Two Digits to “Quality” (with a capital K)

Back in the nineties in New Zealand they aired a US TV show about a guy whose weekly purgatorial task was to possess a given individual’s psyche and hence sort out somebody else’s existential crisis, whilst that individual was despatched temporarily to “the waiting room”.  I suppose it was a variation of The Fugitive, in which Dr Richard Kimble, played by David Janssen (and Harrison Ford in the movie) is a man wrongly accused, and convicted, of murder, who escapes and week by week enters other people’s lives incognito, solves a problem, and then must get on the run again.  He is always hopeful that at some stage he will be afforded the opportunity to solve his own existential crisis.  Similarly the serial possessor of psyches is a reluctant benefactor who is always hopeful that he will find a way out of his own labyrinthine dilemma.  I don’t know if this programme got to the UK, but perhaps you recognise it.

The protagonist had a companion or side-kick, part minder, part amanuensis, who would orientate him each time he glanced in the mirror at his new persona, and wondered what ghastly tangled web he had to unweave.  One week he’d be a concert pianist, the next he would find himself in the electric chair.  The minder would consult a device I did not recognise at the time, which belonged firmly to the realm of science fiction.  In fact it was a cross between a smart phone and a tablet.  It would spew out data about the particular life that needed to be sorted out that week.  The side-kick would consult the screen of his tablet regularly.  He was never off it.

I thought the whole thing was based on an absurd premise, and I had no inkling that it was all going to come true.  Nowadays, everybody navigates their way through life’s catacombs by consulting their mobile, to find out who they are, and what they should be doing.  What a catastrophe. 

Not that these devices don’t have their uses.  I imagine you could download an App, say, to help you navigate your way out of the Hampton Court Maze.  The route from a given location (identified by built-in Satnav) could be coded as a single number, given in binary.  0 is left, 1 is right.  Say the number is 011010010110.  You just navigate each junction sequentially, and escape. 

The trouble is, we have modelled all human dilemmas as an attempt to get out of a maze.  If this, do that.  Medicine is full of algorithms, constructed as a series of binary choices, and hence a series of branching lines.  Does the patient have chest pain?  Yes.  Is it severe?  Yes.  Has antacid medication provided relief?  No.  Is the pain of duration longer than an hour?  Yes.  Does the patient have pallor, sweating, or shortness of breath?  Yes.  Eventually you reach the bottom line.  Phone for a blue light ambulance.   

But of course experienced physicians don’t consult algorithms.  And they don’t think algorithmically.  They understand the severe limitations of this kind of pedestrian trudge, which is more than likely to lead you off into a remote branch line ending in a deserted cul-de-sac from which there is no way back.  We see the unintended and disastrous consequences of algorithms in many walks of life.  Look what happened to the sub-post masters when a computer system identified them all as criminals.  Look what happened to the A-level students from disadvantaged backgrounds whose exam grades were brutally downsized by an algorithm, during the pandemic. 

But in every walk of life, the high priests of information technology reign supreme.  During the first decade of this millennium they sold eye-wateringly expensive computer systems to public services such as the NHS, state education, and the police.  In primary care, the delivery of medical practice began to be dictated by pop-up menus on computer screens, targets enshrined in the Quality and Outcomes Framework, often reproduced as an aide-memoir on mouse pads, computerised systems of test result management such as Docman, and extremely time-consuming team-building exercises such as “Whole Systems Working”.  “Whole Systems Working” had better had been called “Entire Systems Collapsing” because that is the “Quality Outcome” the systems presaged.  Now, you can’t get through to the practice, you can’t see the GP, you can’t even get a timeous response to a 999 call, you can’t get an ambulance, you can’t get into hospital, but if you do, you can’t get out again. 

All the health care workers are either on strike or they are threatening to go on strike.  Mostly, governments, management, and workers talk about, or refuse to talk about, pay.  But in truth, no amount of pay could compensate for the intolerable misery of working in the toxic, dystopian environment we have created.

It goes without saying that there is too much bureaucracy, but I wonder if the problem isn’t much deeper than that.  The binary, algorithmic, digital way of looking at the world is profoundly inhuman.  I don’t believe that our brains are constructed to wander down a series of branches constructed as twenty questions in a Yes-No interlude.  At a deep level, “yes or no” don’t really work.  It may be fanciful, but perhaps the human apprehension of a dilemma is more akin to a series of so-called “double slit” experiments in which a single electron appears to pass through two disparate gateways simultaneously, but only if you are not looking.  (See Richard Feynman’s Lectures on Physics, volume 3, chapter 1, 1-4).

Now I read in the Sunday Telegraph of the “Hospitals at home” plan to save the NHS.  “Elderly and frail patients who fall will be treated by video link.”  Whatever happened to compassion, the human touch, and tender loving care?      

Those whom the Gods wish to destroy, they first make mad.                                            

“Events, Dear Boy…”

Jacinda Ardern, New Zealand Prime Minister, has announced her resignation.  It came as a surprise.  Of course she has her critics, rather more at home than abroad, but there were no murmurs of discontent within the Labour Party, no intrigues, no back stairs jobbery.  She was expected to lead her party into the general election in October.  But she herself has decided that she is not now the person to lead the country.  In her own words, she has nothing left in the tank.  

It has been said that all prime ministerial careers end in failure.  Here, you lose the confidence of the electorate, or the confidence of your own cabinet, and you are hauled out of No. 10, kicking and screaming.  It’s the exact opposite to the way in which the House elects Mr Speaker.  The appointee is dragged apparently reluctantly from the backbenches, by a cross-party posse, to the chair.  There is good humour across the floor of the house.  It’s a piece of pantomime.  But there is nothing light-hearted about an eviction from No. 10.  It is salutary to consider the mode of demise of the post-war British prime ministers. 

Mr Attlee lost the election in October 1951.  Churchill came back and clung on, despite failing health, until 1955, while his heir apparent waited in the wings, increasingly impatient and frustrated.  Yet Anthony Eden himself went in 1957, destroyed by a botched cholecystectomy, and Suez.

Macmillan was in turn destroyed by the Profumo scandal, and That Was The Week That Was.  Accusations of sleaze made the government an object of mockery.  You can’t govern if nobody takes you seriously.  Alec Douglas Home took over, but he lost the general election in 1964.  Still, he was such a patrician figure that he rather bucks the trend, and stepped down with equanimity.  Perhaps the job was always beneath him.      

