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You may knock GB News but it helped me understand the election results immediately



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I had been a lifelong Labour voter since 1992. When I ‘came out’ in support of Jeremy Corbyn as the democratically elected leader of the Labour Party, twice in fact, I was much derided on social media. I was attacked for supporting someone who was alleged to be ‘anti-semitic’, and the whole thing became totally unpleasant with much time-wasting leadership bids from Owen Smith and Angela Eagle.

There’s currently much for all of us to be concerned about – to name a few, the ‘cost of living’ crisis including sky high energy bills, inflation creeping up to 10%, record waits on the NHS waiting list, the possible independence of Scotland and Northern Ireland, crises abroad such as Afghanistan or the Ukraine. I would not consider the numerous fixed penalty fines from Johnson (or Starmer, if they happen) an issue to be one which occupies my mind much (so called “Partygate”), or his dreadful gaffes including the CBI Peppa Pig speech.

You may knock GB News, and to be honest I’m not that interested in the “culture wars”. But watching the channel, with some favourite shows, for a few months has exposed me to an open discussion of many issues which I simply did not hear on the BBC. Likewise, just because I am a regular GB News viewer, that does not make me ‘far right’. To imply that is to imply GB News viewers are all far right. It’s as insulting as saying Brexiteers are lacking intelligence, an easy insult to make in the heat of the moment.

The discussions on GB News tend to be respectful and informed. Clearly, some of the panels are a bit Mail/Sun/Express for me, but I choose to watch these individuals. Some arguments are bit off-the-wall and to my knowledge incorrect, but you get that everywhere. But the election results from England came as no surprise to me. Keir Starmer will not become Prime Minister, and I am certain that the Labour Party in due course will replace him.

The exclusion of Jeremy Corbyn is an admission that we live in a Presidential system, and that there should have been processes and procedures in place to root out all antisemitism in the Labour Party. But that is clearly not the only problem in the Labour Party – others include its funding crisis, the lack of publication of the Forde Report, allegations of Islamophobia, and so on. The attacks on Corbyn simply look like a hate campaign, a highly personal one, and disenfranchises all the people who supported him for the last few years. Last Thursday, the ‘get out the vote’ door knocker who came to my flat was clearly a young person recruited during the Corbyn era, who did not really want to be there.

Having read Paul Embery’s book ‘Despised’, which I strongly recommend by the way, it struck me that I fall into the demographic which did not really understand Brexit, living in North London, a Europhile and University-educated. The book is very elegantly argued, and it has helped me understand what has gone badly wrong from the ‘left’. For example, we have pumped a huge amount of an effort into an university class saddled with colossal debt with few opportunities to build a future sometimes. It happens that, from my personal experience, that the people on the left who have succeeded have come from privileged backgrounds.

Seeing gains in the North East for other parties, and basically the performance of Labour flatlining, made me think that Dehenna Davidson MP’s opponent in a TV debate really didn’t understand why Labour was so unattractive to the voters, almost to the point of lacking all insight. It was totally exasperating, almost to the point that that Labour MP looked dangerously out of touch.

The next general election could come sooner than you think. Starmer offered no alternative thinking in the pandemic, nor on Brexit. OK, he has put all his eggs in the windfall tax basket, but it seems that Starmer cannot put forward a political argument and take people with him. Optics matter. The spectacle of Sadiq Khan euphoric in Barnet in London as a ‘game changer’ was utterly ridiculous, and possibly itself alienated voters. The issue is that Labour did not do well in the rest of the country, and the Conservatives and LibDems even managed to make some gains.

The fact that Labour can’t even discuss Brexit or immigration is staggering. The lack of opposition on Brexit is extremely worrying given the potential effects this is having economically and geo-politically, and even Brexiteers, I assume, don’t want a total cover-up. At a time when freedom of speech is so cherished, why is that the problems regarding Brexit aren’t discussed in a mature manner.

Rather surprisingly, I was called a ‘fat gammon’ this week on Twitter, despite the fact that I troll Tweeps with my profile which says, ‘Woke’. Watching GB News as entertainment has helped me to understand other people’s views, even though I may not necessarily agree with them. There are, for example, reasons why some people felt they did not benefit from membership of the European Union. I suspect some Tory MPs know that Johnson is more in touch with his voters than they are, whatever your personal views about these voters. The election results from England last night therefore made perfect sense to me, even if the BBC pundits seemed extremely surprised.

As it happens, I too feel despised by the Labour Party, and the discussions on GB News have in fact opened my eyes. There’s a lot there I disagree with, rest assured, but I am mature enough to make up my own mind.

 

@dr_shibley

 

The delirium OSCE. We need to talk about this.



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When I sat finals in clinical medicine in Cambridge in 2001, student doctors would be given ‘short cases’ and a ‘long case’. It was all a bit of a carnival in short cases, where you’d be taken to various patients and you might be given a few minutes with them.

For example, in the ‘old days’, you might be taken to a patient wearing a wig, and the discussion might be causes of hair loss. Or even, you might be taken to a patient with a glass eye with a successfully resected choroidal melanoma, and the discussion might be on melanoma.

