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.

Friday, 19 August 2016

Labour devouring itself 2: Pharmaceuticals, an infernal industry. Really?

Many years ago, I led a small team developing a financial reporting application for a new biotech company near Geneva.

It was a strange experience. We went through their existing ‘system’ – essentially a series of linked, and hopelessly confused, Excel pages – and put together a prototype for the customer to approve. But suddenly I realised I’d left out a key element.

“I’m not showing any revenue,” I said, and checking through all the Excel worksheets the company had supplied, asked with some shock, “I don’t see any revenue here.”

“Revenue?” they replied, “there isn’t any. We’ve only been going a couple of years. Maybe in eight more? Generally, it takes at least ten years to get a new product to market.”

“Ten years without revenue?” I exclaimed, “for a single product?”

“Well, to be fair, we’re hoping that the hundreds of molecules we’re working on will eventually enable us to generate two products.”

The figures were in front of me. Ten years would cost something like £200 million. If they emerged with two products, they each would have cost £100 million. They wouldn’t actually take them to market: they would sell them to one of the big pharmaceutical companies who would then invest much more money still to get the drug into production, announce it, promote it and start distributing it. I can’t see how the cost of each could possibly be under £200 million.

Why am I telling this story now? Because in the last piece I posted here, I talked about the sheer ugliness of the present dispute between wings of the Labour Party. Without hiding my sentiments, I tried to be relatively impartial between them. Today I’m throwing impartiality to the winds, and focus on one of the aspects I find particularly irritating in the Corbyn camp.

It’s particularly ugly of Corbynistas to make mileage of the fact that Owen Smith spent some time working for the pharmaceutical giant Pfizer. This, it seems, represents a blot on his character that can never be erased. Pharmaceuticals are evil, and the evil is contagious.

The infernal regions?
It’s a naively binary view of the world, where everything’s good or bad and there are no shades of grey. Naivety, however, is entirely forgivable – it can even be endearing. What really has me laughing wryly is the kind of comment I had from a Twitter correspondent, that the Pharmaceuticals are vile gougers because they charge pounds for pills that cost pence from generics suppliers. As my experience in Geneva showed, that’s a notion that reflects merely ignorance of the issues. To paraphrase one of the better lines from that iconic TV show The West Wing, it’s the second and all subsequent pills that cost pence. The first one, as I discovered in Geneva, cost at least £200 million.

The generics manufacturers never pay for the first pill.

So what does that say about Pfizer? Well, their published accounts suggest that in 2015 they made a profit (EBITDA) of $18.45 billion on revenue of $48.85 billion.

I’ve been in business for approaching forty years. When I was working for companies in which I was part-owner, we aimed for 20% profit on turnover but usually had to settle for 10% or less. It’s not at all rare for companies to scrape along on 3%.

Pfizer’s profit represents nearly 38%.

So they’re running extremely rich.

As Owen Smith puts it, “Yeah, I think medicines should be cheaper, generally. That’s the key criticism I have. I think medicines should be cheaper across the world.” Absolutely right. I like the impact of the generic suppliers, because they pressurise the big companies to cut their costs and generate more reasonable profits. We need more, and a Labour government should legislate to cut into this gravy train.

Smith also faces the accusation that his previous role as a spokesman for Pfizer, a private company supplying the NHS, proves his desire to privatise the service. Backers of this view suggest that somehow the NHS should produce its own pharmaceuticals. That strikes me as extraordinary: the NHS is there to deliver healthcare, not to carry out biotechnology research. That’s not their skillset. And they certainly don’t have the £200m and more it takes for the first pill. Again, as Smith argues, “It would bankrupt the NHS even if it were possible, which of course it isn’t…” But, he goes on, “it’s completely wrong to suggest that… I’m in favour of private provision. I’ve never been in favour of it.”

I like Smith’s attitude and believe he has the will to take the measures we need against excessive profits. He also has the knowledge of the industry to do it well. He understands both the cost of the first pill, and the unacceptably excessive profits of the industry.

