Yesterday, I had the entirely unexpected pleasure of seeing the world’s first web server at CERN in Meyrin, Switzerland.

Over the years, I’ve read a lot about the early development of the world wide web, and I’ve also read about the storied history of Apple, including Steve Jobs’s period at NeXT computers.

Yet somehow, it had spectacularly failed to lodge in my mind that the first web server was a NeXTCube. Before I peered into the display case, my assumption was that I’d see a beige tower, probably with an IBM badge on it. It’s strange to contemplate how assumptions like that take hold, even though I must have read many times over the years that it wasn’t the case.

I also loved the sticker for its real-world mundanity. Not shown in the picture above is the handwritten comment on the top of Berners-Lee’s paper describing his system: “vague but exciting…”

It’s also fascinating to ponder the problem he was trying to solve—managing information about complex, evolving systems—and how we really haven’t applied it in healthcare more than three decades on. Even at the very simplest level, we really haven’t embraced the idea of hypertext, and of live-updating bits of guidance as new evidence emerges—or even just as new policies emerge. Most healthcare guidance remains static, with whole documents being refreshed in cycles.

For example, even the boilerplate description of many organisations at the front of documents is baked in, and only refreshed when the document is updated. If only we had learned from Berners-Lee, that could be a ‘do-once’ update that would be linked into all relevant documents.

Or, more relevantly, look at COVID guidance: each time the isolation period changed, hundreds of pages of guidance documents, including even all of those hosted on gov.uk, needed manual revision. If they’d been more thoughtfully constructed, that too could have been a ‘do-once’ update.

The counter argument, of course, is that changing ‘bits’ can substantially change the meaning of the whole, and a standing document needs approval and sign-off at regular intervals. But really, nothing in medical guidance is more complex than particle physics, for goodness’ sake, and there’s no reason that approvals to updates couldn’t be sought with an eye to where they propogate.

Perhaps we’ll get there one day.

Richard Smith recently proposed banning the word ‘prevention’ in healthcare:

A few years ago, my friend Pritt, one of life’s instinctive radicals and iconoclasts, talked to me about “the deficit model of health.” At first, I didn’t grasp his point, but slowly I came to understand. What is being prevented? Sickness, of course. Prevention leads to health, which is the “absence of sickness.” Health is defined as a deficit, the absence of sickness. And who determines if you are sick? Doctors. If we stick with “prevention” then doctors will determine who is sick and who is “healthy” because they are not sick.

Like most radical ideas, this one took me on a journey. My instinctive response was to agree: I smiled broadly as I read, ‘Dying is healthy; living forever would be unhealthy.’

Of course, ‘we need a bolder and broader definition of health—something to do with resilience, adaptability, coping, interdependence, and relationships with others, our community, the planet, and nature.’

But then, I paused. I work in health protection. Most of my job is about ‘preventing’ illness. If someone is a close contact of a patient with a particular disease, then they may need antibiotics to prevent them from becoming unwell themselves. If there’s a high likelihood that a foodstuff in someone’s fridge was manufactured in a way which has introduced contamination, that food might be better off binned to prevent food poisoning. If a cloud of chlorine gas is rolling towards a housing estate, then the people must be evacuated to prevent them from choking to death.

And then I saw the point. To see my job as ‘prevention’ is precisely the sort of simplification that I myself often rail against. My job isn’t really to prevent people from becoming unwell: they can take as many risks and be as unwell as they damn well please. My job is really to inform them of the risk they face, help them to decide whether they want to act in light of that new information, and to support them to act if they wish to do so.

This is significantly different because—as I frequently find myself emphatically explaining to others—it can be perfectly rational not to act in response to a risk. This is especially true given that most actions generate side effects, which each of us will value differently. We don’t—and shouldn’t and mustn’t—compel people to act based on our assessment of the risk to their physical health, because there might well be other things that they value more greatly.

Banning the word ‘prevention’, even from an area of medicine that might seem to be entirely focused on it, would be enormously helpful in reframing what we do.

The Times front page had a headline yesterday morning proclaiming that “most people die while on NHS waiting list”. The opening paragraph:

More than half of all people who died in England last year were on an NHS waiting list, research indicates.

