jamescalumcampbell

When I was a medical student I went to the Highlands of Papua New Guinea for four months to work in Immanuel Lutheran Hospital, Wapenamanda, Enga Province.  One Friday night a group of us drove 25 miles up the road to the town of Hagen to see a film.  Hagen was pretty rough; bit of a Wild West town.  The theatre was packed.  I can’t remember what the film was, but I have a vague notion Barbra Streisand was in it.  What the burghers of Hagen made of her I can’t say.

Half way through the second reel there was a commotion, the film came to a halt, and the house lights came on.  The police had entered the theatre, in force, looking for a man on the run.  Suddenly the fugitive broke cover and made a dash for the exit, bottom left.  But the police had the exit covered.  He scrambled across the people in one of the front row stalls to the right hand aisle and sprinted up to the rear right exit where half a dozen officers overpowered him and pinned him to the floor.  It was clear that the audience as a whole found all this infinitely more entertaining than the film, and there was laughter and applause as the fugitive was led out.

I found it all reminiscent of the denouement of the Hitchcock version of The Thirty Nine Steps.  The entire scenario was intensely theatrical precisely because of the location.  I didn’t so much observe a fugitive being apprehended by the police, as a thespian playing the part of a fugitive, being apprehended by a troupe of thespians whose police uniforms were from wardrobe.

On another occasion we were driving to a remote location to carry out a paediatric clinic when our vehicle got diverted to an Aid Station and we started to receive injured patients from a pitched battle.  Most of the injuries were spear wounds.  I was given the task of moving from patient to patient, putting up as many intravenous drips as possible.  I had the same sense as I’d had at the movies, that I was not so much treating a group of warriors, as a repertory company depicting the activities of a battlefield dressing station.  The atmosphere was strangely euphoric; even people with serious injuries seemed quite happy.  I wondered if they were overacting.  It all seemed a bit hammy.  Yet their blood was not ersatz.

I have this notion that when we elect to behave at the dangerous edge of things, we first apply the greasepaint and put on a costume.  Psychiatrists call it “acting out”.  Most of the rage you see in hospital emergency departments is sham rage.  The trick of the emergency physician is to find a formula that will permit an aggressive person to step over the footlights, come out of role, “corpse”, and act like a human being.

But occasionally the rage is real.  You have to recognise that.  And it’s a mistake to imagine it’s only other people who can go berserk.  It’s in all of us.  A couple of years ago I had the most hellish toothache.  The dentist couldn’t pinpoint the problem and ended up giving me a course of metronidazole.  I won’t say it was a fob off, but I took it without much confidence.  A week later I had an entirely sleepless night spent pacing the floor, swallowing codeine and gargling with whisky.  Nothing touched it.  I went back to the dentist determined to get an extraction.  She could do a total clearance for all I cared, so long as I was rid of this “hell of all diseases”.  You sometimes hear of an elephant in a zoo with an undiagnosed tusk abscess who suddenly loses the plot and wrecks the joint in a frenzy.  I might have wrecked a dental surgery.   Maybe the dentist sensed it.  At any rate, the extraction worked, God bless her.

But don’t imagine there’s not something out there that will make you flip.

Man walks into a pub…

…and asks the barman for a glass of water.  The barman pulls out a loaded revolver, cocks it, and points it at the man.  The man says, “Thank you”, and leaves.

This is known as a situational puzzle.  What is the meaning of it?  You need to think laterally.  The game can be played out in the form of 20 questions demanding only the answers yes or no, or, as a third possibility, “not relevant”.  Was the barman angry?  No.  Was the man thirsty?  No.  Were his thanks genuine?  Yes.    Did the man and the barman know one another?  Not relevant.  And so on.  If you ask the right questions, you might eventually tease it out.  Hint: hiccups.

A man lives on the 100^th floor of a skyscraper.  When he goes home, why does he only use the lift on rainy days?

Dwarf with an umbrella.

The body of a dead scuba diver is discovered amid the charred debris of a bush fire.

Answer: he had been scooped from the ocean by a helicopter picking up water to fight the fire.  This last one is true.

Writing a piece of fiction is a bit like solving a situational puzzle.  You set up the conundrum and think, what’s the meaning of that?  How did it happen?  And in the process of answering, you write a book.  I don’t say it’s the best way to write a book, but it’s certainly the way I’m landed with right now.  People have been kind enough to ask me, what is my working method?  Do I rise at 5 in the morning and write 2000 words?  No.  I go to my local gym.  I get on the treadmill and run 5,000 metres.  Then I go into the sauna, 90 degrees +, lie down, and go into a reverie.  It must be the combination of all these endorphins and incipient heat stroke.  Ideas beset me.  I have to admit that, on emerging and plunging into the pool’s cool waters, most of them evaporate.  But a few remain.

So I write my first chapter.  And all of a sudden, my character is in a heck of a fix.  I’ve now got to spend the next 24 chapters seeing if I can get him out of it.  That involves an awful lot of visits to the gym.

Talking of “20 Questions”, are you old enough to remember the radio quiz programme?  The panel had to identify an object.  It was animal, vegetable, mineral, a combination of all three, or abstract.  A disembodied voice (I suppose all voices on the radio are disembodied) would announce to the audience (but not the panel), that the next object is:

“A colourless green idea.

“A colourless green idea…”

And the timbre of the voice would be such that you might imagine it had been recorded in a nuclear bunker.

Some of the panellists were extraordinarily adept at the game.  There was a lady named Joy who was so good that she got a solo spot every week.

“And now, for Joy’s Solo…”

“Is it philosophical?”

“Yes.”

“Is it linguistic?”  (Applause.)

“Yes.”

“Does it sleep furiously?”  (Furious applause.)

“Is it… is it… a colourless green idea?”

Hysteria.

Dear Joy, I need your extraordinary imagination to tell my protagonist how to get out of the hole he has dug for himself.   It can’t be a good way to write a book.  You pose a conundrum before you know the answer to it.  It’s rather like composing a crossword clue back to front.  The clue turns out to be the answer and the solution turns out to be the question.  Hence…

“I… God yes mum I think so.  Blob!” (4,2,3,4,3,2,4)

Solution: Does my bum look big in this?

