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Guidelines, Contracts and Revalidation


Posted by Dr No on 28 June 2012

caber_3.jpg"Rules are for the guidance of wise men and the blind obedience of fools."

–attrib. various1

An editorial in the JRSM by the formidable Dr McCartney, who tosses articles as lesser Jockettes do cabers, helped crystallise some bitter salts that have of late been swilling around the vague stream of consciousness that passes for Dr No’s thoughts. The gist of it is that doctors have had enough of being pushed about, demeaned, and generally told what to do, all of which are anathema to the professional mind. For GPs straining to meet Quality and Outcomes Framework targets, the doctor-patient centred consultation has become the government-contract centred consultation. Hospital doctors no longer manage or treat their patients, they protocol them through pathways, all too often watched over by guidelines of not so loving grace. Juniors no longer routinely strive for excellence; instead, they slavishly strive for ticks in boxes. All through medicine, the opportunity for individual, creative, effective and satisfying practise has been flattened under the weight of rules, guidelines, pathways, contracts and targets.

As if all that wasn’t weight enough, soon every doctor will be regularly interrogated against the muvva of all medical guidelines, Good Medical Practice, under the steely eye of first their appraisers, and then Stilton’s Responsible Officers, in a process called revalidation, but which to many will feel like being fed feet first through the rollers of yet another government mangle. Those who survive without their head exploding from an early build up of visceral pressure will emerge on the other side, flattened and chastened; and of those, more than a few will emerge not only flattened and chastened, but broken too. Those that survive will carry with them the burden of yet more imposed obligations, from their appraisals: PDPs goals, ‘must try harder’ areas, and the general panoply of appraisal-revalidation activity. While it is true to say that not all of that activity will necessarily be a waste, and some of it might even have been done anyway, the fact that it is imposed, not self generated, will ensure it feels like one more externally imposed controlling burden to be added to all the other externally imposed burdens and controls that already so dominate a doctor’s time.

The net effect of all these recent developments - none existed when Dr No was a junior doctor, except perhaps a handful of optional guidelines - has been to knock the 'prof' out of professional, and turn the doctor instead into a sessional technician who executes work flows and patterns devised and decreed by others. If we borrow somewhat loosely from transactional analysis, it is as if the once adult doctor has gradually but inexorably been hemmed in by rules and boundaries, to the extent that they are now in all but name a child, unfit to be trusted with, and incapable of, independent thought or action. They must instead be guided and cajoled, watched and monitored, and the miscreants brought back into line. Even worse, it is not just back to school, it is back to school with no graduation day set.

But most doctors are not children, they are adults, usually intelligent and motivated. Older doctors, like Dr No, remember the days when doctors did practice as autonomous adults, always responsible for their actions, but equally always free to decide and do whatever they felt best. With that autonomy, and responsibility, came a sense of will and purpose that came not from without, but within, and with that came the rich satisfaction of achievements achieved, and yes, too, at times, the remorse of failures endured. Above all it was a rich and satisfying life. Belloc could just as well have been writing about medicine as sailing the sea when he wrote: “There…we play every part of life: control, direction, effort, fate; and there we can test ourselves and know our state”. Pity, then, the lot of today’s child-doctor: distrusted, deskilled, ruled on some sides by targets, on others by guidelines, with the Damoclean sword of revalidation forever hanging over his or, increasingly, her untrustworthy head.

Small wonder, then, that some doctors are getting restless. Theirs, they cry, not to do and die, but to reason why! Why, they ask, have we lost our professional autonomy, and with it the sense of purpose and satisfaction that used to drive and satisfy our souls? Twitter echoes – if a tweet can echo – to the sound of doctors lamenting the loss of control and direction in their professional lives. Dr McCartney ends her editorial with: “we need to reclaim medical vocation and put it to the use of our patient”. The groundswell of discontent is already here, the calls to action emerging.

