can fly over it.
You can blow it up.
You can ignore it and pretend it’s not there (usually become Public Health ‘experts’ in the UK).
You can turn around and go back the way you came (doctors who don’t cope and drop out of the tough specialties) .
Or you can stay on the mountain and make it your home (the frontline doctors of any challenging specialty who stick it out).”

[I’m still working on career analogies for the middle four *]

*see first comment below

 

 

 

Why do you want to be a doctor?

doctor-in-the-house-series-large-poster-950
Then…

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.

ds
….now

Junior doctors shouldn’t strike – here’s why

munns
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Although I’m a BMA member, as I suppose we all need protection, I try to avoid the British Medical Journal, a truly PC rag, although it very occasionally prints something of genuine interest. Hence I rapidly flip through the back copies from time to time, and this piece caught my eye.

It’s the best summary of the junior doctors’ issues – and the strikes – that I’ve seen, and having been written in early January, it’s already proving prophetic. The NHS is the UK monopoly employer, and these fresh medics are not all going to go to Australia. The proposed increase in medical school places is a good idea too, though it won’t happen. My beef is how many places go to non UK students (a lot). I would make it a postgraduate degree, if I could.

The author is slightly maverick Glasgow GP, Des Spence, who usually tells it like it is. He works in Maryhill, home of such gems as Munns Bar, and I would imagine he’s a very busy clinician. Certainly a grounded one. A separate BMJ profile of him is enlightening:

Who’s been the best and the worst health secretary in your lifetime?

No one. It makes little difference in the reality of day to day. The work is the same irrespective of the government.

If you were given £1m what would you spend it on?

I could pretend that I would give it all away to fight for world peace and combat global warming . . . but we all know that’s bullshit; that’s not how people really work. I’d have a big party, give some away, save some, buy a black Jaguar F-Type, and generally spend it irresponsibly. Life is for living.

 

The title of the article is “The strike is a bad idea”, and it is one of the few contrary arguments to the whole strike thing in months of BMJ’s. There are, inevitably, tons of counterarguments  by juniors which tend to be a bit solipsistic, though they would deny that. Here is Spence’s timely piece:

I have significant sympathy for Junior Doctors and understand why they have decided to strike. Older Doctors might moan about how it was “tougher in our time” but comparing the past with now is an apple to oranges affair. Expectations are different, shifts are different, the generations are different and our societal culture is different. Striking, however, is the wrong course of action. Consider.

Could evening and weekend care be improved in Hospitals and in General Practice? The answer is yes. And the pressure to provide a 7 day style NHS service is an unstoppable cultural juggernaut of expectation, in tune with so many other services we now take for granted in modern society. Doctors would be best to simply accept this as the new cultural norm and negotiate from this position.

And will striking for a few days make any difference? We are employed by the state. Our employer can at any time change our conditions of employment with reasonable notice. This happens all the time in the public and private sector. Unless Doctors are truly willing to strike for a sustained period, we will not change the resolve of our employer. This Strike is a protest only. But will this protest curry favour with the public to force the government to change?

Many of the public do have great appreciation of what doctors do. But do they have sympathy for our working conditions and pay? (which ultimately is how this dispute will be presented in the media). Doctors might loathe the Daily Mail, but the Daily Mail does not lead public opinion but reflects it. Many of the public consider us overpaid, with great job security, being largely trained for free, having a gold plated pension (unimaginable to most in the private sector), enjoying a high status, and all this paid out of their pockets through taxation. Do we really expect any sympathy for the strike? Regrettably the strike will serve only to inconvenience the public and undermine our professional standing. The strike is simply out of step with the current mood of many in the country, coming out of a sustained period of austerity. Ultimately employers can and will impose a new contract. And Doctors won’t leave in high numbers for there is still lots of milk and honey in the NHS.

The real solution is this. Doctors don’t want to work 50 hours a week. Life/Work balance is more important than money to the current generations of Doctors. And currently we have widespread medical staffing shortages across the NHS. So we need to train perhaps twice as many more Doctors as undergraduates. This costs around £250k per Doctor, but is a notional expense to the NHS which currently spends annually £3.3 billion on agency medical staff (enough to train an additional 12 000 Doctors a year!).

