Goodbye NHS – we miss you now you’re gone

Would I lose my job to save the NHS? Yes, in a heartbeat. In a fraction of a heartbeat. Even in this shitty economy with the shitty attacks on the unemployed. If that was all it took to save the NHS I would be typing my notice now.

Would I lose my job in a futile gesture of distress that will be ignored by a minority government with no mandate for what they are doing? Well, no. And it is eating me up. Which is why I am typing this at half past four in the morning.

Today the NHS is 65 years old.

Earlier this year the Tory government and their Lib Dem partners killed it.

In April, the coalition government passed legislation which means that NHS service provision must be put out to tender and so hefty percentage of every pound spent on healthcare in this country must go into the pockets of the likes of Richard Branson and the MPs with financial interests in UK healthcare companies. They were kids voting for Christmas. They passed this legislation despite the fact it was not in their manifesto and they have no mandate to do so. The media were silent while they did it; the good guys found the story too complicated to tell, the frightened guys were silent because they were cowed by the Leveson inquiry, and the venal guys were lined up side by side with the MPs and their friends in the healthcare companies.

The NHS was imperfect, especially after so many years being undermined by New Labour. But it is no where near as imperfect as the smear stories masquerading as news items these last five years would have you believe. The smear stories are propaganda designed to let us assume that it’s not worth saving.

The thing is, if you ask the question “what do we do about the NHS?” the answer must not be “sell it off to the lowest bidder”. We are already seeing that profit-taking companies fail to provide an improved service, that they actually provide worse services, and that they force people who work in the most emotionally demanding jobs in the world to work in perpetual crisis mode. This is not only bleeding patients for profit, it is bullying staff for profit too.

Today those who care to fight for free healthcare for all are marching for the NHS. But I can’t be with them because I have a presentation to give on Monday, and I lost three days this week to migraine, and I am not prepared to lose my job in a futile gesture.

I’ve marched three times in recent years, each time against the Labour government, once for peace, and twice to protest their ignorant destruction of rural life. I did not feel as hopeless then as I do now. But what I learned is that a government driven by dogma will ignore a million peaceful people in the streets. And revolutions since the start of time show that raging mobs produce governments no better than the ones they overthrow.

Democracy is broken. I don’t know if it ever really worked but here it is broken. MPs milk the system for expenses and sell their votes and influence to whoever will pay them. The whores I’ve known have all been infinitely more honest.

What frightens me is that there is no place in the world and no time in the world that I can think of where freedom has been sustained. I think of all those acts of British rebellion from Wat Tyler, to the Levellers, to the Luddites, to the Rebakkah Rioters, to the Jarrow Marchers, to the General Strike of 1929, to the Miners in the 1980s, to the million of us who marched for peace in 2001, and know that all the government have to do is say “la la la, we can’t hear you”. The only way to overturn an established order, it seems, is over their dead bodies, and that’s no solution.

I have come to suspect that the stirling example and unprecedented experiment in justice and social democracy of Europe in the last 65 years was only possible after the shock of a world war, and a war in which fascism was defeated by the collective actions of coalition governments. By, in fact, the will of the people.

The late 1940s were, I suspect, the only moment in history when the NHS could be established, when enough people were used to acting in consort for the greater good of their fellow men and women. At every time before and since we have been fractured into little silos of selfishness and self-interest.

And today I will go to work to keep my job, because I no longer believe that peaceful protest works. And when the election comes round, I shall cast my vote because, like a beleaguered spouse, I keep faith with democracy though I no longer trust it.

And now I shall take some triptanes (which cost me nothing) and some asprin (which cost me 35p) and go back to bed because crying gives me migraines, and migraines are the reason I can’t go to London in the first place.

PS – apologies for spelling mistakes and typos.  This piece is posted as written, which is something I never do these days.

Treating the parts that real medicines cannot treat – a place for placebos

As a skeptic I have a shameful confession to make: I once had an imaginary condition miraculously cured by a placebo treatment.

