No Plan, No Funds, No Staff

Jeremy Hunt

Junior doctors have been on strike this week, an astonishing thing to happen that, in itself, demonstrates the terrible political diplomacy that Jeremy Hunt, the Secretary of State for Health, has demonstrated as he attempted to push through his agenda.

Mr Hunt’s central talking point is that the policy he is pursuing is a manifesto commitment.  In interviews he suggests that the British Medical Association (BMA) is attempting to block the manifesto commitment, and therefore the will of the British people.

That is not quite true, for several reasons.  First, the manifesto pledge is for a so-called “7 day NHS”, the idea being that routine clinics and elective procedures should also take place at the weekends, when its more convenient for many people.  The manifesto pledge only says that hospitals will be ‘properly staffed’, and nowhere does it say that this will be achieved by reducing the out-of-hours pay for doctors (achieved by re-defining late evening and Saturday work as normal working hours).  It would have been an odd sort of voter who assumed that would be the case. Continue reading “No Plan, No Funds, No Staff”

The Pragmatic Idealism of Team Corbyn

Angel Window by Aidan McRae Thomson

How irritating.  I had drafted a short, blistering blog about how the NHS, the sacred cow of British politics, is a massive socialist project.  “If the NHS did not exist”, I would have said, “none of the Labour leadership candidates but Jeremy Corbyn would dare suggest we invent it”… And when he did, everyone (other candidates, the Tories, the media and yes, much of the British public) would have accused him of being a bonkers socialist, happy to squander billions of pounds of taxpayers money. Continue reading “The Pragmatic Idealism of Team Corbyn”

Hurrah for NHS bureaucrats

“I want doctors with stethoscopes not bureaucrats with clipboards”
—David Cameron, 2 April 2015, #LeadersDebate

In tolerant and inclusive twenty-first century Britain, there is still one group of people that the politicians are happy to demonise: NHS managers.  During last night’s Leaders’ Debate both David Cameron and Ed Miliband were happy to trumpet policies that would see a reduction in NHS managers and an increase in doctors.
This is obviously a vote winning policy.  It’s a simple zero sum equation that ordinary people think they understand.  When we experience the NHS, we see a front-line health professional, not a back-room manager.  So more doctors and nurses, with less bureaucrats, appeals to the natural biases we have due to the way we experience the health service.
But I was sat next to a doctor during the debates and she ridiculed the policy.  If there are less managers in the NHS, then the task of managing will fall to the doctors… Who will have less time to see patients and run clinics!  The admin load placed on doctors and nurses is already a chronic complaint.
The NHS is a vast, multi-dimensional organisation. Running it is a huge logistical challenge.  The doctors, nurses, and technicians all need to be paid, co-ordinated, and to have precisely the right equipment at their disposal when the patient turns up for their appointment.  This requires managers.  The patients themselves need to be piloted through a Byzantine network of ‘healthcare pathways’ as well as the literal corridors of the hospital.  This requires managers.
Moreover, the government and professional bodies set rigorous standards and targets for the service, which are meaningless if they are not monitored.  This requires managers.  And the facilities that power the health service are some of the biggest and most complex institutions in our society.  They need hands on the tiller to set a strategic direction.  This requires managers.
There’s no point in employing more doctors and nurses if you don’t also employ management staff as well.  Otherwise the medical staff will end up doing all the admin and that will be frustrating for everyone.
Hurrah for NHS bureaucrats!

“Amateurs talk about tactics, but professionals study logistics.”
—General Robert H. Barrow, USMC (Commandant of the Marine Corps)

An Enclosures Act of the Mind? Libel and the NHS

Here’s an article I posted yesterday on the OurNHS section of OpenDemocracy.


In many ways, the Defamation Act 2013 was good for medicine. During the course of the Libel Reform Campaign, English PEN met dozens of doctors and medical journalists who had been silenced by the famously restrictive English libel law. Pharmaceutical companies used the archaic law to prevent the publication of valid criticism by medical professionals. Fiona Godlee, editor of the British Medical Journal, told a Libel Reform rally how factual reports on medical treatments had been ‘softened’ or even spiked because of libel fears.

The Defamation Act 2013, which English PEN and the Libel Reform Campaign spent three years fighting for, gives strong legal protections to peer reviewed articles. Patients and commissioners should be able to learn of any doubts that doctors have about pharmaceuticals and new treatments. The Act also includes measures to limit the progress of trivial claims, and a new public interest defence. In 2007 Goldacre faced a libel claim from vitamin pill manufacturer Matthias Rath after he used his ‘Bad Science’ column to critique claims that these pills could cure AIDS. Although Goldacre eventually won the case brought against him, the battle left him significantly out of pocket. The new Act should help journalists like Dr Ben Goldacre see off the pharmaceutical libel bullies.
Continue reading “An Enclosures Act of the Mind? Libel and the NHS”

Health Tourism

Empty Hospital Ward at Hillingdon Hospital, Uxbridge, UK. Photo by Alex @ Faraway
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
On the Ward in Bbowa, Uganda. Photo by Paul Evans. Creative Commons Licence

Liberalism and Legalisation

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.

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

Blocking Facebook

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?

Keeping an Eye on Things

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
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.

Goodbye Doctor

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.

Terrorists and the NHS

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.

Continue reading “Terrorists and the NHS”