NHS

NHS

The Notional Health Service.

Heading in last week’s Economist (13/1/2024). Sad, but true.

Robert Conquest’s third law of politics

The simplest way to explain the behaviour of any bureaucratic organisation is to assume that it is controlled by a cabal of its enemies. (Robert Conquest’s third law of politics)

I tend to think the NHS is directed by people who don’t like it.

Don’t aim to work in the NHS

A little while back, Lisa and I were out for dinner at a friend’s house. The mother, ’M’ was a doctor and the husband, ‘H’, worked in finance. M ticked all the boxes for what you might wish for if you were a patient: technically competent, deeply caring, and worked way beyond her contractual hours. Nor did she park her patients in some tidy box somewhere: her job was part of who she was.

M and H had a few children under 11. As often happens, while watching the children play and interact, the question was asked what they might end up doing as a career. H spoke immediately and with conviction: ‘I just hope neither of them ever works for the NHS.’ Note, not I hope they do not become doctors, but rather I don’t want them ever working in the NHS.

I find it hard to imagine this same conversation a quarter-century ago. Things have changed.

Training is in tatters as doctors prioritise urgent care and discharges | The BMJ

“During my last job on an acute medical unit, one of the FY1s would sit in a box room separate from the doctor’s office for three days a week and write up to 15 discharge letters a day. It’s farcical to suggest that’s rounded training.”

“Prioritising training for juniors isn’t just about having competent and confident doctors in the NHS but actually having them at all. It’s hard to feel compelled to pursue a career in the NHS after a week in which your sole learning point was how to make the ward photocopier work,” she said.

A dog at the master’s gate predicts the ruin of the state. (William Blake)

Doctors, medicine and the NHS 1966

Like many of my colleagues I no longer try to dissuade my juniors from leaving to work in the United States. Medicine is more important than nationalism and will outlive the indifference of governments: it is better that a good man should work where he can make the best contribution to the advance of medicine than that he should stay to be frustrated by a society too myopic to appreciate his potential. A dead patient presents no economic problem.

It would be naive to express surprise at the equanimity with which successive governments have regarded the deteriorating hospital service, since it is in the nature of governments to ignore inconvenient situations until they become scandalous enough to excite powerful public pressure. Nor, perhaps, should one expect patients to be more demanding: their uncomplaining stoicism springs from ignorance and fear rather than fortitude; they are mostly grateful for what they receive and do not know how far it falls short of what is possible. It is less easy to forgive ourselves…..Indeed election as president of a college, a vice chancellor, or a member of the University Grants committee usually spells an inevitable preoccupation with the politically practicable, and insidious identification with central authority, and a change of role from informed critic to uncomfortable apologist.

Originally published in the Lancet, 1966,2, 647-54.(This version in Remembering Henry, edited by Stephen Lock and Heather Windle).

Henry Miller was successively Dean of Medicine, and VC of the University of Newcastle. No such present day post-holder would write with such clarity or honesty.

2001 as metaphor

New Bayer chief plans a radically different style to cut bureaucracy | Financial Times

Anderson wants managers to overcome the traditional top-down approach and allow a team to develop a life of its own.

He likes to compare the situation of senior managers with that of the astronaut in Stanley Kubrick’s “2001 — A Space Odyssey”. In the science fiction movie, the scientists aboard a spaceship gradually find out that the computer had taken over the mission.

In one of his first meetings with Bayer managers, Anderson played a clip from the film. His message was that “the astronaut is us, and we are no longer in control” but at the same time, the system “often is fundamentally flawed”.

Which reminds me of the doctors and nurses stuck within the hull that is the NHS, directed in this case by the political masters who lack the guts to actually even set foot on the ship.

Look up, not down

“in a mammoth bureaucracy obsessed with its own secrecy, the fault lines are best observed by those who, instead of peering down from the top, stand at the bottom and look up.

Absolute Friends by John le Carré

True of the NHS.