Some conditions have symptons but not signs. Symptoms are felt and reported by patients, signs can be detected using some form of test. Headache and nausea are symptoms of migraine, vomiting and pallor are signs.

About 10 years ago I went through some high-stakes changes and made a career-move which required full-on keyboard use.  But I developed Repetitive Strain Injury which affected my hands to the extent that I experienced pain up to my shoulders.  Lawyers have a field day with RSI, because some repetitive strain injuries such as Carpel Tunnel Syndrome have signs, but others are just painful with no measurable physical changes. The long and the short of my story is that I bought a wrist magnet and strapped it on my right arm. Within half an hour my right arm was considerably less painful than my left and over the next few days the pains disappeared completely. I was able to take up my new job with no problem at all.  A miracle cure! For a condition my doctor had been powerless to treat! Woo hoo!

Doctors are often exasperated by patients who turn up with functional conditions (ie ones which have symptoms but not signs) because there is nothing concrete to treat and no objective way to measure outcomes. In the worst case, they consider the patient to be a malingerer and even in good cases trust between paient and doctor break down and create a space for kindly Alternative Medical practitioners to step into. Functional conditions are for Alt Med of course because the intervention needed isn’t medical. It’s in the realm that Terry Pratchett’s Granny Weatherwax calls “headology”. The wrist magnet really did cure my RSI.  It worked, not because it improved the flow of fluids in my body, but because I thought it improved the flow of fluids in my body.

Placebos are a side-effect free way to treat conditions which can’t be treated using evidence-based medicine. Let’s be clear here: these conditions are honestly experienced by people of integrity. Just because their minds and bodies are lying to them, doesn’t mean they are lying to the doctors. But there are no symptoms that can be measured and treated so the medical model and the patients’ experience simply don’t overlap. This creates a gap in the market which alt med happily and sometimes effectively fills. But not all alt med is innocent and all of it is expensive and based on false models and premises. We need medical science to admit there is something going on here that needs treating, rather than dismissing functional conditions as hysterical, imaginary or psychosomatic.

Unfortunately, medics who accept that placebos may indeed be appropriate for these conditions cannot bridge gap by prescribing them, even if they will work where “real” treatments fail. Doctors consider it unethical to lie to patients, and I think most patients would agree with them. So at the moment there is indeed a place for alt med in providing these interventions.  Alt Med has no place in treating pathological conditions of course (ie “real” ones): flower drops and sugar pills cannot treat cancer, and magnetic bracelets can’t cure Carpel Tunnel Syndrome.

Is the NHS modernist or post-modernist?

Someone came here the other day using the following search term: is the nhs modernist or post-modernist. I’ve not blogged on the subject but it’s a peach of a question, so I’ll bite.

One of my dirty little secrets is that I don’t really know what modernism and postmodernism are.  I don’t feel bad about this because the definitions are so slippery: Wikipedia (yes, I know…) says this about them:

Modernism: … affirms the power of human beings to create, improve, and reshape their environment, with the aid of practical experimentation, scientific knowledge or technology. (My emphasis).

Post-modernism: is a tendency in contemporary culture characterized by the rejection of objective truth … It emphasizes the role of language, power relations, and motivations; the term “post-modernism” comes from its rejection of the “modern” scientific mentality developed during the Enlightenment. (My emphasis).

So I’ll take ‘modernism’ to mean ‘empirical science’ in this context, and plough on with the question.

The brief answer, of course, is that the NHS should be both. The scientific method is the best way to find out the truth about the physical universe (how drugs interact with the body); but hard science can’t cast much light on how people interact with each other individually or within organisations. So Western medical practice, which is delivered by complex organisations including the NHS, is a battle-ground for these two philosophies. In fact the history of the NHS over the past 20 years has been a matter of eroding the power of the clinicians and handing it over to the administrators. Whether this has gone too far or not far enough depends on who you listen to.

