A few years ago I wrote a lecture, and presented it to fellow experienced surgeons – all consultants – called “How Clint Eastwood Influenced My Practice”.
It came down to two things, because we were discussing notoriously difficult, prolonged and complex cases, with a substantial risk of serious complications.
Those two points were classic Clint:
A man’s got to know his limitations**
2. Do you feel lucky (punk)?
Because the bottom line is that if a surgeon is not aware of his or her limitations, they will eventually cause avoidable harm, and in addition they will be miserable in their job. Not least because everyone else has already identified those limitations first. Further, any surgical situation which is reliant on luck is the sort of thing that you should think twice about doing. This especially applies to planned care, as opposed to a true emergency where you may have little time, and it’s life or death***.
Well now Clint has provided a third prescient example, from 3mins 39 secs:
Which is how I feel about some of the negative, blocking, non-science based responses to my attempting to (safely) return to a more normal clinical practice in the wake of Covid. Lots of people, at individual level, rather than at the technically legitimate if unwelcome government level, want patient care to be run on their personal view of the future, and consequently want me and other clinicians to bend to their new rules. It’s seriously messed up, and it’s not about patient care or safety. There is a newly emerged Covid bureaucracy rampaging through the public sector, making up the rules, and seemingly pretending to be able to eliminate risk. In my view the least active clinicians tend to be leading this charge.
As Clint rightly says: “well you can just get yourself another delivery boy”.
That sounds like a resignation threat, but in truth, it’s a weak one. Most decent medics who are fed up with all this stick around for two main reasons. Firstly, to support their good colleagues, on the ‘foxhole principle’ (not for the government). The other one of course is for one’s patients who are relying on you, many of whom currently feel abandoned by the NHS behemoth, due to Covid ‘precautions’. Even so, our absurdly overpraised NHS overlords would be foolish to assume in the current climate that experienced, self-motivating, vocationally minded clinicians are easy to recruit. They are not.
**Or a woman’s got to know her limitations, paraphrasing Dirty Harry
*** I’m aware of the likelihood of being criticised by dweebs for not knowing my limitations, and for relying on luck. I can live with such criticism.
I am grateful to the reliable George Neumayr in the American Spectator for citing this quote in the context of the Covid pandemic, and in particular, the aggressive and non-evidence based control freakery of many politicians, the police and so on.
We’ve had further proof that large swathes of the media are incapable of rational independent thought too. In my own sphere it’s been horrific to see NHS patients with non-Covid problems being almost abandoned for 4 months. That varied from one hospital to another, one GP practice to another, but quite a few medics have done very little on full pay, and failed to apply their knowledge and rigorous scientific training to what the virus actually meant. The Victorians understood this. Ultimately a doctor has to be the advocate for his or her own patients. No-one else will do it.
Of course in the first 2 to 4 weeks we had little choice, and the speed of preparation was impressive. We didn’t know what was coming, although Bergamo redux was never likely in the UK – it didn’t happen in the rest of Italy either. And I know what the lockdown fans will claim as the reason – but with no proof. However, after that, getting back to normal is proving hugely difficult, despite the virtual disappearance of the virus.
The reason for this? Well, it’s multifactorial, but as the non-NHS furloughed parts of the economy have found out, people inevitably don’t hate getting paid to do nothing (officially), especially if the weather’s good. And, ‘you can never be too careful’ etc etc. Feel free to die of cancer, but not of Covid.
Back to Neumayr. He’s quoting the sage CS Lewis from The Humanitarian Theory of Punishment, a chapter in his 1970 book, God in the Dock:
Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron’s cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.
We see it every day. In society and sadly in healthcare too, we are about to reap the whirlwind.
The two groups in our society today who enjoy racism – I know that’s an odd way of phrasing it – are actual racists, who when they’re in a group/mob seem to thrive on the toxic atmosphere, and all those commentators/politicians/idiots who casually go around accusing people of racism on the basis of zip. There are quite a lot of these latter group, for whom identity politics is both a way of life and often a source of income. There are literally thousands of examples of this deeply disturbing phenomenon. This recent Spiked! piece, reflecting the UK’s fevered pre-election state provides a brilliant insight. Alternatively, just go on Twitter.
