The SNP: decline and fall (17)

I haven’t bothered to write on this since January. Not because there hasn’t been stuff, but it’s getting tedious just documenting new episodes in the already massive catalogue of Nat failure. There’s no shortage really, Eck still hoovering up the roubles on Russia Today, despite recent events, Humza’s general hopelessness, the mysteriously poorly photographed Zoomer march on Glasgow with outrageously exaggerated attendance (which the SNP decided not to attend, wonder why?), the pathetic writhing about how Scots love the EU (they don’t). The list goes on. In fact the SNP obsession with banning things that most voters like is producing negative feedback, amusingly.

Instead I draw the attention of anyone who is interested to a nuanced piece by former SNP insider, Alex Bell, who in recent times has painstakingly deconstructed the whole SNP edifice of winging it and make believe.

Here he is on Miss Sturgeon’s situation:

She has led the devolved administration into a showdown with Westminster. Holyrood says No to the post-Brexit divvy up of powers, Downing Street says Yes. All that matters now is what the Supreme Court says, and what Westminster concludes when the deal is put to the Commons.

We can be pretty sure the court will rule this is a matter for the sovereign government – Westminster – and so force the deal on Holyrood. It is impossible at this stage to say what Westminster will do, given so much is still unknown, and what is known is so confused.

Yet the SNP’s grip is slipping. Not least because Sturgeon is staking her reputation in a fight over devolution, which isn’t even her party’s policy.

The Tory government wants Westminster to hold power over matters such as agriculture and food standards because British nationalists think they’ll need to cut deals in these areas in order to strike new trade partnerships across the world when out of the EU.

Sturgeon and Holyrood, except for the Tory MSPs, want powers returning from the EU to go straight to Edinburgh.  So we are not getting a constitutional crisis over independence and not because Scotland rejected Brexit.

Instead it’s a crisis over devolution. This is, then, not her fight. If she wins, all she has done is secure the devolution settlement. If she loses, she looks too weak to fight her big cause, independence.

All of which sounds terribly dull and fairly inconsequential, but it’s really a reflection on how the Nats’ general policy is to pick fights, lose them, and pick some more. There is no vision being built. Poor Andrew Wilson, a nice, normal person, was tasked a long time ago with producing a coherent long term economic strategy for independence, to replace Eck’s failed oil bunkum. It’s yet to appear.

Alex goes on:

Yet the last thing the indy cause needs is another referendum any time soon. Asking the same question and expecting a different answer is the pop definition of stupid. In the years since the last vote, not a single bone has been added to the skeletal case of 2014. Yet Sturgeon is in the odd position of having weaponised her own supporters.

Doh.

It’s a great piece, and has a painful, if truthful punchline for the current First Minister….She’s in a bad place, and it won’t end well.

stursalm
M&S need some new models
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Appeasement 2018, and DH Lawrence

The insult ‘Hitler’ has been casually tossed around in 21st century politics for years, with each use  provoking the most cringing of faux outrage, and simultaneously  diminishing the power of the comparison. Similarly, the term ‘appeasement’ has been invoked for all sorts of decisions ranging from pragmatic to cowardly, with numerous references to Neville Chamberlain’s deluded performance of 1938.

But while we genuinely seem to be lacking a new Hitler (pace Trump haters), appeasement is indeed on the prowl. Here is DH Lawrence, back in the late 1920’s, pondering the flaccid state of the nation and its so-called intelligentsia between the wars. It is taken from the chapter entitled The End of Old Europe (primarily relating to Hitler’s rise to power), in Paul Johnson’s invaluable Modern Times. Read it, history really does repeat itself.:

They want an outward system of nullity, which they call peace and good will, so that in their own souls they can be independent little gods…little Moral Absolutes, secure from questions….it stinks. It is the will of a louse

Photograph of D.H. Lawrence and Frieda Lawrence in Chapala, Mexico, 1923
Lawrence – prototype hipster?

Harsh words, but remarkably apposite to much of what we see today. So the reason why the Second Amendment is under attack again in the US (ha!), why Israel is criticised for defending its borders (not that I’m supporting excessive force), why the national armed forces are intended to be subsumed into an amorphous inchoate EU force etc, is so that wet middle class people far from the action can “in their own souls…be independent little gods”. That kind of sums up a certain bien pensant leftie to me. The absolute peak of such appeasement in recent times has been the utterly ineffective Iran Deal, created primarily to give Obama (and the hapless John Kerry) some sort of artificial legacy. The ‘will of a louse’ indeed.