Harold Wilson is another exception.  Yes, he lost to Ted Heath in 1970.  He didn’t see that coming, and neither did the polls.  Mr Wilson looked very rueful.  But he made a come-back, and defeated Mr Heath in 1974.  Margaret Thatcher took over the Tory leadership, and Mr Heath reputedly went into the longest sulk in parliamentary history.  Nowadays, prime ministers can’t continue to lead their party if they lose an election.  They are like football managers, with coats on shoogly pegs.  Yet Harold Wilson found himself PM once more in 1974.  But then, somewhat like Ms Ardern, he surprised everybody by stepping down in 1976.  Rumour attributes causation to an early visitation from Herr Alzheimer. 

Callaghan was undone by a winter of discontent.  Crisis?  What crisis? He lost the 1979 general election to Mrs Thatcher, who was able to cross Downing Street and address the press with a quotation from St Francis of Assisi which now carries an ironic ring.  “Where there is discord, may we bring harmony…”  Her tenure in office was doubtless boosted by the Falklands war.  But in the end she was destroyed by her own party.  One remembers the devastating demolition job in the house by the mild-mannered Geoffrey Howe. 

John Major took over, a surprise choice, even to himself, having had a whistle-stop tour of the high offices of state at breakneck speed.  Then he surprised Neil Kinnock, who snatched defeat from the jaws of victory.  But the close of his tenure was very painful.  Remember “Put up or shut up”.  And “The bastards!”

Then Mr Blair arrived.  Things could only get better.  This is the dawn of a new age, is it not?  It is said that he made a deal with Mr Brown to step aside in good time and give Big Broon a fair crack of the whip.  But Mr Blair was a very successful politician and he won three general elections, so why quit when you are ahead? 

Mr Brown was known as a big political beast with a huge intellect and an enormous capacity for hard work.  But he never looked as if he was enjoying himself, and he didn’t have the knack of making his own luck.  He had the financial crash to deal with.  He lost in 2010.  He tried to cling on and form a government, but the numbers didn’t stack up.

Enter Mr Cameron, on the basis of a slick performance, versus Mr Davis’s lacklustre effort, at the conservative party conference.  The referendum on proportional representation went his way, as did the referendum on Scottish Independence.  But, like a gambler’s lucky streak, it all vanished with the Brexit Referendum, and he had to go.

Mrs May, a Remainer supervising the Brexit negotiations, was handed a poisoned chalice.  She called a snap general election, promising – remember? – “strong and stable government”, and it all went disastrously wrong.  She became reliant on the support of the DUP.  The attorney general bellowed from the despatch box, “This is a dead parliament!”  It was like a Monty Python sketch. 

Hence Boris, who would rather have been dead in a ditch than not “get Brexit done”.  But then the pandemic came along.  As Mr Macmillan said, “Events, dear boy…”  Covid nearly did for Boris, and certainly his disregard for Covid rules did for him politically.  He went with extreme reluctance, hinting at a Cincinnatus-like comeback. 

Ms Truss lasted six weeks.

Against this backdrop, the refreshing thing about Jacinda Ardern is, quite simply, that she is normal.  And she inhabits a country, not without its problems, but open, transparent, and at ease with itself.  Back here in Blighty, on Mr Sunak’s watch, there are two murky stories unfolding, one concerning a government minister’s tax affairs, the other an allegation of cronyism twixt the government and the chairman of the BBC.  Dickens’ depiction of Victorian London still holds good.

Fog, everywhere.                 

Friday the Thirteenth

My doorbell rang early yesterday morning – Friday 13th, take note.  It was my neighbour.  He said, “Do you want the good news or the bad news?”

“I’ll take the good news.”

“I have an air compressor.”

“What’s the bad news?”

“You have a puncture.”

I wasn’t entirely surprised.  I said, “Front, passenger’s side?”  I’d actually checked the pressures the day before, and found the latter to be a little soft.  What was it Matt Damon said to the magnificent Franka Potente in one of the Bourne films?  “I thought your tyres were a little squelchy.”

“No.  Back, driver’s side.”  

True enough, flat as a pancake.  Anyway my neighbour kindly pumped it up.  Not only that, he then followed me in his car, with compressor, ten miles into Stirling and made sure I got there.  Such kindness. 

At the tyre shop, they told me both front tyres needed replacing.  I wasn’t surprised by that either.  I have a talent for ignoring impending problems until they turn into a crisis.  I said, “Whatever it takes.  All-weather tyres, if you have them.”  They cracked on.  While I was waiting I ran into a friend from a German class I used to attend in Stirling, and we had a blether.  Einen Schwatz.  The puncture was repaired and the tyres replaced in double-quick time, and I headed into town for breakfast of coffee and a croissant.  Back at the car, rear driver’s side was flat again.  I hobbled back round to the tyre shop.  They took the tyre off and invited me to join the examination and subsequent morbidity and mortality meeting, glooming me up for the bad news that, basically, the tyre was, to use the technical term, f*****.  I acquired a third all-weather tyre.  Should I bite the bullet and replace the lot?  No, the fourth tyre still had some mileage.  It’s a good place, that tyre shop.  They are straight.  They don’t rip you off.  

Well, if that’s the worst thing to happen to me on Friday 13th, I won’t complain.  I couldn’t help but contrast my experience with the appalling reports we hear of people whose problem is not a leaky tyre but, let’s say, a leaky aorta.  I suppose an equivalent experience in the motoring world might, in the absence of a kind neighbour, look something like this:

I call a breakdown service to find they are on strike, for all but the direst emergency.  A flat tyre is no such thing.  Call again the day after tomorrow.  I do so.  I’m still a low-echelon caller.  Expect a delay of two weeks.  Three weeks later the breakdown vehicle picks me up and drives to the tyre place but can’t get near it because of the tailback of waiting, ailing cars.  My car is incapacitated so the breakdown vehicle has to stay in line with me, inching agonisingly forward. 

Eventually I reach my destination but I can’t get any further than the reception because the bays are all occupied.  The throughput is agonisingly slow because, as it turns out, the mechanics are on strike and are only attending to the worst cases.  And so on.

