Stats tart

Recently one of my MTAS posts has been topping my stats chart. It turns out that it is being sought out by scat-seekers because I had illustrated it with a stolen picture of a turd. Who’d have thought if you put “poop” into Google Images you’d get a link to a post giving my opinions of Ms Hewitt.

Satisfying though it is, I’ve renamed the picture “MTAS” and hopefully the scat-seekers will eventually go away. It pleases me to think that some may do what I did, nick the picture and use it elsewhere, and that eventually a search for “MTAS” will produce a picture of a heap of shit.

An anatomy of anger

Maybe I’ve just been lucky or maybe I’ve been unobservant, but I didn’t know that there were so many ways to feel anger.

I knew that there were many ways to feel happy; there’s the backwash of an endorphin rush generated by laughing for ages with friends about something very silly indeed; there is the animal feeling of well-being which comes from just enough of the right sort of exercise; there is the whooping feeling of joy when something longed-for actually happens, like good exam results. There is the feeling of emotions easing and relaxing when you spend a really enjoyable time doing nothing in the sunshine.

What I hadn’t known is that there are many ways to feel anger.

• There was the feeling of incoherent shock and stomach-sinking horror when Channel 4 revealed the MTAS security breaches which left me breathless and speechless
• There was the sharp feeling of brittle rage at the thought that those responsible for MTAS might destroy the project documentation to hide their accountability and incompetence.
• There has been the ongoing dull ache of anger that Blair and Hewitt were immovably in power, which has been superseded by a persistent feeling of uneasiness about who and what will replace them.
• There has been the sense of joint-aching frustration at the arrogance, disrespect and inhumanity of forcing doctors and their families to up-sticks and move to places they have no desire to be; separating partners, families and generations.
• There have been the sick waves of helpless horror at the administrative cruelties of people who made offers to the most vulnerable individuals – those who will never be permitted to apply for specialist training again – and then withdrawn them with no more than a curt explanation which has been no explanation at all.
• There has been the crawling distaste and visceral withdrawal from the bland complacency shown by the seniors who were happy to hang the whole world out to dry, juniors, patients, health service and all so long as they didn’t lose their chance of rimming Hewitt and Blair in exchanges for political favour.
• There was the pure blast of ice-burning rage at when Hewitt demanded – and got – costs

I had no idea there were so many ways to feel anger, but I guess the thesaurus should have warned me:

In the last six months? All of the above.

You can take the Health Secretary out of Andersens…

You can take the Health Secretary out of Andersens, but you can’t take Andersens out of the Health Secretary.

From the Guardian:

Mr Straw denied reports that officials shredded documents on the troubled NHS IT programme to stop them becoming public.

Mr Heath protested at “the decision of the Office of Government Commerce to destroy the gateway review documents on the cost of ID cards and other misdirected and mismanaged IT schemes”.

Mr Straw said: “My understanding is that these gateway reviews have not been destroyed.”

He said the Freedom of Information Act provided for a “whole series of exemptions” allowing the release of documents to be refused to “ensure the proper functioning of government”.

(If my sarcasm assumes too much prior knowledge, forgive me. Ms Hewitt used to be Research Director for Accenture, the consulting firm spawned by Arther Andersens. Andersens is most famous for shredding tonnes of evidence when one of their largest clients, Enron, collapsed taking Andersens down with them.)

MMC and MTAS – a direct appeal to Junior Doctors

This is a direct plea to junior doctors to hang on to their stethoscopes for at least another 6 months. These are the reasons why I really think it is worth it to hang on in there while the dust settles.

