Past Posts...

No Easy Answers

There’s not much to say, even if Dr No is going to say a bit, about Atul Gawande’s third 2014 Reith Lecture, except that he blew it in the title – overweening confidence, Gawande’s definition of hubris, is not the problem, striving officiously in hopeless desperation is - and then spent thirty or so minutes stating the bleeding obvious. Called The Problem of Hubris, the lecture dealt with doctors’ failure to deal with the inevitable, the appointment we all must keep when our bell tolls, the appointment not with a doctor, but with death.

Time for a Gawande anecdote, this time about a friend called Peg. Emotional strings were taughtened by casting Peg as piano teacher to Gawande’s 13 year old daughter. Given Gawande’s subject, one knew Peg’s cards were marked: at some point, Peg would peg out. Best be grateful for small mercies: at least Peg wasn't called Sue.

Discipline Makes Daring Possible

When the Chief Medical Officer feels uncomfortable, should the nation tremble? Probably not. Certainly, Dr Atul Gawande didn’t, fielding Dame Sally Davies’s troubled comments after giving his second 2014 Reith Lecture, broadcast this morning on Radio Four. Speaking in his now familiar, you know, George W Bush style “Our people done a really good job…of, you know…hauling in a lot of the key operators”, Gawande extolled the virtues of getting systems right. Goaded by air industry experts baffled at the casual approach of surgeons to their work, Gawande developed The CheckList. Depending on viewpoint, the CheckList is either strictly for the dumb-assed, or a sort of systems alchemy that transforms the inept into the ept, and experts into super-experts. Doubters are stumped and declared out for a duck by asking them a simple question: “If you’re having an operation, would you want the team to use the checklist?” Unsurprisingly, ninety four percent did, though that leaves the intriguing question what did the other six percent want? Dr Frankenstein? A one armed blind surgeon with a prosthetic hand and Parkinson’s disease? We’ll probably never know, because by now they will have maimed or killed themselves some other way.

Flat-Lining Round the Corners

Browsing the web about the latest round of Health and Social Care Bill backed pile-em-high, sell-em-higher NHS services currently out to private sector tender, Dr No chanced upon a success statement (SS) so hilarious his eyes would have popped (EWP) were it not for the fact that it came from the Orkneys, where Dr No had the privilege of spending a few weeks as a medical student with a real GP doing real medicine. The statement reads:


We Have No Black Boxes

The annual metronome to British public service broadcasting, the Reith Lectures, have begun this year’s tick, with Dr Atul Gawande doing the tocking. A smooth tocker with hints of George W Bush style pulsing rising enunciation, today’s first lecture – the first of four, we should note - asked ‘Why do Doctors Fail?’. Master of the personal anecdote, Gawande told the tale of a certain Baby Walker – not the contraption, but his son – who survived despite being born with an aortic abnormality, while the baby in the next cot with the same condition did not. The answer, by and large, was systems failure: Baby Walker ended up in the right place at the right time, while Baby Maine next door did not: the right place, perhaps, but too late. Walker walked, Maine died.

What’s God Got To Do With It?

November is the sombrest month. As the leaves complete their fall, we Brits go through two very different but very British annual events, Remembrance and Children in Need. Both have at their heart charitie, in the King James sense of the word, but the tone of each could not be more different. On the BBC, Remembrance commentary comes from National Treasures, Huyuwoo Wedwards and Dimblebug D currently standing in, while Children in Need is forever stamped with the ebullience of a National Buffoon, one Terry Wogan. Heaven forbid that, in the current rush - 1459 comments - to secularise Remembrance, Wogan be ballooned in to Remembrance, or, for that matter, Wedwards be wheeled in to Children in Need. Instinctively, we know neither would do; instead, each to his time and place. Wogan’s 1978 Eurovision commentary, caught all those years ago by Clive James, ‘not by any means full’, simply wouldn’t do at the Royal Albert Hall. Neither would the second half of the phrase, ‘possibly for security reasons’, given that most of what is left of our Armed Forces, and a good few fierce looking Veterans armour-plated with medals and bristling with whiskers if not weaponry, were packed into the Hall for the night. Any sharp-shooters dropping by could be sure of a hot reception.