Resilience and sustainability

Hack the Planet: Tega Brain on Leaks, Glitches, and Preposterous Futures

This quote is actually from an article about washing machines, water supplies and ‘wastage’. But it just reminds me of the technical and intellectual debt that is drowning health care and the NHS

That balancing act reminds me of something engineer and professor Deb Chachra wrote in one of her newsletters. She wrote, “Sustainability always looks like underutilization when compared to resource extraction.”

What will tomorrow bring

by reestheskin on 07/04/2021

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Wonderful piece by Janan Ganesh in the FT on the life choices made by young bankers and corporate lawyers, and the crazy (work) demands placed on them. I was surprised that he also has junior doctors in his sights.

Yes, the graduates knew the deal when they joined, but the appeal to free will is an argument against almost any labour standards whatever. Nine-year-old Victorian chimney sweeps knew the deal. As for all the talk of character-forging, of battle-hardening: to what end, exactly? The point of a corporate career arc is that work becomes more strategic, less frenzied over time. The early hazing should not be passed off as a kind of Spartan agoge.

The ageing process — as I have lived it, as I have observed it in friends — has convinced me of one thing above all. The deferral of gratification is the easiest life mistake to make. And by definition among the least reversible. A unit of leisure is not worth nearly as much in late or even middle age as it is in one’s twenties. To put it in Goldman-ese, the young should discount the future more sharply than prevailing sentiment suggests.

The first reason should be obvious enough, at least after the past 12 months. There is no certainty at all of being around to savour any hard-won spoils. The career logic of an investment banker (or commercial lawyer, or junior doctor) assumes a normal lifespan, or thereabouts. And even if a much-shortened one is an actuarial improbability, a sheer physical drop-off in the mid-thirties is near-certain. Drink, sex and travel are among the pleasures that call on energies that peak exactly as graduate bankers are wasting them on work.

I don’t know enough to be confident about clinical medicine but I do often wonder how things will look in a decade or so. Many junior medical jobs are awful, the ties and bonds between the beginning, middle and end of medical careers sundered. Many drop out of training, some treading water in warmer climes, but with what proportion returning? Some — a small percentage perhaps— move into other jobs, and the few I know who have done this, I would rate among the best of their cohort. Of those who stick to the straight and narrow, many now wish to work less than full time, although whether this survives the costs of parenthood, I do not know. At the other end all is clear: many get out as soon as they can, the fun long gone, and the fear of more pension changes casting an ever larger shadow, before the final shadow descends.

Medicine remains — in one sense — a narrow and technical career. The training is long, and full confidence in one’s own skills may take twenty years or more to mature. By that time, it is hard to change course. This personal investment in what is a craft, leaves one vulnerable to all those around you who believe success is all about line-managing others and generic skills.

I am unsure how conscious (or how rational) many decisions about careers are, but there may well be an invisible hand at play here, too. I imagine we may see less personal investment in medical careers than we once did. It’s no longer a vocation, just a job, albeit an important one. Less than comforting words, I know — especially if you are ill.

It’s just business

by reestheskin on 19/11/2020

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I have rich memories of general practice, and I mean general practice rather than primary care 1. My earliest memories centre around a single-handed GP, who looked after my family until we left Wales in the early 1970s. His practice was in his house, just off Whitchurch village in Cardiff. You entered by what once may have been the back gate or tradesman’s entrance. Around the corner and a few steps up, you found the waiting room. Originally, I guess, it might have been a washroom or utility room for a maid or housekeeper. By the standards of the Rees abode the house was large.

The external door to the waiting room was opposite the door into the main part of the doctor’s house, and on the adjacent sides were two long benches. They were fun for a little boy to sit on because since your legs couldn’t touch the floor, you could shuffle along as spaces became available. When you did this adults tended to smile at you; I now know why. If you were immobile for too long your thighs might stick to the faux-leather surface; pulling them away fast resulted in a fart like noise, although in those days I was too polite to think out loud.

