73. Defending the metric system and other systems from people who say they aren’t real.

Finally, a new logo for the National Health Service.

The first page I look at in the local paper is the obituaries. Call it outcome research if you want, it’s a relief not to see any familiar names. Then I look at what’s happening in the world. I note that the deadline is approaching for the library consultation and resolve to send in my idea that they provide noise-cancelling ear protectors.

Then I read about something called Messy Church, which seems to offer a welcome antidote to Puritanism. I wonder whether a Messy Hospital movement might catch on now that MRSA is dying down. And on the very next page there’s an account of a new plan for the NHS which looks very messy indeed. GPs will be hospitals and hospitals will be GPs, and either of them might pop up anywhere, unrestrained by tired old concepts like buildings. There’s apparently an £8 billion deficit, so I can see why buildings won’t be used. The new NHS, like the shops of the future, will be people in white vans. A spokesperson for NHS England states that they’re ‘going to turn the whole thing on its head’.

I skim over the pages that purport to show old photographs of the town. I suspect that someone with an old model Nokia is taking photos of existing buildings and running them through a sepia filter. I’m sure Gregg’s wasn’t there in 1895 for instance. On the next page the local council has taken out an advertising page, assuring us that it is working not just for today, but tomorrow too. And there’s an intriguing little piece about scratch card quizzes ‘being used to help residents select the best services for health needs’. This is the first piece in the paper that leaves me anxious to know more, but there is no further explanation. Just a photograph of the main sign outside the local hospital, underneath which is the caption ‘scratch card’. Hmm.

And then, just as I was getting into enjoying the gentle rhythm of news about a small town where nothing ever happens, and feeling thankful that I wasn’t living in Sierra Leone or Syria, the bombshell bursts.

Right there on the letters page, in between ‘plant based diet’ and ‘dump the metric system’, is a piece called ‘treatment frustration’ written by a man called Brian Daniels, ‘national spokesperson, citizen’s commission on human rights’.

Brian’s contribution is to assert that mental illnesses do not exist and psychiatrists are not proper doctors. That’s not quite enough to make me choke on my artisan toast. After all, Thomas Szasz was saying the same thing in the sixties and made fame and fortune with his books such as The Myth of Mental Illness. It’s just the worry that someone from the government or civil service might read today’s paper and experience a lightbulb moment. If mental illness doesn’t exist, and there’s a £8 billion deficit, how much are we wasting on psychiatric services?

Normally, the political stance toward mental health is to wheel out Nick Clegg every 3 months and have him state that mental illness should have parity with physical illness and much more needs to be done. This is something we really appreciate. There is no further action beyond the speech you understand, but at least the speech has been given by the deputy prime minister. But we are approaching an election and it’s just possible that Nick Clegg might be replaced and someone like Brian Daniels will gain power.

One of the right wing’s favourite tricks is to hijack a leftist theme and milk it for its unintended consequences. A recent example is the so called Recovery Movement, but further back we have Deinstitutionalisation, Normalisation and other schools of thought that started with the idea of liberalising mental health services. Being in Recovery means you can get on with your life and stop behaving like an ill person. As far as I can see, people are deemed to be ‘in recovery’ when they are still very ill. This suits an overstretched service desperate to get people off the books.

Unfortunately, denying that there is mental illness leads to denying that people should get any mental health treatment.

Brian Daniels probably thinks he’s had a great new idea.The Messy NHS plan is put forward as a great new idea. There’s a big market for Denial.

The scratch card project is apparently an exercise to help people choose an alternative to A and E departments. I wonder what boxes you can choose in case of an acute psychotic episode? Two aspirins and an early night? Pull yourself together? Go straight to Recovery?

Brian Daniels wouldn’t give you any box at all, since he has abolished mental illness. But you won’t get a choice to abolish the metric system. It’s in a museum in Paris. You can’t pretend its not real.

A new style health centre, or possibly just a messy church spilling out onto the road?

72. Falling back on homes under the hammer.

Hull Trains are quite influenced by the Terminator series.

On the breakfast news there is almost always a mental health item. There are two types of mental health news reports: the short one and the long one. On the short one, the presenter merely reads out two statements, one from a survey and one from the health service.

First statement: a survey conducted by a charity reveals that there are no services for the mentally ill north of Milton Keynes and that depressed people in the north are simply rounded up and dropped down coal mines.

Second statement: more people are being treated than ever before due to increased investment in acronyms like IPT and IAPT.

You wait for a moment of analysis or commentary, a denial from someone in the coal industry perhaps, or an acronym buff, but in a blink, its over to the Midi dress. Should it really end at the thickest part of the lower leg?

