Community Scoop

Speech: Powell – DHBs

Speech – Association of Salaried Medical Specialists



Thank you for the opportunity to address you again. As always my comments are personal observations although in broad terms at least I believe they are consistent with the Association’s view on the matters discussed.

There are several issues which we could discuss today. One is the future of district health board mergers. Does the merger of Otago and Southland into Southern provide a sound model for other DHBs and does it herald further mergers? I think not in both respects and it appears the Government’s National Health Board holds a similar view at least in respect of the first question. Another is the future of Pharmac under threat from American interests in the Trans Pacific Partnership Agreement negotiations with unhelpful mixed messages from the Prime Minister and Minister of Foreign Affairs.

But, while happy to comment on these important issues, my theme today is why we need to progress our health system from what I call its pecksniffian state to put it another way, to our DHBs having at their very core, distributive clinical leadership (or, to quote Minister of Health Tony Ryall, clinical leadership from ‘bedside to boardroom’). American revolutionary Thomas Paine can offer us helpful advice. More specifically it is about our national multi-employer collective agreement (MECA) negotiations with the 20 DHBs, about getting the DHBs to adhere to government and their own policies on distributive clinical leadership, and about implementing the blueprint for turning our health system around and getting it out of its workforce crisis. This crisis is the greatest impediment to the quality and cost effectiveness of our health system.

One of my current fads is receiving the ‘word of the day’ from Dictionary Online. An interesting word applicable to this presentation is pecksniffian, an adjective meaning hypocritically and smugly affecting benevolence or high moral principles. It is named after Seth Pecksniff, a character in Charles Dickens’ 1843 Martin Chuzzlewit, a novel (1843). Sadly there are elements and layers within DHB whose smugness and moralistic highhandedness has sufficient influence to obstruct the pathway towards distributive clinical leadership because either they pretentiously believe they already have it or they simply don’t agree with it (it does not square with their managerialism ethos). They need firm direction, referral to a ‘re-education’ centre, or offloading.

Is it too early to say?

I was interested to read recently the debunking of the famous saying of former longstanding Chinese Premier Zhou Enlai who, during Richard Nixon’s visit to Beijing in 1972, was asked about the impact of the French Revolution. Speaking of an event that took place nearly two centuries previously, Zhou famously commented that it was “too early to say”. The witticism quickly became a standard way of emphasising the Chinese ability to take the long view in history.

Yet it seems that Zhou may not have correctly understood the question. Rather than referring to the 1789 revolution, his questioner was speaking of the events of May 1968, and the Chinese leader’s comment was directed toward that much more recent development. Apparently the misunderstanding was “too delicious to invite correction”. I can understand this.

But it does highlight how misstatements and misunderstandings can become the basis of perceived fact. Analogies come to mind in respect of assertive embellishments over the extent of clinical leadership in DHBs. The survey of ASMS members conducted by Dr Robin Gauld last year on the application of the government’s policy statement In Good Hands on clinical leadership in DHBs showed that the performance of DHBs can best be described as ranging from poor to mediocre – this is in dramatic contrast with perceived facts and provide a wake-up call for those in decision-making who are not irretrievably addicted to sleeping pills.

Dissecting the Blueprint (the Business Case)

Integral to our national MECA negotiations, which commenced well over a year ago, were four joint workshops held mid-last year. These proved to be both constructive and productive and provided the basis for the ASMS and the 20 DHBs jointly developing an agreed document last November titled Securing a Sustainable Senior Medical and Dental Workforce in New Zealand: the Business Case.

In our assessment, the Business Case provides the blueprint for the future direction of a clinically and financially sustainable public hospital system (in a broad sense of the term hospital including its community and primary care interactions and integrative connections) by addressing our senior doctor and dentist workforce crisis in DHBs and providing for distributive clinical leadership consistent with the 2008 Time for Quality agreement between the ASMS and DHBs and the commendable In Good Hands (2009). The Business Case provides the wherewithal to transform these documents from noble aspirations to practical delivery, something we would expect would delight the Minister.