You will jalouse, gentle reader, I am making reference to the NHS.  But you know, such an analogy, the leaky tyre leaky aorta analogy, is of little use.  Human beings with hearts are not remotely like cars with internal combustion engines.  Car mechanics might talk about “running diagnostics”, but pathophysiological diagnosis is something quite different.  I remember Joe Epstein, one of the great founding fathers of emergency medicine in Australia, used to say, “People do not come into emergency departments with diagnostic labels attached to their foreheads.  Some people think they do, but I can assure you, they do not.” 

Of course much of the current crisis (sic) in the NHS is due to chronic understaffing and underfunding, but I believe another problem exists at a deeper societal level.  I call it the erosion of the medical consultation.  The sanctity of the medical consultation has been under attack throughout the twenty-first century.  Lay people, and, I have to say, some health care professionals, don’t really understand what a medical consultation is.  The medical profession cannot be exempt from blame in allowing the structures of health care systems to be designed by politicians, management, and the IT industry.  There is no more instructive example of what I mean than Matt Hancock’s dictum (a few Health Secretaries ago) that GPs conduct the main part of their business online, and not return to their “bad old ways”.  You can certainly run a health service on line if all the patients have a diagnostic label attached to their foreheads.  Heart attacks and strokes down this corridor, cancers here in this fast track, hip and knee replacements here, mental health in an entirely different wing, worried well go private, malingerers get short shrift, etc. 

What medicine fundamentally needs, is an ambience in which a patient can meet a doctor in a quiet, safe, confidential environment, and an atmosphere of calm.  The doctor greets the patient, bids him sit down, and says, “What’s up?”  Then the doctor goes into a trance and listens.  For a moment, he steps into the patient’s shoes.  He becomes the patient.  And he doesn’t interrupt.  Only later will he ask a few pointed questions, for sake of clarification.

Next comes the physical examination.  If you don’t look, you don’t see.  After that, nine times out of ten, the doctor will have not only a diagnosis, but a notion of how the diagnosis affects this particular patient, in a unique way.  Further tests may be needed, but they must be used sparingly. 

If ever you want an example of a bad consultation, listen to the response to the first question on Friday/Saturday’s Any Questions (BBC Radio 4) from Newport.  An A-level student asked the panel whether they would advise her to pursue a career in medicine.  The members of the panel translated this question into politik-speak and started haranguing one another along traditional party lines over the management, or mismanagement of the NHS as it currently is.  They didn’t listen to the question.  They didn’t listen.  As usual, the chairperson became a fifth voice in an increasingly incoherent ramble.  Nobody answered the question.  And critically, the chair did not return to the student questioner to ask her opinion of what she had heard.  It was beyond pitiful.

And on Tim Harford’s statistics show More or Less, a study suggesting there are excess deaths in England and Wales due to “A & E” (sic) “waits” (sic) was discussed by an economist and an actuary.  Statisticians I know and love always tell me that when they enter somebody else’s world, it is not enough merely to crunch the numbers; in order to understand the numbers, you need to have some understanding of the field into which you have been invited.  From the discourse and the language, I don’t think the economist or the actuary knew much about emergency medicine. 

Then Sir Keir Starmer wrote in The Sunday Telegraph.  I think he’s glooming up the left for the need for a radical reform of the NHS.  There are no sacred cows.  But he was pretty thin on detail.  And why would he not be?  He’s not a doctor, he’s a lawyer. 

However things turn out to be organised, we need to protect the medical consultation.  Doctors must not allow bureaucrats to tell them how to do their job.  And diagnosing a subarachnoid haemorrhage, or a ruptured spleen, or an aortic aneurysm, is not like diagnosing a flat tyre.  Some people think it is, but I can assure you, it is not.                                                                                     

May You be Dull

On Sunday in Dunblane Cathedral the minister told a story about a boy at school in America, tasked to write an essay on his hopes and dreams for the future.  He had always wanted to create a stud farm, and rear the finest race horses in America.  He drew up an elaborate plan, and submitted his essay.  It received a poor mark.  He approached his teacher and asked what was wrong with his work.  “Well,” said the teacher, “it’s just not very realistic.  Rewrite it, make it more down to earth, and I’ll see if I can award you a better mark.”

The boy went away and thought about this for a while, and then returned to the teacher with the same essay.  He said, “You can keep your mark, and I will keep my dream.”  In due course he went on to found the most successful stud farm in America.  

It’s a nice story.  Who among us has not had a piece of work in which we took pride cast back at us?  And what a great line – “You can keep your mark, I will keep my dream.”  Mind, I wouldn’t have dared say it at school.  That would have been living too dangerously. 

Is it crucial to the story that the boy eventually fulfilled his dream?         

Nowadays, by and large, pupils are encouraged to dream.  Still, there might be a downside to telling people of aspiration that all they need is perseverance, and their dreams will come true.  In the film Dead Poets Society, Mr Keating encouraged and inspired his English scholars to “carpe diem” and discover their potential.  His colleague, the Scottish classics teacher Mr McAllister, warned Keating that his pupils would come to hate him when they realised they were neither Mozart nor Michelangelo.  Perhaps Mr McAllister was the same teacher who told the pupil to rewrite his essay about the stud farm.

During the festive season I played my viola in a ceremony of lessons and carols which happened to take place in a high school for girls in Glasgow, and during a break in rehearsal I took a meander down a school corridor, glancing at the notice boards as I went.  They were full of “rah-rah” calls for increased endeavour.  Realise your potential.  Be all you can be, and more.  Make the difference, be the difference!  I paused to admire the names, embossed in gold on a bronze background, of excelling alumni, “duces” of the past.  And I felt a sense of envy for the pupils who would walk down this corridor, conscious of the propaganda all around them, and entirely impervious to it.  Blessed are the unambitious.  They know, and have always known, at some deep level in their being, that the people who peddle this stuff – well, their heads are full of s***. 

The glossy brochures for the independent schools are full of rah-rah calls, directed in this case at the parents who wish to maximise their children’s potential and, crucially, help them make useful acquaintance.  The freemasonry of the connected.  Sport, especially team sport, is integral.  It encourages esprit de corps.  And IT.  It must be state of the art.  Connectivity is everything.      

