‘When your blood pressure’s
normal, does that mean that your body’s OK… You know,
A patient who has just
discovered she has a normal blood pressure.
THE CYBERMAN COMETH
The Local Health Authority are just finishing off some alterations to
the health centre where my colleagues and I rent accommodation. One of the
many small jobs that still need doing is the fixing of a leaflet rack on
to a wall. So I am pleased when I notice one of the men fixing things on
to the wall close to where the rack has to go. He has all the kit
including an electric drill with a portable power pack. I stop what I am
doing, go and fetch the leaflet rack, present it to him in a friendly sort
of way and indicate the position of the two screws.
‘I don’t suppose you could stick this up as well could you just over
‘Not today I can’t. You’ll have to put it through the office. I have to
enter everything I do on this computer thing.’
In our health authority it isn’t just workmen who carry ‘computer
things’. Community nurses and community midwives do as well.
In the past one of the attractions of community work has been the
independence and responsibility it gives people. They don’t have to work
under the immediate control of superiors as they do in the tightly
controlled hierarchy of a hospital. For a particular kind of nurse
community work represents emancipation and they rise to the challenge and
flower into wonderfully rich personalities who are a joy (and occasionally
a pain) to work with.
It would be nice to think that community staff enjoy this freedom
because those in authority realise its value. But it is clear that this is
not the case. The new era of computer technology is demonstrating that
this freedom and richness has not arisen by design, but by default. It is
no wise insight that has recognized its ultimate necessity and value. It
is simply that nobody has managed to find a way of extending the reach of
central control out into the wilderness.
Information technology is the answer to a central controller’s prayer.
In Britain it’s availability has coincided with two other factors; a tidal
wave of management technology arriving, at last, from across the Atlantic,
and unprecedented pressures to limit spending on health care. In this
difficult climate it is entirely understandable that the central managers
who have the job of co-ordinating health care have adopted the new
techniques with enthusiasm. They genuinely believe that the quality of the
service they see themselves providing is directly related to the precision
with which they can direct the movements of their instruments — the
workers. The result is here for us to see; the man with the drill in the
health centre acting more like a robot than anybody would have believed
possible even a decade ago.
At the same time we have highly trained and responsible nurses, who
deal personally on a daily basis with life and death situations, spending
hours of each week tapping codes into computers in order to describe their
work so that it can be counted up and analysed and made more efficient by
an Orwellian ‘Big Sister’ sitting at some unseen desk. I find this idea
utterly repugnant, utterly naive, and utterly lacking in common sense. I
think that both workers and controllers have become unwitting participants
in nothing less than a madness afflicting the corporate mind of society.
I watch with increasing horror as the tide of this ‘progress’ begins to
lap around my feet — as the Minister of Health begins to settle himself at
the controls of his own new machine and gives a tentative tug at one or
two of the strings with which he plans to bind me as well.
If we are to do something to stop this tide, feelings of horror and
repugnance are not enough. If we want to improve the world we have to work
within its rules and according to those rules feelings don’t count. (For
one thing they literally can’t be counted.) So we have to provide a formal
argument which will make it clear, even to the central controllers, that
the world they are trying to create doesn’t add up and that it never will
add up, however long they go on trying to get their rules and their
Before pursuing this task I will finish the story of the robot workman.
He was apparently not programed to clear up the mess he had made. So he
left brick-dust and debris all over the reception desk for our
receptionists (who do not carry computers but whom we encourage to think)
to clear up. The workman, of course, was himself a specialist and way
above doing menial tasks. Such is the price of progress.
As proud new owners of our first car, a venerable Morris Minor 1000, my
wife and I bought an owner’s manual so that we could look after it
properly. The manual was one of a series published by the Sunday Times.
It was in its third edition, so it must have sold well. It was dated 1965.
Here is what it advised us to do by way of routine, daily maintenance:
DAILY: Check oil level, radiator, petrol, tyres and lights.
Now, it wasn’t at all clear what was meant by the word ‘check’.
Checking the oil level, radiator and petrol, we thought, was pretty
straight forward. Messy, admittedly, but you knew what to do. But we never
did find out exactly what to check the lights for. We guessed that you
really had to make sure that they all worked but hoped that it would
sometimes be OK just to check that none were missing.
The thing that kept me lying awake at night puzzling over was the daily
tyre check. We had discovered from elsewhere in the manual that the enemy
was embedded stones. And the problem, of course, was that at any
particular time three quarters of the tread of the tyres was either
resting on the ground or hidden inside the wheel arches.
So I would imagine myself rolling the car forward exactly a quarter of
a wheel circumference, jumping out and rushing around with my penknife
flicking out the pebbles. Then I would jump in again and repeat the
process. Then I would repeat it again. And then I would repeat it again.