Sadly, none of this is inspiring. It’s an argument based on evidence, it takes both sides of the problem into account, it attempts to think rationally about the real nature of the problem. In short, it’s grey and rigorous and less easy to follow than a simple declamation of radical slogans.

It’s so much easier just to say “the pharmaceutical companies are robber barons. Anyone who has ever spoken for them, as Owen Smith has, is hopelessly tainted. We need to reject everything they stand for.”

Much easier. Much simpler. And entirely summed by one of HL Mencken’s best lines: “For every complex problem there is an answer that is clear, simple, and wrong.”

Wednesday, 17 August 2016

Labour devouring itself: 1. Mutual Malice

They say the first casualty of war is the truth.

In an internal party battle, it gets knocked on the head more quickly still. There’s no worse offence than apostasy: the friend who turns against you is far more hateful than the open enemy.

That’s what’s happening in the British Labour Party now, with a chasm opening between its two wings.

There have been few instances of physical violence, and none against the person: a brick through an office window was the most egregious example. On the other hand, the verbal aggression is pretty ferocious. It means that it’s a less painful experience these days to debate with Tories, officially our opponents, than to fellow party members who favour a different candidate for the leadership.

At its mildest, supporters of Owen Smith (of whom I am one) are all of us categorised as Blairites. That’s bad enough, seeing as rather a lot of us feel that, despite Blair’s many achievements, he lost our respect forever by the unconscionable act of following Dubya into a misguided invasion of Iraq. But the insult is actually far worse, because to Corbyn supporters (of whom I am absolutely not one), ‘Blairite’ is a synonym for ‘Tory’. Indeed, we’re repeatedly referred to as ‘red Tories.’

That’s particularly irritating, because if there’s one constant in my political outlook, it has been complete opposition to the Tories. An organisation which exists to protect privilege and the link between wealth and power strikes me as utterly out of place in our times. So to be called a supporter seems nothing short of ludicrous.

But this isn’t to say that my side has been any more sensible. The accusation these days is that the 300,000 new members of the Labour Party, most of whom seem to be fervent Corbyn supporters, represent a take-over by ‘Trotskyists’.

Trotsky must be spinning in his grave. He did indeed recommend the tactic of ‘entryism’, which meant going into a mass working class movement, taking it over and turning it into a revolutionary organisation. But I’m sure he never intended entryist groups to stay in such an organisation for unlimited periods, as the so-called Trotskyist group Militant attempted to do until its expulsion in the 1980s.

Trotsky rousing Red Army troops
Corbyn or Smith? Nothing to choose between them, he would have said
All Militant achieved was to turn Labour Party meetings, never the most exciting way to spend an evening, into something excruciating. Presumably, the hope was that anyone not of their persuasion would be driven out, if only to try to get themselves a life. Since Trotsky was particularly susceptible to the fault I mentioned before, of hating the dubious friend more than the avowed enemy, I expect he would have had the whole of Militant carted off to a Gulag somewhere. And most of the rest of us would have regarded that as a welcome gesture towards keeping politics interesting and maintaining a sense of humour.

In any case, Trotskyist groups can at best mobilise a few thousand people in Britain. And that’s on their own count. There are probably only a few hundred.

Oh, go on then, let’s be generous: the very low thousands.

Certainly, there are nothing like the 300,000 who have joined Labour. Among that new memberships, there may be a few Trotskyists and some may even be playing a leading role. However, the vast majority are just Corbyn-supporting social democrats. Misguided, in my view, but hardly died-in-the-wool, red-toothed followers of the founder of the Soviet Red Army.

So, on either side of the fence, the slanderous name-calling is tossed back and forth. And there’s no sign of its stopping.

It’s a shame, though perhaps inevitable. Passions are running high, as the stakes are so significant. But that does nothing for the quality of our lives.

To say nothing of our chances of beating the Tories.

Next: one or two of the more irritating slanders.

Sunday, 14 August 2016

Watching badminton. And the surprising political insight it gave me

Badminton’s a game I play, not one I watch.

