Tuesday, 30 August 2016

Labour: getting back to its roots. But which roots?

“The only lesson to learn from history,” to paraphrase the German philosopher Hegel, “is that no one learns any lessons from history.”

In the course of the great debate over the leadership that is currently rocking the UK Labour Party, the supporters of Jeremy Corbyn frequently tell me that we need to get the party back to its roots. It’s because we’ve abandoned them for the last forty years – a precise figure quoted to me on Twitter, though what specifically happened in 1976 I’m not quite sure – that we’re in the mess today.

It never strikes me as a particularly good approach to call for a move “back to” some set of values. John Major, British Prime Minister between 1992 and 1997, Thatcher’s successor, launched a “back to basics” programme that was criticised even within his own party. Generally, it’s best to be moving forward and getting ready to deal with the next set of challenges, for which we’re likely to need different attitudes than worked when we faced the last.

Still, even in a forward-looking process, it’s useful to to see if we can at least learn enough from the past not to make the same mistakes again. Perhaps being aware of our roots might be a more useful approach than getting back to them. However, if we’re to do that well, we need at least to make sure we’re remembering them correctly. A mythical past isn’t going to help us at all in planning our future. It would be a pity to go back to the wrong roots, wouldn’t it?

What, then, were the roots of the Labour Party?

The great historic leader of the early days, and Labour’s first MP, was James Keir Hardie. He died long before Labour had its first chance to form a government, but he had among his advisers a young man, full of fine rhetoric and powerful views, who would lead Labour in government for the first time: Ramsay MacDonald was an early intellectual of the party and one of its most effective voices. He had principles too, and stuck to them: he was a pacifist and nothing could persuade him to back Britain’s involvement in the First World War. So, though he was one of the earliest Labour MPs, elected in 1906, he paid the price for his beliefs, losing his parliamentary seat in the elections at the end of the war.

Ramsay MacDonald: watered the roots of the Labour Party
But it didn’t end well, did it?
MacDonald came back, though, leading the first two Labour governments. Sadly, his second administration took office in 1929 and had to deal with the Great Depression. MacDonald, man of principle, thinker, left-winger, champion of the socialist cause, decided that was needed was a sound-money policy and reduced public spending. So he slashed unemployment benefit, to the fury and dismay of his Labour colleagues. In order to cling on to power, he formed a coalition with the Conservatives and remained Prime Minister, at the head of a government dominated by the party he’d always opposed, until 1935.

Are those the roots we’re supposed to get back to?

To be fair, when people talk about the Labour Party’s roots, they’re much more likely to be thinking of the great, reforming post-World War 2 government led by Clement Attlee. In particular, they’re probably thinking about one member of that government: Aneurin ‘Nai’ Bevan, founder of the NHS. They probably don’t remember that when someone mentioned to Ernest Bevin, Foreign Secretary in the same government, that Nai was his own worst enemy, Bevin growled back “not while I’m alive, he ain’t.”

Nai Bevan, father of the NHS. Much easier to get enthusiastic about.
As long as you’re not too worried abut nuclear disarmament.
Actually, that’s one of those stories that comes up again and again in different contexts, with different speakers. Another version has Bevin saying it about a different fellow Minister, Herbert Morrison. Then again, it was apparently said of Franklin Delano Roosevelt by his fellow Democrat “Cotton” Ed Smith. What all these versions have in common, though, is that they all reflect deeply destructive internal divisions in parties of the centre-left.

Sadly, we’re in exactly the same position today, but surely again this isn’t where we want to be, is it?

