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.
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:
One thing is true about contemporary politics in the UK, the EU and the USA – it’s not boring. Not only the facts, the events, the personalities, but also the conversations. The internet has liberated all of us, and for every crank theory there is an intelligent analysis that you won’t get in the mainstream media. It’s brilliant. A lot of it is also very funny/entertaining, though hardly ever emanating from the more left inclined end of the spectrum, where humour is suspect.
Whether or not we’re currently getting good government, we’re certainly benefiting from the theme of John von Kannon‘s wonderful quote “If you can’t have good government, at least have entertaining government.”
A rising star in 2017 is Thomas Wictor, whose biography is pretty extraordinary, and who has a dedicated bunch of followers on Twitter, waiting for the next in his series of long threads, centring around government, lefties, war, the military, pictorial analysis and flamethrowers. Yes, flamethrowers. In fact, with respect to the latter, read the genius thread starting here.
He’s an erudite man, and a terrific writer. Here is his series of tweets creating the ‘Trump is Leiningen’ meme. A sheer delight. You don’t have to be a Trumpkin to enjoy the point.
Not all figures in public life are venal and self-interested:
During the entire four war years Lord Moulton worked a ten-hour day and took less than ten days holiday
…that was John Fletcher Moulton, who at the outbreak of the First World War became “Director-General of the Explosives Department”. A terrific job title. He’s interesting too because despite being an extremely distinguished legal brain, he was also a very high powered Cambridge mathematician. The man had a hinterland.
Anyway, I owe this post entirely to the polymathic genius of the very funny and very wise Mark Steyn, who in examining the absurd vicissitudes and mores of our decadent 21st century West, noted:
85 years ago English judge Lord Moulton, said that human action can be divided into three domains. At one end is the law at the other is free choice and between them is the realm of manners. In this realm Lord Moulton said, “lies a domain in which our actions are not determined by law but in which we are not free to behave in any way we choose. In this domain we act with greater or lesser freedom from constraint, on a continuum that extends from a consciousness of duty through a sense of what is required by public spirit, to good form appropriate in a given situation”.
That was from 2016. Steyn returned to it a few days ago, in looking at the current NFL shenanigans in the States. It seems such an obvious concept, but there’s a kind of genius in defining it so elegantly.
I think we can all recognise abuse of this precious and ordinarily fairly accepted aspect of human behaviour, which relies on personal integrity and a degree of trust. The new modus operandi is “what can I get away with?”. In hospitals I would identify the increasing trend to not come and see a patient when you’re asked to, at the bedside. You probably will get away with it, but it’s a drop in standards, and every now and then, someone will suffer unnecessarily. It’s a genuinely bad development, because attitudes have changed, and nobody is able – in the NHS – to enforce things, it seems. It’s almost an argument for payment according to work done, as in the US and Canada, where you bill for a ‘bedside consult’. Money talks, even if your conscience is staying quiet.
Life changes, technology advances and only curmudgeonly old farts should object, right? We always have the eternal verities to fall back on, religious belief still provides succour, we’ve never been healthier or more prosperous here in the developed world, etc etc
There are a lot of unhappy people out there. This post is not to condemn all social media, far from it, but a little history is very telling. Over to Jonathan Haidt, quoted extensively in the admirable Spiked:
‘I don’t know if most college students, even at those elite schools, are more fragile. What we do know is that rates of depression and anxiety [have been] sky-rocketing since around 2011.’
Haidt says these issues are not related to the millennial generation, but to those born after 1995, who grew up with social media as the norm. He calls them the i-gen (the internet generation). This tendency towards vulnerability has a number of causes, he says, but there are three main ones: social media, rising national polarisation, and the decline in unsupervised (adult-free) time during childhood.
‘The widespread introduction of social media on a potentially hourly basis occurs after around 2009 or 2010. The iPhone is introduced in 2007, Facebook opens itself to teenagers in 2006. So it takes a couple of years before most teenagers are on social media, but by 2008, 2009, a lot are… The problem seems mostly to involve social-media sites, where a teenager puts out something and then waits to sees what dozens or hundreds of people say about it. That seems to be the most damaging thing – it leads to more anxiety and insecurity.’
On polarisation, Haidt says that cross-partisan hatred has been increasing in the US since the early 1980s, ‘but it’s much more intense now… There is a much fiercer battle going on, and there is more motive to charge the other side with crimes and to claim victimhood for your side. I think this is part of the “speech is violence” movement. It is part of a rhetorical move to convict the other side of more serious crimes.’