Provided, of course, that I had left room to roll the car far enough
To ease this preliminary to each day I tried to imagine more efficient
methods, for example getting the car to roll forwards (slowly, mind you)
by itself, while I trotted alongside doing my checking and flicking, but
they all seemed to have unhappy outcomes. It was a very worrying problem.
You can probably guess the admission I am about to make. It wasn’t just
that we didn’t do this routine maintenance on our precious car every day.
It was much worse than that. We didn’t do it at all. And worse still, we
got away with it!
Somehow (unless we just didn’t notice) whatever it was that checking
tyres for embedded stones was designed to prevent, didn’t happen. I never
did find out what it would have been if it had. But I still feel a little
bit guilty about it. To this day I sometimes reach down and flick a stone
out of the tread of a tyre as a sort of gesture to the car that I do,
really, know how to look after it properly.
We still have that old manual as a souvenir; it is a good example of
what happens when a specialist, in this case a motoring freak, gives
advice to generalists (real people). Nobody in their right mind would
think for a moment that the writer ever seriously intended his readers to
carry out such daily checks. Much more likely he thought that it would be
expected of him to give that sort of advice when writing a manual. That,
after all, is what manuals are for.
To be charitable, he probably thought that he ought to say what he
thought motorists ought to do — in an ideal world.
THE IDEAL WORLD
This is really a sort of game in which common sense has no hand.
Everybody is supposed to agree about what they really ought to be doing
but anybody who actually did it would be regarded as a lunatic. All that
this kind of advice actually achieves is to worry frustrated obsessionals
like myself with the idea that they really ought to go through these
ludicrous rituals. (Frustrated obsessionals are defined as persons who
would like to be obsessional but who can’t keep up the necessary effort.)
So, when we say ‘We really ought to… (do something)’ we mean that in
reality we ought to do it. In other words in the ideal world which is
revealed by figures and facts we ought to do it. The point is that there
is a hidden and unstated understanding that in the practical world we
don’t do anything of the kind.
THE DOUBLE STANDARD OF STONE CHECKS
Medicine, particularly general practice, is full of ‘stone checks’,
many of them, as it happens, emanating from the organisations that provide
us with professional insurance. And we GPs continue to pretend that we try
to do them all because we have not got the courage to admit that the task
is impossible. And we cannot admit that because we lack, both as
individuals and as a society, a clear understanding of the selectivity of
our perceptions. At the same time, however, there is an unspoken agreement
that no doctor in his or her right mind would attempt to do all the
endless things that are being urged upon them from all sides.
Just think, and be honest with yourself. How would you really react if
somebody quietly and calmly showed you that he really could do all the
things that you say to yourself that you really ought to do, and could fit
them into a sane and satisfying life? Would you be pleased? Would you be
inspired? Or would you find something to sneer at and make yourself feel
I remember a contributor to the training course for young GPs that I
help to run. He was showing a video of himself giving trainees mock oral
examinations — ‘vivas’. In the video the first candidate was asked to list
the medical journals he read and was duly castigated for not reading
enough. The second candidate was quite different, he came out fluently
with an extremely impressive list of well chosen journals which could
hardly have been improved upon.
The put-down snapped back at once: ‘Do you do anything else with your
time?’ Only the interviewer’s back could be seen but the sneer was
He was really only playing a game. He didn’t really expect the trainee
to read much at all - he just expected him to feel that he ought to.
THE MAN WHO WAS MAGIC
This reminds me of a short book by Paul Gallico that I once read called
The Man Who Was Magic.
The story was about a medieval town in which everybody was a magician.
Every man, woman and child in the population had some sort of trick or
illusion which they could perform and they had an annual festival when
they showed them all off to one another.
Once upon a time a young stranger came to the festival. And the thing
about the young stranger was that he could do real magic…
When everybody had performed their vanishing lady acts and their
handkerchief acts and their fire breathing acts, he took his turn and
quietly unscrambled an egg. Slowly and undeniably, the scrambled egg
changed into an unscrambled egg and then got back into its shell.
To find out what happened you really ought to read the book, it is
beautifully written. Suffice it to say here that the people did not
appreciate somebody really doing what they spent their entire lives
pretending to do. They didn’t appreciate it at all.
