97. Snakes and ladders, without the ladders.

 

Physician heal thyself / the tailor is the worst dressed man.

This is for my friends who keep asking what’s happened to EP.  I can’t promise it will be a good read, unless you’re one of those rare people who like to hear about other people’s medical problems without getting paid to do so. But, as ABC put it, excuses had their uses, but now they’re all used up.

From February last year my life changed from being a health care provider to a health care recipient. A service user perhaps, or a patient, or to what non-PC doctors used to call a ‘punter’. Seeking health care is very much taking a gamble.

Think of it as a long overdue field trip through the health services. Every doctor should be made ill and admitted to hospital for a few days. I’d bring it in as a short module in year five of medical school, between ethics and breaking bad news.

Early last year I started to get pain in the neck. It began as what felt like a sprained muscle just to the right of C7. It got worse, I went to the GP, he referred me to physio and ordered a lot of blood tests. He forgot to tell me there was a 3 month waiting list for physio, which had been privatised. He also forgot to tell me it was impossible to make an appointment to see him again, ever. 

The pain got worse again, I went back to another GP who prescribed Cocodamol and Naproxen and ordered an X ray. I spent a lot of time lying on the floor staring at the ceiling. 

The X Ray showed some degenerative changes and possibly a facet joint problem. The word ‘mild’ cropped up a lot, which was reassuring. 

But at the same time, a friend of a friend with neck pain turned out to have a spinal cyst which was not discovered soon enough. He developed multi-system failure following surgery and died tragically. An extremely rare occurrence, I was sure, but my subconscious mind didn’t see it that way.

So, seeking further guidance / reassurance, I got referred to the musculoskeletal service, or ‘MSK’ as it calls itself. MSK, whoever they are, have organised their services based on old kidnap movies. The ransom payer is forced to run between telephone boxes and directed towards a remote venue. MSK make a series of anonymous phone calls and lead you a long way down a symbolically pot-holed road, to an industrial area a long way from where you live, leaving you scanning the skyline for snipers. 

A letter arrived announcing that I will be phoned to discuss an appointment. The phone call happened on time and I was sent to a contracted out service in a contracted out building. The receptionist denied all knowledge of my appointment, but luckily I saw a man who looked like an orthopaedic consultant – by this I mean he was wearing a suit – and this time for once my stereotyping proved accurate. The orthopaedic consultant, who was also contracted out, did a test where he pressed my head downwards into my neck. The pain got worse when he did that and I think I am still an inch shorter than I used to be. 

He requested an MRI scan.  

Same process for the scan – a letter announcing a phone call. The scan is in a portable unit on the same site, sadly there are no toilets. I am phobic of closed spaces but by this time Mrs EP has taught me a lot of Yoga and I yoga breathe my way through the scan trying not to open my eyes or sphincters.

The MRI showed some mild degenerative changes consistent with age, just like the XRay but commenting on different bits of anatomy.  I saw a few different physiotherapists, two NHS, subcontracted, and two private. And I got referred to the outsourced pain services, also subcontracted to some agency you never heard of. I waited for the ransom demand phone call.

 

A short holiday in Scunthorpe 

Then came a huge diversion. At the end of May 2019 I took the prescribed dose of Cocodamol for 2 days which caused a massive abdominal problem, a closed loop bowel obstruction (as it turned out, months later, when my CT scan was reviewed). Cue a very interesting day in a urology ward, which will fuel another article once the PTSD has subsided.

Then a month of abdominal pain and a diet of fish fingers and white bread and very little fibre, surgical and gastroenterology appointments leading up to a colonoscopy and another referral back to the surgeons, thankfully postponed due to Covid.

The abdo pain seemed to dislodge the neck pain. I’m not sure how that works, perhaps there is limited bandwidth in the brain. Maybe pains have a rank order, like suits in Bridge. 

As the abdomen settled down, after about a month, the neck pain came back. 

Cocodamol was firmly off the menu, not to mention Tramadol, which another GP had prescribed over the phone, which Mrs EP observed made me mildly delirious. Luckily Mrs EP hid the tramodol, so I never encountered the biggest snake pit in the pain game, rapid addiction to opiates. So I was left with Ibuprofen and Paracetamol, neither of which made any difference to the pain. By this time I was beginning to realise that Pain doesn’t play by any rules and should be given a capital P.

