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.

There’s nothing I could write today that’s even half as spot-on as yesterday’s Economist leader.

The recipe for saving the NHS requires radicalism, but of a simpler sort: turning the NHS from what it has become—a sickness service—into what its name promises—a health service. That will mean spending more money. But to spend it productively requires a shift in focus: away from hospitals to the community, from treatment to prevention, from incentivising inputs to encouraging better outcomes.

A system focused on hospitals is one designed to treat people only after they have become really sick. That is the equivalent of buying more fire extinguishers while dismantling the smoke alarms.

The whole thing is well worth five minutes of your time.

When I was 12 years old, my geography teacher sprang a test on us. Part of the test was to draw various Ordnance Survey map symbols.

I am red-green colourblind. I had learned that a youth hostel was represented by a pink triangle, but I couldn’t identify the pink colouring pencil. I tried my best, and wrote alongside something to the effect of ‘I am colourblind—this symbol is supposed to be pink, but I’m not sure whether I’ve chosen the right pencil.’

The teacher marked my answer as incorrect, noting that she ‘had’ to mark what I had drawn, and what I had drawn was a green triangle. I was annoyed. My mum’s brilliant solution, which saved any future embarrassment, was to use stickers to write the name of the colour on each pencil.

I gave up studying geography less than a year later, though I can hardly claim that colouring-pencil based trauma was the reason for that.

This article by Andy Baio on The Verge made me think about this. He talks about the colourblindness and accessibility in everyday life.

This crops up from time to time in my work, too, though less so these days than it used to. I used to struggle with spreadsheets where people RAG rated things by shading cells. These days, at least in my line of work, people are generally too indecisive to rate things as ‘red,’ ‘amber’ or ‘green.’ Things are generally classified as ‘amber/red’ or ‘green/amber’ or ‘red/amber.’ This replaces a simple three-point rating scale with an absurdly complex seven-point scale, totally negating its effectiveness in a way which would usually irritate me… except for the fact that it means the ratings appear in text, not as shading.¹

But it still happens: guidance has ‘red’ and ‘green’ pathways; our clinical record system has red and green dots to indicate especially high or low consequence diseases; our professional appraisal system colour codes my appraisal form sections as green for ’complete’ and red for ‘incomplete’; people produce wholly inaccessible charts and maps; people like to add comments to text in red and green.

I recently expressed disappointment at Caroline Creado-Perez’s Invisible Women for asserting ‘that if women are the majority practitioners of an activity, then barriers to that activity are automatically a gendered issue.’ Given that about 10% of men are colourblind and only about 0.5% of women, it occurs to me that this is a great reverse example. By Creado-Perez’s yardstick, I should criticise my (female-majority) employer for gender-based discrimination when they produce documents which don’t account for the needs of colourblind people. But that doesn’t seem like it would be a helpful approach to life.

Most of the time, I don’t really think about it, though I’m not shy about pointing out the issue when it arises (and the examples in Baio’s article feel very familiar). Wendy occasionally feels mildly sad at the thought that I’ve ‘never seen the true beauty of a rainbow,’ and is occasionally surprised at my fashion choices, but otherwise… it’s all good.

The Ishihara image at the top looks to me like it has a hazy, slightly wobbly ‘21’ in it. It probably looks like a ‘74’ to you.

1. Some morons even extend the schema by adding a ‘black’ category, to add an additional three points to the scale (‘black,’ ‘black/red,’ ‘red/black’). This is unforgivable. ↩

There are two adverts I keep hearing at the moment. I think the combination of the two might be harmful to health.

The first says:

One in two people will get cancer in their lifetime.

The second says:

One in two smokers will die of a smoking-related disease.

I wouldn’t quarrel with either of those statements. However, I think hearing both might lead people to underestimate the risks associated with smoking. I think people think “cancer = death” and that “a smoking related disease = cancer”. They may therefore—completely inaccurately—conclude that smoking doesn’t change the risk of death all that much.

Of course, not all cancers are life-shortening—indeed, many don’t even warrant treatment, and many require only a one-off minor procedure.

Of course, there are many life-shortening smoking-related illnesses which aren’t cancers.

I worry, though, that people will just compare “one in two” with—well—“one in two.” That wouldn’t be helpful.

The picture at the top of this post is an AI-generated image created by OpenAI’s DALL-E 2.

Reflections are sparked by the strangest things.

I was on my way to deliver a teaching session scheduled for a room off a service corridor in the basement of a hospital. The corridor was familiar. I was transported back to working as a foundation doctor, when building work meant traversing this endless corridor in the dead of night to get between hospital wings.

The sensation was so reminiscent that my hand automatically wandered to my back pocket to make sure I still had my ‘list,’ the indispensable scrap of paper serving as an aide memoire, with tasks and patients scribbled all over it. For a junior doctor, losing your list is akin to losing your mind, but I haven’t carried one in over a decade.

As I walked that corridor years ago, I would often be strategising about how I could fit an almost endless list of tasks into a narrow window of time. Most of my anxiety was related to doing things. These days—and I think this is common to most doctors as they become more senior, not just those in health protection—most of my anxiety is related to not doing things.

When presented with a situation, ‘doing something’ is almost always the easiest option for experienced doctors, not least because the burden of actually doing the work typically falls elsewhere: taking a specimen, giving an antibiotic, calling a meeting, putting up a sign.

But ‘doing something’ is very frequently the wrong option, partly because resources are limited, but more importantly because not everything benefits from an intervention. Specimens won’t always change management and can cause anxiety while awaiting results. Antibiotics don’t work for everything, have unpleasant side effects, and are a limited natural resource. Meetings don’t always achieve anything and sometimes just kick the can down the road, at a huge time cost. The world already has too many signs, and signs rarely solve problems.

‘Doing nothing’ is often right. Time is a diagnostic and prognostic tool. Waiting to see if a risk is realised is sometimes more rational than responding to an uncertainty.

But ‘not doing things’ is hard. As the adage goes, the coroner doesn’t criticise the doctor who gave the antibiotic that didn’t work, but finds fault with the doctor who didn’t give the antibiotic that might have helped.

‘Not doing things’ is exhausting. Going against someone’s expectations and saying ‘no’ can be emotionally taxing as well as time-consuming. It frequently takes longer to explain and justify and document why you aren’t doing something than it would to just do it. It typically sets up a confrontation that needs to be de-escalated before it begins.

‘Not doing things’ is also necessary, particularly when it might save time. My time is limited and the demands on it are—at least as far as I can tell—unlimited. Working out where my time is best spent is not easy. Saying ‘no’ to things that I’d usually enjoy is dispiriting, but often necessary.

More challenging still is when someone else decides that ‘something must be done’ and requests my participation—even when my judgement is that the better option is to ‘do nothing.’ Do I participate to try to limit the madness? Do I opt out and leave them to it, even if this might precipitate bigger risks down the line?

I still worry about how to do numerous things in a short period of time, but the anxiety of commission is far outweighed by the anxiety of omission these days.

The picture at the top of this post is an AI-generated image for the prompt ‘a world of clocks’ created by OpenAI’s DALL-E 2.