There is no wish from me to be nostalgic about this. This was a very hit or mess method of assessment, and suited those people who treated clinical medicine exams like a game show. Exactly twenty years later I find myself writing a station for an ‘objective structured clinical examination’ – the OSCE – where student doctors are given a finite amount of time to take a history or to do a focused clinical examination, and examiners mark off certain competences against checklists to provide a rating overall.

Once qualified, student doctors after a period of pre-registration will become registered by the General Medical Council. This means that they are considered ‘fit to practise’, and their primary duty is to the patient and to observe patient safety. For a qualifying examination, you would therefore expect the candidate, a student doctor hoping to qualify in clinical medicine, to interact with a ‘real patient’ or a ‘simulated patient’ or even mannequin.

The key word here is ‘patient’ not ‘carer’.

When I first embarked on an academic journey into dementia, which led to my first book on dementia published in 2014 entitled ‘Living well with dementia’, it was very much the case that the narrative was individuals with newly diagnosed dementia were individuals in their own right. They had autonomy, independence and are deserving of dignity. It was argued that the stigma and prejudice surrounding people with dementia came from persistent media distortions representing people with dementia as devoid of credible speech and other behaviours.

But it is clear that carers are relevant to patients in all sorts of contexts – such as improving health and wellbeing, shared decision making and integrated care and support planning.

Delirium might be a presenting syndrome in someone who later goes on develop a full-blown cognitive impairment of some sort. In many cases, delirium is said to ‘unmask’ the dementia, comparable to how a urinary tract infection might reveal underlying vulnerabilities in an older person with frailty.

The issue here is that a person with delirium might have no idea who he or she is, might be talking gibberish, might fall asleep mid-sentence, or might not know where he or she is. Therefore, taking a traditional history off him or her might be very challenging, to say the very least. We should like student doctors to feel confident in identifying accurately a patient with delirium. With time, we should expect doctors to be able to complete successfully a quick 4AT on someone with delirium.

Delirium is worth diagnosing because what it isn’t in all cases is totally reversible with no sequelae. With, for example, recurrent delirium episodes, somebody might become more cognitive impaired, lose indeependence, become deteriorated in functional activities of daily living, and might even die earlier than expected. Carers often say to me in person that they have a really awful time communicating with doctors in the NHS. Carers in reality are friends or close family, often, and the bad communication is not intention.

Carers end up being quite important in health and social care services, including unpaid family carers. These family carers are often with a ringside seat to observe an acute change in consciousness and cognition or behaviour over hours or days. They invariably end up being care partners during somebody’s hospital admission which tends to be emotionally demanding for all, including healthcare professionals. They are clearly important at the point of discharge, especially if somebody loses abilities temporarily including physical deconditioning.

I find myself coming full circle studying a Masters in medical education at Nottingham. In designing an OSCE for delirium, I find myself drawing on experience as a family carer, and my situated learning of delirium in that context. As it happens, I am also a physician by training.

I am drawn to the immense distress the delirium episode provides for me as a carer, the loved one (the patient) and the clinician.

If I am to write an effective OSCE for delirium it is therefore to emphasise its position as a medical emergency. This is because delirium is often the ‘canary in the mineshaft’, i.e. the warning for something more sinister like severe constipation or an infection of some sort.

It is therefore a test of the art of diagnosis.

But it is also a test of someone’s communication skills and especially empathy. Distress requires attention. Delirium, or the “acute confusional state”, therefore does merit some practical examination of clinical skills. It is virtually never likely to come up as an examinable case for the membership of the Royal College of Physicians, but conceivably could be a 10-minute GP-consultation “CSA” case in the corresponding clinical examination for the Royal College of General Practitioners.

What is striking to me is the lack of published peer-reviewed literature on the examination of communication skills of doctors with carers, or the ability to take an informant or collateral history prior to undergraduate qualification.

We know that that the official curriculum is over-burdened, and hard to put in practise, but delirium is inherently distressing as well as clearly a patient safety matter.

We might be able to do better.

 

@dr_shibley

 

 

Claire Fox hit the nail on the head. It doesn’t add up at all.



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The narrative from the media is: Cressida Dick bad, the rest of the world good.

I’m not surprised Baroness Claire Fox’s head was hurting after hearing two opinions on GB News, about the resignation of Dame Cressida Dick.

I am likely due to the ‘footballification’ of politics likely to indulge in a bit of conspiracy theory that Dame Cressida Dick is best mates with Boris Johnson, both having been to the same Oxford college (perhaps, I haven’t checked the factoid).

But if the referendum has taught us anything at all, it is dangerous to do ‘binaries’. And the world is full of them: vax or no vax, net zero or no net zero, Brexit or no Brexit, lockdown or no lockdown, and so on. Life could just be a series of referenda.

Dame Cressida Dick is the top of her profession, regardless of her gender or sexuality. And uniquely so, regardless of her politics.

It would therefore be unlikely that Cressida Dick is a misogynist, and so on.

For all the talk of the Met Police being institutionally racist and sexist, why would they need so much training in these domains? Why go to so much effort with rainbow armbands or “taking the knee”?

To reuse a binary, the Met Police is either misogynist and racist – or it’s not.

But I personally am fed up of the abuse of marketing about diversity.

For all the talk of the disability employment gap, the NHS is ineffective in employing people who are disabled at the bottom or the top or in between in the NHS.

