Robert Sharp

Empty Hospital Ward at Hillingdon Hospital, Uxbridge, UK. Photo by Alex @ Faraway, Creative Commons Licence

Last week, I fell into a long discussion with a group of doctors on the problem of health tourism.  This, they say, is when people visit the UK specifically to take advantage of the NHS for treatment of ailments, major and minor.  In particular, women from Africa who think (or know) that they are HIV-positive will visit the UK in order to give birth.  Their children will therefore receive proper medical care and whatever medicines and retrovirals that the current clinical guidelines recommend.  My interlocutors were of the opinion that this was a major drain on resources, especially in the urban centres where they work.

For the avoidance of doubt, these were not the same medics who held the illiberal opinions of marijuana usage, but I did detect in them a slight note of discontentment.  Not intolerance, yet, but certainly exasperation.

If health tourism is widespread, then such feelings of irritation amongst the medical class are also likely to be common, which is not good.  More to the point, it would mean our health system is being abused, perhaps to the tune of millions of pounds.  Definitely not good.

My hypothesis is that health tourism is actually an extremely localised problem, centred around inner-London.  This is where strong immigrant communities already exist, and where health tourists can stay with British residents while they get their treatment.   If this is the case, then it is clearly a particular challenge for the health service in London, rather than a structural issue for the NHS as a whole.

I have put in a poorly worded Freedom of Information request to the Department of Health to find out what statistics are available.

Why bother, though?  What could we possibly do with this information, when we have it?

Simply put, quantifiable information on such an issue will immediately put it in perspective.  Is it a major abuse of the system that we could correct, or just another example of patient-led inefficiency that we will never eradicate?  My suspicion is that it will turn out to be the latter, something akin to the problem of hypochondriacs, that we know is a waste but nevertheless do not have the heart or the stomach to actually address (turning away pregnant Africans at the automatic doors never feels good).  Either way, it will at least address the mutterings of the doctors who see the issue on the ward floor, but have no sense of whether it is a problem beyond their particular hospital.

Second, it may allow for a rather deft sleight-of-policy at the Department of Health.  If the NHS is indeed providing millions of pounds worth of care to people it does not have to, over and above the call of duty, then they could with some legitimacy put that expenditure into a different accounting column.  They could, perhaps, claim it back from DfID or the FCO as a form of targeted, useful government aid.

Let us not be so naive as to think that my request doesn’t carry some risk.   While I do not believe that such statistics (whatever they may be) will actually inspire xenophobia, it is certainly possible that someone might try to use the figures to further some anti-foreigner agenda.  I’m not sure I know what to do about that, but I don’t see this possibility as a reason not to ask the question.  Better me than someone else, I reckon.

What do you think?

On the Ward in Bbowa, Uganda. Photo by Paul Evans. Creative Commons Licence

Last weekend, I had an interesting and surprising discussion with some medical students, on the legalisation of cannabis.

Since they were students, I sort of assumed that they would be in favour of legalisation; and that the hypocrisy in the differing laws on alcohol and cannabis would be self-evident. Not so! Instead, they were almost unanimously in favour of prohibition.

Their objections to legalisation were based on their clinical experience of patients with cannabis-induced psychosis. De-criminalising cannabis would endorse and encourage cannabis use, increasing such mental illness. When I responded with a standard liberal argument on personal responsibility, they made the point that most people were not responsible. Amusingly, they pointed to the vast array of empty bottles on the table, explaining that even they were knowingly binge drinking, despite being probably the most educated group of people in the perils of substance abuse.  What hope for everyone else?

All I could do was remind them that all of the psychotic episodes they will have witnessed would have been as a result of illegal cannabis use. They would not have seen comparative data for legalised, regulated inhalation. Could it be that perhaps regulated drugs were safer?

The debate was a timely reminder that political discourse amongst the general population is very different to the extremely liberal bubble in which I work. Out there in the real world, people are much less libertarian, more authoritarian, and for good honest reasons too. Amongst that group of med-school friends, the perception persists that criminalising something is the natural and appropriate response when confronted with something bad.  The liberal case is often woolly, idealistic and missing crucial pieces.

So, what I should have asserted:   Prohibition is only appropriate for those activities that harm others, and not for self-harming acts.  We could then have had a discussion about whether smoking and drinking harms others or not, where a much more fruitful and divergent discussion is to be had (in this respect, I guess this post serves to shut the barn door, two days after the horse bolted).