Sometimes I think I’m on the spectrum.

“Patient dies on hospital trolley”…

…says the headline on page 13 of Saturday’s Herald.  This is a recurring story in the UK and we are all quite familiar with it.  The subheading is “Pensioner death after six-hour wait for treatment at new super-hospital”.  If you read the ensuing article, you will encounter the following:  a review has been instigated – check; the department in question was under extraordinary pressure at the time, due to patient numbers – check; the incident occurred after-hours – check; staff are working flat out – check; the health secretary has been informed – check; lessons will be learned from the review and the health board will take immediate steps as required – check; the shadow health spokesperson says the incident is symptomatic of serious underlying problems – check; our hard working NHS staff are undervalued and our government is applying a sticking-plaster quick fix – check; they have no strategic vision – check; the government must be held to account if they fail to give the public the care it deserves – check; this must be done before winter sets in properly – check.

What is also predictable about such a report is that which is absent from it.  There is no indication as to what might serve as a suitable “strategic vision”.  And there are no numbers.  The report is neither qualitative nor quantitative.

For this, I have to say some of the blame lies within my own profession.  As a body, we doctors have not provided coherent leadership for the benefit of managers and politicians.  How can they be expected to know what to do if we don’t tell them?  The trouble is, there is no coherent consensus within the medical profession as a whole as to what kind of “strategic vision” might work.  Even in the twenty first century, medicine remains profoundly tribal.  The more subspecialised and super-specialised it has become, the more its practitioners operate within “silos”, largely oblivious to what goes on elsewhere, unless the silo falls under threat.

Yet much of what needs to be done is predicated on the numbers.  How do you manage the front door of your hospital?  What is a reasonable work load for a doctor working in this environment?  You seldom hear this matter discussed – not in the public domain anyway.  In my experience, a doctor working in a busy and a high acuity emergency department offering a high standard of care can see, on average, about 12 patients during an 8 hour shift.  If he is not merely triaging the patients, but actually working them up and managing them in a comprehensive fashion, 12 is enough.

Let us now suppose an emergency department sees 100,000 patients per annum.  That is on average 274 patients per day.  That is busy.  For each emergency physician to see a dozen patients, we need 23 doctors “on the floor” – maybe 9 in the day, 9 in the evening, 5 overnight, depending on local demand.   Let’s give everybody a five day week with 6 weeks holiday and 2 weeks study leave.  Then a doctor will work 220 days in the year.  You only have 0.6 of your medical workforce available on a given day.  So the total medical workforce is 38 full time equivalent doctors.  Let’s make the skill mix top heavy – say 20 consultants, 12 registrars in training, and 6 junior doctors experiencing a “taster” under supervision.

If politicians want a “strategic vision”, there, at least, is one part of it.  Pie in the sky?  My old stomping ground, Middlemore Hospital Department of Emergency Medicine in Auckland, sees about 100,000 patients per annum, and its medical staffing is actually rather better than the above.  But then, emergency medicine in Australasia is in an entirely different league.  That’s why all our junior doctors want to go there.

Every so often, a news item comes along to refresh the Trident debate, and this week we had two at once.  Apparently the estimated cost of the upgrade of the weapons system has skyrocketed (sic!) from £100 billion to £167 billion, with the proviso that this could well be an underestimate.  Simultaneously, the historian Peter Hennessy was interviewed on the Jeremy Vine programme regarding his book (co-authored with James Jinks) “The Silent Deep”, a post-war history of the Royal Navy submarine service.  Much of the interview was taken up with the grizzly details of the mechanics of “pushing the nuclear button”, or, apparently more accurately, “firing the nuclear gun”.  Prof Hennessy got unprecedented access to the submarines in question, visited various nuclear bunkers, and had an unusually candid interview with the Prime Minister.  It seems that in the event of the nuclear balloon going up, the captain of the submarine gets a signal ordering him to open a “letter of last resort” written to him in advance by the PM and kept in a sealed envelope, in a safe.  The captain is then required to carry out the orders contained in the letter, whatever they might be.  If the order is to launch an attack, this involves the simultaneous actions of three people in the submarine.

Every time Trident rears its ugly warhead like this, there is a flurry of correspondence in the letters pages of The Herald, hardly surprising since The Herald offices, 200 Renfield Street, Glasgow G2 3QB, are 33 nautical miles from Coulport, the largest repository of nuclear warheads in Europe.  The burden of these passionate exchanges is always essentially the same as are indeed, the names of the eloquent correspondents themselves, well known to Herald readers.  Indefensible moral obscenity, useless and hellishly expensive, versus deterrent, and “insurance policy” that has kept the peace for 70 years.  The argument has continued throughout this time, with little, if any progress.

When I was a callow youth in the University Air Squadron, the Cold War was still pretty hot, and I remember having a conversation in the bar of the Officers’ Mess in RAF Abingdon, Oxfordshire, about the morality, or otherwise, of “taking out” Moscow.  This was not a theoretical debate; my instructor had taken two years off flying nuclear armed Vulcan bombers to a failsafe point over eastern Europe, to teach me and my pals how to fly Chipmunks.  He told me if ordered to do so, he would drop the bomb, because it was his “duty”.  I told him if I were in his flying boots, I would not, as it would be a war crime.  I wonder now that I had the nerve.  I was after all in the RAF Volunteer Reserve.  I had even signed an oath of allegiance to Her Majesty.  I recall having a conversation with my Squadron Leader, when called upon to sign said document, when I asked him what I should do if I were ordered to commit an act I considered morally indefensible.  To his great credit, the Squadron Leader did not give me a good bollocking (a stock response in the armed services of the time) but he took my question very seriously and gave me a reasoned and ultimately liberal reply that would have stood up at Nuremberg.  So I wasn’t clapped in irons, although I did gain my nickname in the Squadron, “the pacifist intellectual” (wrong on both counts).  “But enough of this airy persiflage, Campbell.  Take your kite out to the local flying area, climb to 7,000 feet, and spin it.  If you haven’t recovered by 3,000 feet, bale out!  Now b***** off, there’s a good fellow.”