I attended a teaching day yesterday, and there was no discussion of the value that disabled doctors could bring to the NHS. The teaching session went straight in with ‘reasonable adjustments’ under law.

Somebody I had never known before tweeted me to say he had been encouraged to seek a non-medical job, despite being a very intelligent doctor, on account of ‘you can’t cure autism’.

I am not especially surprised at this sentiment from others. For ages, I have been wanging on about how adults who suddenly find themselves disabled need a phased return under reasonable adjustments of the Equality Act 2010. That is their right.

In effect, nothing happens. The NHS does not even have a workforce plan for disabled doctors. It instead has a glossy ‘People Plan’ which is no more useful than Grazia magazine.

Not for the first time I find myself in agreement with Claire Fox.

And I am no contrarian!

 

 

@dr_shibley

Starmer and out?



I don’t have any skin in the game.

I voted Labour all my life – between 1992 and 2019. I’ve never voted Tory.

A small confession. I’ve never met Sir Keir Starmer. I have seen him sitting in the audience as he was supporting the then newly crowned leader of Labour, Ed Miliband.

Ed Miliband is somebody I could happily have as Prime Minister.  I remember David Cameron’s Twitter jibe, now infamous:

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That was of course he set in motion a chain of events that led to the referendum, causing Britain to exit out of the European Union. It is widely thought that Nigel Farage can be thanked for precipitating this. He of course is not especially happy how Brexit has gone now. And who can blame him, with fishermen losing business, pig culls, huge loss trade, marked shortages in certain sectors of the economy, to name but a few. Luckily for the current Conservative government there are voters who are desperate for Brexit to work, like they are for the Tories to reverse years of Tory austerity under the guise of ‘levelling up’.

I understand Rachel Reeves’ optimism about a possible Labour victory. I also have experienced this illusion of ‘one last heave’ – where one final push will guarantee a Labour government.

But having followed this for years, I don’t think we’re there yet.

There are a number of reasons.

If “Captain Hindsight” can only be offering ‘constructive criticism’ while continuously to carp irritatingly like a back seat driver, “General Sit on the Fence” hardly inspires confidence with his endless streams of boosterism and lies.

A rosette on a Starmer cannot explain the lack of input into policy on Brexit, coronavirus or even the reorganisation of NHS and social care. Starmer and the whole shadow cabinet are lost in action. Nowhere to be seen.

They indeed, like Hilary Benn was so obsessive about, seem to be more focused on winning power than turning heads with policy. The brut force of Michael Foot intellectually, or indeed Enoch Powell, offered something quite unpalatable politically – though in defense of Foot, he never wore a donkey jacket and much of his 1983 offering has now been assimilated into current policy.

I want a Labour government, more than a Johnson one.

I don’t think people are keeping diaries about what they think of their civil liberties, the vaccination programme, or the battle of the dinghies.

But the step before the public vote for a Labour government is them endorsing a new Tory Party under someone like Liz Truss. I thought nobody would ever vote for Boris Johnson, but it turned out the media loved him, and that people had ‘factored in’ all his misfeasance.

Starmer would prefer to keep his mouth shut on environmental issues, or human rights, or policing, or housing.

But this policy of muscular silence is going nowhere. Nobody knows what he or Labour stands for, much that they find this current Government sleazy and a bit dodgy.  It could be argued that Starmer has bus loaded in a lot of ‘serious people’ but I can’t name many of them apart from Yvette Cooper or Rachel Reeves who were instrumental in making my life hell for much of the 2010s for feeling guilty for being disabled.

The arithmetic is pointing to a solid SNP victory in Scotland, and it’s very hit or miss who will be the dominant party in England and Wales. Possibly Wales might save Starmer’s bacon, so to speak.

Dame Maureen and Dame Margaret are totally irrelevant to me.

Whilst the poll lead is welcome for Labour, I don’t think it is at all meaningful. John Rentoul, for all his brilliance, is badly wrong – or maybe it’s merely wishful thinking.

 

@dr_shibley

Whisper it softly. Keir Starmer is especially crap at politics.



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Donnez-moi a break.

At a time when Labour has voted in a new General Secretary in David Evans, the news is of sacking staff, threatening compulsory redundancies, losing revenue, and a full frontal attack on members. Evans was hardly voted in with a supermajority. Sadly, the vote was not advisory, even if it was at the level of 59/41, almost exactly the 60-40 split estimated.

To revisit an era, things can only can get better.

It’s on days like this that Dame Margaret Beckett had wished that she’d stayed in her caravan.

Labour has had a disastrous start to its latest conference.

The best that the political commentators could say to Keir Starmer’s handling of the launch of the Labour conference was that ‘it is good for Labour to be seen fighting the Unions’.

I suspect it would be good for Labour to be seen fighting the Sun newspaper, but, at the latest count, the Sun newspaper is out in force too.

At the launch of the Labour conference in Brighton, the day normally begins with something motivational for the membership. Not this time.

This time, we are told that, for the Labour leadership, the proposals are to raise the threshold of mp nominations, get rid of the “registered supporters”, and a commitment to review rules inc how to restore vote for unions’ political levy payers.

As far as the membership is concerned, Starmer has spent the last two years brown nosing the Johnson government, having given up even on the slightest of ‘constructive criticism’. Nobody can see the point of what is possibly the worst Labour opposition in my lifetime certainly.

