Balls and Cable sound the alarm over HS2. Who will U-turn first?

It is no longer unthinkable that one or both of Labour and the Lib Dems could go into the next election pledging to scrap the project.

High Speed 2 is an increasingly rare example of an issue on which there is a consensus among the three main parties. But Peter Mandelson's recent rejection of the project as an "expensive mistake" and the 25% rise in its estimated cost to £42.6bn (even before a shovel has touched the ground) has created the space for a more nuanced debate about its costs and benefits. 

So it is striking that both Vince Cable and Ed Balls are now making sceptical noises. Cable told Today this morning:

Well, the case for High Speed 2, which is still being made – I mean, the figures, as you know, are being revisited – have to meet a standard of cost/benefit analysis which the Treasury seeks, and which meet the requirements of the Green Book, as it’s called, on public investment.

And Balls told the FT:

We need to keep a close eye on value for money. I am concerned about the rising costs. As a Leeds MP I can see the benefits for the region and the north of England, but it is not a blank cheque...we have to know the benefits justify the expenditure, so therefore value for money continues to be an important test for me.

It would be wrong to assume that Balls is preparing the ground for a Labour U-turn. Ed Miliband remains personally supportive of the project and HS2 evangelist Andrew Adonis, the party's shadow infrastructure minister, who Miliband has just appointed to lead a growth review, is also determined to prevent any backsliding. But it is no longer unthinkable that one or both of Labour and the Lib Dems could go into the next election pledging to scrap the scheme. In these straitened times, £42.6bn is not to be sniffed at. As one Labour MP recently put it to me, "just think how many houses we could build with that". 

A placard placed by the Stop HS2 Campaign sits in a hedegrow near to the planned location of the new high speed rail link in Knutsford. Photograph: Getty Images.

George Eaton is political editor of the New Statesman.

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The surprising truth about ingrowing toenails (and other medical myths)

Medicine is littered with myths. For years we doled out antibiotics for minor infections, thinking we were speeding recovery.

From time to time, I remove patients’ ingrowing toenails. This is done to help – the condition can be intractably painful – but it would be barbaric were it not for anaesthesia. A toe or finger can be rendered completely numb by a ring block – local anaesthetic injected either side of the base of the digit, knocking out the nerves that supply sensation.

The local anaesthetic I use for most surgical procedures is ready-mixed with adrenalin, which constricts the arteries and thereby reduces bleeding in the surgical field, but ever since medical school I’ve had it drummed into me that using adrenalin is a complete no-no when it comes to ring blocks. The adrenalin cuts off the blood supply to the end of the digit (so the story goes), resulting in tissue death and gangrene.

So, before performing any ring block, my practice nurse and I go through an elaborate double-check procedure to ensure that the injection I’m about to use is “plain” local anaesthetic with no adrenalin. This same ritual is observed in hospitals and doctors’ surgeries around the world.

So, imagine my surprise to learn recently that this is a myth. The idea dates back at least a century, to when doctors frequently found digits turning gangrenous after ring blocks. The obvious conclusion – that artery-constricting adrenalin was responsible – dictates practice to this day. In recent years, however, the dogma has been questioned. The effect of adrenalin is partial and short-lived; could it really be causing such catastrophic outcomes?

Retrospective studies of digital gangrene after ring block identified that adrenalin was actually used in less than half of the cases. Rather, other factors, including the drastic measures employed to try to prevent infection in the pre-antibiotic era, seem likely to have been the culprits. Emboldened by these findings, surgeons in America undertook cautious trials to investigate using adrenalin in ring blocks. They found that it caused no tissue damage, and made surgery technically easier.

Those trials date back 15 years yet they’ve only just filtered through, which illustrates how long it takes for new thinking to become disseminated. So far, a few doctors, mainly those in the field of plastic surgery, have changed their practice, but most of us continue to eschew adrenalin.

Medicine is littered with such myths. For years we doled out antibiotics for minor infections, thinking we were speeding recovery. Until the mid-1970s, breast cancer was routinely treated with radical mastectomy, a disfiguring operation that removed huge quantities of tissue, in the belief that this produced the greatest chance of cure. These days, we know that conservative surgery is at least as effective, and causes far less psychological trauma. Seizures can happen in young children with feverish illnesses, so for decades we placed great emphasis on keeping the patient’s temperature down. We now know that controlling fever makes no difference: the fits are caused by other chemicals released during an infection.

Myths arise when something appears to make sense according to the best understanding we have at the time. In all cases, practice has run far ahead of objective, repeatable science. It is only years after a myth has taken hold that scientific evaluation shows us to have charged off down a blind alley.

Myths are powerful and hard to uproot, even once the science is established. I operated on a toenail just the other week and still baulked at using adrenalin – partly my own superstition, and partly to save my practice nurse from a heart attack. What would it have been like as a pioneering surgeon in the 1970s, treating breast cancer with a simple lumpectomy while most of your colleagues believed you were being reckless with your patients’ future health? Decades of dire warnings create a hefty weight to overturn.

Only once a good proportion of the medical herd has changed course do most of us feel confident to follow suit. 

This article first appeared in the 20 April 2017 issue of the New Statesman, May's gamble

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