Month: September 2013

Human Rights – not Nice People’s Rights.

There’s a lot of debate at the moment about the European Convention on Human Rights, and the Human Rights Act 1998, and whether it’s a good idea or not for the UK to be involved in that sort of thing, which inevitably ends up forcing us to be nice to People Who Do Not Deserve It, or who are Not Nice People, or just Not Our Sort Of People.

Why, we ask ourselves, can’t we get rid of foreign criminals and terrorists and other undesirables? Why can’t we just dump them back where they came from, considering they’re not supposed to be here in the first place? So what if they’re at risk of being tortured or killed – don’t they (whisper it!) deserve it? (Well, just a little bit of torture anyway. Why do we always have to be nice to nasty people? If we aren’t allowed to give them some of their own back, why can’t we send them to where they’re going to get what’s coming to them?)

And therein, of course, lies the problem.

The European Convention on Human Rights grew out of the Nazi atrocities of the Second World War. Never again, said Europe, was any country going to be allowed to do that sort of thing to people. There were some things, said Europe, that were beyond the pale. That no human being should be subjected to.

And those things became the Human Rights of the convention:

  • Article 2 – the right to life
  • Article 3 – the right to freedom from torture and inhuman or degrading treatment or punishment
  • Article 4 – the right for freedom from slavery, servitude and forced labour
  • Article 5 – the right to liberty and security of person
  • Article 6 – the right to a fair trial
  • Article 7 – prohibition of retroactivity (if it wasn’t a crime when you did it, they can’t make it a crime and then punish you)
  • Article 8 – the right to privacy and family life
  • Article 9 – the right to freedom of conscience and religion
  • Article 10 – the right to freedom of expression
  • Article 11 – the right to freedom of association
  • Article 12 – the right to marry and found a family
  • Article 13 – the right to an effective remedy for violations of the other rights
  • Article 14 – the right to freedom from discrimination

And what, precisely, is wrong with these rights? Which right is it with which we don’t agree? Do we think it would be a good thing if the state were allowed to kill people? Or fix trials? Maybe society would be improved if certain people weren’t allowed to marry – or were only allowed to marry certain other people? Would it be preferable for the state to be able to arrest people and imprison them on a whim? Is discrimination on grounds of race or sex actually not that bad?

Let’s face it, people. When we think of the Human Rights Act, there is nothing in it that we would want to change – as it applies to us.

Because we are nice people, and we deserve to be protected from bad things like fixed trials and summary execution. But you look at some people, and you think “Hmmm, torture and summary execution couldn’t happen to a more deserving guy.”

And therein, of course, lies the rub.

These are human rights. These are things that Europe decided, sixty years ago in the wake of the horrors of Nazism, that nobody should have to suffer. The Convention was designed to prevent the wholesale violation of rights of the population by the state, and it has proved to have been mostly used to protect the rights of individuals. But is that such a bad thing? After all, a population is composed of individuals. Is a tortured person any less tortured because he was only one, not one of thousands? Is a criminal worth less as a human being than a priest?

When we get down to it, the European Convention on Human Rights is not about law: it is about ethics. It says “this conduct is morally wrong and there is no justification for it.” The Convention is about making the statement that to be human is to have value. All people have the same value: none are valued less, because they are the wrong race, or the wrong gender, or because they have a disability, or because they are politically inconvenient, or because they’re not British, or because they’re just really unpleasant.

The clue is in the name: Human Rights. Not Nice People’s Rights. Not Our Sort of People’s Rights.

If we repeal the Human Rights Act, we demonstrate that we believe that there are no human rights. That governments can treat their people as they see fit. And those at the margins of society – the unpopular, the minorities, the defenceless, had better look out. And the thing about margins… once you’ve eliminated whoever’s standing at the margin now, the margin moves inwards – and it might just be to right where you’re standing.

As Martin Niemöller said:

First they came for the communists,
and I didn’t speak out because I wasn’t a communist.

Then they came for the socialists,
and I didn’t speak out because I wasn’t a socialist.

Then they came for the trade unionists,
and I didn’t speak out because I wasn’t a trade unionist.

Then they came for me,
and there was no one left to speak for me.