Vastly more Doctors would improve work life balance, broaden the diversity of our bland homogeneous middle class profession and reduce the unhealthy status and entitlement that blights so many lives. The law of supply and demand would certainly reduce pay in time but most would find that an acceptable trade off. Medicine took most of my young adult life, a situation that we no longer have to tolerate. Dear BMA, call a strike for a doubling of doctors in training. Now that would be worth picketing for.

Hard to argue with that.

Maryhill
A quiet corner of Maryhill

 

 

Junior doctors, Trump, and the Overton Window

OvertonLRG
Overton himself, looking good

These junior doctors, eh? Their ridiculous contract ‘negotiated’ by the canny BMA, who steamrollered the Labour government of the day, creating an unworkable melange of the European Working Time Directive and the New Deal, that has badly damaged training, introduced perverse financial incentives (possibly more later) and made hospital rotas (and therefore safety) very difficult to organise. Ever wondered why you can hardly find a doctor at night in a hospital ward? Even the BMJ acknowledges there’s a problem. This is a detailed and very prescient piece on the mess, from NHS ophthalmologists in 2006.

However, that’s not my main point, it’s just one of the most familiar, and egregious, examples of the EWTD, which in theory might affect any of us. A perfect example of how being in the EU has all sorts of unanticipated effects.

The point is this: 10 years ago, if you raised concerns re the EWTD, you were told that it was ‘non-negotiable’, because our membership of the EU was set in stone. The overt implication was that would never, ever change, and very few people questioned it. UKIP were barely on the horizon.

Look at it now. A pro-Europe Prime Minister with a majority is pressing on with a referendum to potentially leave the EU. This is the Overton Window in action. In 2007 the official government view (via a question in the Lords) was reluctantly expressed, by Lord Triesman as: Parliament may amend or repeal any existing Act of Parliament, including the European Communities Act 1972. There is no formal procedure for withdrawal in the EU treaties, nor are there any provisions in the treaties or any other international obligations which affect the ultimate ability of the UK to withdraw from the EU. However, given that the UK has been a member of the EU for more than 25 years, and its laws and economy are intricately bound up with those of the EU, the Government would in practice have to negotiate the terms of any departure over a lengthy period. Otherwise known as: ‘forget it, it won’t happen’. Yet here we are.

The Overton Window is best described as the range of policies acceptable to the public, or more specifically, to quote Wikipedia: a range of policies considered politically acceptable in the current climate of public opinion, which a politician can recommend without being considered too extreme to gain or keep public office.

This week’s main example is of course thanks to Donald Trump, and despite the reflexive Trump hating in the media (and I’m not a Trump supporter), I think he rather cynically made his comment about Muslims and immigration to shift the window. What he actually said was slightly more nuanced than has been widely reported. Specifically: Donald J. Trump is calling for a total and complete shutdown of Muslims entering the United States until our country’s representatives can figure out what is going on. That was Trump moving the window, and already the discourse is changing. A lot of US media types think it will allow the more moderate Ted Cruz to hoover up votes from this part of the political spectrum. They may be right. This beautifully presented discussion by David French is worth reading.

Another current example lies in the reporting of the futile Paris climate change love in. It’s not just the BBC, Sky and ITV are reporting it without any sense that there is a very real and growing debate over the validity of the assumptions that lie behind it. In TV terms at least the Overton Window has shifted to the climate-change-is-real-any-action-however-expensive-or-impractical-is-good axis. Dissent is simply not mentioned. That is probably an example of the TV media’s OW being in a somewhat different position to that of the average punter, on reflection.

No-one at all, back in 2005 when NHS medics were wrestling with producing EWTD compliant rotas, would have predicted that we would now be discussing the possibility/probability that we could dump the reason for the EWTD, yet here we are, and a good thing too.

Control the window, you control the debate.