THE UNSPOKEN AGREEMENT TO PRETEND TO DO THE IMPOSSIBLE
There is a sort of tacit agreement in many areas of life, certainly in
medicine, that everybody will pretend to do some things when to actually
do them is completely impossible. In the past this unspoken understanding
has served us well. But while our instinct warns us of the distortion of
the specialist viewpoint our reason cannot tell us precisely why. The man
who actually did all the checks in that old car manual would have been
regarded as an imbecile. But for anybody to admit, even to himself, that
he wasn’t going to attempt to do them would be an act of considerable
We have a double standard here which is going to get worse as society
gets more and more tightly organised unless we find a way of giving the
corporate mind of society the equivalent of common sense. The hidden
understanding (that it would be stupid to stick slavishly to all these
specialist counsels of perfection) is based on common sense and it simply
cannot be justified with the figures and facts that are increasingly being
used to organize and quantify the world. Therefore it cannot be openly
In our brave, new, formally organized world, all the things we say,
tongue in cheek, that we really ought to do, are increasingly being laid
down as things we must do, and people are being paid to make sure that we
actually do them. More and more impractical edicts, each entirely
justifiable from one particular specialist viewpoint, are adding up to a
society which is being smothered by the complexity of its own rules and
The Morris Minor manual with the advice about checking tyres for stones
may have been written years ago but it would be the greatest mistake to
think that we have since become any wiser. Quite the reverse. If we have
finished wiping away the tears of laughter provoked by the silliness of an
earlier generation of motorists, perhaps we can have a look at the 1993
regulations for the drivers of mini-buses at the tertiary college where I
am a governor:
DAILY VEHICLE CHECK AND DRIVER REPORT
These items should be checked prior to EVERY journey:
Lights/reflectors/rear markers. Wipers/washers/horn/mirrors.
Oil/Fuel/water Brakes, body, load security, tyres, wheel nuts,
jack/tools, brake and electrical connections, number plates.
At one stage (the regulations may even still be in force, for all I
know), all health personnel in our area were told to dress in gloves,
apron, mask and goggles to take every blood sample from every patient.
This was to protect from AIDS and there are all sorts of reasons, some of
them obvious, why this is unnecessary (you don’t catch HIV through intact
skin), impracticable (time, expense, availability, etc, etc),
counter-productive (people wearing gloves to take blood samples have been
shown to prick themselves more often) and will worsen the existing problem
of irrational panic in the community at large.
No matter; the primary object has been achieved which is to allow the
rule-makers (who wouldn’t dream of taking a blood sample, still less of
driving a mini-bus) to rest easily in their beds. Nobody follows the rules
that they dream up while they are there, but they can’t be blamed for
The next stage in the madness is that if somebody somewhere actually
does contract HIV from a patient — and it has been recorded occasionally —
they may be denied benefits, support and sympathy because they manifestly
did not follow the rules. Or somebody may have a crash in a mini-bus, and
that occurs occasionally too, and gets clobbered because it turns out that
they didn’t check the jack or the electrical connections on that occasion
(and was honest enough to admit it). Nobody else did either, of course,
but all the others got away with it.
Oscar Wilde put it well in
An Ideal Husband, ‘Everything is
dangerous, my dear fellow. If it wasn’t so, life wouldn’t be worth
So did a young motor-cyclist patient of mine, ‘Life is a very dangerous
business, Doc, nobody gets out of it alive.’
MEDIA SCALE SUPER-DISTORTION
Why do people who were presumably selected for their ability behave so
stupidly — for there are countless other examples. A great deal of the
explanation has to do with the sorts of distortion of perspective that we
have been examining. In the case of the central control of contemporary
society the distortions are enormously compounded by technology. Whereas
individual people naturally base their judgements on perceptions of life
on the personal scale, society as a whole tends to base its judgements on
the unprecedented perceptions of what we might call the media scale. And
while it might be thought that personal scale perceptions are quite
sufficiently distorted by their selectivity, media scale perceptions are
super distorted by what we might call their super selectivity.
In other words, rule-makers are responsible for large numbers of
workers and they ‘collect up’ horror stories. Horrifying events, by
their very nature, are widely reported and discussed and they make a
wholly disproportionate impression. Because of the super-selective
power of the media scale collective mind we think the events far more
common than they really are. In fact the reverse is true and events
are reported specifically because they are unusual. They become
visible precisely because of their incongruity. The carnage on the
roads, for example, makes relatively little impression whilst a single
horrific murder galvanises the attention of the entire nation.
So, judged by the realities of the personal scale, the likelihood
of the events which are so preoccupying the minds of the controllers
actually occurring seems so exceedingly remote that the complex, time
consuming and expensive precautions which they have decreed to prevent
them seem to lack not only proportion but sanity.
And because of the selectivity of our minds, neither boss nor
bossed can understand what is happening.
RULES ARE NOT SOLUTIONS AT ALL, THEY HAVE BECOME THE PROBLEMS.
The thing goes on and on. Once all the really common and important
issues have been legislated for and solved they disappear from
consciousness and we move on to the next level. Gradually, as the
years pass and the world gets more and more buttoned-down the problems
that the rules are being designed to prevent become progressively more
remote and theoretical. Everybody gets the feeling that the world is
grinding to a halt. Everybody, that is, except the tiny, highly
selected groups of people who make each different category of rules…
The committees that are formed to create these ever more complex
rules and regulations are themselves the product of a selective
process of formidable hidden power. Their members are chosen
specifically because they have the necessary specialised view of life.