What is so often missing from the liberal argument, is the acceptance, even the embracing, of the bad things that happen in an extremely liberal society.  I have twice before made that point here, when discussing ID cards and other civil liberties.  At the Convention on Modern Liberty, Dominic Grieve spoke of the “mythological state of absolute security.”  Perhaps we need to speak of a mythological state of absolute health too, and admit that the consequence of decriminalisation will be an uptick in cannabis use, and an associated increase in the risk of health issues… but that we should do it anyway.  The benefits to society would be greater, and we can work out regulatory ways to reduce that risk.

Drugs can help you see the world differently.
Photo by Ace. No drugs were used in the production of this picture.

From a Primary Care Trust, to an associate of mine:

Recent monitoring of internet usage by staff has shown that there has been an excessive use of social networking websites such as Facebook, MySpace and FriendsReunited, resulting in high bandwidth usage … Staff are reminded that internet access for personal purposes is only permitted during their break times

Leaving aside the sinister concept of “monitoring” internet usage, I think this sort of thing betrays a poor understanding of how people are using the Internet these days.  For many people, Facebook is now the communication tool of choice.  It has a straight-forward e-mail function, which many people seem to prefer to more traditional solutions like Hotmail or Outlook (or Mac OS X Mail).  But most of the other features on the site are messaging services of some form or another, for example on the ‘Wall’, or comments on pictures or status updates.  Just because they occur in semi-public, its not clear to me why this sort of personal communication is considered time-wasting, while simple vanilla e-mailing is still acceptable.  I bet that if they check the stats for Hotmail, Yahoo and GMail, the usage would also be very high.  Moreover, these sites are incorporating more and more social networking features too.  So it looks like this sort of prohibition is made rather inconsistently, a decision made by people who are behind the curve in their understanding of the online world.

There are wider points to make here too.  The first is about the way an organisation treats its staff:  Do you monitor and nanny their usage, or do you ask them to self-regulate in the hope that they will use it sensibly?

The second point is about the way in which people communicate these days.  Instead of writing letters or having long phone conversations, we interact more frequently, in smaller packets (journalism is changing because of this too).  Why should this be stifled?  Will it create a more efficient organisation, or, indeed, a happy one?

I’m at the Liberal Democrat Party conference with the SMF (Labour next week). I wandered over to the Eye Health Alliance stand, where they took a picture of the inside of my eye.

Robert's Left Eye, showing the cornea, foeva, capillaries and nerves

An eye examination can provide an early warning for many conditions, including brain tumours. The picture of my eye was later examined by Liberal Democrat MP Dr Evan Harris, who gave my eyes a clean bill of health.

The NHS will no longer employ doctors from overseas. Too many British doctors have been trained, which has lead to a high demand for places.

Since the NHS has been sustained for so long by migrant workers, clearly there are moral debates to be had: Do we owe anything to overseas doctors who have worked here before? There are also administrative issues too: Where does this leave the Highly Skilled Migrants Programme? However, there are also second order issues, the problems we may not feel for a generation to come.

It is often said that the UK, above other countries, enjoys a good reputation around the world. We are said to enjoy “good links” with other countries, especially the Commonwealth, made up for the most part of former colonies. We know that these good links are embodied not just in formal institutions, aid, and preferential trade agreements, but on the personal level too. Our large immigrant population, with family back in India or South Africa or wherever, form a multitude of individual ties which together forge a strong, enmeshed bond between to countries. We have an army of millions of people around the world, who have worked in the UK at some point in our lives. They are a million secret agents, sleeper cells in their own communities, who will stand up and defend our interests and our reputation when required. This latest decision by the Home Office is the first step in the disbanding of that multicultural regiment, and it will hurt us in the long run. It is another steo away from an open, Internationalist approach that has stood is in such good stead for so long. Let us hope these measures are not extended to other professions too.

I’m sure elsewhere in Blogistan the wags are enjoying the news that all the recent terror arrestees worked for the NHS. No doubt someone will suggest that working under Patricia Hewitt was enough to drive anyone to extremism; no doubt others will quip that the doctors turned to terrorism after failing to secure a job through MTAS. Some might try to suggest that the obvious ineptitude of the terrorists proves what poor quality personnel the NHS is employing these days…

Listening to the radio reports just now, I noticed the repeated use of the phrase ‘linked’. Usually, we hear it as part of that nebulus catch-all, “groups linked to Al-Q’aeda”. To hear instead that the men were “linked to the NHS” manages to portray our Health Serivce in a rather sinister new light.

Perhaps the NHS should be more like Al-Q’aeda. Many people have been saying for many years that the individual hospitals and trusts need to behave in a more autonomous fashion. They should be set a target and left to reach it in whatever manner they see fit. Not unlike a terrorist cell.

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One thing I have witnessed “first hand” is the anxiety – nay, terror – induced by the shocking MTAS system for appointing junior doctors. Various aspects of the mis-management continue to be discussed in the blogs and in newspapers, including the dumbing-down of the profession and the fact that some people are having to take on lower grade positions.

