Sense of duty: Martin Bromiley founded the Clinical Human Factors Group to bring change to the NHS. Photo: Muir Vidler
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How mistakes can save lives: one man’s mission to revolutionise the NHS

After the death of his wife following a minor operation, airline pilot Martin Bromiley set out to change the way medicine is practised in the UK  – by using his knowledge of plane crashes. 

1.

Martin Bromiley is a modest man with an immodest ambition: to change the way medicine is practised in the UK.

I first met him in a Birmingham hotel, at a meeting of the Clinical Human Factors Group, or CHFG. Hospital chief executives, senior surgeons, experienced nurses and influential medical researchers met, debated and mingled. Keynote speakers included the former chief medical officer for England Sir Liam Donaldson. In the corridors and meeting rooms, rising above the NHS jargon and acronyms and low-level grumbling about government reforms, there floated a tangible sense of purpose and optimism. This was a meeting of believers.

A slow transformation in the way health care works is finally gaining traction. So far, it has gone largely unnoticed by the media or the public because it hasn’t been the result of government edict or executive order. But as Suren Arul, a consultant paediatric surgeon at Birmingham Children’s Hospital put it to me: “We are undergoing a quiet revolution and Martin Bromiley will, one day, be recognised as the man who showed us the way.”

Although I knew whom to look for, Bromiley was hard to spot at first. He wasn’t on stage, and he didn’t address the full conference. He was, I discovered, sitting at a table at the edge of the hall, in the suburbs of the meeting. You would hardly have guessed that the CHFG was a group he’d founded, or that everyone at the meeting that day was there because of him. Bromiley doesn’t fit with our preconceived ideas of a natural leader. He speaks with a soft voice. He doesn’t command your attention, though you find yourself giving it.

Neither is he a doctor, or a health professional of any kind. Bromiley is an airline pilot. He is also a family man, with a terrible story to tell.

 

2.

Early on the morning of 29 March 2005, Martin Bromiley kissed his wife goodbye. Along with their two children, Victoria, then six, and Adam, five, he waved as she was wheeled into the operating theatre and she waved back.

Over Christmas, Elaine had suffered a swelling of her face, connected to sinus problems that had troubled her for years. She was advised by a consultant that the only way to deal with the problem once and for all was to undergo a minor operation to straighten the inside of her nose. Bromiley knew of colleagues who had undergone the operation – the sinuses of pilots take a beating from sharp changes in air pressure – so he didn’t feel overly concerned, that morning, as he drove Victoria and Adam back to the family home in a peaceful Buckinghamshire village.

At about 11 that same morning he received a call from the ear, nose and throat consultant. “Elaine isn’t waking up properly from the anaesthetic,” said the doctor. “Can you come back in?” At the hospital, Bromiley was met by the consultant, who explained that there had been a problem keeping Elaine’s airway open after she had been anaesthetised and her oxygen levels had fallen to dangerously low levels. A decision had been taken to move her to the intensive-care unit.

Grasping for medical knowledge from half-remembered episodes of Casualty, Bromiley asked if the doctors had attempted a tracheotomy – a cut to the throat to allow air in. They explained that the safer option had been to let her wake up naturally. He made his way to the intensive-care unit. When he got there, the first person to approach him was the consultant anaesthetist, who, without saying anything, gave him a hug. Bromiley found himself trying to console him. “I said, ‘I know these things happen.’

He took a seat and waited for news. After ten minutes, two doctors emerged and took seats opposite him. In sombre tones, they told Bromiley that Elaine had been without oxygen for a long period of time and, as a consequence, had suffered severe brain damage. He could hardly process what they were saying. “I just thought, ‘Fuck. What? How?’ I was stunned. My whole world changed.”

An hour later, Bromiley was allowed to see his wife. “She didn’t look any different,” he told me. But she was different. After finally settling her oxygen levels, the doctors had put her into a coma to prevent her brain from swelling to the point where it crushed itself against the top of her spine.

It soon became apparent that it was a coma from which she would never recover. Days later, after a series of discussions with the doctors, he consented to having her life support switched off. The doctors were surprised at the strength of her heart, which continued to beat for another week until, on 11 April 2005, Elaine Bromiley died.

 

3.

How could this have happened? When he surfaced from the shock, that was the question to which Bromiley wanted an answer. At first, he accepted the word of the ENT consultant, who told him that the doctors had made all the right decisions but had simply come up against an emergency for which nobody could have planned: the exceptional difficulty of getting a tube down Elaine’s throat.

Still, he assumed that the next step would be an investigation – standard practice in the airline industry after every accident. “You get an independent team in. You investigate. You learn.” When he asked the head of the intensive-care unit about this, the doctor shook his head. “That’s not how we do things in the health service. Not unless somebody complains or sues.”

This doctor was privately sympathetic to Bromiley’s question, however. Shortly after Elaine’s death, he got in touch with Bromiley to say that he had asked a friend of his, Professor Michael Harmer, an eminent anaesthetist, if he would be prepared to lead an investigation. Harmer had said yes. After Bromiley gained the hospital’s consent, Harmer set to work, interviewing everyone involved, from the consultants to the nursing team.

In July that year, he submitted his report. As Bromiley read it, his mind went back to one of the last nights he had spent in the hospital during his wife’s coma, and to something the duty nurse had said to him: “It’s terrible. I can’t believe that happened.” With hindsight, that was a hint.

Harmer’s minute-by-minute narrative of the operation revealed a different story from the one Bromiley had heard when he spoke with the ENT surgeon. The truth was that Elaine had died at the hands of highly accomplished, technically proficient doctors with 60 years of experience between them, in a fine, well-equipped modern hospital, because of a simple error.

4.

Doctors make mistakes. A woman undergoing surgery for an ectopic pregnancy had the wrong tube removed, rendering her infertile. Another had her Fallopian tube removed instead of her appendix. A cardiac operation was performed on the wrong patient. Some 69 patients left surgery with needles, swabs or, in one case, a glove left inside them. These are just some of the
incidents that occurred in English hospitals in the six months between April and September 2013.

Naturally, we respect and admire doctors. We believe that health care is scientific. We think of hospitals as places of safety. For all these reasons, it comes as something of a shock to realise that errors still play such a significant role in whether we leave a hospital better or worse, alive or dead.

The National Audit Office estimates that there may be 34,000 deaths annually as a result of patient safety incidents. When he was medical director, Liam Donaldson warned that the chances of dying as a result of a clinical error in hospital are 33,000 times higher than dying in an air crash. This isn’t a problem peculiar to our health-care system. In the United States, errors are estimated to be the third most common cause of deaths in health care, after cancer and heart disease. Globally, there is a one-in-ten chance that, owing to preventable mistakes or oversights, a patient will leave a hospital in a worse state than when she entered it.

There are other industries where mistakes carry grave consequences, but the mistakes of doctors carry a particular moral charge because their job is to make us better, and we place infinite trust in the expectation they
will do so. When you think about it, it’s extraordinary we’re prepared to give a virtual stranger permission to cut us open with a knife and rearrange our insides as we sleep.