 

The clinic at the end of the world

The Pain clinic was located at the end of a long cul de sac  along the river, in a former pumping station. Therapeutic nihilism had set in at the pain clinic. There was no sign saying ‘abandon hope all ye who enter’ but that was the vibe.

The Pain clinic does not believe there is much relationship between tissue damage and the experience of pain. They suggested I check out the work of Lorimer Moseley on Youtube, which I did. 

So Pain is mostly an illusion. A distorted and amplified rendering of a routine background noise. A warning of some kind, possibly false news, like the antilock brake light on your Ford Focus. 

Knowing  that Pain is mysterious doesn’t give you much direction. Thinking of Pain as a false warning signal suggests two opposite approaches, which are referred to as ‘recalibration’ or – in technical language – ‘building shit up’ and ‘calming shit down’. The former leads to challenging physical activity and the latter leads to lying down and meditating. It’s vague how you actually go about building and calming shit, but the whole thing is DIY by this time.

Mrs EP, who is the only person who comes out of this well, as a heroine in fact, taught me Pilates as well as Yoga. We went for long runs barefoot on the beach. We did meditation and relaxation exercises. We made rich fruit cake and pizza dough.

I kept a Pain diary for months. I gave the different pains silly names to try and diminish them. The ache to the right of C7 I called Boris. The Pain higher up on both sides I called Colin Blenkinsop. The worst Pain, a crushing sensation that sends you looking for the Tramadol capsules that Mrs EP has hidden, I called Agent X47. If that’s not CBT I don’t know what is!

I apologise if there’s a real person out there called Colin Blenkinsop. Or indeed, Agent X47.

 

The magic bullet fantasy

If I was into CBT, which I’m not, I’d mention an automatic thought that goes as follows: 

‘It’ll probably turn out that there’s a simple problem – mechanical or chemical –  that’s been overlooked.’

I was nearly convinced that the experience of Pain is brain based rather than due to tissue or nerve damage. And I began to feel very sorry for people with problems like fibromyalgia and somatoform Pain disorders.  I began to understand how angry chronic fatigue patients got after being consigned to light exercise and extra-light CBT.

In January this year though, the negative ‘magic bullet’ thought cut in again.  I started to believe the facet joints might be causing the problem. I looked at lots of youtube videos of facet joint injection and radiofrequency denervation. After going through another ‘something must be done’ day I made an appointment at a different Pain clinic. 

Luckily the clinic did not recommend facet joint injections or anything else involving needles or machines that go beep. The worlds of Pain perception and tissue damage are parallel universes. They never really meet, not even through portals in spacetime. 

Pain experience is made of Lego and the body is made of Meccano, the specialist told me. Perhaps not a brilliant metaphor, but one I distinctly remember.

He did however refer me to a colleague to work on my posture, core and neck muscles. No guarantee it would help, but I’d have better posture and muscle strength and my shirts would fit better.  His colleague gave me some very specific exercises. She was positive and reassuring, a welcome change from the doom merchants. Things picked up from there. Co-therapist Mrs EP took over the regime as the lockdown hit and added deep relaxation. We built it up and we calmed it down, without even using the word shit.

 

Pain is an illusion, just like almost everything else.

The world is not what it seems. A lot of the news we receive is distorted or made up. A lot of pain we perceive is distorted or made up. The brain employs a cranky, alarmist and unreliable editor, just like the Mail on Sunday. 

Painkillers don’t really kill Pain. The NHS is not the NHS, it’s been outsourced, sliced and diced and provided by people you cannot ever meet or contact. Symbolically, Pain services are located in the dark places on the edge of town. But – don’t tell anybody – you can also find them in posh looking sports medicine clinics.

 MSK sounds like a terrorist group, and in many ways they do strike terror. Millions of people get addicted to opiates and millions more fall victim to bogus therapies and illicit drugs. Pain patients soon become outsiders to science and society.

Because pain is so common, and evidence based treatments are so few, Pain patients are filtered through a series of rationing devices, including waiting lists. These are really just holding areas for legions of desperate people. Sadly, the delay in assessment allows Pain experience and behaviour to set in, like Japanese Knotweed. 

Earlier this month, NICE issued some controversial draft guidelines for managing chronic primary Pain. 