Once you were called — whether it was by the doctor or his wife I cannot remember— you entered his ‘rooms’. The consulting rooms was by my preferred unit measure — how far I could kick a ball — large, with higher ceilings than we had at home. The floorboards creaked and the carpet was limited to the centre of the room. If there was a need for privacy there was what seemed like a fairly inadequate freestanding curtained frame. For little boys, obviously, no such cover was deemed necessary.

I can remember many home visits: two stand out in particular, mumps, and an episode of heavily infected eczema where my body was covered in thousands of pustules, and where I remember pulling off sheets of skin that had stuck to the bedclothes. The sick-role was respected in our home: if you were ill and off school you were in bed. Well, almost. Certainly, no kicking the ball against the wall.

Naturally, the same GP would look after any visitors to my home. Although my memories are influenced by what my mother told me, on one occasion my Irish grandmother’s valvular heart failure decompressed when she was staying with us (her home was in Dublin). More precisely, I was turfed out of my bed, so she could occupy it. The GP phoned the Cardiff Royal Infirmary explaining that the patient needed admission, and would they oblige? The GP however took ten years-or-so off her true age. Once he was off the phone, my mother corrected him. He knew better: if I had told them the truth they would have refused to admit her, he said. (This was general practice, not state medicine, after all). The memory of this event stuck with me when I was a medical student on a geriatrics attachment in Sunderland circa 1981. Only those under 60 with an MI were deemed suitable for admission to the CCU, with the rest left in a large Nightingale ward with no cardiac monitoring 2. I thought of my father who was then close to 60.

I was lucky enough to be able to recognise this type of general practice — albeit with many much needed changes — as a medical student in Newcastle, and to be taught by some wonderful GPs, and even do some GP locums when I was a medical registrar. And although I had never met the late and great Julian Tudor-Hart face-to-face, we are linked by a couple of mutual Welsh friends, and we exchanged odd emails over the years.

So, why do I recall all of this? Nostalgia? Yes, I own up to that. But more out of anger that what was unique about UK general practice has been replaced by primary care and “population medicine”, and many patients are worse off because of this shift. Worse still, it now seems all is viewed not through the lens of vocation, but by the egregious ‘its just business’. Continuity of care and “personal doctoring” is, and has been, lost.

I write after being provoked by a comment in the London Review of Books. Responding to a terrific article by John Furse on the NHS, Helen Buckingham of the Nuffield Trust states — as many do — that “The reality is that almost all GP practices are already private businesses, and have been since the founding of the NHS.” (LRB 5/12/2019 page 4).

Well, for me, this is pure sophistry. There are businesses and businesses. If you wish, you might call the Catholic Church a business, or Edinburgh university a business, or even the army a business. You might even refer to each of them as a corporation. But to do so, misses all those human motivations that make up civil society. Particularly the ability to look people in the eye and not feel grimy. There is no way on earth that the GP who looked about me would have called what he did a business. Nor was he part of any corporation. And the reason is simple: like many think tanks, many modern corporations — especially the larger ones — have no sense of morality beyond the dollar of the bottom line3, often spending their undoubted skills wilfully arbitraging the imperfections of regulation and honest motivation. It does not have to be this way.

  1. Here I am echoing the arguments made by Howie, Metcalfe and Walker in the BMJ in 2008: The State of General Practice — not all for the better. Comments on this article effectively said: the halcyon days of general practice were over. Get used to it! I am not convinced. What has happened is that ‘government led population / public health’ has gobbled up ‘personal doctoring’. For the latter, it appears, you will need more than the NHS.
  2. Many epidemiologists argued that there was no need for CCUs as no RCTs had shown their benefit. Ditto for parachutes, renal transplantation , no doubt.
  3. You can insert your own favourite de jour: Pfizer and Flynn for raising the price of an anti-epilepsy drug by up to 2,600 per cent, or GSK, or Crapita, Test and Trace etc. The list goes on, well before we get to the likes of Facebook or the Financial Services Industry

Peter Piot in the Guardian

As with HIV, “an epidemic reveals the fault lines in society. The big one this epidemic has revealed is how we treat the elderly. We often park them in pre-mortuary type institutions and give a bit of money and hope it is OK”.