The first part of the document is to highlight the unsustainable nature of the health system. In 2009 Dr Robin Gauld published an article noting that DHBs have a specialist workforce crisis. Both before and subsequently this was also recognised by no less than Mr Ryall who acknowledged last year that we have a specialist workforce crisis in DHBs, that we need to maintain more of our “hospital specialists” and that addressing this crisis is his number one priority. The word crisis is used carefully in the Business Case in the pending sense of the term. It is not a state of disaster or collapse but a state of circumstances sufficiently serious to lead to disaster or collapse.
The second part examines the potential substantial gains (including financial) by making an upfront investment in senior medical staff remuneration as part of the national DHB MECA negotiations.

The Business Case records a series of facts which reinforce Mr Ryall’s assessment which include that New Zealand was short of well over 600 specialists (secondary/tertiary) in 2008 according to international benchmarks and that out of 26 specialties (and sub-specialties) where data is collected, 19 require workforce increases of more than 20% to meet the recommended specialist-to-population ratios (eight of which require increases of more than 50% and four require increases of at least 100%).

New Zealand has the second highest emigration of doctors in the OECD and, in attempting to fill the gaps, the highest dependency on overseas trained specialists (41% of the medical workforce).

According to DHB data, over recent years a large majority of the around 300 new specialist registrations per year are being employed, at least in part, by DHBs but resulting in an average net loss of DHB specialists. The Business Case assumes that, allowing for fluctuations, the DHB employed workforce outflows equals the inflows. New Zealand has, in effect, become a medical training ground for other countries, especially Australia which each year attracts an estimated 280 New Zealand doctors (including international medical graduates).

Retention rates of international medical graduates (IMGs) are poorer than New Zealand trained specialists. Whereas around 84% of a cohort of New Zealand doctors with vocational registration are retained in the country nine years post-registration, only two-thirds of vocationally registered IMGs are retained over the same period.

In noting New Zealand’s high dependence on IMGs, a 2006 OECD report concluded that given the relative small size of our health workforce and heavy reliance on immigration, “a sudden change in the international migration flows, which could result from policy changes in OECD countries beyond the control of New Zealand authorities, could have a dramatic impact on New Zealand.” The same OECD paper also conservatively estimates 29% of New Zealand trained doctors are working overseas.

Remuneration is becoming an increasingly important “push” and “pull” factor. While, 80% of a 2002 cohort of anaesthesia trainees’ had intended to eventually work as specialists in New Zealand, only 64.5% were working in New Zealand seven years later. In 2002 13% stated Australia as their preferred destination, but by 2009 26% were still working there. In the 2009 survey 75% of respondents currently working overseas agreed or strongly agreed that salary was an important influence in choosing their country of residence.

[As an aside Australia is a major threat to all medical specialties except for those where there are vibrant lucrative private practice options (the threat here is the reduction of time in the public sector in order to earn more in private). I note that the threat to hospital and community dentistry is the mix of poor workforce planning and attractive opportunities in private dentistry. ]

The Business Case notes that the lack of adequate time for specialists to enable quality supervision of resident doctors and dentists is contributing to job dissatisfaction of the latter. The requirements of service delivery too frequently take precedence over RMO training.

Adverse events were estimated in 2002 to cost New Zealand $870 million per year, of which $590 million was due to potentially preventable events. While a range of factors contribute to this, there are many examples indicating specialist staffing levels is an important factor.

What happens if the current crisis continues

The Business Case describes how these problems will escalate with increasingly negative consequences if this crisis continues, including:
1. The heavy dependence on IMGs will remain and increase, escalating the high turnover of senior medical staff and increasing the current level of wasteful expenditure by DHBs.

2. New Zealand’s health workforce (and therefore services) will remain vulnerable to the effects of the competitive overseas market and the vulnerability of New Zealand’s health system, most severe on provincial DHBs and specialties where staff are already hard to find.

3. Continued and increasing heavy reliance on locums, along with the associated increased costs, will worsen lack of continuity of services; put additional pressures on permanent staff; and limit any effects of improving training and supervision, and developing clinical leadership, multidisciplinary teams and clinical networks.

4. Continued shortages of specialists will nullify efforts to reduce adverse events. With preventable events estimated to cost $590 million a year, an opportunity to improve safety and quality while creating savings will be lost. In fact, an increase in adverse events may be seen in some areas.

5. Some of the Government’s key health targets will not be achieved on a sustainable basis as they depend on an adequate supply of specialists across the whole range of specialties, and government objectives will be compromised.

