8th December 2023
Nothing can simply be ‘good enough’. Before beginning this blog, I thought I would introduce you to the first two laws of regulation ‘regulation-omics’:
I know that many of the things that are obliterating productivity in the NHS are happening in all health care services, everywhere. A couple of blogs back I mentioned a US study which looked at all the guidelines primary care practitioners (PCPs) are now required to follow. If they were to do all the work required, it would take them twenty-seven hours a day.
So, clearly, they don’t.
Which raises a few interesting questions that I shall just let hang there at present. For example, what are these PCPs doing? Making stuff up? Hoping no-one notices? As for those creating these endless guidelines. Does it bother them that the vast majority are being quietly ignored?
Or do they simply announce. ‘Hear ye, hear ye, hear ye. The mighty guidelines hast been written; our work is done. Now, make it so.’ Snapping of fingers, courtiers shuffle off, heads bowed, hidden and exasperated eyebrows raised.
Very recently a conference for GPs in England debated a motion. One that was easily passed. It was reported in Pulse magazine – a weekly magazine for GPs – as: ‘NICE ‘out of touch with reality of General Practice, say GP leaders.’ The motion was:
‘That conference applauds the aspiration for clinical excellence across the NHS but believes:
(i) that NICE guidance is often out of touch with the reality of working in general practice
(ii) in the current climate practitioners should be judged against ‘good enough’ rather than unrealistic ‘gold standards’
(iii) that the GMC and NHS Performance teams should not be judging practitioner performance against NICE guidelines
(iv) that GPC England should lobby for professional and clinical standards to be aligned to current workforce and workload capacity.’ 1
As Voltaire once said. ‘The excellent is the enemy of the good.’
Good enough is no longer… good enough. In the NHS it is now demanded of everyone that all workers should constantly strive for excellence. Woe betide anyone who dares let their standards fall below perfect excellent-ness.
This is where all those one hundred and twenty-six organizations [one hundred and twenty-five, plus NICE] who are involved in regulating the NHS – cause so much pain. Whatever they look at, it requires constant improvement. You must now do this better, and this, and this, and most certainly this. No bed sore shall ever be missed. No patient shall ever fall over. Falls audits shall be completed relentlessly.
All patients shall be asked each and every hour if their every need is being met. At all times all staff shall be attentive, and smiling and helpful and, and, and….and? All guidelines will be met, at all times. All sinews shalt be strained in a constant drive for improvement. To quote Joseph Stalin at the First Conference of Stakhanovites in 1935:
‘These are new people, people of a special type … the Stakhanov movement is a movement of working men and women which sets itself the aim of surpassing the present technical standards, surpassing the existing designed capacities, surpassing the existing production plans and estimates. Surpassing them – because these standards have already become antiquated for our day, for our new people.’
There is nothing wrong in asking people to provide a good, and safe, standard of care. But there comes a breaking point in striving for ‘the excellent’. A point that has long since disappeared in the rear-view mirror.
I have not analysed the time it would take GPs in the UK to meet NICE guidelines, but I strongly suspect it would be far more than twenty-seven hours a day. Here, for example, plucked at random, is a reference to the latest NICE guidelines on the management of hypertension (high blood pressure) in adults. This, the short version document, runs to fifty-two pages.2
Have I read the entire document. No. Has anyone. Possibly. But this, the primary guideline on hypertension for adults, is but one of many. There are associated guidelines on hypertension in pregnancy. In addition, there are links to formal risk assessment in cardiovascular disease. With bonus hyperlinks to NICE’s guidelines on hypertension in chronic kidney disease and type I diabetes and type II diabetes and on and on.
In short, this fifty-two-page document is but the tip of a massive iceberg when it comes to high blood pressure, monitoring, measuring, and treating. Which, in turn, is one very small part of the totality of medical practice. No-one can read all this stuff. No-one can keep up. You sure as hell can’t remember it all. It is, truly, impossible.
So, what do GPs actually do when presented with such demands? Well, at present, many of them are considering RLE. Retire, leave, emigrate. “RLE” is now popular trope in GP discussion fora. This is because the sheer stress and overall unpleasantness of the job has become overwhelming.
There was a time when being a GP was an enjoyable job. No more. Those days are gone my friend. Twenty years ago, a partnership in General Practice attracted hundreds of applications. Today, many adverts result in no applications at all.
