My New Rubik’s Cube

I was most delighted of all this Christmas to get a Rubik’s Cube from my son, largely because it made me laugh that I’d first owned one when I was roughly his age.  I was never able to work it out and like a lot of ten-year olds, I’d more than once peeled off the coloured stickers and replaced them to ‘solve’ the puzzle.  So I set about the problem over Christmas and New Year (with some help from YouTube) to properly learn how to approach things and of course you then realise that there are numerous ways to solve the problem.

It took me four days and a bit of concentrated effort but on December 28th 2014 I achieved a little life ambition and I solved the whole thing from memory.  My son had scrambled it to the best of his ability and he timed me at just under 5 minutes – we’ve since got that down to under 2 minutes and I’m convinced that getting it down to sixty seconds will mean having to learn more ever more complicated algorithms to sort several problems at once.  But at least I’m having a bit of fun and I do find it relaxing and distracting.  I have to admit, I’ve already ordered a 4×4 Rubik’s Cube off the internet and am as excited as a ten-year old about it arriving any day now!

But you’ll remember the frustrations if you’ve ever had a go — once you’ve established certain pieces into their correct positions, it’s a hell of a job to keep them there as you then attempt to fix other problems in your overall system.  It’s the ultimate reminder that everything is connected to everything else and that there are both intended and unintended consequences to actions, unless you are careful enough to avoid them.  Where you don’t manage to avoid those consequences, you may have to go back to fix problem things you have already taken the time to solve and in turn cause yourself yet more problems for those you’ve more recently fixed!

If I’m going to get this thing to my ultimate goal – completion in under a minute – then I simply MUST eliminate all unnecessary activity, minimising effort and ALL failure demand.  It’s a work in progress for 2015!


I woke up on New Year’s Day to a range of media pieces, mainly in the Guardian, about mental health or NHS emergencies.  The first thing that struck me was a piece which outlined that the number of patients presenting to A&E with mental health ’emergencies’ now numbers over a million a year, for the first time ever.  This is more than a three-fold increase on the numbers from 2003.  I found it interesting that apostrophes were used around the word ’emergencies’, as if to somehow suggest that they were less credible emergencies than other emergencies like heart attacks or strokes.  It’s almost as if no-one has died from an overdose or by jumping from a considerable height – it’s if some incidents of self-harm aren’t potentially life-threatening.  The Guardian later changed the title of this piece to something quite different, which only served to reinforce my suspicion: why not just remove the apostrophes?!

But we weren’t done there!

Another Guardian piece on emergency care covered the issues that patients are reporting across the GP, ambulance and emergency department systems – describing these parts of the NHS as the three legs of the stool.  Somewhere buried into the tenth paragraph was –

“People suffering mental health problems are also adding to the pressures on GPs and A&E units because support is not available in the community, as we report.”

This is distinct burden, according to this article – there are pressures and there are things adding to pressures, like patients mental health problems.  Two paragraphs before this, obesity, smoking and drinking were quickly mentioned as part of normality.  So you can eat, drink and smoke yourself silly but still be more deserving in some people’s eyes that a mental health patient traumatised by a childhood of abuse.  What very odd values some of us seem to have – maybe they think some people should just pull themselves together or take a warm bath?!

But we’re still not done!

The Bolton News reported on the same day, “Patient wastes vital Royal Bolton Hospital resources by visiting A&E FORTY times in a year”  That’s right: WASTES.  The opening words of the article told us that “Scores of problem patients ….”  And so it began.  No mention of the possibility that those who attended may not have received optimum care.  For example, the 60% of self-harm patients who leave A&E without receiving the specialist psychological assessment that national guidelines requires.  So let’s deconstruct this —

“There are some patients who attend A&E who could have been treated by their own GP, local pharmacist, or attended the GP Out of Hours Service.  There are also a number of people who frequently attend at A&E for various reasons, some of those are for example, alcohol related, or mental health or chronic conditions, and we support patients to use alternative services for these longer term health matters. We also work with our partners across the health economy to improve these services to patients to avoid unnecessary attendances at A&E.