Emma Radacanu, having won the US Open, has just said goodbye to her coach. Starmer, on the brink of the worst Labour disaster in history, even with the media this time supporting him to the hilt, is about to make all the offenders Knights of the realm or CBEs in his mission to promote failing upwards.

Starmer had a golden opportunity at the start of conference to make his mark over the energy crisis, inflation hike, driver shortage exacerbated by Brexit, dumping the triple lock, UC cut, NI hike, or public sector pay freeze.

As far as the over-spotted Red Wall voter is concerned, Labour is fronted by a Remainer who hated Jeremy Corbyn so much he was more than happy to be in his Cabinet. This particular Remainer, as it happens, can’t wait to get his teeth into the necks of anyone vaguely socialist in the Labour Party.

Let’s face it – not even an interview between Wes Streeting and Gloria Di Piero on GB News can stop the rot now.

The Conservative, Unionist and UKIP Party don’t especially to seem have any ideological direction to their roadmap, apart from an addiction to authoritarianism and the “market” which has consistently failed in the NHS, gas, education, and, you name it. All it cares about is media management of the latest crisis. Even Liz Truss MP is tipped for the top now.

Labour should be a hot bed of democratic socialism. It is instead a hotbed of undemocratic croneyism. A relatively popular contribution could be Labour’s proposed Fair Pay Agreements would give working people a pay rise and boost our economy. Labour would bring together representatives from workers and employers to agree minimum pay and conditions in their industry. A radical look at workers vs employees, and a revision of workers’ rights in a gig economy, to revise the Employment Rights Act (1998), would be a good contribution.

Instead, whilst the Labour rulebook states that conference should have a formal vote (show of hands) on the NEC report. Dame Margaret Beckett is not one for following rules to hold the vote. There’s no need to rig a vote any more. Just don’t hold it.

Of course, the HGV and tanker driver crisis is nothing to do with Brexit, and all to do with those pesky unions in Swansea at the DVLA, or refusal to do medical checks from lazy GPs. This is a weird dystopian Universe where Starmer has been taken hostage by a weird sect in the Labour Party determined to make Labour look out of touch and irrelevant.

@dr_shibley

Different newsreader, different script



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With a new Secretary of State for health and social care, it might look like ‘business as usual’. Different newsreader, but same script?

The script might be more or less the same. But with a possible massive political realignment, the Conservatives and UKIP party, GB News, free market economics and libertarianism, anti-woke culture, all in the ascendancy, the NHS might be about to get ‘cancelled’. And then we have the ‘scorched earth’, provided both by Brexit and the COVID-19 pandemic.

The argument is not at all any more 3 seconds to “save the NHS”, which has been a popular mantra for Labour for decades. But Labour has rarely had such an effective leader, or opposition. Labour is nowhere on all policies, but its opposition to Brexit, COVID-19, and even Matt Hancock’s latest conduct, has been non-existent. There has never been a better time for the Conservative Party to go for it. GB News viewers regularly buy into the “levelling up agenda”, in no way blaming the Conservatives for their policy of austerity. Labour is too busy imploding to intervene. GB News viewers regularly stick up for “home grown” nurses and medics, and make strongly anti-immigration noises, saying that the infrastructure can’t cope with the additional population. Matt Hancock did a ‘brilliant job’, oblivious to the disastrous care home policy or corrupt contracts. Hancock is determined to make a return when the time is right, and it looks as if Boris Johnson will give him his full support. Matt Hancock is one of those people who should be ‘forgiven’ as “we all make mistakes”, according to some. Except – had been a doctor he would have struck off years ago.

The easiest way of not addressing the pensions issue in the NHS, the workforce crisis, the crisis in mental health or social care, the backlog in clinical care across the board in the NHS, would be literally to rip up the NHS and start again. Sajid David has still been a paid JP Morgan advisor, and it is well known that JP Morgan have long wanted to get into private healthcare. For the people who dislike the NHS, this is their chance to get rid of it.  The anti-wokists, contrary to their usual feelings about the ‘cancel culture’, would happily get rid of the NHS, thinking of it as an inefficient relic of yoke culture, which believes too much in equity, equality and fairness. They feel their views criticising the NHS should not be cancelled. Free speech, and ‘polite debate’, is welcome, so long as you don’t disagree. There would be no imperative to provide a comprehensive NHS, nor indeed mental health care, if it is not profitable, even if the demand is there. Social care, for all the initiatives about ‘social care future’, would simply be whatever the multinational corporates propose – and persons with learning difficulties or dementia might not be high priorities. If you believe racism doesn’t exist, racial discrimination won’t happen. If you are out of the EU, then the EU working time directive doesn’t apply. See what I did there?

We live in interesting times. With Labour having killed itself, and with the help of sabotage from the ‘left wing media’, there is the real material prospect of George Galloway depriving Labour of a win in Batley and Spen. The spin will be that the Conservatives ‘won’ Batley and Spen, reflecting how the public don’t really care about infidelity and corruption, in the same way that they don’t actually care about expensive wallpaper. With more dead cats than can be accommodated in a cattery, the privatisation of the NHS has never looked so good. It won’t be a big IPO – no need to  tell Sid. Learning from the utilities, the new NHS England CEO will take care to fragment the NHS into further pieces before transferring the units to the private sector. And with the new NHS reforms, and no immediate blueprint for the social care sector, absolutely anything can happen. And it probably will.