Empiricism lacks the nuances you need to explain how people and organisations behave, but post-modernism’s not the answer either: it  can and frequently does go feral. Post-modernism holds that all ideas are made up; indeed extreme relativists claim to believe that there is no underlying and testable truth in the physical universe and that scientific laws like the law of gravity are “social constructs”.  From this you get the kind of post-modernism which is mad, bad and dangerous to know, for example the idea that using the scientific method to uncover truths about the physical world is an act of oppression “because other methods are equally valid”.  Um. No they’re not.

You’d think this was ludicrous but Ben Goldacre and David Colquhoun have both commented at length on an article which has the following in its abstract:

[Our objective is] …  showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm … [and] showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure.

Goldacre and Colquhoun rightly say that this would be laughable if it weren’t dangerous: medical practice strives to be evidence-based, and so it damn well should be. I want my treatments tried, tested and effective, and only a “scientific research paradigm” will do that.

However, the paper’s authors have a point, badly put though it may be: advocates of the scientific method are indeed snotty about other forms of knowledge.

Let me tell you about my friend Sarah.

Sarah’s widowed mother was dying and the doctors looking after her concluded that any attempt to resuscitate her would be needlessly cruel. The Registrar had just raised the topic of the DNR order with Sarah and her much younger sister when he was bleeped away to another part of the hospital. So the women took the heart-breaking decision themselves.

When I told a Senior House Officer about this he said “but they didn’t take that decision – the Med Reg took it”.

Viewed through rational, modernist glasses, my SHO pal is right: the choice was not theirs to make and therefore they made no choice. But even so, they experienced making it as surely as if the casting vote had truly been theirs. We need the NHS to bridge both perspectives. It seems that patients’ families will complain more about badly delivered care which produces good results than about a team who are kind but made mistakes.

The clinical aspects of the NHS should deliver empirical pills sweetened with subjectivist sugar. If they don’t, medical care seems hurried, emotionally brutal and harsh, and the patient can feel like an item on a conveyor belt, a statistic or an inconvenience. Many of these patients then seek and obtain kindlier treatment among the alternative practitioners. You see, practices like homoeopathy and acupuncture are what happens when therapies operate in a world where anyone’s ideas about what constitute medicine,  evidence and even illness and good-health are as good as everyone else’s.  There is no valid evidence-base, and treatments are chosen intuitively or anecdotally. However, the practitioners provide a service which is not available on the NHS: they sit and listen sympathetically for 40 minutes to the emotional needs of their patients. The emotional landscape is seen as the very fabric of the condition and is the starting point for holistic treatments. They are, quite literally, post-modernism in Practice.

However, those managing the trusts, hospitals and practices that comprise the NHS, should take the opposite approach. We need them to respect the needs and experiences of the different groups they deal with, but they should stiffen this touchy-feely stuff with policies and decision-making based on as much statistical evidence as they can get hold of.  And heaven knows, the NHS can provide huge data-sets.  In fairness I should say that I’m thoroughly impressed by the pragmatic intelligence of the NHS managers I have met, and rather them than me.

Is the NHS modernist or post-modernist? It’s too big an organisation for a single answer.

Which probably makes it post-modernist.

Damn.

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If you’ve the time during your coffee break, then read more Ben Goldacre and David Colquhoun.

Alan Sokal is spectacularly good on just how sloppy post-modernist thinking can be.

And here are a couple of other good links while we are on the subject of alternative therapies and the scientific method:

• Simon Singh’s reflections on his recent libel case
• The Skeptics, the Chiropractics and the Quacklash

Murphy’s Law and the NHS Spine

I am very conflicted about the NHS spine.  This is (will be) the computer system whereby all patient records are stored in a single system and available to any appropriate NHS worker in the UK.

As a cynical IT professional, I laugh in the face of quotes like this:

The NHS Care Records Service uses the strongest national and international security measures available for storing and handling your information.

Ha ha!  I chortle. Tee hee.