On Planet Nice, problems are solved with kindness and clear communication. Possibly a little acupuncture, group exercise and a dollop of homespun wisdom aka CBT. None of those nasty tablets. On Planet Nice GPs are like Doctor Finlay or Doc Martin. You don’t have to wait a month before seeing them, you can see the same doctor more than once ever and they may have read your notes. If you see a specialist he won’t be an agency locum. No-one will give you a poor, skewed photocopy of some youtube weblinks and call that bibliotherapy. 

Sadly Planet Nice is an illusion too.

 

80. Teaching children about factions.

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To save you a lot of work, beer now comes complete with explanatory notes and rating scales.

 

Once I had the good fortune to visit a restaurant in Chicago, towards the top of a very tall building.

On the next table, a man was ordering a very complicated steak. He wanted it done in a very particular way, no seasoning, very rare, in a mushroom and red wine sauce, but without cream, and so it continued. The waiter, maintaining excellent eye contact and nodding, finally said, politely but firmly, ‘sir, it’s not going to happen’.

From that day, this has been one of my favourite catch phrases. Mainly it’s a line best not said out loud, but sub-vocally, it comes into play all the time. It’s a line that should appear as a subtitle every time a politician is interviewed.

Remember before the election, when David Cameron said that immigration could be reduced to tens of thousands per year? Or when Gordon Brown promised to eliminate child poverty? Or when Robin Cook promised an ethical foreign policy?

Now we are approaching another general election and the unrealistic promises are flowing freely.  Nick Clegg says that suicide can be completely abolished. Thousands of new GPs will be recruited to work in Hull. Every child will learn their multiplication tables. All around us, huge neon signs are flashing, ‘Its not going to happen’.

I’m not sure what kind of steak the customer at the Chicago restaurant finally got. Surveys show that behind the scenes in restaurants, nasty things happen to food going out to awkward customers. And its probably the same in the public services. You might think multidisciplinary teams, behind the scenes, are working harmoniously on your behalf. You might think the very words ‘multi-disciplinary’ are so hallowed that they must be illustrated by monks whenever they are written down and recited in plainsong.

And then you read in the Sunday Times  that ‘a turf war raged for years between midwives and medical staff at a hospital in Lancashire’, leaving as many as 30 innocent people dead. Very likely there are similar wars going on elsewhere, yet to be reported.

None of the thirty victims knew they were in the cross-fire. Most of them were babies. That raises the question – if you happen to stumble into a war between professionals, will you realise what is happening before you’re hit?

In an action thriller the first thing you’d notice would be something like having the hot dog sausage shot out of the bun by a sniper bullet, just as you were about to take a bite. There’d be a horrible red stain on your shirt and it would take a few moments to realise it was just tomato ketchup.

Have you noticed every time there’s an enquiry, the conclusion is always that there has been a breakdown of communication between different agencies? And the recommendations always includes words like joined up and liaison and sharing. Maybe we have all seen too many conspiracy thrillers featuring conflict between LAPD and SWAT. Maybe we need to revise Group Psychology for Dummies, but I have never heard a management consultant or HR person suggest that multidisciplinary working is a recipe for disaster . Criticising multidisciplinary working is like criticising democracy, human rights or wholemeal bread, totally taboo.

If anyone suggested starting a new profession that could do everything you needed, they would be roundly criticised from all sides. Otherwise you could construct a mental health professional for the modern era who was part social worker, part nurse, part policeman and part martial arts champion. The result would be pretty similar to the Eddie Murphy character from The Golden Child, who was a social worker and self styled ‘finder of lost children’. Or if you prefer, the Jason Statham character from Safe, or the Bruce Willis character from Mercury Rising, or a combination of all three.

Though sociologists and historians have covered very nicely the struggles between apothecaries and barber surgeons hundreds of years ago, few people dare to write about inter-professional power struggles in modern health care systems. The reality in mental health services is that only one professional is involved at a time, sometimes not even one. That doesn’t stop us waxing on about the multidisciplinary team just as though it existed.

Golden Child or Mercury Rising and Safe were all unpopular with critics. Each film featured a unitary professional (reformed cage fighter in the case of Safe) standing up against splintered and corrupt agencies in order to protect children and as such were felt to be totally unrealistic. What a shame our child protection heroes are just fantasies.