 

@dr_shibley

Is it late for a Starm offensive?




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“If Sir Keir Starmer QC wishes to resign, I will support him.”

Groan. I started the pandemic, it feels like many years ago, being a loyal Labour supporter. I had voted Labour all of my life. But this policy of ‘constructive opposition’ was the pits. All of the mistakes Johnson had made were whitewashed, but in fairness the vaccine rollout from the NHS was a massive success.

Starmer and I have an interesting history together. I once saw him sitting in the audience of an election hustings for Ed Miliband in a primary school which Ed Miliband attended in Haverstock Hill. I remember thinking that Starmer would be the future one day. I remember reading about him in the Times. I suppose in those days there was a strong movement for Labour members to be in the metropolitan graduate class – the wokey class, rather than the working class.

It’s a ridiculous stereotype of course that the working class wear cloth caps, drink beer and eat fish and chips. And yet that is precisely the stereotype Starmer bought into with his photo ops when visiting ‘the North’. The argument from Labour goes that the Conservatives have parked ‘tanks’ on Labour’s lawn. But this framing for me exposes part of the problem. It is not Labour’s lawn. Daniel Finklestein is half right – and has told a half truth. The Tories are good at ‘reinventing themselves’. But unpacking this a little bit, the Tories have been very good at convincing voters, somehow, that they are the “party of change” – and will come to the rescue after years of austerity. This is the austerity that they caused.

It could be that Andy Burnham is also right. His landslide victory is a demonstration that localism can work. Not only can woke. I think there is a connection there with voters who want investment in people and services, and that this energy is both powerful and positive. It might be that extrapolation that Labour is finished as a national party. But Johnson can do localism too – look at the Mayor of Teeside, or the good showing in London. The travesty is that there are many in the Labour Party who want to exit now because they are sick of being victimised, in everything from micro aggressions to finding themselves as defendants in a lawsuit from members of a WhasApp group. My frustration is that this extreme version of navel-gazing meant that decent conversations about a national broadband offering, a national social care service, or a national education service got jettisoned. And from that point in Labour deserved all it got, as far as I was concerned.

If Labour has taken for granted, it could be that the Conservatives have taken the voters for fools. But, if so, I feel it is equally the case that the Labour leadership has taken some of its membership for fools. It screwed up on Brexit. That is public knowledge. If you wish to engage in single issue politics, it is crucial not to misjudge that single issue. And again history repeated itself. Starmer took a single issue. Sleaze, encompassing wallpaper in John Lewis, and Johnson’s morality. Except, this doesn’t work. Why? Most people dislike hypocrites. And we know that Tony Blair, pre-existing widespread use of the mobile phone, himself was embroiled in cash for peerages and Formula 1, and so on.

So Alastair Campbell is partly right too. Johnson is a perpetual liar, and somehow gets away with it. People know this. Millions of people have factored Peter Stefanovic’s video into their understanding of the situation. Supporters of Labour when it was led by Jeremy Corbyn were not all anti-Semitic. The problem was many innocent people, by supporting Corbyn, suddenly became anti-Semitic as a matter of guilt by association.

Starmer of course did another issue on top of the single issues of Brexit and sleaze at different times. He has consistently made hating Jeremy Corbyn his flagship policy since he became Leader, quite ironically given that Starmer was a major architect of Labour’s failure in December 2019. Even Adonis knows that Starmer has no political capital in the bank and wants to sell sell. Some Blairites know their reputation is soiled by having Starmer as the pin-up boy of their legacy. For all of Blair’s faults, his Government had major successes in human rights, minimum wage and freedom of information. And Blair’s fiascos in government that even he is very much haunted by them, one assumes. But Blair had a policy on the NHS. It was a legacy of Thatcher’s, and it could be that many voters think they might as well give the Tories a ‘go’ as Labour has at least contributed as much to this mess as the Tories. And to dismiss community investment as ‘pork barrel politics’ is not the point. Years of underinvestment has been coupled with false promises from Labour about levelling up.

So I might be yet another ‘woke social media warrior’. But I am deeply concerned about the direction of Labour. It could be that there is as much problem with the messenger as the message, but then again I don’t know anyone who forms their views after reading ‘Labour List’. Corbyn may not get away in blaming all his misfortune on media misrepresentation. Nicola Sturgeon and Boris Johnson had both been the targets of intense smear campaigns – and they survived.

Either way, Starmer needs to go. The needs of the Labour Psrty are more substantial than the needs of a single mega-Establishment mouthpiece. Starmer has no vision apart from exterminating Jeremy Corbyn. Starmer’s problems are focal to Starmer, however. Steve Rotheram did well. Mark Drakeford did well. I completely reject the notion that there’s no obvious challenger to Starmer’s leadership. I think Clive Lewis would be a great future Labour leader.

I think Starmer is offensive to my values as a former Labour voter. It’s too late definitely for a Starm offensive in any case.

 

@dr_shibley

Could and should we all shut up about Brexit now?