Philip Larkin wrote a poem, Born Yesterday, for Sally Amis.  He said to new-born Sally, without any sense of irony, far less misanthropy, or misogyny, May you be dull.  I think Larkin must have walked down the same school corridor as me, and realised that those who are capable of happiness, who have conjured the trick of life because they take life easy, they just don’t need any of that stuff.  They don’t need a dream, because they already know how to live in the present.  Oh yes, they are quite happy to be at school.  They will take from school that which they need.  Learn to read, learn to write, to count, acquire the basic skills that will allow you to navigate the world.  You might find you are interested in something, and good at something, and if these things happen to be one and the same, well, as Larkin would say, you’re a lucky girl. 

Yet all the while, they are living life, these people who have solved the trick of life, quite naturally, and easily, on a different plane.  They have friends.  They are sociable.  They probably like going to gigs.  They have a capacity for fun.  They understand, without even thinking about it, the fundamental importance of having fun.   

I was never like that.  I was always living in the future.  As the school motto had it, Spero meliora.  I hope for better things.  I still make New Year resolutions.  Next year, Jerusalem!  I continue to make black marks on paper and submit my plans for the stud farm to newspapers and publishers.  Perhaps I am like one of these guys on a television singing talent show, convinced of the righteousness of his destiny, whose sense of pitch is excruciating, but who can never be discouraged.  Simon Cowell shakes his head and says, “No. No. No.”  I don’t pay the slightest attention.  But perhaps I should have listened to that girl down by the salley gardens, who bid me take life easy.  

So I envy these people who don’t dream, and who live in and for the here and now.  They have achieved what Larkin called

…a skilled,

Vigilant, flexible,

Unemphasised, enthralled

Catching of happiness.       

SCREAM!

It’s Groundhog Day on the apparently dismal “A & E Waiting Times”.  The Herald reported them on Friday, along with the opposition politicians’ calls that the Health Secretary be sacked.  I wrote a letter to The Herald, comme toujours, and was delighted to be published on Hogmanay under the banner headline Time to get clinicians, not politicians, to sort out the NHS.  Here it is:

“We were expecting this week’s A & E figures to be bad, but these are awful” (Analysis, The Herald, December 29th).  Here we go again.

In the 1990s when I was clinical head of the emergency department (ED) of Middlemore Hospital in Auckland, New Zealand, the then health minister, Bill English, shortly to become Prime Minister, dropped by, not to tell me how to run the department, but to ask me, “What do you need?”  I told him we needed to double the staff, a remark which at the time I didn’t think went down particularly well, yet, in the event, it happened.

Our politicians, throughout these islands, would do well to follow Mr English’s example.  I think the standard of political debate concerning the NHS is, frankly, pitiful.  You have been publishing the same story intermittently for years now, in language you might have used in 1948, concerning “A & E”, or “Casualty”, or “Cas” not “seeing casualties” within four hours.  For the record, this means that emergency departments are not discharging patients within four hours.  This seems to be a surrogate marker for catastrophe.  Opposition parties call for the health secretary to be sacked.  

Political point-scoring is useless in this context.  It would be better if a cross-party committee asked clinicians the Bill English question, “What do you need?”

Better funding and better staffing are obvious requirements.  Yet there are profound systemic problems within the NHS and it must be the clinicians who take a lead in outlining what they are, and how they should be tackled.  One example: few members of the public, least of all politicians, are aware of the turf war that exists between acute medicine and emergency medicine, and that has resulted in an apartheid system of patient care at hospital front doors.  Medical assessment units don’t implement a four hour rule. 

The medical assessment unit and the emergency department must amalgamate to form a true specialty of emergency medicine.  The entire delivery of hospital acute care would take place around the central hub of the ED, which would no longer function as a first aid outpost, like a dressing station inundated during the Battle of the Somme, but as an integral part of the hospital.  Emergency Department “waiting times” would cease to have any meaning.  

Sincerely…

It’s not the first time I’ve written this letter, or something like it, but I suspect it might be the last.  I’m not in practice any more, and you lose currency in medicine very quickly.  It is said that there is nothing so “ex” as an ex-politician, and the same might be said of a doctor.  It hardly matters what I think.  It is the opinions of the health care workers in harness that matter.  The trouble is, they are so busy that they have no time to think. 

The last time I time I suggested in The Herald that the acute physicians and the emergency physicians merge, somebody wrote in with a gag, that the new college could be called something like the Scottish College Royal for Emergency and Acute Medicine, or SCREAM.  Well, I had to laugh.  Nevertheless, intentional or not, this was a put-down.  And I have no doubt that if, while I was clinical head at Middlemore, I had made this proposal to the elder statesmen of the Royal College of Physicians, it would have gone down like a lead balloon.   

Where did the specialty of Acute Medicine come from?  There used to be a species of consultant encountered in hospital known as the “general physician”.  In fact, most physicianly elder statesmen were general physicians “with a special interest”.  I think for example of a renowned chest physician at Edinburgh Royal Infirmary.  “Never let a patient die of an undiagnosed chest condition, without a trial of antitubercular therapy.”  He was famous the world over, yet he was still on call for his ward’s receiving night, and in the subsequent morning ward round would have to make clinical decisions about patients with all sorts of conditions not relating to the chest. 

But as medicine became more super-specialised, the general physician became an endangered species. In addition, the model of care whereby the acute management of ill patients rested solely with junior, sometimes very junior, doctors, could not be sustained.  So general medicine morphed into acute medicine.  Acute medicine has its own college, its annual conference, its research publications, its own department, the acute assessment unit (AAU), and its own textbook, the Oxford Handbook of Acute Medicine.  I’m holding it in my hand now, along with a companion volume, The Oxford Handbook of Emergency Medicine.  Of course the remit of the emergency physician is far wider than that of the acute physician, yet the acute handbook (third edition) runs to 869 pages, as compared to the emergency handbook’s (fourth edition) 749 pages.  The main topics of the acute handbook all appear in the emergency handbook, though not vice-versa.  If the acute and emergency physicians were to amalgamate, then it might be argued that while the acute physicians would need to increase the breadth of their knowledge, then the emergency physicians would need to increase their depth.  So, a challenge for all. 