He was talking about the intellectuals of Germany following the Nazis’ rise to power; the people who should have spoken out against the atrocities. The Human Rights Act speaks out for us all: do we want to silence that voice?

If we do, who will speak for us?

Women: too weak to be allowed to choose?

The Daily Telegraph ran an article about Jeremy Browne’s comments regarding banning the wearing of face veils in public to allow ‘freedom of choice’ for Muslim girls and women; Frank Cranmer at Law & Religion UK commented on it.

How on earth is banning a woman from wearing a garment supposed to promote freedom of choice? It sounds a bit Henry Ford to me: “You can have any colour you like as long as it’s black.” So, women would only be allowed to wear what they choose if what they choose is in accordance with what the government thinks women ought to wear?

As a female, I’m not terribly struck with the idea of the government telling me what I can and can’t wear in public, and mandating that I have to expose parts of my body that I don’t want strangers staring at. Personally, I have no desire (at present) to wear a face veil, although I usually wear a hat. [Politicians, please note: my husband does not make me wear a hat. I just like hats.] But I want to have the choice. If I should, at some point in the future, convert to Islam, I want to have the freedom to express my beliefs in the way I believe to be right.

There are two problems with banning face veils in order to ‘protect’ women:

1) The ban would affect women who wish to wear a veil for their own reasons. Of course, those proposing a ban seem to believe that no woman could ever want to wear a veil, so even those women who think they’re acting voluntarily are really the victims of subtle mental abuse. The logical conclusion here is that those proposing the ban believe that women are too weak, easily led, and stupid to be allowed to make their own clothing choices. If they cannot be trusted to make the choices the government approves, then they will have to be told what to wear – for their own good, of course. Because they need protecting.

2) If women are indeed being forced to wear face veils in public in this country, does anyone really think that banning veils would result in a better life for those women? If women are indeed being abused in that way, then the abuser will simply think of another way to maintain his control. The fundamental point here is that if the veil is being used to abuse women, then it’s the abuse that is the problem, not the veil. The veil – in this case – is merely the outward sign. There is no point papering over the problem by banning veils without doing something about the actual problem. Unless, of course, the people in favour of a ban don’t actually care about women being abused – they just want to prevent women wearing a garment that makes them, personally, feel uncomfortable.

A further corollary to this is that if this country’s existing laws on domestic abuse aren’t sufficient to deal with an abuse problem manifesting as veil-wearing, then maybe we need to review the abuse laws. After all, why pick out Muslim women wearing veils? Why not orthodox Jewish women who shave their heads and wear wigs? Why not Hindu women who wear sandals even in winter? Unless, again, we don’t actually care about women being forced to wear particular garments – we just want to indulge in a bit of Muslim-bashing because Muslims are the popular bogeyman du jour?

Another disturbing aspect of the Telegraph article was the comment by Dr Sarah Wollaston, the MP for Totnes, who said the veils were “deeply offensive” and were “making women invisible”.

Again, this statement raises problems for me.

Dr Totnes finds veils offensive; well, that’s her choice. Personally, I find mankinis offensive, and I’m apparently not the only one. But nobody is talking about banning mankinis. Is that, perchance, because we in the UK – despite the climate – are quite comfortable with acres of pallid, hairy flesh on display in public places? It’s people who cover up instead of stripping off to enjoy the watery sunshine as it breaks through the cloud cover for five seconds who are deeply suspicious…

The other point is that ‘veils make women invisible’. How? Well, maybe Dr Totnes has a different experience of veils than I do. In my experience, the typical Muslim woman in a veil manifests as a person dressed in a long dress with a veil, usually in black or dark blue. Definitely not invisible in any way. ‘Invisibility’ all sounds a bit Star Trek to me – I had never previously considered a Muslim woman’s face veil to be the religious equivalent of the Romulan Cloaking Device. What is Dr Totnes a doctor of, anyway? If she’s working in advanced physics, maybe she knows something I don’t…

Unless, of course, Dr Totnes is not talking about actual invisibility, but metaphorical invisibility? Does she think that a woman wearing a face veil is easily ignored and kept out of public life in the UK?