Shakin’ Stevens

Yesterday’s news was bob-a-job docs, £55 for each and every dementia diagnosis, with old hands who should know better – they have been handbagging item of service fees in various shapes and forms since the beginning of time – decrying the idea as bribery, likely to cloud professional judgement, possibly even unethical. Dr No will believe their wails when they start handing back the contents of their handbags. For his part, Dr No thinks the idea, though crude, is not without merit, even if the sum is paltry for what is rather more long-term work than a snap diagnosis, because it sends a signal in terms the ex-apothecaries have always understood – payment for an item of service. Dementia is under-diagnosed, and patients and carers who want to know and plan miss out on help that is or at least should be available. Indeed, upping the recorded prevalence might even push up dementia funding. So all in all, though a bit grubby, the idea gets Dr No’s approval.

The Emperor’s New Data

Some six months after care.data1, the contentious plan to upload personal medical data held by GPs to big-daddy mainframes, was stalled to allow a FF style listening exercise, care.data2 has been announced. The Information Emperor, Tim Kelsey, insists NHS England has listened, and heard – ‘heard, loud and clear’ – but it seems to Dr No that instead of hearing the waves of discontent crashing on the beach, all NHS England has heard is the wind rushing through the night. Getting on for two million patients registered at ‘pathfinder’ practices will have their GP records, including date of birth, NHS number and postcode, uploaded to big-daddy, with the default being opt-in unless the patient explicitly opts out. Since care.data1 had GP records, including date of birth, NHS number and postcode, uploaded to big-daddy, with the default being opt-in unless the patient explicitly opted out, nothing key appears to have changed. The only high profile change, which does nothing to change itself, is that, instead of a bungled central promotion, will be now be promoted by GPs, many of whom, we may note in passing, are not happy to be cast as the Emperor’s new goons.

TTIP – Blofeld’s Charter or Scaremongers’ Chatter?

As acronyms go, it’s the tits-up PITTs, but for many concerned about the NHS, it is a pile of shit. Presented as a partnership, TTIP - the Transatlantic Trade and Investment Partnership – is, depending on your point of view, either a sensible deregulation of transatlantic trade and investment that will free up a few extra bob for the folks back home, or Ernst Stavro Blofeld writ large, hell-bent on a grim SPECTRE TM – much more of this, and Dr No will need treatment for acronymitis - of corporate world domination at the expense of the nation-state. At the crux for health care is a TTIP proposal to allow private capital to sue sovereign states in ‘ad hoc’ tribunals for loss of profit. Claims of this sort have already happened under other trade agreements: in Europe, the private Dutch health insurance company ACHMEA recently sued Slovakia after a new government introduced a more socialised health service that threatened ACHMEA’s profits. The outcome appears for now at least to be in Slovakia’s favour: the tribunal said it had no jurisdiction - ‘the design and implementation of its public healthcare policy is for the State alone to assess’ – meaning, in effect, ACHMEA had lost.

The Union Jarred

Despite the crack in the Union that threatened to appear as things got tighter and tighter in the run up to the vote, the headlines this morning are Scotland Says No. This result is both a golden example of democracy at its best, with the turnout a credit to the Scots, but also a reminder that democracy, though the best of those that have been tried, is not necessarily a good form of government. Instead, it is the least bad. The headlines are misleading: Scotland, the nation, is an abstraction that can no more decide its fate than it can decide what socks to wear in the morning. Instead, it is the people of Scotland who decided, individually, with the referendum result a binary outcome based on counts of millions of individual decisions. The outcome is pure democracy, rule by the majority in the interests of the majority, but as always, and starkly in this case, where for every fifty-five Scots who voted no, forty-five voted yes, there is a substantial minority for whom the outcome is not what they wanted; the result not, as they see it, in their interests. The Union Jack may still be intact, but the Union has been jarred.

Everyone’s a Villain

The unfortunate tale of Ashya King, which the media has devoured as a starving man might devour a double burger and triple fries, has by and large cast everyone as a villain, except the patient himself. The Southampton doctors failed to maintain a working relationship with the parents. The parents became Drs Google & Google, and removed their son from hospital without warning, though it wasn’t ‘without consent’, or even kidnap or abduction, as some have suggested. The hospital delayed telling the police Ashya was missing, and the police, when they were told, responded by firing a high energy proton beam of a warrant, the European Arrest Warrant, at the parents, who ended up in the Spanish nick while their son languished in a distant Spanish hospital. The gruesome cogs of the Court of Protection ground into action, and the parents were left crushed, ex-parents in all but name, as Ashya became a ward of court. Even the private Czech Proton Beam Therapy clinic has been accused of profiteering on the back of Ashya’s media coverage. All the while, the media frothed itself into a foaming frenzy, and on the white waters of the frenzy, thousands of commentators bobbed up and down, each more determined than the last to finger their choice of the true villain. As the froth piled up, facts sank like stones. It became a tale in which all are villains, and none heroes.