41. Finding Tannochbrae, and rolling it out.


The NHS keeps being re-organised. This week we have the new GP contract and post-Francis, a splurge of nurse recruitment from the EU. The feeling is, the NHS has taken several bullets, and if this was an action thriller, we’d be waiting to see if it’s going to fall down or turns out to be wearing a kevlar vest. There’s a kind of impasse as people wait for the inevitable closure of smaller hospitals, walk-in centres and stagger-in centres, aka A and E.

The worst way of re-organising an organisation is to consult widely, sit down with ‘stakeholders’ and listen to experts. Instead, we need to reach down into the collective consciousness and find the archetypes of medical practice. We need to find the icons and copy them and work backwards from there. For medicine, we need to look no further than historical medical TV drama to find out how things ought to be, and in particular, the 1960’s shows, Dr Finlay’s Casebook, and Dr Kildare. This is what we should be reading:

‘The new general practice contract is more prescriptive and detailed than people expected. It looks as though there are going to be two doctors in each practice – one old and one young. Both must be Scottish. Only one other employee is mandated, an older female ‘housekeeper’, ideally called Janet.

The doctors must not be married. Beyond a telephone they will not use any modern form of communication device. The younger doctor must keep up to date and introduce anything deemed new-fangled. The older doctor must act as mentor and companion to the younger, specialising in wisdom and wry expression.

Although comparatively wealthy, both doctors should espouse a liberal stance and champion the disadvantaged. Both of them should know their way round a microscope. At times they may use a Motor Car to visit patients in their own homes’.

The model for hospital doctors is slightly different. Whereas the two Scottish GPs are brimming with lifestyle advice – such as proper fish filleting technique – the hospital team’s job is ‘to keep people alive, not to tell them how to live’. The hospital also uses a team of two, again an older and a younger man, but this time they are American. Both of them look good with stethoscopes and know their way around machines that go beep.

In all cases, tweed is de rigueur, no suits.

Both in general practice and in hospital, the teams will need to fight against rogue practitioners. In the community this is likely to be a toff, who works single handed, mainly in private practice and drives a Bentley. For some unaccountable reason, he has something of a way with the ladies. In hospital the main enemy is an autocratic character who calls himself The Chief. He’s in the board room far too much and never in the operating theatre. The ladies don’t like him, apart from one sycophantic, sado-masochistic type.

Both teams like a lot of background music, favouring lavish strings arrangements. But whereas the GPs prefer a jaunty tempo, in hospital it’s strictly andante, to match the steady flow of trolleys down corridors, with tubular bells on the offbeat.

Jeremy Hunt, you used to be culture secretary, so you know all this. Finlay and Cameron would never have sat around on clinical commissioning groups or attended team building workshops. Finlay would never have gone on about strategic aims and driving down operating costs by standardising the infrastructure. If Cameron had to say something like, ‘we need to front-load the front-loading’, he would at least deliver the line in a huge theatrical splutter.

The archetypes are a little different for psychiatrists, being found mainly in movies. These have been well documented in papers such Theory and Practice of Movie Psychiatry, by Irving Schneider.* The actor Patrick Stewart turns up in two pivotal roles along these lines, first as the decent-sort consultant Eddie Roebuck in Maybury, and much later on, after several years in space, as the evil Dr Jonas in Conspiracy Theory.

In the latter role he offers a poor model of practice, specialising in finishing off the survivors of a brainwashing assassins program. Though there are no NICE guidelines on brainwashing, and how to handle it when it goes wrong, Jonas probably missed the short medical ethics course at the end of year 5.

It’s likely that the new template for mental health practice will be more like this:

‘The psychiatrists, who are brothers, seem a little fussy and pompous but mean well. To compensate for limitations in his interpersonal skills, one of them runs a local radio show where patients can phone in, so that the whole community can benefit from his wisdom. For background music, it’s strictly jazz.

Jeremy Hunt, these are our heroes, not the Kings Fund, nor NHS England, nor the Nuffield Trust, nor the CQC. As culture secretary you were the one person in the country never to watch UK Gold, but now it’s time to catch up.