A sorry state of affairs.
As a white Catholic male of Irish heritage I do tick a few minority boxes, but I’ve never been victimised in any of those categories, although anticatholicism (1, 2, 3, 4) is on the rise worldwide, for sure.
It’s easy for me to say that I don’t think the UK is a particularly racist society, I know, but it is what I think, especially having visited plenty of countries that are far worse in this respect. In terms of endemic bigotry, including race, we do have Corbyn and his chums with their quite blatant Jew hatred – and the Jews are the archetypal race, as opposed to categorising people by colour or other visible features – and of course the Scottish Nationalists, with their longstanding careful nurturing of anti-English sentiment, to which they never admit. Both groups are shamefully part of the establishment, but the people are slowly fighting back, in my view. The imminent election may demonstrate that.
If you think I don’t know what I’m talking about, what with my privilege and all that, just ask an academic sociologist instead: “In the media turmoil surrounding Brexit, many pundits have seized on the prejudice angle, but these data demonstrate that is not actually what makes the UK different from the Continent. Prejudice against immigrant workers or minority ethnic and religious groups is rare in the UK, perhaps even slightly rarer than in equivalently developed EU countries”. Well, who would have thought it?
My take on why the UK is a pretty well integrated society in terms of race – and improving all the time – is quite specific. There are five main factors, but first a brief history of the useful input from politicians on this topic (in living memory):
1965 The Race Relations Act – outlawed discrimination on the “grounds of colour, race, or ethnic or national origins” in public places in Great Britain … It also prompted the creation of the Race Relations Board in 1966
1968 The Race Relations Act – made it illegal to refuse housing, employment, or public services to a person on the grounds of colour, race, ethnic or national origins in Great Britain, and also created the Community Relations Commission to promote ‘harmonious community relations’.
…so two significant pieces of legislation, followed by…
1976 The Race Relations Act which combined the two earlier pieces to prevent discrimination on the grounds of race, colour, nationality, ethnic and national origin in the fields of employment, the provision of goods and services, education and public functions. The Act also established the Commission for Racial Equality with a view to review the legislation, which was put in place to make sure the Act rules were followed.
All good, but then came the Race Relations Amendment Act of 2000, which modified things a bit, but was much less of a landmark, and the Equality Act of 2010, which actually created a few problems for some (non-bigoted people). My point being the main pieces of legislation, particularly regarding race (as opposed to gender etc), were done and dusted by 1976, which was 43 years ago.
Despite that admirable work, the current 2019 number one talking point for many politicians, is racism, because they believe that they can use it to batter opponents with, often diminishing the significance of real racism issues in the process – if everyone is a racist, nobody is.
You see it every day, on Twitter, on the news, and magnified one hundredfold when there’s an election coming up. It takes a bit of creative licence to brand Brexit as a race issue, but that’s exactly what many Remainers have been trying for the past 4 years.
So here are the five main factors promoting racial harmony in the UK, none of which are to the credit of any politician – they came about organically, if you like:
The NHS (in which I work) – where patients and staff come from everywhere. I’ve had colleagues from the Philippines to Paraguay, and all points in between, Interestingly, EU membership works against this, by favouring EU citizens for jobs over those from further afield, which, given the ethnicities, certainly looks like racism to me. It screwed up medical recruitment from India, Pakistan and the Middle East in particular, all areas with which we’ve long had excellent historical ties.
Professional sport, not just football – just watch the TV sport for 5 minutes. I go back to supertough Remi Moses being a legend for Manchester United. There is no more likeable a public figure than Anthony Joshua.
Popular culture, in particular reality TV, Talent shows and soaps – speaks for itself
Higher education, which has been a true melting pot since the start of the 20th century (here’s one brilliant example)
Why did I write this?