Today, the Casey report into child abuse in Rotherham is out and all over the newspapers. The agencies clearly didn’t work together properly and are much criticised. So far no-one seems to be criticising the multi-agency model itself. Will Eric Pickles and the national crime agency sort things out? Will children be safe from predators as long as politicians, police and social services all blame each other? Or do we need a new kind of action hero?

Sir, I fear, its not going to happen.

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

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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.

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

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

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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.

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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.

 

64. Improving posture, for sitting ducks.

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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.

57. Selecting the right animal charity, and other questions.

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Another Free School fails OFSTED.

Some people seem to question everything and some seem to question nothing. And then there are those in between. This week EP attempts to address some of your burning issues, so you don’t have to. Why not send in some more for next week?

Q. Is thinking driven by continual questioning?

A. No, it is driven by nicotine, chewing gum and certain types of chocolate.

 Q. Is Mindfulness the new Mom’s apple pie?

A. That’s probably a bit too concrete and  three-dimensional. It is perhaps more the new Angel Delight, or Dream Topping.

Q. My son has built a scale model of Stockport with fingernail cuttings. Should I call the early intervention team?

A. I’m afraid it’s too late. Try entering him for the Turner Prize.

Q. Should I give more money to charity or try Random Acts of Kindness?

A. It’s best giving to a highly specific charity, rather than one where most of the money goes to a bloated bureaucracy in Chelmsford. Some of my favourite charities are animal related, for instance, Pyjamas for Llamas, and Maracas for Alpacas. The latter is based, I think, in Caracas. If you want a random act of kindness, give the lollipop lady a bullfighting outfit. Tell her it’s just a question of reframing.

Q. Most people assume they are healthy unless they have symptoms of an illness. I’m the other way round – I need constant proof that I am well. Should I be worried?

A.This is called the Inverse Health Cognition. It may just mean you’re American. Otherwise, Kindles and Ipads have very long battery life nowadays – these will get you through long periods in doctors’ waiting rooms.

Q. Why do medical students ask questions all the time, instead of the old system, where I ask them questions?

A. Because the signal strength in hospital is too poor for google to work properly. You are the next best thing. Take it as a compliment.

Q. I’m having trouble understanding the changes to the NHS. Can you explain them?

A. It’s a complicated model, based on the old British Empire. It’s a mixture of colonial administration, piracy and gambling. Don’t forget, the British Empire never went away – they just moved the headquarters to Washington.

Q. What can I do about writer’s block

A. What I do is write in the form of Questions and Answers. If that doesn’t work try Lactulose.

Q. Is it true there is no real person called Ted Baker? My beliefs are shattered.

A. Nothing is as it seems. Compared with faking the moon landings, this was a pretty easy deception. Colonel Sanders was real, but he wasn’t a real colonel. The chicken doesn’t come from Kentucky either. Does it even come from chickens? I bought a Giant bicycle, only to find it was the same size as all the other bicycles. Same thing with Tiny Computers. As Peter O’Toole observed in Stuntman, King Kong was really only six feet high. The list goes on…

Q. If World War Three happens, where shall we hold it?

A. The middle east, during the summer, is completely stupid, see World Cup 2022. Conversely, Russia is too cold. It all points to Belgium, if there’s room.

Q. Have you had any more ideas for blockbuster movies?

A. It so happens yes. My latest idea is a sci fi / historical / heist movie: A team led by John Sentamu, Archbishop of York, mounts a daring raid in an attempt to steal the bones of Richard III from Leicester University’s high security archaeology wing, reclaiming them for York. Only to find, when they break into the lab, that the genetics department have actually re-created Richard III himself from traces of DNA. He’s angry. He wants his kingdom back. And the last place he’s going is Yorkshire. That’s all I can give away at this stage, Brad.

20. Choosing Love, Zero, or the Egg.

Image

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

19. Queuing like you really mean it.

ImageYork’s new rapid transit system.

After the weather forecast comes the Pollen forecast. For some reason I expect to see it presented by a giant bee, in bee language.

Its pretty difficult to get a GP appointment nowadays, certainly for hay fever. I read in The Times that some GPs are averaging 66 consultations per day. If so, the situation is crying out for a production line system like they use in car factories, where patients move slowly along a conveyor belt in a giant shed.

