Author: jamescalumcampbell

It’s Day 86 of the president’s first term, and two nuclear powers would appear to be on the edge of war.  The extraordinary thing about it is that nobody seems much bothered.  There’s no panic buying in the Seoul supermarkets, no nose to tail traffic jams as the 10 million inhabitants try to head out.  One can only imagine they are so used to the intermittent heightening of tensions, the rhetoric and the brinkmanship, that they have become rather blasé.  Certainly the pundits in the British Sunday broadsheets, while recognising a crisis might develop, still think the threats and counter-threats are mostly hot air.  And yet, if we are to take the statements of the leaders of the two powers in question at face value, things are looking bleak.  It is evident that the president wants to curtail North Korea’s nuclear ambitions.  He would rather China do this work on his behalf but has stated that if China does not, he will “take care of it.”  A pre-emptive strike to disable the North Korean nuclear programme has been mooted.  The fact that North Korea’s ballistic missile test failed today, might persuade the US that this is the time to strike, while the opposition appears powerless to reply.  The opposition could effectively be neutralised.  But North Korea has stated that any such strike would inevitably result in retaliation.  This would presumably start the second Korean War.

There is every reason to suppose that the president is not bluffing.  In the course of the last week he has ordered the firing of fifty nine cruise missiles at a Syrian airbase in response to President Assad’s alleged use of chemical weapons on his own people, and he has deployed an 11 ton “Moab” (Massive Ordnance Air Blast) against an ISIS underground installation in Afghanistan.  Meanwhile a US Navy “Armada” is heading for the Korean Peninsula.  (Armada could be an ironic choice of word considering that in the sixteenth century part of the Spanish Armada foundered off Lewis; might the president have Spanish ancestry?)

Why doesn’t the president want North Korea to have deliverable nuclear weapons?  After all, if they are good enough for the US, and the UK, Russia, China, France, India, Pakistan, and Israel, why not North Korea?  The British Government is always extolling the virtues of an independent nuclear deterrent.  This is why Trident is due for an upgrade.  Trident submarines can travel anywhere, anytime, and therefore obliterate any target across the entire planet.  This system is allegedly keeping the peace.  There are thousands of nuclear bombs in existence and only about 200 sovereign states.  Why not get the United Nations to divvy them up and arm everybody to the teeth?  I imagine the answer to this would be that, while there might be a debate to be had between proponents of unilateral and multilateral nuclear disarmament, most countries wish to strive for a world free of nuclear weapons.  That is a long term aim, but in the meantime the world is a dangerous place.  There are, if you will, some bad dudes out there.

I dare say that in this context the president regards the US as the goodies and North Koreans, particularly if they continue on their current trajectory, as the baddies.  The West tends to regard, and depict, North Korea as a repressed and secretive nation run by a bunch of utter nutters.  Certainly the intensity of the enthusiasm of their TV newscasters, and the synchronised and prolonged applause of serried ranks of military in uniform may not be to our taste.  On the other hand the Pyongyang subway stations look rather grand, the vehicles freshly painted and spotlessly clean, and the people – well, much like any other people across the world.  I imagine that the North Korean government, aware of the approaching Armada and aware that a pre-emptive strike is being mooted, might well be feeling very nervous.

I for one am feeling very nervous and I’m 6,000 miles away.  I can’t remember when the world situation last felt this jittery.  It might have been 1961.  We seem to be heading with astonishing rapidity towards a cliff edge.  Brinkmanship is all about Game Theory.  What’s the other guy gonna do?  The trouble is that in making such predictions, in playing out these war games, you have to believe that the players in the game are playing by certain rules and making decisions along rational lines.  You imagine the players have a game plan, a strategy, and they are each methodically developing their position as chess players do.   But this is not like a conventional game of chess.  This is more like speed chess.  You set the chess clocks to two and a half minutes to midnight and then you move so fast you haven’t time to think.  Anything might happen.  You make it up as you go along and you shoot from the hip.  Before you know it the board is laid waste, both sides obliterate one another, and if there is any victory to be won it is a Pyrrhic one.  It’s like Ozymandias.  “Nothing beside remains.” 

Got home the other night to this message on my answer phone:

This is to inform you that HMRC is filing a law suit against you.  Press one to speak to a police officer.

Then I got an email ostensibly from HMRC to inform me I was a due a considerable tax repayment, which I could claim by accessing a certain web site.  The email looked very convincing and cited a London address, in “Parliament Street”.

I didn’t press one and I didn’t access the web site.  I did let my accountant know.  He said I did well to ignore both messages as they were clearly scams.

Then promptly on April 6^th HMRC sent me forms SA100-6 and SA101 2017 with a notice I am required, by law, to file a tax return.  It’s that dismal time of year again.  Might this be a scam also?  I think not.  I’ve also received from them my latest tax code for the New Year.  This is a combination of letters and digits with an explanation as to how the code was arrived at, and an accompanying set of notes to help me crack the code.  Now in an amateurish way I’m rather fond of codebreaking.  Crosswords and the like.  But this particular conundrum has me stumped.

The explanation starts out promisingly enough with a tax free personal allowance to which is added Gift Aid.  I’m having second thoughts about Gift Aid.  I recently sent some money to the Disasters Emergency Committee but I didn’t gift aid it.  DEC promptly sent me a form with a polite request that I consider it.  It made me wonder, why have I gone off Gift Aid?  I don’t intend to claim any tax relief on my gift either for myself or anybody else.  I think the tax system is too complicated and needs to be grossly simplified.

Anyway the rest of the procedure for working out my tax code involves a series of deductions such as “adjustment to rate bands”, “higher rate tax adjustment”, “underpayment restriction” etc. etc. which not only reduces my personal allowance to zero but turns it into a considerable negative quantity.  What can it mean to have a tax free amount that is a negative number?  I presume it must mean that I must pay tax not only on all of my income, but on all of my income plus this not inconsiderable amount that is expressed as a negative.  I will not weary you with the arithmetical convolutions that arrived at this sum, but proceed to Note 9, “Tax-free amount”:

To create your tax code, we’ve removed the last digit of your tax-free amount and included a letter…  We tell your employer(s) or pension provider(s) your tax code but we do not tell them how we worked it out.

This Bletchley-like utterance is reminiscent of the rubrics you come across above the 12 x 12 crosswords in the Sunday broadsheets that take you (or at least, me) all week to solve.  I’m thinking of compiling one and sending it to The Telegraph:

Enigmatic Variations No 666: “Gimme a break.”

Solutions to clues are a combination of letters and digits.  Prior to entry to the grid, solvers must remove the last digit to each solution and include a letter.  Solutions should reach The Telegraph by Oct 31^st (Jan 31^st if filing on line).  Do not tell us how you worked it out.

Incidentally, HMRC didn’t, as far as I can see, remove the last digit at all; they removed the second last.  It’s a nice point.

It’s enough to make you chuck your hand in, take their word for it, fill in the form and keep your fingers crossed you haven’t inadvertently made a mistake.  This is why I get an accountant to do it and I pay insurance against being investigated.  The professional fee protection blurb says:

HMRC are coming.  Even innocent taxpayers are caught out… a visit from (HMRC) can deal a severe blow to anyone… Nothing to hide?  Unfortunately even innocent taxpayers get caught up in the process and are under threat of investigation… It is an unfortunate fact, but it is often impossible to second guess when a tax investigation will take place…

It’s positively Kafkaesque.