 

OvertonWindow
*

 

 

Those junior doctors: another viewpoint

I’ve taken the original post down for a while. I can’t be bothered with the possibility of lots of online whingeing/abuse.

The essence was: the current Junior Doctors’ Contract is  a rubbish contract for reasons of complexity,  training/experience, continuity of care, harmony, financial transparency and vocational medicine (as opposed to highly paid serfdom).

It needs reforming. The devil is in the detail, of course

I’ve left one pic, to give people a taste of how it currently works

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Vote Nicola and die

The best of Scotland...(Edinburgh 1920, by Alfred Buckham)
The best of Scotland…(Edinburgh 1920, by Alfred Buckham)

Five years ago, just after the last election, The Knife posted a piece called Vote Labour and Die. It actually became my most viewed piece, simply because it got highlighted by Guido. It resulted from a paper in the BMJ, on Public Health (which is purely the specialty’s name, it doesn’t necessarily mean the actual health of the public). Written by a leftie (as are many PH docs, see Prof Ashton), published in a leftie journal, it noted that in Labour voting areas, you were more likely to die young. This was the fault of New Labour, and by extension, wicked Tories etc.

It was an observation, rather than cause and effect, although the two are regularly conflated, both by the Daily Express and by ‘top doctors’ on a mission.

Fast forward to the imminent general election. Here is Scotland’s First Minister:

‘The Tory/Lib Dem government’s plan to further increase the state pension age is a worry to people across the UK who are planning for their future, but the failure to take Scotland’s specific circumstances into account is particularly unfair. SNP MPs will reject any plans for a further increase in the state pension age Our comparatively low life expectancy rate is an issue which I will do everything in my power to change but in the meantime it would be completely unacceptable for people in Scotland who have paid in to a state pension all of their lives to lose out. That is why SNP MPs will reject any plans for a further increase in the state pension age.’

Note that phrase ‘Our comparatively low life expectancy rate is an issue which I will do everything in my power to change’. Ms Sturgeon, in case anyone had forgotten, was Scottish Health Minister from May 2007 to September 2012. Much of that time was spent bossing hospitals about arbitrary targets. The Scottish life expectancy remained dire in the usual areas of the country. Despite her careful phrasing, Ms Sturgeon’s schtick is quite clearly that we’re dying young, give us the money now. There is no meaningful attempt to rectify a serious social issue. The answer is certainly not more dependency, more welfare state.

Basically the SNP now regard Scotland as a block vote client state, to do their bidding. It is likely that one day their emerging capacity to take the populace for granted and avoid genuinely improving their lot will rebound on them. How do I know this? It is because it is exactly what Labour did for years, with their Scottish block vote, and for which they are about to pay a very high price. The absolute high priest of that movement was Gordon Brown, now a broken figure, despite his referendum swansong. His prolonged bribe of the Scottish electorate has utterly failed.

All of this begs the question, what is wrong with the Scots? Why do they lurch from one unambitious greedy socialist regime to another?

Most commentators invoke the Enlightenment, and the spirit of Adam Smith as the example of Scotland at its best, what it could still be. The truth is there has been no thinking of that kind, no figure of stature in power or influence in Scotland for a very long time. The country actually did pretty well in many ways under the bogey figure of Thatcher, but such a claim doesn’t suit the narrative of either Labour or the SNP, for whom droning on about misreported events of thirty years ago is almost a form of prayer.

Here is one person, Chris Deerin, who gets it:

Scotland has become a soft and sappy nation, intellectually listless, coddled, a land of received wisdom and one-track minds, narrow parameters and mass groupthink. It slumbers, like a once-feared dragon now hidden away in a mountain, dozily coiled around its ancient, pointless treasures, interested only in its own welfare…..The Scottish Labour Party, now perilously close to oblivion, has only itself to blame. For decades, it has gleefully demonised the Tories, blaming them for all of Scotland’s ills even as it made a pig’s ear of running the Edinburgh Parliament. This cheap tactic, aped since the 1980s by the then newly left-wing SNP, created a sense of otherness, of moral superiority, in relation to England….