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Brexit is not the direct reason why the Nightingale Hospitals can’t be staffed adequately in the current pandemic. But it is a boil which David Cameron wanted to lance once and for all.

 

I apologise that, before writing this, I haven’t “cancelled” the use of labels such as ‘Brexiteers’ and ‘retainers’. We are a deeply divided nation, and even more so due to the 2016 referendum. The UK could become even more divided, literally, if Scotland becomes independent, and Northern Ireland splits to unite with Southern Ireland. Even if Labour abstains on the deal today, it would still be partly responsible for the whole package. This is because when the referendum result was announced Jeremy Corbyn launched a three-line whip to trigger Article 50. Labour has had no part to play in the negotiations with the European Union, so it has played the silent bystander since 2016 about exiting the European Union. It chose to leave the single market, and it chose to set up a hard Brexit. So it shouldn’t be surprised now that that was what was negotiated. With all the best will in the world, you would expect Alastair Campbell and Lord Andrew Adonis to reject the resultant trade deal. You’d expect Ben Bradshaw MP to reject it. To all intents and purposes, the proposed trade deal might be quite fair in that both parties have made massive concessions, but it is not what anyone wanted ideally.

 

The terms of the EU trade deal in large part are not a surprise, given the way that the Conservative Party negotiated it. This is why it has ‘passed’ the inspection of the Star Chamber, some operation within the ERG. There is no sovereignty about fish quotas, there is an abolition of freedom of movement, and so on. What is more mysterious is why the British government are so trenchant about our departure in ERASMUS, but it has hard to tell what the vision of UK in the world is from the Tories. We do however know that Boris Johnson has held repulsive, racist and xenophobic views, which might quite play well with members of both Labour and Conservatives in ‘Red Wall’ Britain.

 

The vote today is irrelevant in far as rubber stamping this deal is concerned. The Tories have the numbers there, despite the position of the SNP and the Liberal Democrats. Also irrelevant to the general public is the view of the current professor of EU law at Cambridge about how the new legislation is good for a supremely powerful Executive and international public lawyers. How the Conservatives got into a position of abolishing free movement of persons and abolition of frictionless trade through the erection of non-tariff trade barriers is easy to understand for the need of the Conservative Party leadership to control a micro-culture heading back to the leadership of Enoch Powell. The rot has persisted under Hague, Cameron, and Major. And now Johnson. The hard Brexit is an ideological position which could mean EHIC is replaced by some private subscription to private health insurers, but that is entirely the choice of certain individuals who want to see private insurance flourish.

 

Labour is not supporting the terms of the deal as such, but says that is opposing a “no-deal”.  The trouble is, however, that everytime something goes wrong with the deal, the Conservatives can legitimately say that Labour voted for it. Labour could of course abstain. What is ridiculous is that a lawyer can agree to a document without having read it. This is like a surgeon agreeing to do an operation without reading any of the medical notes of a patient.

 

The European Union is sick of the excessive time they’ve spent on it, but they are not pursuing arrangements out of love or goodwill. They are agreeing to the deal to protect the single market in future. And they’ve been utterly united throughout. The main political parties have got away with taking a wrecking ball to the geo-political relationship between the UK and the European Union, and our international reputation is one of a basketcase. The deal is still subject to the UK’s co-operation with the European Court of Human Rights, which is in the sights of certain members of the Government (like the death penalty.)

 

The positions taken by Alastair Campbell and Lord Andrew Adonis are totally understandable, in that the actual deal is nothing like the requirements for passing the ‘tests’ Labour had set. But they are also not flavour of the month of some ardent Brexiters. And Frances O’Grady leading the TUC has opined that the proposed deal is barely better than ‘no deal’, as regards issues as fundamental as workers’ rights. So there is a strong case to oppose the proposed deal, but it is better than ‘no deal’. But voting for the deal makes the perception of the Scottish independence case amongst the Scottish nationalists. It trolls the ‘remainers’ in the Labour Party, who are not easily going to forgive and forget in the name of unity. The damaging effects of Brexit will be felt for decades, and there are no obvious advantages to the UK’s exit from the European Union.

 

But whatever Labour does now it will never be perceived as having got behind Brexit. It will have successfully alienated some of the ‘remainers’ in the Labour Party if it votes for the proposed deal, but it will also have garnered the support of others who feel that this is the time to move on. The time to move on is possible if Labour has a vision about what it wants from its place in the world, but it needs to spell out what it wishes to surrender in the name of improved sovereignty. The problem is that in the real world sovereignty is a bogus notion, because international market entry depends on nurturing relationships between party and understanding the law of conflicts as well as contract.

 

The leadership of Labour does however have to be called into question over this. The approach taken by Keir Starmer elsewhere of ‘divide and rule’ is unlikely to work over the thorny European question, and could precipitate the splitting of the Labour Party at the very worst. The Labour Party is quite unlikely to split over this, although it could split over Jeremy Corbyn. And if Labour sits on the fence then perhaps it can be seen to work better with the Liberal Democrats who remain utterly opposed ideologically to the current deal. But it is completely unclear what Labour wants to achieve in a renewed negotiation in the European Union, and whether it really wants to fight for it in the pursuit of voters more interested in ‘flag and country’. However, the argument that the European Union is not the source but rather the potential solution has never been put vociferously by Labour recently. At the moment, it looks as if it is being opportunistic in waiting for the deal to unfold, rather than being in any way pro-European.