I know I sound like a barrack-room lawyer but I think the whole tax system should be simplified on to one side of a sheet of A4.  If you need more than one sheet of paper to explain it, it’s too complicated.  You have an income tax rate at x%.  You pay x% of your income per annum to HMRC.  How hard can it be?

Mrs May’s letter to President Tusk triggering Article 50 is a strange document.  President Tusk waved it in the air in a manner rather different from that of Neville Chamberlain returning from Munich.  “Here is the paper…”  President Tusk said, with evident consternation, “Six pages!”  What did he mean?  Was it too long or too short?  The important message was contained in two sentences buried within the text:

I hereby notify the European Council in accordance with Article 50(2) of the Treaty on European Union of the United Kingdom’s intention to withdraw from the European Union.  In addition, in accordance with the same Article 50(2) as applied by Article 106a of the Treaty Establishing the European Atomic Energy Community, I hereby notify the European Council of the United Kingdom’s intention to withdraw from the European Atomic Energy Community.  

I think Mrs May might have done well to leave it at that.  The rest of the text was reminiscent of a “Dear John” letter designed to effect the break-up of a relationship while letting the other side down gently.  You know the sort of thing.  “We can still be friends…”  There was even a hint of “It’s not you, it’s me…” in Mrs May’s contrite “there can be no ‘cherry picking’” (it crossed my mind that might be because there will be no East European labour available for the crop next harvest).

But let us subject Mrs May’s 2200 words to close textual analysis (not that I counted: Eddie Mair, sitting in for Andrew Marr on Sunday morning, did.  Gibraltar’s not mentioned.)

Dear President Tusk,

On 23 June last year, the people of the United Kingdom voted to leave the European Union.

True.

As I have said before, that decision was no rejection of the values we share as fellow Europeans.

Now, how does Mrs May know that?  A referendum is rather a blunt instrument, usually offering an electorate, as in this case, a binary choice.  Cabinet decision-making is liable to be more nuanced and may more reflect the rationale underpinning an executive action.  Mrs May would need to peer into the minds of millions of voters to know whether or not European values were being rejected.  On the face of it, the much cherished four freedoms – freedom of movement of goods, people, services, and capital – might be said to be EU values which the British electorate has rejected.

This letter sets out the approach of Her Majesty’s Government to the discussions we will have about the United Kingdom’s departure from the European Union and about the deep and special partnership we hope to enjoy – as your closest friend and neighbour – with the European Union once we leave. 

That is like flirting with your spouse while suing for divorce.

We therefore believe it is necessary to agree the terms of our future partnership alongside those of our withdrawal from the European Union.

This is an important point for Mrs May because she actually makes it in her letter three further times, as follows:

The United Kingdom wants to agree with the European Union a deep and special partnership that takes in both economic and security cooperation.  To achieve this, we believe it is necessary to agree the terms of our future partnership alongside those of our withdrawal from the EU. 

Note that on this second occasion of stressing the necessity of conducting withdrawal and renegotiation discussions in parallel, Mrs May also conflates economic with security issues.

We want to be able to agree a deep and special partnership, taking in both economic and security cooperation.

This is a third iteration of the parallel negotiations theme, with a second iteration of the economic-security conflation.  Mrs May also points out that the failure to reach a deal, and the resulting default to the fall-back position of World Trade Organisation terms, would weaken the fight against international crime and terrorism.  But she does not explain why this should be so.

It is for these reasons that we want to be able to agree a deep and special partnership, taking in both economic and security cooperation.

Fourth economic, third security iteration.  Is Mrs May being so repetitive because she fears President Tusk will not pick up on these points?  She need not have worried.  President Tusk said immediately that parallel talks were not going to happen.  You can hardly blame him.  Imagine resigning from a golf club, cancelling your subscription, then insisting on setting the green fees for visitors.

The process in the United Kingdom

This is a paragraph about the business of converting the body of existing European law (the “acquis”) into UK law.  What will be tweaked, devolved, reserved, or dumped?  Why should President Tusk be remotely interested?  It’s a bit like the divorcee telling her ex, having settled the inventory, how she is going to dispone her cut of the CDs around her new living room.  Not only that, she wants to retain a close interest in the affairs of the ex, when all the ex wants to do, following a short period of mourning, is to start afresh with somebody else.

Proposed principles for our discussions

Mrs May expounds seven principles.

i We should engage with one another constructively and respectfully, in a spirit of sincere cooperation.

When I first read that I thought, well, she would say that, wouldn’t she?  Yet I can hardly say it is a truism.  Indeed it is worth saying.  I remember on the day after the referendum Nigel Farage addressed the European Parliament in a breath-taking display of schadenfreude (remember: “you laughed at me; well, you aren’t laughing now”).  It was clear that he did not consider the EU to be a benign institution.  Mrs May needed to tell the EU that she wishes it to prosper.  Having said that, however, five of the six remaining principles do seem be of the “taken-as-read” variety, to wit –

ii We should always put our citizens first

iii We should work towards securing a comprehensive agreement

iv We should work together to minimise disruption and give as much certainty as possible

vi We should begin technical talks on detailed policy areas as soon as possible, but we should prioritise the biggest challenges

And vii We should continue to work together to advance and protect our shared European values.

Six pages.  A thicket of platitudes?

Yet, buried away inside all of this, there is one further crucial principle.

v In particular, we must pay attention to the UK’s unique relationship with the Republic of Ireland and the importance of the peace process in Northern Ireland. 

It strikes me that it is this issue more than any other, the reality of a land border between the EU and the UK, which will result in a profound alteration in the constitutional arrangements within the British Isles.

 

 

 

In Dunblane Cathedral a couple of Sundays ago a prayer of intercession was given up on behalf of people who struggle at this time of year with the recollection of an event which in the magnitude of its evil seems completely incomprehensible.  On March 13^th 1996 a man entered Dunblane Primary School and shot dead a school teacher and sixteen members of her class.  Ten other pupils and three teachers were wounded.  The perpetrator committed suicide.  It so happened that week I read A Mother’s Reckoning by Sue Klebold (W H Allen, 2016).  Sue Klebold is the mother of Dylan Klebold, one of the two perpetrators of the Columbine High School Massacre in Denver, Colorado, 20^th April 1999.  Dylan Klebold and Eric Harris, two students at the school, shot twelve students and killed one teacher.  Twenty four other students were injured.  Klebold and Harris committed suicide.  Seventeen years after the event, Sue Klebold has written a book about Columbine which is an attempt to understand why her son did what he did.

I probably wouldn’t have read her book but for two factors.  I was lucky enough to win the Impress Prize for New Writers in 2014 with my book Click, Double-Click.  In Click, Double-Click, the narrator of the story becomes convinced that somebody is going to “do a Columbine” on a specific University Campus.  For reasons intrinsic to the structure of the book, I needed to cite four previous, I might say notorious, examples of similar events.  I chose Dunblane, Hoddle Street, Aramoana, and Columbine.  Why did I choose these specifically?  I live fifteen minutes’ drive from Dunblane.  I spent the better part of fifteen years in Australasia – hence Hoddle Street (Melbourne) and Aramoana (South Island, New Zealand.)  And Columbine?  Well, Columbine is so notorious that it is a kind of archetype for these sorts of events.