Perhaps because of the almost superstitious faith we need to place in surgeons, we hate to think of them as fallible; to think that they perform worse when they are tired, or that some are much better at the job than others, or that hands can slip because of nerves, or that bad decisions get taken because of overconfidence, or stress, or poor communication. But all of these things happen, because doctors are human.

 

5.

Within two minutes of Elaine Bromiley’s operation beginning, the anaesthetic consultant realised that the patient’s airway had collapsed, hindering her supply of oxygen. After repeatedly trying and failing to ventilate the airway, he issued a call for help. An ENT surgeon answered it, as did another senior anaesthetist. The three consultants struggled to get a tube down Elaine’s throat, a procedure known as intubation, but encountered a mysterious blockage. So they tried again.

“Can’t ventilate, can’t intubate” is a recognised emergency in anaesthetic practice, for which there are published guidelines. The first instruction in one version of the guidelines is this: “Do not waste time trying to intubate when the priority is oxygenation.” Deprived of oxygen, our brains soon find it hard to function, our hearts to beat: ten minutes is about the longest we can suffer such a shortage before irreversible damage is done. The recommended solution is to carry out a form of tracheotomy, puncturing the windpipe to allow air in. Do not waste time trying to intubate.

Twenty minutes after Elaine’s airway collapsed, the doctors were still trying to get a tube down her throat. The monitors indicated that her brain was starved of oxygen and her heart had slowed to a dangerously low rate. Her face was blue. Her arms periodically shot up to her face, a sign that brain tissue is being irritated. Yet the doctors ploughed on. After 25 minutes, they had finally intubated their patient. But that was too late for Elaine.

If the severity of Elaine’s condition in those crucial minutes wasn’t registered by the doctors, it was noticed by others in the room. The nurses saw Elaine’s erratic breathing; the blueness of her face; the swings in her blood pressure; the lowness of her oxygen levels and the convulsions of her body. They later said that they had been surprised when the doctors didn’t attempt to gain access to the trachea, but felt unable to broach the subject. Not directly, anyway: one nurse located a tracheotomy set and presented it to the doctors, who didn’t even acknowledge her. Another nurse phoned the intensive-care unit and told them to prepare a bed immediately. When she informed the doctors of her action they looked at her, she said later, as if she was overreacting.

Reading this, you may be incredulous and angry that the doctors could have been so stupid, or so careless. But when the person closest to this event, Martin Bromiley, read Harmer’s report, he responded very differently. His main sensation wasn’t shock, or fury. It was recognition.

 

6.

Shortly after 5pm on the clear-skied evening of 28 December 1978, United Airlines Flight 173 began its descent to Portland International Airport. The plane had taken off from New York that morning and, after making a pre-scheduled stop in Denver, it was reaching its final destination with 189 souls on board.

As the landing gear was lowered there was a loud thump and the aircraft yawed slightly to the right. The flight crew noticed that one of the green landing gear indicator lights wasn’t lit. The captain radioed air-traffic control at Portland, telling them, “We’ve got a gear problem.”

Portland’s control agreed that the plane would orbit the airport while the captain, first officer and second officer worked out what to do. The passengers were told that there would be a delay. The cabin crew began to carry out checks. The flight attendants were instructed to check the visual indicators on the wings, which suggested that the landing gear was locked down.

Nearly half an hour after the captain told Portland about the landing gear problem, he contacted the United Airlines maintenance centre, informing the staff there that he intended to continue the holding pattern for another 15 or 20 minutes. He reported 7,000lbs of fuel aboard, down from 13,000 when he had first spoken to Portland.

United’s controller sounded a mild note of concern. “You estimate that you’ll make a landing about five minutes past the hour. Is that OK?” The captain’s response was ostentatiously relaxed: “Yeah, that’s a good ball park. I’m not gonna hurry the girls [the cabin crew].” United 173 had 30 minutes of fuel left.

The captain and his two officers continued to debate the question of whether the landing gear was down. The captain asked his crew how much fuel they would have left after another 15 minutes of flying. The flight engineer responded, “Not enough. Fifteen minutes is gonna – really run us low on fuel here.” At 18.07 one of the plane’s engines lost power. Six minutes later, the flight engineer reported that both engines were gone. The captain, as if waking up to the situation for the first time, said: “They’re all going. We can’t make Troutdale [a small airport on the approach route to Portland].” “We can’t make anything,” said the first officer. At 18.13, the first officer sent the plane’s final message to air-traffic control: “We’re going down. We’re not going to be able to make the airport.”

 

7.

This story of United 173 is known to every airline pilot, because it is studied by every trainee. To the great credit of the aviation industry, it became one of the most influential disasters in history. Galvanised by it and a handful of other crashes from the same era, the industry transformed its training and safety practices, instituting a set of principles and procedures known as CRM: crew resource management.

It worked. Although we usually notice only the high-profile exceptions, crashes are at the lowest level they have ever been, and flying is now one of the safest ways you can spend your time. As they are fond of saying in aviation, these days the most dangerous part of a flight is the journey to the airport.

CRM was born of a realisation that in the late 20th century the most frequent cause of crashes wasn’t technical failure, but human error. Its roots go back to the Second World War, when the US army assigned a psychologist called Alphonse Chapanis to investigate a curious phenomenon. B-17 bombers kept crashing on to the runway on landing, even though there were no apparent mechanical problem with the planes. Rather than blaming the pilots, Chapanis pointed to the instrument panel. The lever to control the landing gear and the lever that operated the flaps were next to each other. Pilots, weary after long flights, were confusing the two, retracting the wheels and causing the crash. Chapanis suggested attaching a wheel to the handle of the landing lever and a triangle to the flaps lever, making each easily distinguishable by touch alone. Problem solved.

Chapanis had recognised that human beings’ propensity to make mistakes when they are tired is much harder to fix than the design of levers. His deeper insight was that people have limits, and many of their mistakes are predictable effects of those limits. That is why the architects of CRM defined its aim as the reduction of human error, rather than pilot error. Rather than trying to hire or train perfect pilots, it is better to design systems that minimise or mitigate inevitable human mistakes.

In the 1990s, a cognitive psychologist called James Reason turned this principle into a theory of how accidents happen in large organisations. When a space shuttle crashes or an oil tanker leaks, our instinct is to look for a single, “root” cause. This often leads us to the operator: the person who triggered the disaster by pulling the wrong lever or entering the wrong line of code. But the operator is at the end of a long chain of decisions, some of them taken that day, some taken long in the past, all contributing to the accident; like achievements, accidents are a team effort. Reason proposed a “Swiss cheese” model: accidents happen when a concatenation of factors occurs in unpredictable ways, like the holes in a block of cheese lining up.

James Reason’s underlying message was that because human beings are fallible and will always make operational mistakes, it is the responsibility of managers to ensure that those mistakes are anticipated, planned for and learned from. Without seeking to do away altogether with the notion of culpability, he shifted the emphasis from the flaws of individuals to flaws in organisation, from the person to the environment, and from blame to learning.

The science of “human factors” now permeates the aviation industry. It includes a sophisticated understanding of the kinds of mistakes that even experts make under stress. So when Martin Bromiley read the Harmer report, an incomprehensible event suddenly made sense to him. “I thought, this is classic human factors stuff. Fixation error, time perception, hierarchy.”