The longer version of the mental health report is just the short one followed by an interview with a ‘service user’. Typically, the service user seems suspiciously mentally well, despite their long period of suffering and eventual escape from the coal mine. It took years of waiting, but eventually they reached the top of the Mindfulness Therapy waiting list, after which they were cured in a jiffy and made ready for TV.

This week, we just had the short version: One in six people attempted suicide while on the waiting list for psychotherapy, which is more than a year on average. NHS England says that there are more mental health services than ever before and even now new acronyms for services are being coined at their new DOA. (gettit?)

It is such a relief when the news stops and Fred Dibnah’s World of Steam, Steel and Stone finally begins, even though every episode is the same. Then there is a program where people buy a small house at an auction, paint it magnolia and rent it out. After that two people try and decide whether to emigrate to Australia, nearly go and then don’t quite go. Following on, a lovable cockney sorts out some dodgy builders in the style of Jack Regan from The Sweeney. Daytime television can seem massively interesting, but only under certain circumstances.

Normally these programs leave the viewer underwhelmed, but that all changes if you get ill. Once you are debilitated and a little delirious, daytime television takes on a whole different dimension. The level of stimulation the human system requires, or can even tolerate, is greatly reduced in cases of biological malfunction.

The key to successful television seems to be following a formula. Even though we’ve seen it a thousand times, we still love a plot that ticks along like a Swiss clock. To a very alert person, formula means repetition and repetition means boredom. To a stressed or unwell person, formula means familiarity and familiarity means comfort. Entertainment has a long history of formulaic productions, from Punch and Judy through James Bond to Strictly Taxidermy. Every time we are presented with a repeatable pattern, the part of the mind that ticks boxes is comforted.

I once asked an older colleague how people used to treat serious mental illnesses before the invention of antipsychotics. His reply was ‘Institutionalisation’. At the time I took this to be an attempt at irony, especially as institutionalisation had come to be regarded as oppression. Now, I realise he was giving a serious answer. Reducing stimulation and imposing regularity were ways of calming people. Perhaps it is just a coincidence that large asylums closed just as daytime TV began. Or perhaps, television just happened to hit the right level of stimulation to suit chronically ill people. One person’s stultification is another persons action thriller. On the acute ward, I noticed that really ill people hardly watched TV, not even football, but could just about manage old Top Gear repeats on Dave.

Disruption of biological rhythms is almost the hallmark of Depression and the first thing that psychiatrists ask you about. Sleep pattern, diurnal mood variation, bowel habit etc. Disruption of biological rhythms is also the hallmark of twenty-first century society, now that shops and the internet are open all hours, pubs never close and you can watch Dr Who whenever you want. I’m not saying the two are causally related, any more than fridge ownership is causally related to crime statistics (other than ice pick murders).

But possibly Stress is being met with De-Stress, in the form of Repeatable Pattern Seeking Behaviour or RPSB, as it will never be called again (too similar to the RSPB, who are a very powerful lobby). Accordingly I may have to forgive people who own pets or buy lottery tickets as simply stressed people in search of fixed schedules. Perhaps they just have nothing to do – besides panic – between Street Patrol UK and Cash in the Attic.

If you just don’t ‘get’ the Fast and Furious series, now you can understand why the same bits are in every film. Humans like patterns. Much of our brain is a scanning device and every cell has a system of time clocks.

Which is why, even before they had CAT scans, Interferon or Clozapine, Regional Health Authorities had their own carpet designers. One design was blamed for people hallucinating. Another type caused terrible friction wounds to frail people. Our own hospital replaced carpets with ‘abattoir-chic’ red lino. Cue carpet jokes: Where to sweep things now?

Like TV programs, carpet that can look fine – just a bit hectic – when you are fully conscious and alert, may look like a pit of vipers to a delirious person. Wetherspoon’s know this only too well.

Last time I was really sick, I remember thinking The Weakest Link was a brilliant program. But after taking a Zantac it suddenly lost all its appeal. It goes to show, if you are sick, you need to titrate your choice of programming carefully against your drug therapy.

Like hospital carpet design, there probably needs to be special programming for sick people. Or just accept that most television is aimed at people with impairment and should be run by Occupational Therapists. It already has? DIY SOS, Blue Peter, Celebrity Master Chef, Come dine with me, Extreme Fishing…

TV is the new OT and we even have one on the ward.

71. Not going looking for trouble, rather, knowing where to find it.

I’d like to say he won’t hurt you. But statistics show it’s possible.

Remember the beginning of Three Days of the Condor, when Robert Redford goes out for a sandwich, and returns to find that an assassin has moved systematically from room to room with a machine gun and murdered all his colleagues? That was pretty much the scene I found when I visited my old workplace yesterday.