6. Lack of time outside of clinical duties for specialists will prevent the establishment of comprehensive clinical leadership. This will hinder development of multidisciplinary clinical networks, deter reconfiguring services with a more regional focus, inhibit creation of more innovative ways to deliver services, and prevent integration of hospital and community based services. The considerable potential for improved cost-effectiveness and service performance, as indicated in overseas research, will be lost, and the counterfactual of slow, inefficient services will ensue.

This crisis is fiscally wasteful and unethical when considering the costs of training doctors. The Business Case notes that the current cost of training a doctor up to their final year as a registrar is estimated at approximately $1.5 million per doctor ($500,000 as an undergraduate and at least $1 million postgraduate). Across the spectrum of undergraduate and postgraduate training, about $500 million of government investment is graduating each year. There is no reason not to believe this situation also applies broadly to hospital and community dentistry.

The Government’s plan to increase the number of medical school places by a further 200 over the next five years equates to an additional investment of around $300 million. The loss to New Zealand of a relatively small number of New Zealand-trained resident doctors (and specialists) represents a loss of tens of millions of dollars of government investment.

Future state: pathway to addressing the crisis

The Business Case then focuses on achieving a ‘future state’ centered on the importance of developing a sustainable specialist workforce in DHBs and concludes that we need about 6,740 specialists in 2021 (a 52% increase on estimated current numbers) equating to a net annual increase of 232, mostly through improved retention.

It recommends that the ‘future state’ should include specialist numbers targeted at 1.4 per 1000 population as projected for Australia in 2021 (the current average for the OECD is 1.8) and, further, specialist – resident doctor & dentist ratios increasing from the current 1:1 to at least 2:1 and possibly 3:1 in some areas and specialties.

There should be a decreased reliance on short-term IMGs, and a decrease in overall numbers of IMGs while the current average non-clinical time should increase by 10% nationally.

The benefits of realising these components are, in summary:

• Stronger clinical leadership – recognising that when change is led by clinical leadership, the quality and cost effectiveness of care are improved, staff are energised by it and patients and the public more likely to support it.
• Integrated and collaborative models of care including improved patient journey, patient safety and service quality.
• Increased specialist role in the training of resident medical officers including improved recruitment and retention of both groups.
• Meeting of health targets and improved quality and safety.
• Substantial financial and economic benefits.

Achieving the sustainable ‘future state’

The complexity of public hospitals has grown immensely over several years. In 1970 at John Hopkins Hospital it was estimated that the number of doctors, nurses and other staff involved in the care of a typical hospital patient was 2.5 full-time equivalents. By the end of the 1990s it was more than 15. This highlights the changing demands on hospitals and increased quality and complexity of services provided. Senior doctors and dentists are the most specialised staff employed by DHBs and, more than other skilled occupational groups, are central to the cost effective management of this complexity. You and your colleagues are decisive in terms of avoiding the high potential of cost blow-out and the achievement of genuine efficiency.

Achieving the sustainable future state requires a financial investment in the senior doctor and dentist workforce in DHBs. However, this investment is modest – after a period of phased in implementation only 2% of current DHB funding levels for addressing what the Minister of Health has recognised as his top priority and which is expected to be recouped.

But this relatively small investment has the realistic potential to, over time, generate through improved cost effectiveness and reduction of wastage, savings which exceed this investment. The benefits identified in the Business Case for addressing what the government has identified as a crisis and its major health priority from this modest investment are profound both through a quality and financial lens. It is an untruth to argue that investing in the Business Case is unaffordable because it is a small proportion of total DHB funding and there are offsetting financial gains. It is also disingenuous to assert that the Christchurch earthquake has changed everything. After the devastating February earthquake the Minister of Health had advised DHBs that their individual funding levels for 2011-12 (as announced in their funding envelopes last December) would remain unchanged.

Some of these returns are ‘bigger ticket’ issues such as adverse events (the Government’s Ministerial Review Group in 2009 assessed potential annual savings of $800 million) based on the assumption that this investment should mean that a high level of savings should be possible over time predicated on preventing harm currently occurring in public hospitals.

Taking the lead from the ‘Canterbury initiative’ prior to the earthquakes when the workforce was stronger relative to other DHBs, specialist-led initiatives could result in savings of $300 million per annum.

Further, in respect of hospital beds, it notes that if all public hospitals were able to meet the current average length of stay, this would save 382 beds, effectively the costs of building an entire new hospital along with the associated ongoing capital charges and depreciation.