The second factor compelling me to read Sue Klebold’s book was that recently I happened to hear Private Passions on Radio 3 with Michael Barclay.  (Curiously enough that shows up in Click, Double-Click as well.)  On this occasion the guest was Andrew Solomon.  Andrew Solomon has written a book about unusual children, be they gifted or challenged.  During the course of his research he met with Sue and Tom Klebold, Dylan’s parents, confident that he would discover the cause of Dylan’s catastrophically aberrant behaviour.  He was disconcerted to find that he liked the Klebolds.  He was left struggling to explain how an apparently normal teenager raised in a normal, and indeed loving, environment, could have perpetrated such an act.  Solomon wrote the preface to A Mother’s Reckoning.  That was a nudge to make me read it.

A Mother’s Reckoning was not an easy read.  Not that the book was in any sense dull, turgid, or obscure.  Quite the contrary.  It is extremely well written, lucid, highly intelligent, heartfelt, and at times compulsive.  It is just the pure pain of the narration that makes the read so difficult.  Any act of grieving involves going over the same material again and again and so it can hardly be surprising that the book contains a lot of repetition of angst and fear and horror.  Sue Klebold also knew that in her narration she was laying herself open to criticism.  Was this simply to be some kind of exercise in self-expiation?  No.  Instead, there is incessant self-condemnation.  She says, frequently, I should have seen this coming.

So Sue Klebold compels us to ask ourselves, the readers, would we, to avoid a tragedy, have done any better?  I fell to wondering if the home life she depicted in an idyllic setting just outside Denver held any clues.  I tried, specifically, to envisage Dylan’s life, his home life, his school life, his social life, as he would have envisaged it.

I got the strong sense of a personality who, faced with the “norms” of North American life, the need to aspire to the American dream, to do well in class and at sports, to be part of the community, to please his parents and his mentors and his peers, to “shape up”, just found it utterly impossible.  But why did he choose to make his final act an act of brutality?  That remains an enigma.

“Six Jobs Osborne” is the catalyst that has forced Parliament this week to examine the issue of MPs taking on work outwith their constituency and parliamentary duties.  I was curious enough to try to track down what the ex-Chancellor’s half dozen jobs might be.  They are allegedly as follows:

1. Member of Parliament
2. Editor, London Evening Standard
3. Consultant, Blackrock, a US hedge fund (one day a week)
4. Chairman, Northern Powerhouse Partnership
5. Fellow at McCain Institute (a US think tank)
6. Speaker, Washington’s Speaker’s Bureau.

Such a portfolio is not without precedent.  None other than Sir Winston Churchill had a career divided between politics and journalism.  He even started off as a newspaper war correspondent reporting on military campaigns in which he was taking part as an officer in the British Army.  Conflict of interest?  He caused outrage by being critical of the senior officers under whom he served.  Throughout his parliamentary career he continued to write for the newspapers.  He even, albeit briefly during the General Strike, put himself up as a newspaper editor.  He was an author and historian.  He was also a painter and a bricklayer.  Clemmie said Winston lived like a Pasha.  I think she meant he organised his life exactly the way he wanted it.  He famously took a siesta.  On September 15^th, 1940, he went to bed between 4 pm and 8 pm.  September 15^th is Battle of Britain day.  That was the day Field Marshall Goring sent over the entire Luftwaffe.  That was the day Len Deighton’s SS GB might have become a reality.  Churchill intoned “Never in the field of human conflict…” and then went to bed.

It just shows you; some people are walking, or think they are walking, with Destiny.  I cannot imagine what it must be like to have this degree of Inner Belief.  When I was a medical student I had the opportunity to take on a second job, playing my viola in 50% of the Scottish National Orchestra’s gigs.  It was feasible on paper; I could have timetabled it, for a year.  I said no.  I never had cause to regret that decision.  I realised that medicine was an all-or-nothing pursuit demanding nothing less than total commitment.  Of course it was possible – indeed essential – to have hobbies, of which playing music might well be one.  But my brief experience of playing in the SNO taught me that the life of a professional musician was also a life of commitment and devotion.

So I confess I’m sceptical about Mr Osborne editing a London newspaper in the morning and then attending the House of Commons in the afternoon to cast a vote.  Might he not wish to take part in the morning’s debate?  Maybe Her Majesty Opposition will deploy an argument so persuasive as to make him change his mind on an issue of the day.  Or am I being hopelessly naïve?  It occurs to me that the six jobs annotated above are not really jobs at all, in the sense that most people hold down a (single) job.  If I said to a medical colleague, “I’m off to edit a newspaper” (or play my viola, or whatever), he might reasonably ask, “Who is going to look after the 32 patients booked in to see you?”  I have this notion that the more exalted we become in our various fields of endeavour, the less useful we are to humanity.  If the Minister of Health wakes up in the morning with a migraine he can reasonably throw a sickie.  The Grand Strategy can wait.  The GP migraineur on the contrary will take two paracetamol, drag himself out of bed and go to work because if he doesn’t, chaos will ensue.  All the transactions that really matter to mankind are one-on-one.  I venture to say this is what Jesus had in mind when he told his disciples that if they wanted to be first, they must put themselves last.

I’m intrigued by Mr Osborne’s one day a week with Blackrock (salary allegedly £650,000).  I don’t even know what a hedge fund is.  I looked it up in Bloomsbury:

Hedge fund n 1 US an investment company that is organised as a limited partnership and uses high-risk techniques in the hope of making large profits 2 a unit trust that invests in derivatives and other instruments that involve substantial risks and may yield extraordinary returns.

Well well.  It’s a funny old world.

Whenever I sit beside a stranger, on an aeroplane or in a theatre or concert hall, I make a point of engaging in conversation, if only for a moment.  At the Usher Hall in Edinburgh on Friday evening, the cloakrooms were closed.  Short staffed, they said at the bar.  We just had to take our cloaks into the auditorium.  The place was full because Nicola Benedetti was playing the Bruch Violin Concerto.  Ms Benedetti had played the Brahms in the Glasgow Royal Concert Hall the previous evening and it had been packed also.  Anyway everybody in the Usher Hall just had to sit in their overcoat or stuff it under the chair.  It gave the occasion a fleeting sense of transience, an atmosphere not unlike, I imagine, these occasions in 1945 when scratch ensembles gave hurried renditions of the great German classics in bombed out halls lacking a roof and before huddled masses starved of culture as well as food.

I said to the lady on my left, who turned out to be a relative of Enid Blyton, “You’d think they’d be able to offer a peg, even a shoogly one.”  She said, “I’ll tell my son-in-law. He’s the hall manager.”

By contrast, at the Festival Theatre for the opera on Saturday evening, the cloakrooms were accommodating not only cloaks, but guide dogs.  I saw two of them settling in for the evening, a black lab and a golden retriever.  I thought of them as a couple out for the evening, the gentleman in black tie, the lady in a gorgeous golden coat.  They seemed to understand very well the social norms of attending the opera.  I imagined their conversation.

“What’s on tonight?”

“Pelleas et Melisande.  Debussy.”