So, while I can concede that there are dozens of political groups that I could campaign for, I’ve lent my support to the junior doctors at Remedy Scotland by setting up a campaign blog for them. They have quite a focused campaign, with an achievable reform agenda, in a single policy area, so I am hoping that it can be quite incisive. Since so many people in Scotland will be affeced, a fairly disparate group of people will need to be mobilised. I am planning to utilise the full arsenal of Web 2.0 technologies to help spread the message. Expect blog buttons and such things very soon.

Do please visit the site and sign the petition. There is also a protest march planned for mid-July, in Glasgow.

Since Monday, when the Medical Training Application Service (MTAS) announced which doctors would be shortlisted for an interview in their new system, a tsunami of discontent has been rumbling on the horizon. It has taken until Friday for the full scale of the problem to reach the media: Under the guise of ‘modernisation’, the government has effectively culled 8,000 jobs at once. Predictably, this has inspired anger among doctors, especially since many of the applicants have found themselves off the shortlist for the post that they currently hold!

Many are considering leaving the country.

As one would expect, Dr Crippen has more information on how poorly the process has been managed. But a quote from a person named ‘fishgoth’, posting on the doctors.net.uk website, sums up the problem:

MMC is an ill thought-out wankfest, destined to destroy the careers of thousands of junior doctors. This shameful cuntathon of an online exercise in humiliation will leave large numbers of doctors, some with several years experience in a speciality, fighting over the crumbs of a few jobs that will ultimately produce ’specialists’ with fuck-all experience

‘Fishgoth’ is a surgeon, writing late at night after an exhausting shift. In addition to the problems raised, it is clear that the Modernising Medical Careers process has actually served to raise the blood pressure of doctors who we hope remain calm during a crisis, our crisis. He (I suspect it is a ‘he) rages on:

My future, my earnings and my ability to pay off a mortgage have suddenly been channeled into a two week wank-fest of an online application which kept crashing

It may be that, despite the MMC policy being so flawed, the fact that it is a government policy means that there is very little redress for juniour doctors who complain, or protest about it. All policies, after all, have winners and losers. However, I think that the problems with the MTAS website may be an achillies heel.

When many doctors found that, for one reason or another, they could not submit their application properly, they naturally asked for assistance from the MTAS team. MTAS recommendations were embarrasingly amateur. They suggested that all doctors log-in using Internet Explorer, and try submitting their application in the early hours of the morning. This is totally unacceptable, akin to shutting a government agency when it is supposed to be open.

What is more, it looks very much to me like maladministration (i.e. when a government agency has not applied policy correctly). All government websites must comply with accessibility standards, allowing a fair measure of the population to access any particular site. The MTAS site would fail even the least demanding of these standards. It is therefore in breach of the governments own legislation in this regard. Disappointed doctors may find that the most effective means of redress may be via the Parliamentary and Heath Service Ombudsman.

In the coming days, I hope to compile a more detailed post here, on what is meant by ‘accessibility’ in the web design sense of the word, and how the online application forms employed by MTAS fail accessibility standards.

NHS ‘moles’ are like the Malawian Orphans of the British blogosphere.

Doctor Crippen and Devil’s Kitchen think they are soooo clever with their inside information, don’t they? The Doc reports on the persecution of junior doctors, by revoking their right to prescribe drugs; while the Devil has a bizarre story about nurses secretly performing medicals on asylum seekers.

Well, I’ve got one too (actually, I have five or six, but let’s not be boastful). I’ve been forwarded a particularly amusing letter from Mr Mike Grieve, University Hospitals Division, NHS Lothian. He is leading a financial recovery team to reduce over-spending, which is currently running at £1 million per month.

Our immediate task is to return to a position of month-on-month income and expenditure balance … Much of this is incurred in four areas of expenditure namely, the cost of doctors in training, bank and particularly agency nursing costs, clinical supplies and some medicines.

So, they need to cut costs in the areas of: doctors, nurses, medical supplies, and medicine! Is that not, like, everything that goes into making a hospital a hospital!?

To be fair, at least they are on the case, and trying to get back on budget. My source is not impressed:

Without bank and agency nursing staff the service would collapse. There is a high level of sick leave amongst nurses, due to high levels of stress, low morale, poor pay, shift working etc.. A ward not well staffed by nurses is not safe.

What is interesting is there is no mention of managers, the ones who clearly fucked up in the first place.

That’s fine, but I can’t shake the worry that this would be not so different if the running of hospitals were sub-contracted out to private companies. What’s to stop them cutting the same costs and services to maintain profit margins?