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.                                            

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