Dr No looks forward to Dr McCartney tossing a few more cabers into the complacent ring. He may even get round to tossing a few of his own. From a strategic standpoint, the answer, he believes, is already clear. Doctors, both individually and as a profession, must reject external control, and reclaim internal control. All that remains is to decide tactics; and boycotting revalidation is as good a place to start as any.

1. Some say it was Douglas Bader, the WW2 fighter pilot, others say it was Solon, an Ancient Athenian. The wording also varies, and some omit ‘blind’; but the message remains clear enough…or does it? Fools do (blindly obey, because they are foolish)? Or fools should (blindly obey, because they don’t know any better)? Wiser men than Dr No will have to tell us which it is.

27 comments:

Dear Dr No,

I suspect that if the Patients Association were asked the question "Do you want your doctor to spend an extra 2 hours per week on form-filling and box ticking rather seeing patients?" the survey would have come up with a very different answer.

I wrote recently about the process of evil, which rests on the incremental aspects of change in that direction. The process of de-professionalisation is the same. Doctors like you and me are closer to retirement than qualification, and we are being replaced by a new generation. In many ways the new generation will be better doctors than us, but they will also be the graduates of a system of eportfolios and MSF's. They may well associate being better doctors with these things, but correlation is not causation.

Revalidation is MTAS for grown - ups, and will create a similar exodus, coupled with the pull of pensions and the push of the unpopular Lansley reforms. I have even been browsing the possibilities in the antipodes myself. Those who are left will accept all the things that we rail against as the normal landscape of British Medicine.

In the words of Arthur "Bomber" Harris (on the day of the unveiling of the Bomber Command Memorial) "They have sown the wind, they will reap the whirlwind"

Boots

Boots - we musn't get too bogged down in what is only after all a rather silly PA survey question. The original question was in the form 'should your car have an annual check up to make sure it is safe to drive' and such questions are very difficult to answer no to, since a no answer suggests you don't think car safety is important. As noted before, the error is to conflate two question into one (regular checks?/desirability of safety?). A much better question would be yours (even if it conflates paperwork with clinical non-availability) or, perhaps better still, a rating type question eg Doctors currently average a working week of XX hours. How many of those hours should be spent documenting they are up to date? (a) none (b) no more than one hour (c) between one and two hours etc etc. The importance of how you ask questions in surveys is all too often sadly over-looked.

Long overdue - Dr No has added your blog to 'Dr No Reads...'. Your latest 'Steps to Evil' post describes the process the WD calls 'creep' - the invisible shuffle of the blind from good to bad, and then evil. Because each individual step of the shuffle is so small, we do not notice it much if at all, but incrementally a lot of small shuffles can add up to one hell of a big step.

The impending exodus from the profession (notwithstanding any possible training influx) is going to be a catastrophe (or, if you happen to be the government, or one of the other groups that want to cut doctors down to size, a resounding success). The ones who will go will be the ones we - and most of all patients - need most. Only the quislings will remain, a process Dr No once described as Survival of the Conformist. Similar process are at work in Unnatural Selection. The situation will be made even worse by the fact that, as we saw here, there are relatively few older (and so more experienced) doctors. As they that do remain depart, medicine will increasingly becoming a profession of young (and inexperienced) quislings.

Dr No's recent experience at a famous teaching hospital situated not so far from the River Cherwell gave him very little reason to hope today's juniors are any better than in our day. The juniors he encountered seemed to have escaped from the set of a Dennis Potter movie - only it wasn't a movie, it was for real.

The core of Dr No's prescription, to answer Anonymouse's request for suggestions, is that, far from increasing external governance and regulation (guidelines, targets, QOF, CQC, contracts and yes revalidation, and all the other paraphernalia that attempts to control doctors' behaviour externally), we need instead to remove all that which stifles, inhibits and generally wears down, and replace it with internal regulation: doctors do the right thing because that's what they do, because of what they are. Dr No's shorthand for this is internal regulation.