Make masks compulsory in public in UK, says virus expert | Coronavirus outbreak | The Guardian

When the tide goes out you see who is not wearing bathing costumes…

Even those who liked it at the beginning are becoming wary of the creeping clapping fascism,

I’m an NHS doctor – and I’ve had enough of people clapping for me | Society | The Guardian

Indeed.

Quis custodiet ipsos custodes?

by reestheskin on 07/05/2020

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One of the pleasures of retirement from medical practice is not being on the General Medical Council (GMC) register. If you were able to listen in on many doctors private conversations, and run some Google word analytics, the word you might find in closest proximity to the term General Medical Council (GMC) would be loathe. There would be other less polite words, too. As the BMJ once wrote: there is very little in British medicine that the GMC cannot make worse. It is a legalised extortion racket that fails to protect the public, messes up medical education and makes many doctors’ lives miserable.

The following are quotes from the Lancet and the FT. They are about the horrendous crimes perpetrated by a surgeon, Ian Paterson. The full Independent Inquiry report can be found here. I am not surprised by anything I have read in the  investigation into these crimes and the attacks on those who attempted to draw attention to them.

Health-care workers reporting concerns often come under substantial pressure from health-care management, and sometimes have to justify their own practice and reasons for speaking out. Four of the health-care professionals who did report Paterson were subject to fitness to practice scrutiny by the GMC during the later investigation because they had worked alongside him

Complicit silence in medical malpractice – The Lancet

The FT draws up some lessons. Here is number four:

The fourth lesson is that those who speak up are likely to suffer. Some of Paterson’s colleagues were worried about his practices. When six doctors raised concerns with the chief executive of the NHS trust where Paterson worked, four were themselves investigated by the General Medical Council because they had worked with him.

Maybe after clapping this Thursday evening people need to take a long hard look at the culture of NHS governance and its proxies in the UK. Pandemics just open up the cracks of incompetence that are hidden in plain sight.

And that was then

by reestheskin on 20/03/2020

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Dr Chris Day writes:

Two weeks ago, I swabbed my first positive Covid-19 patient during an A&E Locum shift. I must say back then, I hadn’t fully taken in what we as a country will have to face over the coming months. The reports from colleagues in Italy and China are beyond belief.

The UK has been left to fight Covid-19 with half the Intensive Care beds per capita of Italy. Back in 2014, the trigger for my whistleblowing case was my attempt to try and secure more ICU resources for South East London (see Private Eye).

Instead of spending 5 years and £700k fighting /smearing me and damaging whistleblowing law, the NHS could have just fixed the problem. There has never been a more important time for the public and the politicians to understand Intensive Care resourcing and what is decided on their behalf by NHS leaders.

Some links here and here

Out of time

by reestheskin on 13/11/2019

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The following is from Janan Ganesh of the FT. The title of the article was “The agony of returning to work in September”.

A personal ambition is to reach the end of my career without having managed a single person.

It seems to me a very sensible ambition, one which used to be the lot of many academics — usually the better ones. He goes on:

Friends who have been less lucky, who have whole teams under their watch, report a quirk among their younger charges. It is not laziness or obstreperousness or those other millennial slanders. It is an air of disappointment with the reality of working life. They will be among the people described in Bullshit Jobs by the anthropologist David Graeber….

A generation of in-demand graduates came to expect not just these material incentives but a sort of credal alignment with their employer’s “values”. The next recession will retard this trend but it is unlikely to kill it.

At one time the words ‘manager’, ‘management’, or worst of all, ‘line-manager’ were alien to much of medicine or academia. Things still got done, in many ways more efficiently than now. It is just that our theories of action and praxis have been ransacked by Excel spreadsheet models of human motivation and culture. It is the final line from the quote that those controllers of ‘managers’ should be scared of:

The next recession will retard this trend but it is unlikely to kill it.

