We are developing the social individualist meta-context for the future. From the very serious to the extremely frivolous... lets see what is on the mind of the Samizdata people.

Samizdata, derived from Samizdat /n. - a system of clandestine publication of banned literature in the USSR [Russ.,= self-publishing house]

The NHS and the single thank-you

I was ill recently. In the end it was “just a virus” but I had symptoms enough one Saturday that I braved the local NHS walk-in centre. This is where you end up if you have the bad manners to get ill on a weekend.

It was functional, in its way. I was told there would be an hour-and-a-half wait and that is what it was. There are no doctors, only nurses, but they are skilled enough to determine whether you are likely to survive until Monday, or so I imagine. But the economics of this kind of place are such that every body through the door is nothing but a drain on resources, and no-one is making any effort to conceal this fact.

Truly it is a miserable place to be. I do not expect a medical waiting room to be jolly, but I saw not the merest hint of a smile from any staff, and the receptionist was very grumpy about my address being out of date on her computer. There is no welcome; no sympathy; no bedside manner.

If you want to find a deep root cause of problems with the NHS, I submit the inevitable hatred of the staff for the burdensome customers.

Here is another piece of evidence: when I said “thank-you” to the nurse, she replied, “you’re welcome.”

Why is the National Health Service in crisis?

This post was written by my regular correspondent “ARC”, who has several family members working in the NHS. – NS

I’ve been discussing the NHS A&E issue that’s been in the news of late with the medically knowledgeable and NHS-aware members of my family and thought you might be interested in their background information, so have written it up while the conversations are still fairly fresh in my mind. I summarise, then give my own thoughts at the end.

The immediate cause of the NHS A&E issue being such a story in the media at this time (other than the upcoming election, of course) is simply that at Christmas a great many staff take holidays. The resulting shortfall exposes long-term trends in an area under pressure. There is no other immediate cause, as distinct from long-term trends: these problems have been growing for 15 years and more as follows.

1) Flow-though is crucial to A&E: you must get people out the back-end of the process to maintain your rate of input to the front-end. However ever-increasing regulations mean a patient without family cannot be released until a boat-load of checks have been done. This is clogging up the back end. It may be preventing the release of a few who had better not be sent home yet (not much and not often, is the general suspicion) but it is definitely delaying hugely processing the release of all others who could be. All this admin takes time and effort – delaying release and also using up time of staff in non-health work – and costs money.

This effect needs to be understood in the context of the 15-years-older story of the destruction of many non-NHS nursing homes by galloping regulation. These homes were mostly owned and operated by senior ex-NHS nurses and provided low-grade post-operative care. The NHS relied on them as half-way houses to get patients out of NHS hospitals when they no longer needed intensive care but were not yet recovered enough to go home. These nurses did not want to spend time form-filling instead of caring for patients, and for each home there was always one of the 1000+ rules that was particularly hard for that given home to meet without vast expense or complication. So they died one by one. The ‘waiting times have increased’ story of Tony Blair’s early-2000 years – “If the NHS were a patient, she’d be on the critical list” – was caused by this and the resultant bed-blocking more than any other one cause.

A more recent context is over-regulation of local councils’ social services leading to declining throughput, unrealistic expectations for their visit times, etc., and there have also been some social services cuts by said councils. These also have an impact on a hospital’s ability to get people out of the back-end to free up beds for A&E incomers.

2) The new 111 service is sending many more patients to A&E.

2.1) The service’s advice is very risk averse. The people who set up the process were afraid of the consequences of the statistical 1-in-a-million time when anything other than mega-risk-averse advice would see some consequence that would become a major news story blaming them.

2.2) Thanks to the post-1997 reforms, GPs work less hours on-call but the doctors are not just slacking off and doing nothing. The huge growth in regulation means they are in effect putting in as many hours as before, but on form-filling and admin to provide all the info the NHS and other government demand, to ensure they tick every box, etc. The out-of-hours on-call time they used to have is now swallowed by this work. So they are not in fact working less; it is the balance of what they are working on that has changed: less on healthcare, more on admin. Thus 111 must send people to A&E, not an on-call GP (and, of course, fewer on-call GPs mean more people phone 111).