“What’s that about?”

“The usual human preoccupations.  Abuse of women and children, lust, infatuation, jealousy, murder.”

“Are you going in?”

“I don’t think so.  It’s a long sit.”

My conversation with a stranger turned out to be with a lady from Aberdeen who as a child had known Mary Garden (1877 – 1967).  Mary Garden created the role of Melisande in the 1902 premiere at the Opera Comique in Paris.  She joined the Manhattan Opera House in New York in 1907 and also sang Melisande in the US premiere.  Some people said she was Debussy’s mistress but I believe Ms Garden was not one of them.  Her acquaintance and I fell to talking about Nicola Benedetti and the Royal Scottish National Orchestra’s lightning tour this week of Florida.  She hoped that if Nicola met President Trump she would give him a good piece of her mind.  I remarked I rather thought President Trump would like to meet Ms Benedetti.  She raised her eyes to the ceiling.

The RSNO are doing eight concerts in nine days in places like Palm Beach, Fort Lauderdale, and Sarasota.  They are playing two programmes presumably four times each.  Frankly it sounds like very hard work and not much fun.  They are playing, among other things, Beethoven 5 and Tchaikovsky 4.  That strikes me as odd programming.  Beethoven 5 is a wonderful piece of music, but why would you go all the way across the Atlantic to perform it four times?  If somebody said to you, “Fancy going to see La-La Land?” they would not be surprised if you shook your head and said, “I’ve seen it already.”  Similarly, “Fancy going to hear Beethoven 5?”  “I’ve heard it already.”  The flautist Sir James Galway says he made up his mind to leave the Berlin Phil during a power cut when they were playing Beethoven 5.  The orchestra played on, undaunted, in the pitch black.

I remarked to Enid Blyton’s relative in the Usher that the classical concert-going audience was grey haired and is now white haired.  Another decade, and perhaps the RSNO will be playing Beethoven 5 in a Peabody Auditorium, Daytona Beach, that is deserted.  Scary thought.

 

When I was a kid there was a cinema in the west end of Glasgow, the Hillhead Salon, which specialized in what repertory theatres call revivals.  Psycho made a comeback.  Big Jobs said, “Fancy going?”

“It’s an X,” I said redundantly.

Big Jobs took out a pack of Peter Stuyvesant – he had expensive tastes – and expertly flicked up the cigarettes so that they formed a histogram like the pipes in an organ loft.  He deftly snatched a 32 foot diapason between his teeth.  He lit it in one smooth motion.  Ian Fleming would have said something like, “he snapped open the tiny jaws of the Ronson…”  He took in a deep lungful of smoke and exhaled it luxuriously through his mouth and nostrils.

“So?”

Ian had asked his faithful reader, William Plomer, (I was obsessed with Bond) how Vesper might have exhaled.  How d’you get the smoke out of her?

I thought, it’s all right for you, Big Jobs.  You are six feet and 180 pounds.  You’ve looked middle aged since you were about eight.  I’m twelve and I look twelve.  How am I going to get in?  But Big Jobs said it was okay.  He knew the guy at the kiosk.

In these days of glorious simplicity, the British Board of Film Censors had three categories:  U for Universal… anyone could go.  A I think for over twelve with accompanying adult, and X for…well, X.  You had to be over 16.

Why X?  Why not G for grown-ups?  X definitely had a wrong-side-of-the-tracks connotation for us.  At school when we were right we got a tick; when we were wrong, an X.  Taboo.  Verboten.  Perhaps the film distributors, mindful of the lure of the forbidden, bribed the censors to use the term X.

There were two types of X.  Either the film was scary or it was dirty.  Occasionally it was both.  Werewolves, for example, preferred beautiful semi-clad women for their prey.  Psycho started out promisingly dirty and then seemed to go off at a complete tangent and ended up scary as hell.  Young people used to sit in the back stalls for a snog up; it all seems a bit innocent now.  There were seats designed specifically for snoggers at the back of Green’s Playhouse.  They were called “fauteuils”.  You would say to the man at the box-office, “Two, please,” and he would embrace you with a halitotic grimace.

“Fauteuil?”

Pornography on the whole wasn’t on general release.  You had to be in a club for that.  Pathetic old men in raincoats joined up at some fleapit.  If we weren’t tempted to go it wasn’t because we didn’t want to see the movies.  But the idea of being seen queuing with the dirty old men was just too much to bear.

We didn’t all make it into The Salon.  My classmates Big Jobs, Brian and I went, but for some reason kiosk man took exception to Brian.  We’d already decided that we’d live with whatever outcome we got so all we could do was shrug apologetically, leave Brian at the entrance, and pass into the darkness of the theatre.  At least he’d saved himself 1s 9d.  I envied him.  I’d much rather have gone to see North by Northwest.

There are three big frights in Psycho.  The immortal shower scene of course.  Then the long silent ascent of a detective up a stairway.  Finally the encounter with the remains of Norman’s mother.  There was a lot of hype about Psycho so to an extent you knew what was coming.  What must it have been like to go to the premier and not know to brace yourself?  After Janet Leigh’s character is murdered there is a long and essentially silent scene when the camera pans across her dead visage as the blood trickles down the plug hole.  It is curiously calming.  Catharsis, the purgation of pity and terror. You can imagine the first audience in the theatre auditorium, buzzing, almost laughing hysterically, and then gradually calming down.  Whatever next?

I had known what was coming, but I wasn’t prepared for the terrible violence implicit in the Bernard Hermann score.  The shifty, unsettling theme of the opening credits and of Janet Leigh’s exhausting drive through the night rain did not prepare you for these high-pitched squawking staccato down bows and the great fortissimo hammer blows in the lower strings.   I thought to myself, what the hell are you doing here?  You know you’re of a nervous disposition!  I stole a glance at Big Jobs.  He was lighting another Stuyvesant.  He was thoroughly enjoying himself.

Quatermass and the Pit.  Ever since that poor man in East London went back into the capsule unearthed in the London underground station to collect his spanner, and his world went berserk, I’ve been a nervous viewer.  When the policeman went into the derelict building in Hobs Lane and felt some malevolent presence, I felt it too.  A for Andromeda, The Big Pull, The Scarf.  Even The World of Tim Fraser was a bit spooky.  I watched from behind the sofa.

But there was one thing I couldn’t watch, and I discovered it with Knock on Any Door, a story about a young man drifting from juvenile delinquency to serious crime and eventually, inevitably, to the Chair.  Live fast, die young, and have a good looking corpse!  Even a defense attorney as eloquent as Bogey couldn’t get him off.  “Knock on any door, and you’ll find a Nick Romano…”  So handsome Nick combs his hair for the last time, and, surrounded by his implacable gaolers, takes that last walk down the long corridor to the blinding light in the doorway at its end.  I wasn’t just scared; I was phobic.  The first sign of a noose, a gas chamber, or device attaching you to the national grid and I’m out of there!  In Glasgow there had been a man named Peter Manuel who had broken into houses and shot people in their sleep.  He had been one of the last people to be hanged at Barlinnie.  A colleague of my father’s had been present at his demise and he said it had been terrible.  But I didn’t want to know. There was no way you could dramatise judicial execution without its horror spilling over into real life.  I preferred to watch Perry Mason, because he always won his case.  The defendant was safe.  You wondered why the DA’s office bothered to give Hamilton Burger the brief, why they bothered to take a statement from Lieutenant Tragg, when they knew Mason, his secretary Della Street, and his private detective Paul Drake were on the case. The credits rolled by against the backdrop of a pile of old law books.  Lex Angelicorum.  The music was hard, noir, inviolable, the music of jurisprudence.