Because I am heartily sick of the politicisation of this societal issue, for cynical reasons unconnected with ending actual discrimination. And also to point out that the citizens of the UK, without the input of politicians, do a very good job of racial integration themselves, without fuss. The emphasis on alleged racism plausibly harms efforts to tackle real racism.
There are problems, there probably always will be, but they will not be solved by the shrill ranting of our political classes and their hangers on**, ***, **** for reasons mainly concerned with personal and political gain.
The citizens don’t need their advice on this one.
**This post went out just before Boris’ remarkable win in the general election. As night follows day, up pops a ludicrous ‘serious’ celebrity (Lily Allen), to blame it all on racism.
They have no idea what their own country and its citizens are actually like. They have no faith in human beings to broadly do the right thing.
***then along comes absurd luvvie John Hannah, to, guess what, tell us that: “This whole Brexit cluster -f*** is really about 1 thing. Immigration ! Like it or not turns out we’re a country of racists and Brexit/EU scepticism is the cover. It’s all about English nationalism. Shameful!”
Which gives him the added pleasure as a Scot – despite living in London and the US – of pulling Sturgeon’s trick of accusing the English of that which she is guilty of herself, bigotry.
Awful, stupid, malignant people, with zero ability to relate to the average citizen. Who will of course be racist.
**** and here comes trendy but thick attention-seeking multimillionaire Stormzy, to add his predictable tuppenceworth
If you want to know just how out of step the NHS is with the healthcare in the rest of the developed world, consider this, from a piece by Conrad Black on Bernie Sanders’ policies. The italics are mine:
Like everyone on the Left, he bandies about the phrase “single payer” as if it were a silver bullet. It isn’t, other than in the sense of being a self-inflicted wound.
The single payer is the government, federal or state, but under a unitary system and the government pays all doctors on the basis of number of appointments and formulaic relative complexity of treatment. It is arbitrary and challenges the free market in that no distinction is made for results, thoroughness, or special circumstances that attach to most medical conditions. The doctors essentially are public service employees. There are customarily no user fees, so hypochondriacs and lonely people turn waiting rooms into therapeutic or social occasions, and the experience of single-payer countries is generally one of unacceptable waiting times for many treatments. In his Town Hall meeting with Fox, Sanders was good at emphasizing the shortcomings of the present health care system for the 25 percent of people who have no public or private plans, but he simply ducked and dove when costing arose.
What Lord Black is describing with a degree of scorn is actually more sophisticated than the current NHS setup. Irrespective of workload, talent, complexity, productivity, all NHS consultants get paid basically the same. No other country in the ‘developed world’ would see merit in paying the heart transplant surgeons the same as geriatricians and public health consultants – for good reason.
Try watching the unusually excellent BBC series Surgeons: At the edge of life. These are serious professionals with exceptional skills and high stress jobs. They’re all rewarded on the same scales as people who do two ward rounds a week and a clinic.
Interestingly, although anaesthetists occasionally grumble about it, the UK private sector (in which I don’t work, for the record), recognises these differences explicitly – surgeons often get about three times what the anaesthetist does.
Not only is the NHS ‘everyone is the same’ approach intrinsically unjust, the poor rewards combined with a punitive level of scrutiny (at times) is making recruitment a nightmare. I used to see a value in paying everyone roughly the same – not any more. Again for the record, I do alright, I’m not complaining about my salary.
I am grateful to blogger Charles Chu for highlighting this one, though it crops up from time to time anyway (Jeffrey Archer, here, for example). Who was the last non-Nazi commander in chief of the German army, the reichswehr, before Hitler? The answer is Hitler-hater Kurt Gebhard Adolf Philipp Freiherr von Hammerstein-Equord. Quite a name.