If I were PM, you may imagine what I might write in my letter of last resort.  “If Blighty toast, proceed to friendly port.  Suggest Auckland.  Oh no!  They’re nuclear free.  Try Melbourne.  Peace.”  Mr Corbyn says something similar.

There is something very odd about these “letters of last resort”.  Nobody, apart from the PM, knows what’s in them.  At the end of the PM’s period in office, the letters are destroyed unopened, and the new incumbent writes new letters.  He becomes the sole arbiter at Armageddon.  He might decide the issue over a Ouija board, or with the toss of a coin.  That seems an extraordinary excess of power for one individual to have in a parliamentary democracy.  But this is how deterrence works.  The idea is to put any potential aggressor into a state of not-knowing.  It’s like a game of poker.  The opposition needs to be convinced that their act of aggression will set off a chain of events as surely as night follows day.  The Trident weapons system therefore is like a hand grenade whose pin has been removed; all the grenadier need do is cast the grenade, and it will explode.   Are we bluffing?  The reason why the establishment is so annoyed with Mr Corbyn is that he is not playing with a poker face.

We remain at an impasse.  Is there any way we can move this debate forward?  I think there is.  I can readily see that that unilateralists and multilateralists are nowhere near any agreement; but there is one point of view I believe we could all rubbish unreservedly.  It is the notion that the “nuclear umbrella” (I call it “GAMP” – Generally Assured Mutual Pulverisation) is anything other than a highly volatile and highly dangerous canopy to be under.)  Rather than creating a new generation Trident, we need to start – just start – dismantling these hellish contraptions.  The notion that the reason why we have avoided nuclear war for 70 years is because of the existence of these weapons, needs to be replaced by a different view: the fact that we have avoided a nuclear war for 70 years despite the presence of a plethora of these weapons, is nothing short of a miracle.  Sooner or later, our luck will run out.  You can conjure various nightmare scenarios and give them a name – the Strangelove Scenario of the rogue general, the Failsafe Scenario of the computer glitch, the Thunderball scenario of the international terrorist, the “win-win going forward” scenario of a modern manager’s absurd set of protocols…

To these I would now add the “TalkTalk scenario”.  This is the way the world ends.  A fifteen year old computer whizz in a bedroom in a West London suburb figures out a way to contact the silent deep, bypass the letter of last resort, and pull the trigger.

Just for the fun of it.

In April, 1874, the Scottish geologist Charles Lyell received this letter:

Dear Sir,

I thank you for your great kindness in having sent me the new Edition of yr remarkable work; and I am very glad that it has been so highly successful for a 4^th Edition to have appeared within so short a time.  Pray believe me Dear Sir,

Yours with much respect

Very faithfully

Ch. Darwin

Contrast this with the sign-off closing an email I received yesterday:

Best

I have to saying, knowing the sender, “Best” was uttered with a certain irony, by which I don’t mean he wished me the worst, rather he knew I’d be amused by the absurdity of “Best”.  The last time I got an email ending with “Best” was a couple of years ago when I sent a tome to a literary agent who sent me an acknowledgement of receipt, for which I was grateful, even though I immediately knew that we would not establish a connection.  “Best” was truly valedictory.  He might just as easily have written, “Later” which in this case would have signified “Won’t see you later.”  Getting a communication that ends with “Best” is like your girlfriend dumping you by text.

Saying goodbye seems to be inherently socially awkward.  What is the right formula for a given situation?  I once received a job application from a strong candidate whose covering letter was fatally flawed – at least in the eyes of a colleague of mine – by the fact that he had not ended with “Yours sincerely”, but with “Sincerely yours.”  My colleague thought it smacked of insincerity.  I defended the candidate on the grounds that he had worked for a time in the USA.  “Sincerely yours” has a trans-Atlantic ring to my ears.  It sounds insincere on this side of the Pond precisely because it’s so sincere.

“Yours faithfully” sounds old fashioned and formal.  It is the language of the bank manager.  You seldom see it now.  Maybe nobody takes seriously the idea that anybody “acts in good faith” any longer.  North of the border, you sometimes hear “Yours aye”.  I don’t care for it.  A military man at a Burns supper with whisky on his breath would say “Yours aye”.   “Yours truly”?  Yours truly wouldn’t adopt that either.  I’m either yours or I’m not yours.  I might say “Yours” and leave it at that but I’d have to know you just a little.

Whatever formula you apply, it generally needs to be preceded by a qualifier, to avoid a sense of abruptness.  It’s a bit like taking your leave from somebody’s house after a dinner party.  You can’t suddenly say “Goodbye” and vanish (though doubtless on occasion your hosts wish you would).  You need to linger for a moment on the doorstep.  The Canadian humourist Stephen Leacock wrote a short piece about a socially awkward young man invited to tea who stays for ever because he can’t find the right words on which to depart.

“With kind regards and best wishes…”  Best wishes are okay, but why are the regards kind?  Only the recipient of the kindness can evaluate it.  You could write, “With regards kindly meant…” but this sounds as if you are bestowing your pity on someone.  It’s a minefield.  “Best regards” sounded a bit gauche a few years ago but has become quite fashionable.

But to return to the email which ended with “Best”, I’ve just looked at my reply, which ends thus:

Go placidly amid the noise and haste.

That wasn’t entirely serious either.  It set me thinking, why have we stopped writing like Charles Darwin?  What is the fatal attraction to us in particular, who inhabit these islands, of irony?  Why are we embarrassed by an expression of sentiment?