In an ideal world (in which we are not), internal regulation would allow doctors who know they are below par to step forward without fear, just as it would allow others (whistleblowers) to step forward without fear when the internal regulation of others has visibly failed. Dr No fully appreciates this is a vast, even grandiose, proposal, but the rewards, in replacing a culture of control, ennui, fear and crippled performance with one of independence and progress seem, at least to him, to make the idea one which is, at the very least, worthy of some consideration.

I am glad that you find my blog of interest. It is like me rather inconsistent and often needing challenging. While politics may be different all medical bloggers desire to explain the ills of modern medicine.

In your link unnatural selection you pick out how career preferment works. This is something that exercises me also. Medicine is becoming physically more diverse but the emphasis on assessing values and similar skills does go against true diversity. Increasingly the powers that be have a monocultural world view. Whether through creep or the quicksand of evil; this groupthink is often the first step down the slippery slope. We need a true diversity of doctors so that there is real and passionate debate. This is how the light of reason is shone on ideas. If the ideas are sound they can tolerate fierce criticism, if they are weak they will be found out by it. All too often real diversity is the victim of received wisdom. The dynamic and free exchange of ideas is the base for science and progress. It is the mutation that allows evolution to work.

Revalidation is symbolic of much activity by our betters; a solution in search of a suitable problem. It is all about being seen to be doing something rather than doing something useful. If there were a poll on revalidation I suspect there would be an overwhelming vote against it amongst doctors. It will be a futile effort and the final straw for some. I plan to do the minimum required, no more.

Best wishes

Boots

" we need instead to remove all that which stifles, inhibits and generally wears down"

Hear, hear

", and replace it with internal regulation: doctors do the right thing because that's what they do"

I'm not sure, like you, that this would identify those who are below standard though, given the rife gang culture within the NHS, who would dare speak?! So, it won't encourage whistle blowers to blow either!

JD's post about transparency, and the current drive by the government in his link to the DM's article is a more realistic idea, all over the public sector including the NHS, if followed properly and across the board as the article claims ... a big 'If' me thinks! ... but I like the idea ....

http://www.dailymail.co.uk/news/article-2166235/Government-plans-release...

"the quicksand of evil"

This four letter word is such a despiriting, cruel on the ear and the eye ugly word! You don't sound as a pessimist to me Dr Phil! But that's bottom of pessimist, cheer up! ... it's too short, and not worth it! Life is, of course :-)

Dear Sam,

Evil.It does exist, and it is ugly, as are my moods sometimes. I am convinced that the temptation to evil exists in us all, but that also the ability to resist evil also exists in us all.

Evil things are not just done by bad people, often the worst evils seem to come from those with good intentions, convinced that their actions will improve the world. I include myself in this.

The educationalists, revalidators and commissioners behind MTAS, revalidation and the Lansley bill are acting with good intentions. Unfortunately these good intentions give great power and drive to these plans. Group think in a place where ideas go unchallenged due to lack of real diversity of thought has real consequences in terms of harms done.

I know no doctor who consciously wants bad practice to continue unchallenged, but know very few who support revalidation. Even the College officers (in private conversation) express major concerns about it.

I fear that Revalidation has the power to become a Spanish Inquisition, where the main activity is directed at doctors expressing dissident views and with challenging personalities rather than bad medical practice. Not only is this a disaster for the individuals concerned, it has adverse consequences for us all. The enforcement of the groupthink orthodoxies by this means the new ideas that are the mutations essential for evolution of progress go unheard. I strongly support real diversity of thought, not just of ethnicity gender class and sexuality.

This groupthink view within the profession affects other areas also. British doctors are so deep in the culture of state provision via the NHS that they are unable to see that some aspects of the commercial world would improve things for our patients. Groupthink is a problem on both sides of the fence.

Boots

Dr Phil, it is interesting how many of our thoughts over time are converging.

