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22nd May 2026

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News and comment from

Roy Lilley



Disappointed...

_____________

Short on time? Get yer ears-on and listen to Roy Lilley read this morning's eLetter... free!

Paul Goldsmith sent me the manuscript for his new book


What do you think’… he said.


Well, Dr Goldsmith, having done my homework, read, it… I am pleased to report; I think it’s fascinating, thought provoking, I learned stuff and thank you!


The book, The Evolving Brain, is an ambitious and I think, successful attempt to reconcile two stubborn facts I hadn't really thought about.…


… the human brain is ancient, and the world it now inhabits, is not...


... and that explains a lot. 


The central proposition… that much of modern distress stems from a mismatch between our evolutionary wiring and contemporary life… is intriguing. Goldsmith gives it clarity, clinical grounding and a narrative that drives through the pages.


From the outset, he frames the paradox neatly…


…unprecedented prosperity, connectivity and knowledge sit alongside rising anxiety, burnout and dissatisfaction…


… his answer is disarmingly simple...


...the brain is not designed for happiness; it is designed for persistence.  


Ouch!


Yup… everything else; emotion, motivation, even meaning, is subordinate to that evolutionary imperative... persistence.


Where the book stands out and in its readability, is its structure.  


Rather than a loose tour of neuroscience, Goldsmith gives us an understandable, ‘inside-out’ model… starting with the most primitive circuits and then, layering-up our understanding. 


Chapters such as;


The Continuity Brain, 

The Motivating Brain and 

The Melancholic Brain…


… give the work coherence and momentum.


I’m no doctor nor nurse but it strikes me, at first go-around clinically, the book is at its strongest, but …


… for managers of people, understanding them better is a good place to start and starting with this book is a good place. 


Case studies;


  • patients with motor neurone disease,
  • stroke-induced apathy,
  • Parkinsonian syndromes...


... are Goldsmith’s explanatory tools. Through them, Goldsmith reveals how motivation, movement and mood are inseparable. 


A patient who cannot initiate action is not lazy or depressed in the colloquial sense; their dopamine system has lost its grip on behaviour. 


It’s a powerful answer to the moralising language that often unhelpfully, stains mental health sufferers, but does not impede patients with physical health needs.


The discussion of dopamine is especially good.  


Goldsmith resists the pop-science temptation to caricature it as a ‘pleasure chemical.’ 


Instead, he presents it as a calibration system… tracking effort, reward, and prediction error. 


The insight that satisfaction comes not from achieving goals but from progressing towards them...


...is one of the book’s most useful contributions and why it is something every manager, leader, policy maker and politician should read.


Drip-fed happiness works best,’ Goldsmith argues. Drip-fed happiness, if only…


This feeds into one of the book’s most compelling arguments;


‘… modern life is structurally misaligned with how the brain generates motivation.’


We pursue distant, abstract, status-driven goals, often with poor feedback and long delays…



... managers please note…


… the brain, evolved for short cycles of effort and reward… delays mean chronic stress, disengagement, and what Goldsmith terms ‘melancholy’, as a signal to stop pursuing unproductive goals, (and targets).


On the one hand, that is liberating. It shifts the narrative from personal failure to biological context. On the other, does it risks oversimplification?  


It’s easy for social determinants, trauma, and structural inequalities to be underplayed. The book kindles a fascinating debate…


... exactly what books are supposed to do and this book does it, very well.


Goldsmith insists this is not a self-help book, yet practical advice emerges throughout… 


  • break goals into subgoals, 
  • prioritise movement, 
  • seek rapid feedback, 
  • avoid passive rewards…


… I would like more of that from him.


Where the book really lands is in its critique of modernity.  Sounds pompous, I know but I'm talking...


... social media, sedentary work, and the pursuit of status are not just cultural phenomena, they’re what screws us up. 


We are born antiques, navigating a digital world has dawned on eminent predecessors;


  • Darwin laid the groundwork by arguing that human traits are shaped by natural selection. Not designed for modern civilisation.
  • Konrad Lorenz (a Noble laureate) discussed the mismatch between evolved instincts and modern society.  
  • Desmond Morris in ‘ Naked Ape' argued humans remained fundamentally Stone Age animals… 


… they all make the case; many modern behaviours are rooted in ancient adaptive mechanisms…


… but Goldsmith gives it renewed urgency, clinical credibility and practical application.


Readers like you and me, interested in health systems and getting the best out of the people who run them, there is an implicit subtext…


… if individuals struggle because environments are misaligned with biology, what does that say about how we design work, education and care? 


The Evolving Brain is thoughtful, readable and provocative. Absorbing and oddly hopeful…


… we can't change the brain we have, but we can change how we live with it.


You can buy the book here… and you should, you won't be disappointed!


Have the best weekend you can.

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Mayor of Greater Manchester

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Tony Blair Institute

Rob Webster

ICB CHEx

Sarah Woolnough

CEO of the King's Fund

Sir Jim Mackey

Dame Jennifer Dixon

Lord Darzi

Professor Tas Qureshi

Dr Penny Dash,

chair NHSE

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Insomnia


'... we have all lain in bed watching the clock and seeing the hours tick away...'  

News and Other Stuff

---

>> Growing unease - about the future of stroke care.

>> Chair of Barts Health Trust criticises “lack of structure” on neighbourhood health - as someone who lives in the Bart's bailiwick, it's hard to see how neighbourhood will be defined, other than by brutal geography and administrative convenience.

>> CQC warns Health Bill could leave it fighting itself in court - as if we really care what they think?


Tissue Viability, Heel Project












This is what I'm hearing, unless you know different. In which case, tell me, in confidence

__________


>> I'm hearing - In 2024 a total of 11 million fit/sick notes were issued in England in 2024. Of these, 93% declared the person “not fit for work.” It'll be interesting to look at the numbers of the new trial areas and changes.

>> I'm hearing - Nurses at this year's RCN congress have voted to challenge the increase in the NMC annual registration fee, branding it ‘unacceptable’ and ‘soul-destroying’. Thinking about the cost of living the NMC are spectacularly tin-eared.

>> I'm hearing - Burnham’s team is working on a plan for his first 100 days in government in the event that he wins and replaces Keir Starmer, the plan is in its early stages but is likely to include reforms to the creaking social care system.

More News

...

>> Royal Cornwall adopts digital tool - to help identify liver disease risk.

>> A dozen ICBs and clusters have set up a live ringfenced “left shift” fund in 2026-27 - One cluster axed a £33m fund within 24 hours of formally approving it.

>> Why Have All the Doctors Gone? Insights Into Early Clinical Departure Among Physicians in the United States: A National Survey - this is really important. All the reasons we hear, here are duplicated in the US. Looks like AI can't come quick enough!

>> The CQC has just admitted that no one is checking NHS staff are calling patients by preferred names - really? How about making the places safer, too.

My Substack

Three Minute Read

'Pride'

Perhaps they could use Penderyn...

'Biscuit-Boy', wasting everyone's time, 'visiting a hosptial'... as usual, in London. I wonder if they had any Jaffa-cakes?

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