Monday, 28 May 2012

Riding the tides

The morning you finish a set of nights is always an interesting time: there is a mixture of physical and mental fatigue, combined with the buzz you feel from having successfully survived the experience, and from the ward round in the morning. There is something about the social nature of the post take ward round that lifts you up. It doesn't matter how tired you might have felt during the night, when you leave the hospital, you are fizzing.

 When I first became a medical registrar, I assumed that the challenges of the job would get a lot easier, but in many ways, it just gets harder. I was chatting to one of the A&E SHOs last night about this realisation, and she gave it short shrift, saying that it must be a job that you get better at. And she is right, but perhaps her view of the role is skewed by her vision of what she imagines the role of medical SpR to be, which, in my experience, differs from what it actually is.

 Being a medical SpR is not just about being the on-call physician to the hospital, providing assessment and treatment of patients with acute medical problems presenting to the hospital via their GPs and A&E. It is a whole lot more than that. For example, you have to manage acute deteriorations and complications that occur to the medical in-patients out of hours (ie when their usual teams aren't there to sort things out). That's probably fair enough, but from here on in, there is a great deal of mission creep, and encroachment from other specialties.

 The medical SpR is also expected to manage medical problems that occur either as complications of, or in parallel with, problems that are being managed by other non-medical specialties. This can mean that you end up dealing with problems in very unfamiliar environments - the labour ward is probably the most alienating place that the medical SpR gets summoned to. This is definitely away turf, and sometimes you have to wonder whether the general principles that you are applying to patients with very different physiological parameters need modifying a great deal more than you have done.

 All of the above can be daunting, but they can also be prepared for: there is a great deal of learning to be done about managing medical problems in surgical, obstetric and gynaecological settings, so the issue remains one of experience and training. However, there remains an aspect of the med reg role which cannot be pre-prepared, because it is the med reg to whom the hospital often turns as the general fixer and problem-solver. It can be a nervy experience trying to apply yourself to a problem that no amount of training can predict, and which isn't actually predicated on your medical knowledge, but rather on your ability to busk and improvise.

 Many doctors I know prepare for the stress and responsibility of the job by learning as much as they can about the problems they are likely to face, but no text book teaches you about the rare and unpredictable occurrences that keep all medical SpRs on edge. However well you think that a shift might be going, as med reg, you know that you are riding a tide over which you have no control, and at any moment, the current could drag you under.

I have often found myself scratching my head over a problem, simultaneously wondering both how to fix the issue and how I got there in the first place. Sometimes it seems that all routes to disaster go via the med reg. It is the prospect of the unpredictable that ages the med reg. It is preparing for events for which there is no adequate preparation that keeps them awake. And that is why it doesn't always get easier with experience, because all experience teaches you is that you are a passenger on much greater forces that your medical knowledge and training could ever overcome. And that is why being a med reg is something that is only enjoyable after you have finished the shift. The satisfaction is all retrospective, when you know how it all turns out. And that is also why it can be so thrilling.

 A few people find out what it is like to play the perfect round of golf, drive the perfect race, or write the perfect prose. An equally small number of people experience what it is like to run the perfect medical take, because even if it all goes well, there is the background appreciation that however smoothly it went, it could have gone worse, and that it didn't was a function of forces much more powerful than one medical registrar.

Sunday, 20 May 2012

Value temperance

I have been wondering whether there is an elephant in my room recently. The evidence is inconclusive at present: I certainly can’t see one, and there are none of the usual tell tale signs that one might expect, such as mountains of dung, and flows of urine, but there is the nagging sense that there is one there, perhaps hiding in a cupboard, seeing how long he can remain undiscovered.

Today, I think I worked out what it was. I was hit by the realisation that recently I have been writing about issues that ask all of us to decide what we value, and yet, I have not on all of these issues, decided what my definition of justice and fairness is. It can be difficult to confess to an audience of unknown people exactly where one stands on a potentially divisive issue (such as social care) and I’m still not quite brave enough to lay it all bare, particularly as I’m not convinced that my particular values are that relevant to the wider world right. Perhaps that’s not quite right: my views may be relevant, but perhaps they are not needed. And yet saying that feels like an act of cowardice - a piece of intellectual chicanery to absolve myself of the responsibility of actually telling you what I really think about something. But that, for now, is my own personal demon.

A good friend of mine recently asked me to be Godfather to his daughter (is it Godfather or godfather?). There are perhaps two areas for discussion that this could lead us to. Firstly, we could debate the wisdom of my friend and his wife asking a committed atheist to be a godfather, but that is a relatively short discussion, as I clearly was not chosen for my belief system. Instead they have paid me the complement of suggesting that I might be a good moral rudder for their daughter as she grows up. Knowing her parents well, I am pretty sure that there will be very little steering for me to do, but this situation raised for me an important issue on what it means to have values, and to be consistent in one’s thoughts and judgements about others. And this I think is the issue worthy of discussion.

