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Mamma Mia

Friday 17 January 2020

Here I go again. Last weekend I was mainly in Stockholm and Copenhagen. ‘Scandi’ is more ‘noir’ than not at this time of year, and we had about seven hours of daylight as the watery sun scuttled along the southern horizon. As ever after a short break away there’s a lot of catching up to be done. I was back in the practice at the sparrow’s crack on Tuesday; Wednesday and Thursday were rammed with seven meetings of one sort or another, so I’ve had to wait until this morning to get some emergency dental treatment for a tooth, initially broken chomping on a piece of elk horn (probably), and aggravated by significant clenching of everything as we landed sideways into Storm Brendan at Gatwick on Monday.

The great and the good (and me) wedged ourselves into one of the smaller meeting rooms at the County Council offices on Wednesday morning for the Somerset Leadership Board meeting. There’s an increasingly cohesive feel to the way that the health and care sectors are working together at the moment, commended at the meeting by the NHSE representative. One agenda item was preparation for the Somerset Board to Board meeting in Yeovil on January 22nd. As the name suggests, this will bring together all the executives from the three Trust boards, as well as the Clinical Directors and other senior figures. Normally the Council would also be represented but their meetings had to be re-arranged due to (bloody) purdah and so they won’t be there but are planning to send a supportive message via a video link.

In addition to updates on what’s happening around the county, the main business will be to discuss the development of the Integrated Care System (ICS), mandated for all STPs from April 2021, but which Somerset is hoping to have in place earlier on the back of the collaborative work already taking part across a (relatively) simple system. The leadership structure is being re-designed, and we are now getting a much clearer picture as to how the Primary Care provider voice will be represented in the system.

Yesterday we held the third of five meetings with the CCG to negotiate this year’s contract settlement, including the latest Primary care Improvement Scheme (PCIS) specifications; what might be included, and what we feel definitely shouldn’t. The atmosphere has been positive and collaborative, and we are negotiating what might be realistic against an increase of £1.97 per weighted patient for this fifth and final year of the scheme. More anon.

It was a bitter-sweet LMC County meeting for me yesterday afternoon. An early item on the agenda was a call for nominations for the election of the new LMC Chair, to be held at the next meeting in mid-March, signalling that I’m approaching the end of my four-year term. The committee are a great bunch, and meetings usually a cinch and joy to chair. Although dealing with meaty and serious issues, against a backdrop of Primary Care under severe strain, the sense of humour (often black, admittedly) is never far from the surface. As you might imagine, there was considerable discussion yesterday about the draft Primary Care Network Direct Enhanced Service (PCN DES) specifications, and the possible consequences for the NHS as a whole.

Regular readers will know that I have a penchant for things that float, and an even bigger one for things that sink. In past blogs I’ve recounted visits to the Titanic centre in Belfast, and the Mary Rose exhibition at the historic dockyard in Portsmouth. Imagine my delight last Friday, then, to come across the Vasamuseet in Stockholm, housing the salvaged 17th century Swedish warship, the Vasa. Apropos of nothing in particular, but recounted here at the end of the consultation period for the draft PCN DES specifications, is a tale of failed design, workforce issues, missed warnings and ultimate disaster.

In 1625, Sweden was developing into one of the most feared naval powers in Europe, and King Gustav II Adolf produced an enhanced service specification for four new ships, including the Vasa, which was to be the most powerful warship in the Baltic, possibly the world. The commission was taken up by a couple of Dutch boatbuilders, and construction started beside the harbour in Stockholm. The local workforce was insufficient to meet the specifications, so half of the 300 workers were immigrants from the Baltic states, the Netherlands and Germany. Rates of pay were significantly different, the groups spoke different languages, used different boatbuilding methods, and maybe most confusingly, different systems of measurement. Perhaps it shouldn’t come as a surprise that the finished hull wasn’t quite symmetrical.

It was two years in construction, and on a sunny Sunday in August 1628, the Vasa cast off for her maiden voyage in front of Stockholm’s elite and assembled foreign dignitaries. The sea was calm, but after travelling only 1300 metres, a gust of wind caused the huge vessel to list, allowing water to flood through the open gun ports. There was panic on board and she quickly sank, claiming the lives of about 30 sailors in the process. The ship settled into the mud on bottom of the harbour, where the cold and reduced salinity preserved her wooden structure almost perfectly until she was raised to the surface in the mid 1970s. An impressive 98% of the original ship was salvaged and painstakingly rebuilt, and she now sits in carefully controlled climatic conditions in a dedicated museum on the waterfront.

Mrs. Chair isn’t necessarily a household name where naval architects foregather, but even she had no difficulty spotting the problem with the design, as demonstrated by a cross-sectioned scale model. ‘It’s obvious that was going to topple over,’ she said. The board of enquiry, convened to look at the cause of the disaster, had come to the same conclusion nearly 400 years earlier.

At the inquest, the master revealed that a month before the ship sailed, having loaded as much ballast as he could, there was still concern that it wasn’t stable, and a captain had arranged a demonstration for his vice-admiral in which 30 men ran back and forth across the upper deck to make the ship roll. After a few such runs, the ship was heeling so badly it was thought it might capsize at the quayside and the demonstration stopped. For a ship of her size, she was far too ‘top-heavy’ and had too little ballast to keep her level in the water. Engineers have since calculated that if she had been sufficiently weighted, she would have sat so low that water would have flooded through the gun ports with even a slight list in the lightest of winds. Incredibly, nobody wanted to upset the king and delay her commission, and so nothing in the design was altered, and the ship later put to sea with that same captain in command.

Not a great triumph of design, then. The designer, Henrik Hybertsson, had died a year into the project so didn’t witness the disaster. He was an experienced master shipwright, but had never built a ship of this size before. The mathematical and engineering expertise to predict speed and stability was still a century away, so design relied on experience and feel. Typically, large ships were unstable when first put into service and said to be ‘tender’ or ‘crank’, with accepted methods for fixing the problem after the ship had been launched: cannons could be moved, or the shape or height of the hull altered later. Unfortunately, the Vasa was said to be so ‘crank’ that she didn’t survive long enough to be improved.

Which brings us back to the PCN DES. You may have seen the statement from the GPC (our negotiators) last evening, saying that they had voted against an amended proposal that they had seen and discussed yesterday. Just how ‘crank’ were the original ideas that NHSE had come up with an improved design before the original consultation period had even ended? We’re not privy yet to the details of the new offer, but at least it appears we’re not going to be asking practices and the networks to put to sea with the draft design as published. The GPC are looking to arrange a ’Special Conference’ of LMCs in a month or so to discuss the situation, by which time Somerset LMC might well have a new captain.

For now at least, I’m still at the helm, but I’m also the LMC cultural ambassador, so it was obviously incumbent upon me to pop in to the ABBA museum, just a brief shimmy away around the harbour. If nothing else I needed to check out their costumes to pick something suitable for my last few months in office.

Gimme, gimme, gimme a spec. after midnight.

Niklas

PS. ​​​​​Several people have asked me for details of our trip. I’m not in the travel-agency business (or on commission), and I’m not sure at these prices there’s a living to be made in it, but I’d thoroughly recommend it: return flights, 2 nights bed and breakfast in each of Stockholm and Copenhagen, with express train between the two, all for less than £300 per person. Take a hat.

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