Actually, I find that thought even more disturbing than the idea that an MP believes in some kind of strike force of invisible Muslim women. Because if the mere wearing of an all-covering garment renders a woman metaphorically invisible to society, then the converse must be true: women are only noticed by society if are attractive. Women, in fact, must be purely decorative – a non-decorative woman (or one in possession of a Muslim Cloaking Device) can be ignored. And that’s OK by Dr Totnes.

Because Dr Totnes is not saying “We need to make sure Muslim women can play a full part in public life regardless of what they wear” – she is saying “We need to make Muslim women dress more attractively before we can take them seriously as individuals.”

But what about the security aspects? Those who are not bleating about how face veils are the sign of oppression are waxing lyrical about the security implications of people wandering around our streets and schools, completely unidentifiable.

OK, these are my objections to that line of thought:

1) On a personal level, I’m very bad at recognising faces. Consequently, pretty much everyone is unidentifiable until I know them well. A face veil is hardly likely to make a difference (except so few people wear them in the UK that it’s an identifying mark on its own…).

2) Why is it so important to be able to identify everyone as they walk down the street? Are we in the middle of an epidemic of veiled Muslim women committing heinous public acts and I haven’t noticed? (Maybe they’re all invisible…)

The necessity for being able to identify a person only occurs in certain circumstances, such as in court, in exams, and possibly in banks and similar institutions (motorcycle helmets already have to be removed). However, in the first two instances, surely it is enough that the woman’s identity be established? Once her identity is established, she can put the veil back on. Identifiability is not a reason for a blanket ban of face veils in public – if it was, we would already have banned fancy-dress masks, thick makeup, and broad-brimmed hats (which prevent CCTV cameras getting a good view of the face). For that matter, a ban on face-coverings in public would have serious implications for road safety, as it would involve a ban on many types of motorcycle helmet…

Communication is another valid reason for restricting the wearing of a veil: if it is important for a person to communicate clearly, particularly to large groups, a veil may interfere with this.

But these are specific examples, where the restriction would apply to any kind of face covering, not just Muslim women’s veils. A particular, immediate, problem is identified; removal of the veil (whether temporarily, for identification purposes, or for longer periods, such as while teaching) is the only practical solution.

In conclusion, therefore, a ban on face veils (blatantly directed at Muslim women) cannot be supported:

  • If veil-wearing is a sign of abuse, then the abuse itself should be targeted. And, in fact, if this is the case, veil-wearing provides a useful signal of when abuse is happening – a signal that would be lost if veil-wearing were banned.
  • If veil-wearing is not necessarily a sign of abuse, then banning veils prevents women from exercising their right to manifest their religion and their right to choose their own clothes.
  • A ban on veil-wearing implies that women are not sufficiently strong, sensible, or intelligent to be allowed to make their own clothing choices, because no woman acting on her own volition would ever wear a veil.
  • Framing veil-wearing as preventing women taking part in public life implies that women can only take part in public life if they look attractive – and therefore that their contribution is decorative rather than substantive.
  • While there may be circumstances in which veils should not be worn (for identification, security or communication reasons), these are few. And the restrictions should equally apply to any other type of face-covering, such as a mask or a motorcycle helmet.

A new legal principle? No – a transcription error.

When reading a legal case and the judge appears to have formulated an entirely new legal principle from, as it were, whole cloth, do not panic. It may simply be a transcription or OCR error: Consider the ‘new’ legal concept of ‘atrophies acquit’ in Connelly v DPP [1964] A.C. 1254autrefois acquit, anyone?

On the other hand, if it’s Lord Denning, it probably is a new legal principle and you should sit back and enjoy the ride.

The Francis report, time to care, and ethical passivity

Scarcely a day seems to go by without the news featuring some new horror story about the NHS. If you formed your opinions of the NHS by what you read in the news, you’d be surprised that anyone survived contact with it at all. If the dirt doesn’t kill you, the staff will (either on purpose, by incompetence, or by accident)…

If you look at the numbers, though, a different picture emerges. In 2011, the Commonwealth Fund produced a report on the health services of fourteen developed countries. The UK NHS ranked consistently highly for access to care and fewest errors – yet the UK was amongst the lower spenders on healthcare, as a percentage of GDP and on a per capita basis.