At dinner last night, another friend was talking about ‘Religion for Atheists’, by Alain de Botton, which he has been reading (and enjoying) recently. It is difficult to have a conversation about atheism, without Richard Dawkins, the great enforcer, rearing his head. My friend and I have both been turned away from Dawkins by his humourless and critical approach to traditional religions, and the inevitability that such strongly phrased criticism has only lead to entrenched positions, and not any kind of friendly discourse on the basis of religious belief. The elephant in Richard’s room is that while organised religions do have strong beliefs underpinning them which he disagrees with, often  they are also defined by the social structure and values that they lend to their communities. They offer support, wisdom and community in a way that I imagine that many atheists long for. It is perhaps to Dawkin’s credit that his recent activity has been slightly softer, but much of the damage was already done.

Maturity in my case has been marked by a greater degree of moderation. Not long ago, I was a Dawkins disciple, (I still think the Blind Watch Maker is brilliant) and to some extent I relished the drawing of lines that the publication of ‘The God Delusion’ represented. I went to a debate at a church about the book, only to be disappointed (actually, I was outraged) that traditional debating rules had been abandoned, and instead of having one person argue in favour of a motion, and one against, they presented the religious argument why the central thesis of the God Delusion must be wrong, followed by the scientific reason why the God Delusion must be wrong. This second argument was spectacularly obtuse: I remember that the man presenting the ‘scientific’ case against the book closed with the following sentiment:

‘And remember that if you believe in evolution, and you have a friend who has a child, and that child dies, then, as an evolutionist, you would be unable to offer that friend any sympathy at all, because that child would have died from forces of nature. And put in evolutionist’s terms, that is simply the survival of the fittest.’

Sentiment like that upsets me: it is factually wrong, and it is unkind. But it represents the nature of the debate at the time. A great many atheists have offered more excoriating, unjust criticism of people with religious faith, so it cannot be surprising, when someone puts the boot on the other foot.

Values are important. And so is temperance. Particularly when talking about the big stuff. We are never all going to agree, but we do all have to live together in the same world.

Tuesday, 15 May 2012

The confusing challenge of learning lessons from the past

I am all at sea this week. I feel like I am being pulled in all sorts of different directions intellectually. Let me set it all out for you, and then perhaps, you can give me some pointers.

Following a suggestion in Paul Corrigan’s blog, I have started reading the second volume of Michael Foot’s biography of Aneurin Bevan, written in 1973. The combination of Nye’s rhetoric and Michael Foot’s prose is a heady mixture - surprisingly so for such a dry subject matter - the formation of the NHS and the nationalisation of the steel industry rarely make for a pacy read, but I am hooked. It’s a solid tome too - praise the lord for ebooks (If you’re not converted, think of the posturing and hand contortions required to read a 700 page book in bed, and ask yourself why you still insist on doing it). 



The book feels like a return to a more chivalric era, when there could be objective satisfaction in an argument well-made, and there was a real appreciation in the performance of politics. Is it me, or is politics a lot more ruthless than it used to be? Perhaps that’s not right: perhaps it’s a bit like rugby in the professional era: the skill levels of modern players are no better than of the best players from the amateur era, but they are certainly fitter than they used to be, and they get a lot more back up nowadays. I want to say modern politicians get more help, and have access to more support than they used to, which leads to a more relentless brand of politics, practiced full-time by people for whom politics is all they have ever done, and will ever do.

The narrative of Bevan’s efforts to win over the medical profession is compelling reading. One’s impression of how people behaved is inevitably tainted by how it all turned out. As a friend of mine says, Harry Hindsight is the best trader in the bank (I bet Jamie Dimon wished Harry worked for JP Morgan right now) and the knowledge of how successful the NHS was colours one’s interpretation of the resistance that the BMA in particular put up against the NHS Health Bill. But it must have been a hugely unsettling time: in spite of the admirable aims to provide comprehensive health care to the country, doctors were faced with moving from a system of practice that they were used to and understood (even if it was inequitable for patients, and difficult to establish oneself in as a young doctor) to one they did not know, that had never been tried before, which was due to implemented at an unprecedented pace. And all the while they had to negotiate with a man who appeared to them to be really good at hoodwinking them, smoothing over their concerns with charm and wit, and probably left them feeling  after every negotiation that they had been duped, but without really knowing how. If I had been a doctor then, I would have been deeply suspicious, and almost certainly, at least a little resistant to the whole plan.

Does this remind you of anything? Are there any more recent health reforms that you have been suspicious of, or resistant to?