1. MTAS won’t be used next year – recruitment will be done locally
   • It cannot be fixed in time. I it would have to be up and working by October and 5 months simply isn’t long enough.
   • The next Secretary of State is NOT going to put their reputation on the line to try to save Patsy’s. They’ll ditch MTAS as fast as they can say “oh god, not health”.
2. MMC will be changed
   • I believe that those who don’t get a number this time, even at S3 level, will be given a second chance. How gutted would you be to leave now and then find you could have got a number if you’d stayed?
   • I cannot second-guess the outcome of the Tooke Review in the way I can second guess the canning of MTAS, but it is clear that MMC won’t remain the same.
3. You can leave but you can’t come back
   • If you wanted to become a Lawyer or work in the City you wouldn’t have spent the last 7, 10, 12, 15 years of your life working at becoming and being the best doctor you can be. Do you really want to give it up? Hang on in there for 6 or 12 months and stay current.
4. The grass isn’t necessarily greener
   • Face it, there aren’t 8,000 vacancies in the City or the Legal profession. I’ll admit that’s an argument for leaving sooner. But how shitty would it be to abandon a profession you love and are good at and end up being a grockle in another profession because the market just got flooded with doctors?
5. We still need doctors, and the locum rates will be pretty good while the dust settles
   • Face it, in the short term you will be able to get work. Intermittent, unreliable, below your level, in unfamiliar hospitals maybe. But you’ll be able to pay your mortgage and keep current while the dust settles.
6. You don’t know what the future will be like till you get there
   • Many years ago I was facing a future of divorce, personal bankruptcy, loss of my house and the loss of my business. Just contemplating it made me hyperventilate, set off a bout of hysterical screaming tears and gave me panic attacks. I – quite literally – could not think about that future. When I got there I didn’t go bankrupt but everything else I described did happen. None of it was as bad as I expected, and some of it was actually rather fun. I enjoy my life now, and am hugely happier and more settled than I was in the years leading up to that time. The point that I am making is that just now this seems like the end of the world. But in fact it is just a spectacularly unpleasant and traumatic episode in what will be a long and healthy life. When you are looking back on this, you will always think of it as a horrible time of enormous stress and uncertainty. But you will also realise that it was just a turning point, and that the rest of your life is the rest of your life.
7. If you can get a job in Australia, New Zealand or Canada go for it.
   • To be honest I’d give my eye teeth to be under 30 and going to live in any of those countries. They are great places to live and raise kids, and you would keep your options open.
     
     
8. If you hang on in there, you can still be a medic. If you leave now, you never will be again.

MMC – made simple

Here’s a simple, straight-forward and dignified explanation of MMC which I only just came across today:

It isn’t the StarWars tribute; it covers a much wider spread than that and it deserves a wider audience.

Vindictive Fucking Bitch

The Vindictive Fucking Bitch has demanded costs.

From the email update on the Judicial Review from Mums4Medics:

What leaves a particularly nasty taste in the mouth is that the lawyers for the Secretary of State have applied for costs against Remedy, and have made it clear that Ms Hewitt was directly involved in that decision. The judge was very unhappy about this, and suggested in the strongest possible terms that Counsel for the Secretary of State might like to ask his client to reconsider. Counsel indicated that reconsideration was not an option. Reluctantly, the judge awarded costs. To quote the immortal words of Francis Urquart, ‘You might call such an act vindictive, but I couldn’t possibly comment.’

I am so shocked by the bitch’s vindictiveness that I am sending Remedy another donation today – money well spent if you ask me. Click here if you wish to do the same.

PS – the expletives here are all my own unaided work. Mums4Medics are much wiser and politer than I am; only the words in the blue are theirs.

PPS – at least Remedy got under her skin; a thought which gives me a warm glow of satisfaction every time I think it.

Ain’t got no algorithm, baby

Just when I think I’ve got my head around the MTAS debacle, yet another thing happens which takes my breath away.

This, from Remedy’s website, reporting on the Judicial Review of MTAS:

Mr Greenfield states “The decision not to proceed with MTAS for matching candidates to training posts was taken as a result of recent security difficulties and the fact that the Defendant could not be certain that the algorithm necessary to operate the ‘single offer system’ would be effective.“

That statement, right there, is worth the cash I put in their fighting fund.

That’s me, breathless again.

What can you say?

What can you fucking say?

MTAS – The silent “SH” in Department of Health IT

Five out of eight reasons why IT projects fail come down to the the project team failing to understand how the system will be used or what it it should do – MTAS ran depressingly true to form.

I found an MTAS Milestones document on the web some time ago and didn’t know what to make of it. I still don’t. However, MTAS is now officially dead, so I’m going to critique it here before it disappears forever.