I didn’t get a chance to read beyond that point, but as I walked to work, it played on my mind. I thought a lot about how it was a sad inditement of modern medicine. How depressing, I thought, that so many people are dying in limbo, expecting some kind of treatment for something, rather than being supported to achieve a good death. People who are at the end of their life should not be worrying about clinic appointments and waiting lists.

On the other hand, I thought that perhaps this news was perversely positive: it was good, I thought, to see realistic medicine enter the national conversation as never before.

And then I read the full article. And The Guardian’s coverage.

And ho-hum, I’d got it very wrong. It turns out that I was supposed to be thinking:

Record numbers of people are spending their final months in agony, waiting for treatment that never arrives. The basic promise of the NHS — that it will be there for us when we need it — has been broken.

And that the statistics represent a:

terrible indictment of this government’s mismanagement of our health services.

And:

These figures are a stark reminder about the potential repercussions of long waits for care. They are heartbreaking for the families who will have lost loved ones and are deeply dismaying for NHS leaders who continue to do all they can in extremely difficult circumstances.

I suppose my reaction differed from that of the various spokespeople because they assumed that most patients were dying while on waiting lists for treatment for the thing that killed them.

That seems so unlikely that it simply never occurred to me, and there’s nothing in the cited data to challenge my view. It’s not uncommon for someone to languish on a waiting list because they are being treated for something else: people don’t get hip replacements while they’re going through chemotherapy, for example. Certainly, some people are referred for treatment for a condition, deteriorate unexpectedly quickly, and die while waiting, but those events strike me as quite exceptional, quite far from the norm, not least because lists are generally arranged by clinical urgency.

But really, this statistic is intriguing for being an interesting combination of meaningless and significant. It’s meaningless because it is extrapolated from a small data set, we have no evidence of any causal link, and it’s not immediately obvious that improving it would improve patient care. Yet, it is significant because it helps to give some emotional context to bland waiting list statistics and reminds us that people’s lives continue while they wait.

The image at the top of this post was generated by Midjourney.

Richard Smith recently shared this editorial he wrote more than thirty years ago, on the subject of preventing whistleblowing. It seems entirely relevant to the present day.

I was particularly struck by this passage:

Most organisations eventually have to take tough decisions. Difficult choices, particularly over allocating resources, have long been part of working in the NHS. The choices will become tougher, and there may be more losers than winners. The fear that the losers will tell all to the media is what leads managers to reach for their gags. They make a mistake. Instead, they need to create organisations-be they hospitals or health authorities -where employees feel enough part of the decision making process not to need to blow their whistles.

You begin by letting everybody know what is going on. If the rhetoric is glossy brochures full of the word “quality” and the reality is elderly patients with pressure sores in back wards with peeling paint, then staff will become cynical and demotivated. They need to be convinced that the available resources are used fairly, efficiently, and effectively. The surest way to convince them is to involve them in decision making. The decisions that are made must be clearly and honestly communicated. Staff must have a chance to come back on poor decisions, and managers should not be afraid to reverse decisions that are wrong.

If staff understand the true circumstances of the organisation and feel that their views have been given serious attention then they will accept tough decisions. But if seemingly arbitrary decisions appear from nowhere then staff will be unhappy and one or two will contact the press. Managers who try to create a climate of fear will neither stop whistle blowing nor run an effective health service.

That second paragraph is remarkable: it is common sense, it has been clearly articulated for more than thirty years, yet it is seldom followed.

The difficulty so often seems to come at the point of involving people in decision-making. Frequently, efforts to do this appear as cynical attempts to justify decisions that have already been taken. This isn’t solely a problem in the health service: we can see similar cynicism, for example, towards the ongoing consultation about closing railway ticket offices.

If we choose to be as uncynical as possible, then it strikes me that this often boils down to poor communication. Smith talks about ‘glossy brochures full of the word “quality”’—and I think he’s right. Starting a conversation about funding cuts with rhetoric around ‘quality’ and ‘efficiency’ drives cynicism more than collaborative decision-making. Too frequently, managers fear being honest, and too often, managers choose not to be plain-spoken. You cannot have shared decisions if the people sharing in the decision have no idea what you’re talking about.

Later today, NHS England will release quarterly waiting time statistics for A&E attendances and emergency admissions. This will doubtless spark political discussion about ‘reform’ of the NHS, including greater digitisation.