Much more significant than any comment of Bevin’s on Bevan, though, is a remark of Bevan’s himself. Jeremy Corbyn has made himself a bit of a name by his resistance to the renewal of the Trident nuclear missile programme. Interestingly, for a man and a member of a movement that swears by the sanctity of party decisions, he took that stance against Labour policy. He nonetheless enjoyed widespread support among his fan base, who tend to be pretty keen on Bevan too. So perhaps they need to ponder the words Nai spoke at the Labour Conference of 1957, during the debate on unilateral nuclear disarmament:

I knew this morning that I was going to make a speech that would offend and even hurt many of my friends. I know that you are deeply convinced that the action you suggest is the most effective way of influencing international affairs. I am deeply convinced that you are wrong. It is therefore not a question of who is in favour of the hydrogen bomb, but a question of what is the most effective way of getting the damn thing destroyed. It is the most difficult of all problems facing mankind. But if you carry this resolution and follow out all its implications and do not run away from it you will send a Foreign Secretary, whoever he may be, naked into the conference chamber… You call that statesmanship? I call it an emotional spasm.

Curious, isn’t it? That a past idol of the left referred to the policies espoused to the policies of today’s idol of the left as an “emotional spasm.”

So – are those the roots we’re supposed to be getting back to?

Sunday, 28 August 2016

Supporting clinical decisions and helping triage

Most of us understand the need to keep healthcare costs low. On the other hand, when we become patients, we’re not keen to see savings made at the price of increased risk. When it comes to avoiding the avoidable in healthcare, we like to think that costs are unavoidable if they ’re incurred ensuring our safety.

The Netherlands have an out-of-hours service patients can call when their GP practice is shut. The aim is to reduce visits to emergency departments in lieu of family practitioners. Nurses take callers through guidelines, asking a series of questions to establish what care the patient needs and with what urgency.

An out-of-hours call centre at work
A 2007 study set out to find out how well the service was performing. The results were disturbing. In 19% of cases, nurses underestimated the urgency of the patient’s condition. The study’s authors conclude that the service was “possibly not safe,” which feels like an understatement.

Denmark’s out-of-hours service gives evidence of the opposite effect: excessive caution by nurses. The Danish service is principally staffed by GPs, but there’s pressure to use nurses as an economy measure. However, a 2013 investigation found that nurses might be too inclined to refer a case for a GP to see instead of taking a decision themselves. The result? On top of the cost of employing the extra nurses needed, the service, far from reducing calls on GP time, might increase them. Costs could rise instead of falling.

What’s the answer? How can we reduce expenditure by having nurses or, even better, non-medical staff, take responsibility for triage, without either increasing risk to patients or incurring higher costs?

The 2007 Dutch study came up with one answer: it found that the more training nurses had received in the use of the call centre guidelines, the less frequently severity was underestimated. Certainly, telephone triage isn’t simply another application of already acquired skills. It’s a legitimate healthcare service in its own right, needing its own knowledge and expertise.

There is, however, another way in to  improve services. That’s the field in which I’m currently spending much of my time: clinical decision support.

What we’re talking about here is software that helps nurses or non-clinical call handlers work their way through guidelines. At the most trivial level, such software can ensure that nothing’s forgotten. A question might be mandatory, so the handler simply can’t move on until it’s asked. That would ensure essential information isn’t missed. Even with optional questions, their mere appearance on a screen would at least prompt the handler to ask them and might trigger a new line of enquiry.

That, however, is far from enough. There has been research (not enough, yet, but what there has been is telling) into the impact of clinical decision software. A revealing article showed that a call handler might be pushed down the wrong line by the software itself. It cites the example of a handler, a nurse, who had begun to explore what the software offered on the subject of nausea, while the caller had moved on to talk about back pain. With one line of questions already under way, the call handler failed to pick up the second symptom, however important it may have been.

Again, on some occasions, the lack of an appropriate response to certain questions led to a distorting effect: the patient was saying that she felt sick each time she ate, but the software hadn’t allowed for that reply, imposing instead quantitative entries – once a day, three times a day, and so on.