However, when revalidation was first mooted, my resolve was different from yours. I would not do the minimum required of me. Instead, I would decide on one of two approaches. I would refuse point blank to participate at all, loudly or perhaps silently (don't do it and see how long it takes for anyone to notice!). The second approach would be to take the piss out of it by overdoing it in the extreme and continually and sweetly asking the GMC and every other body imaginable very specific and unanswerable questions. I would certainly, for example, keep a timetable of every activity perfectly performed. Witches use this technique quite a lot and it can be quite fun watching the medical politicians squirm when they are forced to pay attention to detail rather than the crude big picture.

Boots - a long time ago, it now seems to DN, so now it perhaps feels a little dated in its detail (the GMC's failure to act decisively in the case of Jane Barton), he did a spoof likening Revalidation to the Spanish Inquisition. Be the dating as it may, the fact is that revalidation has all it needs to become a very real inquisition - and the GMC won't always use use cushions or comfy chairs for confessions.

It is also very refreshing to hear a self-declared Christian facing up to the reality of evil. Far too many Christians, in DN's experience, start behaving as if they have sea-water on their PCBs when they see/hear the word. Too many hide behind all will be well in the best of all possible worlds (or whatever the actual saying is). At best this is hiding under the rug with fingers in ears, at worst it is passive complicity.

DN is not a Christian, let alone a Christian theologian, but he always crudely understood that Christianity (alone, of the three Abrahamic/revealed monotheistic religions?), through the Garden of Eden and Original Sin, teaches that we all have evil inside us, and, just as importantly, we all have a choice as to whether we follow the light or the dark. Even as a non-Christian, Dr No can see the importance of the capacity for evil in all of us, for it is by so doing that we at least stand a chance of preventing sinister creep, and the terrible horrors of the Nazi progression to the Holocaust. Group think, of course, is one of the several mechanisms by which sinister creep can happen. No one in the group sees the evil they are up to, and all in the group take understandable but very dangerous comfort from the fact all agree.

On the other hand, in a spirit of hope - Dr No seriously doubts whether any Responsible Officer will have a counter-spell even half as strong as that needed deal with the witches hidden in their patch. It may even be that all too soon, just as in Gilbert & Sullivan, they will discover that the policeman's lot is not a happy one, and want out. How then will Stilton manage his medical police state, with insufficient goons on the ground?

The Theological explanation of evil has never been an easy one, and my own understanding of it is often inadequate.

As a Scot (even an athiest one) you must have been, like me, exposed to the dour Calvanism of the Scottish Kirk. The belief in the fallen nature of man is one of the foundations of Presbyterianism. While in many ways an unappealing philosophy, it is so ingrained that it continues to strike a chord in me. This same roots have very positive aspects including a strong work ethic and strong drive to education and self-improvement. It is not so easy to seperate the baby and the bathwater, to keep one and discard the other. The development of the great medical schools of Scotland and the advances of medicine are in large part this tradition.

The first step in self improvement, including moving away from evil, is the aknowledgement that mistakes have been made. To learn from mistakes we have to own them. Much educationalism centres round the issue of self reflection, and it will also be a large part of revalidation methodology. A problem arises as soon as such reflection is tied to career progress. It quickly degenerates into a box ticking excercise of negative value. For it to be effective reflection it has to be unforced and driven by self motivation to improve, and kept private or shared only with a trusted mentor. Good doctors have always done this, but revalidation shares these private thoughts too widely, and thereby turns gold into lead.

Dr Phil " I am convinced that the temptation to evil exists in us all"

Dr No " we all have evil inside us"

No we don't. The devil is a 'visitor', and will only enter if you allow him in. No devil, no evil, hence;

" the worst evils seem to come from those with good intentions"

Is a contradiction of terms. Those are two opposites, they can not co exist in the same place at the same time Dr Phil, or they will cancel each other out, unless there is more of one over the other., which proves the point; that 'good' intentions can not exist with or do evil

The problem is that the devil is the prince of lies, and often enters in disguise.