In the latest Wired, Yinka Makinde (Director of Digital Workforce at NHS England) talks briefly about some of the reasons that ‘digital’ projects in the NHS fail:

70 percent of digital transformation programs in the NHS, particularly complex ones, will fail to meet their desired objectives. There are many reasons for this. For one, we focus too much on technology and often forget to ask what problem our clinical staff and patients are facing and how they want things to change. We also have organizational silos, where digital is still often seen as the IT department with the office in the basement, rather than something more integral to the health service.

I’m not an expert in digital technology, and my personal experience of leading ‘digital transformation’ is limited to upgrading the router at home. Yet, as a doctor, I’ve been on the receiving end of these programmes more times than I’d like to count, sometimes in the NHS and sometimes in allied organisations. It almost always feels like something that is being done ‘to’ me—not ‘for’ me or ‘with’ me—and a seventy percent failure rate sounds about right. Some projects ‘fail’ in the sense of never reaching full roll-out, usually after a last-minute screeching emergency stop; others ‘fail’ in the sense of rolling out, but not delivering the intended outcome.

Today, I’d like to offer a few reflections on where—from my perspective—some of those programmes have gone wrong.

Failing to understand the problem

Lots of projects I’ve been involved in seem to start with process mapping. Someone might ask to interview me, or to observe me, and to diagrammatically represent what I am doing, often concentrating on the ‘information flows’ that I’m generating. This raises a practical problem and a philosophical problem.

The practical issue is that the generated process map is a subjective abstraction of reality. It does not completely record what is done, and some of what is recorded will be scenario-dependent. This ought not to be an issue, as the map ought only to be an aide memoire and understanding of the problem ought to be regularly checked back with the person observed. In my experience, this rarely happens. Worse, the opposite often happens. The process map is redrawn, refined, and reinterpreted, abstracting it further and further from reality.

I vividly remember one occasion on which someone misunderstood what was meant in a process map by ‘agreeing’ a decision. In practice, this meant chatting it over and sense-checking it with a senior member of the team, most often retrospectively, possibly up to a week or so after the decision was made. The resulting software had a mandatory field to be completed at the time the decision is made, including the name of the senior person ‘agreeing’ the decision. The team responded through a workaround, replacing the ‘name’ with a standard phrase regarding delegation; the bug was never fixed. The software misunderstood the process, and the resulting workaround means that records are slightly worse than they were before, as the name of the person providing ‘agreement’ is no longer recorded in a standardised form.

The philosophical problem is that process mapping does not always provide insight into why something is done, which can be valuable information. It appears to be common that processing mapping results in a finding that a particular process is stunningly inefficient: for example, it can be suggested that telephoning someone as part of a process is much less efficient than using some form of asynchronous communication. This is often true, but if the phone call has multiple purposes, only one of which is caught in your process map, then the phone call is still going to have to happen. The ‘more efficient’ approach will be an additional, and therefore inefficient, step.

I’m reminded of an IT-driven project in a general practice surgery which recalled patients for annual reviews pertaining to specific diagnoses—say asthma, or hypertension—using text messages, allowing them to use an automated system to book themselves in at a convenient time. The aim was to reduce pressure on receptionists. The project missed that a large proportion of the patient population had multiple conditions, and that many of them called for multiple reasons. The consequence was that patients ended up attending multiple appointments for annual reviews of multiple conditions, instead of them being covered in a single appointment. Call volumes also dropped less than expected because people were still calling about the ‘other business’ they would have completed during their appointment booking phone call.

Failing to set limits

In large organisations, everyone wants any new IT system to do something specific for their part of the business. Some requirements will inevitably be mutually incompatible—or, at least, not best suited to be completed on a single platform. All too often, the response of the developer seems to be to say ‘yes’ and add to the project cost, rather than setting limits.

This comes up in my field all the time. One common issue is the conflict between surveillance and case management. Surveillance is knowing how much of a disease is in the population at any given period of time. Case management is responding to each individual case. These sound superficially like sensible bed fellows, but they are not.