I am sure they do use the strongest etc, etc.  But let’s face it, it’s going to leak like a sieve. Health service staff are not particularly IT savvy. There’s professionalism and an awareness of patient confidentiality on the one hand, and there’s keeping your notes on a USB stick and having your handbag nicked on the other.  There’s IT policy mentioned in your induction day, and there’s using someone else’s log on because yours isn’t yet activated and the patient’s going to die (or the Daily Mail will dance with glee) if you make the wrong decision in the next 3 minutes.

One Nation under CCTV – Banksy, photograph by unusualimage

But a far greater worry is the scope creep that surrounds any government technology. Of course they shouldn’t use our medical records to vet public sector job applications.  Of course they shouldn’t create an MRB check like a CRB check to ensure that people with – I dunno – chronic mental illness don’t get jobs as clowns (all that working with children and animals…)  Of course they shouldn’t let the anti-terrorist bunch trawl through to find whatever it is they look for these days.  Of course they shouldn’t. And of course they will.

So Ha ha! I say again.

But…

A lack of joined-up medical record-keeping kills.  I don’t have the stats, I don’t even know what audited stats exist, but hospital medics of my acquaintance assure me that a lack of vital and timely medical histories is a killer. And you only have to talk to anyone with a chronic condition to glimpse the exhausting grimness of having to explain their history to whoever it is they’ve landed in front of this time.

So… do I allow this privileged position to ease me out of the data danger zone? I am relatively healthy and check No, No, No, No on life insurance forms. Not being on the database won’t kill me. If I turn up in A&E what they see is what they have to deal with because there’s nothing nasty in my medical history.  And I am very well aware of how hard security is to achieve (I’m an IT worker in the financial sector). And I am old enough and cynical enough to know that if great big databases are there, they will be used by self-serving governments. Do I opt out at no risk to myself because Big Data is Evil and Should Not Be Encouraged?

Or should I support the health service’s laudable attempt to save lives not to mention reducing wear and tear on the patients’ patience, even though that will only encourage Big Government?  It’s a nice gesture, and with my nice clean bill of health when the CID looking for a sex killer search through the database for local nutters prescribed nonutterherein there is minimal risk to precious me.

What would Pastor Neimueller do?

What would he wish he had done?

I find this a tough ethical call.

Soft is hard

One of the things that annoys me about the industry I work in is how much it undervalues what it persists in calling “soft” skills. Tech skills are the hard skills which command respect. Don’t get me wrong. I love geeks, in fact I find geekiness really sexy. I like it when a guy’s skillset is really hard. But before we tumble too far down the road of pornuendo, I want to wave a flag for soft skills.

(Incidentally, it’s not just my industry: surgeons are godlike if they do good scalpel but their bedside manner is considered irrelevant because you can’t quantify it, despite the rather obvious thought that the placebo effect is a neat way to improve a post-op complication rate and that there is a direct relationship between faith in the practitioner and the power of the placebo).

Now I have pretty good soft skills. Give me a bunch of folks and half a day and I can get just about any form of coherent analysis out of them you’d care to mention – be that a plan, a process, a set of requirements, a list of deliverables, a taxonomy. You name it, all we need are post-it notes, marker pens and caffeine and carbs, and we’ll end the day tired, happy and in agreement. I’m not bad at training sessions, though it’s not really my thang. I can plan a series of activities to take a group of people through the acceptance cycle when we are imposing change on them. I know a reasonable amount about NLP and how to use it appropriately in business situations. I spent more of my life than I care to remember selling, which is the ultimate test of soft-skills in action.

The problem is that soft skills are hard. They are hard for a lot of reasons. They are hard partly because soft processes are only logical in hindsight. You can look back at a soft process – the process used to manage a series of changes to the way that people work, for example – and think it was all pretty obvious. But try to design it… ah that’s another thing.