3) Regulation prevents fixing the problem as well as causing it. A Birmingham hospital (Queen Elizabeth in Edgebaston IIRC), said to be very efficient as such things go, tried to create a low-level care unit precisely to solve the problem. Because of the regulations, the attempt had to be abandoned – they just could not tick all the boxes.

4) Back in the early-80s, when my sister (a doctor) did her elective in A&E, she loved it. Now, doctors are avoiding A&E as a speciality because they know how brutal is the pressure there. So the problem is beginning to compound itself.

There is a great deal more one could say, but the above are what my informed relations see as the key immediately-relevant causes. So far my summary. Now some thoughts of my own.

What I observe has most changed in the last two decades in these either left-leaning or were-left-leaning people is firstly their belief that “No party can fix it”. (This I heard from a previously definitely-left individual who would probably still cut her hand off before it voted Tory and whose heart wavered between Labour and [Scots] Nats although her head despises Nats ideas and despairs of Labour.) There is an expectation that no likely government will do anything other than talk of reform while actually causing yet more regulation. Some of this in some of them might be a reluctance to think that the side of politics they’ve loved to hate in the past might be the place to look for an answer (I am reminded of Gore Vidal in 1979, “I feel the despair of coming to think that the Soviet Union may be as despicable as the U.S.” – quoted from memory) but it also reflects their opinion that the Tory-led coalition has failed to reverse any of the above trends, and this opinion I fear is not mere prejudice but has a basis in their experience of the last three years, just as much of the above reflects their experience of the last 15 years.

Secondly, they report a widespread belief within the health service that this time “a bit of money can’t fix it”. There is no expectation of an ocean of money (and – I sense – awareness that the NHS already consumes an ocean of money, so can hardly demand another ocean of money even as a righteous goal, however impossible to arrange).

Lastly, I know that behind all this inefficiency of regulation, there lurks a compounding problem of looming social trends. The number of patients who have no family ready to help is rising. The promise that the state will look after all has led more people to lead lives that make no other arrangements. But these long-term trends are not the reason the NHS operates much worse now than two or three decades ago.

The Dance of the Deaf

Reported in yesterday’s Daily Mail:

Company bosses who claimed £130,000 in benefits for sign language interpreters despite not being deaf walk free from court

Two company directors who pocketed tens of thousands of pounds in taxpayers’ money from bogus claims for sign language interpreters have swerved prison.
Tracy Holliday, 39, and Ian Johnston, 43, sent their children to private school off the back of the £134,000 they made from bogus claims for interpreters and support staff they did not use.
Despite their crimes being branded ‘sickening’ by the Minister for Disabled People, the pair have walked free from court on suspended sentences.

The Northern Echo has the same story, although Ms Holliday’s name is given as “Tracey”, as it is in several other sources.

This being the Daily Mail, everybody is outraged about everything. The Mail commenters are outraged that the couple committed the fraud, that they escaped jail, and that they get to keep the money. “People like this are crippling our welfare system by stealing from us daily – they never suffer any kind of real punishment and so it will continue,” runs a typical comment.

The Minister for Disabled People, Mark Harper, shares the commenters’ outrage and manages to get in a plug for the Access to Work scheme the defendants were abusing, “This is a sickening example of two people milking a system designed especially to support disabled people to get or keep a job. ‘Access to Work helps over 35,000 disabled people to do their job. More and more disabled people are getting into work thanks to this fund and our Disability Confident campaign – as employers recognise the tremendous skills they bring to business.”