Surveillance requires very rigid, fixed case definitions: a person is a countable, confirmed case of Disease X if liver enzyme Y is above standard value Z. Absolute certain is required. The real world of case management is much murkier: the validity of interpreting a person with liver enzyme Y above standard value Z to be a confirmed case of Disease X might be questionable if their liver is already inflamed by disease A. The case might be epidemiologically confirmed, but in terms of individual case management, found to have something else entirely. Keeping those two seemingly contradictory facts in the same system is probably not advisable: the potential for confusion is endless, even with the best system architecture in the world. But that doesn’t stop people…

Failing to understand the environment

This is the error I find least straightforward to understand: people creating ‘IT solutions’ that fail to understand the environment in which they are being deployed. Some of these seemed screamingly obvious: rolling out electronic prescribing to wards with one or two computers, or asking care homes without computers to fill in an online dashboard.

Others lacked a more subtle kind of awareness: developing a system to communicate with staff across multiple Local Authorities which required the IT teams in each Authority to install specific software on their systems, for example, or expecting a website which required an up-to-date browser to be accessible in NHS hospitals running on ancient versions of Windows.

The common factor tends to be that it’s the environment external to the organisation commissioning the ‘IT solution’ that is often poorly understood. For a project to succeed, it needs to understand the limitations faced by its users, not just its commissioners.

Failing to plan to evaluate

In medicine, we’re almost obsessive about assessing outcomes. All too often, IT projects only plan to evaluate processes. This is a mistake: an inability to show that a system improves outcomes is often an inability to argue for continued funding.

I was once involved in a project which replaced emailed reports with an online dashboard. The function of the reports was to generate ‘awareness’: for example, to give people a bit of background awareness as to where in the country there might be outbreaks of a specific disease, to help inform risk assessments about individual potential cases who have travelled to the area.

The evaluation plan was entirely about the accuracy of the data on the dashboard and whether the dashboard was accessible to staff. That makes sense if viewing this as an ‘IT problem’: but the actual requirement was for awareness: moving from a model which pushed information to staff to one where staff had to pull information in from a dashboard was an unlikely way to achieve that goal. If those designing the system had planned a proper evaluation up front, that significant hurdle would have revealed itself early on, and they may have taken a different approach.

It’s interesting to reflect that these problems are not just problems with ‘digital transformation’: the broad topic areas are exactly the same as those that trip us up in outbreak management. Sometimes, we don’t understand the problem, perhaps because we misinterpret clinical results or talk to each other in language that means different things to different groups.¹ Occasionally, we don’t properly set limits around what we’re managing, and so end up with outbreak control groups that last for eternity and consider every issue under the sun. We don’t always properly understand the environment, and can give advice that makes no sense on the ground.² And we aren’t perfect at remembering to evaluate our approaches and share our learning, however much we try.

Perhaps these issues are universal. Perhaps they are problems of professional life—or just _life_—rather than anything specific to IT projects. The thing they have in common is that they seem superficially simple, but are hard to both spot and tackle in practice. Communication and teamwork are crucial to solving them: as Makinde says, organisational silos are unhelpful.

And, perhaps, we all need to be a bit—or maybe a byte—more humble in the face of complexity.

1. Communication is the hardest bit of my job. I’ve reflected before about how I’ve gone wrong by fundamentally misunderstanding what someone is saying to me. I’ve mentioned the example of ‘vulnerable’ prisoners, which are two completely different groups of people from a health perspective (likely to become unwell) and from a justice perspective (likely to be attacked by other prisoners). Another example, which often caused confusion in the covid pandemic, is ‘contact tracing’, which can sometimes mean tracing those who have been in contact with an infectious person (to see if they’ve caught it) and can sometimes mean tracing those who were in prior contact (to see where the known case has caught it. The result is that doctors in my profession spend a huge amount of time and effort in trying to make sure that everyone has a shared understanding of what we’re trying to say, but even then, we sometimes fail. ↩
2. I’m a big advocate of visiting places and seeing them with my own eyes when trying to give outbreak advice… which has made recent times challenging.
   

The image at the top of this post was generated by Midjourney.

In his most recent piece for The TLS, hospital doctor Druin Burch writes:

The optimum amount of medicine to have in your life is the minimum possible, and private healthcare lacks the essential spirit of parsimony. A fee-for-service system rewards those who do as much as possible, not the thoughtful minimum. Those who can pay for everything run the risk of getting it.

As so often with Burch’s writing, I find myself both agreeing and disagreeing.

First, the disagreement: the optimum amount of medicine is not the minimum possible. This is self-evident. It is perfectly possible to live your life without a measles vaccination. Most unvaccinated people will not catch measles. Yet failing to get a measles vaccination is far from ‘optimal’: it forgoes the tiny risks associated with vaccination in favour of the much greater risks of acquiring disease, and it puts others at unnecessary risk.