*Am J Psychiatry. 1987 Aug;144(8):996-1002)


20. Choosing Love, Zero, or the Egg.


Trying to see the big picture.

Does it make any sense at all to go to the National Gallery, look at Turner’s The Fighting Temeraire for a few moments, and state, ‘I’ll give it a 7’?

This week we read that the NHS has produced a series of 8 commandments. Some of them are a bit basic, like patients having the right to food and drink. It also seems they have to be given ‘the right amount of  medication, when they need it’, which is an excellent idea, rather than using random number tables.

Whether the commandments will be on stone tablets or not depends on Health Secretary Jeremy Hunt. If he spends too long carving them, NHS staff might make a golden effigy of his predecessor, Andrew Lansley, and pray to that instead.

My first thoughts are that eight is an unusual number. Did they start with 10 and drop two of them? Which two didn’t make it? Consultants should wear top hats? The layer of butter on toast should be exactly one molecule in depth?

Nevertheless I see the makings of a scoring system with a maximum of 8.0, maybe more if there are sub-scales for each commandment.

Does it really help to measure everything? Today we were urged to catch ladybirds in a net and report them using a special app. At school, children dig up one square metre, to count the number of earthworms. On the main road, other children wait with clipboards, counting the number of cars that go by, so the distribution of car makers can be made into a bar chart.

I’m forced to conclude there is something in the human mind that likes to assign numbers to concepts. Perhaps its a desire to bring order to the universe.

People love scoring systems, often far more than the activity that is being scored. The ultimate ‘scorathon’ is the Eurovision Song Contest, where the scores are luxuriously accumulated over a half hour period, layer after layer of numbers added to a chart.

The shipping forecast gives scores for both wind speed and visibility, for exotic parts of the North Sea, which are given a name and a number, like ‘forties variable four’. Its incredibly atmospheric.

As far back as 1964 Eric Berne wrote ‘Games people play’, introducing his theory of Transactional Analysis. The book contained nothing about Monopoly or Risk, let alone Cribbage or  Texas Hold’em, which were games people played at the time, making it something of a swizz to my mind, but nevertheless it became a best seller.

Unfortunately Eric’s games were relatively light on scoring, mainly win or lose, comprising self defeating scenarios like, ‘why don’t you yes but’.

Psychologists had been using numerical scores since the early 1900s, when IQ tests were invented. Psychometric testing spread like plague in schools, more so than in clinical psychology or psychiatry. Most of the summer term in schools and universities is taken up with exams. You don’t grow onions by weighing them, as they say in Yorkshire.

Nevertheless, around the time Bob Dylan ‘went electric’ (psychologists and psychiatrists had gone electric in different ways many years prior to this), Max Hamilton introduced his Depression Rating Scale, the HDRS. In Yorkshire.

Everyone has their own scoring favourites. I like the ones where stern-looking judges from Eastern Europe hold up cards with numbers between 5 and 6. For some reason our exams at medical school used a similar system, where everyone scored between 50 and 60. All those numbers, above and below, just wasted.

The scoring system for football is reassuringly simple, being based merely on goals scored. There are no subscales for creativity or artistic interpretation, gentlemanly behaviour, nor even hairstyle. Tennis has an unusual non-linear scoring system: Love, 15, 30, 40, etc. ‘Love’ is probably the odd one out in this list, especially if translated from French to mean ‘the egg’. For some reason the French say ‘zero’ instead of ‘love’, and ‘egalite’ instead of ‘deuce’. Social historians, please discuss why.

One of the most comforting rituals of Saturday afternoon is the ‘full classified’ football scores, which is very similar to a long prayer, such as the Rosary, but without beads. How many families gather together to find out how Hamilton Academicals have done? (Is there also a non-academic Hamilton team, such as ‘the pragmatics’?) The trick is, you know who has won, before the second score is stated, from the intonation of the first score. Its the one job that could not be done by Robert Peston, or King George the Sixth, for that matter.