He was very far from even sympathising with the Nazis (“I am ashamed to have belonged in an army, that witnessed and tolerated all the crimes”), although he died of cancer well before Hitler (in 1943), and never saw what happened next. These old Germans with patriotic military histories are interesting. The maverick Ernst Junger, for example, despised Hitler partly because he thought he was riff raff,
A member of an old military family, a brilliant staff officer, and the last commander of the German army before Hitler seized power, Hammerstein, who died in 1943 before Hitler’s defeat, was nevertheless an idiosyncratic character. Too old to be a resister, he retained an independence of mind that was shared by his children: three of his daughters joined the Communist Party, and two of his sons risked their lives in the July 1944 Plot against Hitler and were subsequently on the run till the end of the war. Hammerstein never criticized his children for their activities, and he maintained contacts with the Communists himself and foresaw the disastrous end of Hitler’s dictatorship.
Anyway, here is his famous quote:
“I divide my officers into four groups. There are clever, diligent, stupid, and lazy officers. Usually two characteristics are combined. Some are clever and diligent — their place is the General Staff. The next lot are stupid and lazy — they make up 90 percent of every army and are suited to routine duties. Anyone who is both clever and lazy is qualified for the highest leadership duties, because he possesses the intellectual clarity and the composure necessary for difficult decisions. One must beware of anyone who is stupid and diligent — he must not be entrusted with any responsibility because he will always cause only mischief.”
I suppose any organisation’s hierarchy could be split this way, but speaking from experience, I can confirm that the NHS has all this in spades. The single most worrying group, given its prevalence is the last one. There are many, many examples.
I’ve worked in the NHS for 32 years, man and boy, so to speak.
I don’t do private work, though I don’t have an issue with it ideologically.
I admire Bevan and Beveridge who kicked off the whole enterprise in 1948, although I’m pretty sure that they’d be horrified by what much of the NHS and the associated welfare state has become.
We do seem however, to be approaching an NHS End of Days scenario, by which I do not mean the ludicrous cry of “they’re privatising the NHS”. ‘They’, generally speaking, are not capable of such sophisticated thinking, and ‘they’ are unable to tame the behemoth of NHS spending. It’s probably not possible under the current provision. The answer is not more money.
It’s always interesting to gauge what outside healthcare providers think of the NHS. When I get tourists and similar in as emergencies, they often can’t believe that all this is ‘free’. It isn’t of course, if you pay tax, but you know what they mean. The unappealing spectacle of billing and insurance checks is absent from our clinical areas. But what seemed free, high quality and good value, has been overtaken by hangers on, from the shop floor to the upper tier of government. Everyone wants a slice of the pies – both the goodwill and ‘nobility’ associated with providing healthcare, and also the financial rewards*** embedded within its now enormous bureaucracy.
Here is Ted Noel, a retired US anaesthetist, musing on the problem:
Bevan succeeded, but his victory is being erased by the Law of Subsidy**. What was sold as a boon to the poor has become a subsidy for bureaucrats. The Law of the Bureaucrat declares that while a bureaucracy may have been created to deal with a perceived problem, the bureaucrat’s Prime Directive is to ensure that he has a job forever. And because he was appointed to solve the problem, he’s smarter than everyone else and should be paid accordingly.
Perversely, the bureaucrat can never solve the problem, or his job would disappear. So he continues with the language that created him, trying to sell greater and greater funding for his failed enterprise. And when it fails more dramatically, he blames anyone but himself, and gets rewarded with a bigger budget. Ultimately, as Margaret Thatcher famously quipped, “The problem with liberalism is that eventually you run out of other people’s money.”
The Law of Subsidy has killed the NHS. It just doesn’t realize that it is dead. But thousands of those it was created to care for are dead, because it simply cannot fulfill its promised goals.
He may be right.
**The Law of Subsidy says that “When you subsidise something, you get more of it and it gets more expensive.”
*** subsequent to this blog post, here’s a nice confirmatory piece from the estimable Max Pemberton
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 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?
….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)…
…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.’
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.
