Random Lists (3): things I can’t stand in NHS management/groupthink

These things seriously peeve me, despite my tolerant and accommodating nature. Honest:

  1. People who claim they ‘speak truth to power’ – the opposite is usually true
  2. Quoting TED talks
  3. Bringing in expensive outside advisers – who are all in it for the money. They are treated with a reverence they do not deserve, and they have no ‘skin in the game’.
  4. The (occasional) unspoken assumption that acute care mysteriously takes care of itself, when it comes to allocating budgets
  5. The lack of challenge to the New Deal and the GP Contracts – time to shift the Overton Window on these, they are not in the public’s best interests

I have to add, though, that there is much to admire and praise in NHS management.  Many of these colleagues work their socks off and do a great job. It’s just not that exciting to blog about, sadly.

Thomas Sowell never lets you down
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The future of the NHS, AKA “stopping doing some things”

ab1
…he has a point

Nearly 70 years ago,  the declared bases of the NHS, were the much-quoted three founding principles, courtesy of Aneurin Bevan, a remarkable politician:

  • that it meet the needs of everyone
  • that it be free at the point of delivery
  • that it be based on clinical need, not ability to pay

This nice summary from the NHS’ 60th birthday in the BMJ provides the narrative:

The three principles stand up well. American patients admitted as emergencies often can’t believe how good things can be in a quality NHS unit. It’s true though that maintaining such quality without financial incentives/disincentives (unlike most developed countries) is getting harder to do.

Did we need to add to these three principles? I don’t think so, but in the time honoured manner of bored self important managers and clinicians drifting away from the frontline, we have. Try this, from a big cheese Welsh NHS seminar in 2011:

Universal access, based on need
Comprehensiveness, within available resources
Services free at the point of delivery
A shared responsibility for health between the people of
Wales and the NHS
A service that values people
Getting the best from the resources available
A need to ensure health is reflected in all policies
Minimising the effects of disadvantage on access and outcome
A high quality service that maximises patient safety
Patient and public accountability
Achieving continuous performance improvement across all
dimensions of healthcare

I’ve italicised the ones that I would call mission creep – they’re not strictly NHS issues – and also the ones that are platitudinous and glaringly obvious. I’ve put in bold the bits with which I agree, but nobody really means, as ‘within available resources’ in practice means rationing. I have yet to hear a sensible debate on real rationing of NHS services, which means stopping doing some things. The Scottish NHS goes on about ‘realistic medicine’, but despite lots of hype, it remains somewhat undefined in terms of stopping doing some things.

Principle 6 in the now seven principles of the NHS spelt out in the NHS Constitution, also from 2011, alludes to this:

nhs6

Which actually is worth spelling out. It’s the only way to keep the NHS viable. And what that means is….stopping doing some things. There are plenty of things that would have appalled Bevan and his colleagues, had he realised that’s what the NHS smorgasbord would end up providing. I have my particular favourites, you may too, and I include in my unpublished list quite a few of the elective procedures offered by my own specialty.

Bevan was following on from the flawed intellectual William Beveridge, who had a slightly broader remit looking at the role of the postwar state in more general terms:  “five giants on the road to reconstruction” that needed to be slayed: want, disease, ignorance, squalor, and idleness.

Beveridge was on to something then and now.

None of this is new of course, but my suggestion is that these admirable and clear principles have been abused by the sprawling megacity of the welfare state of 2017, the most loved component of which is the NHS.

For the record, I’ve worked in the NHS for decades, I don’t do private work. What we badly need, as taxpayers, patients, healthcare workers, rational human beings etc, is to restructure what the NHS does (which means stopping doing some things). It’s not hard in principle. Here’s the order of priorities:

  1. Lifesaving emergency treatment
  2. Pragmatic management of life-threatening conditions, mainly cancer
  3. Rapid access General Practice that includes real out of hours care
  4. Elective procedures that work – so stop doing things that don’t have proven benefit of adequate clinical significance. That’s actually quite a lot of things that currently go unquestioned.
  5. Appropriate public health/screening. So more colonoscopies, fewer stupid campaigns against booze (just to be topical).
  6. Better end of life care

There are lots of other areas of neglect – for example the adult physical handicapped – but many of these are primarily social care issues, and I would like to see that separated from the NHS conceptually and financially, whilst accepting that the much neglected interface between the two is very important.