Even if a measure were to be proposed of such obvious imbecility that
only half a dozen people in the world thought it would be a good idea,
the committee, time and again, will turn out to consist of those six
people. This is partly because nobody else is prepared to waste their
time with it but mainly because belief in it is the primary criterion
for selection. Thus we get European directives on the straightness of
bananas. God help us.
When mistakes are made which gain media scale attention, whoever is
unfortunate enough to be deemed responsible will almost always be
judged according to media scale perceptions.
To take an example, as fire regulations improve further, serious
fires in modern buildings are becoming extremely rare events.
Uncontrolled fires in sky-scrapers hardly ever happen except in horror
films. But when such a fire does happen, and the officer in charge
makes the mistake of thinking it is just the two hundredth false alarm
of the year and sends someone up to the fourteenth floor to check,
and, as happened in 1988 in Los Angeles, to their death, people are
inclined to think the officer was incredibly stupid. Even though those
same people would probably have done exactly the same thing in the
circumstances — and would probably have called anybody who actually
ran a full scale fire alert for all of the two hundred false alarms a
silly old woman.
This is a very serious problem and the answer is not just better
fire alarms. We are going to have to accept that there is a level of
safety beyond which people cannot reasonably be expected to go and
which can easily be exceeded when events are viewed on the media
The same applies to people in any walk of life in which they deal
on the daily, personal scale with matters which may occasionally
result in a tragedy which will later be viewed, and judged, in
retrospect and on the media scale.
Teachers taking parties of schoolchildren on adventure holidays,
social workers responsible for ‘at-risk’ children and others in
similar positions have come under enormous pressure in recent years
with catastrophic consequences for their morale. We desperately need
more understanding of this or people are simply not going to come
forward to do these vital jobs.
Doctors have been in this game longer and have protected themselves
better than most. But even so, times are changing. Some of the risks
that doctors are now expected to take account of are so phenomenally
remote that they can only be regarded as ‘stone-checks’. But that does
not prevent armchair critics from throwing the book at the occasional
doctor whose misfortune (it can be called nothing else) has been
highlighted by the super selectivity of the media scale.
In many fields of life and certainly in medicine we have now
reached the point at which the very implementation of some of the new
rules presents far more difficult problems than the original problems
the rules were intended to solve.
All doctors in the EEC are now supposed to record the date of
purchase, source and batch number of every pill and injection they
administer. It doesn’t matter how many other things they are trying to
do as well, this is the only aspect of life that that particular
committee was told to think about. Nobody will follow the rule, of
course. They would be stupid to try. But in the unlikely event of
their being found out they will be in the wrong. Absolutely,
definitely, undeniably and above all, measurably wrong. And when that
happens the court that judges them won’t be interested in the
‘everything else’ that they were trying to do at the same time,
And what was the problem the EEC rule was trying to solve? You tell
me. I think it was a theoretical problem to do with something called
product liability. I don’t get many patients with that.
So the rules are not solutions at all, they have become the
problems. And although that may seem funny, it’s no joke, we have to
live with it.
Of course some mistakes are culpable and those responsible must
answer for them. Of course standards must be kept up and improved
where possible. But while some control of dangerous activities is
essential in society we have to find a way of deciding at what level
to pitch that control. And to do this we have to accept that there is
no correct answer — no certainty that the chosen level is right.
Perhaps it would be easier for us if it was otherwise, but it isn’t.
The level of control will always be a human judgement. The media scale
gives an artificial perspective on the world which has distorted that
judgement and detached it from the practicalities of real life.
The great danger is that people will react to these unrealistic
requirements for perfection by abandoning their common sense and
working to rule. Working to rule and not to life is in fact the only
way in which individuals can hope to achieve perfection in their
lives. Then if something goes wrong they can’t be blamed. They were
only doing what they were told.
WE ARE TRYING TO TURN THE WORLD INTO A MACHINE
Specialization has been enormously successful as a tool for human
progress at both the individual and the cultural levels. It has seemed
to be a perfect solution to the two great impediments to our making
sense of the world; complexity and uncertainty. But by its very
success in solving these problems it has created an entirely new
Incompatible ingredients have been mixed together and they won’t
make a cake. The ingredients are on the one hand isolated, specialised
fragments of life and on the other a network of defined, precise rules
intended to co-ordinate those fragments. The catalyst which has
accelerated the exposure of this incompatibility is modern technology,
especially information technology.
The world is being dehumanised. We are trying to turn it into a
machine. It won’t work that way and the evidence is all around us.
Civilisation seems to be running into the sand and we are looking to
more and more technology to get us out of it.
But that way leads logically away from life — it leads to a logical
conclusion to everything that makes life meaningful. If we want to
move forward we must go another way. Towards living, human, ordinary
Then we must create a new synthesis which combines the best of both