It doesn’t make any sense to have two work forces operating in more or less independent silos seeing the same, or at least an overlapping, patient population.  Why not merge?  What is the impediment?  Traditions run deep.  Both disciplines would need to surrender a degree of sovereignty.  No doubt the emergency physicians would be frightened of becoming swallowed up by one of the ancient royal colleges, while the acute physicians would be frightened of opening their portals to a tsunami of undifferentiated humanity.     

There’s more bleak news in The Herald today.  “Patients turn to ‘DIY medicine’” and “Health chief warns 500 could be dying each week due to delays in emergency health care”.  One thing’s sure: the status quo is not an option.         

Heiligabend

There’s something very odd about Christmas.

But soft!  That could be a song lyric.  It is after all an iambic pentameter.  It might be crooned, in supermarket aisles, by Michael Bublé.  On the other hand, perhaps it lacks festive cheer.  There is the suggestion that all is not well, a whiff of bah-humbuggery, reminiscent of the setting, for solo violin, by Schnittke, of Stille Nacht.  All proceeds quite sweetly until the violin comes to rest on an excruciatingly dissonant double-stop, and you come to the realisation that something has gone, societally, hideously wrong. 

Christmas, like the fourth movement of Anton Webern’s Six Pieces, is an enormous crescendo leading nowhere, except to a deafening silence.  Tomorrow, the world will be as abandoned and as deserted as the Marie Celeste.  For all of December we have had to endure wall-to-wall Christmas songs on the radio.  It’s not that I object to the songs individually.  I like Christmas pudding, but would I wish to survive on it for a month?  Of course some of the songs are pot-boilers.  I rather like the Chris Rea one about the guy stuck in a traffic jam.  I thought of it the other day when I took my car into a multi-storey carpark to do some last minute shopping in town.  Big mistake.  I returned to the carpark, punched in my car registration at the kiosk and paid by card (“Thank you, and have a nice day”), and then discovered I couldn’t get out.  Total gridlock.  Hundreds of cars in a low-ceilinged Platz, their engines all running.  I just had to sit and listen to Wham.  But then I thought, I am being poisoned by carbon monoxide and all sorts of evil nitrates.  I swung back into a vacant lot, and went back into the mall to find a coffee shop.

When I got back to my car, nothing had changed.  I conducted a piece of sociological research, involving a perambulation around the carpark, trying to figure out where the bottleneck was.  The Checkpoint Charlie-style barriers at the exit seemed to be on a go-slow.  I started to compose in my imagination a stiff letter to the management of the shopping centre, pointing out that traffic congestion in a confined space is a serious health hazard, and they really ought to lift the barriers and get everybody out ASAP.  I never wrote the letter.  Instead, I took another coffee back to the car, re-joined the queue, and listened to Mr Rea.

Top to toe in tail backs, yeah…

Like a run on the bank, Christmas shopping is a collective hysteria.  The crescendo to Christmas seems to have started earlier this year.  Christmas lights of considerable extravagance bedecking our households, inside and out, were switched on earlier.  That is understandable.  It has been a fraught year domestically and internationally, and now in this winter of discontent we need all the cheering up we can get. 

Take a look at the driver next to me…

I raised my coffee cup in his direction and pulled a face to empathise with him over our shared plight.  He pulled one right back.  An hour later, I reached the barrier.  Of course the barrier took one glance at my number plate and stayed resolutely in situ.  An attendant came over.  “It took so long to get out,” I explained.  I didn’t tell him about the two cups of coffee, and the sociological survey.  If the attendant decided to make life difficult for me, I could only imagine the drivers behind me getting more and more irate.  Fortunately he lifted the barrier, and I got out.

But now I had a headache.  Headache is a symptom of carbon monoxide poisoning, as is mental confusion.  There can be long-term sequelae to such an insult, including decline in cognitive function.  Hyperbaric oxygen is an effective treatment.  I imagined myself dialling 111.  “I’ve got CO poisoning.  You need to dive me.”

“Pardon me?”

“I need to be put into a high pressure oxygen chamber, you know, like, for the bends.”

“Are you saying you’ve got the bends?”  The call-handler would have difficulty locating the appropriate algorithm.  She would be endlessly patient with this latest fruitcake on the line.  The Health Secretary has warned us all not to indulge in risky activity while the NHS is under stress, and here am I, deep-sea diving in the bleak midwinter.

In the bleak midwinter…

Not my favourite carol.  Tends to drag.  Too much snow. 

That’s enough carping for one day.  If I listen to Carols from Kings this afternoon, I might just be able to calm down.

Ich wünsche euch allen ein entspanntes Weihnachtsfest und einen guten Rutsch ins Neue Jahr 2023!

JCC                 

Crucifixus

Canterbury remarked to Ms Kuenssberg on Sunday morning that we live in a very unforgiving age.  You make a mistake, he said, and you are absolutely…  I could see him searching for a word.  I consulted the thesaurus of the imagination and addressed the television screen.  Vilified? Demolished?  Cancelled?

…crucified.

Ms K remarked that it was a good joke, and Canterbury, with a trace of a smile, said that it probably wasn’t very funny at the time.  It crossed my mind that the brief exchange, making somewhat light of Golgotha, might come back to haunt him.  It is ironic that he might become an exemplar of the very point he was trying to make.  The Pharisees might take umbrage and crucify him.

But he’s right.  We live in a pharisaic age.  One strike and you’re out.  You make a mistake – actually you don’t even need to err, you just need to voice an opinion at odds with the zeitgeist – and the Pharisees will trap you.  They might not do it to your face.  The generation of vipers has moved on line, trolls trawling the surf, surfing the net, vigilantes on the lookout for misdemeanour, much like the Morality Police. 