 

8.

It’s a miracle that only ten people were killed after Flight 173 crashed into an area of woodland in suburban Portland; but the crash needn’t have happened at all. Had the captain attempted to land, the plane would have touched down safely: the subsequent investigation found that the landing gear had been down the whole time. But the captain and officers of Flight 173 became so engrossed in one puzzle that they became blind to the more urgent problem: fuel shortage. This is called “fixation error”. In a crisis, the brain’s perceptual field narrows and shortens. We become seized by a tremendous compulsion to fix on the problem we think we can solve, and quickly lose awareness of almost everything else. It’s an affliction to which even the most skilled and
experienced professionals are prone.

Imagine a stalled car, stuck on a level crossing as a distant train bears down on it. Panic rising, the driver starts and restarts the engine rather than getting out of the car and running. The three doctors bent over Elaine Bromiley’s throat were intent on finding a way to intubate, just as the three pilots in the cockpit of United 173 were determined to establish the status of the landing gear. In neither case did these seasoned professionals look up and register the oncoming train: in the case of Elaine, her oxygen levels, and in the case of United 173, its fuel levels.

When people are fixating, their perception of time becomes highly erratic; minutes stretch and elongate. One of the most striking aspects of the transcript of United 173’s last minutes is the way the captain seems to be under the impression that he has plenty of time, right up until the moment the engines cut out. It’s not that he didn’t have the correct information; it’s that his brain was running to a different clock. Similarly, it’s not that the doctors weren’t aware that Elaine Bromiley’s oxygen supply was a problem; it’s that their sense of how long she had been without it was distorted. When Harmer interviewed him, the anaesthetic consultant confessed that he had no idea how much time had passed.

Imagine, for a moment, being one of those doctors. You have a patient who has stopped breathing. The clock is ticking. The standard procedure isn’t working, but you have employed it dozens of times before and you know it works. Each of the senior colleagues around you is experiencing the same difficulty, which reassures you. You cling to the belief that, between the three of you, you will solve the problem, if it is soluble at all. You vaguely register nurses coming into the room and saying things but you don’t really hear what they say. Perhaps it occurs to you to step back from the patient and demand a rethink, but you don’t want your peers to see you as panicky or naive. So you focus on the one thing you can control: the procedure. You repeat it over and over, hoping for a different result. It is madness, but it is comprehensible madness.

Team trauma: British Midland Flight 92 came down near the M1 at Kegworth after a breakdown in communication among the crew

 

9.

In the months after Elaine’s death, as Bromiley tried to rebuild his family life, he couldn’t stop wondering about the difference between the way people in health care treated accidents and the way his industry dealt with them. So he would phone people in and around the National Health Service and ask them about it.

He discovered that many others – an anaesthetist in Scotland, a medical researcher in London – had been wondering the same thing. Eventually, he accumulated a long list of like-minded people, none of whom was talking to any of the others. So he booked a room in a hotel, called a meeting and invited them all, along with experts from other industries and academics, including James Reason. Everyone agreed that when it came to safety, health care was languishing in the Dark Ages. Hospitals more or less pretended that mistakes didn’t happen, failed to learn from them and, as a result, repeated them. If we don’t like to think that doctors make mistakes, doctors like to think about it even less.

One of the biggest problems identified was the unwritten but entrenched hierarchy of hospitals. Bromiley, who has worked with experts from various “safety-critical” industries, including the military, told me that the hospital is by far the most hierarchical workplace he has come across. At the top of the tree are consultant surgeons, the rock stars of the hospital corridors: highly driven, competitive, mostly male and not the kind who enjoy confessing to uncertainty. Then come anaesthetists, often quieter of disposition and warier of risk. Further down are nurses, valued for their hard work but not for their brains.

A key principle of human factors is that it is the unspoken rules of who can say what and when that often lead to crucial things going unsaid. The most painful part of the transcript of Flight 173’s final hour is the flight engineer’s interjections. You can sense his concern about the fuel situation, and his hesitancy about expressing it. Fifteen minutes is gonna – really run us low on fuel here. Perhaps he’s assuming the captain and his officers know the urgency of their predicament. Perhaps he’s worried about being seen to speak out of turn. Whatever it is, he doesn’t say what he feels: This is an emergency. We need to get this plane on the ground – NOW. Similarly, the nurses who could see the urgency of Elaine Bromiley’s condition didn’t feel able to tell the doctors that they were on the verge of committing a grave error. So they made tentative suggestions that were easy to ignore.

John Pickles, an ENT surgeon and former medical director of Luton and Dunstable Hospital NHS Foundation Trust, told me that usually when an operation is carried out on the wrong part of the body (a class of error known as “wrong-site surgery”), there is at least one person in the room who knows or suspects a mistake is being made. He recalled the case of a patient in South Wales who had the wrong kidney removed. A (female) medical student had pointed out the impending error but the two (male) surgeons ignored her and carried on. The patient, who was 70 years old, was left with one diseased kidney, and died six weeks later. In other cases nobody spoke up at all.

The pioneers of crew resource management knew that merely warning pilots about fixation error was not sufficient. It is too powerful an instinct to be repressed entirely even when you know about it. The answer lay with the crew. Because even the most experienced captains are prone to human error, the entire aircraft crew needed to act as a collective intelligence, vigilant for problems and responsible for solutions. “It’s the people at the edge of the room, standing back from the situation, who can often see it best,” Bromiley said to me.

He recalled the case of British Midland Flight 92, which had just taken off for its flight from London to Belfast on 8 January 1989 when the pilots discovered one of the engines was on fire. Following procedure, they shut it down. Over the PA, the captain explained that because of a problem with the right engine he was making an emergency landing. The cabin staff, who – like the passengers, but unlike the cockpit crew – could see smoke and flames coming from the left engine, didn’t pass this information on to the cockpit. After the pilots shut down the only functioning engine, British Midland 92 crashed into the embankment of the M1 motorway near Kegworth in Leicestershire. Forty-seven of the 126 people on board died; 74 sustained serious injuries.

The airline industry pinpointed a major block to communication among members of the cockpit crew: the captain. The rank of captain retained the aura of imperial command it inherited from the military and from the early days of flying, when pilots such as Chuck Yeager, immortalised in Tom Wolfe’s book The Right Stuff, were celebrated as audacious mavericks. The pioneers of CRM realised that, in the age of mass air travel, charismatic heroism was precisely the wrong stuff. The industry needed team players. The captain’s aura was a force field, stopping other crew members from speaking their mind at critical moments. It wasn’t just the instrument panel that had to change: it was the culture of the cockpit.

Long before they started doing more good than harm, surgeons were revered as men of genius. In the 18th and 19th centuries, surgical superstars performed operations in packed amphitheatres before hushed, admiring audiences. A great surgeon was a virtuoso performer with the hands of a god. His nurses and assistants were present merely to follow the great man’s commands, much as the planets in an orrery revolve around the sun. The advent of medical science gave this myth a grounding in reality: at least we can be confident that doctors today make people better, most of the time. But it reinforced a mystique that makes doctors, and especially surgeons (who, of course, still perform in operating theatres), hard to question, by either patients or staff.