I think of irony as a kind of perpetual in-joke.  The less foreigners understand it, the more it is valued.  Continental Europeans are exasperated by it and North Americans just don’t know it’s there.  The English in particular have this crazy compulsion to say that something is what it is not.  Some people’s entire mode of expression is like a Constance Garnett translation of a Dostoevsky novel, to the accompaniment of Shostakovich’s Fifteenth Symphony.  Every utterance has a hidden agenda.  Some people live out their entire lives at an ironic remove.   Irony is a survival mechanism for people who have been put in a bind.  It is the seditious expression of people compelled to live in a lunatic asylum.

Now I need to think of some way of winding up this rambling blog.  Enough already.  In the immortal words of Brian Matthew, that’s your lot for this week.  See you next week.   I thank you for your continued indulgence, hoping to remain, believe me, your most obedient servant

Best

Later

JCC

On September 2nd, the literary website NewInBooks interviewed me, and asked me some searching questions.  They kindly published my answers last week, and here they are!

Tell us a little bit about your new release, Click, Double-Click.

In Click, Double-Click, Dr Alastair Cameron-Strange, a bereaved and emotionally labile young doctor, solves an obscure cryptic crossword, and realises that, deeply embedded within the puzzle’s solution, lies a terrorist threat.  His attempts to alert the authorities are met with derision.  The more he struggles with the puzzle, the more unbalanced he becomes.  The question is, is he mad, or is he the only sane person in a vast lunatic asylum?

I was intrigued by the idea of constructing a plot around a crossword puzzle.  If you are not a cruciverbalist, never fear; Alastair does the solving for us.  Mind you, there is one vital piece of information buried in the solution that he never divulges.  To find it, you need to solve the puzzle.  And even then you might not see it.

What draws you to the crime thriller genre?  What about it makes you want to write?

Click, Double-Click is a bit subversive.  I’ve tried to turn the crime thriller on its head.  My protagonist, rather than discovering a crime and working through the clues towards a solution, discovers a solution that may or may not allow him to prevent a crime.  I supposed I’ve hijacked elements of the crime thriller genre for my own nefarious purposes.  I don’t think I quite knew what Click, Double-Click was about until I’d finished it.  Somebody pulling it off the “Crime” section in the bookshop might justifiably feel he’d been tricked.  Click, Double-Click is not about the detection of crime; it’s about the detection of humbug.

What are your favourite books to give – and get – as gifts?

Oddly enough, it’s my birthday today!  I’ve been given A Stranger in My Country, the 1944 Prison Diary, by Hans Fallada, translated by Allan Blunden (Polity Press, 2015).  I’d never heard of Fallada until this morning.  He was a German novelist who on 4^th September 1944 was committed to the Neustrelitz-Strelitz state facility, a prison for “mentally ill criminals” in Mecklenburg.  At great personal risk, he kept a diary.  I can’t put it down.  It’s quite phenomenal. The description of life in Germany under the Third Reich is so vivid; I read it and think, yes, that must have been what it was like.

A gift, given or received, is something that comes out of the blue.  It should surprise the recipient, perhaps send him down a road he had not thought to travel.

What are you currently reading? 

I’m actually reading a textbook of Thermodynamics.  Nerdish I know.  Delta G = Delta H – T Delta S.  I’m determined to get to the bottom of it!

C P Snow used to accost his literary friends at cocktail parties and ask them if they knew what the Second Law of Thermodynamics was.  He told them that acquaintance of the Second Law was equivalent, in educational terms, to knowledge of a Shakespeare play.  F R Leavis the distinguished Cambridge literary critic famously demolished Snow’s “Two Cultures” argument and wiped the floor with him.  But I think Snow had a point.  How can you read PPE at Oxford and not know a bit of Thermodynamics?  I have this theory that economics is basically applied thermodynamics, and that every time the moguls of high finance land us all in deep trouble it is because they have tried to defy the First and Second Laws.

But what do I know?

Where is your happy place?  Why does it bring you joy? 

Is this a geographical location, or a region of the mind?

I’m sitting in Dunblane Cathedral, listening to a rendition, on the fine Flentrop organ, of the St Anne Prelude and Fugue in E flat major, BWV 552, by J S Bach.

What’s not to like?

What advice would you give your teenage self? 

Don’t be so miserable.  Stop trying so hard.  Take it easy.  Chill.  Don’t be a fake.  Just be yourself.  Go out with Jennifer Marsden.

Who are your literary heroes?

Richard Hannay and James Bond.

They’re actually quite alike.  Of course, Hannay would have found Bond’s womanizing unconscionable, but occasionally their dark worlds of espionage overlap.  In Mr Standfast, Hannay endures the after dinner conversation of a Conscientious Objector for whom he doesn’t have much time.  He stands with his back to the mantelpiece, smokes a cigarette, and looks steadily at the man’s face.  That could be Bond. There’s something cold and steely about that.

Yet Bond himself continually surprises us with little acts of courtesy and chivalry, even in the amoral carnivorous world in which he moves.  And he’s very funny.  He seems to walk a tight-rope between extreme menace, and extreme farce.

It has been virtually a lifelong ambition of mine to create a character who might surface and resurface in a series of books.  I hope he is Dr Alastair Cameron-Strange.  He’s nothing like Hannay or Bond.  Thank goodness.

What’s your favourite quote or scene from Click, Double-Click?

Favourite quote:  I rather like, “The atmosphere was thick with sycophantic, meretricious concupiscence.”  It’s way over the top.  Favourite scene: Dr Alastair Cameron-Strange stands up at a medical meeting, loses his temper, and tells the group that the particular piece of managerial pseudo-science they are peddling is the biggest load of tosh he has ever heard.  I once did that.  It was very satisfying.  Mind you, it didn’t do any good.  And Dr Cameron-Strange gets hauled before the Patient Safety Committee and suspended from his hospital post because he appears to have gone off his rocker.

Do you have a motto, quote or philosophy you live by?