There’s a simple solution: switch off the computer, and live your life off-line.  Of course the irony of this statement is that I am making it, sitting at a computer composing a piece which I will shortly post on-line.  It is a truth universally acknowledged that there is nothing intrinsically good or evil about the digital world; it’s what you do with it that counts.  All technical innovations in the field of communications have suffered a reactionary response, from the printing press to the telegraph, the telephone, radio, television, mass media, the movies, the world wide web, and now… Facebook, Instagram, TikTok…

In West Stirlingshire on Friday morning we woke to six inches of snow.  I wrapped up, took a flask of coffee, braved the blizzards, and walked down to Flanders Moss where the blanket of white was completely pristine, save for the prints of deer and rabbit.  The world was left to nature and to me.  There is a beautiful sentence in Thomas Hardy’s The Return of the Native…

The time seems near, if it has not actually arrived, when the chastened sublimity of a moor, a sea, or a mountain will be all of nature that is absolutely in keeping with the moods of the more thinking among mankind. 

Who needs a digital “platform”?

Luddite?  Well, the critical thing is that you remain in control of the on/off switch.  Recall that in 1984, Winston Smith could turn the volume on the telescreen down, but he could not turn it off.  The evil thing about social media is that people, especially young people, feel compelled to stay connected.  They are addicted, much as they might be addicted to cigarettes, or opiates.  Addiction is not an accidental phenomenon.  The entrepreneurs in any business enterprise that thrives on addiction will purify and refine the agent of addiction such that the lag time to the state of dependence is quicker, the “high” headier, the time lapse to need for a booster dose quicker.  The movers and shakers understand what sort of material will grab your attention, and hold it, keeping you glued to a smartphone screen. 

I’m very fortunate that I’m not vulnerable to such enticements.  It is as incomprehensible to me as gambling addiction.  But I mustn’t be a prig.  I’m as prone to addictive ruin as anybody.  I’m partial to an Islay single malt, and fond of the occasional Cuban cigar.  It’s as well both commodities are hellishly expensive.  Incidentally, I was perturbed that the New Zealand government are outlawing tobacco for everybody born after January 1st. 2009.  Every time you think you are about to attain the age of responsibility, the Beehive in Wellington moves the goalposts.  Terrible idea.  They’ve just created a new black market.  I digress.    

So I’m not convinced by this truism that the digital world is morally neutral.  You have to assess any human activity, not by what it could be, but by what it actually is.  The fact is that the promise of connectivity is a lie.  With each new digital technical innovation we dig ourselves deeper into our entrenched individual silos, content to listen to nothing but the voices in our own echo chamber.  Steven Spielberg remarked the other day on Desert Island Discs that he much preferred the experience of seeing a movie on the big screen in a film theatre, to watching it on a smartphone.  Why?  Because you shared the experience with a community whose individuals might hold views quite different from your own; yet a shared experience offered a possibility of connection, within that community.   

With this in mind I braved the icy conditions yesterday and went into Glasgow to play my viola in a ceremony of lessons and carols.  I’ve been taking part in this particular gig for years, thanks to the kind and generous invitation of my hosts.  With the pandemic, the last time we met up we had to be on-line.  Such a relief this year to be back in the real world.  The church in the west end is unusual in all sorts of ways, not least that, certainly for the lessons and carols, the audience was large and unusually heterogeneous, particularly in age range.  You seldom see such variety in churches or concert halls, in which the grey-haired audience is fast becoming white-haired.  Who will be attending such events a decade from now?  Where is the next generation?  Are they all wired up to their devices? 

Two Minutes’ Claptrap

It’s bitterly cold out there.  Wrap up!  I remarked to a lady outside Dunblane Cathedral yesterday that conditions were very treacherous underfoot.  She agreed.  She advised me not to have a fall, because there would be nobody to pick me up.  I would die of hypothermia waiting for an ambulance, or even if one turned up, I’d languish in it for sixteen hours outside “A & E” (to use an expression as anachronistic as squills, bleeding or cupping).  She was voicing a concern that has become very widespread in the community: don’t, whatever you do, fall ill, or fall over, because the health service is in dire straits.

During the 1990s I was Clinical Head of the Department of Emergency Medicine in Middlemore Hospital, South Auckland, New Zealand.  The then Health Minister, Bill English, who went on to become New Zealand Prime Minister, visited the department one day, and sat down in my office, not to tell me how to do my job, but to ask me a question.  What do you need?

There’s the difference.

I always suspected that the Thursday 8 pm two minutes’ clap held for the NHS during the pandemic was a load of tosh.  It might just as well have been George Orwell’s “two minutes’ hate”.  The doctors and nurses on the front line were compared to “the few”, who ensured the survival of Great Britain in 1940 during the Battle of Britain.  We were encouraged to clap, while members of the government were partying, flagrantly breaking all the Covid rules.  They were spending millions giving out PPE contracts to cronies who didn’t know what they were doing.  The NHS might have borrowed a line from President Zelenskyy, when Russia invaded Ukraine last February.  The Americans offered him a flight to safety, but he said no, I don’t need a ride, I need weapons.  The NHS might have said, we don’t need applause, we need resources. 

And now that the nurses in England have asked for a pay rise, the government has distanced itself.  The nurses’ union has never called for a strike throughout its long history.  They clearly don’t want to go on strike now.  On the Kuenssberg Show on Sunday their leader Pat Cullen asked to meet with Steve Barclay the Health Secretary in England to work out a deal.  If Mr Barclay did not wish to meet Ms Cullen face to face, then the nurses were willing to negotiate with him through ACAS.  But Foreign Secretary James Cleverly distanced the government from the row, which is apparently only between the nurses and the NHS.  Keep the politics out of health, he said.  Nothing to do with us, gov. 

But the government in England has never previously been shy of telling health care professionals how to do their job.  Five health secretaries ago, Mr Hunt got offside with the junior doctors by telling them how and when they were going to work.  Four health secretaries ago, Mr Hancock, of celebrity fame, got offside with the GPs by insisting they go more or less permanently on line.  Three health secretaries ago, Sajid Javid got offside with the public when they told them to get vaccinated and not “cower” under Covid.  Two health secretaries ago, Thérèse Coffey drew up a masterplan, bullet-pointed “ABCD”, which never got off the back of a fag packet because she was only in post for six weeks.  And now, bizarrely Steve Barclay says his door is open, as is Pat Cullen’s, but he doesn’t want to talk about money.  There is no sign of a meeting getting scheduled.   