If you set people an endless barrage of targets and guidelines that can never be reached, it drains people of any, and all, enthusiasm. Every day at work becomes a day of failure. Rolling that great rock up a slope, only to see it roll straight back down again.
Yet, those who drive this catastrophic system just can’t stop themselves from cascading more and more guidelines, and targets, upon a workforce that long since gave up trying to meet them all.
Not only does this crush morale; it also obliterates productivity. So very many pointless tasks. So much time doing work that has only the most tenuous link to patient care, and benefit. I have focussed on GPs in this blog, but everything I have written is much the same, everywhere. Primary care, secondary care.
I think nurses have it worse than doctors. Indeed, from chatting to them, I know they do. Whilst doctors have still managed to cling onto some small scraps of clinical freedom. By which I mean the ability to manage and treat the patient in the way they think best. Nurses have no such freedoms. Their guidelines, and targets, are cast from hard, unbending iron. You do it, or else. And do not dare deviate.
Why can’t these organisations just, stop? Even better go into reverse. Can they not even attempt to define what is ‘good enough.’ No, we the mighty, have told you what constitutes perfect care for raised blood pressure. So, this is what you must do. Even if it takes about ten hours per patient, per year – for one condition.
How long does a GP get with each patient? On average, ten minutes, six times a year. That is, to deal with everything.
There are a number of interconnected reasons why regulations and targets and guidelines cannot, currently, be reversed, and I intend to look at a couple of the most important in the next blog.
Dr. Malcolm Kendrick 
F***
At the age of 74 and counting I am returning to nursing practice in the New Year. I do not see myself ever again running a shift on a ward, but I believe that there is still something I can do to keep people out of hospital and increasing healthspan. Thinking Public Health Collaboration, since you ask.
I have yet to discover how much nursing regulation has changed since I last stood a at a bedside, but you fill me with disquiet. We shall see..
May I be nosy and ask why you are returning? 🙂
Only just spotted this!
I’ve become increasingly interested in the tidal wave of metabolic ill-health that we are witnessing – the rise of non-communicable disease. Having looked into it quite deeply, partly out of self-interest, I feel that there is no point in keeping it to myself.
There is also some selfishness: in an era of increasingly constricted resources, the more I can save on others, the more might be available for me. That is, if enough of us do this.
I think there is a job to be done and I want to add my penny weight to the scales.
It’s the same in every regulated industry. I’ve worked in finance for 40 years and compliance sucks the life out of the enterprise culture. Economists and politicians can’t figure out why productivity stopped rising in the mid-2000s. There are two reasons – social media distractions and compliance/regulation overreach.
Prior to the 2008 crash, the FSA regulations on their website ran to 1.2 MILLION paragraphs, yet the conventional wisdom – determined by those who write regulations- is that wicked bankers were not regulated enough.
IMO, it’s the same in engineering.
Either you cannot do stuff because of the ‘rules’ or else you have to go on a course to be trained to do that stuff.
As a real example, an electrician cannot climb a ladder or steps to change a light bulb unless they’ve done a ‘working at heights’ course. One of the happiest days of my life when I retired. Lunatics, assylum, …
Thank you
Bureaucracy gone mad
Dear MalcolmI have a copy of a new book byProf. David Anderson and Dr. David Grimes entitled Vitamin D3 and the Great Biology Reset.It is dedicated to Giulia Lucenti aged 16 who died on 18th Sept 2021.There is a free download at dgreatbiologyreset.com Best wishesRobert Theobald
Sent from Yahoo Mail on Android
Thanks. I communicate with David Grimes from time to time. A good man, and I am sure it will be a good book.
This Richard Vobes interview with Dr Bob Gill explains a great deal of what has, and is happening within the NHS. The film that Dr Gill made : The Great NHS Heist is on you tube and worth a look.
Is it even possible to stop, or to slow down this runaway train of petty regulations before it destroys the NHS? Interestingly, you note that the problem is international.
One of my sons works from nearby home most days and visits the old folks at lunch time to check we are still alive. Today he told me there is a new directive – the lunch hour will be from 12:30 to 13:30. He said that at 12:30 he might be in the middle of thinking something out and clearly sensible to finish some phase of the work before stopping, or it could be he’s finished a job at 12:00 and might as well have the break then before starting something new. This is the developing bureaucratic totalitarianism.