But the wider point—that too much medicine is bad medicine—is a truism that’s too little discussed. I was amazed to read recently about Zoe, a programme that uses real-time blood glucose monitoring, genetic sequencing of gut bacteria, standardised meals with associated blood tests to create a diet plan. Perhaps medicalising one’s diet to that degree is helpful for some, but it’s not something I’d sign up to.

My gut reaction to all of this is that I don’t want to be unnecessarily investigated for anything, nor screened without good reason and evidence. Most incidental findings are unhelpful, resulting in further investigation and sometimes treatment which is entirely unnecessary—and where the benefit doesn’t come close to outweighing the harm.

My view on this is, in theory at least, pretty firm. But theory is not reality: as I type this, I can also see my Apple Watch, silently and continuously screening me for atrial fibrillation. I have scales at home which screen me with each use for peripheral neuropathy. My bed monitors me for sleep apnoea. I occasionally take my body temperature, even when I’m feeling well. This stuff is insidious, and it’s not necessarily good for overall health.

As a result of being based in a shared regional office, I’m in the strange professional position that my desk is about 30 miles away from the geographical area I cover. This setup results in a fair amount of unavoidable travel from the office to the people and places that my eyes need to see.

For my first few years in the role, I tackled this by driving a lot. This was convenient, especially because my parked car could often become a ‘mobile office’ where I could catch up on work, chair teleconferences, and even sometimes deliver online teaching sessions. I even bought a desk that clipped onto my steering wheel to assist with this.

I came to realise, though, that this wasn’t great for a person whose job is focused on protecting the health of the public. I drive a small car, but I was still no doubt emitting more carbon than I needed to be. I therefore made a special effort to start using public transport whenever possible… but there were two problems with this.

The first was that I wasn’t all that convinced that this was truly helping the carbon issue. Typically, it meant taking a diesel-powered train or bus, often as one of only a handful of passengers. But I decided that this was out of my control, and I had to trust the system to do the right thing: if I adopt the ‘right’ behaviour, then it’s up to others to make sure that it counts.¹

The second was that it didn’t seem to be possible all that often. I’d either have back-to-back meetings, or there would be a teleconference straight after a meeting, or the transport timing didn’t line up, or the venue wasn’t especially accessible. Basically, I still ended up driving quite a lot.

I’ve noticed something interesting, though: post-pandemic, I’ve found this transition to public transport somewhat easier. I’ve taken public transport much more often. As I sat on the train back from James Cook this week, I was pondering why this was. I think there are maybe five factors.

The first is that in-person meetings have become much rarer these days. Online meetings have become the default option, even for things where they were previously considered impossible. This means that I don’t feel so bad about taking slightly longer to travel to and from them, and that the occasions where I have back-to-back in-person meetings at poorly connected places have become far more unusual.

The second is that I’ve genuinely adopted a mindset of public transport being the default, which has been helped by the break in physical meetings occurring. This has resulted in a subtle but significant change in my thinking: if I can’t do two meetings because they are geographically incompatible, then I’ll have to miss one of them. If I’m supposed to be chairing a meeting when I’m scheduled to be on a bus, then the meeting is going to have to move or find another chair. The option of driving has become a last resort, whereas it was more of a second-preference before, despite my intentions.

The third—possibly related—is that I’ve become phlegmatic about public transport disruptions. If I am supposed to be somewhere, but public transport lets me down, then I no longer feel a sense of responsibility about that. I plan my days with reasonable buffers to account for predictable problems, but if exceptional events disrupt it, then that’s out of my control. The same was always possible when driving, in any case.

The fourth is that technology has moved on. I can now do a lot more when I’m on public transport than I could before. Most of these changes are relatively ‘soft’. People often default to chatting to me on Microsoft Teams instead of phoning, which turns out to be much easier to handle on a noisy train. More services have moved to the cloud, which means that I can do more work on my phone rather than having to try to balance a laptop on my knee on the bus.

Finally—and I’ve only realised this belatedly—I have a responsibility to role-model behaviour that accords with an understanding of the threat posed by the climate crisis. I’m not claiming to be an environmental saint by any means: my overall patterns of behaviour are probably quite poor. Yet, it doesn’t really inspire change if the doctor in charge of protecting the public from environmental hazards is happy to drive everywhere. I realised this after I recently gave some junior colleagues an email address, and the only thing I had to hand to write on was a used bus ticket: they looked at it as though they’d never been on a bus before, and it set me thinking.