I’d like to think there was more to morale than petty behaviour behind the scenes. And that whatever the atmosphere, patient care wasn’t affected. But that is plainly ridiculous. Now that I am a patient more than I am a doctor, I’d rather my doctor wasn’t grumpy even before I tell him about my knees.

The NHS is an intensely tribal organisation, where the various power groups live within a precarious ceasefire. Only a thin membrane of etiquette stands between normal working and bouts of senseless slaughter. Sometimes it only takes one small incident – like shooting an Arch Duke – to set things off.

Etiquette is an intensely important aspect of medical culture. It’s history goes back to the middle ages, where practitioners were divided into three ‘medical estates’ – barber surgeons, apothecaries or physicians. Barbers had the sharp instruments and physicians had the sharp suits. Apothecaries, as now, had the shops on the high street. The professional codes of practice we have inherited are derived from power sharing agreements worked out centuries ago.

The thrust of recent changes has been the ascendency of Management, at the expense of the older professions like medicine and nursing. Like a new religion, or political party, managers have yet to establish a proper code of etiquette. Like the dog in the park, they jump up at people and leave muddy prints. Their owner tells them, fifty times a day, not to jump up at people, they’re not supposed to. But it takes a long time before a dog gets a firmware upgrade.

It’s unbearably rude to write about the position of the medical profession in terms of power relationships. As I write, I almost have to change fonts to something spidery, to reflect the delicacy of the discussion. Should we say, at least, that managers and doctors have an ambivalent relationship? Not love / hate exactly. More fear /loathing to be honest. This probably just reflects a wider unease about elitism in British society. The NHS is locked in a post-war time warp where snobby types need to be cut down to size. The NHS tends to regard eminent persons as ‘toffs’. If you’re a decent sort of toff, you can be a ‘boffin’. But just because you can recite the periodic table, including the rare earth metals, don’t think you can start telling anyone what to do, let alone bring your bike in your office.

I suspect other skilled technicians like engineers and pilots are still treated this way in their industries, apart from finance and banking, where elitism is positively glorified. I’d love to say something like, ‘it doesn’t take much to keep people happy, it’s the little things that matter: just bring back the lady with the tea trolley; let’s renew the subscription to The Guardian’. But I fear its gone too far. Max von Sydow is still lurking in the building. In fact he’s just reloading. But whose side is he on now?

70. Reporting soap shortages, before they get serious.

A poster reminding people, in several ways, that they are too old.

The techno-thriller genre gave readers a thirst for irrelevant information. It wasn’t enough to say someone travelled on a Boeing 707. You had to hear about who made the engines, how the landing gear was inspected by a man with a set of tuning forks and how the pilot’s socks were monogrammed in alpaca by a silent order of nuns in Seattle.

The behind-the-scenes stuff became obligatory for thriller writers – quite a feat before the days of google. Presumably, Forsyth and Clancy spent huge amounts of time visiting airports, submarines and arms factories, asking people, ‘what does that yellow handle do?’

The most obvious spin-off has been the increased number of adjectives we find in grocery products. It’s not enough to say Oven Chips. You need to give them a bit of character development: Maris Piper, thrice-fried, goose-fat oven chips, at the very least. And even then, you’ve said very little about the goose. People want detail nowadays.

Another consequence of the increased audience for background information is the ‘Troublehooter’ style of TV series, started by John Harvey Jones and continued by the likes of Gerry Robinson and Digby Jones.

A man in a striped shirt and hard hat wanders round a huge factory, shaking his head slightly, asking every now and then: what’s that thing for? As a TV show, it’s a tired formula. But, as a metaphor for personal growth, it’s got potential. The striped shirt man is a therapist of sorts. He’s an independent expert, but he’s neutral and polite. He’s robust and challenging, but he’s kind and might even hug you, though you’re still getting fired. Like a certain type of clinical psychologist, he’ll make you a flow chart, showing you which arrow is missing, such as the one between Theakston’s Old Peculiar and poverty.

It could be helpful to get someone to troubleshoot your life. But what about businesses – can an outsider really understand them? Does expertise in the field really matter?

Troubleshooter appeals to people who like to look behind the scenes and are disappointed that Arthur Hailey died before he could write ‘NCP Car Park’. Ironically, the Troubleshooter himself is not the slightest bit concerned about forged composites or digital motors. He’s looking at the system as a whole. He’s drawing Venn diagrams and talking about Synchronicity, just as though it wasn’t the worst Police album.