Which really means! –

“There are some patients who attend A&E who should have been treated by their own GP, local pharmacist, or attended the GP Out of Hours Service.  There are also a number of people who frequently attend at A&E for various reasons, some of those are for example, alcohol related, or mental health or chronic conditions, and we would prefer patients to use alternative services for these longer term health matters. Other people are not pulling their weight and as a consequence, it’s all coming to A&E.

It was the last sentence that nailed me to the wall, in the end.

Social media debate about all of this was considerable and I’d encourage you to read a BLOG piece by the award-winning Charlotte Walker, known on Twitter as @BipolarBlogger.  Of course one of the ironies of this push by A&E to define their boundaries, is that it’s being done independently by A&E at a point where other parts of the NHS are doing likewise.  No mention in these pieces at all, from what I could tell, of how Crisis Teams and GP services are actively pushing demand in A&E’s direction when we can see here that it’s obviously not welcome.

Patient after patient will testify how often they’ve been told to attend A&E when they’ve rung the Crisis Team for help out of hours – it was a feature of last months #crisisteamfail hashtag, started on Twitter by Charlotte.  I recently heard of AMHPs asking the police to take detained criminal suspects to A&E for mental health assessments – I’m far from convinced that the AMHP world has discussed this with the CCG / Acute trusts concerned!  I can only imagine the President of the College of Emergency Medicine lying down in a dark room at the very idea of criminal suspects being taken to A&E when no police officer or force medical examiner thought they need to be there, but because AMHPs would prefer that environment to custody.


We’re waiting now for the publication of Part II of the Keogh Review into Urgent and Emergency Care.  Mental health was mentioned very little in part one of the review – just once in passing.  It was mentioned in various appendices as a statistical backdrop, but I worry that NHS England’s large systemic review treats mental health in the same way that these news articles conceive mental health – not part of the core paradigm, very much an added, frankly irritating burden to be squeezed in.  The additional demand on A&E and ambulance services has seen renewed vigour in the publicity material for the NHS ‘Choose Well‘ initiatives – encouraging people to think about alternatives to 999 and A&E.  Very little mention of mental health in there either, as has also been highlighted in social media.

Last week the College of Emergency Medicine issued their view on the criminology of drunkenness offences in Accident & Emergency Departments, so I hope they don’t mind if I use my (out of date) first aid certificate and give them some advice on emergency and unscheduled care: if you just keep doing all those things you keep telling us you shouldn’t have to do, it should come as no shock whatsoever that people keeping asking you to do so.  If you really believe that 15% of the patients turning up to your departments are inappropriate, signpost them at the reception or triage stage top the appropriate service and decline further involvement.  It’s what the police do, for example when people ask for a taxi-ride after they spent all their money on booze and can’t get home – it’s what we do when they ask for legal advice as part of their civil disputes around child access.  It’s also what we do when A&E departments ask the police to remove people to police custody under s136 when there are no legal grounds whatsoever to do so.

But my main point here is to return to my analogy of the Rubik’s Cube:  A&E are getting themselves into difficulties because of rising demands and we have to agree that some of this will be increased amounts of ‘failure demand’ deflected from other parts of the health and social care system which are themselves struggling  A patient recently told me that to see her own, named GP involved a waiting time of three weeks.  If you want to complete one side of the cube it’s fairly straight forward to do so – just arrange all the pieces with white on them around the white centre piece.  It’s only very slightly harder to make sure that as you do so, those three white pieces that also contain red are positioned on the same face as the red-centre piece.  This is how you build the first layer of the cube so allow you to complete it.  White pieces also continuing blue go on the same side as the blue centre piece and so on.  The person completing the cube is in control of how carefully they consider each move and how much care they take to manage the unintended consequences of a decision – and they are accountable for the overall completion of the cube so it immediately matters to them.

What these three articles taken together show what we already knew: that our over-functionalised NHS system has decided to put one person in charge of each side of the cube and they’re either not talking to each other sufficiently to control the unintended consequences or they’re not talking to each other at all.  I admit to still finding it hard to take in claims that this is all to do with funding restrictions given how many billions the NHS has under-spent over recent years.  Irrespective of cause: I can tell you for free – you’re not going to solve a Rubik’s Cube very easily, if at all, where you have six people each working on one just one side of the cube whilst not really talking to each other.

Update: ten minutes after I published this blog, my 4×4 cube arrived so it could be a while until my next blog! 🙂

IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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