The relationship between business and the Government is comically bad, beyond a few pro-separatist oligarchs.

We have become a land peppered with conspiracy theorists who believe in secret oil fields and MI5 plots and rigged polls, all of which is tacitly encouraged by the Nat government. If anyone on social media – especially, God forbid, a non-Scot – dares to challenge these ludicrous myths they are descended on by the ‘cybernats’, a swarm of angry oddballs who refuse to read the ‘mainstream media

Deerin references another Scot, Bruce (the Brute) Anderson, who in a very eloquent piece, correctly entitled ‘Never before has Scotland been quite this deluded‘ spells it out:

The Scottish public mood is extraordinary. Over the past few months, millions of Scots have been baying at the moon. The most bizarre fantasies have not only circulated; otherwise sane people have given them credence….How can this be happening? The Scottish Enlightenment represented the triumph of rationalism, always in a calm and restrained fashion. Its philosophers and economists believed in using reason to improve the human condition, not to reshape human nature. They virtually invented free enterprise; they elevated Scotland to the intellectual leadership of Europe. In a splendid setting, the Castle on one side, the sea on the other, their contemporaries laid out the New Town. Calm, rational and beautiful buildings: it is the Enlightenment as architecture.

While it would be absurd to claim that every Scot has read Adam Smith, there were grounds for believing that Enlightenment values had influenced the Scottish character. Keynes poked fun at so-called practical men, dismissive of theories, who were actually in thrall to some long-dead economist. If that economist had been Scottish, the thraldom would be benign.

…(after Thatcher) there was a quarter of a century of demonisation, which drove economic common sense out of Scottish public debate. By the end, many young Scots had come to believe that Scots’ values were superior. Scotland stood for social solidarity, and indeed socialism. It stood for the public sector, not for private enterprise. Mrs Thatcher and her English capitalist friends hated the Scottish ethos, which is why they had set out to destroy the Scottish economy. This brainwashing explains why Nicola Sturgeon will have earned huge applause in Scotland for attacking Ed Miliband from the Left. Scottish Labour helped to sow the dragons’ teeth, never expecting that the dragons would turn on them. They ken the noo.

Not since the Thirties has a once great nation been in the grip of so many delusions. This is malign thraldom

So there you have it. One day, probably sooner than anticipated, Sturgeon et al will meet hard reality. I do not believe, even if there is another referendum, that the result will be any different. No Scots Nat has in living memory produced a coherent plausible argument supporting an independent economy, and the country knows that. However, as long as Labour and the Tories continue to assuage lunatics like the SNP with large tranches of public money, and no real responsibility for obtaining it, the current ‘malign thraldom’ will continue.

In the meantime, vote SNP and die. Just make sure you get your pension early, it’s what the First Minister wants.

…and the worst. I find this picture unsettling

Don’t be an incredible surgeon

One of my former surgical bosses, now deceased, had a slightly cruel wit. In describing the work of a newly appointed consultant in vascular surgery, he claimed that the new colleague’s latest operation was “a middle cerebral to inferior rectal artery bypass”, which is indeed funny, in a surgical sort of way (you should be able to work it out). The new guy was a productive academic, but a patchy surgeon. His interest in vascular surgery – as opposed to, say colorectal or breast – related to the availability of consultant jobs, rather than any great skill in that domain.

The point is a real one.  A problem in medicine in general, and very much surgery in particular, where you actually do things to patients, is credibility. That vascular surgeon (long since retired to research), lacked it, from the start.

In surgery credibility is everything when it comes to peer approval. This is emphatically not an ‘old boys club’, rather an essential recognition that your work is generally good for patients, that you have the chops to deal with things when they go wrong, or when you encounter the unexpected. Both scenarios will happen. Lack of credibility can be a career-long problem.

