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Armando Iannucci in the Observer

Last month, a young mother in Brighton unexpectedly went into labour at home. When she rang up the midwife unit for someone to come out, she was told: ‘We’re shut for home births today.’ She was then asked to call back later. The interesting and frightening revelation comes in the subsequent statement by a spokesperson for Brighton and Sussex University Hospitals NHS Trust who said it was ‘totally committed to providing all women with a choice of where they give birth’.

That’s it. This is a statement of aspiration rather than an apology for reality. It’s like if I were to hit you in the face with a hammer and, instead of apologising afterwards, merely said: ‘I remain firmly committed to not hitting people in the face with a hammer.’

My contention is that it takes a very special development in the mental synapses to respond to a story like this without apologising. What we’re seeing is a creeping inability on our part to say we made a mistake.

Have I mentioned before how much I hate PR double-speak?

The medical profession is still awaiting an apology from the architects of the MMC / MTAS muddle.

Dr Crippen pulls together a number of threads to this story in the Britmeds.

As are we all for the cynicism and / or naiveté exhibited by those who fell for the Trap.

We already have a system - the free market - under which consumers can vote every day for what they want, instead of every five years as in politics! And that’s not only more democratic but also cheaper, because it means we can get rid of all those bureaucrats, who as we now know have just been (rationally) feathering their nests at our expense! There is no such thing as society! Order out of freedom: no wonder it looked like the end of history, the final triumph of democracy and free markets.

One of the revelations of The Trap is that Alain Enthoven, the guru behind Thatcher’s internal market NHS reforms of the 1980s, was US assistant secretary for defence under President Johnson, and before that - one guess - nuclear and game theory strategist at the Rand Corporation. ‘Consumer choice, competition and strong incentives to modernise’: no, not Brown, but Enthoven’s NHS prescription for New Labour, circa 2000.

The Trap’s bringing together of a number of strands, including psychiatry, medicine, politics, economics and management, is wide-ranging and controversial. But a virtue of its broad historical context is to bring into sharp focus otherwise-puzzling aspects of the agenda that New Labour has pursued since 1997 even more zealously than the Tories before them.

In this perspective, the assault on professionalism - teachers, doctors, lecturers, police - suddenly appears not an unfortunate by-product of policy: it is the policy. Ministers want doctors and lecturers to be motivated by money and league tables. It is only by ridding them of pesky notions of doing good or knowing best that game theory and public choice can be made to work.

Left to themselves, humans obstinately refuse to be bad enough for these grotesque theories to come true. When Nash tested his system games on Rand secretaries, he was bemused that they insisted on co-operating instead of betraying each other every time. Only later did it transpire that Nash himself was suffering from paranoid schizophrenia, believing everyone, including work colleagues, was out to get him. In fact, it turns out that the only people to reliably exhibit the behaviour required to make the equations work are psychopaths and economists.

That sounds bleakly funny, until you consider the implications. As the economists’ experience suggests, self-interest can be learned. The trap is that this is what organisations in both public and private sectors, all based on the same reductive assumptions about human nature, are teaching us. Slowly but surely, organisations are remaking us in their own stunted and cynical image.

More about the Trap in the Times with Simon Jenkins who argues for greater local democracy:

A tradition of the public realm once built round autonomous institutions, elected leaders and public accountability has been overtaken by the demons of quantification and control. The means by which the Treasury regulates public money has become the means by which the centre controls everything on which money is spent.

To every activity is attached a pecuniary value and thus a performance. To every performance is attached a target and to every target a league table. The targets may seem to be guided by what people say they want in focus groups, but in reality they are “negotiated” by power blocs within the public service. Their enforcement depends on matrices of budgets, feedbacks and incentives, covered by quasi-contracts and internal pricing systems. Orwell’s future, depicted as “a boot stamping on a human face for ever”, is now a computer mouse implanted in the brain.

Quantification makes computers honey-traps for ministers. John Reid and Patricia Hewitt are putty in the hands of their salesmen. Yet a 2005 survey showed that, of seven comparable governments, Britain had the highest computer “scrap rate”, the weakest contracts and the most uncompetitive market, quite apart from the poor value added of many of the machines. Yet these computers now have a validity of their own, blighting the NHS budget, farm payments, child support, ID cards, criminal records, tax credits and, most recently, doctor recruitment. They do not measure value but are a surrogate for it, so that what the computer cannot measure is valueless.

After all, these voices are not worth listening to, since what do they know, being professionals who have a vested interest & anyway, the special advisers know better.

Medics will face a “stark choice” between carrying out operations for which they are not trained and simply abandoning dying patients, according to a joint paper by the British Association of Emergency Medicine (BAEM) and the College of Emergency Medicine.

The professional bodies representing A & E doctors say the new system - which could see casualty departments operating without back-up services such as intensive care, paediatrics and surgery - is too dangerous.

The Royal College of Paediatrics and Child Health and the Royal College of Surgeons have raised similar concerns, warning that hospitals with an A & E but no surgery could struggle to keep enough intensive care staff on their books to support patients who suddenly fall critically ill.