Depersonalisation and deprofessionalisation

by reestheskin on 28/10/2019

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I am generally nervous about doctors or academics working for the government. Not that I think the roles are unnecessary, far from it. But what worries me is when instead of resigning from their academic role, they end up working for more than one master. So, I tire of the use of university titles when the principle employer does not subscribe to the academic ideal. I think if you have been at Stanford and you go to Washington it should be as a regular civil service post. I think the Americans get it right.

But the retiring CMO, Dame Sally Davies, in an interview in the RCP in-house journal ‘Commentary’ speaks some truths (Commentary | October 2019, p10).

I hear non-stop stories from unhappy juniors. In my day, we (consultants) made up the rotas for the juniors, but now administrators do it without understanding all of the issues. I’m told you can’t go back to the ‘firm’ structure because there are so many doctors in the system, but whenever I meet a roomful of young doctors I ask: ‘Does your consultant know your name?’ It’s rare that a hand goes up. We have depersonalised the relationships between doctors and that can’t help the workings of the medial team, or with the patients.

Your mileage may vary, but when I was a junior doctor it was us — not the consultants — who came up with the rotas. But the point she makes is important, and everybody knows this (already). At one time junior doctors didn’t work for the NHS, rather they worked within the NHS for other doctors, for good and bad. I find it hard to imagine that the current system can deliver genuine apprenticeship learning. Training and service may often have resembled a bickering couple, but there was a broader professional context that was shared. I am not certain that this is the case anymore. Whenever people keep pushing words such as ‘reflection’ or ‘professionalism’, you know — pace Orwell — that the opposite is going on. Politics is a dominant-negative mutation.

We have no doctors (again)

by reestheskin on 09/04/2019

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We have no  incentives doctors.

Shortage of GPs will never end, health experts say | Society | The Guardian

OK, maybe the subeditor is to blame, but spare me the cartel of health think tanks and their pamphlets. Enticing people into general practice and keeping them there is not rocket science. When I was a junior doctor getting onto the best GP schemes around Newcastle was harder than getting the ‘professorial house-jobs’. Many people like, and want to be, GPs. If general practice is dying , it is in large part because the NHS is killing real general practice.

A few years back I wrote a personal view in the BMJ, arguing that an alternative model for dermatology in the UK would be to use office dermatologists, as in most of the first world. It is likely cheaper and capable of providing better care as long as you consider skin disease worthy of treatment. The feedback was not good or in some instances, even polite. The more considered views were that my suggestion was simply not possible: how would we train these people? Well jump on a ferry or book Ryanair, and look how the rest of Europe does it.

There are some general discussion points:

  1. The various NHS’s in the UK do many things very badly. The comparison is all too often with west of Shannon, rather than that body of land closer to us.
  2. The proportion of ‘health staff’ who are doctors has been dropping for over a century. This trend will — and should —continue.
  3. I write from Scotland: Adam Smith worked out the essential role of specialisation in economic efficiency many centuries ago. Conceptually, little has changed since, except the cost of health care.
  4. The limit on my third point is transaction costs of movement between specialised agents. This is akin to Ronald Coase and the theory of the firm: why do we outsource and when do firms outsource? How do we create — to use a software phrase — the right APIs
  5. Accreditation and a professional registration are there to protect the public. We will only encourage staff to take on the new roles needed  if  there is a return on their personal investment, in return for formal admission to the appropriate guilds. These qualifications need to be widely recognised and transferable, and the guilds will need to be UK wide (or, in the longer term, wider still).
  6. The current system of accreditation for those providing clinical care is bizarre. Imagine, you know a bright and ambitious teenager. You tell her to come and sit in your dermatology clinic for 5 years and, at the end, you employ her in your practice as a dermatologist — initially under your supervision. Well, we know that is not a sensible way to train doctors, but this is indeed the way the NHS is going about training those who will provide much face to face clinical care. Got a skin rash — see the nurse! (for a couple of personal anecdotes,  see below).
  7. The current system of accreditation for a particularly role for doctors is based around individual registration (with the General Medical Council). What the public require is however evidence of registration for defined roles and procedures (using the term procedure in a broad sense, and not just as in a ‘surgical procedure’). If somebody is a dental hygienist they are registered with the General Dental Council. This makes sense. The sleight of hand in medicine is that individual hospitals or practices have taken on the role of accreditation. I suspect if private individuals — rather than the NHS or its proxies — did this, they would be considered to be riding roughshod over the Medical Act (I am no lawyer…).
  8. Accreditation of  medical competence at the organisation level is indeed a possible alternative to individual personal registration. It might even have advantages. But this has not been the norm in the UK (or anywhere else), and the systems to do this are not in place.