That’s what makes the search for effective software design such an interesting challenge. It’s not enough just to list all possible questions, in a fixed order. It’s vital to take all the information concerning any particular patient into account, without deciding too soon that one item has overriding importance or letting the software itself drive the direction of the investigation. In fact, the system has to:
  1. take into account all the information about the patient, entered in whatever order. In other words, as in a real, face-to-face medical consultation, the patient should be able to describe all his or her symptoms without making a judgement about which is the most important 
  2. suggest questions to the call handler based on all the symptoms, not just one of them 
  3. drop irrelevant questions but propose all the others 
  4. handle unquantified information, such as “I feel sick each time I eat”
That would be the kind of clinical decision support software that can really make a difference, because it emulates what happens in a medical consultation: the patient describes symptoms as they come to mind, not in an orderly or pre-filtered way. Alongside the kind of comprehensive training we’ve already seen is needed, such support software could bring us closer to the goal we seek: a triage service that delivers a reduction in costs without an increase in risk.

In fact, it would be valuable for far more than triage. It can make a major contribution to managing medical pathways in general. But that’s the subject of my next post.

Saturday, 27 August 2016

Republican values and the burkini ban

In Britain, we proclaim the sanctity of “national values”. These are wonderful things, like tolerance and respect for the views of others. Sadly, they’re often espoused by people who want to ram them down the throats of minorities, whether they like it or not.

In the States, as far as I can see, the preference is for “American values” or “traditional values”. They tend to be much the same, and there seems to be just as little compunction about inflicting them on other people. Some championing them might, say, propose to ban an entire religious community from entering the country.

In France, the equivalent concept is “republican values”. In one of my favourite films, Casablanca, there’s a moment that grates each time I hear it (and I’ve watched the film a lot). It’s when the character Yvonne, tearful after singing the Marseillaise, cries out, “Vive la France! Vive la démocracie!” That’s a splendidly American slogan artificially transferred to the mouth of a Frenchwoman. In reality, her words would have been, “Vive la France! Vive la République!”

The founding document for France’s valeurs républicaines was the Declaration of the Rights of Man, adopted as the Revolution was getting under way and before the country had even become a Republic.

Article 4 boldly declares:

Liberty consists of being able to do anything that does no one else any harm: in other words, the exercise of the natural rights of each man has no limit other than those that guarantee to other members of Society the enjoyment of those same rights. Those limits may only be established by Law.

The declaration isn’t a religious document. It makes no reference to God or to any Church. But it isn’t anti-religious either. So article 10 asserts:

None may be disturbed for their opinions, including religious ones, as long as their expression does not disturb public order as established by Law.

France is currently gripped by a debate over whether the burkini, the whole-body covering swimsuit favoured by a tiny minority of Muslim women, can legitimately be banned from French beaches. Those who favour the ban include the former and likely-to-be future President, Nicolas Sarkozy, the current Prime Minister, Manuel Valls, and naturally the leader of the far-right Front National and presidential contender, Marine le Pen.

A Muslim woman obliged to remove a long-sleeved top on a beach
Not so nice of the Nice police
They all see the ban as a necessary precaution to protect republican values from the threat posed by Muslim extremism. They are all the more urgent in their call for the ban as a response to the terrorism of recent months. This despite the fact that, to my knowledge, not a single act of terrorism has ever been carried out by a woman in a burkini.

It’s not obvious, on the other hand, how they reconcile it with the Declaration of the Rights of Man.

First of all, let’s dispose of the simplest objection: ‘Man’ in this context means ‘mankind’. The rights apply as fully to women as to men.

Is the ban consistent with article 10? Is the wearing of the burkini likely to lead to a disturbance of the peace as foreseen by law? There have certainly been nasty scenes of public disorder over the wearing of Muslim garb, but generally in the form of abuse of the Muslims. “Go home” people have shouted, at women who in many cases were already at home, being French. The women were the victims of the disorder, not its instigators. Describing their actions as a breach of the peace seems like turning rape victims into criminals.