The other side of this coin is a sense of entitlement, best defined in this context as “belief that one is deserving of or entitled to certain privileges “. Surgeons crash and burn when they claim that they have all the answers, and demand special privileges accordingly. Even the finest cancer surgeon may find that they best operation they did all month was incision and drainage of an abscess, in terms of patient outcomes at least. One feature of the 21st century NHS is the rise and rise of bogus superspecialisation where newly appointed 35 year olds claim to have special skills in dealing with complex problems, and should be treasured accordingly. The truth is that however well trained you are, nothing can substitute for experience, gained over time. A humility failure, where you claim those special privileges just because you briefly worked in a famous institution (as a common example), will always lead to problems – interpersonal, professional and clinical.

Tracy, next to one of her masterpieces
Tracy, next to one of her masterpieces

All this has parallels elsewhere, which is what stimulated me to write this post. Take, for example the world of fine art.  Mark Rothko’s later (and lucrative) work is really just abstract blocks of colour, which may or may not be to your taste. It’s certainly not technically difficult. But earlier on in his career, he had already shown himself to be a fine figurative painter. Tracy Emin, on the other hand, sells works for significant sums of money (see also the slightly more gifted Damien Hirst, for whom there remains a suspicion that his technical accomplishments may be down to his assistants). She became the Professor of Drawing at the Royal Academy in 2011. I have yet to see anything by her that suggests any significant skill or inspiration that would merit that, but there you are. Successful monetarily, but not credible, I would suggest.

In music, when John Coltrane, in the few years prior to his death, wandered off into realms of jazz that quite a few people still consider to be unlistenable – all free improvisation and some squawking – one of his would be imitators, Sonny Sharrock (on guitar) was getting advice from Coltrane’s long term bass player, Jimmy Garrison. Garrison told him to “get those (chord) changes together man”. The confused Sharrock responded “Come on, you played with Coltrane. You know what was happening in that band”, to which Garrison simply said “Coltrane can play his changes”. It’s the same lesson as in surgery: you can start branching out only when you’ve mastered the essentials, and that can be a long, arduous process.

Why am I writing this? I suppose it’s partly frustration at the whole concept of demanding respect, a very modern vice, as opposed to earning it. NHS management is just as bad. I’ve written previously of the need to hold at arm’s length any manager who claims to be ‘strategic rather than operational’. Operational is what gains you credibility.

We all want to be good surgeons and doctors, we like to be able to do the occasional genuinely amazing operation, we want to be admired by our peers and our students, we all want to make people better, but we don’t want to be incredible.

The IT geek business clearly has the same risks. Quoting Tom Hayes, a Silicon Valley executive and blogger:

“Claiming that you are what you are not will obscure the strengths you do have while destroying your credibility.”

 

 

*Coltrane, effortlessly demonstrating his credibility

Luck, cancer, me, and you

A colleague of mine wanted to implement an idea put to him by one of his friends, when faced with a pile of CV’s  – a hundred or more – belonging to job applicants. He would throw them in the air, and then chuck half of the randomly scattered CV’s in the bin. He knew he didn’t want to employ them, because “they’re the unlucky ones. I don’t want unlucky people”.

A neat circular argument, and actually, when you think about it, a correct one. They are indeed unlucky. In fact, the best argument against the scheme is to say that ‘luck’ as a personal attribute, irrespective of its ubiquity in everyday speech, doesn’t actually exist.

...his luck ran out
…his luck ran out

A tricky one. Napoleon famously said “I know he’s a good general, but is he lucky?”, which suggests that he did view it as a personal quality. He muddied the waters a bit by expanding in a subsequent conversation: “All great events hang by a hair, I believe in luck, and the wise man neglects nothing which contributes to his destiny”. Which suggests that the ideal, where someone is so fortunate they can sit around without making any practical efforts, probably didn’t entirely convince Bonaparte either. This chimes with the associated famous quote of Gary Player, which everyone knows, “the harder I practice, the luckier I get”.

This is on a day when the papers have latched on to the tantalising concept that most people who get cancer are just…unlucky.  All those bad habits – and a few good ones  – usually aren’t involved.