Two personal examples:

I received an orthopaedic operation under a GA at a major teaching hospital. I was in the my mid 50’s, and previously fit. At the clerking / pre-op assessment by a nurse, my pulse and BP were recorded, and my urine was tested. I was asked : “Are your heart sounds normal and do you have any heart murmurs?” (There was no physical examination). My quip — that how could you trust a dermatologist on such matters — was met with a total lack of recognition. I recounted the story to the anaesthetist as a line was inserted in my arm. I also mentioned, for effect, that they didn’t ask about my dextrocardia….( I achieved the appropriate response — to this untruth). Subsequent conversations with anaesthetists confirmed that their opinions were in keeping with mine, and this “was management” and ‘new innovative ways of killing working’.

As a second year medical student, with a strong atopic background (skin, lungs, hay fever etc). I came out in what I now know to be widespread urticaria with angioedema. On going to the university health centre, the receptionist triaged me to the nurse, because it was ‘only skin’. I didn’t receive a diagnosis, just an admonition that this was likely due to not washing enough (which may have been incidentally true or false…). A more senior medical student provided me with the right diagnosis over lunch.

The latter example chimed with me, because  DR Laurence in his eclectic student textbook of Clinical Pharmacology lampooned the idea that nurses had ‘innate’ understandings of GI pharmacology, a delusion that remained widespread through my early medical career. Now, sadly, similar prescientific reasoning underpins much UK dermatology. The public are not well served.

The not so quiet revolution

by reestheskin on 02/01/2019

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General practice has been undergoing a quiet revolution in recent years that has had little fanfare: it is now an overwhelmingly part-time profession.

Official figures suggest almost 70% of the workforce work less than full time in general practice – the highest proportion ever.

[Link]

The affair is over

by reestheskin on 26/06/2018

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Did the NHS save your life, or did Doctors and Nurses save your life?

It’s an earnest question. A comment on an excellent FT piece: “Is Britain loving the NHS to death?”

Most lawyers don’t make anything except hours.

by reestheskin on 17/10/2017

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This was a quote from an article by an ex-lawyer who got into tech and writing about tech. Now some of by best friends are lawyers, but this chimed with something I came across by Benedict Evans on ‘why you must pay sales people commissions’. The article is here (the video no longer plays for me).

The opening quote poses a question:

I felt a little odd writing that title [ why you must pay sales people commissions]. It’s a little like asking “Why should you give engineers big monitors?” If you have to ask the question, then you probably won’t understand the answer. The short answer is: don’t, if you don’t want good engineers to work for you; and if they still do, they’ll be less productive. The same is true for sales people and commissions.

The argument is as follows:

Imagine that you are a great sales person who knows you can sell $10M worth of product in a year. Company A pays commissions and, if you do what you know you can do, you will earn $1M/year. Company B refuses to pay commissions for “cultural reasons” and offers $200K/year. Which job would you take? Now imagine that you are a horrible sales person who would be lucky to sell anything and will get fired in a performance-based commission culture, but may survive in a low-pressure, non-commission culture. Which job would you take?