Today, however, I made an exception. I was with a friend who regularly gives me a thrashing on the court, and he wanted to watch some of the Olympics matches.

My first observation was that those competitors played a pretty mean game. They too would probably thrash me. Well, perhaps not if they gave me a 19-point lead, though I suspect that even then they’d beat me 21-19.

Canada's Michelle Li, one of the players I watched
Not someone I'd like to see across a net
The second observation was that the commentators are just as delightfully dumb as in any other sport.

We watched one player win a game 21-6. In the second game, when the loser of the first reached 12 points, the commentator solemnly assured us that he was doing better than in the first game. With twice the score he made in the entire game before, I’d say that was probably true. I suppose I should be grateful to have it pointed out, in case I failed to spot it myself.

We learned that it was necessary for both players to win the game. I suspect they each knew they needed to win. I’m not convinced that there are any circumstances in which both players could win the game. It’s not a situation I’ve ever met and, while I play at a far lower level, I’m pretty certain that both players winning isn’t a feasible outcome at the Olympics either.

Then came a game where the players level-pegged it most of the way up – you know, 10-10, 10-11, 11-11, 12-11, 13-11, 13-12 and so on – until the scores reached 17-12. At that point, the commentator kindly informed us that the player who was ahead had some momentum.

That didn’t just strike me as true, it also provided me with a chilling reminder of the unpleasantness of reality away from the TV. Momentum is the organisation which is taking over the Labour Party at the moment, and achieving two effects: turning it into something much more brutal and unpleasant than it has been in the last thirty years, and making sure that it falls into the trap of believing it’s more important to have good policies than to get the opportunity to put any of them into practice.

Momentum, it seems, is something that drives you forward, but without a heed as to whether it’s straight into a wall or over a cliff.

Momentum in the badminton match led to joy for one player, tears for the other. The fruits of victory, in other words. Sadly, the victory of Momentum over Labour will only be tears, and shed all round.

Friday, 12 August 2016

Luci's diary: amazed at my amazedness

It’s amazing what amazes human number 2.

The other day, number 1 wasn’t feeling too well, so she went to bed. It’s true that normally I lie next to number 2 on the couch as he taps away annoyingly on his computer, biting his hands sometimes to make him stop, but that gets him annoyed and makes him even more annoying.

“Stop that, Luci,” he says in a pathetic voice, “lie down.”

But he always strokes me while he’s saying it, so what does he expect me to do? If he rewards me, I keep on going. If he punishes me, I’ll stop.

Well, I assume I would, but he’s never actually got around to punishing me, so I’m not sure what I would do, really.

Or does he think raising his voice is a punishment? I just bark at him. And I make a lot more noise than he does, so I tend to get the better of those exchanges too.

Anyway. Like I was saying. Normally I lie on the couch next to him while he gets on with what he calls work, though how anything you do sitting down can really be called work, I can’t imagine. But that was number 1 upstairs. And in bed. Of course I went upstairs too.

Maybe he was upset. You know. Felt neglected and all that. 

What he did was sneak into the kitchen. With a banana. A banana. My absolutely best food ever. Maybe he thought I wouldn’t notice. But you know the noise a banana makes when the peel gets broken? It’s so distinctive. Of course I heard it, and I nipped downstairs immediately.

I knew I had to be specially endearing. He might have been upset, after all. So I did the whole act. I made sure I went tappy-tappy-tappy with my paws on the floor, because he likes that.  And I got the tail going so hard it made my whole behind wag. And the eyes thing: deep pools of pathetic black that just cry out, “please, please be nice. Feed me, feed me.”

It’s the sad eyes that work the magic. Every time
It worked too. He’d eaten quite a lot of the banana but there must have been a third of it left, I reckon. And, instead of chopping it up into silly little bits, he just fed me the whole thing. Much better than the choppy-uppy way. I got lots more.

It seems he was amazed that I’d heard him.

“How did you know?” he kept saying. “All the way upstairs, with doors in between and everything, and you still knew I was having a banana.”

Well, yeah. Duh. If I hadn’t known I wouldn’t have been there, would I? I mean, why give up on a perfectly good rest in the bed if there wasn’t a banana going?

