Why you have to listen to this year's Reith Lectures

Two programmes on Radio 4 this week explore how it is not cash that our health systems lack but a way of processing all our knowledge

6 December 2014

9:00 AM

6 December 2014

9:00 AM

Each year the Reith Lectures come round as Radio 4’s annual assertion of intellectual authority, fulfilling the BBC’s original aspiration to inform and educate (although not always to also entertain). Each year, though, it’s hard not to feel a certain resistance to Lord Reith’s lofty legacy. Radio might be the perfect format for delivering a talk. Perfect for the lecturer because there is just an audience of one to focus on. Perfect for the listener because there’s nothing else to distract you. No intrusive soundscape. No other voices to confuse. But not all intellectual giants have the ability to communicate, nor an understanding of radio’s particular qualities. Sometimes the lectures sound as if they’re going to be jolly hard work, requiring the time (and energy) to listen, really listen to what’s being said about a subject that you know you should know more about but feel a bit daunted by.

This year, though, we’re being given a cracking series (produced by Jim Frank) by the American surgeon and writer Dr Atul Gawande. It’s not just that his chosen subject, The Future of Medicine, is of direct, not to say intimate, interest to everyone listening. How will we be cared for in later life by an NHS that’s already in crisis? Gawande is also a brilliant communicator. Listening to the second lecture, when he told the story of the three-year-old Austrian girl who was brought back to life after being underwater in an ice-cold pond for half an hour, you could hear the silence in the room, not a rustle of paper or a single coughing fit.

Gawande, who has written a book called The Checklist Manifesto, argues that what we face now in our health systems around the world is not a cashflow crisis, or a lack of knowledge, but a crisis of complexity. We have too much knowledge, and not enough intellectual capability to process it effectively. His solutions sound so easy; not to say too easy — except that he also gave us vivid stories to show just how effective such solutions can be. In the case of the Austrian girl, she was cared for in a small community hospital, not a state-of-the-art specialist facility. What gave her life was the simple fact that not a single person among the hundreds who cared for her made a mistake. Everybody had to do everything right. Any small mistake could have been fatal. A nurse who forgot to wash her hands just the once could have brought bacteria into the child’s open chest wound. ‘Game over,’ said Gawande, not wasting a word.

‘We have been fooled by penicillin,’ he suggested. Six million people across America and Europe pick up an infection while in hospital because someone has failed to follow basic infection-control procedures that have been known for decades. His solution is to set up simple but detailed checklists. A solution that, he says, 20 per cent of surgeons really resent having to use — but 94 per cent admit they would want the team treating them to use if they ever found themselves under the knife.

Trauma Medicine, also on Radio 4 (produced by Rami Tzabar) in another subtly designed example of synchronised scheduling by the controller, echoed Gawande’s thoughts. Dr Kevin Fong works for the air ambulance service and he, too, through experience has learnt that what often saves people are the systems rather than the medicine. In the first stages of an emergency, those first moments after the shock, the trauma, what counts is the speed with which some degree of order is introduced. Fong, too, gave us a vivid example, which like Gawande he told with the skill of a true storyteller.

In February 1976 an American surgeon, Dr Jim Styner, crash-landed a plane containing his entire family in rural Nebraska. His wife was blown out of the aircraft and killed and his four children were critically injured. He himself suffered broken ribs and a fractured spleen but he knew he had to get his children out and drag them to safety, fearing that the plane would catch fire. He then had to drag them back into the plane once he realised no help was on its way, and the only shelter from the bitter cold was inside the damaged aircraft. Next he had to crawl through the woods to the nearest road and flag down a passing car for help. But once in the hospital he was horrified to discover that the doctors and nurses were not able to provide the right care. They had no experience of dealing with multiple and critical injuries.

He initiated Advanced Trauma Life Support, a system of protocols designed to manage an emergency in those crucial first minutes. Fong himself first saw ATLS in action after the nail-bomb explosion in Soho in 1999 where in an instant almost 80 people were injured (and three were killed). He came up with the surprising (to me) assertion that trauma is not a collection of injuries produced in a moment: ‘It’s a disease.’

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Show comments
  • Anthorny

    I once sat next to an NHS accountant on a flight who revealed to me at some length some of the NHS clinical process (or lack of) horrors. It seems that in the UK, we still put our doctors on a pedestal of assumed brilliance and competence relative to our EU partners. In the UK our doctors are assumed to be all-knowing demigods, whilst in Germany they are viewed simply as above average intelligence individuals, simply doing a job. This means in the UK, our doctors cannot be told to follow government defined processes or procedures or their right to “clinical autonomy” is compromised. Thus we get the situation where the wrong leg is cut off or the wrong organ removed or the wrong drug pumped in because of professional resistance to the imposition of simple processes for eliminating these errors. In Germany this doesn’t happen. The clinicians follow government defined processes and procedures as in aviation. I’m not in any way involved in medicine, so can’t verify the NHS accountant’s views. But is sounds plausible as one who has to use the NHS.

    • QED

      Actually the processes and procedures in any technical area, and especially where lives are at stake, should certainly not be defined by governments. No governments have the necessary competence. Good governements merely collate, publish, and authorise specialist procedures which have been devised, tested, and recommended by specialists. And when government departments start to take over these functions you get abominations like Health and Safety regulations refusing to permit emergency workers to pull a drowning child out of a metre of water in a ditch.

  • greggf

    It is totally inappropriate that politicians should run any public business or service. The competitive arguing about this, that and the other concerning NHS performance often on PM’s questions is simply an embarassing crock of s**t!
    The NHS should be broken up into Insurance based units, headed by suitable medical authorities with the accounting based on actuarial principles. There are various models on the Continent which uses similar principles successfully.

    • davidofkent

      Strictly-speaking, politicians do not run the NHS. However, they do interfere rather a lot. Nevertheless, our doctors and nurses are definitely not demigods. They are high average, at best, intellectually but like teachers tend to think of themselves as all-knowing. I agree that our NHS is not fit for purpose and the only way of dealing with it is to introduce a proper, privately-managed insurance based system. How this can be done when there are millions of people in this country who pay nothing towards the public services they consume, is the big question.

      • greggf

        Perhaps it’s time for benefit recipients to start paying National Insurance contributions david.
        Since, by any comparison, noncontributed benefits (plus their passported goodies), which largely support a lifestyle, are overly generous it may be a way to trim such generosity and gain a small return.
        Then there are immigrants whose abuse of the NHS Baroness Betty Boothroyd has been campaigning against for decades; they should produce health Insurance.
        An insurance system may creep in with NI conts as “premiums”.

  • ReferencePointGold

    Dr Gawande is excellent to listen to on R 4.

  • anyfool

    We should just consider Doctors on the same level as we consider car mechanics, there to rectify problems, I don’t want some stranger to empathise with me, I just want him to fix my problem.
    Some of the Quacks who treated my wife, would not pass muster as pump attendants let alone mechanics.
    The nurses and ancillary staff in most hospitals are in desperate need of mechanical aids, as they waddle down the corridors, to block the entrances while having a fag.