I can’t resist opting for the last four words of Max Ehrmann’s Desiderata.  I’d better not quote them as Max Ehrmann died on September 9^th 1945 so, at time of writing, he has one week of copyright left to run, and quoting Desiderata over the years has been a contentious copyright issue.  So look it up.  The words remind me of my late mother.  She was completely indifferent to worldly success and she could never understand why I got exercised about academic examinations.  Mind, she was a Queen’s Nurse and a midwife so she did sit a few in her time.  She once came up against an intimidating and irascible consultant obstetrician who barked, “Give me a cause of early miscarriage and don’t say syphilis.”  She said, “Syphilis!”  I once asked her what she would have liked to be if she hadn’t been a midwife.  She said she would have loved to mend roads.

What the hell.  Let’s risk it.  Strive to be happy.

Last week’s blog centred on Scottish Health Minister Shona Robison’s speech on day 1 (October 1^st) of the Royal College of General Practitioners’ annual conference held in Glasgow.  Fast forward to the morning of October 3^rd.  One of the presentations was given by Nick Ross, erstwhile BBC TV Crimewatch presenter talking, not surprisingly about crime.  GPs are interested in crime because crime and pathology are inextricably linked.  Mr Ross’s talk followed that of Shami Chakrabarti who was an extraordinarily charismatic and inspirational speaker whose talk “On Liberty” received a standing ovation.  The chairperson said “Follow that, Nick!”  Well, he did, with his own style and aplomb.

Mr Ross’s thesis was that crime prevention could learn a lot from preventative medicine.  He thought that crime, like disease, has a propensity to be endemic.  Society, he said, is not made up of crims and non-crims.  We are all potential criminals.  He challenged the audience. “If you have never committed a crime, raise your hand.”  I didn’t look round, but I gather there was no show of hands.  The Left, said Mr Ross, thinks that crime is caused by poverty; the Right thinks that crime is caused by individuals who choose to commit it.  Neither side is right, claims Mr Ross.  Crime is a product of temptation, and opportunity.  Remove the opportunity, and hence remove the crime.  If your car is burglar proof, it will not be stolen.  Society needs to take steps to vaccinate itself against crime, by removing temptation and opportunity.

To be honest, I found the notion rather dispiriting.  But I can see it has a certain validity.  Injury prevention has proceeded along similar lines.   I was reminded of the work of William Haddon, the father of injury prevention in the United States.  He would say, “There is no such thing as an accident”; he would fine his colleagues whenever they used the “A-word”, and thus he applied epidemiological principles to the disease of trauma. He devised a system known as “The Haddon Matrix”, which examines any traumatic incident in terms of the incident’s host, vehicle, and environment, along a time line of pre-event, event, and post-event.  So, with respect to a road crash, pre-event you get the driver to wear a seat belt, you give him a car with a good set of brakes, and you put a speed limit on the road.  During the event, the airbag deploys, the car doesn’t disintegrate, and the crash barrier withstands the impact.  Post event, the fuel tank doesn’t explode, the driver receives excellent Advanced Trauma Life Support, and the scene is investigated in order to learn lessons to improve outcomes in subsequent incidents.

Yet even Prof Haddon didn’t neglect the need “to fix the nut behind the wheel.”  He didn’t try to exonerate bad drivers.  Mr Ross seemed to imply that dishonesty, the propensity to commit crime, is inevitable.  I don’t believe this is so.  I know plenty of people who choose not to commit crime, all the way from breaking the speed limit to grand larceny, not because they are frightened of getting caught, but because they know it is wrong.  My father, who happened to have been a policeman, used to say, “There are two kinds of criminals.” (I think possibly he was referring specifically to the crime of theft.)  “There are the needy; and there are the greedy.”  It might be a stretch to say that that is the difference between blue collar crime, and white collar crime, but greed does seem more obviously to be a propensity of the wealthy.  The more you have, the more you want; the more you consider yourself “entitled to”.

Mr Ross’s pragmatic approach, to remove the moral dimension from the debate, is certainly the modern way.  If a group of senior executives are found to have rigged the bank rate, or to have diesel emission software rigged on their watch, they will put their hand up to own up, not because of a crisis of conscience, but because they have been found out.  They certainly won’t admit that they did wrong, rather they will say that they “fouled up”.  They “let people down”.  It was “an error of judgment.”  And so on.  This is of course all bullshit and I use that technical term specifically, in the sense of Harry G. Frankfurt, the Professor of Philosophy Emeritus at Princeton University, whose two tracts, On Bullshit, and On Truth, are surely the definitive treatises on present day moral philosophy.

The trouble with removing the moral dimension from crime prevention is that all you are left with, all you can do in response to criminality of any kind, is put systems in place designed to prevent a recurrence of malpractice, by manipulating the environment to make it impossible for people to transgress.  It’s the only thing you can do if you start with the presumption that “everyone’s a dodger”.  This is what happens when inquiries are conducted into institutions such as hospitals or care homes placed into “special measures” because of a scandal, usually involving cruelty, bullying, neglect, perhaps even wrongful death.  The inquiry takes a very long time and then comes out with a fantastic number of recommendations – maybe hundreds of them.  These are designed in part to placate the desire of deeply wounded relatives who understandably wish that “nothing like this must ever be allowed to happen to anyone else”.   The Mid-Staffs Inquiry into the failings at Stafford Hospital, published on 6^th February 2013, had 290 recommendations.   Individuals implicated in such inquiries may or may not be held accountable, but either way the entire institution will in effect be punished and diminished – rather than helped – because it will be made impossible for the workforce to live and work normally.  The larger the number of recommendations, the less likely it is that the persons conducting the inquiry have reached some sort of diagnosis and formulation as to what has really taken place at the institute.  If they had, they could probably have put it all into an executive summary on one side of A4.  Critical to such recommendations would be the one that is paramount:  a small group of people in charge of the institution must be honest, trustworthy, kind, and competent.  That’s all.  Rather than trying to micromanage the institution, the inquiry should make it possible to empower a trustworthy leadership, and then say, “We trust you to fix this.”  An inquiry with 290 recommendations cannot see the wood for the trees.  Such inquiries are the product of communities whose members no longer trust one another.  I return to the Duke in Shakespeare’s Measure for Measure:

There is scarce truth enough alive to make societies secure, but security enough to make fellowships accursed.

