In the latest attempt to get the Assisted Dying Bill through Holyrood, the champions of the cause are mindful that patients in the remote areas of Scotland, particularly the Western Isles, may be disadvantaged by not having willing medical facilitators on hand to smooth the process. Never fear. The transaction can take place remotely. Two doctors on Zoom can declare you terminally ill and mentally competent. The relevant boxes can be ticked. It may not surprise you to hear that this, according to at least one palliative care consultant, “beggars belief”. But the Member of the Scottish Parliament pushing the bill has said, “The dying must not be left behind”.
When I heard that the dying must not be left behind, I thought of the Bakhtiari. Jacob Bronowski described their way of life in The Ascent of Man. I don’t know if this ancient Persian tribe still follows the flocks in the great spring migration across the Zagros Mountains. During the year they cross six mountain ranges on the way out, and six on the way back, braving snow and flood. The great test is the crossing of the Bazuft River. When the herd plunges into the meltwater, this is the moment when the elderly and infirm may choose to pause at the water’s edge, and say, “I’m not coming with you this year. I’m going to stop here for a bit”, rather after the fashion of Captain Oates stepping out of the tent and remarking that he might be detained for quite some time. Nobody demurs. It is the way. As Dr Bronowski said, only the dogs look puzzled. The dying are, in fact, left behind. But I doubt if the Bakhtiari sanction the process by laptop.
Well, if the assisted dying bill goes through at the third time of asking, no doubt provision will be made for “Distance Dying”. There will be an app. I dare say it will be downloaded and utilised. This is a useful context for me to introduce Campbell’s Law. Campbell’s Law is a sociological observation much like Parkinson’s Law, Murphy’s Law, and Sod’s Law. Parkinson noted that the work expands to fill the time available; a special case of Murphy’s Law is that if two engineering components can be fitted together the wrong way, then they will be fitted together the wrong way; Murphy’s Law is a special application of the more general Sod’s Law, which states that if something can go wrong, it will go wrong.
Campbell’s Law is a generalisation of Parkinson-Murphy-Sod, a grand unifying theory, if you will, of everything. Here it is:
If you introduce a public service in an attempt to decrease the demand on an already existing public service, you will increase the demand on the existing service proportionate to the extent to which the new service is taken up.
This phenomenon is observed in medical practice all the time. Too many patients and not enough GPs? Solution, get the pharmacists to consult and prescribe. And indeed, patients do consult their pharmacist. But this hasn’t lessened the demand to see the GP; indeed it has increased it, because the pharmacist becomes an additional source of referral to the GP. Face-to-face GP-patient interaction too time consuming? Solution, consult on Zoom. Of course this has been necessary during the pandemic, and the previous English Health Secretary, Mr Hancock, was very keen that remote consulting become the default mode for General Practice. He told the GPs not to go back to their “bad old ways”. But Mr Hancock has moved on – albeit not to the UN – and now Mr Javid is trying to cajole GPs once more to see their patients face-to-face. He is offering financial sweeteners. Perhaps he will echo the words of Mr Bevan back in 1948. “I stuffed their mouths with gold!” (Actually I’m not sure Bevan said that. He stuffed their mouths with silver.) Anyway it has become evident that despite, or perhaps because of all this Zooming, people are crying out to see their GP in person, while the waiting list for hospital appointments and procedures has gone way off the scale. It was another previous Health Secretary, Enoch Powell, who recognised early on that the demand on the National Health Service would turn it into a bottomless pit. I fear that the integration of health and social care will make the pit even more bottomless, if such as thing is conceivable.
Is there any way we can short-circuit this never-ending spiral of supply and demand? I believe GPs are ideally positioned to put a break on the conspicuous consumption of health care products. An experienced GP’s most powerful therapeutic tool is masterly inactivity; his or her most potent and efficacious prescription is reassurance. But you can only carry it off face-to-face, and given the time and space. “I think we should hold our nerve, and keep a watching brief. It’s okay. You’re going to be fine.” I suspect that the doctors who are good at masterly inactivity will not be keen on filling in the forms for the elderly Bakhtiari on Eigg, Rum, Canna, and Muck.