Better safety involves bringing doctors off their pedestal or, rather, inviting them to step down from it. Modern medicine is more reliant than ever on teamwork. As operations become more complex, more people and procedures are involved. Operating rooms swarm with people; various specialists pronounce judgement or perform procedures, and then leave. Surgical teams are often comprised of individuals who know each other only vaguely, if at all. It is a simple but unavoidable truth that the more people are involved in something, and the less well they know each other, the more likely it is that someone will make an error.

The most significant human factors innovation in health care in recent years is surprisingly prosaic: the checklist. Borrowed from the airline industry, the checklist is a standardised list of procedures to follow for every operation, and for every eventuality. Checklists compensate for the inbuilt tendency of human beings under stress to forget or ignore what is important, including the most basic things (the first item on one aviation checklist is FLY THE AIRPLANE). They also empower the people at the edges of the room: before the operation and at key moments during it, the whole team goes through each point in turn, including emergencies, which gives a cue to more reserved members of the team to speak up.

Checklists are most effective in an atmos­phere of informality and openness: it has been shown that simply using the first name of the other team members improves communication, and that giving people a chance to say something at the beginning of a case makes them more likely to speak up during the operation itself.

Naturally, this spirit of openness entails a diminishment of the surgeon’s power – or a dispersal of that power around the team. Some doctors don’t mind this – indeed, they welcome it, because they realise that their team can save them from career-ruining mistakes. Others are more resistant, particularly those who treasure their independence; mavericks don’t do checklists. Even those who see themselves as evolved team players may overestimate their openness. J Bryan Sexton, a psychologist at Johns Hopkins University in the US, has conducted global surveys of operating-room staff. He found that while 64 per cent of surgeons rated their operations as having high levels of teamwork, only 28 per cent of nurses agreed.

The lessons of human factors go far beyond the status of surgeons. From his earliest conversations with insiders, Bromiley realised that the NHS needed to undergo a profound cultural change if it was to reach the level of the aviation industry in terms of safety. Hospitals gave little or no thought to how their teams functioned. Doctors underestimated the effects of tiredness on their own performance. Medical schools taught doctors that technical excellence trumped everything else and spent little or no time teaching communication or team management skills. Specialists saw their job as fixing parts of the body, rather than helping a person (at this year’s Clinical Human Factors Group conference, Peter Jaye, a consultant surgeon at Guy’s Hospital in London, remarked: “At medical school I was trained to think of a patient as a pair of kidneys”). There was little or no data on which hospitals and doctors were making mistakes, and therefore which required the most urgent improvement.

Safety risks were routinely misperceived. The “can’t ventilate/can’t intubate” emergency happens about one in every 20,000 times, which anaesthetists consider a remote possibility. Yet as Bromiley told me: “In aviation, when we find out there’s a one-in-a-million chance of an engine failing, we worry. To me, one in 20,000 means a regular occurrence.”

As James Reason showed, mistakes arise out of coincidence. Suren Arul, the consultant paediatrician in Birmingham, told me that “when mistakes happen, it’s almost never one person’s fault. It’s usually a whole series of things, some of them tiny.” Bromiley asks hospital boards to consider their procurement of marker pens, used to mark the part of the body about to be operated on (best practice is for the surgeon to make the mark and to sign it with his initials). “I tell them, ‘I understand your need to cut budgets. But do you realise that because you didn’t buy those marker pens you’ve just trebled your likelihood of having a wrong-site surgery case?’

There is now greater awareness of the complexity of safety than ever. The body that Bromiley founded, the Clinical Human Factors Group, has no official status within the NHS, but its influence has been felt right across that sprawling and multifarious institution. At the meeting I attended, everyone to whom I spoke seemed to believe that things are moving, albeit too slowly, in the right direction.

10.

It was a trauma situation: an 18-month-old baby boy had fallen down the steps at Euston Square station, smashing his head and injuring his leg. Through a one-way mirror, I watched as a young doctor entered the operating room and was greeted by the baby’s distressed mother. The woman sitting next to me turned to her team. “Why don’t you play the orthopaedic surgeon this time, Dave?” she said. “Clare, can you be the anaesthetic consultant?”

In recent years, simulations have started to become part of the training of doctors. Sarah Chieveley-Williams, the consultant anaesthetist who is director of clinical simulation at University College London Hospitals (UCLH), had invited me to watch junior paediatricians being put through their paces. The room before us was a near-perfect replica of an operating theatre, with an anaesthesia machine, various equipment, monitors and a stock of medication. The dummy baby had pupils that dilate, a heartbeat and a noisy cry.

Chieveley-Williams and her team were interested in the doctor’s ability to identify the right priorities: first, stabilise the baby’s condition by anaesthetising it; second, get a neurological consultant to look at its head injuries, in order to prevent or minimise brain damage. On our side of the glass, one of the team sat by a computer from where she could manipulate the baby’s vital signs. She slowed down its heart rate, ratcheting up the urgency of the situation.

Chieveley-Williams turned to another colleague: “Dave, see if you can get her fixated on the leg.” Dave left us and a moment later reappeared in the operating room wearing a white coat. After examining the patient, he proposed, with the air of someone used to being agreed with, that an X-ray be taken of the injured leg. Chieveley-Williams watched intently. In a quiet but firm voice, the young doctor said, “Right now, the priority is his head injury. The leg will have to wait.”

Chieveley-Williams turned to me with a grin. “That told him,” she said.

Over the next 20 minutes, a succession of people entered and left the room. Specialists were summoned, medications ordered and procedures arranged. At times the impression was one of near-chaos. A trauma incident, Chieveley-Williams explained to me, presents an acute management challenge, as well as a medical one. Because it often involves injuries to different parts of the body, many specialists come into the treatment room, each with his or her own agenda. “The doctor needs to establish leadership and keep everyone focused on the big picture – the patient’s health.”

In the case of Elaine Bromiley, there was too much hierarchy and too little. On the one hand, the nurses didn’t assert themselves. On the other hand, nobody was taking ultimate responsibility for the patient’s safety. As John Pickles remarks, “You had three very senior people in the room and no one in charge.”

Hierarchy, in the sense of clear leadership, is a good thing, as long as the leaders are confident enough to confess uncertainty. A common problem, Chieveley-Williams said, is young doctors being reluctant to say they don’t know what the answer is because they are so eager to project competence. A member of her team told me, “We tell them that when you’re stuck, ask everyone in the team for their view. One of them probably has the answer, but until you speak up they’ll assume you have it, too.”

These sorts of lessons weren’t being given ten years ago. Like UCLH, Great Ormond Street children’s hospital in London is at the forefront of the new thinking about patient safety, and is absorbing lessons from other industries. The transfer of patients from surgery to the intensive-care unit is a complex process that has to be accomplished at speed, and involves several people. Unsurprisingly, it is a well-known danger zone: things get dropped, tubes are left unattached, and patients suffer. In collaboration with the human factors researcher Ken Catchpole, the hospital studied the process of pit-stop changes in Formula 1, learning the importance of every individual on the team being allocated a precisely defined task. Mistakes fell.