Gerry Robinson wants the NHS to have more centralised reporting systems, like the food industry:

‘Imagine a McDonald’s in Leicester, say, where things are going wrong. Perhaps the wrong number of chicken nuggets are being handed out, or the washrooms aren’t supplied with soap. These problems would show up immediately via a weekly reporting system which compared its performance against every other McDonald’s in the country, and you’d have a senior manager down in days to sort out the problems’.

Gerry’s background is in catering, so he’s comfortable with that model.

But, senior managers never visit NHS units, partly for fear of infectious disease, but largely because it would never occur to them to do so. Boards and Hospitals are different planets, with different atmospheres and gravitational fields.

Whereas the coffee available to senior managers comes out of a capsule machine, the coffee provided to wards comes out of industrial size tins labelled Maxwell House. It’s Maxwell House, Jim, but not as we know it.

Whereas NHS management premises are carefully protected behind air-locked entry systems and fierce receptionists, anyone can walk, unchallenged, into most hospital departments, including intensive care units and even operating theatres. This fact is portrayed in countless thrillers, where assassins get a second chance to finish someone off by stealing a white coat and strolling in.

As further evidence that NHS Boards and Hospitals are separate worlds, consider the fact that boards comprise upwards of 12 members, only one of whom is a practicing clinician. Does Gerry not think this is a bit odd? Does he not realise that Boards and Clinicians, like matter and antimatter, must never come into contact with each other and if they do, the universe will be annihilated?

I am not a management guru. But even I can spot the key differences between Macdonald’s and the NHS, such as Product Range. Which leads me to ask: who troubleshoots the troubleshooters? It suits managers to propagate the notion that it doesn’t matter much what the company does or makes, that you can move between Catering, Television, NHS and it’s all the same. But often, the detail is what matters most. John Harvey Jones forecast the demise of Morgan for instance – he just couldn’t understand how cars could be made of wood. It’s not a mistake Tom Clancy would have made. He’d have known all about the aerospace properties of ash.

Whereas thriller writers regard craftsmanship in awe, managers regard it in contempt. In a techno-thriller, the emperor’s new clothes would be made of kevlar. And the boss would know what the yellow handle did.

To be fair to John Harvey Jones he did tell the Chief Constable of South Yorkshire that his strategic plan was ‘a load of bloody cobblers’. This comment pretty much ended their foray into footwear repairs.

69. Nailing down pastry, using big data.

Suggested toolkit for shortcrust work

There’s only one proper way to resign. Drive your Lotus 7 at high speed into Central London, thump your fist on the boss’s desk a few times and storm out, before the end of the opening credits. The downside is getting kidnapped and imprisoned on a mysterious island, being known only by a number, interrogated weekly, escaping only when the series is finally pulled by the TV company.

My own recent resignation failed to follow ‘The Prisoner’ guidelines and in fact was quite accidental. HR had forgotten somehow to renew my contract, it was a sunny day, the long holidays loomed ahead and I just had that end of term feeling that gets imprinted during all those years of school and university. So, regarding renewing the contract, I found myself thinking, ‘nah’.

So, today, instead of treating people, I’m making pastry. But that doesn’t mean my skills are totally wasted. I’m coming into pastry from a very scientific point of view. In particular I’ve recognised there are a large number of ‘confounders’ or variables that aren’t easily recognised and controlled.

Our old next door neighbour, Mrs Perks, made the best pastry I ever tasted. I could never get her to reveal her secret recipe. I just knew she’d take that secret gooseberry pie formula to the grave. She said there was no particular magic ingredient, but was she telling the truth? Was that white powder dusting really only icing sugar? Sadly, I never got Mrs Perks to talk.

It’s one thing to follow a recipe, but, for brevity, recipe books don’t give a lot of detail about the precise environmental conditions. For instance, what music should be playing in the background? Should the room be colder? Should ultra violet light be restricted? What does ‘light kneading’ mean, in terms of Newtons per square metre? How much iodine is in the salt? Mrs Perks had a solid fuel Aga, whereas I am using nuclear electricity made in France – does that matter?.

All this suggests a Big Data approach, where every conceivable variable is measured and recorded as we go along. Finally we need a valid and reliable rating scale; let’s call it the Perks Scale. The scientists are here now, and the measuring devices are set up. I’m going with James Martin Rich Shortcrust as a starting point. Martin’s recipe is not referenced or annotated, except to say use hands, not machinery. 21 degrees, moderate humidity, silicone rolling pin and pastry board are in the freezer, background music is also chilled, Cleanbandit I think.

Just wondering, if I add some betnovate cream, will it be less flaky?