As for article 4, what could be clearer? You have the right to do whatever you like as long as your action doesn’t limit anyone else’s rights. How does the wearing of a burkini affect anyone else’s liberty? It doesn’t stop other people using the beach. It doesn’t stop them wearing revealing clothes. It doesn’t even stop them thinking the burkini inappropriate beachwear. It limits no one else’s rights.

Far from upholding republican values, the burkini ban seems to trample on the very principles they enshrine.

The truth is that the ban has nothing to do with republican values. It’s about people who have been frightened by an enemy who reaches into our midst and kills at random. A hidden enemy against whom we can’t hit back. Fear and frustration have brought to the surface a tendency latent in us all: racism is on the rise again. Muslims today must feel like Jews did when anti-Semitism was rampant but the holocaust hadn’t yet got going: they must be worried to go out, they must be worried to travel, they must feel that they can expect no protection from state.

We’ve been her before and we know where it leads. We need to stop it now before it descends to the next stage.

The signs aren’t good. Sarkozy is a significant political figure. In Britain, Nigel Farage campaigned against the EU with a poster declaring the country to be at breaking point, against a photograph of Syrians queueing to enter Europe. In the States Donald Trump is Farage’s pal, and he’s called for a wall against Mexicans and a ban on Muslim entering. This is the establishment giving racism a respectable face.

There’s hope yet, though. The Cour Constitutionnel in France has ruled the ban illegal, which suggests that some in France remain truly committed to republican values. However, Sarkozy had already said that if the court made that choice, he would campaign for a change in the constitution. The court's resistance was edifying but may not last long.

More encouraging was hearing Angela Merkel speaking to German TV.

“If I have to apologise for showing a friendly face [to people from other nations],” she said, then this is not my country any more.”

Merkel’s no radical Lefty. She’s the Christian Democrat leader of Europe’s most powerful nation. If such voices are still speaking out, and can still be heard, then hope isn’t wholly lost. We just need to join our voices with theirs.

In defence of republican values. Or American values. Or traditional values. Or national values.

In fact, in defence of decent values anywhere.

Thursday, 25 August 2016

Camber: tragedy and tragicomedy

Camber Sands is one of those magical places that you sometimes find on the English coast. Miles of dunes, followed by miles of beaches, with the sea beyond – sometimes a long way beyond, because it’s shallow and when the tides out, you can walk over two or three hundred metres of sand before you reach the water.

Since it’s in the south, it can even be reasonably warm at times.

Camber Sands: charming. But maybe deceptively
It’s amusing how nothing makes a day out more memorable than its going comprehensively wrong. My wife and I, accompanied by some friends and assorted kids, decided to head for Camber on a day visit way back in 1989. We’d lived in Hastings for a while and we remembered that Camber wasn’t that far away. Sadly, as it turned out, it was rather further away than our memory suggested. What’s worse, it was further away in a completely different direction.

It’s amazing – well, actually, not particularly amazing – how much longer it takes to get to a place if you look for it for it in, well, the wrong place. With kids, you always leave late. With an extra hour and a half added to the trip to find Camber in the first place, it meant we were only going to get two or three hours on the beach before we headed back.

I was in a lousy temper by the time we finally got there.

It turned out that things had barely started to go wrong. Because within minutes of our hitting the beach, we found that our youngest son was, well, nowhere to be found. He’d vanished. Considering he was five, this was not particularly good news. Considering the beach is long and it was crowded, we could see the news wasn’t going to get any better any time soon. Considering the state we were already in, it was obvious this wasn’t going to do any of us much good.

We hunted up and down the beach. We asked people if they’d seen any sign of him. We looked in the dunes, behind umbrellas, occasionally with our hearts in our mouths, out to sea.

It didn’t help that we kept asking people whether they’d seen a little boy in a red shirt and tan shorts. Because when, after a two-hour search, we finally did find him, he was wearing absolutely nothing at all. Nothing, that is, other than a completely innocent, even slightly plaintive expression, as though to say, “What? What? What’s your problem? It’s a beach, isn’t it? We’re here to have fun, aren’t we? And I’ve been having fun, haven’t I?”