Even Ms Holliday and Mr Johnston themselves manage a little hopeful outrage, over the way that that they were, they say, obliged by family circumstances to plead guilty with all its potentially unpleasant consequences (not that the actual consequences for them were much more than bad publicity), when really they just didn’t get how the system worked and hadn’t noticed the illegitimate origin of all that cash piling up in their bank accounts.

No one seems outraged or even surprised by the idea that even if Ms Holliday and Ian Johnston’s claims had been genuine, their company would be getting services worth approximately forty-five thousand pounds a year provided by the government to make it worth their while to employ deaf people who could not do their jobs without an interpreter. You don’t get 45 grand per annum to make it worth your while to employ monolingual Tagalog speakers, although by some counts the number of people in the UK whose first language is British Sign Language and whose first language is Tagalog is similar. You might argue that, unlike those who have a foreign mother tongue, deaf people have a disability making them deserving of state aid to compensate for their misfortune – but if you did you would be contradicting Deaf (note the capital D) activists who maintain that deafness is not an impairment but a cultural choice, not to mention government guidelines on how to refer to the Deaf community.

Nobody seems to give any credence to Holliday and Johnston’s claim that they just did not realise that what they were doing was wrong. Could they really be capable enough to run a business and yet still be under the impression that the government would every year squirt tens of thousands of pounds in their direction without checking how it was spent, just because some of their employees were deaf?

Be fair, why should they not have received that impression since that is indeed the way the system is meant to work?

Here is an almost spookily similar case from 2008. Notice how the culprits in that case sought out employees disabled enough to qualify for the Access to Work benefits. Applicants who could not apply for AtW support were ignored. Notice also how the real business of the “businesses” in both cases was subsidy farming. There are thousands of deaf employees and employers doing real work, providing things that people both deaf and hearing really want enough to pay for – including, of course, translation between signing and English. There are no doubt thousands more who would like to do likewise, but the mushrooming of “Community Interest Companies”, “Social Enterprises” and similar much subsidised and little scrutinised sources of employment has normalised a sort of performance dance choreographed to look like people working. Deaf employees, sign language interpreters, support workers, and those whose jobs depend on administering and policing Access to Work and similar schemes all join the dance, gracefully exchanging partners until La Ronde is complete.

NHS Kremlinology

Back in the bad old days, Kremlinologists used to try to figure out what was going on in the leadership of the USSR by observing signs and portents.

During the Cold War, lack of reliable information about the country forced Western analysts to “read between the lines” and to use the tiniest tidbits, such as the removal of portraits, the rearranging of chairs, positions at the reviewing stand for parades in Red Square, the choice of capital or small initial letters in phrases such as “First Secretary”, the arrangement of articles on the pages of the party newspaper “Pravda” and other indirect signs to try to understand what was happening in internal Soviet politics.

To study the relations between Communist fraternal states, Kremlinologists compare the statements issued by the respective national Communist parties, looking for omissions and discrepancies in the ordering of objectives. The description of state visits in the Communist press are also scrutinized, as well as the degree of hospitality leant to dignitaries. Kremlinology also emphasizes ritual, in that it notices and ascribes meaning to the unusual absence of a policy statement on a certain anniversary or holiday.

Brian Micklethwait has often written of the “sovietisation” of various parts of the British State such as state schools and the NHS. To illustrate this process, take a look at the way a “major incident” at Colchester Hospital has been reported.

What major incident you ask? My point exactly: you ask, they don’t answer. Likewise “safeguarding” is repeatedly mentioned. Something needs to be safeguarded.

Late last night or early this morning there were oracular bulletins from the Telegraph and Times, all chock-full of unspecified “incident”. From the Times:

On Wednesday, the Care Quality Commission (CQC) inspected Colchester Hospital’s accident and emergency department and emergency assessment unit and told trust it had concerns over “safeguarding” there.

The major incident is likely to last for a week, and the trust has reminded members of the public to only visit A&E if they have a “serious or life-threatening condition”.

A spokesman for the hospital said the inspection was not the sole reason for the major incident being declared, although it played a role.