Protestant theology, and much Catholic theology is about the internal life. My knowledge of other religions theology is much less. As the internal life is the critical one, that is where the contest takes place, rarely is there a deliberate choice to do evil, much more often a self justification that a particular act is either neutral or even positive. It is not a contest without allies and the fundamental distinction of Protestantism is that while scriptures, ministers and traditions all are useful; the critical support is the individual relationship with God. It is not just the devil who knocks on the door.

Now, on to free will or predestination...

Well maybe another day for that one!

Boots

"The problem is that the devil is the prince of lies, and often enters in disguise."

If you agree that we are all born clean, then in turn the soul at birth is clean too, hence, no matter the disguise, clean soul can detect. Meaning, again, that you have to allow entry yourself, or the devil can NEVER get in! ... but we're all sinners! Why? Not because of the devil's talent for disguise, but because of the 'temptation' he puts in his lies ... he plays on our weakness!

"Protestant theology, and much Catholic theology is about the internal life. "

And same for Islam, and it's all about that 'weakness' and teaching how to deal with it so we can become stronger in the face of the 'price of lies''s tempation

"rarely is there a deliberate choice to do evil, much more often a self justification that a particular act is either neutral or even positive."

... but that's precisely the reason you give yourself, then allow the 'temptation'; this is the 'invite' ... and you do it yourself, me too! And that's, in part, what religion is for, to help us overcome this sort of justification ... but we don't 'learn' that easy!

"while scriptures, ministers and traditions all are useful; the critical support is the individual relationship with God"

'Intentions' again then! Hear, hear ... and beware of some, if not all, ministers for those never do what they are ordained to do, preech God's message of 'love'. If they did, they would only talk 'positive' as love is ... but they always talk 'negative' too, this is why the world is in trouble! Look around, and that's a millenea old habit too, hence

"It is not just the devil who knocks on the door." is wrong, because it is Always just the devil who knocks, in his many disquises, who knocks at the door, hence

"Now, on to free will or predestination..."

Free, to a point because no man is perfect, if you've learnt enough, and predistined, if you allow the 'prince of lies' to convince you that you are so that you can succumb to his temptations ...

... and BTW, there is no such a thing as an athiest! No one can live without 'soul', for that's where we are 'clean' ... We can't live without 'clean', surely!

My Oh My! we do get to discuss a wide range of things here and Dr No is very glad we do!

Dr No's understanding is that Christianity alone amongst the Abrahamic religions embodies the concept of original sin (which came about because of the fall of man). It might have been more correct if Dr No had said "we all have the capacity for evil inside us", and thus we have the choice of whether to invite the devil/evil in, but it does seem to Dr No this getting precious close to semantics, in that the real world point is that we can all do evil; and that is why we, all of us, need to remain vigilant. One does not need to be a Christian, or go along with the doctrine of original sin, to recognise that it perhaps contains within it a reflection of a universal truth.

Dr No is also pretty sure a + and a - can coexist - that is what the Taoist/Yin-Yang symbol is about (light contains dark and vice versa; each opposite contains its own opposite).

"...the worst evils seem to come from those with good intentions" - nor is Dr No sure this is always a contradiction in terms. Hitler had the 'good intention' of building a strong state, a Thousand Year Reich, but his means contained elements that are about as evil as you can get.

The saying "The road to hell is paved with good intentions" also suggests that good intent can co-exist with bad outcomes.

Boots - your earlier last paragraph perfectly describes the dangers of converting what should be internal regulation into an externalised process. The candour of internal reflection and regulation mutates into a shallow and distorting two dimensional mirror in which even the fingers no longer point at the moon.

"The problem is that the devil is the prince of lies" - Screwtape, and after that Peck's People of the Lie. DN has long held the view that evil is the denial of truth.

PS All Dr No said was that he is not a Christian - he didn't say what he is.