How it turned out

68. Getting told not to be so stochastic.

A new design to discourage revolving door admissions

If you don’t use sub-headings nowadays, people will laugh at you. Reports, for instance, need to be have all the paragraphs and lines numbered.

For the time being, everything has to be written in fives or tens. If I had to write about my recent trip to Wakefield, for instance, it would go like this:

Five brilliant things about Wakefield:

Industry: If you buy a can of Coke anywhere across Wakefield and the north of England, the chances are it’s been manufactured using water from East Ardsley reservoir
Talent: Ed Balls visited Wakefield College recently where he had the opportunity to speak with senior College staff and also to try his hand at bread making with a group of talented catering students.
The Arts: Wakefield had a brilliant new art gallery called The Hepworth. It’s free but parking costs £4.50
Celebrity: Shadow Chancellor, Ed Balls, paid a visit to HC-One’s Carr Gate Care Home in Wakefield to spend time with his godmother, who is a resident there
Free speech: Outside the cathedral, a man is shouting loudly to himself, stating that something should be done about the smackheads.

The cathedral should be in the top 5 instead of Ed Balls, but it was closed, despite a large banner saying ‘the cathedral is open’. Smackhead trouble, I presume.

In conclusion, Wakefield just cannot be itemised. There’s a square concrete gallery full of curvy shapes, on the banks of a river that seems to be flowing in several directions at once. It’s all a bit random.

Our response to complicated questions tends to be five simple answers. For example, surveys keep revealing that there are absolutely no available mental health beds in Britain, and patients are having to be sent to the International Space Station by rocket ship, as there are still vacancies in the sick bay.

Like most other mental health news, such revelations cause no reaction whatsoever, as mass readerships turn to more interesting news within a millisecond, like Desmond Morris’s scintillating analysis of why Kelly Brook is the most attractive female, ever.

Yet, ‘on the ground’, the bed drought is massively stressful for the agencies involved, not to mention the service users and their families. What might begin as a bad hair day, muddling your tablets and starting an accidental chip pan fire, ends up as a 200 mile trip to a private sector secure unit in Yorkshire.

Why the shortage of beds?

Here are some reasons. At first glance, as often seems to happen, there are exactly five:

The number of beds has been reduced by at least 1700 over the last 3 years
The population has increased
Community services have been pruned along the lines of Norman Tebbit’s rose garden in March
Agencies are increasingly risk-averse
The hospitals are inefficient in their workings

At least, that’s the common sense explanation, based on an analogy with any other system. This week we had floods. And overcrowding on the railways. The prisons are overflowing again. Similar reasons – simple reasons, to do with not getting quarts out of, or into, pint pots. Researchers have analysed the flow through hospitals using so called ‘stochastic’ modelling, which is derived from the mathematical properties of random events.

Once hospital departments are more than 85% full, the system jams up, just like a Dyson. Mental health acute wards are more than 100% full all the time. All the leave beds are in use and occasionally, mattresses are put down in day rooms.

But the ‘bed crisis’ is not really a simple capacity issue. Like roads – with the single exception of the M181 into Scunthorpe – and housing, there will always be excess demand. But society is quite flexible in determining which marginal group goes to which marginal venue. My impression is that there are large numbers of semi-homeless people – sofa-surfers – existing in the penumbrae between prison, hospital, homeless projects and the public library. This group meanders between the different institutions, like a shallow stream, filling any gaps it finds. Some of them fall into the police, some fall into A and E. From there, a random selection fall into the mental health system. By accident, some get into the cathedral.

Managers know there is no ‘irreducible minimum’ for mental health beds.

Managers know that beds mean hospital staff and hospital staff are a nuisance. Managers love community services, because dispersed personnel manage themselves. They seldom meet to fight or plot.

Trust managers are continuing to close mental health beds, like sheepdogs that have tasted mutton. The impact of these changes is that if you are depressed, you are extremely unlikely to get admitted to a mental health unit.

And if you do get admitted, you will very quickly decide you weren’t feeling quite so bad after all and ask for another go at community care.

Luxury items like research centres, respite care, therapeutic communities, specialist units for resistant depression, alcohol rehab, etc, are just material for Michael Gove’s new history syllabus.

Here’s the bullet point version. It turns out there are five main points:

There’s a rising tide of homelessness
Depressed people, for better or worse, have been displaced from the residential part of the mental health system
People unable to manage themselves are milling about the country like fluid particles
Put away the Airfix Kit – it’s time for Stochastic Modelling.
If you have a cathedral, you need to check regularly for smackheads.

67. Choosing exactly the right cakes, by law.

A guard tried to stop me taking this photo. That’s Sheffield for you.