 

11.

Martin Bromiley has rebuilt his life. Happily remarried, he is stepdad to his second wife’s two children, as well as still dad to Victoria and Adam. He is not haunted by the tragedy of Elaine’s death but driven by it. Between flying commitments, he talks to doctors, nurses, researchers and NHS boards, connecting the like-minded; telling his story to those, whether managers or medical students, who most need to hear it. It is a heavy workload. I wondered if he was ever tempted to leave it behind, now that the CHFG has its own momentum. He shook his head. “This is a duty.”

Improving the safety of patients in health care doesn’t necessarily require spending on expensive new technologies, or complex structural reorganisation. It requires forethought, empathy, humility and a willingness to learn from mistakes. Which, after all, is a duty to those who have suffered from them. Bromiley insisted that the Harmer report be made public as happens with air accident reports, and he chose for it an epigraph borrowed from aviation: “So that others may learn, and even more may live.” All of the medical staff involved in Elaine’s operation are back at work. That, says Bromiley, is exactly what he wanted, because they will be better clinicians for their experience, and advocates for the cause.

There are two approaches to reforming a large institution. You can impose change from outside by invoking the will, or the wrath, of the public – or you can persuade those inside to let you in and to listen to your message. Both can work. When Julie Bailey exposed the gross malpractices of staff at Stafford Hospital, she shook the health service from top to bottom. Bromiley greatly admires what Bailey has achieved, but he has taken a different path. Rather than using his story as a club – and nobody would have blamed him for doing that – he has deployed it as you would wish a surgeon to apply the knife to someone you love: with skill, subtlety and precision.

“From the moment something went wrong with Elaine, it was different, because they knew my profession,” he says. Responding to his calmness and extraordinary ability to empathise with their situation, the team rose to their best. As Elaine lay in a coma, they involved him in every decision they took, right up until the last one. It was proper teamwork, and a model for the long campaign that followed. “I’m an outsider who is also an insider,” he says.

Martin Bromiley has reminded clinicians that not everything is or should be clinical. His legacy, says Professor Jane Reid, a researcher in nursing at Queen Mary’s Hospital in south London, is “a new safety culture” in the NHS. He has no desire to take up any official position. “I’m not an expert on medical practice,” he told me. “I’m just a guy who flies planes.” 

Ian Leslie is the author of Curious: The Desire to Know and Why Your Future Depends on It (Quercus, £10.99)

Ian Leslie is a writer, author of CURIOUS: The Desire to Know and Why Your Future Depends On It, and writer/presenter of BBC R4's Before They Were Famous.

This article first appeared in the 28 May 2014 issue of the New Statesman, The elites vs the people

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Is it Ruth Davidson's destiny to save the Union?

Ruth Davidson is a Christian, gay, kick-boxing army reservist who made a passionate case for the EU and has transformed the fortunes of the Tories in Scotland.

In the end it made no difference, but during the EU referendum campaign Ruth Davidson achieved something that nobody else did: she made the case for Remain sound thrillingly righteous. In a live, televised BBC debate at Wembley Arena in London, she denounced the “lies” of the Leave campaign, turning to the crowd to declare, twice: “You deserve the truth!” Funny, fervent and pugnacious, Davidson pounced on the bluff assertions of Boris Johnson with gusto, a terrier savaging a shaggy dog. As she departed the podium, flashing a light-bulb grin, she left a question hanging in the air: how far can Ruth Davidson go?

On the face of it, it was a risk for the ­Remain campaign to send the leader of the Scottish Conservatives to Wembley, when most of its persuadable voters lived in England. Yet, according to Andrew Cooper, David Cameron’s pollster and an influential Remain strategist, “Ruth’s name was inked in from the beginning.” After the debate, nobody called this confidence misplaced. Davidson was acclaimed as the star of the night. English observers began to appraise her as a major player in national politics, even as a possible future prime minister.

The EU debate was, for Davidson and for Scots, the least energetically contested of four recent contests, following the Scottish independence referendum in 2014, the general election in 2015 and the Scottish Parliament elections in May 2016. In the last one, Davidson led her party to second place, overtaking Labour, and the Conservatives became the main opposition to Nicola Sturgeon’s Scottish Nationalists. It was their best result in nearly 60 years and evidence of an astonishing turnaround.

When Davidson was elected leader in 2011, it was like being declared the mayor of a ghost town. Her party’s core voters had long fled, first to Labour and then to the SNP. Margaret Thatcher and successive national Tory leaders had made it almost impossible for Scots to admit to voting Conservative, or even to being friends with anyone who did. It wasn’t just that the Tories were poisonous to the touch; they were on the verge of irrelevance. They held 15 out of the 129 seats at Holyrood. They barely mattered.

They matter now. The stigma of voting Tory has not been entirely erased, but the Conservative brand has been saved, or perhaps subsumed by its Scottish leader’s personal brand. On the ballot paper in May, voters were invited to put a cross next to the slogan “Ruth Davidson for a strong opposition”; party activists knocking on doors introduced themselves as being from “Team Ruth”. A recent poll found that Davidson was the most popular politician in Scotland, surpassing Sturgeon.

Ruth Davidson has been a politician for just five years. If you need reminding of how hard it is, even if you are clever and able, to become a high-level political performer on half a decade’s experience, recall the defining moments of a few Labour MPs of the 2010 generation: Liz Kendall’s flameout, Chuka Umunna’s failure to launch, Owen Smith’s bellyflop. David Cameron’s rise might seem to have been comparably quick, but he had been working in Westminster politics, on and off, for 13 years before he ­became an MP. Three years before being elected leader of the Scottish Tories, Davidson hadn’t even joined a political party.

Davidson may be the most gifted politician in Britain. “She’s a natural, and they are very rare in politics,” Cooper told me. The question for her is whether she will ever convert talent into power.

 

*****

In August, I went to see Davidson speak in Belfast at an event organised by Amnesty International on behalf of the campaign for gay marriage in Northern Ireland. She made a case for equal marriage that was also a case for the institution of marriage. “More than 40 years married and my parents still love each other – and I look at what they have and I want that, too, and I want it to be recognised in the same way,” she said.

She paused to note that the passage was taken from an address that she made at Holyrood during the first reading of Scotland’s equal marriage bill in 2013: “I’ll be honest. I was absolutely bricking it.”

Davidson met her partner, Jen Wilson, in 2014. The couple got engaged this year on holiday in Paris, just after the May election campaign. Wilson, who is 34 and from County Wexford, Ireland, works in the charity sector. In 2015, she appeared with Davidson in a party political broadcast, which showed the couple strolling along Elie Harbour, Fife, and taking selfies with Davidson’s parents. It wasn’t a big deal and yet, at the same time, it felt significant. As Davidson noted in her speech, homosexuality was still a prosecutable offence in Scotland in the year she was born (it was not decriminalised north of the border until 1980).