She came down later and they had dinner in the garden. That’s always good because they’re less careful about not dropping things in the garden. I can get quite a good meal out there. Misty joined us for a while, but then he went and climbed on to a shed roof.

“Look at the cat,” she said, “he’s worrying the honeysuckle.”

It was true. He was batting the top flowers with his paw. Which seemed unfair: they hadn’t done anything to him.

“I shouldn’t think they’ll mind,” said number 2, who really likes pointing out the bleeding obvious. I mean, I don’t expect they even noticed. They’re pretty dumb, flowers are.

“Yes,” she said, “but I don’t see the point. Why can’t he leave them alone?”

And as soon as she’d said it, Misty moved away.

What is he thinking of? Why let them know we speak English? Why give up that advantage?

I’m certainly not going to.

Wednesday, 10 August 2016

Triage: one way of avoiding the avoidable

Just because something’s avoidable, it isn’t necessarily easy to avoid.

That’s certainly true of avoiding unnecessary hospital admissions. When we’re ill, we want to feel better, as quickly as possible. Indeed, if we’re in pain or great discomfort, we want our care to start immediately – to us at least, our condition is urgent. If we can’t see a professional in one of the relatively inexpensive settings, such as a GP practice – perhaps because we can’t get an appointment soon enough, or because our condition arose out of hours – we might be inclined to head straight for a hospital. Why, we might even call an ambulance to get us there.

When we need one, we really need one
When we don’t, we really don’t
A while later, we would be standing in our local Emergency Department and explaining how ill we are. It’s possible that the person we’re talking to is a relatively junior member of medical staff or nurse, inclined to be risk-averse: that is, they would prefer to err on the side of caution, offering more treatment than we really need rather than too little.

The next thing we know is that we’ve been admitted as an emergency inpatient to the hospital. Now, if that’s what we really needed, then that’s fine. If it wasn’t, then the system has failed us. From its own point of view, it will have behaved wastefully – as I argued last time, it may have spent twenty times as much on our case than it ought to have done.

But unlike a good meal or a good holiday, where spending more generally gives greater quality, in healthcare that’s not necessarily the case. In hospital, we’re surrounded by sick people. There’s a serious chance we might pick up a disease from some of them, and actually find ourselves becoming less well rather than better from our hospitalisation. It was clearly avoidable, and avoiding it would have been desirable for both sides.

The process that would have avoided it is called triage. From the French word for sorting, triage was first extensively used in the First World War, to identify three classes of injured soldiers: those who it would be a waste to treat as they were beyond rescue, those who could wait because they weren’t that seriously hurt, and the intermediate group on whom to focus.

Today, it’s come to mean a process by which the medical condition of a patient is assessed before a decision is taken on treatment. Triage can take place in a number of ways. For instance, a GP in effect carries out triage in deciding whether a patient needs hospital care or not. But we tend to think of triage more as the kind of service a patient might phone for advice before taking off for the hospital, or that an ambulance call handler provides when we dial an emergency number.

A conversation takes place between the caller – who may or may not be the patient – and someone able to advise on treatment options.

That sounds simple enough and provides an obvious way to avoid an unnecessary hospital visit. Unfortunately, it’s not as straightforward as it sounds. Triage is a skilled task, and there are two traps, at opposite ends of the scale, that have to be avoided.

  • Excessive caution: to ensure a patient doesn’t miss out on treatment that might be necessary, the call handler decides on a referral to an urgent service when one isn’t necessary. A paramedic I once dealt with told me that the triage service locally had simply become “another way of calling an ambulance.” Far from reducing highly expensive but unnecessary care, the triage service might well increase it.
  • Under treatment: the call handler fails to spot a condition that does need urgent care, and the patient suffers as a result. In January this year, the Guardian published the horror story of a doctor who needed urgent treatment but might have been left blind by a triager failing to spot the real problem.