The document is a one-page timescale for the MTAS IT Project including the engagement of sub-contractors. There is much here that I am not qualified to comment on, but even so there are a few points that I find interesting.

One month (Oct 05) to scope and set up the project

Fairy nuff. There’s not enough information here to assess whether this is enough time or not.

One month (Nov 05) to initiate the project, set up project board and agree project brief

As above.

One month (Dec 05) to “agree requirements” and that month is December, so in effect you have only two weeks.

This is what has set my alarm bells ringing like klaxons. The Standish Group did a survey, admittedly in 1995, which discovered that five of the eight major reasons for IT project failure are requirements based. In other words if you don’t know what your users need, you won’t be able to build it. I could get rather tedious on this subject.

Let’s just say that I would allocate between 6 and 12 weeks for requirements gathering assuming that I had full access to representatives of those who might use the system. The first thing would be the conceptual stuff including the security of the system, (hah!), the amount and nature of the data, how would it be searched and sorted, how many users in total, how many users at once, and stuff like that. The next thing would be the step-by-step process, and the final stage would be a screen-by-screen storyboard.

You can see that this is not something that can be done in 2 weeks, and that you would need to speak to a very wide range of people including security specialists and sample end users, (sample Junior Doctors, sample Consultants, sample final year students).

This sounds to me like a system designed entirely in theory, with no reality checks or sanity checks from real people.

Four months (Jan-Apr 06) for the procurement cycle.

Four months to choose a supplier, and two weeks to say what they will be delivering? Yes, that is as insane as it sounds.

Five months to deliver (April-Sept 06).

This is the infamous “Miracle occurs here” step. There is nothing about taking the list of requirements and turning them into a design, nothing about building the system, nothing about testing it.

The DoH has kept for itself the luxury of time – a whole third of the time available has been allocated to picking a supplier. The poor supplier has had nothing like that wriggle room: they have had to design, build and test the system in less than half of the total time available.

Now, picking the right supplier is crucial, no doubt about it. But no matter how beautifully built a car is, no matter how gleaming the paintwork, how smooth the leather, how fast it goes from 0-60, it’s no bloody use if what you want is a tractor.

As I said, I am hesitant to rip this document to shreds; I have no idea whether it is a final copy or a draft, I have no idea what other documents supported or contradicted it, I’m not even an IT Project Manager. But I am both competent and qualified to comment on the idea of allocating only two weeks for requirements gathering.

If the rest of the project was as mad as that is, then it is a wonder the bloody thing lasted as long as it did.

Modernising Medical Careers: on babies, bathwater and the risks of early specialisation

Sir Francis Bacon, it is said, was the last Englishman to have read every book ever written. In the early 17th Century it was possible, if you were rich and leisured, to do so.

We have no choice but to specialise now: 206,000 new titles were published in the UK in 2005 which is 565 per day. (Distractingly, the USA only managed 172,000 in the same year which is an alluring statistic for a US-sceptic like myself). The British Library holds over 150,000,000 items. One could hardly read the catalogue.

It is a cliché that we know more and more about less and less; it is a cliché because it is true. We have no choice. But that does not mean that we should specialise before we have to, or that early specialisation is better.

You cannot learn more in a fifth of the time

My first issue with MMC is my simple disbelief that no schedule of improvements can produce a five-fold efficiency gain in training. (Specialists will qualify as consultants after 6,000 hours of post-grad training instead of the current 30,000 hours). I’d believe that a 20% improvement might be possible; maybe even that someone could be trained to the same standard in two thirds of the time. But not in one fifth. Who the hell are they kidding? If anything smacks of penny-pinching it is this. It is simply not possible that this approach will produce better educated specialists.

Losing the benefits of experience

My second issue is that the baby of experience is being thrown out with the bath-water of time. (My god – I am turning into Humphrey Littleton). It is of course fully in line with the management mantra that “you cannot manage what you don’t measure” because Hewitt’s crew have conveniently failed to devise a way to measure experience. Call me a traditionalist, but the combination of CVs and references seems like a good place to start, and I am sure that the wise and devious question-setters at the Royal Colleges could examine for experience if they were so minded.