The academicals were not named after Max Hamilton, who was not even Scottish, although he was an academic – a medical statistician as well as a psychiatrist. Hamilton invented the HDRS for Depression in 1960. It is still the gold standard today, despite many alternatives. Its freely available, so you can use it on someone in your kitchen to see if they are depressed. If you want to use one on yourself you need a self report scale such as the Beck Depression Inventory.

They don’t work on pets by the way.

Its hard to believe that as recently as 1960 people already had electric guitars and long playing records, but didn’t use rating scales for everyday decision making. The notable exception to this was the Michelin star rating scale for restaurants, which had been around since 1936.

Rating scales for mental health problems were born out of the need to establish whether treatments were effective or not. Antidepressants for instance, started to come out in the sixties. To do this, some kind of yardstick was required that allowed people to compare treatment A with treatment B. The Hamilton scale was more ambitious than the Michelin guide, using 17 items instead of 0 to 3 stars. It was made in Leeds, instead of France, so it did not contain any items about truffles or vintage champagne. (It was before they had Harvey Nichols).

Now we have rating scales for all kinds of everyday activities, such as Trip Advisor, so we can know whether hotels cook sausages properly or choose tasteful enough wallpaper. This is presumably the way the NHS is going, with the commandments system.

Perhaps the major religions missed an opportunity for developing rating scales for the actual ten commandments. It seems likely it would not have been as simple as just a mark out of 10. It looks as though some of the commandments are more important than others, for instance not killing should be allocated more marks than not coveting your neighbour’s donkey.

Then there is the problem of setting the time frame for making judgements. Is it at the end of the person’s life, or at the end of time, or at a cross sectional point, such as age 34, when you are just old enough to know right from wrong? Or could it be a random point in time, like in musical chairs, when the music happens to stop?

There are other problems with a whole of life scorecard. One of these is whether a handicapping system is needed, as used in golf. People dealt a poor hand by nature or circumstance ought to get some kind of start over people who were born rich and brainy.

The system for football clubs seems a bit unkind. If the club goes into administration a further 15 points are deducted, something that co-incidentally also happened in Leeds. If that’s not kicking someone when they’re down, I don’t know what is.

I stayed at a hotel last week, where a rating of 8.2 was proudly displayed at reception. How would the rating be affected by price? I paid half the ‘proper’ price, so that should put the rating up somehow, but surely not to 16.4?

No-one states these scales are linear, and in fact the distributions they relate to are probably bell shaped or skewed in some way, like the people who invented them. Many of them are called Likert scales, which typically offer a five point scale, from strongly disagree to strongly agree, or from nought to stupid, as Spinal Tap would say. The more abstract and subjective the concept, the more people try and impose a number scale. Ten out of ten for irony.

The most interesting thing about Likert was his first name, Rensis, which is in the top 12 ‘most unusual real names’ according to the experts at Nancy’s baby names. Five point Likert scales are everywhere now, from Amazon to Army Generals.

Should we use a scorecard to measure our life? We’d have to set the goals and the scoring system as early as possible. Strokeplay, matchplay, Queensbury rules, tiebreakers and sudden death play offs all need factoring in. I’ve a feeling the goalposts might get moved at times, certainly widened.

The ten commandments seem like a starting point. The deadly sins and corresponding heavenly virtues could form the basis for a seven item linear analogue or Likert scale. But that might be overly religious for many people.

We may have to stick with our old friends, the annual appraisal and the personal development plan.

Or we could use the 360 degree appraisal, as in the NHS, where we give feedback questionnaires to family members and neighbours on a regular basis.

I’d give one to hotels and shops so they could get their own back on me. (I really regret asking why one hotel had attempted to cook the breakfast with a hairdryer. But sarcasm doesn’t seem to be a deadly sin, so I haven’t lost any points, technically.)

To my knowledge, no sports have brought in a feedback based scoring system, not even cricket.

As they say in golf, and at the National Gallery, and now in the NHS, there are no diagrams on the scorecard, only numbers