 

But there is not going to be an imminent “second vote”, and at the moment there is no contemplation of the re-running of the arguments. It would be hard to tell that, if the economy implodes, whether that’s due to Brexit or the worsening coronavirus pandemic. But the increased cost of living and the increased unemployment may not be a price worth paying. One thing is for sure that, whilst David Cameron’s wish that we all shut up over Brexit may not be heeded, the Conservatives maintain their competitive advantage in completing Brexit whatever the consequences.

 

@dr_shibley

Ships in the night



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Like ships in the night, I have seen many millions of opinions shoot past about visiting loves ones in care homes. My loved one is with me at home, but she has advanced dementia. Not everyone who’s a resident in a care home has a dementia. I get that. But I would like to put down on paper a personal opinion about this. This was provoked by an excellent comment made by Vic Rayner in the Commons Health Select Committee this morning.

 

Vic Rayner emphasised the importance of relationships in social care. I couldn’t agree more. It happens to be a pivotal part of the ground-breaking work that Prof Julienne Meyer led on. Relationships are a crucial part of preventing burnout in staff, and they are also in understanding the resident as a person. It’s impossible to understand a person without understanding his or her social context, people who do or don’t matter to them, and the people who light up a life.

 

I worry that – and there are many people like me – that mum will soon forget who I am if I leave for too long. I have her nextdoor to me basically. But imagine if I had to be without her for a week. I’d be heartbroken. I often ask her if she remembers who I am, and sometime she hesitates. When she can finally remember, I feel as if I have won the lottery. It’s that one confession that keeps me having a tangible link with my mother. She can remember me. She can possibly remember giving birth to me. She can perhaps taking me up to school or university.

 

In about 1881, a famous French neurologist published on a theory of the formation of long term memories. Paraphrasing what he said in French, Ribot wrote ‘the old perishes after the new’. Speak to anyone with moderate or advanced dementia of the Alzheimer type, the person will find it much easier to remember what he or she was doing six years ago, compared to six minutes ago. I find that making a connection with me keeps her in the present. I think divorcing mum from me would be very upsetting for her – and very upsetting for me.

 

But it is also important, I think, to be open about a certain taboo. That family carers are essential care partners. When for example mum has to go into hospital for an acute emergency admission, I get a massive sense of loss as all the care transfers from home to professionals in a hospital. There are, furthermore, certain instances when my account of what has been happening is important, not being hyperbolic about my own contribution. A way of ascertaining whether mum has had an acute change in personality and behaviour, through delirium, is by asking me. Delirium is a medical emergency. Secondly, I know mum’s past medically, and can overcome any cultural including language difficulties. Thirdly, I can act as a reassurrance to mum while she goes through the distress of being a patient with an acute medical emergency. Finally, if care is not appropriate, such that someone does not treat her with dignity or totally misunderstands a situation, I can contribute to help. Unfortunately, it happens to be the case that in health and social care environments people can feel threatened by unwelcome additions to the care team. I’ve experienced this myself when one member of a care team actively makes an official complaint against another. But, when it works well, we can all act together, united, to help the health and wellbeing of people we love.

 

I understand how this conversation has become one of process and procedure, infection control and even dispute resolution. I could theorise for hours, even days, on the jurisprudence of the human rights involved. But I feel it’s fundamentally a lot more than that – the inhumanity of the separation from people we love. As was put a long time ago, care homes are not fortresses or prisons – they should be somebody’s home. Turning them into prisons is not a proportionate response. It saddens me deeply that so many people have clearly lost their way, but I am heartened by some exceptional leaders such as Kate Lee, Dr Jane Townson, Prof Adam Gordon and Vic Rayner on this.

Matt Hancock would like it to be known that he is trying his best



 

 

Peter Drucker, the icon of business management, is widely credited with one of the most important phrases of the field: “If you can’t measure it, you can’t improve it.”

And prima facie that would seem the purpose of Matt Hancock wanting to ‘ramp up’ the number of tests to 100,000 per day minimum.

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The NHS has long had a problem with metrics, and this has been encapsulated in Goodhart’s law. Charles Goodhart first advanced the idea in a 1975 article, which has been phrased by Marilyn Strathern as “When a measure becomes a target, it ceases to be a good measure.”

It has been argued for some time that this approach is actually very dangerous, as it is related to an approach that says that what can be measured matters and that what is not measurable does not exist. (1)

In 2017, Dr Peter Bennie, who was at the Scottish council of the British Medical Association, said: ”Multiple targets, an ageing population and the funding gap are creating a vicious circle, stretching the system and the workforce beyond their means. The current culture of using crude measures, often taken in isolation, to judge the complexities of the whole healthcare system, and to apportion blame, must end.” (2)

And target chasing can result in strange behaviours. It must be that Hancock was desperate to fulfil this metric, if a recent interview is anything to go by. Maybe he was trying to avoid blame – and the sack.

The presenter, Nick Ferrari, said: ‘Are you prepared to have a £100 wager, and I will never be happier to write a cheque for £100, when you deliver that 100,000 tests on May the first and the money goes to NHS charities. Are you up for the bet, Mr Hancock?’