Nearly 70 years ago, the declared bases of the NHS, were the much-quoted three founding principles, courtesy of Aneurin Bevan, a remarkable politician:
that it meet the needs of everyone
that it be free at the point of delivery
that it be based on clinical need, not ability to pay
This nice summary from the NHS’ 60th birthday in the BMJ provides the narrative:
The three principles stand up well. American patients admitted as emergencies often can’t believe how good things can be in a quality NHS unit. It’s true though that maintaining such quality without financial incentives/disincentives (unlike most developed countries) is getting harder to do.
Did we need to add to these three principles? I don’t think so, but in the time honoured manner of bored self important managers and clinicians drifting away from the frontline, we have. Try this, from a big cheese Welsh NHS seminar in 2011:
Universal access, based on need Comprehensiveness, within available resources Services free at the point of delivery A shared responsibility for health between the people of Wales and the NHS A service that values people Getting the best from the resources available A need to ensure health is reflected in all policies Minimising the effects of disadvantage on access and outcome A high quality service that maximises patient safety Patient and public accountability Achieving continuous performance improvement across all dimensions of healthcare
I’ve italicised the ones that I would call mission creep – they’re not strictly NHS issues – and also the ones that are platitudinous and glaringly obvious. I’ve put in bold the bits with which I agree, but nobody really means, as ‘within available resources’ in practice means rationing. I have yet to hear a sensible debate on real rationing of NHS services, which means stopping doing some things. The Scottish NHS goes on about ‘realistic medicine’, but despite lots of hype, it remains somewhat undefined in terms of stopping doing some things.
Principle 6 in the now seven principles of the NHS spelt out in the NHS Constitution, also from 2011, alludes to this:
Which actually is worth spelling out. It’s the only way to keep the NHS viable. And what that means is….stopping doing some things. There are plenty of things that would have appalled Bevan and his colleagues, had he realised that’s what the NHS smorgasbord would end up providing. I have my particular favourites, you may too, and I include in my unpublished list quite a few of the elective procedures offered by my own specialty.
Bevan was following on from the flawed intellectual William Beveridge, who had a slightly broader remit looking at the role of the postwar state in more general terms: “five giants on the road to reconstruction” that needed to be slayed: want, disease, ignorance, squalor, and idleness.
Beveridge was on to something then and now.
None of this is new of course, but my suggestion is that these admirable and clear principles have been abused by the sprawling megacity of the welfare state of 2017, the most loved component of which is the NHS.
For the record, I’ve worked in the NHS for decades, I don’t do private work. What we badly need, as taxpayers, patients, healthcare workers, rational human beings etc, is to restructure what the NHS does (which means stopping doing some things). It’s not hard in principle. Here’s the order of priorities:
Lifesaving emergency treatment
Pragmatic management of life-threatening conditions, mainly cancer
Rapid access General Practice that includes real out of hours care
Elective procedures that work – so stop doing things that don’t have proven benefit of adequate clinical significance. That’s actually quite a lot of things that currently go unquestioned.
Appropriate public health/screening. So more colonoscopies, fewer stupid campaigns against booze (just to be topical).
Better end of life care
There are lots of other areas of neglect – for example the adult physical handicapped – but many of these are primarily social care issues, and I would like to see that separated from the NHS conceptually and financially, whilst accepting that the much neglected interface between the two is very important.
Where Beveridge, Bevan and the modern welfare state collide is in at least two areas. Firstly, it would have been impossible for them to foresee the exponential expansion of high quality, effective but costly medical interventions. The human race got good at this very quickly. Affordability became difficult within a few decades of the 1948 landmark.
Secondly, note Beveridge’s specific mention of ‘idleness’, which is effectively a codeword for what is loosely referred to as the Benefits Culture. Guardianistas don’t tend to focus on it. It is equally unaffordable in its current iteration. I’m not going to explore it, but interested readers will find illuminating references to it throughout the works of a master medical chronicler of these two centuries, Theodore Dalrymple (1, 2). Anyone with their eyes open in the developed world, particularly the UK, will know what I mean. As would Beveridge.
It’s fascinating to learn from the acerbic and erudite Geoffrey Wheatcroft something that may seem minor, but isn’t: Beveridge detested the expression “welfare state”.