The impact of good triage was shown by a study carried out by the journal Acute Medicine in 2015. It showed that when triage was carried out by senior hospital physicians, 28.5% of admissions were avoided – a huge success rate. But do we really want triage carried out by senior physicians who should be treating patients?

The elusive solution would be a way of increasing the quality of decisions by call handlers who are experts in triage as such, rather than medical specialists. That’s a matter of training, though of course it can also helped by providing better support.

Another study, in BMC Medical Informatics and Decision Making in 2014, suggests that providing a clinical decision support system can help. Since that’s my own field, it’ll be the subject of the next post in this series.

Monday, 8 August 2016

We're all in this together: the shared pain and triumph of austerity economics

“We’re all in this together,” David Cameron assured us when he first came to office.

Labour, it seems, had caused a terrible worldwide financial crisis. Just how the Blair and Brown governments had managed to inflate the sub-prime mortgage market in the US and then bring it crashing down, was never made clear. But the British Conservatives are honourable men (and a few women), so who are we to question their pronouncements?

Cameron: who are we to question his judgement?
What was bountifully clear, in any case, was that we would all of us be paying the price. Austerity economics would be applied without fear and favour. That meant belts would be tightened in every part of society so that we could pay off the colossal debt Labour had accumulated and wipe out the government’s spending deficit. 

The pain would be hard to bear but such a prize was surely worth it.

Labour’s behaviour had indeed been intolerably bad. It had amassed a debt amounting to 76.6% of GDP by 2010. Fortunately, five years of enlightened Conservative rule delivered a figure of only 89.2%. Labour’s legacy was an unforgiveable debt to be passed on to our children and grandchildren. What the Tories have achieved is, I’m assured, a huge step in the right direction.

What about the deficit? Here, Tory success has been even more spectacular. At the height of the crisis, the deficit reached £103bn. That has been pretty much wiped out, as George Osborne, Cameron’s Chancellor of the Exchequer promised to do within five years – wiped out, that is, apart the final obstinate residue of £40bn or so. Still, look how that compares with the lamentable Labour government’s figure of £20bn in 2005, before the crash.

Which, don’t forget, it caused by manipulating the US sub-prime mortgage market.

These successes don’t come without a cost, of course. There has had to be a cut in the top rate of income tax, paid by those on the highest salaries, from 50% to 45%. Funnily enough, overall tax and benefit changes have reduced household incomes by about 3.3% on average.

Tough but fair, I’m sure you’ll agree. Especially as the elderly are much more assiduous in voting Tory.

Meanwhile, public sector workers have shouldered their share of the burden. They took two years of pay freeze from 2010, and since then have lived with a cap of 1% on pay increases.

Private sector employees have played their part too. For five years, their increases averaged 1.5%. But last year, there was a great loosening of the shackles as pay soared, on average by 1.8%.

There was at least one consolation for those coping with pay restraint. At least they know that everyone is shouldering their share of the burden. For instance, top executives of the biggest companies saw their salaries rise by a mere 10% last year. It seems that these fine gentlemen (there are no ladies among them) are now paid £5.5m a year on average which is 129 times as much as their employees, or just shy of 250 times as much as median income in the UK.

Achievements like taking the deficit down to twice what it was in 2005 and public debt from 78.4% of GDP to 90.6% don’t come free. Someone has to pay.

Isn’t it comforting that the pain has been so well-shared, confirming that we are indeed “all in this together”?

Saturday, 6 August 2016

Corbyn, leadership – and Lincoln

The British Labour Party’s tearing itself apart in a contest to choose a new leader, Owen Smith – or possibly to re-elect the existing one, Jeremy Corbyn. 

For many, the dispute is about principle or policy, but in reality it’s about something far more fundamental. It’s about leadership itself, which is hard to define, but easy to spot when we see it. And one historical figure has shown it far more powerfully than any other.

When Abraham Lincoln won the presidential nomination of the Republican Party, he started as far from the front-runner.