There are very few “how-to” guides to soft skills. I think I’ve found two on requirements analysis in all of the IT bookshops I have ever been to. There’s a lot of literature about training skills and some about introducing change to people, but a lot of it is either off-puttingly pretentious (“Soft Systems Methodology” – I mean, wtf?) nauseatingly cute (“The one-minute cheese-monger”) or theoretical but not practical (“The Tipping Point”).

The other challenge is that soft skills are implicit skills; they are hidden, obscure, almost invisible. This doesn’t make them easy but it does mean they are undervalued. The people with the best soft skills don’t make it look easy. Oh no. When you are with people with really good soft skills, you don’t notice that anything is happening at all. On the other hand when change is introduced badly, it is obvious for all to see. The best and most recent example I can think of from this blog is the MTAS debacle where change was imposed on the victims with no attempt to get them to actually want the change. MTAS could have been a success; the system it replaced was broke enough to be worth fixing. MTAS needed better technical implementation for sure, but those affected could have been brought at least to a state of neutral acceptance of the concepts behind it, and maybe even trust and support, if had been handled right.

Soft skills are subjective skills, when using soft skills you need be aware of context and to exercise judgement. You need imagination. You have to be willing to walk in someone else’s shoes. They involve taking risks and making yourself vulnerable. When you are exercising soft skills, you have to be willing not to know. This subjectivity makes them difficult to turn into a system or a methodology.

With soft skills there’s no right or wrong answer, there is better and worse, more useful and less useful, but no right and wrong.

That’s not easy.

In fact, it’s hard.

Doctors’ Arrests

It is hard to know what to make of the recent arrests of the Indian and Iraqi doctors.

The foreign press in particular express some surprise that the presumed terrorists are neither ignorant nor uneducated and this is briefly echoed in some of the UK reporting. We should remember though that Mohammad Sidique Khan was neither ignorant nor uneducated. He seemed to be the epitome of a well integrated, westernised muslim right up until the point where he set off the Edgeware Road bomb on 7/7.

But this is more middle class, closer to home. What is so hard to assimilate is that these are doctors working for the NHS. They are proximate: as with the McCanns, as with Christopher Janaway and Matthew O’Donnell who were killed on the M25 in May, there’s only a degree or so of separation. They are trained as scientists; they should not be influenced by ignorant, rabble-rousing muslim clerics. Most confusingly of all, these are men dedicated to saving lives, not taking them. While I find it comprehensible that someone should feel sufficiently powerless, threatened and angry to commit indiscriminate acts of terrorism (or “resistance” as it was termed in war-time France) I find it almost impossible to comprehend that doctors should do that.

It seems that I am not alone. The Telegraph is running a predictable leader entitled “Muslims must raise their voices in anger“. Well yes. But why aren’t they running one entitled “Doctors must raise their voices in anger”?

The GMC, the BMA and Remedy are noticeably silent on the subject. So are all of the medical blogs that I’ve read recently. This is presumably because it is just too alien to understand. It is unsettling and challenging that people we are used to trusting could do this, and I suspect that the Medical community simply cannot comprehend that one of their own, eight of their own, could do such a thing.

This leaves me with so many questions about assumptions, prejudice and denial that I don’t know where to start.

What makes a good doctor, anyway?

It seems to me that the debate to take to the public is the one about Modernising Medical Careers. The public really are not interested in the kafkaesque unfairness of MTAS, and there is no reason why they should be.

As a patient* I don’t really care how badly junior doctors have been treated, but I do care how well, or badly I am treated. What I want from the medical profession is:

Doctors who are

1. Good diagnosticians
2. Competent and selecting and administering treatment
3. Able to communicate clearly and appropriately what is going on
4. Good at administration and able to steer you and your notes through the labyrinth effectively

I would certainly want my doctors to be ethically sophisticated and good at working with other professional carers. I’ve no idea how representative my views are of other patients.