All this came back to mind when I heard about the five young men who decided to travel down to Camber, from London, for a fun day out, in the glorious sun earlier this week. Who could blame them? The conditions could hardly have been better.

And yet, near a beach full of people, all five lost their lives in that idyllic place. Bystanders tried to help and rescue services arrived by helicopter but, even so, none of them survived.

What happened? It still isn’t clear. It’s possible that they wandered out all that distance when the water was out, and then were caught when the tide came ripping back in, as it does when the sea’s shallow. If they weren’t strong swimmers, they might have found the current and the deep channels between sandbanks too difficult to manage. 

A dismal tale.

My wife and I naturally thought back to that day and the little lost boy. How easily an annoyance could have turned into a disaster. The beach was crowded that day too, but what good does that do? The people on the beach tried to save the five young men and couldn’t. 

Our son could so easily have drowned.

Though, to be fair, there were times that day when I was ready to inflict a far more painful fate on him.

We never did find his clothes, by the way. Not even his sandals.

Tuesday, 23 August 2016

There are lies, damned lies and Tory health policies

A seven-day NHS. Sounds good. Perhaps for patients. Above all for a governing party which was never strong on ideas and needed a catchy one to win an election.

It’s been a bit of a Tory mantra, “do more for less.” They don’t actually believe in it. If they did, they’d never have cut the top rate of tax down to 45%. Instead, they’d have said, “do more for less – you’re rich enough.” But for its major supporters and paymasters, the lesson is “do more with the lot more your shareholders keep giving you, and which we’re going to ensure you keep your clutches on.”

Instead, what they really meant was, “do more while we pay you less.” That’s why the junior doctors are up in arms. To get this “seven-day NHS up and running, the Tory governments insisting that people in one of the most stressful occupations in the world give up more of their limited relaxation time at the weekend.

Nurses haven’t struck, but the constant decline in working conditions, to which this initiative will surely contribute, is behind the increasing difficulty we have in recruiting sufficient numbers.

The alternative would be to come up with a bit more money, but that’s not going to happen. How do you fund an increase for the NHS if you’re cutting the top rate of tax? Instead, the NHS stumbles from one crisis into another. At the end of the 2015-16 year, an unprecedented two-thirds of English NHS Trusts (the organisations that run hospitals) were in deficit.

How deficits have grown
Source: King's Fund
There is talk of some more money to fund the seven-day NHS. But it’s £10bn and will only be available at the end of the parliament – just in time for the next election, but rather too late to ease the pain in between.

Most of us knew the idea of a seven-day NHS was just a ploy for votes. There was nothing realistic there. But people could still claim that it was meant, for real. Until internal government papers were leaked to the Guardian and Channel 4. These make it clear that the government itself was warned about how difficult it would be to achieve the seven-day target, without “workforce overload.”

I suppose that at least proves the junior doctors are right. The government has no compunction about overloading its workforce.

Not when there’s something really important at stake. Like votes.

Sunday, 21 August 2016

Lessons of Rio

So Britain has come second in the Olympics medals table.

Most of us Brits will take some pleasure in that result.

Letting the elation pass, though, and thinking about the symbolism of the games, gives a somewhat less satisfactory picture.

Iconic moment from the iconic athlete Mo Farah:
Completing the double double: 5000 and 10,000 metres in successive Olympics
First of all, what were taking so much delight in isn’t winning, it’s coming second. Winning would have meant beating the US, and no one even dreams of pulling that trick off. Not just in the Olympics, come to that. 

Secondly, while finishing ahead of China is satisfactory, it’s not entirely down to British prowess. A part of it reflects China’s underperformance. Again, that’s probably a reasonably accurate reflection of the world situation: between Britain and China, what’s being played out is a zero-sum game. What one gains is lost by the other, good performance here is mirrored by poor performance there. Similarly, in other fields, China’s growing economic and political might won’t pull Britain up with it, but lead to her decline.