Professor Sir Stephen Powis, National Medical Director NHS England, also appeared on the Kuenssberg Show.  Ms Kuenssberg asked him if a strike by nurses could cause patients harm, serious harm, could, ultimately, result in fatalities.  Sir Stephen gave a politician’s answer.  “We are doing all in our power…”  I had rather he had said, “Yes.”  After all, if the nursing profession withdraws its labour and the health of the nation does not suffer, then what’s the point of nursing?  But people who spell out unpalatable truths without qualification tend to get removed from office.  Ms Kuenssberg informed us Professor Powis receives his knighthood this week.  Once you are the recipient of a gong, it becomes very difficult to voice unpalatable truths. 

If the government is not going to sort this problem out, and if the Medical Director is going to restrict his remit to operational matters, then who remains to solve this problem?  It raises the issue, what, precisely, is a Health Secretary for?  If the Foreign Secretary says his cabinet colleague is not there to micromanage the NHS, then surely he is there to resource it.  It cannot have escaped the government’s attention that the NHS is on the brink of collapse.  In England, they are trying to reduce waiting times for out-patient appointments from two years to eighteen months.  There are huge numbers of job vacancies, partly because there is nobody to recruit, and partly because doctors and nurses are leaving in droves.  The hospitals are bursting at the seams.  The focus of the log-jam has moved sequentially backwards from the discharge suite, to the ward, “A & E”, the ambulance bay, and now the community, where the elderly lady lies on the kitchen floor all night with a fractured femur.  Surely in that context, the Minister of Health needs to sit down with the health care professionals and ask them, what do you need?                   

English nurses are the lowest paid in Europe. If the nurses can’t survive without recourse to food banks, then there is a problem.  The government’s solution to the problem seems to be to introduce new legislation banning the right of members of some professions to go on strike.  It doesn’t seem to have occurred to the government that they might not be the solution, they might be the problem.          

Whence Comest Thou?

About twenty five years ago in Middlemore Hospital emergency department, Auckland, New Zealand, I said to a doctor who I thought might be Chinese, “Where are you from?”  He coloured slightly, and said, “Auckland.”  That was the first time I realised that my question, even if well-intentioned, was fraught with difficulty.  At least I didn’t follow it up with, “Yes, but where are you really from?”

In New Zealand, people enquired of my provenance all the time.  “Do I detect an accent?”  (Actually they said, “Do ah duteect un uk-seent?”)  I would reply, “I don’t have an accent; you have an accent.”  Thus we would josh one another and that was okay.  Context is everything.  It seems that Lady Hussey compounded a problem last week by her persistence; an enquiry became an interrogation.  And I dare say there would be an issue of tone.  I remember seeing a fly-on-the-wall documentary on TV some years ago, when during a palace reception a lady from an African country asked her hostess, a lady of extremely high caste, whether she had visited her homeland.  “Visited it?  I gave you your independence!”  The whole purpose of the documentary was to pick up such nuggets as this, and to broadcast them without comment.  The aristocrats were so tin-eared that they might have watched the programme later and not realised they were being ridiculed.    

The “Where are you from?” question is common in language classes.  An introductory spiel round the table is almost de rigueur.  “Ich komme aus Glasgow und ich wohne in Stirling.”  So far so good.  In Gaelic, people might say, “Who are your people?  Ah yes, I know them.”  Again, context is everything.  But even here, difficulties can arise when one’s resumé continues to unfold.  Marital status – Married/single/divorced/separated/widowed/it’s complicated/no comment!…  Children/ no children…  Student/employed/retired/unemployed…  It can be quite intrusive.  Some textbooks actually remind you that you’re simply practising language and there is no need to tell the truth.  But this I think can backfire.  Rather than saying, “Single, retired, no children, I am a sad old git…” you might be tempted to construct a phantasy world that will spill over into other areas of your life.  At this time of year, for example, you might be tempted to send out a Round Robin circular with the Christmas cards: “Jack loves Gonville and Caius as much as Ophelia does Brasenose.  Letitia had time to scale Everest during her Nepal gap year…”    

The trouble with “Where are you from?” is that it can be code for “You are not one of us, are you?”  I remember when I was a medical student in Edinburgh a consultant physician asked me, “What does your father do?”  I had no idea at the time that he was trying to place me, socially.  I guess he chose a reasonable surrogate for potential social mobility, or immobility.  According to Sir Paul Collier, Professor of Economics and Public Policy at the Blavatnik School of Government, and Fellow of St Antony’s College, Oxford, who gave the annual Bowman Lecture at Glasgow University last week, the two most powerful indicators of life chances are where you live, and what your parents did.  In the UK, to have any chance at all, your parents had better have gone to University, and you had better live in the South East of England, or the East of Scotland.  I don’t think he was referring to Hastings, or Thurso; rather London and the Home Counties, and Edinburgh, the centres of power. 

Sir Paul’s special area of interest is in regions of extreme poverty across the world.  (He included his own home town, Sheffield.)  Why can’t they escape the cycle of poverty?  Incidentally, Sir Paul’s own life chances may not have looked particularly rosy when he were a lad.  Not only did he come from Sheffield, both his parents left school aged twelve.  Now he is an academic in Oxford, advising such august bodies as the IMF, the World Bank, and the Minister for Levelling-Up.  He attributed his own success to the post-war Prime Minister Clement Attlee, a modest man, according to Churchill, “with much to be modest about.”  I have a notion Churchill also described him as “a sheep in sheep’s clothing.”  Yet Attlee’s government founded the welfare state, despite the fact that post-war Britain was bankrupt. 

Sir Paul’s graphs depicting the gap twixt rich and poor in the UK were startling.  It occurs to me that in our society, that question, “Where are you from?” is being asked all the time.  This is what an interview for a place in medical school is all about.  They want to know if the candidate is “doctor material”.  In other words, is he, or she, one of us?  Did they go to the right school, have they prepared a faultless “personal statement”, were they groomed to pass the UK-CAT test, have they got umpteen A* A-levels, did they find a cure for cancer during their gap year, above all, do they, at interview, sound like a doctor?  Yet the end product of this exhaustive and exhausting process is a health service on the edge of collapse, with burnt-out professionals leaving the sinking ship in droves. 

Talking of sinking ships, Sir Paul compared the UK to a sailing dinghy.  A sailing dinghy has two conditions of equilibrium – one when it is sailing, and one when it is capsized and upside down.  Sir Paul considers the UK to be in the latter state.  He did not mince his words. 