Pah pah paaaaaaah…. Pa PAH!  

Other noir TV sound tracks are forever etched on the memory.  The Dick Powell Show.  The music was an American version of a British Imperial March of the style of Elgar or Walton, with a spacious and eloquent maestoso melody preceded by a rhythmic, edgy, syncopated allegro.

Pa pa pah!- pa pa-ra Pa-rah!

  Pa pa pah! – pa pa-ra Pa-rah!

  PAH! PAH! Pah! Pah…

Hollywood Noir conveyed the sense that civilization in America was the thinnest veneer.  The good and the true were vastly outnumbered.  Nothing had changed from the days of the Wild West.  High Noon is the great exemplar of a notion that has been attributed to Edmund Burke, that in order for evil to prevail, all that is required is that good men do nothing.  So Garry Cooper trawls his way around town looking for deputes, and the good men do nothing.  Even Grace Kelly, for all that she looks great, isn’t much help.  By the time he has exhausted all the possibilities, Cooper is on a suicide mission.  Why didn’t he quit and get out of town?  Did he have a death wish?  Was it fortitude? Was he resolved to do the right thing come what may?  Was it, as Grace saw it, sheer bloody-mindedness?  Could he not bear the shame of acquiescence?

All of the above.  One thing’s for sure, he didn’t do it for love.  By the time he’s through, Cooper has shot up the men he hates and anybody who is still alive he despises.  They crawl out of their shuttered houses obsequiously and he turns his back on them and rides out of town.  Even his relationship with his bride is scarred – who knows – irreparably.

Extraordinary figures, these big stars of Hollywood in the golden age.  Cooper, Fonda, Wayne, Stewart, Peck.  Who compares with them now?  Cooper seemed to radiate an extraordinary moral power.  He could convince you he was a man big enough to face insurmountable odds, and win through.  It was a recurring theme in American culture, this notion of one brave individual versus the bad guys, with no help from his erstwhile tepid spew-thee-out-of-my-mouth friends.  The hero was sympathetic because he didn’t go out looking for a fight.  He didn’t seem by nature to be braver than any of the rest of us.  In fact, he was rather vulnerable.  He had sensitivity.  His enemies mistook it for weakness.  That was their mistake.  Capone v Ness.  Robert Stack played Ness on the TV.  Like Richard Greene playing Robin Hood on this side of the Pond, Stack had the demeanour of a bank manager.  The ordinary man in extraordinary circumstances.  He alone stopped Chicago from sliding into complete mayhem and anarchy.  The booze factor was almost a side issue.  It was all about power.  The saloon cars with the duckboards screeched around town and the machine guns went ratatatatatatat and the man in spats lay in a puddle of his own blood in the gutter.

Frank Nitty!  A dirty death for a dirty man!

Power, wealth, and sex – these were the ingredients of Hollywood Noir.  These were the driving forces, the things that made the American world go round.  And the women were worse than the men.  Look at Barbara Stanwyck in Double Indemnity. The ultimate femme fatale.  What chance did poor Fred McMurray have?  At least he plugs her in the end.  It’s like Macbeth.  There doesn’t seem to be any possibility of redemption for anybody.  Even Edward G Robinson, on the side of right, is a strangely amoral figure, a virtuoso of insurance law, devoted to the aesthetic of his calling for its own sake. Fred loves him, hates him, respects him, fears him.

“Straight down the line, Keys!”

It was a terrible vision.  It seemed to be at odds with one’s personal experience.  The psychopaths at school numbered less than a handful, shared more or less equally between staff and pupils.  If somebody got seriously out of line and, say, stabbed somebody in the toilets, the police would come and there would be an expulsion and the headmaster would say, “So-and-so had to go.  He was seriously interfering with the activity of the vast majority of our pupils who come to school to learn and who just want to get on with their work.”  And it seemed to be true.  Most of the time the school seemed to function, not because of any evident manifestation of tyranny, but by a mutual consent.

Yet maybe the Hollywood Noir vision was true.  Maybe it was all on a knife edge and all this civilisation of ours could collapse in a minute.  It had happened before.  Had it not happened that way in Germany between the wars?  In the land of Bach, Mozart, Beethoven, and Schubert, the gangsters had taken over.  Could it happen here?  If it were to start happening, would I recognise it? And if I did, what would I do?  Would I keep my head down and feather my nest (there’s always somebody making money out of a war), or would I, for sheer cussedness, be Garry Cooper?

I asked my father, a policeman, about villainy.  After all, confronting villainy was his calling.  Were we all wicked?

My father said, “There are two kinds of villains; there’s the needy, and there’s the greedy.”  That rings truer than ever.

 

 

 

 

 

 

Last week a friend said to me, “Have you read Robert Harris’s Conclave? I couldn’t put it down.”  It’s an irresistible recommendation.  I got a copy (Hutchinson, London, 2016) and read it.  My friend was quite right.  The book exercises a compulsive grip upon the reader.  The action takes place behind the locked doors of the Sistine Chapel over the course of 72 hours, and concerns the election of a new pope.  118 cardinals are present, and there are a series of ballots during which the field is narrowed down until a leader emerges.  “Habemus papam.”   It is not so much a whodunit as a who’s gonna do it.  I didn’t think that I could get particularly exercised about a papal election, but the various candidates, as seen through the eyes of an individual who himself turns out to be a contender, are drawn with humanity, and I found myself taking sides.  In its attention to detail, the book had clearly been meticulously researched.  Was I surprised at the outcome?  Without introducing a spoiler, I can say the denouement had a sting in the tail that I didn’t see coming.

I fell to wondering about books like Conclave that grip us.  To say of a book, “I couldn’t put it down”, suggests a compulsion to read bordering on addiction.  Now that I have completely run out of shelf space at home, I’m clearly a book addict.  A bibliomane.  Is there such a word?  My bijou cottage resembles not so much the local village library as an asylum for a sufferer of Diogenes Syndrome.  So in the management of my book repository I have introduced a rule; if I acquire a new tome, I must pass on an old one.  (Having read Conclave I did try to fob it off on somebody who, on hearing my blurb, said, “Not much sex, then?”) You think of the remark “I couldn’t put it down” as a recommendation but the strange thing is that it is precisely this sort of book which, once laid aside, you don’t pick up again.  Such books are read linearly, and once.  You wouldn’t dream of skipping to the last page because foreknowledge of the outcome would remove the motivation to read.  By contrast, the books that you keep on your shelves are the ones you want to pick up and reread over and over again.  They may not need to be read chronologically, even first time round.  There is joy to be had in picking up such books and reading a chapter at random.  The books we revisit are written in beautiful language over which we wish to linger.  In addition, their individual chapters often have a stand-alone quality; the mastery of the whole work of art resides in the fact that it is made up of a series of entities that simultaneously work autonomously and contribute to the whole.