Where Beveridge, Bevan and the modern welfare state collide is in at least two areas. Firstly, it would have been impossible for them to foresee the exponential expansion of high quality, effective but costly medical interventions. The human race got good at this very quickly. Affordability became difficult within a few decades of  the 1948 landmark.

Secondly, note Beveridge’s specific mention of ‘idleness’, which is effectively a codeword for what is loosely referred to as the Benefits Culture. Guardianistas don’t tend to focus on it. It is equally unaffordable in its current iteration. I’m not going to explore it, but interested readers will find illuminating references to it throughout the works of a master medical chronicler of these two centuries, Theodore Dalrymple (1, 2). Anyone with their eyes open in the developed world, particularly the UK, will know what I mean. As would Beveridge.

It’s fascinating to learn from the acerbic and erudite Geoffrey Wheatcroft something that may seem minor, but isn’t: Beveridge detested the expression “welfare state”.

wb1
…another zinger

 

 

Random Lists (2): likeable lefties

gorbachev_and_reagan
…historic stuff. Could it work with the Norks?

I’m not always sure why I like them (and I don’t always like them either), but here you go:

  1. George Galloway (right about so much eg. Iraq **, wrong about everything else)
  2. Neil Clark (journalist and ace tipster)
  3. Yanis Varoufakis (for being sharp about the EU)
  4. John Pilger (a certain gritty integrity after all these years)
  5. Gorbachev (never got as much credit as he deserved)

(Note that the list does not include irritating boorish underachieving egotistical ‘national treasure’, Dennis Skinner)

**though to be fair on one point,  the Iraq army is a very effective fighting force now, in 2017

The SNP: decline and fall (15)

Things are ticking over nicely. Three little gems:

48. Unfunny ex MP Eck could be going on tour

What is it about the bullying despotic politically inclined type that makes them want to go on stage? Eck is possibly following in the footsteps of gruesome thug Alastair Campbell (1, 2), in selling his tedious schtick for cash and adulation once the political spotlight has begun to fade.  German journalist Matthias Matussek, reviewing Campbell’s nonsense thirteen years ago said: He provided a strange white noise, two hours long. Sounds about right for Eck. What could go wrong?

49. Well this could..

Eck continues (see 47) to damn his successor with faint praise, knowing exactly what the headlines will say.

DISLOYALECK
…with friends like these…

 

50.  More seriously though. Money.

There is now a more open, and less adulatory mood in parts of the Scottish media when it comes to following whatever the SNP party line is this week.  Former Salmond adviser, Alex Bell, transformed himself into a sharp and knowledgeable critic of Salmond and the Nats some time ago. Here he is this week:

There are days when Nicola Sturgeon must wish Alex Salmond gone. Not for the sexist gags or the disloyalty to her (though how he would have hated that in return). It is the legacy which leaves her trapped between hard numbers and soft promises, destined to disappoint the nation…

….But she is never free of the legacy, the memory of her political mentor, as Salmond is built into every atom of the modern SNP. She can no more be free than start a new party – a thought that must have crossed her mind in darker moments. Her dilemma is when the annual round of economic figures (GERS) come out showing a big gap between what Scotland earns and what it spends within the UK.

If she admits the truth, that Scottish spending would have to be different to the UK budget, she exposes Salmond’s trickery. If she defends it, she holds the movement back from seeing the truth and facing questions about spending priorities and tax increases…

….Most of all, she has wrestled with the SNP belief that Scotland can afford what it wants because Salmond told them so. Whether Salmond ever believed this, I can’t tell. But it seems unlikely as the man isn’t stupid.

The numbers are the numbers – and they show that UK spending attached to Scotland is greater than Scotland could afford if it was detached. Salmond was smart enough to realise that admitting this would end up irritating voters so he never did. And because of what Salmond spun and the SNP believed, the party are based on an illusionist trick – that anything is affordable.

Painful stuff  for true believers, although evident to sentient thinking punters for years. If you want to know what those GERS actually show in their cold, uncomfortable detail, then visit the indispensable @kevverage over at Chokkablog.