It will be interesting to see whether this changes over time.

1. This is a position I also adopt on recycling. I sometimes read about questionable recycling practices, such as allegations that plastic recycling ends up in landfill or in the ocean or whatever. But I’m not in charge of that. If I’ve reduced and reused as much as I can, and presented my recycling according to the supplied guidelines, then I just have to trust that the ‘system’ will do the rest.
   

In 2005, I was just starting to be released onto the wards in the third year of my medical degree. One of the dullest weeks focused on orthopaedic surgery. The operations were life-changing for the patients but struck me as a sterile version of Meccano. The techniques were ingenious, but their application to a conveyor belt of patients felt depressingly repetitious. Give me a knotty, intractable problem to tilt at (and fail to solve) any day.

The specialty wasn’t right for me, and I wasn’t right for the specialty: I have neither the ego nor the bravado to be an orthopaedic surgeon. I sincerely hope things have moved on in the past two decades, but the male orthopaedic surgeons’ changing rooms were Lynx-Africa, Page-3, clothing-on-the-floor hellholes ripped from straight from a sleazy gym. No thanks.

My over-riding memory of that week, though, is not the surgery: it’s a specific patient. She was in her late 80s, she lived alone, and she was fiercely independent. She had never married and was proud of the fact: woe betide anyone who prefixed her surname name with ‘missus’. She had fallen a couple of years previously and broken her hip. She was in hospital because, unfortunately, the nail which was holding her femur together had fractured following another fall.

I met her shortly after her admission, when I was allocated to her to practice my history-taking and examination skills. We fell into a long chat about her fascinating career, an area of work I knew (and know) nothing about.

One thing she was keen to tell me was how ‘miraculous’ the NHS was. She grew up in a poor household. She talked about her experience of TB in her youth, and of being isolated in a charitable sanatorium with no contact with her family for months on end. She talked movingly about one of her younger brothers becoming very unwell when she was a teenager, her parents being unable to afford to call a doctor and having instead to seek help from the church. Her brother died, having never seen a medic.

I remember going with the occupational therapy team to see this lady’s house: a standard part of their practice to see what home aids she might require, or what trip hazards might be lying around. The house was immaculate, not a thing out of place. I could scarcely believe that someone in their late 80s could keep a house so beautifully.

Her surgery turned out to be more complicated than was initially expected. The broken nail proved difficult to remove—by virtue of being broken, it couldn’t just be cleanly pulled out of the hole it had been driven into. Once it had been quite traumatically extracted, the patient required a plate to be screwed in to hold her femur together, with something like a dozen screws. It wasn’t a light undertaking, and this lady ended up spending quite some time in intensive care.

By rights, my story should end there: I moved onto other training weeks. But I kept popping back to see this lady. Every time I saw her, without fail, she talked about the ‘miracle’ of the NHS. She talked about how, when it was first introduced in her twenties, people were terrified to call a doctor as they couldn’t believe there would be no bill. It took a long time and countless leaflets and word-of-mouth until people really trusted that they could use the service. She talked more eloquently than I ever could about how it transformed the life chances of those around her: how gradually, over time, illness came to lose its life-changing significance, and became more of an irritation than a life event. She lamented the loss of her brother.

She talked, too, about her concern for the future of the NHS. She thought that those who hadn’t lived without it didn’t appreciate it. For some reason or other, NHS waiting lists were in the news at the time. She saved a newspaper clipping for me, and when I went to visit, remonstrated with me: why did these people not realise how lucky they were to be on a waiting list for free care? Would they complain if they were on a waiting list to win the lottery? People won’t realise what they’ve got until it’s taken away again.

Over the course of about six weeks, her tenacity and drive—plus support from nurses, physiotherapists, occupational therapists, and pain management specialists—resulted in a truly astounding recovery. My last memory of her is of her being wheeled off the ward—backwards, for some reason—with a massive grin on her face, arms waving in the air, thanking everyone she passed (even the other patients). Remarkably, she was going back to her own home, to continue living independently.