If an entire society loses belief in the trustworthiness of its members, it can only be sustained through the application of totalitarianism.  We come to inhabit a monochrome moral universe in which, as Prof Frankfurt has said, we lose even the sense of where our own individual identify stops and another’s begins.

At the annual conference of the Royal College of General Practitioners held in Glasgow (Oct 1^st to 3^rd) Shona Robison the Scottish Government Health Minister announced the demise of the “Quality Outcomes Framework” (QOF), to the applause of 2000 GPs.  The QOF was embedded in the 2004 GP contract and awarded GPs points, and income, on the basis of fulfilling certain tasks such as recording patients’ blood pressure and smoking status.  GPs, medical students and doctors generally, are very good at fulfilling set tasks and jumping hurdles; they’ve been doing it all their lives.  The 2004 QOF was easy.  Most of the GPs got near maximum points.  So the QOF evolved.  It became more complicated, more bureaucratic, and more burdensome.  I was about to say the paperwork mushroomed, but it would be more accurate to say the electronics went haywire, and before they knew it, GPs were spending twelve hour days glued to computer screens, fulfilling more and more obscure tasks.

Running parallel to the contractual obligations were the requirements of continuous professional development (CPD).  Previously, GPs were required to demonstrate maintenance of professional standards largely by demonstrating attendance at a number of medical education meetings or courses.  Just before the inauguration of the new contract, annual GP appraisal was introduced as a means of monitoring GP CPD, checking not only that GPs were putting in the CPD hours, but were also doing so in a planned way based on their own (and their appraiser’s) perception of their educational needs.  GPs were required to “reflect” on their educational experience.  Appraisal was put in place not long after the trial and conviction on 31/1/00 of Dr Harold Shipman who was found guilty of the murder of fifteen of his patients.   The Shipman Inquiry commenced on 1/9/00 and ran for about 2 years.  Dr Shipman committed suicide in prison on 13/1/04.  By an extraordinary non sequitur sections of the lay press somehow developed the notion that the purpose of GP appraisal was “to prevent another Shipman”.  Any newspaper article on the subject of GP appraisal would almost certainly mention the name Harold Shipman.  Then, as with QOF, the paperwork, or electronic-work, of appraisal also began to burgeon and grow more complex.  The medical profession began to suspect that it was being punished and made to suffer as an expiation and apology to the public, because a serial killer happened to have been a doctor.   This was felt all the more keenly as the demands of QOF and appraisal became more surreal.  It is well known that if you wish not only to punish people but also to damage them psychologically, you give them a futile task like writing out lines at school, or painting coal white in the army.

Hence GPs would be subjected to a directive like this:

Reflecting on the practice’s outpatient referral dataset and comparison with other practices, list the internal factors that contribute to any variation in the practice overall and individual GP referral patterns (eg clinical expertise; learning needs; demographic profile etc).  If your discussions around activity levels confirm your current practice; outline specific areas of your own practice internal to the practice which are aimed at supporting independent management in the community and avoiding potentially unnecessary referrals.  List a minimum of three useful elements which could be shared with other practices.        

I’m not sure, but I think it means, are you referring too many people to hospital, and can you think of a few ways of cutting it out?

When I read the above paragraph about three years ago, I wrote an incensed letter to a prestigious medical journal, which started thus:

Dear Doctor,

I would like to invite you into Fellowship of an august medical society, DAMASK.  DAMASK stands for Doctors Against Muddle and So-called Quality (with a capital K).  You will be relieved to hear there is no subscription, no journal, no conference, and no AGM.  It’s more of a kind of freemasonry than a society.  All that is required of you is that, when you are attending a medical meeting at which somebody who doesn’t know anything about medicine propounds something utterly preposterous, you stand up and make, either figuratively or literally, a bad smell.

I got an email back from the journal to say yes, we’ll print that.  We’ll just run it by the letters editor.

Then, stony silence.

I find that stony silence is the modern way.  In this day when communication was never easier, it is only the passage of time that tells you you have become a “lapsed action”.  We have email we have twitter we have facebook we have text we have SMS we have smart phones we have landlines we have The Royal Mail.  We even have, I discovered while dining with friends this weekend, “Snapchat”.  The defining characteristic of Snapchat is that the message dissolves in the ether after 10 seconds.  Maybe my prestigious journal snapchatted, “On mature consideration, we’ve decided your piece is too inflammatory.”  And I was just too slow on the uptake.  I would have accepted that.  It’s the silence I can’t abide.

(Incidentally, why snapchat?  I can only think it’s useful if you’re into sexting or internet trawling.  You know you’re going to send out something you regret, so get your expression of regret in first.)

Medicine has learned a great deal from the world of aviation in terms of managing risk through the use of checklists.  Medicine – actually any large corporate activity – should also adopt the aviation practice of “read back”.   Read back is vital on the r/t.  I recall with nostalgia the romantic poetry exchanged between the control tower and the big jets on the runway at Glasgow while I, a callow youth, was doing circuits and bumps in the Chipmunk.  “BA 53 you are clear to Heathrow via White Nine, Amber One, to cross Lanark and Talla at flight level 55 and to climb when instructed by Scottish radar to flight level 320 today.”

And it would be read back, verbatim.

“Read back correct.”

Falling foul of a lapsed action is one of the great dispiriting experiences of modern life.  When you write a letter to a bank, or a utility company, or the Inland Revenue, or a multinational conglomerate, and get no reply, you are like a pilot in a stricken aircraft sending out a Mayday call and hearing nothing in your headphones except static.

But here I must write in praise of Shona Robison, who had the courtesy to let us know she is scrapping QOF.  Of course, being a politician, she said something along the lines of, “QOF was of its time; but it has outgrown its usefulness and is no longer fit for purpose.”  It’s not true.  It was never fit for purpose.  The politicians might not know that, but the doctors always knew it.  I like to think we went along with it out of naivety rather than out of cynicism.