Finally, add together the medal hauls of all the other EU nations – a post-Brexit EU, in effect – and they’d be way out in front, with 74 golds and 235 medals in total. In comparison, the US took 44 golds and 119 medals in all.

So, if they pull together, the European nations can beat the world – even the US. Only if they pull together.

The big lessons for the British? They could do it without us.

Still. We can enjoy the Olympics results for now. As long as we don’t think too hard about our post-Brexit future. In a world where we face the real China and the indomitable US. On our own.

Postscript: the talk today is of Mo Farah, who took gold in both the 5000 and 10,000 metre men's races, in both London and Rio, being given a knighthood. 

Sir Mohammed? Wouldn’t that be fabulous? A magnificent poke in the eye for all the xenophobes and Islamophobes: a Somali immigrant and devout Muslim winning a knighthood for the glory he brought Britain...

Saturday, 20 August 2016

On line shopping: the antidote to a modern nightmare. But it needs skill

Isn’t a visit to the supermarket one of the more dismal experiences of life today?

They do try to make it less unpleasant. Wide aisles, plenty of light, background music (though I’m not convinced that tinny music, particularly the kind most supermarkets play, does much to enhance the experience rather than the reverse). However, no attempt to improve the feeling can disguise the fact that essentially it’ s just a long haul, up and down aisles, in an often forlorn search for the most essential items on your list.

Have you noticed that, if you’re after 25 products, you’ll find the first 20 in no time? Then comes you can’t remember whether the cat food is on aisle 16 or 52; by the time you’ve checked them both out, some kind person in a uniform jacket will tell you that it’s actually in aisle 2, back at the other side of the shop. Then you start the same process over again, looking for olive oil.

Having walked the equivalent of three miles up and down the aisles, you will now have 23 of the 25 things you wanted. That’s when another kind assistant will tell you that one is in aisle 4, the other in aisle 76, and even accompany you to both, to establish that both products are out of stock.

A joy of modern life
By this time, the tills that were all invitingly empty when you first arrived, have filled up neatly with six-deep queues, complete with squabbling kids and shoppers who’ve picked up the burst bag of flour or the wrong brand of peanut butter, and need to dash across the shop for a replacement.

You may choose the self-checkout instead. Thiss always a wonderful experience. 

“Using your own bag?” it asks you. 

You press “Yes”. 

Place your bag in the bagging area and press done.” 

You do that. It asks you to do it again. You do. It asks again. You call the assistant over. She turns up just as soon as she’s dealt with the five other people with queries; she swipes her card and taps in a code. The machine returns to normal, looking smugly satisfied, as though there was never a problem in the first place.

“They get a bit temperamental on a Friday,” she says.

“As well all do,” you reply, and then start scanning items again. Until the machine interrupts you once more.

“Using your own bag?” it innocently asks.

It’s the joy of that experience that has made me such a fan of on-line shopping. It’s brilliant. A few clicks and a whole supermarket trip is done. In fact, the really good thing is that it even keeps track of your favourites so that you can produce a whole new order just by whipping through a list of what you most frequently take, and deciding what to include it in this week’s shop.

Sadly, though, it’s not quite as simple as that. You do have to make sure you’re clicking on the right items and choosing the right amounts. I’m not always quite careful enough, as I discovered over the last couple of weeks. I seem to have fallen into the habit of ordering grated cheese all the time, leaving me this week without butter, on the brink of running out of coffee, but with a fridge that looks like a grated cheese repository.

Inside my fridge
It’s not like there’s a shortage of the stuff
The odd thing is that, though I like grated cheese, I’m not that wild about it. Then again, my subconscious may be telling me otherwise.

Or perhaps I just need to learn to handle a computer touchpad more skilfully.