I’m conscious of these issues as I find myself this week nearing the completion of my draft of the next troubled instalment in the life of Dr Alastair Cameron-Strange.  It has 27 chapters and is a little longer than its predecessors.  I’ve striven to give each chapter an autonomous life, to avoid writing a chapter which merely moves character A towards a destination without pausing to admire the view.  I guess I’m less beguiled by the notion of a reader compelled to rush to the end, and more intrigued by the thought of the reader content to read one chapter a night, and sleep on it.

At any rate, I’m nearly there.  Time to stop setting alight the rough drafts and creating all that black smoke.  Time to send some white smoke up the chimney.  Habemus librum. 

This happened one Christmas an age ago, in another galaxy.

I had repaired to my office with a copy of the Annual Proceedings of the Medical Protection Society – a bulky document with an appropriately black cover – to read a few salutary tales of medical mishap, misadventure, miscalculation, misbehaviour, missed diagnoses, and occasional miscarriages of justice.  A large number of the episodes described had occurred in hospital emergency departments.  We were a high risk area.  These vignettes were post-mortems, metaphorically and also sometimes literally.  They resembled the reports of a civil aviation crash inspectorate; by their detached regard for the truth, they could be brutally frank.  And ‘pilot error’, of one sort or another, was a recurring theme.  I read the reports and would feel a familiar crawling sensation in the pit of my stomach.  I would think to myself, “I’ve done that.”

One particular report I found almost unbelievable.  And yet the details had the starkness of authenticity about them.  A thirty year old man had come to a hospital emergency department complaining of chest pain.  He had been seen by a young doctor who had made a diagnosis of ‘dyspepsia’.  The patient had been given some antacid, and discharged. Shortly afterwards (the scene had been reconstructed following the hearing of evidence in a court of law) two hospital orderlies had approached the young doctor.  “Hey doc, remember that young guy with the chest pain you sent home?  Well, he’s dead.  Collapsed behind the steering wheel of his car a couple of hundred metres up the road.  But don’t worry.  We’ve turned his car around.  It looks as if he’s driving towards the hospital, not away from it.”  So the doctor had gone ahead and destroyed all evidence of the patient’s visit to the hospital – demographics, patient file, chest X-ray, ECG, lab results.  The memory banks were erased.  The patient no longer existed.  He had never existed.

I developed sweaty palms when I read that, and I thought about that wretched young doctor.  Had he conducted himself honourably he would, no doubt, have been rapped over the knuckles.  He would have been censured by the General Medical Council, perhaps severely.  He might have incurred public humiliation.  But he would have survived.  Not now.

There was a soft knock on my office door.

“Come in!”

Delegation of two.  Mike Ruddell and Sandra Cunningham, two orthopaedic house surgeons.  “Sorry to interrupt.  Could we ask your advice?”

“Take a pew.”  Was this a clinical matter?  I noticed they weren’t carrying any notes or X-rays.  I knew them vaguely as two first year doctors who worked on the same team together, and I had an idea they were an item.  They were both about twenty three.  Mike was dark and studious looking, while Sandra had shoulder length red hair, freckles and mischievous eyes.  For a moment they looked as if they sought counselling.  Perhaps they needed the morning-after pill.  I said, “What’s up?”

“We need your advice on a ‘turf’.”

My interest waned.  “Oh yes?”

“Which service in this hospital looks after cellulitis?”

“You ask difficult questions.”  I closed the MPS disaster file.  “Let’s see.  Mondays, Wednesdays, Fridays… orthopods, unless there is no evidence of bone or joint involvement, in which case it goes to the general surgeons.  Tuesdays, Thursdays, Saturdays… plastics.  Sundays alternate.  If, however, there is evidence of an underlying disease process, for example diabetes, it would go to the physicians.  Then there are special cases.  A periorbital cellulitis generally goes plastics.  But if there is ocular involvement, it would go to the ophthalmologists.  On the other hand, if there were cerebral involvement, it might go to the neurosurgeons, but some of these patients are so sick they end up with the Intensivists.  Simple.  What’s your problem, exactly?”

Mike and Sandra exchanged glances.  “Can we run the case by you?”

“Go ahead.”

Mike presented the case.  “We admitted a twenty five year old man on to the ward last Wednesday.  A Mr Cart.  Ronald Cart.”  The hint of a smile played on Mike’s lips.  “A motor mechanic.  He presented with a hot red right upper limb and a temperature of 38 degrees. Examination revealed a large cellulitic area over the flexor surface of the right arm extending from mid-forearm to ten centimetres above the elbow.  His hands were the typical hands of a mechanic, dirty, callused, with cracked fingertips in various stages of disrepair.

“We stuck him on the ward and put him on intravenous antibiotics.  The temperature came down overnight.  Ordinarily, at this stage, we would have sent him home on oral antibiotics.  But we noticed some abnormal neurology of the right arm.”

“What abnormal neurology?”

“Wasting of the intrinsic muscles of the right hand, with some motor loss, about four-fifths.  Proximal muscle bulk seemed okay – maybe a subtle power loss.”

“Perhaps related to pain?”

“Well, that’s the funny thing.  The cellulitis wasn’t painful.  Mr Cart demonstrated this by pinching the area.”

“And he didn’t feel it?”

“He felt it.  It just didn’t bother him.”

“Anything more on that?  What had Mr Cart himself noticed?”

“Actually,” said Mike, “he had a rather strange complaint.  When he went into the fridge for a cold one he had to use his left hand.  If he used his right, he couldn’t decide which beers had been chilled.”

“Interesting array of symptoms and signs!  What did you decide at the morning ward round?”

“Unfortunately,” said Sandra, chipping in for the first time, “the boss didn’t see him.  We had sent him for a repeat X-Ray of the right arm because we thought we could see a foreign body in the cubital fossa.  So Mr Cart was down at X-ray during morning rounds, and the boss missed him.  Actually the X-ray was normal – the ‘foreign body’ was just an artefact.”

“So what happened next?”

“Well, on the basis of what we told him, the boss decided to hold on to Mr Cart and investigate him.”

“Who’s the boss?”

Mike mentioned a name.

I gave a low whistle.  “The Incandescent Light!”  It was absurd to feel intimidated by the mention of a name, but I had an image of a small, compact figure swaggering down the main hospital corridor with the glaring, crazed eyes of the occupying dictator marching down a deserted Champs-Elysees.  “If you think The Incandescent Light is ferocious now,” elderly Charge Nurses used to tell me, “you should have seen him twenty years ago.  Remember the time he beat up his House Surgeon because he couldn’t remember a patient’s haemoglobin…”  Of course, I realised, The Incandescent Light would investigate Mr Cart.  He would, if necessary, bleed Mr Cart dry to get to the bottom of Mr Cart’s problem.  He would not hand Mr Cart over to another service unless it was absolutely necessary and in particular he would not ask for nor expect any input into the management of the case from the physicians, for most of whom he had scant respect.  Poor Mr Cart!  Which was the lesser of two evils, to put up with a dodgy limb or be subjected to the full brunt of The Incandescent Light’s investigative and therapeutic zeal?  I silently transmitted my thoughts to the patient.  “Mr Cart, I don’t know you, but self-discharge now, while you have a chance.  Take to the hills – with a chilly bin of cold ones.  You can still gauge the temperature with your left hand…”

I said, “So what investigations have you done?”