But the key message for me is:

Speaking of culture, why should the sales culture be different from the engineering culture? To understand that, ask yourself the following: Do your engineers like programming? Might they even do a little programming on the side sometimes for fun? Great. I guarantee your sales people never sell enterprise software for fun. [emphasis mine].

Now why does all this matter? Well personally, it still matters a bit, but it matters less and less. I am towards the end of my career, and for the most part I have loved what I have done. Sure, the NHS is increasingly a nightmare place to work, but it has been in decline most of my life:  I would not recommend it unreservedly to anybody. But I have loved my work in a university. Research was so much fun for so long, and the ability to think about how we teach and how we should teach still gives me enormous pleasure: it is, to use the cliche, still what I think about in the shower. The very idea of work-life balance was — when I was young and middle-aged at least — anathema. I viewed my job as a creative one, and building things and making things brought great pleasure. This did not mean that you had to work all the hours God made, although I often did. But it did mean that work brought so much pleasure that the boundary between my inner life and what I got paid to do was more apparent to others than to me. And in large part that is still true.

Now in one sense, this whole question matters less and less to me personally. In the clinical area, many if not most clinicians I know now feel that they resemble those on commission more than the engineers. Only they don’t get commission. Most of my med school year who became GPs will have bailed out. And I do not envy the working lives of those who follow me in many other medical specialties in hospital. Similarly, universities were once full of academics who you almost didn’t need to pay, such was their love for the job. But modern universities have become more closed and centrally managed, and less tolerant of independence of mind.

In one sense, this might go with the turf — I was 60 last week. Some introspection, perhaps. But I think there really is more going on. I think we will see more and more people bailing out as early as possible (no personal plans, here), and we will need to think and plan for the fact that many of our students will bail out of the front line of medical practice earlier than we are used to. I think you see the early stirrings of this all over: people want to work less than full-time; people limit their NHS work vis a vis private work; some seek administrative roles in order to minimise their face-to-face practice; and even young medics soon after graduation are looking for portfolio careers. And we need to think about how to educate our graduates for this: our obligations are to our students first and foremost.

I do not think any of these responses are necessarily bad. But working primarily in higher education, has one advantage: there are lost of different institutions, and whilst in the UK there is a large degree of groupthink, there is still some diversity of approach. And if you are smart and you fall outwith the clinical guilds / extortion rackets, there is no reason to stay in the UK. For medics, recent graduates, need to think more strategically. The central dilemma is that depending on your specialty, your only choice might appear to be to work for a monopolist, one which seeks to control not so much the patients cradle-to-grave, but those staff who fall under its spell, cradle-to-grave. But there are those making other choices — just not enough, so far.

An aside. Of course, even those who have achieved the most in research do not alway want to work for nothing, post retirement. I heard the following account first hand from one of Fred Sanger’s previous post-docs. The onetime post-doc was now a senior Professor, charged with opening and celebrating a new research institution. Sanger — a double Laureate — would be a great catch as a speaker. All seemed will until the man who personally created much of modern biology realised the date chosen was a couple of days after he was due to retire from the LMB. He could not oblige: the [garden] roses need me more!

“Certainly, for frontline doctors like us who are used to wrestling with clunky NHS IT systems, the biggest surprise of the malware attack was not that it happened but why it had taken so long. It is an irony lost on no NHS doctor that though we can transplant faces, build bionic limbs, even operate on fetuses still in the womb, a working, functional NHS computer can seem rarer and more precious than gold dust.’

Here.

Core service training

by reestheskin on 11/04/2017

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“Core surgical training in the UK has been dubbed “core service training” because many trainees believe it does not provide enough surgical experience. At the southern tip of Africa, I felt I was being taught to operate, not to just watch and hold retractors. My commitment and progression were judged on hard work and merit, not on how many courses I had attended.”

Here.