Bureaucracies are a pseudo-organism. Like all organisms, they want to grow, eat, reproduce, and most of all survive. What drives this? It’s a frequent topic of discussion in many substacks, my favorite of which is eugyppius.com.
He who can, does; he who can not, regulates.
Here’s an answer (check the blurb reviews on Amazon before buying) https://www.hughwillbourn.com/book
All risk must be eliminated. Nobody can be allowed to be injured or die. Every accident or mistake must be intricately analysed and actions taken to ensure it can’t happen again. Two accidents at an intersection? Put in a roundabout or traffic lights. Six children die in a freak jumping castle accident? Ban jumping castles nationally. You wouldn’t think that could be done, but it’s actually much worse than that – getting public liability insurance for anything inflatable in Australia is now almost impossible. That includes party balloons (I checked with our insurer). And anything with tyres. Any fun thing that carries any risk will be stamped out. Which means that nothing can be fun any more. And nobody will learn to manage risk either, as it has been eliminated. After all, the expectation is that everything IS safe, so we don’t need to worry about our own safety, because the govmint (or the insurance industry) has already worried about it for us. No need for US to think. If anything goes wrong, it will be someone else’s fault, and we can sue.
Which leads to the necessity to follow regulations. If, for instance, you managed to follow all those BP dictates, you would be safe regardless of what happened to the patient. No GMC hearing could criticise you if a patient died because of your treatment, because you followed the rules. The rules might need changing, but you are safe this time. Thinking outside the rules is dangerous: for you. If, through a Herculean effort you manage to follow all the conditions that the rare company that will insure risk for bouncing castles requires (yes, it is possible, I have read them, it doesn’t go to 52 pages – yet) there is every chance you’ll miss a fairly obvious risk because you’re focussed on minutiae. We had a bad flood a few years back, exacerbated by poorly timed releases from a major dam. I knew the operator of the dam and thus also knew that there would be no repercussions, because he would have followed the manual to the letter. He would not, could not, consider two sets of very unusual coincidental weather circumstances because they weren’t in the manual. The manual has been rewritten, but I doubt to the extent that the operator is allowed to think.
The phrase ” stay safe” makes me want to run around screaming. If I can be bothered I point out that noone is safe from the moment they are conceived.
I’m with you on this. Also, I want to punch people who say “Take care” when parting. I am resisting the latter by saying “Take a chance”, when we say goodbye.
There we will have to differ then. I might say take care to someone who is significant in my life, and whom I rarely see. I consider it very different from “stay safe” which is just crap speak, usually indicating a NPC (Non Playable Character). Similarly someone very significant might get a hug, but that’s rare. Somepeople hug people at every occasion. I don’t.
It’s a sad, appalling state of affairs. I wonder how many of those 126 organisations are funded, directly or indirectly, by those with a vested interest, financial or political.
It’s very difficult for anyone who has some understanding of their condition/s to not feel cynical about whether the treatment they are offered is being done so for the right reason.
I just look at the ‘NHS Healthy Plate’ and know that the only way I could stomach that dietary advice would be with the help of medication. My diabetic nurse doesn’t appear to understand that sensible and simple lifestyle interventions could negate the need for meds.
Presumably she and many others working within the NHS have to follow the ‘rules’ or lose their livelihoods.
126 organisations – for goodness sake!
As if it’s necessary – here’s a bloviating speech by someone boosting Pfizer’s adherence to DEI (something else that’s wrecking every industry in the world – not that I have any fondness for the pharmaceutical industry, that’s for sure) – but listen to/watch this nonsense – managers (and everyone else working in any group anywhere) beware:
(Just in case the link doesn’t work, I saw this on the Dark Horse podcast #202 today.)
Such evangelistic drivel I rarely have seen.
All the Pfizer employees featured in this video have job titles that give absolutely no idea of what they actually do. I suppose that means that they are all ‘bullsh**t jobs’ to use David Graeber’s classification of jobs
“Yet, those who drive this catastrophic system just can’t stop themselves from cascading more and more guidelines, and targets, upon a workforce that long since gave up trying to meet them all.
“Not only does this crush morale; it also obliterates productivity”.
The people who impose those regulations aren’t, in the main, interested in the welfare of patients, doctors, and nurses; or in patient outcomes.