After the event, I met her for a drink with members of her team at the bar of her hotel. She had returned to Edinburgh from a holiday in Spain in the early hours of that morning, shortly before boarding a plane to Belfast for a full day of engagements. Yet she bristled with energy, giving the illusion of movement even when she was sitting still, her attention distributed between emails on her phone, the conversation at the table and the level of everyone’s drinks. She had enjoyed the event, she said, although she had been hoping for more argument.

In September, we met again for a longer conversation in her small office at Holyrood. In person, she is friendly in a businesslike way, mentally fast (often starting her response before the question is finished) and generous with her answers. As she talks, her eyes fix you in your seat. “Ruth is a brilliant reader of people, including our opponents, and spots weaknesses very early,” her colleague Adam Tomkins told me. “She can see through me. I would hate to play poker with her.”

Before our meeting, I watched First Minister’s Questions, the first after the summer recess. The atmosphere in the chamber at Holyrood is very different from that in the Commons: quieter, less theatrical. The leaders of the main parties are not cheered to their seat. Sturgeon, dressed in black, walked to her desk at the front of the hall, unacknowledged by her colleagues, as a cabinet secretary answered a question on national parks. Davidson entered shortly afterwards, in a violently pink jacket that contrasted vividly with the muted tones preferred by most MSPs.

In the chamber, Davidson often holds her own against the First Minister. The two have contrasting styles: Sturgeon poised and coolly effective, Davidson a study in controlled fury. “Ruth has a real aggression to her,” says the journalist Kenny Farquharson, a columnist for the Times in Scotland. “She’s always looking for the next fight.”

 

*****

Ruth Elizabeth Davidson was born at the Simpson Memorial Maternity Pavilion in Edinburgh in 1978, the second of two daughters to Douglas and Elizabeth Davidson. Her family lived in Selkirk, where her father worked at the wool mill. This was Douglas’s second career: his first had been as a professional footballer, for Partick Thistle and Selkirk FC. The Davidsons moved to Fife when Ruth was a child, after the mill closed. Her parents were Tory voters, without being especially political.

When Ruth Davidson was five years old, she was run over by a truck near her home and nearly killed. The accident shattered her leg, fractured her pelvis and severed her femoral artery, leading to a huge loss of blood. In interviews, she makes quick work of what other politicians might be tempted to craft into a narrative turning point. “My legs are still a bit squint . . . but it has never really stopped me from doing anything,” she told the Scotsman in 2012.

Her family was Presbyterian, in the Church of Scotland, a more austere and morally fiery tradition than Anglicanism. (A Scottish journalist remarked to me, “To us, Anglicanism is Christianity with all the fibre removed.”) Davidson is a practising Christian. Her piety does not extend to abstention from alcohol or profanity – she is a world-class swearer – but it is manifest in her moral muscularity, preacher-like cadences and horror of malingering.

In Fife, Davidson attended Buckhaven High School, a large comprehensive with a working-class intake. She is often referred to as working class, which isn’t quite right. Her mother and father were working-class Glaswegians. Her mother left school at 15, her father at 16. Douglas grew up on an estate in Castlemilk, a district then infamous for its deprivation and crime. He was one of the few Protestants in a solidly Catholic community, during a time of deep divisions.

The Davidsons, however, were upwardly mobile. Douglas had been a manager at the mill in Selkirk and then ran a whisky distillery on the Isle of Arran. The children had the importance of effort and self-improvement drummed into them. Ruth has recalled getting a school report that gave her a 1 for results in science – the best possible mark – and a 2 for effort. “I got a mini-bollocking for that. My mum would have been much happier if it had been the other way round.” Both children attended university (Ruth’s sister is now a doctor).

Davidson did well at school and excelled at sport. She played squash for her county and tennis to a level at which she can teach it. In adulthood, she took up kick-boxing, condemning herself to be forever tagged as a “kick-boxing lesbian” in the British press. Sport has been central in her life, not so much a leisure activity as a method of striving for new goals.

After graduating from Edinburgh University, where she studied English literature and took part in debating competitions, ­Davidson moved to Glasgow and started a career in journalism. In 2002 she joined BBC Scotland, becoming a radio presenter on a drive-time show, reporting on gifted pets one minute and traffic disasters the next. By all accounts, she was excellent: fluent, well prepared, interested in whomever she was talking to. Her producer Pat Stevenson remembers her as “a fantastic interviewer, incisive and forensic, able to spot bullshit a mile off. And she was fun.” Her abiding image of Davidson at the microphone is of a head thrown back in laughter.

Stevenson recalls being vaguely aware that Davidson held right-of-centre views, though these were less of a talking point with her BBC colleagues than her Christianity, or, even more so, her weekends spent deep in a forest, being shouted at while trying to read a map. Davidson served as a signaller in the Territorial Army for three years from 2003 and trained to be an officer. “It was very tough,” says Steve Bargeton, who oversaw the officers’ course. “Most fail or drop out, but Ruth flew through. She had tremendous character.” Davidson won a place at Sandhurst but broke her back during a training exercise, forcing her to end her military career.

She soon set herself a new goal: to be elected to parliament by the time she was 40. In 2009, she left the BBC and joined the Tory party. Davidson has attributed her career change to David Cameron’s call, after the MPs’ expenses scandal, for people who had never been political to get involved, but it is likely she had already decided that politics was the next hill to climb. Either way, she quickly acquired influential sponsors in Edinburgh and London. By the 2010 election, she was head of the private office of Annabel Goldie, the then leader of the Scottish Tories. She stood for an unwinnable Commons seat in Glasgow, twice, both times winning barely 5 per cent of the vote.

Even as the elections to Holyrood came around in May 2011, she was not expected to make it to parliament. She was second on Glasgow’s regional list, which all but ruled her out. A couple of months before the vote, however, the candidate at the top of the list was removed following allegations of past financial problems. The Conservative Party chairman promptly promoted Davidson, who was elected to Holyrood (she won a constituency seat of her own this year in Edinburgh, where she now lives).

In the 2011 election, the SNP, under Alex Salmond, won an unprecedented overall majority in Holyrood. This success transformed the politics of Scotland, and thus that of the UK. Labour’s grip on the votes of working-class Scots was broken. The Conservative Party, already a corpse, failed to twitch. It at once became clear that Salmond had won a mandate for a referendum on independence and that this would be the defining question of Scottish politics until it was resolved.

On the Monday after the election, Annabel Goldie announced that she was resigning. Four days after her election to the Scottish Parliament, Davidson began to consider a run at the leadership of her party. She was encouraged by senior figures, including David Mundell (then a Scotland Office minister, now the Scottish party’s sole MP in Westminster) and David Cameron. In her way stood the Scottish Tories’ deputy leader, Murdo Fraser, an Edinburgh-based lawyer who had been a Conservative activist for a quarter of a century. It was, by common consent, his turn.

Fraser, sensing a threat, committed to an act of excessive radicalism that proved to be his undoing: he proposed that the party ditch the name “Conservative” and break entirely from its southern counterpart. He argued that this measure (Alex Massie, writing in the Spectator, called it the euthanasia option) was the only way to move on from the past and compete with the SNP as a truly Scottish party. He did not recommend a new name; mooted alternatives included the Scottish Reform Party, the Caledonians and Scotland First.