The third major cause has been the ‘general decline in unsupervised time and the rise of adult protection’, says Haidt. In the US in the 1980s, there were two high-profile abductions and murders of two young boys, and parents panicked, he says. ‘Now there never was much of a risk of abduction from strangers… But America freaked out and overreacted and stopped letting kids out of their sight.’ By the 1990s there were pictures of missing children everywhere – ‘as if it was an epidemic, but it never was an epidemic’, he adds. At the same time, there was more of an emphasis on anti-bullying, as well as a decline in unsupervised play. ‘Studies of how kids spend their time show that up until the early 1980s kids spent a lot of time outside playing without adult supervision, but by the early 2000s that has almost disappeared, especially for younger kids’, he says.
Ironically, this over-protection of children may have done more harm than good. ‘The key psychological idea in understanding the rise in fragility is the idea of anti-fragility’, says Haidt. ‘It’s a word coined by Nassim Taleb and it describes systems that are the opposite of fragile. If something is fragile then you need to protect it, because if it breaks then it’s broken and it won’t get better. But there are some things that if you protect them, they won’t get better; the immune system is the classic example. If you protect your kids from germs and bacteria then the immune system can’t develop and your kids will be immunologically fragile… So protection can sometimes be harmful if there is an anti-fragile system at work.’ He continues:
‘Kids need conflict, insult, exclusion – they need to experience these things thousands of times when they’re young in order to develop into psychologically mature adults. Every adult has to learn to handle these things and not get upset, especially by minor instances. But in the name of protecting our children we have deprived them of the unsupervised time they need to learn how to navigate conflict among themselves. That is one of the main reasons why kids and even college students today find words, ideas and social situations more intolerable than those same words, ideas and situations would have been for previous generations of students.’
Haidt is obviously making several points here, but they are related. The key period of 2007-2010 that he highlights is exactly right. People in their twenties and younger do not really know the previous world and its social structures and norms. The social challenges though have multiplied.
On balance I would say this is a bad thing, and the mental health issues that he identifies are very common indeed.
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”.
In case anyone is interested, here is the list of Remainers in Scotland who, and I quote: …call for a national debate on Brexit. We ask our fellow citizens, and our politicians, to think again. It is time to call a halt to Brexit.
They wrote to the Glasgow Herald, which is behind a paywall, on 18th July. The Herald excitedly dubbed them a “Who’s Who of Scotland’s intellectual elite”, and made it their front page.
Well, judge for yourself. I am personally unpersuaded.
(Spoiler alert: it is a very boring list, but there’s more stuff at the end if you scroll down)
Professor David Bell, Stirling Management School, University of Stirling; Andrew Bolger, former Scotland Correspondent, Financial Times; Professor Christina Boswell, School of Social and Political Science, University of Edinburgh; Professor Sir Harry Burns, Professor of Global Public Health, University of Strathclyde; The Rt Hon Lord Campbell of Pittenweem CH CBE PC QC; Dr Chad Damro, University of Edinburgh; Professor Emeritus Sir Tom Devine, University of Edinburgh; Christine De Luca, poet; Dr Richard Dixon, Director, Friends of the Earth Scotland; Sir David Edward, Professor Emeritus Edinburgh University Law School and former ECJ Judge; John Edward, Former Head of European Parliament Office in Scotland/Former EU Policy Manager, Scotland Europa; Colin Imrie, European policy analyst; Maria Fletcher, Director of Scottish Universities Legal Network on Europe (SULNE); Lord Foulkes of Cumnock; Dr Peter Geoghegan, University of the West of Scotland; Gwilym Gibbons Creative Help Ltd; Dame Anne Glover, Vice Principal for External Affairs and Dean for Europe, University of Aberdeen; Vanessa Glynn, Chair, European Movement in Scotland; David Gow, Editor, Sceptical Scot, Editor, Social Europe; Dr Eve Hepburn, Chief Executive, Fearless Femme CIC; David Hood, Director, Edinburgh Institute for Collaborative & Competitive Advantage; Dr Kirsty Hughes, Director, Scottish Centre on European Relations; Helen Hunter Education Officer (retired); Helen Kay M.A., M.Sc.; Stefan G Kay OBE; Patricia Kelly, retired teacher; Lord Kerr of Kinlochard GCMG; Mark Lazarowicz, former Labour MP 2001 – 2015, Edinburgh North; Graham Leicester, International Futures Forum (in a personal capacity); Baroness