To be honest, writing blog posts like this always feels a bit smug and a bit sour – it’s not something that gives you much pleasure – but we live in difficult times, and Lawrence’s quote is just too good to ignore.

It’s probably the best thing he wrote.

 

 

Ash Wednesday

I usually blog on this with a painting – Goya, Bruegel, Spitzweg (genius) and more. I was prompted today to look at Rembrandt’s** late work, The Return of the Prodigal Son, which, if you know the parable, is highly apposite for Lent. Wikipedia is good on this. Kenneth Clark called it “a picture which those who have seen the original in St. Petersburg may be forgiven for claiming as the greatest picture ever painted” –  a fairly high bar, I’d say.

Henri Nouwen had a more overtly human and religious take on it, expressed very poetically: “Rembrandt is as much the elder son of the parable as he is the younger. When, during the last years of his life, he painted both sons in Return of the Prodigal Son, he had lived a life in which neither the lostness of the younger son nor the lostness of the elder son was alien to him. Both needed healing and forgiveness. Both needed to come home. Both needed the embrace of a forgiving father. But from the story itself, as well as from Rembrandt’s painting, it is clear that the hardest conversion to go through is the conversion of the one who stayed home”

We’ve all been there, and we will be again.

RvR1
Rembrandt, The Return of the Prodigal Son, 1668. The Hermitage, St Petersburg

 

**The Knife is in awe of a few painters, Rembrandt is one of them: 1, 2, 3, 4

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

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Pretty simple, and universally applicable

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

That’s guaranteed.

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

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

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

Well…….

committee1

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

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

What’s the answer to this?

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

committee2

…for money, read clinical practice.

You can guess the author, I would imagine

 

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

 

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

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

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

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

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

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

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

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

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

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

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

There’s a suggestion for 2018.

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

Multipurpose soundbite (1): apply as necessary

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

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

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

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

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

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

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

Metaphor, Trump and the antlike Antifa

Army_ants
…Antifa, sundry mad lefties etc…

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.”

la-ol-le-berkeley-antifa-radicals-20170829
….army ants

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.

A story.

Leiningen Versus the Ants,” by Carl Stephenson (1893-1954). A plantation owner versus army ants.

Leiningen is a middle-aged man who refuses to give up. He enemies are the ants–robotic, vicious, inhuman.

My father’s most inspired quote: “Can you reason with a wasp?”

Of course not. Leiningen tries everything to save his plantation.

The ants won’t be stopped. They want what they want, and they’ll get it by any means necessary.

When all seems lost, Leiningen realizes that there’s one last chance, but someone will have to run through two miles of ants.

So Leiningen tells his men what will happen:

“I’m not going to let you try it; if I did I’d be worse than one of those ants.”

“No, I called the tune, and now I’m going to pay the piper.” Middle-aged Leiningen will run through two miles of ants.

How many people know that those who call the tune must pay the piper?

President Trump knows. He pays the piper daily, without complaint. That’s why Trump is winning and will be completely successful.

Army ants–no matter how many there are–can’t think. Last night I was told by THIS person that leftism will win.

Delusional army ants. That’s what Trump and his supporters face.

“Leiningen Versus the Ants” has one of my favorite lines ever:

“They had been delivered into the annihilation that was their god.”

Watch it happen. And celebrate.

…and Tom goes on to provide a handy CNN video. Hilarious

Praise the Lord (of explosives)

F1.large
..also, moustaches are back, take it from me…

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.

The domain of manners. Look around you.

 

A Brief History of Social Media – it’s not good

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

But…

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.

The irony is that the all powerful Zuckerberg with his $70billion+, and various ludicrous attempts to be normal pending his presidential run, seems to be a long way from being a “psychologically mature adult”.

reading-facebook-an-act-of-isolation-4-638
*

The future of the NHS, AKA “stopping doing some things”

ab1
…he has a point

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:

nhs6

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:

  1. Lifesaving emergency treatment
  2. Pragmatic management of life-threatening conditions, mainly cancer
  3. Rapid access General Practice that includes real out of hours care
  4. 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.
  5. Appropriate public health/screening. So more colonoscopies, fewer stupid campaigns against booze (just to be topical).
  6. 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”.

wb1
…another zinger