I have worked in a few hospitals where cuts have led to situations like these & it is part of the reason why I no longer work in A&E or indeed the acute sector.

The DoH asked for recommendations for a new system for acute hospitals after David Nicholson, the NHS chief executive, revealed that the NHS must agree about 60 “reconfigurations” across England within a year.

The elephant in the room that no one will admit is that the reason is money. Just what are your lives worth? Any claims that there are not enough doctors to maintain services will now be laughed out of court but that was the excuse used all these years when the plans were being developed.

The plans to downgrade district general hospitals were drawn up by the Academy of Medical Royal Colleges, an umbrella body representing a number of doctors’ specialities.

Even it admits there are problems to overcome if its proposals are to work. It cites a lack of evidence showing what the outcomes are for patients who travel longer distances, but insists “big is not necessarily better” when it comes to hospitals.

Unfortunately as demonstrated by the past few months, the Academy & the senior members representing its constituents might be said to have lost touch with sanity.

One of the other reasons for my move into the primary care sector was the framing of unrealistic duty rosters which pretended that staff were machines. The scientific evidence behind shift patterns that ask you to do a few day shifts followed by an afternoon shift, then to be followed by a night shift, on consecutive days with just one day before you go back to the grind of day shifts again or indeed any other similar scheme escapes me. A look at the genetics of sleep.

This Doctor appears to be sticking it out:

I am not a consultant, but I feel that the term ‘junior doctor’ requires a little qualification. I started at medical school in 1992, qualified as a doctor in 1998, and have worked as a registrar (middle grade doctor) since 2003. I am junior in that I am not yet a consultant, but I have been around for a few years and seen a lot of disease.

Midwifery comes under scrutiny again in the Independent, after the recent front page article.

The most important factor in labour was one-to-one continuous care - this came from midwives, obstetricians, the National Childbirth Trust and natural birth gurus. In other words, mothers should be attended throughout by a devoted birth professional - ideally, a trained midwife. In reality most maternity units were woefully understaffed and it was commonplace to hear of midwives running between four women in labour. The Royal College of Midwives said forlornly (and still does) that at least 10,000 extra practitioners are needed to bring the maternity services up to scratch.

But I am afraid I have no sympathy with the argument that insurance is not required. I would support mechanisms of providing that cover however it might be structured as not many insurance companies are going to consider a few hundred midwives in a high risk occupation a viable business.

The Times looks at claims of the increasing medicalisation of labour & again pushes independent midwives.

Patricia Hewitt, the health secretary, is preparing to announce a new drive to improve maternity services.

There will be a promise that every woman will have a named midwife to care for her throughout pregnancy and a guarantee of one-to-one care by a midwife during labour. How long that promise will take to be delivered is anyone’s guess.

Since 2004 the government has been promising women “real choice” over where to give birth. In reality mothers face not a choice but a dilemma: home or hospital?

Last week the government watchdog Nice (the National Institute for Health and Clinical Excellence) issued a warning that babies born at home have a higher risk of dying if serious complications occur. But last week, too, a health department study found that the NHS is letting down new mothers in hospital, treating many like “meat on a conveyor belt”.

So the NCT have a good PR department. However safety comes first and if the practitioners are not able to keep their knowledge up to date & to accept responsibility for their mistakes, they have no business providing care. So the focus should be on the means of obtaining insurance & proving competency, not denying the need for it.

As for this, the best gloss that can be put on it is a wilful blindness to criticism & a lack of interest in a range of views, preferring sycophants. Much worse has been claimed. No wonder so many schemes run into trouble.

Claims made in Liam Halligan’s Dispatches programme of a few weeks ago are re-examined in this article in the Times.

Cancer patients who have had tumours removed are dying because they are waiting so long for for follow-up radiotherapy that their tumours return, a government report has found.

After surgery, patients should receive radiotherapy within 28 days, according to the Royal College of Radiologists. However, in some areas, patients are waiting three times as long. In Kent, for example, the waiting time for breast cancer patients who have had tumours removed by surgery is three months.

Dr Michael Williams, vice-president of the Royal College of Radiologists and co-author of the report, said that, in addition, some patients were not receiving enough radiotherapy.

Williams said: “One problem is delays in some areas of the country and the other is that, when patients are treated, they receive fewer fractions [doses] of radiation than they would receive elsewhere in Europe and America.”

It is understood that the report, co-authored by Mike Richards, the government’s “cancer czar”, also says that the NHS is administering only about half the amount of radiotherapy needed to treat British patients properly.

The government report has been subject to repeated delays. A draft was ready in August and the document has been with health ministers since February. Critics suspect the Department of Health (DoH) will suppress it until it is ready to announce a new plan to improve cancer services in the autumn.

Healthcare in the private sector makes an appearance in the Telegraph with a profile on General Medical Clinics but I wonder how the restrictions on private screening will impact on other parts of the industry.

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This entry was posted on Sunday, March 25th, 2007 at 11:01 am and is filed under Clinical, Management, NHS, Politics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.