Fraser’s gambit propelled Davidson into the race. She felt that his proposal would unmoor the Scottish Conservatives from their purpose, and also that it was politically naive, as there was little chance that voters would not realise that this was the same party in different clothes. In tactical terms, Fraser had opened up space for a candidate to run on preserving the status quo, rarely an unpopular position among Tories. For his challenger, it was a ripe alignment of conviction and opportunity, a ball bouncing into the perfect position for a killer forehand. Davidson declared on 4 September 2011 and won the final round against Fraser, 55 per cent to 45 per cent. She was 32.

 

****

It is easy to underestimate how much politics, in opposition, is simply about getting noticed. When Davidson became leader, Scottish politics was a (rather one-sided) battle between the SNP and Labour. She needed to fight her way to centre stage and into the calculations of voters – there wasn’t much point repositioning the Tory brand if nobody was watching. As Andrew Cooper put it to me, “You didn’t get to the toxic problem until you dealt with the irrelevant problem.”

Davidson excels at getting noticed. She has – even if she would not appreciate the comparison – a Donald Trump-like understanding of how to get and keep attention. She is at home on social media, something that is true of all the Scottish party leaders, though Davidson’s tweets are the most fearless and funny. She is also an artist of the photo opportunity: here she is in a pink scarf, bestriding the gun of a tank, a Union flag fluttering in the background; playing the bagpipes, or being played by them, eyes popping out of her head; smashing a football into the back of the net.

Such photos do more than get attention. They reinforce the sense of a person unintimidated by the rules of political protocol; indeed, of someone who scorns limitations. There is something almost cartoonish about Davidson’s public profile: the big eyes, the flashing grin, the unstoppable, barrelling walk. In debates, as she winds up to a clinching point, you can, if you half close your eyes, see her swinging her arm through a hundred revolutions before extending it across the stage to smack an opponent. She is one of us, and not like us at all. Flattened by a truck, she gets up and walks away.

Davidson’s willingness to play the fool wouldn’t work if she was not able to convey seriousness at the same time. The leadership race set the template for her political profile as an untraditional traditionalist. Davidson doesn’t look or talk like a typical Tory, but her ideological touchstones are profoundly Conservative. She is a British patriot, a churchgoer, a passionate supporter of the armed forces, an advocate for marriage, a believer in self-reliance. On becoming leader, she set about reviving a type of blue-collar Conservatism not seen since the 1980s. The former Scottish Tory MP Sir Teddy Taylor coined the expression “tenement Tories”: working-class voters with conservative instincts, sceptical of high taxes, patriotic but not nationalist. Davidson, the daughter of tenement Tories, is able to pitch herself as one of them.

To do so has required performing a balancing act with respect to her party in Westminster. She admired Cameron and, politically speaking, was in his debt. Her leadership is staked on the unity of the Scottish and English branches of the party. Yet she has managed, somehow, to position herself against the party’s privileged English elite – the “private-school boys”. Her evident animus against Boris Johnson is both strategic and personal. During the EU campaign, as the polls tightened, she asked Downing Street if it wanted her to go on a “suicide mission” against Johnson, a senior aide to the former prime minister says.

 

****

In Ruth Davidson’s first year as leader, her inexperience showed. She made a prolonged and embarrassing climbdown from a foolhardy promise, made during the leadership campaign, to draw a “line in the sand” against further devolution. Meanwhile, Alex Salmond, a skilled and pitiless debater, successfully patronised her every week at First Minister’s Questions. An impression that she had been promoted prematurely was discreetly given credence by members of her own party (most Scottish Tory MSPs had voted for Fraser).

Davidson was learning not only how to be a leader in public, but how to manage an organisation, a skill for which journalism had not prepared her. A rule change that came into effect when she took over gave her far-reaching powers over the party. As she says, she suddenly found herself responsible for MSPs, staff and activists, but with “no idea how to manage”. She fell back on her training in the Territorial Army. “I had to apply what I learned about leadership in the British army. The toolkit I used was from officer training: how to identify problems, make decisions, bring people with you.”

At Wembley this summer, debating national security, Davidson remarked icily, “I think I’m the only one on this panel who’s ever worn the Queen’s uniform.” Her TA training provides her with a rhetorical trump card and legitimises photo opportunities on tanks, but it does more for her than that. Military metaphors pervade her thinking and fire her imagination. One of her favourite books is Defeat into Victory, an account of the Allied forces campaign in Burma in the Second World War, by William Slim, a British field marshal. “It is the best examination of leadership you’ll ever find,” she told me, and then related, excitedly, an encounter she once had with a Second World War veteran who had witnessed Slim addressing his troops.

After getting heard, Davidson’s most urgent task as leader was to overhaul a demoralised and moribund institution. She focused on candidate recruitment – looking for better signallers. “I wanted to rebuild around the message carriers,” Davidson told me. After their run of bad elections, the Tories had stopped trying to pick winners: “They were asking good, hard-working foot soldiers to stand, just to get a name on the ballot.” Long-standing members would be asked to put their name down and reassured that they wouldn’t have to do anything, and so, by and large, they didn’t.

Davidson put together a new candidates’ board: a former human resources director for Royal Mail, a QC who had been a world champion debater, an expert in corporate leadership. She designed a series of tests based on the officer assessment test that she underwent before Sandhurst (“minus the assault course and press-ups”).

Applicants were asked to sit around a ­table with three others, each with a piece of paper in front of them. When they turned it over, they discovered who they were and what they needed to solve. A new policy was about to affect voters in four neighbouring constituencies, but in different ways: it would be detrimental to those in the first constituency, neutral for those in the second and third and advantageous for those in the fourth. Each candidate represented a different constituency. How would they agree a position?

“It was about making people interact in a way they hadn’t before,” Davidson said. “I made every sitting MSP go through it, including myself.” Her aim was to assemble a team of experts, from business, law, the armed forces and the third sector.

Among her recruits was Adam Tomkins, a professor of public law at Glasgow University, now an MSP and one of Davidson’s closest allies. “By late 2011, it was clear the referendum was coming. I wasn’t involved in party politics but I was a strong believer in the Union and I knew I wanted to do something. I wasn’t a Tory, though. In fact, I had been pretty hostile to them.” He offered his expertise to Labour but came away from meetings with the party’s leaders depressed by their tribalism. Davidson was different: intellectually curious, open-minded, eager to take advice. In 2013, she formally asked him to help the Tories formulate a constitutional policy and he agreed. On New Year’s Day 2014, he joined the Conservatives.

The Scottish independence referendum was the making of Davidson as a national leader, as it was of Nicola Sturgeon, who escaped Salmond’s shadow to become a force in her own right. In TV debates during the campaign, Davidson was the most compelling defender of the Union, capable of winning sympathy for even its most unpopular ingredients. “Ruth emerged as someone who could defend Trident and get applause,” says the journalist David Torrance.

After the referendum in September 2014, she once again had to battle for attention. She needed to convince the media that the Conservatives might yet play a big role at Holyrood – that she was more than an amusing sideshow. The referendum had shown her how decayed Labour’s relationship was with its own voters, and this gave her renewed impetus. She also grasped that, far from enabling Scottish politics to move on from independence, the referendum was still having the opposite effect.