“Full blood count, ESR, blood cultures, urea and electrolytes, liver function tests, calcium, phosphate, alk phos, urate, albumen, Rheumatoid Factor, Antinuclear Factor, Anti-DNA antibody, urinalysis, syphilis serology, you name it.”

“Turn up anything?”

“Everything is essentially normal.”

“How about radiology?”

“Upper limb normal.  Chest X-ray normal.  Cervical spine, normal.”

“Did you get thoracic inlet views?”

“Looking for cervical ribs?  Yes, we did.  No extra ribs.”

“So what else have you done?”

“The Incandescent Light came to see him on Friday, but unfortunately he missed him because we had sent him for some electrical studies.  Myography.  He left instructions for him to have a CT – head and neck – at the beginning of the week.”

“So has he gone home for the weekend?”

“No.  Incandescence wanted him to stay on the ward, in case he was developing a cervical stenosis, and ‘went off’.”

“How has he been over the weekend?”

“Much the same.  Three to four on five global right upper limb power loss with associated muscle wasting.  Sensory changes.  Loss of reflexes.”

“Signs all unilateral?”

“Yes.”

“Any neuro signs higher up?  Bulbar palsy?  Horner’s Syndrome?  Balaclava helmet sensory loss?”

“No.  What are you thinking of”

“He’s got classical dissociative sensory loss – loss of pain and temperature sense, with preservation of light touch and, presumably, proprioception.  I don’t say it’s pathognomonic, but you have to consider syringomyelia.  What does The Incandescent Light think?”

Mike nodded.  “He thinks it’s got to be syringomyelia, too.  Just on the basis of history alone.  He still hasn’t seen the patient.  He came in to-day, but we got the chance of fitting Mr Cart in for the CT this afternoon.  Radiology offered us a slot.”

“What did the scan show?  Was it helpful?”

“Equivocal. The head scan was normal.  The radiologists thought there was cervical enlargement and maybe evidence of a syrinx, but they weren’t prepared to be categorical, and they said it could all be within normal limits.”

Sandra said, “That brings us up to the present.  He came in on Wednesday.  To-day is Sunday, and we think it’s time he was turfed from our service.”

I shrugged.  “So turf him.  Turf him to the neurosurgeons.  What he needs is an MRI scan.  You need to know whether he’s got an Arnold-Chiari malformation.  Get the scan, confirm the diagnosis, and get him across to neurosurgery.”

Mike and Sandra looked at one another.  Mike said, “Thought you might say that.  That’s what we think.  That’s what The Incandescent Light thinks.  There’s only one problem.”

“What’s that?”

“It’s Mr Cart.  He doesn’t exist.”

*

Ronald Cart was a little Yuletide diversion that had got out of hand.  His name was a bastardisation of Rene Descartes, the French Philosopher and mathematician who had attempted to establish a solid foundation for all human knowledge based on the cogito.

Cogito ergo sum.

There was collateral invested in Ronnie.  Mike had bet Sandra one bottle of fifteen year old Laphroaig single malt whisky that he could present a figment of his imagination on the ward round of Thursday, December 19^th, and keep the figment alive until Christmas morning.  It had been planned that, during the customary Christmas ward revelries, Mike would reveal to The Incandescent Light that Ronald’s empty bed had always been empty, and that Ronald had never been to X-ray, Myography, CT, or any of the other venues to which he had been hurriedly despatched whenever The Incandescent Light was sighted on the ward.  And they would laugh – this at least was the plan – at the recollection of how the morning round had repeatedly assembled with due gravity round the foot of Ron’s bed, studying the factitious temperature chart.

It was a good, imaginative scam.  It would have been easy if the boss had been a physicianly elder statesman who spent large tracts of his week out on the golf course.  The Incandescent Light could, of course, be as much of an absentee landlord as any of the other eminent wise men of the hospital, but he was not, as far as I knew, a golfer.  I knew he was a workaholic whose whole life was tied up in hospitals, theatres, wards, clinics, and medical committees.  He started early in the morning and worked late into the night.  His movements were unpredictable and he was often seen prowling the hospital corridors in the wee small hours.  He would have taken in all the information he had been given on the airy Mr Cart, he would have forgotten none of it, and, if asked at any stage, he would have been able to tell you what particular investigation was pending, and what the likely diagnostic possibilities were.  It occurred to me that specialist registrars and nurses on the ward must have been brought in on the act.  The Incandescent Light would quite likely have phoned the ward at three o’clock in the morning to ask how Mr Cart was progressing.  So how would he take it when he found out he had been duped?  I couldn’t imagine.  I had never seen The Incandescent Light smile.

I said to Mike, “I wouldn’t care to be on your ward on Christmas Day when you tell the old man, but now that he’s sanctioned an MRI scan, I should say your Laphroaig is in the bag.  Merry Christmas.”

But Mike was shaking his head.  “No, no.  You don’t understand.  I’ve already conceded the Scotch to Sandra.  We need to turf Mr Cart.  We need to get rid of him and we need to get rid of him now!”

“Why?”

By way of reply, Mike delved into his pocket and produced a wad of computer printout paper.

“What’s that?”

“It’s the monthly budget for the ward.”  He flicked through some pages.  “This is the cost of the investigation of Mr Cart thus far.  If you add up hotel services, treatment for the cellulitis, lab work, scans etc. etc., you reach this figure.”

It was a substantial five-figured number.

“If we go ahead with magnetic resonance, we arrive at this figure.”

It was a very substantial five-figured number.  For the second time during the conversation, I gave a low whistle.

“If The Incandescent Light finds out about this,” said Mike, “there will be hell to pay.”

“But surely this is just a paper exercise.”

“No!  We have spent the money.  It’s gone.”

“Well where has it gone?  Who has it?”

“I have no idea.”  Mike’s understanding of the microeconomics of the hospital was as thin as mine.  “It seems to have vanished, down a great entropic sink.  So you see, Mr Cart mustn’t have that MRI scan.  We’ve got to cut our losses and run.  We’ve got to turf him.”

What an absurd predicament.  I idly fingered the pages of the black-covered Medical Protection Society publication I had lately been reading.  It occurred to me that Mike and Sandra’s little difficulty was exactly the opposite to the nightmarish case report I’d just read, concerning the young man with chest pain whose records had been systematically annihilated without trace.  There, it had been as if a man of real flesh and blood had been swallowed up and lost in an amorphous Soviet Gulag.  He had been a real patient of whom there was no record.  On the contrary, Mike and Sandra’s creation, the figment, Cart, was an imaginary patient with an embarrassing superabundance of annotation, an exuberant profusion of recorded data that had assumed an independent life and was now reproducing itself with promiscuous abandon.  All over the hospital, and throughout the connected network of the Area Health Board, the name Cart was steadily gaining substance as the laser printers spewed forth his credentials.  Could he be stopped?

I said to Mike and Sandra, “Do you like Soviet symphonic music?  Shostakovich?  Prokofiev?”  Mike gave me an impatient shake of his head.