The parallels between then and now are uncanny. Will my grandchildren be reading (and enjoying) biographies of how Andrew Lansley revolutionised the delivery of health care in the UK, against a tide of opposition from the entrenched views of a self-protectionist medical profession? Maybe, but I suspect not. But let’s not shy away from the important issue for reflection: that there is the possibility that some of the resistance to health care reforms that has played out over the last few months, may have somewhere within it, the fear of change, and a reluctance to try something new.

But while I was busy challenging myself on this point, I realised that while Nye Bevan reformed the health service on the back of a manifesto pledge, and an unarguable mandate from the British public, those conditions are not met today: we are witnessing the second biggest health care reform in British history on the back of a promise to stop top-down reorganisation of the NHS, by a Conservative party who limped into government by forming a coalition with the third most popular party in the country.

Is it fair of me to challenge Andrew Lansley on these grounds, or is this me desperately hanging on to the idea that we have been done over?

And it gets harder. Just as we embark on health care reforms that I am beginning to believe might just deliver improvements, I read an essay in the BMJ by Arnold Relman, from Harvard Medical School (and former editor of the NEJM) that health care in the USA is being bankrupted by the influence of market forces, and the only way that health care can be adequately afforded and provided is by the genesis of a system defined by ‘a single public payer that provides universal access to comprehensive care.’

Blimey, just as it feels we are moving away from that definition, Arnold argues that the USA should move towards it. And I am dizzy from all the spinning around I have been doing this week.

Friday, 11 May 2012

Losing sleep over social care

Having written once about social care, I went to bed last night knowing that it is more than a one-hit issue - in fact, every facet of the topic has in-built complexity, varied value judgements, and a strong undercurrent of morality to it. A divide and conquer approach is needed to tame this beast. Some of the questions we need to answer are based on the standard lines of cost, affordability, and level of individual contribution vs state subsidy. But some of the questions we need to post to ourselves have the potential to be uncomfortable indeed, and it was to some of these issues that I alluded in my last post. It is difficult to frame the discussion of social care without revealing one's own opinion. The current discussion about social care is not just framed by the realisation that it is becoming unaffordable, it is also framed by the understanding that it is something that we are not doing very well. Does that ring true? Do we offer our elderly the kind of care that they both need and deserve? It's really difficult to get away from the value judgements. There are two ends of the spectrum: at one end is the view point that our elderly have had long working lives, and should get all the help and support they need via the state. At the other end, is the view that one of the requirements of your active years is to ensure that one's subsistence can be afforded after retirement. Your views on where the state fits in to this scale will vary, but one of the important roles that society plays is to protect individuals from the vagaries of misfortune and catastrophe. Let me put this another way: on average, each of us will have to find £20,000 to cover care costs in later life, but 1 in 10 of us will have care costs in excess of £100,000. A strong parallel exists here with the NHS, which manages the risk of very high individual health costs, by central risk-pooling: we all contribute through our taxes, and the majority (in a financially-balanced health service) will put in a larger amount of money than we ever withdraw in the form of treatment. This cross subsidisation was one of the things the Britain voted for in the landslide Labour win of 1945. And the same must also be true of social care: it seems fair to operate the same kind of cross subsidy that ensures that individuals who end up, through no fault of their own, with exceedingly high care costs will be supported. But implicit in this value-judgement of fairness, there is also an assumption that there is a fair level of self-provision. Again, this operates on a scale: at the one end, we have the NHS model of social care, whereby we all contribute the money that we would otherwise save in anticipation of our future care costs, pool it together and operate a free-at-the-point-of-delivery and comprehensive social care service, from which people can opt out, but from which there is no rebate if you do not avail yourself of the state provided services. At the other end of the scale is a privately funded system, whereby you either afford your own care services, or you do not receive them at all. Surely no one wants this kind of set-up, but where on that scale do we want the level of cross-subsidy to be set? And this is where the current debate on social care is missing the point slightly: the issue of funding social care can only really be discussed in the context of the value judgements that we as a community wish to apply to the issue. Do we want to institute a revolution in social care, along the lines of the NHS, or do we wish to aim for more modest ambitions of satisfying unmet need where we can, but in an overall context of mostly private funding of social care? If like me, your head is beginning to hurt, then perhaps that merely indicates how far we still have to go.

Thursday, 10 May 2012

The social care issue - my initial thoughts

Social care has the potential to become an issue through which society learns a lot about its values, both through reflection on how we currently treat our elderly and vulnerable, and discussion on how we would like it to work.

The perception of social care is clouded by our experiences of how health care is provided - there is something of mission creep in all of this. Our success in effectively creating  a health service that deals with the issues of equity and access of health services effectively creates an expectation that other services will be provided in the same way. Social care suffers by comparison with health care due to its close affiliation, and the fact that distinctions between the two are often blurred.