Cato the Elder used to end all his addresses to the Roman Senate by reminding them, no matter the topic of discourse, “Oh – and by the way, Carthage must be destroyed.”  He knew that if he said it often enough, one day it would happen.  For a period of about five years I adopted this technique and made a point of saying, at the end of any and every medical meeting I attended, “Oh – and by the way, the QOF must be destroyed.”  I made myself an utter pain in the neck.  My colleagues would say, “James, put a sock in it.”

It just shows you.  You plug away at something.  You think your effort is futile.  You think you’re trapped. But you’re not.

         

Towards the end of term, Mr McIvor our maths teacher lightened up and cut us some slack.  “Here’s a problem for the weekend – but only if you like.  It’s not particularly mathematical.  All you need is pure logic.  It’s called the twelve cannon ball problem.”

You have twelve cannon balls.  They look identical, and eleven of them are, but one has a different weight from the others; it could be heavier or it could be lighter.  You have a simple set of scales – two pans on a fulcrum.  Can you identify the unique cannon ball in three weighings, and say whether it is lighter or heavier?

I realise this blog might be aimed at a minority interest group.  If you are allergic to numbers, it may be you are more interested in the qualitative rather than the quantitative aspects of cannon balls.  Therefore I digress for a moment on your behalf.  I had always thought the expression, “It was cold enough to freeze the balls off a brass monkey” had a somewhat vulgar connotation.  Not so!  It turns out that a brass monkey was a rack for holding cannon balls, and that in very cold weather the rack contracted more than the cannon balls and extruded them.  Back to the twelve cannon ball problem – but, as Mr McIvor said, only if you like.

So, to return to the dim and distant past, I was up for it.  I took the problem home with me and wrestled with it.  It absorbed me completely.  By Friday night I had realised that to put six balls on each pan was a squandered shot because it yielded too little information.  I was pretty certain you needed to place four balls on each pan.  All throughout Saturday I experimented with four ball patterns.  Didn’t go to the swimming baths, didn’t go to badminton club.  Didn’t watch telly.  I became a recluse and an irritant to my family.  By Saturday night I had solved the special case, when your first weighing, four x four, shows equilibrium.  Therefore the rogue ball lies within the remaining four.  You leave three of the balls you have already weighed on one pan to act as a control; you know they are all normal.  You take three of the four untested balls and put them on the other pan.  Suppose there is equilibrium.  Then the remaining unweighed ball is the rogue ball.  You use your third weighing to weigh it against any control ball in order to establish whether it is lighter or heavier.

Go back to the second weighing, three x three, however, and suppose there is disequilibrium.

(Are you still with me?  Or have your eyes glazed over because you’re not that interested?  Don’t fret.)

Well, now you know the rogue ball is one of three, and you know, depending on which way the scales have gone, whether it is lighter or heavier.  So take two of the suspect three balls, clear the scales, and weigh one suspect ball against another.  If there is equilibrium, the third ball is the rogue ball, and you already know whether it is lighter or heavier.  If there is disequilibrium, you identify the rogue ball because you know whether you are looking for a lighter or heavier ball.  Take note of this last paragraph; it is a recurring theme.  If you know the rogue ball is one of a group of three, and you know the relative weight of the ball you are looking for, you have a scenario in which the ball can be identified with just one further weighing.  Let us call this scenario “The Brass Monkey Scenario”.

Fine.  Saturday midnight, and I have my special theory.  But I’m miles away from my general theory.  I still have no idea what to do if the first four v four weighing shows disequilibrium.

Sunday.  Sunday is murder.

I struggle with combinations and permutations and seem to be getting nowhere.  Moreover, I am dogged by a nagging sense of guilt that I’ve wasted a precious weekend in a futile gesture.  But I can’t stop.  It’s not fun any more, yet I can’t stop. Isn’t this what it is supposed to be like to be addicted to something?  Am I in some kind of trouble?

Give it till Sunday teatime.  I’m sure I’ve missed something.  There’s something creative I need to do.  Something I haven’t thought of.  A little piece of lateral thinking.

I skipped Sunday evening youth orchestra.

Eureka!  I worked on, with growing excitement.  Yet still with that nagging sense of guilt, that would just not go away, even when I was on the brink of success.

Late at night, when Barry Alldis was doing his Top 20 countdown on Luxembourg 208, the dark metallic strangled voice of Gene Pitney recounted the tale of the man who lost everything twenty four hours from Tulsa.  I had it.  And yet that terrible sense of squandered energy just wouldn’t leave me.  Why are you wasting your substance on this rubbish?  This is a complete waste of time.

Maybe not completely.  If this weekend has taught me anything, it has taught me that, even when a problem seems utterly insurmountable, when you have run out of rope, still with a little bit of creativity, and lateral thinking, there might just be a way out.

McIvor had me demonstrate my general theory on the blackboard before the class.  The extra pressure of performance might have snarled up my logical circuits, but I was fired up, and my exposition was sound.

Let the balls be numbered  1,2,3,4,5,6,7,8,9,10,11,12.  First weighing:  balls 1,2,3,4 v balls 5,6,7,8 gives disequilibrium.  You know the rogue ball is somewhere on the scales.

Second weighing is 1,2,3,5 v 9,10,11,4.

That’s the little creative leap, the little piece of lateral thinking.  You swap two of the balls.

Consider now what might happen.  The scales show equilibrium.  Therefore the rogue ball is in the group of three you have removed, namely balls 6,7, and 8.  You already know whether the rogue ball is lighter or heavier because of the disequilibrium of the first weighing.   This is The Brass Monkey Scenario.  All you need do now is weigh ball 6 against ball 7.

Consider now that in the second weighing a disequilibrium occurs but the scales tip over in the other direction.  Now the rogue ball has to be one of the balls you have swapped  – 4 or 5.  If 4 is on the down scale and it turns out to be the rogue ball, then it is heavier.  If 4 is on the up scale and it turns out to be the rogue ball, then it is lighter.  Same scenario for ball 5.