Scottish National Party Hold Their Annual Conference
…keep him where you can see him Nicola…

 

 

 

 

Great landscapes: Jan van der Heyden

I have an enduring soft spot for Dutch art in general, well beyond the big names. The second tier, like Hobbema, Avercamp and so on are not just technically gifted, but also supremely evocative of real life, only several hundred years ago. Taking your time to closely scrutinise their works is like entering a time machine. One could say the same for the Brabantine twins Bosch and Bruegel, except with those supreme masters their admittedly great landscapes are frequently in the context of the wackier end of the imagination. Not always though, as I detail here.

Back in 2010 there was a terrific exhibition at Holyrood Palace, featuring works from the Royal Collection, called Dutch Landscapes. No-one could even approach the scale and quality of the Royal Collection if starting from scratch today, not even Bill Gates. It is an amazing body of work, technically still in private hands. The original cover of the book that went with the exhibition, was a painting by Jan van der Heyden. He was a bit of a polymath, not least because he seems to have invented the fire engine. This painting of the Vliet, near Delft repays your attention. It is a classic of structure, technique and numerous small details – the flying birds, the bridge, the human activities. As with most of these Dutch Golden Age pictures, it seems like a good time and place to be alive, health/social circumstances permitting (see also 1950s USA, Habsburg Spain etc).

Jan-van-der-heyden-a-country-house-on-the-vliet-near-delft
Jan van der Heyden A Country House on the Vliet near Delft, Royal Collection. 1660

As a comparison, which in terms of the aesthetically pleasing rural idyll shows you what has been lost, here’s an up to date view of a scene from the same vicinity:

Stompwijk_-_boerderij_langs_de_Vliet
…it lacks a certain something

…and if you didn’t believe the fire engine thing, here’s JVDH’s sketch of his design. Quite an all rounder...

Jan_van_der_Heyden_-_Comparison_of_the_old_fire_engines_with_Van_der_Heijden's_hose_fire_engine
*

The SNP: decline and fall (14)

This is brief, because not much needs to be said, so complete is the SNP’s descent from the commanding heights (or whatever) of arrogant Holyrood hegemony, to the current state of bickering, embarrassed, low energy, intellectually barren bewilderment.  It didn’t take long.

So….

45. Alex Salmond kindly provides further proof that he is an unfunny, unrefined bully

Otherwise known as his Fringe show. If Eck  seriously thought that his opening ‘joke’ was actually funny, he has a problem. Given his longstanding propensity to marvel at his own wit,  one doubts he has much insight.  His doubling down insult was actually even worse, via an unnamed spokesman, suggesting that Scottish Labour  – lead by lesbian Kezia Dugdale  – were just miffed as they didn’t get a mention. Classy as always. His successor, Ms Sturgeon, struggled to support him, which may well be the start of a trend (see 47, below).

46. Scottish Nationalist Party leader belatedly regrets the word ‘nationalist’.

Possibly feeling shifty after the confected media/VIP overreaction to Trump’s press conference, Ms Sturgeon, also at the Edinburgh shindig, was put on the spot by Turkish writer Elif Shafak. Nicola claimed, wholly unconvincingly, given the last few years: “If I could turn the clock back . . . to the establishment of my party, and choose its name all over again, I wouldn’t choose the name it’s got just now.”

Really? Tell the zoomers that. Amusingly, whatever you think of them, neither Trump nor Farage ran on ‘Nationalist’ tickets. Unlike Le Pen and Hitler. Perhaps Nicola has finally seen the light.

47. Unemployment is a terrible thing.

It can open the door to bad behaviour and causing trouble, to fill all that empty time. Sacked (by the voters) former MP and ex newspaper columnist Alex Salmond is spending his days hanging round Edinburgh street corners, telling tall stories and claiming it was better when he was in charge. It’s already started (1, 2). One almost feels sorry for Nicola Sturgeon.

Alex Salmond Makes His Last Keynote Speech At The SNP Conference
..worse. Siamese. twins. ever…

Progress

cs lewisA little practical philosophy** from the remarkable, on many levels, CS Lewis. Applicable to almost any situation. Try it.

We all want progress. But progress means getting nearer to the place where you want to be. And if you have taken a wrong turning then to go forward does not get you any nearer. If you are on the wrong road, progress means doing an about-turn and walking back to the right road and in that case the man who turns back soonest is the most progressive man. There is nothing progressive about being pig-headed and refusing to admit a mistake. And I think if you look at the present state of the world, it’s pretty plain that humanity has been making some big mistake. We’re on the wrong road. And if that is so, we must go back. Going back is the quickest way on.

