'Publish and be damned' (1)

Lord Leveson has just released his long awaited report into the recent (and not so recent) excesses of the Press in Britain (2):

At the heart of this investigation is the conundrum of, on the one hand, preserving the freedom of the Press, which relies at least in part on self-regulation and which historically, as His Lordship points out, has resulted in much good being done, and on the other hand, curbing the excesses of the Press that very freedom can allow to germinate and fester.

 

In a statement that could as easily be about healthcare as about the Press, Lord Leveson observes that:

 

‘There is no organised profession, trade or industry in which the serious failings of the few are overlooked because of the good done by the many’.

 

In other words even if self-regulation enables a lot of good to be done, we may have to compromise self regulation if it also allows some bad to be done.

 

It appears that the activities of the Press that led to the setting up of the Leveson inquiry suggested to his Lordship that the self-regulating body for the Press had lost its way:

 

‘The fundamental problem is that the PCC, despite having held itself out as a regulator, and thereby raising expectations, is not actually a regulator at all. In reality it is a complaints handling body’.

 

This did not, however, diminish Lord Leveson’s appetite for self-regulation of the Press:

 

‘I should make it clear at the outset that I consider that what is needed is a genuinely independent and effective system of self-regulation. At the very start of the Inquiry, and throughout, I have encouraged the industry to work together to find a mechanism for independent self-regulation that would work for them and would work for the public……’.

 

Lord Justice Leveson

I recently wrote a case study on self-regulation in the medical profession for the ISQua Fellowship Programme. In this I attempt, by way of citing a particularly tragic episode in the annals of healthcare and by storytelling, to present both sides of the self-regulation in healthcare debate.

Writing in the JRSM, Ash Samanta, and Jo Samanta (3) refer to ‘…a series of high-profile inquiries that cast a noxious miasma over the medical profession and provoked demands for strict regulation.’ However, they conclude that ‘Somehow, a balance must be struck whereby the public can be confident that doctors practise competently, with due regard to ethical and technical standards, yet the regulations are not so overwhelming as to represent a sword of Damocles permanently hanging over doctors' heads’.

 

The Samantas say complete self-regulation in the medical profession has long been a fantasy – and so it has – but as they also say, correctly, the standards by which the profession is controlled (by a combination of itself and others), ‘…have been set largely by the profession itself’.

 

So Lord Leveson and the Samantas both argue for the retention and strengthening of professional self-regulation albeit with safeguards.

 

I believe Lord Leveson’s observation that the body responsible for regulation of the Press had in fact become a complaints tribunal, and the fact that in many parts of the world the (often statutory) bodies established to regulate the healthcare profession go the same way, highlights the importance of keeping these two functions separate. I further believe that, in healthcare at least, the profession itself is best placed to establish appropriate standards and to monitor adherence to those standards. However, the profession should not at the same time have the responsibility of investigating alleged breaches of those standards and of deciding what (4) action to take should it be determined that those standards have been breached. Nor should the profession be de jure or become de facto a complaints tribunal. The roles of professional standard setting and monitoring on the one hand and of policing and adjudicating on the other are incompatible. Certainly the profession’s role as I have outlined it is compromised to the point of paralysis if it ventures into the other arena.

 

As I write this I see that it appears Lord Leveson’s attempts to have self-regulation retained and indeed strengthened but at the same time introduce statutory or quasi statutory regulatory oversight may fall on deaf ears. The lesson for the healthcare profession, which as the Samantas so colourfully remind us has had a ‘…. series of high-profile inquiries that cast a noxious miasma over the medical profession’, is perhaps for various national or provincial jurisdictions to act now to preserve what is best in professional self-regulation and leave policing, investigations, adjudication, complaints and any (4) subsequent action to others'.


(1)This is attributed to the Duke of Wellington, Arthur Wellesley when he was threatened with the publication of some rather sensitive material (letter written to, and the memoirs of one of his courtesans).

(2) An Inquiry into the Culture, Practices and Ethics of the Press: The Right Honourable Lord Justice Leveson. November 2012.