In fact I see no reason why hospitals shouldn’t operate like this, making so called ‘care pathways’ something of a reality. There would be a faster track through the A and E department, in the same way as East Coast trains fly past First Capital Connect at Potters Bar.

If we have a track for Depression though, lets not make it a tunnel.

Recently I made a GP appointment – I couldn’t really say it was urgently needed, since, like most doctors in fact, I am a bit of a hypochondriac.

Also I made the big mistake of saying ‘its probably nothing’ to the receptionist.

I got an appointment more than 3 weeks later. Of course, like most self-limiting conditions, which is most conditions, it had already got better by the time I got to see the GP. I went in with a grovelling apology and came out in less than a minute. I felt I had blown a bit of credibility though, in case I get a genuine illness one day. Several Cry Wolf points thrown away.

Perhaps there should be a special ‘disloyalty card’ where persistently not attending earns you extra points. Every now and again these could be traded for a free consultation without prejudice.

This set me wondering whether anyone knows how to use the health care system properly. And if so, how can we learn how to do it?

After all, most illness behaviour is determined by social learning.  But no-one ever properly teaches us how to ‘do healthcare’.

We all have a huge stake in the NHS, but, amazingly, the NHS comes with no instruction manual.

Its the kind of thing Michael Gove definitely hasn’t put on the schools’ national curriculum, revealed today. But should he?

At the end of every human interest piece on the news, such as spontaneous combustion in sheep, the damage done by carrier bags or how yogurt can become dangerous under certain circumstances, the answer is always a call for ‘better education’.

This must be hugely irritating to teachers, whose curriculum is already big enough and struggling to cope with constant tinkering.

But along  these lines, instead of say, History, or Geography, why not some basic Medical Sociology?

We could learn about the pernicious effects of the private sector, the inverse care law that affects poor people, how health care systems struggle to constrain costs and how it took the French Revolution to smash the four humour system.

We could learn the difference between Disease, Illness and Sickness, and how the sick-man has disappeared from Medical Cosmology*. Perhaps he will turn up in the cafeteria or X Ray.

We could learn about the sick role and how to play it. We could have a field trip to the Broad Street Pump, where Snow discovered how cholera got transmitted.

Maybe answer the question, why isn’t holistic spelled ‘wholistic’?

We could look at screening programs and learn – very quickly – which ones are worthwhile. Borrowing a few sessions from Science we could look at Causation versus Association and show improving movies like Moneyball. (Subtitle: the art of winning an unfair game.)

If that’s not better than learning the details of World War One peace treaties, I don’t know what is.

We seem to have an insoluble problem in the UK. It is free to go the doctor or see a specialist. Although if we need to get medication it costs £7.85 per item, plus 90p to park. If it involves driving into Nottingham then there’s a £30 charge for getting in the tram lane by accident, and by accident I mean by being careless.

If we try and impose any charge, it looks as though we will discourage the very people who need to see the doctor most often, and the people who most need to drive over tramways. A number of famous studies suggest the most deprived people are those who have the highest rates of illness and shortest life spans.

But being free, the NHS system seems to attract a large number of people whom car dealers would call tyre – kickers.

Perhaps the fairest and most effective way to ration health care would be to create a giant lottery for appointments, or to make them transferable, so that slots could be traded on the open market.

In the GP waiting room, as I cowered in my corner, peering over a 1998 edition of Auto Express magazine, it looked as though the other aspiring patients needed a bit of weeding out, or triage, as it’s called in health care.

With images of Taksim Square in mind, I imagined a military type person coming out with a loud hailer every few minutes:

Anyone whose temperature is 37 or less, please leave.

Anyone with a bad cold or flu, out!.

Anyone with backache, headache, neckache, tennis elbow, golfers’ elbow, or any other kind of elbow – out!.

Anyone with a twinge.

Anyone with insomnia.

Anyone with indigestion.

Out, out, out!

Anyone here for a screening test not based on sound epidemiological evidence?

(Pauses for a moment) It’s 95% certain you should leave.

Now we are seeing a definite thinning in the crowd and a line of people heading for the Cooperative Pharmacy or the alternative practitioners ghetto. No need for the water cannon and rubber bullets after all.