The Business Case also provides examples of smaller scale but cumulatively significant financial savings. As an example of wastage, DHBs spent in excess of $6 million on specialist recruitment and relocation during the 2009-10 financial year. By improving retention this level of annual expenditure can be significantly reduced. Further, DHBs spent in excess of $50 million on senior medical/dental officer locum costs, mainly to cover vacancies. With a fully staffed specialist workforce, locum expenditure could be significantly reduced by up to 50%.

The benefits for patients and for the financial sustainability of DHBs provided in the blueprint that is Securing a Sustainable Senior Medical and Dental Workforce in New Zealand: the Business Case are immense and far outweigh the cost of the investment in the senior medical and dental workforce necessary to achieve it. The challenge is whether our DHB and political leadership have the insight and awareness to make it happen.

Whither our MECA negotiations and ‘distributive clinical leadership’
I don’t want to go into the details of our negotiations for a new MECA with the DHBs or into our criticisms of their recent conduct. This has been said elsewhere and more forcefully than in this address. Further, there are signs that we might be able to get around the table again within the framework of the blueprint Business Case. But some summary observations are appropriate.
For much of the time since our negotiations began, following informal discussions with the DHBs in December 2009, the process with the DHBs has been positive and constructive. In fact, if it had continued in the way it began right up until early April this year, it might have provided a good model for other parts of the workforce. We had positive workshops mid-2010 followed by, on the initiative of the DHBs but consistent with the flavour of the workshops, the development of the joint Business Case late last year to fit in with the Government’s budget cycle.

It was endorsed by both parties. The chief executives on behalf of the DHBs identified only two qualifications – rather than seek additional funding from government they wanted to fund it from baseline funding (although surprised, given that the cost of investing in the Business Case was only 2% of the funding received for the services they fund and provide and that the investment was expected to eventually recoup this cost and more, this was not seen by us to be unreasonable) and they wanted a supplementary ‘operational document’ (something we were sympathetic to).

Good progress was made by the parties in the early months of this year working on applying the investment in the Business Case to the MECA and the ‘operational document’. Both parties expressed cautious confidence that we might conclude a settlement subject to ratification by the end of April.

Custard, bloody custard

Well, didn’t we get that wrong! We were conscious because of its original link with the budget cycle of the confidentiality of the Business Case, that we had not reported the details of the document to our members except in the most general form. Consequently, after discussing this well in advance with the DHBs and with their consent, we gave a full and positive report back in mid-April. Then unexpectedly the DHBs publicly distanced themselves from it in a way that contradicted our private interactions.

The proverbial hit the fan with things going to custard. Without recounting what has previously been said there were two things that particularly wounded us. First, the DHBs representative ran down the Business Case in the media, including describing it as merely a discussion paper (which they had agreed with us was not the case a few weeks earlier). Second, they released a media statement alleging that we had made a claim which would have costed a specified amount. This was not true. By agreement in the negotiations we had been developing a number of costing scenarios in order to assess what might be done with the investment identified in the Business Case. It would have been dishonest to have taken one of the DHBs’ scenarios and described it publicly as a claim; it should not have been done to us.

There are two possible explanations for this state of affairs. One is that the DHBs have deliberately misled and strung us along. While this is a common view I don’t agree. I know some of the individuals involved in the process too well to accept that this was deliberate. Further, I doubt their organisational ability to pull this off at a national level.

The other is that DHBs really struggle to coordinate nationally in an effective manner and within their hierarchy there are several differing elements. Further, the ethos of ‘distributive clinical leadership’ is something that some elements simply don’t get (or don’t like). With the Minister hammering them all the time over no more money, those that don’t comprehend or agree with ‘distributive clinical leadership’ are hardly going to be enamoured by the Business Case which is premised on the potential to improve cost effectiveness and make savings. The net result is dysfunction (or as some might say, the ‘cock-up’ rather than ‘conspiracy theory’).

Nevertheless it has been damaging and a major set-back. Our DHBs have exhibited signs of umbra in our negotiations with them – a noun involving a shadowy apparition or ghost-like image of someone or something not physically present. I am also reminded of a recent advertisement in a British newspaper:

Wedding dress for sale. Worn once by mistake. Call Stephanie.