"Christianity alone amongst the Abrahamic religions embodies the concept of original sin"

Well, we're not far off Dr No, Cristianity [not all branches as far as I am aware, am I right?] says everyone is born sinful already [original sin], while we believe we're born with a 'neutral self', but one that is ready to be influenced. Much like water for example, in that you can use water to doing good, as in watering plants to sustain life, or drowning those very plants thus killing life. Hence, self which in it's neutral state at birth has the inclination to turn towards both ways. Hence, it can be positively nortured by good upbringing for example, and the opposite is true. The reason why believing and returning to god throughout life is it's saviour, thus at the end of life the soul goes back to God 'Radyatan mardeya' or 'pleased and pleasing to The Lord', here is the relevant part from the Qur'an, but note that translation is never a true depiction of the original, which is mighty powerful:

(27) يَا أَيَّتُهَا النَّفْسُ الْمُطْمَئِنَّةُ(To the righteous soul will be said:) "O (thou) soul, in (complete) rest and satisfaction!
ارْجِعِي إِلَىٰ رَبِّكِ رَاضِيَةً مَّرْضِيَّةً (28) "Come back thou to thy Lord,- well pleased (thyself), and well-pleasing unto Him!
فَادْخُلِي فِي عِبَادِي (29) "Enter thou, then, among My devotees!
وَادْخُلِي جَنَّتِي (30) "Yea, enter thou My Heaven!

So, it's the same idea of 'saved' really, but said in a different way ... you'd be surprised how similar Ibrahim and all his children are! Did you know that Muslim believe that 'God is beautiful loves beauty' and that one much always endeavour to do good without waiting for any return but do it [to God's face], meaning, to affirm 'God's beauty' ... you think about this one :-)

"we can all do evil"

Yes, and this is where reisistance to temptation comes inor vigilance as you said.

"One does not need to be a Christian, or go along with the doctrine of original sin, to recognise that it perhaps contains within it a reflection of a universal truth. "

Fair enough, after all, as you see above, the same is in Islam too, and must be there in other religions, hence, yes, striving to do what's right is a universal truth.

"Dr No is also pretty sure a + and a - can coexist"

Well, science says not, proven. But then science is limited by it's necessity for wanting proof for evrything. Wisdom is way wider and is therefore more accepting. Anonymouse, as the name implies, is just a simple being, hence forever endeavours to simplify rather than complicates matters so that her simple brains can comprehend, the reason perhaps why she will stick to science on this one. Same goes for dark in light too. But, then again, forever inquisitive mouse would be grateful for a lesson on that bit, please ... because;

"Hitler had the 'good intention' of building a strong state, a Thousand Year Reich, but his means contained elements that are about as evil as you can get. "

!!@@ isn't it because the original plan was based on an 'evil' idea though [pure race and 'stuff', like dispose of the rest?], hence evil will result in evil, which then proves that good and evil can not co-exist?!

I should've removed this bit of the first line of that translation above as it is not in the original Arabic text;

(To the righteous soul will be said:)

The original text is speaking of 'soul', and did not put conditions such as 'righteous'.

It might at first sight appear as if this post and its comments have gone way off topic, but to Dr No it seems to have gone full circle. The OP was about the deprofessionalising and undesirable effects of external controls on professional behaviour, be those controls protocols, guidelines, contracts, targets, CQC tick-boxes, revalidation or any of the other goonery associated with the regulation industry. It fosters a culture in which individual professional responsibility is negated; instead, control is handed to those so called 'systems in place', which are invariably oh-so-robust etc etc. Yet here, it seems, in the comments, we are converging on certain certainties: that we can all be subject to temptation; and the best guard against that comes not from without, but within: which was Dr No;s point all along: internal, self regulation is the best regulation. External regulation should only be there for when that primary regulation fails (as if can, spectacularly). It should never be the primary regulation - for that doth make fools of us all.

Don't even think about getting me started on banking regulation - what we lost when Hacksaw got her way!

Dear Dr Phil

Not only a devil in many disguises, but it seems you are right about 'self' ordering you to do bad too, hence you have to resist self as well.

I had to refer to an Islamic book and you were right on this one, and I was wrong

Told you, Ibrahim's children are very similar!