Third weighing: ball 4 against any control ball.  If there is equilibrium, then ball 5 is the rogue ball, and you already know whether it is lighter or heavier.  If there is disequilibrium, then ball 4 is the rogue ball and it is lighter or heavier depending on how it now tips the scales.

Consider now that in the second weighing the same disequilibrium occurs as in the first weighing.  Then the rogue ball is in the group 1, 2, 3, because balls 9, 10, 11 are control balls, and, had balls 4 or 5 been rogue, the scales would have tipped over.  We are back to The Brass Monkey Scenario.  We now know that the rogue ball (1,2, or 3) is lighter or heavier depending on how the scales tipped, and, as before, we clear the scales and weigh ball 1 against ball 2, knowing we are looking for a lighter or a heavier ball.  If the scales show equilibrium, then ball 3 is the rogue ball, and we already know whether it is lighter or heavier.

That’s it.  Every situation dealt with.

I sat down.

There was no applause from the class.  They had long since lost interest.  Mr McIvor said, “Well done!”  And indeed there was admiration.  Yet I could sense something else.  I thought I could detect a sense of guilt that he had subjected me to this conundrum in the first place, and driven me to spend so much time on it. I was completely confused.  It crossed my mind that he pitied me. He might have shaken his head and said, “You poor sad boy!”

How is the news where you are?  The news where I am isn’t very good.  In fact, it’s so bad, I’m tempted to turn the sound down when it comes on my car radio.  But that’s a bad thing.  That’s what we did in the 1930s, closing our ears to the rumblings of continental Europe.

In Shakespeare’s Measure for Measure, Vincentio, the Duke of Vienna, goes undercover, disguises himself as a Papal emissary and moves about his own Dukedom, taking the temperature.  He meets Escalus, one of his lords, who asks him, “What news abroad i’th’ world?”

“None, but that there is so great a fever on goodness that the dissolution of it must cure it.  Novelty is only in request, and it is as dangerous to be aged in any kind of course as it is virtuous to be constant in any undertaking.  There is scarce truth enough alive to make societies secure, but security enough to make fellowships accursed.  Much upon this riddle runs the wisdom of the world.  This news is old enough, yet it is every day’s news.”

I’ve been pondering this enigmatic utterance for the duration of my adult life, and making little headway with it, until this past week.  It occurred to me, the Duke’s utterance really is a summary of the news.  Three items dominated the news during the week – the refugee crisis; the election of Jeremy Corbyn to leadership of the Labour Party; and the unprecedented interview with the head of MI5 on the “Today” programme, coming out to gloom a nation armed with desktops, lap tops, tablets and smart phones, that it will need to be snooped on to an extent that would make even the Rector of Glasgow University raise his eyebrows.

The Duke makes five points, which I venture to precis as follows:

We are suffering from an institutional malaise so profound that we can only recover by making a radical change to the way in which we conduct our affairs.

There is an appetite for change, but we seem incapable of turning our ideas into reality.

You may think it praiseworthy to be resolute in a course of action; but if your policies are outdated and no longer fit for purpose, it is not.  On the contrary, it is positively dangerous.

Public life is full of humbug.

Our lives are being rendered miserable by surveillance.

Now, I could marry up the Shakespeare remarks with this week’s items of news, but that seems rather a pedestrian route to take, and I will leave it to your imagination.  Let’s just focus for a moment on the idea of change:

At Prime Minister’s Question Time last Wednesday, Mr Corbyn made a request, on our behalf, that PMQs be less “theatrical”. Well, good luck with that.  I’m intrigued by the way the British right wing press have already ganged up on Mr Corbyn to nip him in the bud, by criticising everything about him from his demeanour to his dress to his apparent espousal of dodgy ideologies to his silence during the National Anthem to his apparent reluctance to kneel before Her Majesty as a Privy Counsellor.  And I think, why are they carrying out a demolition job?  After all, if he is the loose cannon that they say he is, wouldn’t they want him to head the opposition for ever?  I wonder if it’s because they are afraid.  They are afraid of anything they do not understand, and cannot predict.  And they are afraid of that quality of Mr Corbyn’s that won him the leadership – authenticity.  He isn’t the concoction of a focus group of spin doctors; he’s the real deal.  I can’t say I’m a fan of Old Labour, but I do think the media should cut this guy some slack and see what he has to say.  History never quite repeats itself.  Mr Corbyn is not Mr Foot.  He might surprise us.

But to return to Shakespeare, I wonder if his Duke of Vienna is right, that the news is always the same, that the old news is every day’s news.  Sophie Raworth, Fiona Bruce, Mishal Husain et al might say, “Welcome to the BBC news at ten.  The headlines tonight – we are in a terrible mess; we’re trying to get out of it but we seem to be stuck; we make a virtue out of repeating our mistakes over and over again; we completely lack any moral leadership and hence we are creating a dystopia. And now, the news wherever you are…”

So I checked it out, and you may care to do the same next time you hear the news; apply the Measure for Measure test.  I watched the news late on Sunday night.  (As Lennon put it, “I heard the news to-day, oh boy…”)

Well let’s see.  There’s chaos in Croatia where migrants are struggling to get on board west-bound trains.  Jeremy Corbyn wants to renationalise the railways line by line.  Jackie Collins has passed away.  Andy Murray has got us into the final of the Davis Cup.  Gas explosion in Derby.  Pope Frances addressed an enthusiastic crowd in Revolution Square, Havana, then met with Fidel Castro.  Good news about the release of some hostages in Yemen.  The Greek General Election is veering leftward.  75^th anniversary in Westminster of the Battle of Britain.  Rugby World Cup.  Footie.  And now, the news where you are.

And then – how often does this happen? – something slips under the radar.  Something momentous passes unnoticed.  Johann Lamont, the ex-labour leader in Scotland, recognises that a lot of Labour supporters voted Yes in the Referendum just over a year ago.  Kezia Dugdale, the current incumbent, says she won’t shut down a debate on a repeat referendum.  She said Labour MPs and MSPs should be able to argue for Independence.

It was all reported quite casually.

I don’t think Westminster will be too happy about that.