Each of them has his or her own personal goals, and aims steadfastly at them. Promotion, more pay, reputation enhancement, publicity… The welfare of patients and staff, or even better outcomes, are unlikely to affect those personal goals.
Eons ago, I did an Open University course in technology. One interesting idea was that, in any hierarchical organisation, the formal goals at each level are notified to the next level down, where they are given lip service but ignored in favour of that level’s “operational goals”. In other words, what the managers at that level really want. Those operational goals become the formal goals of the next level down…
Among other results, this mechanism easily turns top management’s plans round by 180 degrees within one or two levels. A kind of oraganisational Chinese Whispers.
Thank you
Hi Dr Kendrick, Last week I had an appointment with a consultant, after being referred due to very high LDL level. I came away from that encounter totally bewildered. It was like talking to a robot. She was adamant that getting my LDL level down as low as possible was the target. Statins as usual ! I asked if LDL seven any purpose in the body. Her answer was a firm & adamant NONE AT ALL !! Lots of studies to support this. Well after that, to me she lost all credibility. I am 72 years & follow a very low carb diet, bordering around Keto levels. I was on Atorvastatin but have decided they are going in the bin & I will take my chances ! She did, of course recommend coming off the diet & replacing with a low fat diet & keep taking the pills ! I may as well not bothered turning up. Have read all your books & are a valuable source of reference, as well as helping keeping my sanity ! Keep up the good work & uphill battle. Kind regards. >
Ditch the lot. I have just sat next to a super fit 53 year old, for three or four hours (of my latest 9 hour NHS appointment) perplexed at his stroke (20 days after injection), telling me of the multiple side effects of the many medications he takes for no end of new problems. Ditch the lot. Watch what you eat.
Stephen, well done for resisting
Play with the cardio risk calculators online to get an idea of what the “science” says regarding cholesterol and cardio risk. Plug in your current LDL and other vitals and see the risk that comes up. If this is a larger number, before you freak out, play with that LDL number by reducing it to the “ideal” level currently being pushed by TPTB. You will see that your risk doesn’t change much. Play with some of the other input numbers and you’ll see that most of the cardio risk is related to age, which you can’t do a thing about. I plug these various numbers in and use it against any doctor who tries to push statins onto me. I don’t agree with using a cardio risk calculator at all but while it’s online and used by some doctors, I’ll use it against them.
Stephen, I feel your frustration. What it boils down to is that we, in my case non-medic with a condition or two, have to take care of our own health. That means researching, and yes, I have followed Malcolm Kendrick and others for a number of years. Plus read personal testimonies and seen anecdotal evidence on various forums. Take it all in and make our own minds up – that’s what we have to do.
Very early on I read about relative and absolute risk regarding statins. What was claimed by the drug companies V actual benefits. For me, that was a turning point. That con made me look at everything more analytically and with scepticism.
Right through the pandemic, where we made an absolute shambles of it, the narrative was led by money and perpetuated by lies and misdirection spewed by politicians, ‘experts’ and most HCPs. There were voices of reason, but not many, and they were throttled and threatened if they didn’t stick to the establishment mantra. And all the while people were dying of the cure!
If we can’t trust our healthcare professionals, who the hell can we trust?
You, Stephen, have been forced to make you own decision feeling unable to trust your consultant. You’re right of course, but it should not be the case.
Are the members of Parliament subject to these regulations ? “How long does a GP get with each patient? On average, ten minutes, six times a year. That is, to deal with everything.” Or are the MP’s outside of “The Law”?
Harvey.
How many MPs do you think actually use the NHS ?
Consider that some NHS trusts provide private medical cover as a benefit for their staff !
It’s time for anyone Parkinson’s Law for medicine. Apparatchiks got round impossible Soviet targets by lying or cheating. I worked with someone who lived in the USSR and most creativity was spent in this.
Sent from my iPhone
I asked a Hungarian man “how they as communists could support something that they knew didnt work?”
He replied ” The human mind is amazing. It can have two different opinions at the same time. Public and private. We learnt to say one thing and believe another”
Very true, Andy. I have been noticing it more and more. George Orwell was right in defining doublethink in “1984”; he was quite wrong in suggesting that it was unique to brutal dictatorships.