I’ve picked up a tail on the way to Costa. When I order a Flat White and the enormous jaffa cake, a person behind me in the queue nods, makes notes and ticks boxes. Someone is looking through all my bank statements and receipts. My texts and emails are all copied and filed. My cupboards have all been disturbed. My relatives are being interviewed about my habits and desires. Someone’s been at the pub asking what beer I like.

Am I a character from a John Le Carré novel?

Am I a teacher at an Islamic school?

Or have I just missed my Risperdal tablet today?

Is it a song by the Alan Parsons Project? Somebody out there…

None of the above. In fact all this snooping is to my benefit. I am being assessed to see what are my Best Interests.

Admittedly, to have got to this point, I have to fall within the protection offered by the mental capacity act, which means I must have a disorder of mind or brain. There has to be some doubt over whether I can make decisions properly. I have to spend some of my time being supervised in an institution. And people would probably stop me if I chose to leave.

It applies to nearly everybody then.

Carrying out a ‘Best Interests Assessment’ under the mental capacity act is estimated to take about 25 hours of social work time. Since a Supreme Court ruling in March, tens of thousands of institutionalised people are deemed to be deprived of their liberty and are awaiting assessment under the ‘DOLS’ procedure. One of the cases was called ‘Cheshire West’, which would be a good name for an stage actor. If the assessments are delayed, those deprived of their (Article 5) rights will be lined up for compensation payments. At 5pm every day your phone will ring showing an 0843 number and an automated message will ask whether your right to liberty has been infringed. It’s the new PPI.

What will social services do about the pile of referrals, which if stacked end to end, would stretch from all the way from Purgatory to Hell?:

Manager: How long does it take you to do a best interest assessment?

Social Worker: At least 25 hours.

Manager: From now on, you’ve got 25 minutes, and I’m being generous because it’s your birthday.

Social Worker: There are 56 pages of forms to fill out.

Manager: Then you better get started right away.

Social Worker: We’re supposed to find out all about that person. We wouldn’t want them to get the lemon tart instead of the big jaffa cake.

Manager: Save that cake routine for the Supreme Court, why don’t you? I’m guessing Baroness Hale of Richmond will set fire to your ass and mine too.

Social Worker: Whatever happened to you, chief? You’ve taken down the picture of Shami Chakrabarti too!

Manager: If it’s toasted on one side it’s still toast. Three little letters son: G4S. And now you’ve got 22 minutes left.

It’s easy to blame the supreme court, but all they seem to have said is that someone should look out for people who have lost their mental capacity and have been locked up by the state. No-one expected the Spanish Inquisition, except perhaps Dan Brown.

66. Consuming your own smoke, but coughing a bit.

Evergreens, preparing to march.

The last gas canister is nearly used up on the blow-lamp and the Poundland Firelighters have long since expired. And now it’s raining again. I’m pouring some delicatessen grade canola oil on to a pile of smouldering vegetation and I’m wondering how all this began.

I should have been commenting shrewdly on the mental health news, but I’ve had to let things slip. This is the Day of the Hedge, the story that John Wyndham never dared write. I think it began with an innocent attempt to help someone. A number of weeks back a man suddenly turned up and asked if I wanted my hedge trimming. He looked a bit unofficial, but he had a lightweight aluminium bike and a matching petrol hedge trimmer in a duffle bag. It was a cool look, quite unlike the usual tree surgeons, who wear protective gear and drive Land Rover Defenders. I suspected he was new to the war on hedges. I asked him his name, and where he lived. When he told me, I was pretty sure I’d seen that name in the local paper a few times as a person convicted of petty theft and sent to jail. So what? I also remembered that, in mitigation, he was said to have had a drugs problem. So what? We believe in rehabilitation don’t we?

I negotiated him down to £10 and showed him where to put the hedge cuttings. All this passed off smoothly. Before leaving, he glanced at our long line of dissident conifer trees and offered to take them on. Maybe, I thought.

Some weeks later he turned up to do the hedge and we negotiated a price for a full days work. I felt like the man in the vineyard parable. Part of the deal was to come back and take all the cut vegetation away. Again, this all went smoothly. He trimmed the line of trees and made a huge pile of branches. Next day he was going to come and collect them in a trailer.

A few days passed until he turned up again. Could he have an advance of £20 to buy a new tyre for his trailer? OK I thought. At worst I am only going to be £20 poorer, and I still have his ladder, saw and lopper device.