The military style triage is unlikely to prove acceptable in the era of consumerism. Tesco don’t use it, even for the people who turn up at 9pm to get the reduced loaves and then ride around the car park in trolleys.

Instead we have had NHS Direct and 111 – who tend to ‘direct’ you to A and E.

The A and E department have their own filtering system, using time and, to a lesser extent, squalor. More recently they have taken a lead from Heathrow and created a stacking system for ambulances, which circle the hospital, waiting for a landing slot.

I made the mistake of trying to reach Leicester Royal Infirmary by car recently. Like the health care system in microcosm, there is no way in and no way out. I felt like an Apollo space capsule, orbiting the moon, but I had no lunar module to send down.

Those with self limiting conditions have probably got better by the time they are seen. Even those people who are seeking healthcare mainly to meet other people who are seeking healthcare and chat to them, have had enough social contact after 3 hours in a hot little waiting area with a very expensive Coke machine and a silent, armoured television showing volleyball from Belgrade.

Using time as a subtle disincentive is an example of the ‘British’ way of filtering access to healthcare, which is called ‘implicit’ or ‘covert’ rationing. For example, many people who are referred to primary care mental health or substance misuse services receive a letter asking the prospective patient to ring up and make an appointment. Sometimes this also involves filling in some forms and rating scales. A really off-putting one is asking an open question like, ‘what would you say are the aims of this appointment?’

This little change in the Choice Architecture reduces the number of people given appointments significantly. Perhaps these not-very-motivated patients are the right ones to weed out. Or perhaps not. Maybe those who are least forthcoming are most in need.

Because mental health services are very limited, and mental health problems are very common, there is a massive amount of covert rationing for psychological treatments.  Which brings us to the pressing issue. If it’s that difficult to get an appointment for something concrete and medical, like muscle cramps and twitching, oops I gave it away, how much more difficult must it be for a depressed person to enter the system?

Most people with Depression have reduced energy and motivation. Often they are ashamed of seeming weak or useless. Studies have shown that it takes most people a long time to get round to making an appointment. Often it takes a crisis of some kind to bring people into contact with services.

Recently I’ve seen people turned away from blood-doning sessions because they had not made an appointment, even O negative donors, like myself, who should be given the red carpet and chocolate digestives.

I heard would- be donors say things like, ‘I just like to come down here when I’m able to, I just can’t plan that far ahead’. The person in charge assured them that the new appointments system was much more efficient.The Times (10.06.13) reports that the number of blood donors has fallen by 23% in the last ten years.

NHS blood and transport are apparently looking to attract young donors, so perhaps this should also be included in the national curriculum. I’d have given more blood if doning had been offered as an alternative to PE.

It would perhaps make sense to abandon or reduce the system of making appointments in favour of just turning up. We seem to like walk in centres and A and E, where we go when we need to.

In fact I seem to remember GP surgeries used to be like this, before appointments took over. I am sure GPs can produce evidence supporting the idea of appointment systems. And further evidence to support their recent system of the mad telephone rush for slots, jamming the  lines at 8.30 am.

But there has been a massive change recently in the number of things you can do while you wait. This has transformed public transport and it could transform access to healthcare.

If you have a tablet computer, or smart-phone even, you can listen to music, read a book or two, watch a movie and play a few games.

You can skype your relatives and buy a new cardigan online.

This is quite different from even 10 years ago, when you had to be content with old copies of Golf Monthly, collections of curling pucks and a fish tank.

Somehow we have created a system where people’s time is felt to be incredibly important and they can’t be released from work. Did planners fondly imagine that people would pop out of work during their lunch break to have a quick endoscopy?

It looks as though ill people will seek help, providing they know which queue to join and where it starts. All they need is a sign saying, ‘Stagger this Way’.

The biggest crime in the NHS is to make covert rationing ‘explicit’. It’s a bit like a magician showing how the tricks are done.

Perhaps there’s something more honest and straightforward about a queue. A bit like Stargate, we’d call it a ‘Portal into Care’.

Take your iphone. And the charger. Food and drink also. And if you see the sick-man, please send him back to Medical Cosmology*.

*The disappearance of the sickman from medical cosmology, by Nick Jewson,  Sociology May 1976 vol. 10 no. 2 225-244

3. It looks a bit DIY

Experts - do we need them?