Yet he was not without hope.  Even if the antiquated institutions of the UK are no longer fit for purpose, if they ever were, people needed to be empowered to solve problems at a local level.  I thought of this when I heard a lady on Friday’s Any Questions, a nurse of 40 years’ experience, ask the members of the panel, given the dire state of the NHS, what they would do about nurse recruitment and retention.  After the panel had had their say, the chairperson returned to the questioner and asked what she would recommend.  Answer: a £500 bonus, bursaries, a pay deal in line with inflation, on-site nursery facilities, subsidised meals, and subsidised car parking.  As a doctor, nine times out of ten, all you need to do is sit and listen, and the patient will hand you the diagnosis on a plate.  I hope the government was listening.       

It’s a Wrap!

In my German conversation class at the Goethe Institut we have a weekly slot in which a member of the class gives a Vortrag or lecture on a subject of their own choosing.  It is generally a light-hearted and interactive affair.  The element that differentiates a conversation class from a more traditional language class with its accent on grammar and syntax, is that the conversation can go off at a tangent into unknown and unpredictable regions, for which you can’t prepare.  For „Jims Vortrag“, for example, we each had to bring along a paperback book, any book.  “In English or in German?” we asked.  “Any paperback book!” said Jim, with an expression of mock exasperation.

I picked off my shelf, more or at less at random, an ancient and dog-eared paperback of Ian Fleming’s You Only Live Twice.  Now, I mused, would I be required, in the language of managerial break-out groups, to “talk to it”?  Better prepare a few stock phrases.  The title, for example.  I settled for, Nur zweimal lebst du.  Same number of syllables as in the English.  That, after all, is quite important, because the title is the first line of a haiku, or poem of seventeen syllables, which James Bond composes after the fashion of the Japanese poet Basho.

You only live twice:

Once when you are born,

And once when you look death in the face.

Bond’s Japanese mentor in all things cultural, head of the Japanese secret service Tiger Tanaka, enchanted, claps his hands softly.  He scribbles a few ideograms in Kanji to see if the haiku will work in Japanese, but no, too many syllables.  The haiku form is quite strict – three lines of five, seven, and five syllables respectively.  It occurred to me to see if, with a little poetic licence, I could get it to work in German.  I came up with

Nur zweimal lebst du:

Einmal geboren, einmal

Vor Todes Gesicht.

I’m very fond of You Only Live Twice.  It is late Bond, psychologically damaged, bruised and battered Bond who has somehow retained his humanity, and a sense of humour.  It is as much a travelogue, ein Reiseführer, as a thriller.  What else might I be able to tell the class about it?  It is really part three in a trilogy, concerning Bond’s arch-Nemesis, Ernst Stavro Blofeld, the head of SPECTRE.  Blofeld is, naturally, a megalomaniac.  How do you say that in German?  Ein Größenenwahnsinniger, apparently.  SPECTRE is the Special Executive for Counterintelligence, Terrorism, Revenge, and Extortion. 

Der besondere Vorstand für Gegenspionage, Terrorismus, Rache, und Erpressung.

Pithy.

So there we are.  I attended the class, armed to the teeth.  And of course, true to form, the conversation went off completely at a tangent.  I should have known.  Jim did say, bring a paperback, any paperback.  So the content didn’t matter.  His Vortrag was, timeously, a lesson on how to wrap up a book in Christmas paper.  We were issued with paper and sellotape, and directed with close instructions in German.  I really ought to have paid more attention, because I am the world’s worst wrapper of Christmas presents.  Captain Maladroit.  I have this notion that the constituents of parcelling conspire against me.  First, I allow the end of the sellotape on its roll to adhere to itself, and completely disappear.  I can’t find the end, and when I do, I can’t figure out which direction on the roll to direct my gouging fingernail.  If I can get past this hurdle, I generally attempt to cut three generous lengths of tape, and adhere their ends to the edge of my worktop, for subsequent use.  The lengths of tape generally curl underneath the table there to adhere.  Meanwhile I align my book on its sheet of wrapping paper, cut more or less to size, and fold two opposing ends across the front of the book along its long axis.  I pinion this first fold with my left hand, and must now, with my right, extricate the first length of sellotape from the clutches of the table’s underside, and secure the first fold of paper with the tape.  This is of necessity a one-handed manoeuvre, and it has to be my right hand, because I am an incredibly right-handed person.  Truth to tell, my entire universe is right-handed.  I won’t say I suffer from spatial neglect.  I wouldn’t go that far.  I know the left-hand side of my world is there.  I just don’t pay it too much attention. 

There are various things that can, and do, go wrong, in the transfer of sellotape from table to book.  Generally the sellotape attempts to adhere to itself.  The adhesive is so strong that this is a terminal event, requiring a fresh start.  If I can get the sellotape to the paper in an uncurled state, the next challenge is to affix the first fold, one-handedly, with the sellotape running parallel to the paper edges.  This I achieve rarely.  But at least, at this stage, the paper’s fixation is serviceable. 

I turn my attention now to the short axis of the top of the book.  This is a complex piece of origami requiring me to infold the two ends of the paper in two triangular shapes, then to fold the rest of the length over the top of the book, then to repeat the pernickety task of transferring sellotape to paper.  It becomes clear at this stage that I am using too much paper; there are redundant wrinkles and creases, and the inner aspect of the paper is visible, like the underwear of somebody who has dressed too hurriedly. 

Repeat stage two, at the bottom end of the book. 

An absolute pig’s breakfast.  Jim told me as much.  I handed the wrapped book on to the class teacher, who double-wrapped it, perfekt. 

I can’t say I’m too phased.  Maybe I’m just not that interested in Xmas wrapping.  I do as little DIY as possible and I hope never to assemble another flat pack.  I was complaining to somebody the other day about my clumsy ineptitude, railing about the sullen recalcitrance of things, and they replied, “What are you talking about?  You play the viola, you can stitch people up!”  True enough.  This profession of incompetence, it’s really an affectation, like women who say they can’t do mathematics.  I said to another friend on another, other day, “D’you know, I’ve never done a jigsaw in my life.” 

She said, “Do I sense a certain pride in that assertion?”

“Ah!” said I.  “You see through me.”