Replace Stephanie with ASMS and this is what many on our negotiating team feel.
However, perspective is required. Things have not yet deteriorated to the acrimonious level of our last MECA negotiations in 2006-08 when we were dealing with inexplicable macho mania, attempts to claw-back on existing conditions and rights (and to impose a managerialism agenda), and the DHBs chosen advocate at that time was also holding down two chief executive positions in Southland and Vancouver (without either knowing about the other). Last month we had an informal meeting with key DHB leaders which, touch wood, was useful and we expect to resume this process soon.

High risks of failure

But the risks of failure are high. If the Business Case does not become the blueprint it deserves to be and if the DHBs do not agree to make the investment in their senior medical and dental workforce that is necessary to make it happen, then ‘distributive clinical leadership’ as a systemic feature of our health system (as distinct from the various impressive pockets that occur currently) is very unlikely to be achieved in the working life of all but the ‘spring chickens’ at best on our negotiating team. They would be looking to sell our wedding dress on ‘Trade Me’.

This is because of the loss of trust and confidence that too many of our leaders and too many of our members would have in the collective commitment of DHBs to clinical leadership beyond formal positions of leadership and tokenism. Trust and confidence is easy to lose but very difficult to get back.
I was struck by a discussion at the British Medical Association’s annual conference in June on industrial action where it was reported that the British legal definition of strike action includes “working without enthusiasm”. If this definition applied in New Zealand jettisoning confidence in the achieving of distributive clinical leadership might inadvertently contribute to widespread industrial action by senior doctors and dentists without anyone realising it.

This does not mean that senior doctors and dentists would not work with their managers and DHBs. But I am reminded of the witticism of the Chair of the BMA’s General Practitioners Committee, Dr Lawrence Buckman at the BMA annual conference. He was commenting on the preparedness of GPs to participate in discussions over changes to commissioning as a central part of an ill-advised massive restructuring of the National Health Service. Just because we are getting into the lifeboats with government that does not mean we support the sinking of the Titanic.

The crisis we face can’t be swept under the carpet. The bleeding of New Zealand of the quality specialists we train and our excessive dependence on international recruitment where, because of low salaries and other conditions, we are weak is unsustainable. Arguably it would make more sense to close a medical school in terms of fiscal responsibility. The influential European Observatory, which partners with the European World Health Organisation and European Union, noted last year that there is “little benefit in educating adequate numbers of doctors…and then seeing them migrate to other countries…because the working conditions are not attractive enough.”

In January I did a Che Guevara tour in Bolivia seeking inspiration for Plan B if our Plan A Business Case did not work. While a fascinating tour I learnt two important things. One was that I am built for comfort, not guerrilla warfare. Second, Che’s assessment of the failure of the mission seemed to boil down to not enough guerrillas and not enough guns. As much as I would like, somehow I don’t think we can apply this corrective measure to New Zealand (political correctness gone mad I say!).

The Minister will see his commitment to clinical leadership, including what should have been a landmark in the form of In Good Hands, as effective as his predecessors’ calls in their annual ‘Letters of Expectations’. The stakes are high for his credibility as well in this even though he is not a participant in the process. He would have ended up getting so close to his objective but, at crunch time, also so far away.

Getting DHBs out of their orgone box

I have puzzled over the DHBs’ conduct since late April and their national dysfunction but may have by chance seen the answer in a recent Guardian article on cult sexual therapist Wilhelm Reich. As well as author of the popular Sexual Revolution, he invented a bizarre machine which he called the ‘Orgone Energy Accumulator’, a wooden cupboard about the size of a telephone booth, lined with metal and insulated with steel wool. Reich believed his almost magical device could improve its users “orgasmic potency” and, by extension their general and mental health.

While Albert Einstein quickly concluded that the claims of its success contradicted all known principles of physics and rubbished it, the orgone box offering a form of pre-packaged sex became very popular in the United States, especially in the 1940s and 1950s, with adherents including Norman Mailer, JD Salinger, Allen Ginsberg, Saul Bellow, surprisingly Sean Connery at the peak of his James Bond fame, and (no surprise here) Woody Allen who installed his with carpet and who nicknamed it the ‘Orgasmatron’ in one of his films.

Aside from the irony of a promoter of sexual liberation (also a believer in UFOs) successfully encouraging a generation to shed its sexual repressions by climbing into a closet and, putting salacious innuendo to one side, for some reason reading this article gave me further insight into DHBs’ national dysfunction.