Clare Gerada, the president of the Royal College of GPs, once wrote:

One cannot see patients, day in day out for years, without being profoundly affected by this experience and the struggles we witness. Even now, as I write this chapter, I see the faces of my patients and hear their words, some long deceased. I see their ghosts as I walk my dog, shop in the supermarket or walk past their old homes. Many of my patients still live in my mind.

I agree, and today—the 75th anniversary of that day in 1948 that this patient remembered so well—this patient is making her unique presence very well known to me.

Of course, her reflections aren’t really about the NHS as it is currently structured: her point is about the value of care which is free at the point of use, funded through general taxation. Politicians like to politic about the specifics: organisational structures, social insurance models, completely free care¹ versus co-pay models, the level of involvement of the private sector. At it’s founding, NHS hospitals were made into a single organisation. These days, there are countless separate organisations, many operating in competition with one another, mostly on the basis of finance rather than quality of patient care.

But sometimes, and particularly on an anniversary like this, it’s worth taking a step back and realising what we’ve got: the NHS is a miracle. We shouldn’t forget that it wasn’t always like this, and won’t necessarily be like this forever.

The NHS is under extreme pressure at the moment: it feels like it’s falling apart in front of our eyes. But at least we still have an NHS which strives to deliver its founding principles. Sadly, these days, political rhetoric around the NHS has become entirely about patching it up, about making it live within its means—as though those means are not entirely determined by us.

How wonderful would it be if we used the 75th anniversary to invent the same thing for social care? To have the vision to say “the whole of society will take the risk” instead of the individual? To proceed with visionary boldness to meet the need, not balance-sheet-driven timidity. To prioritise compassion over efficiency.

My birthday wish for the NHS is that, perhaps, we’ll have moved in that direction before it reaches its century.

1. We don’t have completely free care in England: there are prescription charges, dental charges, optical charges, and so on and so forth.
   

The image at the top of this post was generated by Midjourney.

I vaguely remember having a conversation with someone once about the different between the Red Cross and Médecins sans Frontières.¹

The Red Cross focuses solely on the individuals in need. It will work with corrupt regimes to get access to prisoners of war, and it will summarily ignore any wrongdoing it comes across beyond its narrow focus on the immediate needs of the people it is there to serve. This means that the Red Cross can provide care to people in some of the most extreme circumstances, across boundaries and within facilities that no-one else might ever be able to access.

Médecins sans Frontières tries to do the greatest amount of good for the greatest number of people. It published reports condemning wrongdoing it has seen. In extreme circumstances, it will pull out of facilities and territories rather than be complicit in silence. This means that it can bang the drum, or threaten to do so, to secure safety and health for whole groups of people.

In practice, the Red Cross and Médecins sans Frontières coordinate to make sure that they can both meet their goals while leaving as few people unserved as possible.

This has been playing on my mind recently in the context of health protection. Sometimes, for example, hospitals have outbreaks of infectious diseases, and sometimes, they ask for my advice and support. I approach these situations in a very ’Red Cross’ manner: as in, “your secrets are safe with me, let’s talk openly, honestly and frankly, and let’s fix the problem.”

Others in my role would approach these situations from a more ‘Médecins sans Frontières’ perspective: as in, “I want you to listen to my advice, make an action plan to fix this problem and report to me on progress regularly, or I’ll escalate my concerns to your commissioner.”

These two approaches aren’t as mutually exclusive as they might first seem: even with the ‘Red Cross’ approach, the reality might be that I’d have to involve regulators or commissioners eventually if I was deeply concerned.

Yet, I see my primary role is to be a friendly independent source of help and advice to help steer things in the right direction; others in the same role see it differently.

I convince myself that my approach is based on experience and evidence, and that it’s the most effective approach for me. But I can’t deny that it also aligns with my personality and preferences, and that almost certainly colours my thinking.

I suppose my reflection is that different approaches work for different people, probably in part because they suit different personalities and contexts. There is often a drive in life to standardise things, but sometimes, greater things can be achieved through having two opposed approaches working in harmony, just like the Red Cross and MSF.

The image at the top of this post was generated by Midjourney.

1. The details of this might be a load of misremembered rubbish. ↩

Earlier this year, I recommended one of the books by Dr Gavin Francis, a Scottish GP.

Today, I’m recommending his recent article in 1843 Magazine which describes the ongoing collapse of the NHS. It’s heartbreaking.