 

**As ever, there is a biblical connection. It depends on what you prefer, but the most poetic translation of Jeremiah 6:16 is a beauty: Put yourselves on the ways of long ago and enquire about the ancient paths: which was the good way? Take it then and you shall find rest. Which is 2,600 year old wisdom with a universal application

Twattish comments: an occasional series – Mick Jagger

Despite Bob Dylan winning his Nobel Prize – the best thing about which was Bob’s indifference/disdain for the whole shebang – pop lyrics are generally asinine. When they’re removed from their protective musical cloak things tend to get even worse.

There are still many gems – I always liked “you ain’t no punk, you punk” (The Cramps, Garbageman) – though rarely ones that involve a multimillionaire self-consciously ‘making a point’.

So here is Sir Mick Jagger (last good song, 1980), who has bestowed on us his lofty thoughts on Brexit:

‘Lock the shutters, bolt the doors, London’s gonna be like Singapore’.

Apparently that’s a reference to the ‘horrific’ thought of the UK becoming a tax haven after Brexit. Mick has obviously forgotten the 70’s. 

His piercing insights on politicians are hard to beat too:

‘The world is upside down, led by lunatics and clowns. No one speaks the truth and the mad-house runs the town.’

He’s obviously keen on rhymes.

mj1
Officer my car ain’t startin’, Even though it’s an Aston Martin… (will this do?)

The SNP: decline and fall (13)

The wind has rather gone out of the sails of the whole SNP schtick. Those heady days of 2014 (up to 18th September that year) seem like last century.

So it seems a bit harsh to continue to point out their failings. However, I’m up for it.

39. The upper chamber beckons…

Here’s a Twitter snapshot series:

snpa1

snpa2

Yup, the Daily Record has mysteriously floated the idea of unemployed Eck hitting the House of Lords – where The Knife has personally sipped at the finest subsidised booze in the kingdom – followed quickly by the Scotsman doing the same thing. Funny that. It’s almost as if Eck is regretting his rash promise about rocks and the sun (his usual), to which the True Believers of the SNP still cling. Don’t hold your breath. Eck’s perceptively brilliant finger-on-the-pulse style of leadership is sorely missed.

40. Indyref is not very popular

Not just amongst us plebeian voters, some of the sharper knives in the SNP box have begun to have doubts. Isn’t that verboten, under party rules? Not sure if the message is getting through though. That kind of authoritarian bullying has real world consequences.

snpf1
…this is actually all true…

41. Experienced hacks are taking the mick

Admittedly @JournoStephen and @davidtorrance have never been SNP flavour of the month, they’re not sycophantic enough, but this piece by the former is a gem of Holyrood observation:

Why, she demanded to know, genuine frustration in her voice, wasn’t Labour praising her achievements? Cruelly, Kezia Dugdale’s group broke into sarcastic applause and cheering. The SNP leader was baffled by it all. You would be too if you got your news from The National and had rules against internal party dissent that make the Chinese Communist politburo look like a model of open debate.

….and Twitter remains invaluable:

snpd1

snpe1

snpdoomed1

…watch the development from the last tweet. Gerald Warner is always precise:

So, a few little local difficulties, then, for the poor man’s Angela Merkel. At least she still has the consolation of being the highest paid politician in Britain, which suggests that, among the political class, remuneration is in inverse proportion to ability.

42. They’re still not good at running things

See what I mean?

snpg1

…and when they do mess up, the UK bails them out.

43. There’s a problem with Labour…

Gordon Brown ruined his own party partly by taking the Scots for granted, and amusingly if  predictably, the Nats are copying him. Corbyn is now going for them. Corbyn of all people – Mr Free Stuff versus the party of Free Stuff. And if you read wise owl @euanmccolm, they don’t know what to do about it.

44. The Fringe beckons…

Salmond promises to talk about his relationship with Trump at this year’s Fringe. Heavily redacted, no doubt

—————————————————————————————————————————-

As I often point out, none of this is about a problem with Scotland as such. It’s all about a problem with the SNP  – who for the most part are bullying, limited, rabble rousing, unimaginative power freaks. They almost never make a legitimate case for independence based on sovereignty, with all the risks honestly explained.

They never will.

what-is-molten-rock_e9b070f7-d7ef-45b5-abac-240b4c3fbf29
…molten rock, in case Eck’s not seen it before…