Unfortunately living in social housing, I can confirm that the communist social credit system is swinging into action. This 1960s bungalow has subsidence and a multitude of problems, but hey, at least we are sticking it to the (pick your own geopolitical monster) man by installing smart storage heaters and making gas central heating only available to the wealthy.
I already had a chilly 3-hour power cut today. Was it something I said on youtube? 😅
One of the reasons I retired early as a nurse in general practice = we were ticking the box not caring for the patient! I always cared for the patient and I hope asked how he was. Caring for the whole person not just the diagnosis!. It breaks my heart and doesn not bode well for us in old age.
This syndrome is not limited to the public sector. I still remember a brief article I read in the “Daily Telegraph” back in the 1980s. It concerned a telephone inquiry service operator who had been fired by BT. The pretext for her firing was that she worked too slowly. The powers that be had decreed a work rate of one customer inquiry “closed” per minute, or something equally ludicrous. The lady who lost her job was guilty of pursuing each inquiry until the customer was completely satisfied! That caused her to exceed the quota for average time spent per call.
The underlying problem is that pointy-haired bosses are fairly stupid, and prefer to “manage by numbers”. Ideally single digits. This Stakhanovite approach leaves no room for quality.
Too many government-funded and directly government bodies employing far too many people in jobs that have no rationale let alone justification. So they regulate.
Hmmm… I think this is what happens when an entrenched, 500-year old bureacracy, the British state and in the final stages of senility, is forced to deal with computers, or rather, it’s very ill-equipped bureacracy gets digitised and outsourced to a bunch of crooks. Bureacracies are all about compartmentalisation–it’s how the state handles complexity through regulating choice by breaking things down into their constituents. An example would be the queue: When visiting say, Motor vehicles or the Town Hall, people form queues for different things and we’ve all experienced what happens when we join the wrong queue. The computer presents the bureacrat with the ideal tool of control, by regulating choice with the ‘Network’ as mediator’, the bureacrat controls the outcomes by controlling the nature and flow of information. One of the figures the good doctor cited in Episode 1 of this series, stood out and that was the vast number of managers the NHS bureacracy has acquired. Yes , it’s about budgets but it’s really about control and given that the government is hell-bent on privatising the NHS, at least the profitable bits, then the role of managers reflects the ideology, well, of neo-liberalism. How effective it is can be seen by looking at the British economy, it’s tickbox capitalism. The NHS was a compromise solution from its inception in 1948, the NHS was a concession by the ruling class to a radicalised working class following WWII (my dad’s generation); to stave off revolution? Whatever, this is a battle about ideology, the ideology that the Sunaks and Starmers of this world. What’s at stake here is whether the Private or the Public will prevail? Either, we bring the NHS, a public institution, under public, democratic control or, it will be carved up, like so much meat and sold off.
Grrrr. I’ve just come back from the hospital appointment. I went in at 9.15am and left at 18.10pm.
A time of 8 hours and 55 minutes.
This breaks down to:-
1 hours waiting,
2 hours taking blood pressure, a blood sample, and waiting for results.
3 hours waiting for Xray and result
20 minutes with Doctor consultation
2 hours 35 minutes waiting for nurse to perform (3 minute) nasal swab.
There was, of course, no food possible in that time (or miss your call).
I wondered, looking at the endless seats of hopeful souls, how many actually pass away there in such conditions.
Parking fee £12
It’s bad here too. Hospitals were incredibly quiet in 2020 (I had plenty of visits that year).
Something is causing an NHS disaster in 2021/22/23 and nobody can put two and two together! What began in January 2021 that could have caused such a medical crisis? 🤷
Unless you are truly superhuman, I bet the experience caused your blood pressure to rise.
I don’t have my blood pressure checked. Instead, I eat and drink carefully, exercise and sleep as much as I can, and take a little potassium citrate with my evening ascorbic acid. (Thanks for that tip, Dr K!) After all, if they did decide that my pressure is too high, what would they do about it? My treatment regime starts with reducing stress – among other ways, by having nothing to do with the NHS unless I have an actual fracture or heart attack. (And if the latter, I hope for a massive one that finished me off before they get their hands on me).
As the old American Civil War song has it,
“I’ll eat when I’m hungry
And drink when I’m dry
And if the Johnnies don’t kill me
I’ll live till I die”.