Sorry Dr No, but I thought I owed it to Dr Phil, my mistake!

Good day:-)

Dear Sam,

I suspect that most faiths have common theology; Karen Armstrong's "History of God" shows how many ideas are common between Judaism, Islam and Christianity. I think she is a little unfair on Protestantism, but she is a former catholic nun so a Catholic Athiest! We cannot escape our roots entirely.

There are problems with only having internal controls on behaviour; banking being a pertiinent one at present. Getting the balance right between self regulation and enforced external regulation is difficult for doctors and bankers, and many spheres of life. The key is to make the external regulation effective. Recent history shows how easy it is to circumvent regulation in banking and tax accountancy. I think that the key is for the regulators to have the support of the vast majority of the regulated; I am not at all convinced that this is the case for revalidation.

Mouse has loved ones who live in a far away burrow that's not so peaceful at the moment. So mouse here just wanted to be a bit more free when out of her own 'place'

Ah, forgot to tell you, mouse used to be a cat! Of course cat has no idea who visits or what can be the result of her meaowing on far away burrows. But there you go, that's what 'love', and uncertainty, even fear, does to cats; it turns them into MICE!

But you had to ...

As for my previous post, I just wanted to illustrate how it feels like when you have your name framed in such a negative way you did mine @ your 6.15am. Even though I was just trying to be friendly in my post prior to that. It throws you off balance when things like that happen, doesn't it? Just as I was to the point that a most fundemental part of what I believe in just went out of the window, totally obscured - that bit about that 'self'! The same medicine obviously had the same effect on you too, although I shouldn't have succumbed to the temptation really. But that's always the effect of the [-], doesn't it doctor? Perhaps a lesson for us both?

I like [+] and hope you join me, if you wish

The regulation industry is well and truly over-heated these days: external, 'independent' regulation, it is said, is the clear and obvious answer to excess and incompetence, be it in the media, the banks, the professions, even amongst politicians.

But it has many problems. It tends to mistake the finger pointing at the moon for the moon, and those caught in its endeavour are doomed, like Sisyphus, never to get on top of their task. Far better, Dr No suggests, to return instead to primary regulation being internal. Sure there are notable exceptions, the Police and the Catholic Church being well known examples, but forty years ago many walks of life were internally regulated. Even the City, before Hacksaw came along and carved everything up, had its own internal code of conduct: dictum meum pactum - my word is my bond - so much so that the London Stock Exchange adopted it as their motto.

Once Hacksaw told us there is no such thing as society (yes, DN knows this quote is usually quoted out of context - but look at what the woman did!), and let the greed cat out of the bag, 'dictum meum pactum' became a hollow joke, the laughable motto of a few anachronistic old fogeys; and, crucially, the culture shifted, to one where anything goes, as long as you can get away with it (and even, as we have seen, when you can't - which is another reason why external, as opposed to internal, regulation is such a poor cousin: the regulator's jaws are rarely near enough let alone sharp enough in the face of temptation).

So what Dr No proposes is a shift back towards a culture of internal regulation - people do what is right because that is what they do - as the primary regulator; with external regulation the secondary but very necessary back-stop for when primary internal regulation fails - as it always will from time to time. Culture shifts that reduce bad behaviour can and do happen. Drink-driving is perhaps one of the best known examples: what was commonplace thirty or forty years ago is now rare (but not extinguished, so we still need the external criminal justice back-stop), not so much because of that back-stop, as the fact that today drink-driving is culturally unacceptable. It is not 'the done thing'. Similar, but so far perhaps less successful and pervasive, changes have happened in race relations.