And that, dear reader, was the last I saw of him, some 3 weeks ago. I can’t say I’m not concerned about him, but the pressing problem is the huge pile of branches outside the back door. I have a slight tendency towards pyromania, but let it be said, I have never set fire to anything major, not even an NHS Trust. If I was admitted to a forensic unit, I’m pretty sure I’d be allowed into the smoking area on my own after a month or two. Fire would not figure strongly on my risk assessment. Nevertheless, there is a tall plume of smoke over my house. I reassure Mrs EP that it is mainly steam and not smoke. I hear the neighbours coughing loudly and I reassure myself they are heavy smokers. My legal advisor tells me there are heavy fines if any nesting birds get made homeless. I prepare a Richard Nixon style deniability defence.

My carbon footprint is growing, but the pile seems as big as ever. For the sixth time, I climb inside the green recycling bin and jump up and down to make just a bit more room for foliage. As I jump, I ponder, and I realise there is a very easy solution.

How many psychiatrists are needed to get rid of a pile of trees? At least four. The first to recognise we are in Denial. The second to find a garden dude in the free local magazine. The third to dial the number. The fourth to mix the martinis. Perhaps an extra one to reassess fire risk.

65. Sleepwalking blindfold, into an amorphous tapestry.

Historians agree that modern times began in 1980, with the invention of Pac-Man.

When did it all go wrong? The answer it seems is 1980. And, to a lesser extent, 1988.

Certainly, quite a few things went wrong in 1980. John Lennon was murdered, the Iran / Iraq war began, Robert Mugabe was installed and worst of all, the post-it note went on sale. In mental health, our particular Chernobyl was an explosion of toxic diagnostic heterogeneity. 1980 saw the invention of the concept ‘major depression’ (MDD). With the publication of the DSM3 diagnostic manual, most emotion-based illnesses was fed into a diagnostic Magimix. This turned out to be very convenient for certain people. One, (sloppy) people who don’t like making diagnoses. Two, the (wicked) inventors and propagators of so-called SSRI antidepressants. Rampant heterogeneity was very inconvenient for anyone who wanted to investigate the possible causes and treatments of Depression. Edward Shorter explains the story much better than I can.*

Certain discrete entities, that should have been studied much more carefully, got lost in the new, amorphous tapestry of MDD. One of these was the notion of ‘biological symptoms’ such as appetite and weight loss, early waking and diurnal mood variation (DMV). The classic ‘melancholic’ patient felt much worse early in the morning. Studies of cortisol and other hormone levels throughout the day showed a changed pattern in most depressed people. Of particular interest was the finding that most depressed patients failed to reduce their cortisol levels even when given a steroid tablet the night before. This led to the ‘dexamethasone suppression test’ and other early attempts to find a definitive lab test for Depression. Old school psychiatrists regarded DMV as a cardinal symptom of melancholia. They separated melancholia from other types of depression with barbed wire, landmines and a no-fly zone.

Today, research into circadian rhythms in organisms and the body clock in humans is a major strand of research in life science. Gene expression studies are the way forward. And this week, even the BBC acknowledged this by holding a ‘Day of the Body Clock’.

Quite what the editors had in mind for the body clock day remains a mystery. Each news program had to slot in a body clock item but the presenters looked bewildered as to why. We heard that sportsmen performed better in the evenings. Some brave schools are shifting their timetable for teenagers later into the day, when they are more likely to be awake, although the teachers are more likely to be asleep. More interestingly, scientists told us that society was guilty of a ‘supreme arrogance’ in trying to over-ride our need to get enough sleep. Prof Russell Foster, at the University of Oxford, said people were getting between one and two hours less sleep a night than 60 years ago. We were warned that ‘Modern life and 24-hour society mean many people are now “living against” their body clocks with damaging consequences for health and wellbeing’. Further support then for the Blur Theory – Modern Life is Rubbish. Sleep, like lunch and the concept of Melancholia, was abolished in the eighties.

Studies continue to reveal that a sub-group of depressed patients show an abnormal expression of clock genes. Several promising types of non – drug therapy for depression were based on trying to adjust the body clock: Sleep Deprivation, Phase Advance and Bright Light therapy. Unlike SSRI antidpressants, these are treatments that cost hardly anything and can easily be implemented at home. Also unlike SSRIs, these are treatments that no-one ever tries. The post-it note and Robert Mugabe are here to stay, but Shorter is correct to say that MDD must go: ‘melancholia and non-melancholic depression are quite separate illnesses’. I’m having the bumper stickers printed now.

The idea that deliberately reducing sleep can act as an antidepressant seems counter-intuitive. But it’s possible that the insomnia in depression is the body’s attempt to defend itself against low mood. Which means that society as a whole may be trying to stave off existential despair by staying up late.

*Edward Shorter, 2014, The 25th anniversary of the launch of prozac gives pause for thought: where did we go wrong? BJPsych, 204, 331-2.