I once heard of a conversation between a clergyman who was ordained late in life and his bishop. The clergyman said “I am worried that I cannot preach about theology” to which the bishop replied “you have 50 years of sin behind you, preach about that and if they want theology call me in”. When you are dealing with people in extremis here is no substitute for experience, and this is what MMC is ripping out of our medical training system.

Generalise first then specialise

More fundamentally: I am sceptical that early specialisation is good in the first place. There is a lot to be said for generalising first. I am assured that the following joke is funny:

Qu: “What’s a holistic orthopaedic surgeon?”
A: “One who looks after the whole bone”.

It puts its drill-bit neatly on the problem: if you are going to specialise it is much better to specialise from a broad-based understanding of the subject. If you don’t, then you may miss what John Cleese would describe with graphic appropriateness as “the bleeding obvious”.

Oddly, after I had started writing this, I read the following in The Elephant and the Flea by Charles Handy:

“‘The fox,’ said Archilochus, ‘knows many things but the hedgehog knows one big thing.’ …. Life is long” adds Handy. “We should keep our options open for as long as possible.”

I’ll admit that I am one of nature’s foxes, but we live far longer than they did in Archilochus’s day. We can afford to give the hedgehogs more to think about before they specialise.

What the doctors lose

The benefits of having a rounded practice (rather than just a rounded curriculum at Med School) are two-fold. Firstly it makes it easier for them to think and treat holistically (a useful concept we should reclaim from the flower-sniffers). Secondly it makes specialists less vulnerable to changes in medical technology. For example, specialists in Upper GI surgery (that’s stomachs and gullets to the rest of us), are now hardly needed because new drugs treat stomach ulcers medically. A problem if Upper GI is all you’ve ever done; not so much a problem if you are a general surgeon who can return to bowels, (mmm, you’d concentrate on the top end if you could, wouldn’t you?).

In the words of Patrick Barrington:

A bustle-maker can’t
Make bustles for his aunt
If the bustle-maker’s aunt
Is
Dead.

Quite.

It is not as if doctors don’t have the time to generalise first. These days we are all living longer and will have to work until we are older. Doctors face a good 40 years of practice when they graduate. What on earth is the benefit of keeping them in the dark and forcing them like celery? They aren’t ballet-dancers or footballers: they don’t peak at the age of 18 and retire at the age of 30. There is no benefit to us, as patients, if they qualify younger and I find it hard to believe that there is any benefit to us as tax payers.

Do you want to know the thing that I find richest about all of this?

Politicians are the ultimate generalists.

May their souls drift from waiting list to waiting list. Forever.

So why did the MTAS site spring a leak?

It’s taken me almost two weeks to calm down enough to think clearly about the MTAS leaked documents fiasco.

I now have three questions to ask Mike Clement of MTAS:

Does he ascribe the MTAS leaked documents to:

1. Lack of clarity about the requirements for the system – was it being used to do things that were not agreed with the client at the requirements stage?
2. Lack of technical skill in those who specified the security architecture of the system?
   or
3. Lack of user-training – were users over-empowered but under-trained?

I’ve emailed him to ask the questions, but I doubt I’ll get any kind of answer.

I’ve been thinking about this off and on ever since it happened, and I can only ascribe it to one of the above three causes or a combination of them all. They are of course interlinked:

• if the requirements weren’t fully thought through then MTAS staff would do what was necessary to get the functionality they needed;
• if the system’s security had been properly built in from the start, then they would not have been able to do it even if they wanted to;
• if they had been properly trained then they would have known about crawlers and bots (which are automated systems dedicated to finding and harvesting personal data) and understood why they should only publish the data on a secure server even if they had the ability to publish it on open servers.

Whichever way you look at it, it’s a fuck-up; call me histopathological, but I want to understand why.

I nicked the slide from the Ferret Fancier. This is not just any jokey slide about IT security. This is from Sarah Thomas’s illiterate and uninformative slides specifically about MTAS.

They’d make great satire, but Ms Thomas (Dr Thomas?) is one of the masterminds behind the flawed MTAS: she is the Lead Dean for National Electronic Recruitment and MTAS is based – very very loosely – on some of her research. Oh, and call me a quibbler, but she cannot spell. I am now feeling a whole new wave of rage about this thing.