DHBs are not sufficiently unitary when working a national level, are diffuse in decision-making processes, suffer from variable leadership skills (from the good to the opposite), are under constant pressure (including political text terrorism) to continue to provide services while under severe funding constraints, and are expected to collaborate regionally and nationally with a legacy of fragmentation and localism. It is no surprise that a number of DHB leaders function as if their working life has been spent in a claustrophobic metal-lined box.

Continuous quality improvement

The way forward for DHBs as statutory bodies with the responsibility for the funding and provision of our public health system is to focus on continuous quality improvement in its core processes. This, rather than short-term decisions or searching for magic bullets is where the real quality and financial gains lie. But it will not happen until DHBs invest in the capacity building of our senior medical and dental workforce. Even Basil Fawlty would call this ‘bleeding obvious’ especially when in the context of total DHB funding it is only 2% to address the Minister’s top priority and introducing improvements that will recoup this investment.

As reported to the OECD Health Ministerial Meeting last October, OECD analysts distinguished between measures of a ‘command and control’ nature which can hold expenditures down in the short-term but do little or nothing to moderate the underlying pressures and may also harm access, equity and quality, and those which focus on further performance improvement in the system. The latter will only occur with the right investment in this workforce.

It is also worth noting that when the financial crisis hit in late 2008 New Zealand was in a much better position than most developed nations. Rand Europe has been engaged by the Department of Health in the United Kingdom to report on how European countries have responded to their health systems in the financial crisis. In developing its assessment two of the key indicators are used – unemployment and government debt. In both respects New Zealand had performed well at the time of the crisis – the lowest unemployment rate in the OECD and surpluses – making us well placed by comparison. The recession should not be used as a reason for not investing in the specialist workforce in order to achieve distributive clinical leadership. Instead the improved cost effectiveness is an important reason why we should invest.

Health Minister Tony Ryall has a role in achieving this. While not having a formal role in our negotiations, his objectives are affected by the outcome and he should be concerned about the high risk of losing the opportunity to achieve cost effectiveness while at the same time enhancing access, equity and quality. With the appropriate level of discretion he needs to encourage DHBs to recognise that the Business Case should provide the framework for the settlement of the MECA as a precursor for it becoming the blueprint for distributive clinical leadership.

Further, he should ensure that adherence to this blueprint becomes a core Key Performance Indicator for DHB Chairs and Chief Executives. We should be appointing (and dis-appointing) chairs and chief executives on the basis of whether they can embrace and inspire confidence in their commitment to distributive clinical leadership.

Tom Paine: custom, wisdom and time

One of the most influential books in political processes was Common Sense written by Tom Paine in 1776. This powerful publication shaped in a major way the American independence movement leading to the Declaration of Independence and the break from Britain. In his opening paragraph Paine noted that, in the context of using his book to promote the cause, the time was not yet right to win the day and there was a “formidable outcry in defence of custom”. He then affirmed sagely: “Time makes more converts than wisdom.”
Time did achieve conversion more quickly than Paine may have anticipated following the publication of Common Sense. Given the calls for enhanced clinical leadership of Mr Ryall’s predecessors, the recognition of distributive clinical leadership in successive MECAs, its further development in the Time for Quality agreement, its incorporation in the current Health Minister’s policy advice In Good Hands, and now the blueprint Business Case, the DHBs and the Minister need to come to grips with the fact that the system’s continued ‘defence of custom’ is passing its ‘used by date’. They risk regression through increasing loss confidence in their ability to provide the environment necessary for senior doctors and dentists to engage effectively in distributive clinical leadership.

If they are not careful they will put themselves in a position of zugzwang, a fascinating German word derived from chess and meaning a situation in which a player is limited to moves that have a damaging effect.
Time is up. The decision (or lack of) taken by DHB and government leaders will determine whether they have the courage and leadership calibre to provide the wherewithal to make distributive clinical leadership happen or whether the opportunity is lost and the cause is set back years. It is their call how they want to be remembered.

I prefer to try to see this through an optimistic lens. The glass is half full rather than half empty. If it does not seem so my father’s advice is apt – put a little whisky in it. In fact, I would prefer to still see the glass as half full even if there is no water in it and, further, no glass in my hand.

Ian Powell

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