Liddell of Coatdyke, former Secretary of State Scotland and former High Commissioner to Australia; Dr John MacDonald, Director of the Scottish Global Forum and editor of CABLE magazine; Gordon Macintyre-Kemp, Author and chief executive, Business for Scotland; Dame Mariot Leslie; David Martin, MEP; Monica Martins, Managing Director, WomenBeing Project; Marilyne MacLaren, retired politician and educationalist; Rt Hon Henry McLeish, former First Minister; Maggie Mellon, former executive board, Women for Independence and social work consultant; Professor Steve Murdoch, University of St Andrews; Isobel Murray, Professor Emeritus Modern Scottish Literature, Aberdeen University; Dr Kath Murray, Criminal Justice Researcher; Andrew Ormston, Director of Drew Wylie Projects; Alex Orr, Managing Director, Orbit Communications (in a personal capacity); Robert Palmer firstname.lastname@example.org; Ray Perman, author and journalist; Willis Pickard, former editor TES Scotland and Rector, Aberdeen University; Dr Janet Powney, consultant in education and evaluation research; Lesley Riddoch, journalist and broadcaster; Ian Ritchie, software entrepreneur; Baron Robertson of Port Ellen, KT, former Secretary of State for Defence, former Secretary General, Nato; Bill Rodger, Treasurer, European Movement in Scotland; Anthony Salamone, Research Fellow and Strategic Adviser, Scottish Centre on European Relations; Prof. Andrew Scott, University of Edinburgh; Anne Scott, Secretary, Women’s International League for Peace and Freedom, Scottish Branch; Peter K. Sellar Advocate, Axiom Advocates Faculty of Advocates, Edinburgh; Prof. Jo Shaw, University of Edinburgh; Dr Kirsteen Shields, Lecturer in Public Law, University of Dundee; Martin Sime, Chief Executive, SCVO; Alyn Smith, MEP; Grahame Smith, General Secretary STUC; Professor Michael E. Smith, Professor of International Relations, University of Aberdeen; Prof Chris Smout, Historiographer Royal of Scotland and Emeritus Professor, University of St Andrews; Struan Stevenson, former MEP and European Movement in Scotland Vice-President; Bob Tait, philosopher and former Chair, Langstane Housing Association, Aberdeen; Lord Wallace of Tankerness, Liberal Democrat peer and former Deputy First Minister; Sir Graham Watson, former President of the Alliance of Liberals and Democrats for Europe Party (ALDE Party), former MEP; Dr Geoffrey Whittam, Reader, Glasgow Caledonian University; Fay Young, Director of a digital media company, c/o 3 Fettes Row, Edinburgh.
That last one is especially poignant.
The must read piece on this self serving malarkey (as all these ridiculous multiple signature proclamations are) is from a genuine Great Scot, David Robertson, a Wee Free minister. He correctly points out that the authors’ views may not be entirely unconnected to their incomes, in some cases. Rigorously objective they are not. Read his whole piece, but here’s a telling excerpt:
Which brings me on to the state of the Scottish intelligentsia. This is the land of David Hume and the Scottish Enlightenment. The land which produced missionaries like David Livingstone, politicians of the calibre of John Smith and medical innovators like Sir James Young Simpson. We are the land which created writers like Burns, Stevenson, Scott, Conan-Doyle and George MacDonald. We are the land of the radical Christianity of Knox, Chalmers and Mary Slessor. This is the land where a railway worker’s son like James Mackay can rise to become the highest legal official in the land. This is a land that even today produces composers like James MacMillan. Scotland has thrived because of its intellectuals. So how have we descended to the state where several of our leading intellectuals manage to produce a letter of such vacuity and banality, that if a student in college had produced it, they should have been failed?!
As he goes on to state:
This is what Scotlands metro-elites regard as intelligent debate nowadays – they talk to each other, tell themselves how important their conversation must be and so they continue in their wee circular world
This is the 6th post I’ve done on this topic, slightly to my surprise (1, 2, 3, 4, 5). They always get regular hits, presumably from people googling Mercedes W126/SEC/coupe. I do it myself.
I previously noted that racing drivers liked to drive SEC’s in their civilian lives, and if you’ve seen the remarkable movie documentary Senna, you’ll know that he was in some ways the greatest of them all, a true archetype.
One of my patients knew him from back in his Formula 3 days, and has nothing but praise for him as a driver, naturally, but also as a man.
Well, the excellent Mercedes Enthusiast magazine has done some detective work and unearthed Senna’s original 500SEC, which clearly has had a harder life than some. It’s been somewhat transformed, but this car has real pedigree, something not very common in the used vehicle market.
As before, here are expandable .jpeg files (just click) and a pdf…