That position belonged to William Seward, who’d taken a strong position against slavery, the most controversial issue in the United States at the time. Another candidate, Salmon Chase of Ohio, had been even more strongly outspoken, and had the backing of the abolitionists within the party. The Republican Party was, however, new and had been formed by disparate, sometimes incompatible trends; the conservative faction, inclined to preserve the Republic’s traditions, even at the cost of retaining slavery, had its in Edward Bates, from the slave state of Missouri.

The most powerful expression of leadership
Despite his personal abhorrence of the institution, Lincoln’s position on slavery was that it had to be tolerated where it was already established, but it should not, on any account, ever be allowed to extend into any of the new territories of the still expanding United States.

Lincoln was initially in poor second place to Seward. But the latter, as well as enthusiastic supporters, had also made numerous enemies within the Republican Party. As supporters of other candidates switched, Lincoln closed the gap, overtaking him and winning the nomination on the third ballot.

At a time when it was regarded as inappropriate for candidates to campaign on their own behalf, Lincoln had to depend on others to canvass for him. In what is an extraordinary tribute to his generosity, no one campaigned more extensively than Seward. He started with a nine-state tour, addressing huge rallies; he ended with an intense campaign in his own state of New York, without which Lincoln might have been denied his victory.

If Lincoln wasn’t campaigning, that didn’t mean he was uninvolved. From his home in Springfield, he directed operations throughout the country, gave newspaper interviews and decided the content of the campaign. He kept himself astonishingly well-informed, as one visitor discovered to his consternation. Doris Kearns Goodwin tells the tale in her highly readable book, Team of Rivals: “I found that he was more conversant with some of our party performances in Oneida County than I could have desired.”

On campaign content, his view was that he would say nothing more than he had already published. But he was careful about the messages others were communicating. In another passage, Goodwin tells us:

John Wentworth, now the mayor of Chicago, was continually making references to an argument the party was trying to avoid – that a Republican win would bring an eventual end to slavery altogether. Knowing Wentworth was set to introduce Seward [at a public meeting], Lincoln asked the New Yorker to reassure the audience that Republicans “would not interfere with slavery where it already existed.” Seward readily agreed… In distancing themselves from Northern abolitionists, the Lincoln team was far more concerned with reassuring Northern conservatives than with conciliating the South.

A brilliantly-run campaign, to which Lincoln was able to recruit even his most powerful recent foe, with judicious use of silence or at least moderation on the key issue of the day, won Lincoln the presidency.

One of his first official actions was to form a Cabinet. As Secretary of State, the most senior position, he appointed William Seward. As Secretary of the Treasury, the second, he chose Salmon Chase and as Attorney General, Edward Bates. So all three his rivals for the Republican nomination were in his Cabinet.

The other four posts in the then seven-strong government went to Democrats. Not just rivals, but opponents of his party. With just one change, the appointment of Edwin Stanton, also a Democrat, as Secretary of War, Lincoln had the team that would help him win the Civil War for the Union – one of the most effective Cabinets the US has seen.

As the nation descended into civil war, Lincoln’s discretion on slavery proved invaluable once more. It was instrumental in keeping four slave states in the Union, and out of the Confederacy. And that was crucial to victory.

What about the question of slavery itself?

In January 1865, just months before he was murdered, Lincoln engineered the passage by Congress of the 13th Amendment banning slavery from the US for ever. Something he could never have done without winning the presidency and then the Civil War, by then all but over.

The lesson for us?

The road to political success is often a tortuous one. It takes a great deal of ingenuity, even deviousness, to follow it. It’s not enough to grab a megaphone and keep blaring out the message, however principled it may be, or even right. Sometimes, a little silence is far more effective.

You also have to use the political structures in which you live to bring in the changes you know are needed. Lincoln built a cabinet that maximised support for his government; he worked with Congress to build majorities for the measures he knew had to be passed; and because he handled the issue with care, he exorcised the great bane, slavery, that had poisoned his country at its roots since its foundation.

It’s too much to ask that Labour today finds itself a leader of the calibre of a Lincoln. But I don’t think it’s unreasonable that we set that kind of leadership as a benchmark to aspire to. And, sadly, our present leader, unable to win the support even of his own parliamentary colleagues, falls far below that standard.