This unlucky thing makes sense, at first. The scenes out of Breaking Bad, or the British TV ads that show the bad news being delivered – you’ve got a tumour – are pretty close to the mark. Not a moment you forget.  And yet, there is another perspective. Richard Smith was the editor and (former) clinician who transformed the august British Medical Journal into the public health/global warming obsessed lefty house rag that it is today. After accomplishing that he then amusingly skipped off into the enormous international private healthcare business. For all his faults though, he’s not an idiot, and he’s just got himself into some trouble with the counterintuitive (at first sight) observation that getting cancer could actually be a lucky thing. The caveat, perhaps, is it depends how old you are. Here’s the Daily Mail quote:

Death from organ failure – respiratory, cardiac, or kidney – will have you far too much in hospital and in the hands of doctors. ‘So death from cancer is the best… You can say goodbye, reflect on your life, leave last messages, perhaps visit special places for a last time, listen to favourite pieces of music, read loved poems, and prepare, according to your beliefs, to meet your maker or enjoy eternal oblivion.

‘This is, I recognise, a romantic view of dying, but it is achievable with love, morphine, and whisky. But stay away from overambitious oncologists, and let’s stop wasting billions trying to cure cancer, potentially leaving us to die a much more horrible death.’

As it happens, I blogged on this a bit last May. Smith has a point. The original BMJ blog is beautifully observed, and well worth reading, as is the thoughtful response after he’d endured his 10 minutes of gleefully overhyped public indignation, and a Twitterstorm. As I write, I can report that the acute takes in my hospital are crammed with elderly people with variable degrees of cognition, multiple pathologies and travelling from care home to hospital, then back again. Many are in their nineties. There is such a thing as living too long.

A semi-detached clinician like Smith, then, gives a valuable ‘alternative’ perspective. Two economists of sorts provide more. Christopher Snowdon of the Institute of Economic Affairs has a brilliantly acerbic blog which performs the truly valuable function of skewering numerous self regarding ‘public health’ initiatives and propaganda. Here he is musing on the bad luck argument versus the ‘ban everything’ crowd:

This is really just another way of imparting the same information. ‘Large minority of cancers caused by lifestyle factors’ is no different to ‘Most cancers not caused by lifestyle factors’ except in its emphasis…….But the change in emphasis is very significant. The Boxing Day story was inspired on a Cancer Research UK press release whereas today’s report is based on a study published in Science. Moreover, the CR-UK press release gives a much higher estimate of how many cancers are lifestyle related. It attributes more than 40 per cent to lifestyle factors (smoking, diet and drinking, mostly) whereas the new study finds that only a third of cancers are due to lifestyle factors, environmental factors and hereditary factors combined.

None of this is to decry cancer research or cancer medicine, but a more philosophical overview has its place. We’re all going to die eventually, as Richard Smith eloquently notes. Tim Worstall, something of a polymath, offers a counterweight,  in this blog from the invaluable Adam Smith Institute:

But we’re afraid that it’s still an insane thing for anyone to say that we should not try to cure cancer. The mistake is akin to that made by so many of the slower thinkers about market interactions. Sure, if there’s only one single market interaction then as game theory tells us the incentive is to rip off the other party. But most market interactions are not one off transactions, they’re simply a part of a number of iterations of the same transaction. In which case the incentive is to cooperate to mutual advantage.

Looking to cancer the assumption being made is that OK, once suffered from one should simply fold one’s tent and steal away into that long dark night. Which is to entirely ignore the fact that as cancer treatments get better it’s possible to have a series of iterations. That first, that skin cancer, say is treated and two decades later the luck of the draw brings on, say, colon cancer which may or may not be treatable. The whisky and heroin option taken at that first iteration would then have robbed one of that 20 years of life. It’s entirely possible that cancer is that “good death” but surviving one or two brushes with it before succumbing would be even better.

This post began with luck, and ends with it. Worstall again:

It’s necessary not to starve to death, avoid being eaten by sabre toothed tigers, not get smallpox, for long enough for those multiplying cells to go wrong. Something is going to get you and the later, whatever it is, the more luck you’ve had.

...here's one I made earlier. Genuinely.
…here’s one I made earlier. Genuinely.