64. Improving posture, for sitting ducks.

Pfizer’s new team arrive, looking benign at first.

If you buy something in Waitrose you are given a green plastic token. On the way out you must make a choice between three charities by placing your token in the respective glass jar. To be honest, Waitrose have handed you a burden of responsibility you could well do without. Imagine what would happen if an ethical committee ever popped into Waitrose – they’d be stuck there for hours. Luckily, most people can resolve ethical dilemmas by throwing a set of mental dice, much like answering the last few multiple choice questions as the examiner is coming towards you collecting the papers. If you don’t have this kind of moral adaptability; if you’re a person who never uses the word ‘whatever’, you might turn into a whistle-blower.

In a quiet news week NHS whistle-blower stories are a good way of filling up Page 8 in The Times. The new head of NHS England, Simon Stevens, wants to reassure whistle-blowers that they can speak out safely. He has even had the shark tank removed from under his office floor.

If you want to be a whistle-blower – and remember your careers teacher said not to – it’s important to brush up on your movies. Start with ‘Serpico’, noting that it begins with the whistle-blower being shot and rushed to hospital. Serpico contains all the essential components for exposing poor practice , apart from the getting shot in the face aspect. Firstly, the character must be something of a Bohemian, with excellent hair and a Honda Superhawk. Secondly, the organisation that needs exposing has to be corrupt, through and through. In a conspiracy thriller it’s a given that corruption goes ‘all the way to the Mayor’s Office’. Never trust and confide in the mentor-like figure, played by an avuncular character actor, like Cliff Robertson. And thirdly, there has to be an audience that cares about the information revealed – proper journalists and a Congressional Committee. If your situation doesn’t have the Serpico ingredients no-one will take any notice and you will be marched out of the building, transferred to Runcorn, shot in the face, or all three.

The whistle-blower likes to be seen as a strong, principled and altruistic person who stands up against a corrupt system. Firstly, they exhaust the proper channels, then, finding everyone is in on the cover up, they take it outside the organisation, to the papers. In most cases, the whistle-blower is suspended from duty and very slowly discredited by the employer. Mostly they seem to lose their eventual employment tribunal and people assume that a lot of them are cranks. If they had paid attention to ‘The Insider’, they’d have been wise to all these shenanigans. For revealing that tobacco was surprisingly bad for you, Russell Crowe’s tobacco executive character was subjected to all sorts of dirty tricks by the company.

Whistle-blowers seem to get stuck in the system, sometimes for years. Some of them get stuck in embassies or Russia. Few of them get compensation or vindicated in front of a congressional hearing or portrayed as heroes.

Stories about deficiencies in the public services have lost a lot of their shock value. And employers have become more sophisticated in their powers of discrediting people. Whistle-blowers are often accused of non PC activities, such as being religious, arrogant, or failing to attend the fire lectures. That’s mavericks for you.

Essentially, whistle-blowing is not the British way of doing things, which is to muddle through and make the best of a bad situation. However, that changed a little since the ascendency of ‘management’ in public sector organisations. Managers made the mistake of believing they were running small private companies, when really they were administrators. All the major decisions, and all of the risk, is taken by central government. Yet managers have been successful in calling themselves Boards, styling themselves on private industry and paying themselves accordingly.

Local Trusts expected staff to be loyal to the Trust, but in reality they are only loyal to the NHS as a whole. This mismatch in loyalty plays out as follows: local manager as Sheriff of Nottingham, employee as Robin Hood, Simon Stevens as King Richard, David Nicholson (previous NHS chief) as King John.

The biggest problem for whistle-blowers is a sea change in public perceptions of organisations. No-one is surprised to find there is bullying or abuse within large institutions such as Oakwood Prison, or BBC’s Front Row program. Expectations are lowering and the shock threshold is rising. Medical whistle-blowing stories are losing their impact. I suspect that the conspiracy thriller genre has been so influential that everyone now assumes that large organisations are corrupt propaganda machines. The only exception really is Waitrose. Feed the words ‘waitrose’ and ‘whistle-blowing’ into google and nothing happens – apart from one dark moment in 1997, when Waitrose were accused of organising duck shoots for their staff. According to a leading member of the National Anti-Hunt Campaign, ‘Up to three times a week at the Leckford Abbas Estate near Stockbridge, Hants, parties of drunken John Lewis staff blast away at the pheasants, along with ducks, grouse, pigeons, squirrels and anything else that moves.’ These accusations were soundly refuted, which is reassuring. I don’t think the Anti Hunt Campaign get many green tokens down there, even now.

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