Anonymouse - DN doesn't suppose Boots intentionally framed your name (e* - dear Sam - e*), despite the inescapable order of the words. Instead, he would just observe that, in broad brush terms, people divide into those who can contemplate that short four letter word, however much they may despise it, and those who cannot/will not even cast their eyes on it. Indeed, Dr No has in his own life lost contact with individuals for whom the word was just too horrible, too unpalatable, to unspeakable, to bear mention. But such approaches worry Dr No, partly because he believes it does exist (and as the saying goes, first know thine enemy) and partly because denying its existence seems to Dr No to risk denying the truth of the reality of the awful and dreadful harm done by it, and so the experience of those who have been so awfully and dreadfully harmed. Denying evil risks - in Dr No's view - denying the full reality of, for example, industrial genocide. The alternative response often proposed - something along the lines of all will be well in the best of all possible worlds - somehow doesn't quite cut the mustard in the grim face of truly horrific reality.

For those who can, despite its abhorrence, contemplate the nature of evil, in the hope of doing something about it, there is an interesting (if that is the right word) book by Scott Peck (he of The Road Less Travelled) called People Of The Lie. It is written from a openly Christian standpoint, but notwithstanding its declared bias, it is a thoughtful and thought-provoking (and, for many, difficult - you have been warned) read. It was after reading it that Dr No adopted (from the book, indeed it is in the title) his working definition of evil: that it is the denial of truth.

Boots - on a mundane after the above admin note - have deleted your duplicate comment - hope that is OK.

"DN doesn't suppose Boots intentionally framed your name (e* - dear Sam - e*), despite the inescapable order of the words."

There is been numerous times of similar but not as hard things before though. Despite that, every time I tried with Dr 'Phil', many times. This is because we used to be friends 'before' or I would've given up, but I hold a lot of respect for him, and he knows that. I have learned a lot from him too, and on many occasions he did make an effort to teach me. He is very erudite as you know, and he's not a boot filler at all, quite the opposite. Maybe the reason he's disappointed that I no longer oppose reform or competition, but that's because my whole life has been competition, and hence that life has taught me to be practical, to accept that things will always evolve and to deal with that how and when it comes. Everything comes with opportunity, I firmly believe that, but I am sad today.

All the best

"Boots - on a mundane after the above admin note - have deleted your duplicate comment - hope that is OK. "

You mean the 'identical'one he posted 21 minutes after the his post of 03 Jul 2012 @ 5:34pm?! I've since been wondering, how did he do that?!

You are right Dr No, I should face up to evil, revalidation is the answer!

:-(

Dear Dr No and Anonymouse;

I am not sure how or what I did to manage a duplicate posting. I suspect that It was a draft that I was part editing, no intention to insult anyone. I have been my own foil in demonstrating how the road to hell is paved with good intentions.

I think that posting from my smartphone while suffering insomnia was in part the cause. Somehow I must have posted the draft. Religion is such a personal thing that it is hard to discuss without causing offence. It is rare for me to get drawn into discussing via this moniker; and I shall resist temptation a little harder next time. Please accept my apologies.

I am not anti revalidation per se, like other spheres of life self regulation does occasionally fail. I do not like the system that is proposed and shall have a think about how I would do it were I to be in charge.

Boots

... now that you explain.

But it was that 'framed' comment that got me, and in turn got everything that followed to go wrong. There's been a few little things before, but since you explain, and as a fellow insomniac, who very much cherishes the moony condition, then no hard feelings Dr Phil.

As for discussing religion, I'm actually very much for more of that, with respect for the sake of a proper and fruitful dialogue. It's how people can then understand and find the similarities, which are the majority, rather than concentrate on the little differences as those are the reason for friction, and the bad sentiment that follows which in turn can and does lead to all sorts of ills, and causing all sorts of hurt.

... and I still believe real 'good' intentions can not lead to anything but 'good' ...

... and please excuse what my kids call the 'one child syndrome' tantrum .... but there you are, no Mrs perfect here! ... but now that we know each other a bit better, and have insomnia to share, you never know, we may even end up being friends! .... if you want to of course ... then I'll spare you the occasional tantrum, if you spare me the occasional twist!

:-)

Definitely a difficult problem. It's ridiculous the regulations that hold doctors back. It's kind of like the regulation that infant car seat covers have to endure because of the red tape.

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