The crisis in dermatology

by reestheskin on 14/06/2015

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Fairly dismal reading here and here. Much of what has happened in the UK is a result of a health service that is not based around clinical need, and in which most decision makers might as well believe in fairies. The mistake is to imagine that we got into this mess because of a lack of money. We got into this mess for much the same reason that much of  UK industry has collapsed: the people making decisions have no technical competence in the relevant domains. If it was left to the NHS,  BMW would not employ engineers (‘its just process management, isn’t it, so let’s reorganise the workflow, and set some targets?’).

‘Health policy is in tatters. Markets haven’t worked, inspection hasn’t worked, demand management has failed, morale at an all-time low and workforce planning botched. The sky is dark with chickens coming home to roost. The NHS is now all about muddling through’. Roy Lilley calls it right. But what is a young graduate or student to do? [link for this post]

NHS supremo says ‘too early for hindsight’. A little foresight would have helped.

by reestheskin on 26/11/2014

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So the English NHS is to stop paying GPs to diagnose dementia. The NHS supremo is quoted as saying,  ‘I think it’s too early for hindsight. We need to look at the dementia diagnosis rate through the year before we do that. It is not driven by patient preference, but by different levels of focus on this topic. ‘ Well forget hindsight,  a little foresight would have helped.

Not enough hours in the day

by reestheskin on 09/03/2014

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A long, long time ago, I was sitting in the biochemistry coffee room in the medical school in Newcastle. Roger Paine, a professor of biochemistry came and sat next to me. I knew of him, but he didn’t know me. He was a FRS, I was a dermatology research registrar taking my first steps in learning some wet bench science in the Medical Molecular Biology Group there. Coffee rooms work, as do Aeron chairs. Sometimes you need to talk, and ramble around what interests you; and sometimes you have to sit alone, and dream. If you don’t, you will do ‘kit’ science, or act out being an administrator by conducting randomised controlled trials.
We got chatting—we shared a mutual colleague—and he expressed his puzzlement to me about how medics managed to do any research. He pointed out what with seeing patients, and some undergraduate teaching and postgraduate training, how on earth could you hope to do any meaningful research. I listened, not wanting to hear what he said. And I should point out, he was a keen collaborator with medics,  nor stand-offish in any way.

Many years later, in another setting, I was talking to another successful scientist, a geneticist, also a FRS. We knew each other reasonably well, and by this stage I had been working in wet-bench science for a dozen years or more. Some modest successes, and plenty of failures. He told me that because he knew the details of many clinical medics research careers very well, he would be loathe to ever approach any of them if he needed medical care. He had the highest regard for them as academics, and researchers, but he too couldn’t see how they could carry on all the various activities expected on them. (And no doubt be able to go to the cinema once in a while: Steven Rosenberg, a one time Chief of Surgery at NIH, in his autobiography, describes how he would struggle to leave Sunday evening free of lab and clinical duties, so that he could go to the cinema with his wife).
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Clinical skills

by reestheskin on 19/02/2014

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“What of attempts to improve skin cancer diagnostic skills in primary care, or to develop GP specialists as seen in Australia or the UK? There are various points to make here, and perhaps a lot of wishful thinking about how the problem could be solved if only ‘GPs’ knew more about this or that subdomain of medical knowledge. In truth, such blandishments, must be frustrating to many GPs: there are only so many hours in the day. There are studies showing that it is possible to improve diagnostic skills over the short term following organised tuition (cited in Rees (16)). To find anything else would of course be surprising: if we expose intelligent people to formal tuition or learning, we expect short-term performance to improve. But, the critical point is whether this improvement is maintained, and what aspects of performance suffer because they have been replaced by training in another domain (16). There is no free lunch. If we run a course on skin cancer, then the rheumatologists, cardiologists etc. will all want to run courses. And much of what we know about such one off tuition is that in the absence of consolidation and feedback, the benefits are short lived only. How many of us remember all the history and geography we learned at school?” Here.