Experts – do we need them?

There are surprisingly restrictive laws to prevent you doing bits of wiring and plumbing around your own home. Anything gas related is particularly strict, needing someone who is CORGI registered.

If you replace your gas hob, despite the fact that you can turn the gas off with a big tap, that the hob uses a simple bayonet joint, that gas is very smelly in case of leaks, that you have watched the CORGI man do it several times, that you don’t intend to do it with a lighted cigarette behind your ear – despite all that, if you disconnect it yourself you will be placed in the Tower of London for 100 years and tortured every Tuesday. Your crime is that you thought you knew better.

Surprisingly, when it comes to helping people with health problems, things are much looser.  There are professional bodies regulating the top end of the market – doctors, nurses, psychologists, but even here there is very little regulation of what types of therapy they actually do.

Lower down, blurring into the alternative therapy market, pretty much anything goes. This market is full of therapists who think they know better. Better, that is, than any evidence they can produce to support their work.

Its often fascinating, as a psychiatrist, to see how people have attempted to deal with mental health problems prior to ‘calling in’ the NHS.

We know people delay seeking medical advice for health problems. People tend to adjust to symptoms for a long while, often attributing them to random and coincidental events such as biological washing powder or a mystery virus.

Such accommodation to symptoms only breaks down if something happens – you notice specks of  blood over your white piano keys, like Chopin; your mum makes you an appointment for the GP. Or you are arrested in a public place under section 136 of the mental health act and taken to a place of safety.

Before we get to the point of needing professional advice, how long have things been deteriorating? In the case of psychotic and depressed patients, we know they have been unwell on average for many months before seeing anyone for help.

Some events are so traumatic that the person goes straight to hospital without passing GO or collecting £200. But the majority of medical events develop slowly, more like accepting a £10 fine, or, like Mr Huhne, taking a chance card instead. The first part of any illness is usually in our own hands to manage.

That means we have to consider health issues within the reflective mind, however much that part of the mind wants to sweep them under the conscious carpet.

When it comes to mental health problems there are times when we need an objective person to give advice. Another person can be a vital source of insight. Often just talking to another person helps us reflect better. Before we tell another person we are on our own and at the mercy of the limited perspective of the single view.

Even after we have convinced ourselves, and maybe our mums, that we have a problem, we encounter barriers around the health care system. These have been built good and high to filter out the excess demand placed upon a free health system.

The ‘culture of fear’ that NHS-managementism has created extends downwards towards service providers and users.

Firstly there is a healthy scepticism about what motivates the NHS  behind the scenes: 1. the nanny state; 2. targets that determine payments; 3. drug companies.

Then there are simple filters such as a permanently engaged phone line, KGB receptionists and a lack of appointments.

Perhaps more of a barrier for most people is just not knowing how to engage. What should you take to the doctor, how do you describe it, how do you present it? Should you take someone with you, should you write things down on a bit of paper, should you google it first?

Once into the mental health system we are very unlikely to find an ideal therapist we can relate to. One reason is that the demography of the NHS workforce nowhere near reflects the demography of the population it serves.

Another reason is the very small number of trained professionals relative to the number of people who suffer from mental illnesses.

For example, our GP has 2000 patients on average. Lets assume 3% of them (more later about the 3% issue) have severe depression – that’s already 60 people. Our local psychiatrist serves – again on average – 40,000 people. He or she will have a caseload of several hundred.

How many hours are there in a week? In the NHS, about 12, by the time we have allowed for bureaucratic intrusions, mandatory training, focus groups, and having our hair done.

Without wishing to denigrate anyone involved, or indeed undermine the foot-ware industry, the NHS mental health services are run on a shoestring. The negative halo effect that surrounds mental health issues also effects prioritisation and funding, relative to hotter specialities like Fever.

Having thought about all these barriers – starting with our own reluctance to think about our health, stigma, bureaucracy, shortages, shouldering our way into a system that feels like rush hour in Naples – its amazing that anyone gets treated at all.

Luckily, unlike with the CORGI fitter, a lot of it can be done by yourself. Often using equipment you can find in your own kitchen, such as another person.

But the first rule has to be: don’t think you know better (until you can prove it).

The second rule is: no cigarettes.