In September 2015 the new Scottish Labour leader, Kezia Dugdale, announced that Labour MSPs would have a free vote on independence in the event of another referendum. In April 2016, she committed to an increase in the top rate of income tax. Together, the two moves were an attempt to move past the issue of independence. “I want people who voted both Yes and No to see that the Labour Party is the vehicle for progressive change in this country,” she said. Yet Dugdale misjudged the relentlessly centrifugal dynamic of Scottish politics after the referendum. Every policy position – from tax rates to tuition fees – returned to the question of what it signalled about Scotland’s relationship with England.

Davidson understood that if Labour was softening its position on the Union, she need only harden and amplify hers. At this year’s Holyrood election, she presented herself not as an alternative first minister, but as the most forceful voice of opposition to Sturgeon. In the campaign debates, she demonstrated it. By doing so, she was able to convince enough pro-Union Labour voters to defect to achieve second place.

For someone who is still relatively new to politics, Davidson has well-tuned strategic instincts. When I asked Tomkins what she excels at, he said: “Her framework is politics, not policy as such. She is brilliant at tactics, messaging, strategy.”

Davidson seems to have developed a serious interest in politics only as an adult, and then only because she thought that it presented a worthy challenge for her abilities (by contrast, most of the leading Scottish Nationalists joined the SNP before they were 18). A little like David Cameron, she just thought that she would be good at it. When I asked her to name her political heroes, or politicians whom she particularly admired, she struggled to come up with any from real life, naming Thomas More in A Man for All Seasons, Shakespeare’s Henry V and Atticus Finch in To Kill a Mockingbird. She wasn’t being coy – it’s just that, like most people, she has never looked to politics for role models. With prompting, she eventually named Peter Mandelson, for his part in making the Labour Party electable again, and William Hague, for his work on women’s rights while foreign secretary.

This lack of political nerdery is part of what makes her able to connect so directly with voters, but it is also a limitation. A consistent criticism of Davidson, even among those who admire her, is that she is not interested in policy, or at least that she does not have a set of distinctive policy ideas. This isn’t quite fair – she has published a paper on education and successfully focused attention on the attainment gap between poor and middle-class students. But she has not yet committed to a detailed alternative (a school vouchers policy was raised and then quietly dropped). Other than “maintain the Union”, it is difficult to know what a Davidson-led government would do.

The word everyone uses about her is “authentic”; like Sturgeon, she projects comfort in her own skin. But in a sense Davidson is a lucky politician, as well as a precociously accomplished one. It is much easier to be yourself in politics when what you believe matches so neatly with what you need to do to win. Her decision to present herself in the Holyrood elections as an effective opponent, rather than an alternative first minister, was tactically smart, but it raised a larger question. As one observer put it to me, “We know what she’s against. But what is Ruth Davidson for?”

 

*****

On 12 July, the day after it became clear that Theresa May would be the new Conservative leader, Davidson spoke at a Press Gallery lunch in Westminster and delivered what was, in essence, a stand-up comedy set. Even by her standards, it was indiscreet. On the difference between the Tories’ truncated leadership contest and Labour’s lengthy deliberation, she remarked: “Labour’s still fumbling with its flies while the Tories are enjoying a post-coital cigarette after withdrawing our massive Johnson.”

It is difficult to say it without sounding like a stick in the mud, but to me this routine felt misjudged. Political leaders can be funny but not that funny – not without compromising our sense of their stability. Nor was it wise to be so rude. Johnson is in the same party as she is, after all, and may yet become leader (nobody, possibly least of all Davidson, is sure what she would have done had Johnson succeeded Cameron). Like many funny people, Davidson metabolises anger into humour and I suspect that, after Brexit, her anger was surging.

It wasn’t just that she thought the decision was profoundly wrong, or that she was contemptuous of Leave’s tactics. It was also that she was being forced to rethink her future. If Remain had won, the chance of another independence referendum may well have receded, allowing Scottish politics to normalise. The SNP would have found it harder to present itself as being simultaneously in office and opposition. Davidson could have embarked on the last stage of the Scottish Tory recovery: making it an alternative government. She might even have considered the option of taking a Westminster seat – after which, who knows?

The vote in favour of Brexit knocked all of this on the head. It put independence firmly back on the agenda. Instead of either disappearing or becoming imminent, the prospect of a second referendum will squat in the middle distance of Scottish politics for years to come. In a sense, this is convenient for Davidson, because she will remain the strongest voice on one side of the only real issue in town. She can make further inroads into the heartlands of a Labour Party that, at a UK-wide level, is strangling itself to death, while picking up SNP voters who lose patience with Sturgeon when she blames every problem with the National Health Service or schools on London.

Theresa May is not nearly so good a bogeyman for Sturgeon as Cameron was. Davidson gets on well with her despite some stylistic differences. Both are observant Christians and care about their duties to the Tory flock. When May came to Scotland to meet Sturgeon in the week after she became Prime Minister, she also attended a meeting of local Conservative members, which Davidson greatly appreciated (Cameron wouldn’t have done such a thing). Davidson has not, as May has, marinated for years in local Tory association meetings but she takes her responsibility to the membership seriously, in the manner of a general concerned with the troops’ morale.

Yet a referendum that is always two years away is one that she can never win or lose. It is hard for her to come up with distinctive ideas when there is little point devoting effort to envisioning a policy agenda that will be distorted through the prism of independence. Given the odds that she overcame to take her party to where it is now, nobody should dismiss the chance that she might one day become first minister. But Scottish politics is defined by long periods of single-party hegemony and the SNP under Sturgeon may well have just started its turn.

Then there is the option of running for a (Scottish) seat in Westminster. Davidson says that she has no interest in swapping Edinburgh for London, either politically or personally, and I believe her. Yet there may come a point at which she is forced to confront the possibility that this is the only way to escape a career in permanent opposition. She might also come to see it as the best way to defend the Union. Sturgeon has suggested that there is no longer any such thing as British politics. What a rebuke it could be to that idea to have one of Scotland’s most popular politicians in the cabinet at Westminster, or, indeed, in 10 Downing Street (a possibility hardly less plausible than Davidson’s elevation to first minister). On the other hand, Davidson may leave politics altogether. She was strikingly keen to emphasise, in our interview, that at some point she will seek an entirely new challenge.

We like to think that the best politicians will somehow find their way to power – that talent will rise to its appropriate level. But Davidson has only two paths to high office open to her: becoming first minister, or quitting Edinburgh for Westminster. Both are exceedingly steep. If she cannot or will not take either, in decades to come she may be remembered as we now recall her performance at Wembley: a firework show, lighting up the landscape without changing it.

Ian Leslie’s “Curious: the Desire to Know and Why Your Future Depends on It” is published by Quercus. Twitter: @mrianleslie

Ian Leslie is a writer, author of CURIOUS: The Desire to Know and Why Your Future Depends On It, and writer/presenter of BBC R4's Before They Were Famous.

This article first appeared in the 29 September 2016 issue of the New Statesman, May’s new Tories