(3) Ash Samanta, LLB FRCP and Jo Samanta, BARGN.

J R Soc Med. 2004 May; 97(5): 211–218.

(4) Initially I automatically inserted the word ‘discipline’ and ‘disciplinary’ in these places. That would have ignored the fact that while some breaches will call for disciplinary action some, perhaps even many, may be better managed through rehabilitation and/or retraining. If the latter is indicated, then the profession is the place to manage this. There will also be some cases, perhaps few, where both disciplinary action and rehabilitation/retraining are called for. In such cases consultation and collaboration are required.

'Train of Thought'

The DART (suburban train) pulled out of Pearse Street Station (Staisiun na bPiarsach – named in honour of brothers Patrick and Willie Pearse, executed by the British for their part in the 1916 Uprising ) on a clear Dublin autumn holiday Monday bound for Malahide. We were for Malahide Castle. This is a lovely part of Ireland, just out of Dublin. In the past it was called the breadbasket of Ireland.

The Talbots built Malahide Castle, first as a single fortified tower in the 12th century, then added a series of towers and joining rooms. The family would live there for 800 years.

Malahide Castle

You are probably aware that the several Ireland chieftains were at war with each other on and off over the centuries, disputing all sorts of things but mainly it was about land and affronts taken. In the 12th century one particular chieftain, who was being worn down by another, rather foolishly as the subsequent troubles in Ireland bear testimony, called on Henry II of England for help. Henry sent an army to his aid and the chieftain, with this help was victorious. Henry promptly rewarded his officers with the best of Irish land – and lots of it.

Lord Richard Talbot was such a knight and in 1170 he was rewarded with the beautiful countryside of Malahide (Mullach Ide meaning sandhills of the Hydes).

So Richard, to protect himself from night time attacks from local disgruntled chieftains, built the first of four fortified towers.

With the exception of about a decade in the mid 17th century when Cromwell confiscated Malahide Castle and installed one of his civil servants therein – a tax collector – the Talbots were at Malahide for 800 years. Finally, in 1973 Lord Milo Talbot died and his sister and heir Rose, burdened with death duties, sold it all up– to the Dublin Council thankfully –and took off to Tasmania where the Talbots had long owned prime grazing land. Rose died there in 2009; the last of the line.

The history of the Talbots is in many ways the history of Ireland.

But, I digress. Back to the DART, the Train of Thought.

I have been impressed as Acting CEO of ISQua by the wide global reach ISQua has. This is exemplified nowhere better than on the ISQua Board where all continents on the planet with the exception of Africa (and the Polar Regions) are represented. And this brings to one table an amazing diversity and range of safety and quality in healthcare issues for the Board to ponder.

The ISQua Conference. They came from near and far. 

How does one, quite small, resource rich but cash poor, yet influential organization decide where to start?

The answer for the ISQua Board was first to understand the issues; then to understand ISQua’s current relationship with each of the world regions; then how it was dealing with the various issues in the various regions; next to undertake a gap analysis; and finally to decide on priorities. This all has to be aligned with resources available to address the issues identified. It certainly helps that we hold our Annual International Conference in a different part of the world each year and involve local organizations in the planning of the Conference. And it helps that we are increasingly convening regional meetings worldwide. In fact, our next regional meeting is to be held in the only continent not represented on our Board. That meeting is to be held in Ghana in February next year. Already in the planning of the Ghana meeting we are learning more about the healthcare challenges facing Ghana and surrounding countries.

I will keep you informed of progress as the ISQua Board tackles these issues.

Now where was I? Ah yes the Talbots. The Talbot legacy lives on in various namings around this part of Ireland. Coincidently, one of my fellow swimmers at the Dublin Council Pool, The Markievicz Centre (and there is another wonderful story, Countess Markievicz, heroine of the rebellion - one of the rebellions at least and one of the heroines – ahh but that is for another BLOG), about which I told you in an earlier BLOG, invited me down to the Celt for a pint last Sunday; when asked where the Celt was located he said ‘Talbot Street of course.’ And so it is!