All clear now? There was a similarly opaque article on the AOL homepage. It has been updated since, as has the Telegraph one, I think, but the Times, like a good horror movie, is delaying the big reveal.

The BBC followed suit: “Colchester Hospital declares major incident.” The BBC did tell us what sort of general thing might constitute a “major incident” but not about this major incident. As a result everyone thinks it’s ebola and as I write this it’s the most looked-at article on the BBC website.

Stand down. It’s not ebola. The Guardian was slow to get the story but does actually tell it:

A major incident has been declared at Colchester hospital after a surprise inspection this week found patients being inappropriately restrained and sedated without consent and “do not resuscitate” notices being disregarded.

The ward concerned has been closed to new admissions, an emergency control centre has been put in place to address capacity problems, and patients are being urged to go to A&E only if they have a serious or life-threatening condition.

Inspectors from the Care Quality Commission (CQC) found that the Essex hospital is struggling with “unprecedented demand”, but the Guardian understands concerns were also raised about safeguarding issues relating to inappropriate restraint, resuscitation and sedation of elderly people, some with dementia.

Oh dear, what a let down. Just as it used to in the days of Pravda and Izvestia the secrecy concealed mundanity. It’s just the NHS in crisis again. Can’t they do anything right? The zombies they make aren’t even dead yet.

Call that an epidemic? This is an epidemic.

This is how in 1918 Times readers first found out about Spanish flu:

The Times 3 June 1918 p5

The Times 3 June 1918 p5

You can say that again. It ended up killing 40 million people.

Incidentally the Wikipedia page on the subject is an appalling mess. At one point it claims that it began on the Allied side of the front, at another that it began on the Central Powers’ side. At one point it claims that it was particularly lethal to those with strong immune systems and at another to those with weak immune systems.

Having said that I love the suggestion that it was called Spanish flu because that was the origin of the first reports of the disease. It was the origin of the reports not because it was the first place to get the disease but because wartime censors did not want to encourage the enemy by admitting its presence.

So, it’s possible that this was not how Times readers first found out about it.

A tale of two paradigms

Here is an interesting observation by Jo Nova of two sets of reactions in an article titled Company stops Ebola, Bureaucracy puts it on a plane:

The rubber plantation has 8,000 workers with 71,000 dependents. It is an hour north-east of Monrovia, surrounded by Ebola outbreaks. The virus arrived on the plantation in March. Knowing that the UN and the Liberian government were not going to save them, the managers sat around a rubber tree and googled “Ebola” and learned on the run instead. They turned shipping containers into isolation units, trucks into ambulances, and chemical cleaning suits into “haz-mat” gear. They trained cleaners, and teachers, they blocked visitors, and over the next five months dealt with 71 infections, but by early October were clear of the virus. There were only 17 survivors (the same 70% mortality rate as elsewhere). But without good management, there could have been so many more deaths.

In contrast, the nanny-state takes a good brain and stops it thinking. In Texas, trained health professionals were caught unprepared, following inadequate protocols they assumed were good enough, and even risking their own lives. A nurse who cared for a dying Ebola patient — and knew how bad Ebola could be — still needed to phone someone to ask if it was OK to board a plane with a slightly raised temperature (99.5F or 37.5C). The official she spoke to “didn’t Google”, they just said yes because her temperature was lower than the official threshold of 100.4F.

Read the whole thing.

A bet on Ebola

Bryan Caplan, over at the EconLog blog, has issued a sort of challenge to folk in the US getting worried about Ebola:

Mainstream scientists assure us that Ebola poses very little threat to Americans; unless you’re a health worker who cares for the infected, Ebola is almost impossible to catch in a rich, modern society.  Yet many populists and borderline conspiracy theorists are convinced that the experts are seriously understating the danger.  In their contrarian opinion, we desperately need to close the border now. Fortunately, this is an easy argument to put to a bet. My tentative offer: $100 says that less than 300 people will die of Ebola within the fifty United States by January 1, 2018.  I’m willing to switch to “Unless the U.S. changes its Ebola-related policies, $100 says that less than 300 people will die of Ebola within the fifty United States by January 1, 2018,” but then we’d have to carefully define what policy changes count.