“Prokofiev composed a symphonic suite based on the Russian tale of Lieutenant Kije.  Do you know it?  The Russian Tsar was reading a report from an army officer which contained a sentence beginning ‘Lieutenantki je…’, which means, ‘The Lieutenants, however…’  He misread it as ‘Lieutenant Kije…’ and took it to refer to the name of an army officer, Kije.  In order not to frustrate the Imperial pleasure, the Tsar’s military commanders-in-chief had to create a Lieutenant Kije, and furnish him with a biography, much as you have done with Mr Cart.  As a matter of fact, the army ended up in just the sticky situation you are in.”

“And what was their solution?”

“They killed him off.”

Mike pursed his lips.  “What are you suggesting?  A motor vehicle accident?  A fall?  A heart attack?”

“Definitely not.  That might go as far as the coroner.  There would certainly be a post-mortem.  No.  The solution is simple.”  I took a form of self-discharge from my pocket – I have the habit of carrying one around with me.  “Get Mr Cart to sign himself out, against medical advice…”

It was as if a cloud had suddenly evaporated from above Mike’s head.  His face broke out into a serene smile.  He said, slowly and meaningfully, “That is perfect.”

And it was perfect.  It was a perfect solution because if there was anything to make an archetypal psychopathic orthopaedic surgeon lose interest in a patient, it was a form of self-discharge against medical advice.  The Incandescent Light would quietly and irrevocably take offence.  If Mr Cart was not going to be grateful for the service offered, then he could bloody well take himself out of the hospital, and take his precious self-discharge form, and stuff it up…

And the bed clothes would be changed, the name of Cart erased from the blackboard in the doctors’ office.  The electronic record would be despatched with a click of a mouse to some virtual repository on cloud nine, and any paper notes sent back down to the bowels of the hospital records department.  With any luck, no inquisitive eyebrows would be raised at the cost of keeping Mr Cart for five days prior to his departure, and the alarming cost of Mr Cart’s upkeep would be lost amid the details and complexities of a host of other expenditures.  The Incandescent Light would deliberately and unforgivingly erase from his mind all thoughts of Mr Cart and his condition and, with any luck, that would be that.

Mike looked at me squarely.  “Thanks for that.  It’s a brilliant turf.  A self-turf, back to the community.  I owe you.”

“You do.”

Thus Mike and Sandra went off with the self-discharge form to forge the signature of Mr Cart, as it would be written in a hand that felt nor hot, nor cold, nor pain, thus to placate their Tsar.  And I returned to reading more Gothic medical horror stories, absentmindedly whistling the Troika from Lieutenant Kije by Prokofiev, who died on March 5^th, 1953, the same day as Stalin.

 

 

 

On Question Time from Torquay (BBC 1, February 9^th), the panel was asked, “If one of your elderly relatives was admitted to “A & E” tonight, how confident would you be that that person would get a bed, or stay on a stretcher?”  This pointed question soon promoted a general discussion about the parlous state of the NHS.  Owen Smith put that down to underfunding; Billy Bragg identified reducing hospital bed numbers as a cost-cutting exercise; Ann Widdecombe thought increased funding was not the answer; we needed a “grown-up” debate, on how to fund Health – but she didn’t actually say how she thought Health should be funded.  Claire Perry agreed with Ann Widdecombe.  She thought the NHS shouldn’t be a “political football”; she also thought 30% of the patients attending emergency departments didn’t need to be there.  Peter Whittle thought Health and Social Care needed to be integrated, and that moneys could be redirected from the overseas aid budget in order to help with funding.  Even the chair had a view.  David Dimbleby considered the typical left-right political posturing as represented by the panel to be sterile.  The prevailing opinion from the floor was that the NHS was poorly managed by an inflated bureaucracy.

The whole debate seemed to generate more heat than light.  There was a general expression of apprehension and anxiety that one’s putative elderly relative might end up languishing for many hours on a stretcher.  But what I found remarkable about the discussion was that, while there was general consensus that the NHS is in trouble, not one single concrete initiative was proposed.  Not one.  If for example, you want to spend more money on the NHS, you might say precisely how much more you wish to spend, and what precisely you want to spend it on.  If on the other hand, you think the NHS needs reform, you might make a suggestion as to what a reformed NHS would look like.  If you think the NHS has to offer the public a different product, you might wish to describe what this new product would be.  You might even wish to scrap the NHS.  There was none of this.  In other words, it has to be said, the standard of debate was very poor.

But it’s hard to see how it could be otherwise.  You really can’t begin to organise a health service unless you know a bit of medicine.  The construction of an NHS is an act of integration.  You might ask, how do you manage a patient who presents with a headache?  You can’t begin to answer that unless you know about the epidemiology and pathophysiology of headache, what headaches are benign, what headaches are sinister, can we intervene, should we intervene, and so on.  Then you might ask, how do you manage a patient with chest pain, and again you have to go through all the different kinds of chest pain.  Then you do exactly the same for abdominal pain, back pain, nausea and vomiting, cough, shortness of breath, altered consciousness, auditory hallucinations, suicidal intent…  It’s a huge undertaking.  You can’t begin to make any sense of it unless you immerse yourself in it for a lifetime.  This is why there is some sense in the suggestion that people should indeed not make the NHS a political football.  It would surely be better if the politicians approached the doctors and nurses and said, “What do you need?”

The trouble is, they wouldn’t get a straight answer.  It has to be said, the medical profession lacks cohesion and leadership.  The specialties still operate within their own isolated silos.  Medicine is profoundly tribal.  Interestingly enough, this is most evident at the front door of the hospital.  Most members of the public are unaware of the fact that, for patients who are acutely unwell, there are two modes of admission to hospital – either via “Accident & Emergency” (“A & E”) or via the “Acute Assessment Unit” (“AAU”).  If you visit your GP with your headache and she decides you need urgent investigation, she will send you to the AAU.  If you front up to hospital directly with your headache, you will be seen in “A & E”.  Same patient, same presenting complaint, same diagnosis – different pathway.  Depending on which path you take, you will be assessed by one of two doctors with very different training backgrounds and career pathways.  If you arrive at AAU you will have with you an accompanying letter of referral from your GP.  It’s a kind of invitation or admission ticket.  If you front up to “A & E”, you are a gate-crasher and let’s face it you might be one of the 30% that Claire Perry (and indeed Westminster Health Secretary Jeremy Hunt) say shouldn’t be there.  You need to be disposed of ASAP (certainly within four hours).  AAU will happily keep you for 48 hours, if necessary.  The front door of the hospital operates a system of apartheid.  The public don’t know about this.

Why should this be so?  It’s historical.  There used to be an entity called “General Medicine” or “Internal Medicine”.  With the rise of specialties and super-specialties the general physician became a dying breed.  AAUs started springing up about 30 years ago and internal physicians morphed into “acute” physicians and a subspecialty of “Acute Medicine” was born.  So acute physicians have a college and a career pathway and an annual conference, and emergency physicians have a college and a career pathway and an annual conference, and a lot of the time they are discussing and researching and treating exactly the same conditions, in their isolated silos.  It’s completely potty.

I’ve accused the Question Time panellists of offering no solutions so the least I can do is make one concrete suggestion.  I’m not suggesting for a moment this would be any more than a start, but at least it’s a start at the front door where that elderly patient is languishing.  I think Acute Medicine and “A & E” should amalgamate to form a single specialty which runs a single department.  Call it the Department of Emergency Medicine.