'Fi Li or Why Irish Writers Win so Many Nobel Prizes for Literature (and should have won more)'

I hope my Irish friends will forgive me for writing about something quintessentially Irish; but it is something that has fascinated me since coming to Ireland – the fi li.

 

In ancient times the fi li were the exalted fraternity of professional poets and narrators in Ireland.

 

The fi li’s main activity was the composition of verse celebrating his patrons and detailing the genealogy and lore of families and tribes.
 

However the tradition allowed plenty of room for improvisation and personal expression, especially in regard to creative hyperbole and clever kenning. (Eleanor Hull: Textbook of Irish Literature). And the fi li were also expected to be skilled in the oral transmission and performance of traditional prose tales - “the poetic profession”.

 

Early Irish literature

 

The ancient Irish word scél is ambiguous in that it can mean ‘news’ on the one hand and ‘tale’ on the other. The skill of the fi li in taking advantage of this ambiguity has been referenced in the literature. A favourite story of mine which illustrates this is to be found in an article by Joseph Falaky Nagy (Oral Tradition 1/2 (1986): 272-301; Orality in Medieval Irish Narrative: An Overview).

 

In this example, a notable storyteller’s household is raided by the kinsmen of the king Domnall mac Muircertaigh, the angered poet goes to the royal residence, where he is greeted by Domnall and asked to tell his news (“iarmifocht in righ scéla dosum iar tairisiem,” Byrne 1908:42). The storyteller, careful not to accuse directly the relatives of his powerful host, takes advantage of the semantic ambiguity of scél and interprets the king’s polite question as a request for information concerning the storyteller’s repertoire of tales and traditional lore. What the storyteller eloquently then presents to Domnall is a remarkable catalogue of traditional tales. At the very end of his list of titles the fi li refers obliquely to the story of his own misfortune, and the king, unfamiliar with the title, asks the storyteller to tell the unknown story. He does so enthusiastically, and after the telling of the thinly veiled composition, the informed monarch sees to it that justice is done.

 

This is not quite satire but it does resemble the writer’s and orator’s technique of shining a light on the ills and excesses of society, in particular those attributable to the governing classes and social convention, by way of storytelling. Of course this has been and is still done no better than by the wonderful writers and orators Ireland has produced over the years. For a small country, under five million today, down from over eight million before the potato famine and successive waves of migration depleted numbers, Ireland has produced four Nobel Laureates in literature – and arguably at least another two should have been so honoured.
 

There are various theories about why the Irish ‘punch well above their weight’ when it comes to literature – is it the ‘craic’, is it the family, is it the pubs? For me the answer is that it is the legacy of the fi li.
 

In looking for a connection between the fi li’s role and healthcare I was reminded of ‘whistleblowers’.

 

In another place I am the ‘Protected Disclosures Officer’. This means that anyone in the organization in which I hold this post can report to me any practices or incidents they believe are illegal or inappropriate in the knowledge there can be no legal or management reprisals or repercussions (such as an action in defamation or inhibition to career advancement). So they can ‘shine a light’ where they may otherwise have been deterred from doing so. There have been a number of instances in healthcare where this has resulted in unsafe or inferior quality activities being exposed. Caution is needed however lest this protection be used in a cavalier or vexatious manner.

 

There is also now qualified privilege that is enjoyed by healthcare workers in some countries. The idea being that healthcare workers can frankly discuss outcomes in a peer review setting in the quest to improve practice without fear of legal action based on what is disclosed in such meetings (unless what has been done is illegal).

 

I would like to give credit to the fi li for the emergence of these initiatives too but that would be drawing too long a bow.

'Use it or lose it'

I am enjoying my time in Ireland; wonderful people – wonderful country (wonderful weather?!).

Meanwhile my 77 year old swimming partner back in Australia is painting his house (first of all when he said he was painting ‘the house’ I thought he meant my house as he is house sitting for me at the moment – but alas, no!).

My local pool, Byron Bay.