Leaving aside what you think about the specifics of the Ebola case, this idea of economists and other commentators making hard financial bets on specific claims has the merit of injecting a certain edge to proceedings. There is nothing quite so much like a bet to make people prove they are convinced of something. And as the late Julian L Simon proved when he bet against a neo-Malthusian about commodity price trends, there is nothing more satisfying than being proven right.  (Paul Ehrlich, who lost the bet to Simon, was invited to have another go and declined the offer, despite responding to Simon with singular ill grace.)

Direct health care: register your interest

Recently I wrote about Simon Gibbs’ idea to find doctors willing to offer direct health care, providing better care at good value to customers and making a profit at it. Now his site Libertarian Home is gathering a list of people in the UK interested in such a service.

Register to express your interest in purchasing, for your own needs, a monthly subscription for GP services such as check-ups, disease management, minor treatments, obstetrics, and advice.

Simon explained to me that he wants to find a cluster of people who make a potentially viable business for someone, and put them in touch. You will be signing up to be notified of opportunities.

I hope he can help make this work. For the right price I would welcome such a service: it would be valuable to just have access to a doctor who I could chat with at leisure for general advice and not feel like I was being a nuisance.

The Ashya King story: am I missing something here?

This seems like a very odd story. Some parents remove their child from a UK hospital after they determine the NHS will not provide what they conclude is the most appropriate treatment for a brain tumour. They then go overseas where they hope to find somewhere such treatment is available. And this triggers a Europe-wide manhunt?

Is there more to this than meets the eye? Because if not, what possible justification is there for state involvement at all, let alone hunting the parents down in Spain.

Health and safety law in action

All eggs that are sold in the United States would be illegal according to European health regulations.

Also, all eggs that are sold in Europe would be illegal according to US health regulations.

Simon Gibbs on direct health care

Last Friday Simon Gibbs spoke at Brian Micklethwait’s. He explained that libertarians are very good at talking, which is important and useful, but that he wanted to see them doing more, and that inspiring such action is what his Libertarian Home project is really about.

He had many ideas of things that libertarians could do. Some were simple and obvious, such as attending demonstrations so that the media is forced to explain who this strange new breed of demonstrator is, or handing out leaflets at events such as Occupy demonstrations where some of the attendees might not be fully sold on all of the ideas of their movement and might be amenable to persuasion. But what he really wants to see is demonstrations of things that would be everyday in a libertarian society actually working.

An example of this is direct health care. In the USA, Dr Josh Umbehr runs AtlasMD. You pay $50 per month for access to a general practitioner. You get better service, email and phone advice, and out of hours appointments. And someone who sees you as a customer rather than a nuisance, and spends time with you and helps you to find the right consultant or to try different medicines instead of rushing you out in time for the next appointment. Simon found one doctor in the UK who offers such a service for £125 per month for a couple.

I would like to see more of this. Simon explains:

It would not need to be the dominant form of healthcare, but merely to be available for about the price of a gym membership to 10% of the population. We can then start to use this kind of care as a counter example to the sainted NHS. To get there, we need to stimulate demand. We need to talk about this idea with friends and talk about the various ways in which this would be more pleasant and more convenient than the GP service we get from the NHS. We would then be able to talk about the NHS as something like a safety net for very serious medical catastrophes, not something we rely on every day for every kind of medical assistance.

The British Medical Association – auf den Tag!

Teresa May, I could learn to like even you. Just deal with the BMA as you have dealt with the Police Federation.

Soon, soon, oh let the day be soon!

Doctors vote for ban on UK cigarette sales to those born after 2000.