But the distinction is important - to boil it down, healthcare, particularly in the circumstances I work in, is about how we help others at times of acute and unexpected need (the role of primary care in all of this is an argument for another day), whereas social care centres around the responsibilities of society in the subsistence of others on a daily basis. The transition of patients from the hospital (where they do not have to pay any costs) to social care (where they do) can be stressful and hard to understand.

A sense of entitlement is perhaps justified: the idea that when we are frail or vulnerable, society will ensure that we are looked after is ambition that I share, and one that should not be beyond the wit of modern society to make reality. But what does it mean to be looked after?

Loneliness is a disease of modern society, and one that many of my patients suffer from terribly. Yes, there are repeated problems with the quality of care that the elderly experience both in their own homes and care environments, but perhaps we should take a step back, and instead of echoing the same criticisms of outsourced care, ask ourselves whether the model of social care we use now is the best one available.

Most of the debate about social care that I have heard has focused on the models of funding. This debate needs to happen - the Dilnot report makes it clear that the means-testing model currently used for social care is a very poor model indeed. But there is more to it than that. Perhaps we need to challenge ourselves, and ask whether the kind of care that we provide the frail and vulnerable among us is a function of the priority that we give it.

A great many of our elderly either live in social isolation, or in congregations in care homes, often without any role in wider society. We know that people live healthier and happier lives when they have function and purpose, and yet it is very difficult for a large number of the elderly to continue to maintain important social functions within their communities, living as they do at a distance from their families. And society is complicit in this.

I suspect that financial imperatives will have a greater impact on the choices that we make with social care than anything else: the high cost of social care may well ensure that many families will have to choose to look after their elderly relatives themselves. But an important question that I do not see discussed a great deal, is what we can do as a society to encourage and support families that wish to look after their parents and grandparents at home.

There will always be people who require a level of care that cannot be provided in their own homes, or the homes of their relatives. But perhaps it would make a difference if families were supported in their endeavours to look after their own relatives. There is scope for significant invention here - perhaps through paying for the time that informal carers spend looking after their relatives, or creating communities of carers in different localities. And there is huge scope for programmes to keep the elderly engaged in the wider community, which will also serve to keep them healthier. For example, what would the benefits be if children’s nurseries also doubled up as day centres for the elderly, and vice versa? What if the elderly at day centres ran reading groups for local children, or helped out with after school clubs? Perhaps the little ‘uns could teach their elders a thing or two about using computers, while they were also getting some help with their homework.

Some of this is of course wishful thinking, but perhaps something good can come out of asking the question ‘How should we include our elders in society?’ alongside the question, ‘How can we afford to look after them?’

Wednesday, 2 May 2012

The Network Casebook

Tonight marks the launch of The Network Casebook at the Kings Fund. I always love events like this, because it is often a chance to catch up with old colleagues and friends, but mostly because these occasions give me a burst of energy and enthusiasm for some of the things that I am trying to do.

But this event isn't really about my personal utility - the message is something much broader. The Casebook is a collection of quality improvement projects that have been submitted by doctors from around the country, outlining their own experiences of service improvement projects they've worked on.

The Network is all about sharing this kind of experience, but one has to wonder whether it is yet part of our routine. Much of the emphasis that I think we come out of medical school and junior doctor training is quite positivist in its slant - that there is only a message worth sharing, if your project worked, or delivered what you hoped it would.

In compiling the Casebook, we took a slightly different approach, and purposefully chose some projects that failed to deliver. We think that these projects are worth celebrating for a number of reasons: firstly, even though they fell short of the hopes that their authors had for them, they often showed great commitment in trying to drive them forwards. Furthermore, these projects often include some really important learning about how to approach service development that are worth sharing with others new to the field, that you won't find in projects that succeeded.

I remember some of the projects reflecting on the need for senior champions supporting their projects, or on the importance of multi-disciplinary input, or on the need for the project to have relevance to all the people involved in it, not just one professional group. Those are just a few examples - there are many more. Reading peoples' reflections on what worked and what didn't is a powerful experience. Some of the authors of submissions that I read clearly bore the scars of their efforts, and the frustration at having fallen short of their often ambitious goals.

And hearing it first-hand gives it a salience and power that you often don't get from reading it in a how-to guide.

We're quite good at celebrating success, but perhaps not good enough. We're definitely not good enough at celebrating endeavour, regardless of outcome, so perhaps The Network Casebook can contribute to a constructive change.

We received about 250 submissions to the Casebook, and included 50 in the final selection. I salute every one who took the time to send us their projects, but in particular I give an extra wave to those of you who didn't create a lasting change: at least you had the courage to give it a go.

And please, don't give up - if those around you don't recognise what you've tried to do, there's a whole heap of people at The Network who do.
www.the-network.org.uk