He observed to me that he does not think he could have taken on this task before we started swimming a couple kilometers each morning about eight years ago now. For him it is about achieving something against the odds and enjoying every minute of it; for me it is about mobility – being a chronic back pain sufferer – and simply how ‘good’ it makes me feel.

Now we do our morning ritual on opposite sides of the world.

All manner of people turn up at the Dublin City Council Pool at 7 each morning. Apart from the Dublin Fire Brigade crew (‘Fireies’ we call them in Oz) most are not at all good swimmers and choose the ‘slow’ lane. But they try and they stick at it and leave in much better humour than when they arrived.

Now the last thing I want to do is preach. I have checked the ‘10 signs that you might be an annoying fitness freak’ and so far I am OK. I am not inflexible (I can miss a day or two and I work my exercise around other things rather than the reverse), not one-dimensional or intimidating. But I must confess to being just a little self righteous and judgmental from time to time (read on and you will notice this!).

However, on one point I am a zealot; that is the quest to eradicate those who prey on people who have already been indoctrinated by the (perfect) image makers. ‘If you do not measure up to this image we have created (which in real life does not exist) no one will admire you, in fact you might be ignored, or worse, you might be despised’. These are the peddlers of products and services that promise miraculous changes in beauty and even personality, with no particular effort or change in lifestyle, but simply by using a particular product or service.

From time to time regulators ban those that make false claims or sell stuff that is obviously ineffective, but marketing and the vulnerability of consumers being what it is the regulators can’t keep pace.

Make lifestyle choices and, if necessary, changes that are not onerous, that are sustainable, that are informed, which can endure and, most of all, which are fun. No shortcuts.

Use it or lose it.

Now, Snowy, there is a colour, a blue, called ‘inspiration’, I would like for the outside, and inside perhaps ‘renoir’, which is an off white pinky colour….

'From Little Things Big Things Grow'

('From Little Things Big Things Grow' title of this post inspired by the Paul Kelly and Kev Carmody song)

Given I have worked in education and change management for over 40 years, mostly in healthcare, it will not surprise you  that I believe that at the heart of all sustainable change is education.

My other passion is animal welfare. When contemplating recently how to advance the lot of non human animals – was it to be wildlife rescue, or neglected domestic animal rehabilitation – it soon became clear to me that, as necessary as these interventions are, the way to ensure that future generations develop attitudes and values that respect all inhabitants of this planet is through education. These newly acquired attitudes and values will then be passed down the generations, enhanced on their journey.

My dog, 'Mr Johnny Angel', off on a journey of his own. 

And so it is with healthcare.

Alfred Marshall was a turn of the century social scientist who is probably better known for his economic theories. Among other things Marshall wrote about ‘price elasticity of demand’ which describes how price increases lead to a fall in demand.

The extent to which demand is driven down varies depending on a number of factors but chief among these is the essential nature of the good or service in question. In healthcare demand is highly inelastic with a 1% increase in price leading to just a 0.2% drop in demand. One can reasonably speculate that this drop would be in elective healthcare. You are not going to cancel your life saving surgery just because it suddenly got more expensive (but you may decide not to have those wrinkles removed).

You and I have an almost insatiable demand for health care services. The cost of healthcare is high yet we continue to use it. In fact the demand for healthcare services vastly outstrips the supply – or at least the timely supply. So, whatever it costs, one way or another we will likely continue to use it. In fact, as medical science daily finds new ways to cure or alleviate illness the take up of health services increases.

World healthcare costs increase and our demand increases right along with it.

Here is where education comes in. If we as a literate population took the time to understand more about what happens to us as we age or sustain minor injuries we can make more informed decisions about the nature and level of care we need to alleviate health problems and global health cost would come down. But we need to be careful. I am not talking here about self diagnosis websites – although there are some that are useful – but rather a professional structured approach to educating populations about the who, where and when of healthcare interventions.

In time, animals will occupy a better place amongst us through our enhanced understanding of who they are. It is not too much to expect that education can also move global health standards forward.