Hancock replied saying: “I’ve got enough riding on this already, Nick.” (3)

The  current Secretary for State for health and social care has now further been embroiled in accusations of artificially inflating the number of coronavirus tests, in framing the rapid increase in numbers that allowed him to get up to a self-imposed 100,000-a-day target as a “national achievement”. Following meticulous investigation from the HSJ, it later emerged that a third of the 122,347 tests included in the final 24-hour period before the deadline were counted before they had been carried out. They had merely been sent out in the post. (4)

Following a target ignoring other issues is a problem which is a great threat to patient safety in medicine. “Fixation errors” occur when the practitioner concentrates solely upon a single aspect of a case to the detriment of other more relevant aspects. These have especially become recognised in anaesthetic practice, where they can contribute significantly to morbidity and mortality (5).

Take for example one repercussion of focusing on that target of the number of tests. It distracts, for example, from a sensible discussion of where other clusters or outbreaks of infection might take place. There is now the realistic possibility that mental health units will be the next locus of an outbreak in the NHS akin to the crisis in care homes. We don’t know how many infectious doctors or patients there are on mental health wards, which we know have had a problem with supply of personal protective equipment too. Only recently, for example, of the longest-serving staff members, a ward clerk at the Highgate Mental Health Centre, died of coronavirus, as staff nationally have continue to speak out about their safety fears over lack of personal protective equipment (6).

We’ve been here before back in 2008, when the then Labour Government was inundated with complaints of a “culture of fear”, where  patient safety came second to presenting a set of statistics suitable for dispatch-box delivery.

In oral evidence, Sir David Nicholson in 2013 said famously, “When I was first appointed to the job, when I came into this particular job, I coined a phrase, which at one level sounds trite but it is really quite an important phrase-“Hitting the target and missing the point.” This is the dangerous place that some organisations got into.” (7)

A later King’s Fund’s review into leadership and engagement for improvement into the NHS, recognised a “command and control style” of management had contributed to poor care, leading for a new ‘push’ for a style of leadership that engages staff and patients (8)

Other industries have had problems with ‘command and control’ cultures. There has clearly been much resistance dragging the NHS away from the nostalgia of the Lancelot Spratt consultant figure-head towards one where a more junior member of the team is actually listened to (9)

The NHS has been desperately trying to move away from ‘command and control’ culture in recent years, not least because international research has mandated that collective leadership is taken seriously, where staff at all levels act to improve care – within and across organisations (10)

If anything, the recent coronavirus crisis has emphasised, furthermore, potential deep seated problems in the culture of the NHS. Particularly worrying has been there has been talk of institutional racism arising from social inequalities.

It has now become imperative for the government to look at the full range of structural inequality impacting BME people in the NHS (11). This means that more attention has to be given into making sure that the NHS culture is truly diverse, rather than relying on a few BAME leaders to make a public show that senior BAME figures can find themselves in leadership positions.

Dr Chaand Nagpaul, Chair of BMA Council, recently stated, “We need to ensure that ethnic minority doctors, alongside all medical staff, can confidently speak up if they feel they have inadequate personal protection. They must not risk their lives due to feeling inhibited from doing so.” (12)

The coronavirus crisis has thankfully, at least,  allowed us all to take a step back and think how we would do things differently. Thinking about whether much has changed in NHS culture would be a good start.

@dr_shibley

 

 

(1) Davies, P.G. Measuring performance and missing the point? BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39377.387373.AD (Published 22 November 2007)

(2) Cramb, A. Doctors call for end to target-driven ‘blame culture’ in NHS, 28 December 2017, https://www.telegraph.co.uk/news/2017/12/28/doctors-call-end-target-driven-blame-culture-nhs/.

(3) https://www.dailymail.co.uk/news/article-8265219/Matt-Hancock-makes-100-bet-Nick-Ferrari-UK-meet-100-000-coronavirus-tests-day.html Daily Mail, 28 April 2020.

(4) https://www.theguardian.com/world/2020/may/01/ministers-accused-of-changing-covid-19-test-tally-to-hit-100000-goal, Guardian, 1 May 2020.

(5)  Fioratou E, Flin R, Glavin R. No simple fix for fixation errors: cognitive processes and their clinical applications. Anaesthesia. 2010 Jan;65(1):61-9. doi: 10.1111/j.1365-2044.2009.05994.x.

(6) http://camdennewjournal.com/article/two-minute-silence-at-health-trust-after-psychiatric-hospitals-ward-clerk-dies-from-coronavirus, Camden New Journal, 24 April 2020

(7)  https://publications.parliament.uk/pa/cm201314/cmselect/cmhealth/657/130305.htm

(8) https://www.theguardian.com/healthcare-network/2013/jun/05/culture-of-management-in-nhs

(9) https://thesystemsthinker.com/transforming-a-command-and-control-culture/

(10) https://www.kingsfund.org.uk/blog/2016/01/if-it’s-about-culture-it’s-about-leadership

(11) https://www.tuc.org.uk/blogs/coronavirus-why-structural-racism-putting-bme-lives-risk

(12) https://blogs.bmj.com/bmj/2020/04/20/chaand-nagpaul-the-disproportionate-impact-of-covid-19-on-ethnic-minority-healthcare-workers/

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