Maybe current health services and heart attacks are not a good combination?
https://rumble.com/v1lwnfw-heart-attacks-webinar-from-september-28-2022.html
I have just been sent a letter from the NHS telling me I have been removed from the cervical screening program. Considering that I had a total abdominal hysterectomy 27 years ago for endometrial cancer…what???. What a waste of postage, someone’s time. Absolutely ridiculous.
Thanks for highlighting a general malaise in all large organisations.
Three responses,
1) government the world over has become too big, too dominant, all consuming. Government is the largest industry by far because only it has access to unlimited resource (money printing). Consequence is that this attitude pervades all of society. It has become a method to screw the system for money.
2) management (at all levels) is becoming more incompetent because those that can think for themselves leave for smaller or owner business where competence is recognised in the profit line. Consequence is incompetent management, which begets incompetent management ad infinitum, must be protected by rules, procedures, and process guides. = Risk management
3) Mediocracy rules
The NICE guideline Hypertension in adults: diagnosis and management reference other guidelines. Tedious indeed.
No mention of insulin or uric acid.
The things they should be regulating, they don’t – the MHRA has announced that it is now an ‘enabler’.
North’s law of bureaucracy: “Some bureaucrat will inevitably enforce an official rule to the point of utter imbecility.” – Gary North.
I am a retired manufacturing engineer. In my industry (vehicle manufacture in the later part of the ’80’s) we discovered that setting impossible targets destroyed moral and resulted in people giving as little as they could get away with.
My point — why has not the NHS absorbed that lesson?
John Burgoine BSc Tech
Dear Malcolm,
If I were a doctor I’d be outraged if I bothered to read this NHS stuff. I did read a few paragraphs: If I were ten years old I might think it a bit childish; if I were a doctor I’d be bewildered at its insulting my training.
All best,
Robin . . . . . . . . . .
Robin Hull 15 Horsell Road London N5 1XL 020 7609 2764
indeed
I think this nonsense has spread everywhere. Back in 2008 we went to visit my partner’s mother , who was in hospital. Above her bed was a little slot for a ‘named nurse’. It was just left empty. This was a bright idea of Blair’s government – that everyone should have a ‘named nurse’ – but what happened when the NN went on holiday or was on her day off wasn’t ever clear.
I didn’t ask, but I’d guess the rule was still in force, but simply ignored.
Likewise, after the truly dreadful case where a school caretaker lured two girls to his house and killed them, the government just had to ‘do something’. They instigated a scheme in which people – men and women – wishing to work with children had to be regularly vetted. As far as I could see, this could only reasonably use the person’s criminal record – which would not have worked in the case that precipitated this rule. The man in question had been a suspect for a while in relation to one or two lesser offences, but no court case was ever brought against him.
I listened to a number of politicians discuss this new law, and they never explained how it would have helped to prevent the original crime.
Some years earlier, I worked in an office block and was told that everyone had to sign in and out as a precaution in case of fire. Some of us ignored this rule, and after about 3 weeks the book simply disappeared.
I can see where we need to bribe the CDC to come over there and get you guys on the right side of the ledger.
Very short answer:
The NHS is wonderful at patching people up. In an emergency, you can’t beat our medics on diagnosing, finding and fixing the problem.
The big new-ish problem is “preventative” medicine. That’s where the tinkering, meddling and paperwork (and big money) lies.
The control freakery is so pervasive it is abusive and so strong as to be deliberate. It is intended to eliminate autonomy and independent, moral action, instead instilling blind obedience and robotic conformity.
Entirely consistent with what has been required to support the ‘pandemic’ terror.
Entirely consistent also with a future world controlled though digital IDs, CBDCs, and the constant fear of … well, whatever.
Resistance is sanity.
Tell them not to emigrate to Australia.
It’s just as bad if not worse.
From someone who spent the last 17 years in GP in Oz.
Struck off for attempting to inform your patients about the possible risks of the covid vaccines
Ethics have just gone out the window
Gary Fettke was hauled through the courts trying to demolish his career, the crime? Suggesting diet changes so he was less likely to have to amputate bits of patients.
Just noticed wordpress has even messed with the auto-icons. Yet another “improvement”.
I call it Cairn Management Theory….new manager, new stone on the cairn….no rationalisation of current structure. Result? Cairn eventually collapses.