It seems as if the medical profession itself is not united on what comprises a good doctor, and this has left a vacuum which the government have opportunistically exploited. Research and academic qualifications used to count – but were they being used to separate excellent Registrars from other excellent Registrars? In other words, was the increasing academisation of the middle level of the profession a symptom of the triangular structure with too many Registrars competing for very few Consultants’ posts? Don’t get me wrong. Research is a vital part of the profession, but is it being done in the right place and for the right reasons? Does being able to do research make you a better surgeon, because what patients want and deserve are good Consultants, not good academics.

Forgive me for saying this, but the architects of MTAS tried to use “frozen” interview questions to elicit information about the stuff that doesn’t show up in CVs, such as approach to communications, ways of interacting with other team-members, ethical stance. They f**ked it up, big time, but they did address the things which – simplistically – patients want their doctors to have.

The questions to put to the public are:

1. Do you want to be treated by Consultants who have approximately 60% less experience than previously (shorter hours, fewer years)?
2. Do you think that the service you get from the NHS will be improved or made worse by making 25% of junior doctors and specialist trainees redundant? (If only they were being given redundancy packages….)
3. Do you think a Consultant will be better or worse if their experience of medicine outside their own speciality has been reduced from half a dozen years to two?

Tabloid questions, yes. But this is what will outrage patients, not the complexities of the MTAS computer system.

However, in order to shape this debate, the medical profession must consider the profession, both in terms of individual career options and in the more philosophical terms of “what is a good doctor” and “what do we want from the profession as a whole”. Specifically, the profession must consider:

1. What qualities, skills and experiences are required in a good doctor, and how to assess them
2. How to change the structure of the profession so that it is not limited to two tracks: pre-Consultancy and the rest
   and
3. How to make successful, interesting and rewarding careers available within the profession without becoming a Consultant and without being sidelined and degraded

Just a thought before I post this: I am older than the MD of the company I work for and much the same age as most of his board. Yes, he is paid two orders of magnitude more than I am, but I love what I do on a day to day basis, my contribution is appreciated and valued by my peers and stakeholders (jargon – sorry), I have good career prospects, the assessment and promotion system is transparent and reasonably fair, and if I want to move around within my profession it is up to me do to it and the entry points are there. This is possible, because career progression isn’t based on the model of a railway track or a ladder, it is much more flexible than that.

I’m keen to hear the views of those not directly involved, those from other countries, and those who are patients or work elsewhere in the NHS. Also, I am curious to know if what I am saying makes sense, or if I’ve missed some fundamental points, so please feel free to comment.

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* I do of course care personally about MTAS and its effect – (as Mums4Medics puts it) – on ‘my’ doctor’s career

Abortions, sex changes, genetic defects

I offer you two thoughts from two different sites.

First – 21st century data in the UK: “A patient will not be entitled to refuse to make their personal data available to the [NHS] Spine [data systems]. Data about all patient events may be routinely communicated to the Spine without the consent of the patient. … The citizen has no legal right to stipulate what will and will not be recorded … nor where those records will be held.”

And secondly – 20th century data in Germany: “Only after Jews were identified — a massive and complex task that Hitler wanted done immediately — could they be targeted for efficient asset confiscation, ghettoization, deportation, enslaved labor, and, ultimately, annihilation. It was a cross-tabulation and organizational challenge so monumental, it called for a computer. Of course, in the 1930s no computer existed. But … punch card technology did exist. … [and] Hitler was able to automate his persecution of the Jews … from the identification of the Jews in censuses, registrations, and ancestral tracing programs to the running of railroads and organizing of concentration camp slave labor.”

The problem of course is not with data, per se. NHS staff are a pretty benign bunch. The problem comes when people with strong convictions have relatively friction-free access to data, and it is compounded when data becomes more enduring.

In this world of increasing fundamentalism, I am not comfortable that the health service can record abortions, gender re-assignments, genetic abnormalities, and other politically, socially or financially sensitive information, that they can record it in ways that mean that the data is pervasive and enduring, and that they can record it against our will.