The numbers say that we have an effective, efficient healthcare service – yet that isn’t what the news reports say, and as a person who has worked in the NHS for more than a decade, continual negative news coverage destroys morale. No-one comments when the NHS does a good job – even when staff go above and beyond their duty to do their best for patients. No: that is taken for granted. As a healthcare professional, you are expected to devote not only the time you are paid for, but a lot of extra time (unpaid), to patient care. And you are expected to be happy about it.

Then, there are the ever increasing numbers of targets, coupled with funding cuts. Healthcare is inherently expensive. And the better we get at keeping people alive, the more expensive it gets. We have an increasingly elderly population – because people aren’t dying early, the way they used to. Cancer isn’t an automatic death sentence, the way it used to be. We can treat it – with expensive drugs. For instance, sunitinib, used to treat various tumours, costs over £3000 per pack of 28 x 50mg tablets. Without VAT.

Keeping people alive is expensive. Skilled healthcare professionals are expensive. If you want good staff, you have to pay them – or they’ll go and work elsewhere.

So you get to the point where reducing costs in order to hit targets means that you can only do it by reducing quality. This was brought out in the Francis Report which found that one of the major causes of the events at Mid-Staffordshire Hospital was the drive to hit politically imposed targets and cut costs. Staffing was cut to below the level at which safe care could be given; hitting targets was prioritised above providing effective care.

A simple example of concentrating on targets at the expense of care is that of the four-hour waiting time target in A&E. There are three ways you can ensure that you hit this target without doing anything about what the target is really meant to prevent (i.e., excessive waiting for healthcare):

1. See those patients who are about to ‘breach’ the target, even if someone else who arrived later is more seriously unwell.

2. Move the patients who have been waiting for nearly 4 hours out of A&E by admitting them to an ultra-short-stay ward, which you call something like ‘Clinical Decision Unit’ – created by partitioning off part of A&E. They’re still waiting, but since they’re not doing it in A&E, they don’t count.

3. Don’t let patients into A&E in the first place. The clock doesn’t start ticking until they come through the doors, so keep them out. Make them wait in ambulances until you’re good and ready.

In all three cases, you can meet your target, but patient care is not improved – in fact, it may be made worse, especially in cases (1) and (3). This type of target is the classic ‘easy’ target designed by people who don’t really know much about how healthcare really works. It only works at a superficial level – and it’s very easy to meet the target without dealing with the problem it is meant to solve. The problem is that because healthcare is a system, how some parts work depend on how other parts are working. A hospital only has a finite number of beds – so if an outbreak of diarrhoea and vomiting occurs, closing wards so that patients can’t be admitted, this has an impact on A&E, because the whole system clogs up. If you don’t have enough staff (and many A&E departments don’t) then you can’t see all the patients fast enough if you do the job properly – so you have to find workarounds and shortcuts instead.

If you are simply concentrating on targets, therefore, it’s sometimes actually easier to fudge the problem to achieve the target without doing anything about the more fundamental issues the target was supposed to track.

The thing is, fudging doesn’t make healthcare professionals happy. Nursing, for example, is not a job you do because of the mega status and the fantastic pay and benefits. At some level, you do actually have to like looking after people, because if you didn’t, it would probably be easier to get the same amount of pay doing something less messy – and in the case of A&E staff particularly, less likely to get you assaulted.

So how do we reach the Stafford situation, where the hospital was apparently staffed by uncaring, incompetent nurses?

Like A&E waiting time targets, it’s a more complicated problem than it looks. A large part of it – as the Francis Report recognised – is that without adequate staffing levels, you cannot expect to get good care. The University of Birmingham produced a report entitled Time to Care in 2011, pointing out exactly the same thing. Looking after people takes time. Nurses only get issued with the same 24 hours in every day (or 8-12 hours in every shift) as the rest of the human race. The fewer nurses you have, the less time there is for looking after people.

But that is only half of the problem. What about the accusations of nurses being hard, uncaring, and cold?

This, too, is a result of too many targets, and not enough time.

Firstly, and most simply, the more the system encourages you to think of your patient as the locus of a number of boxes to tick, targets to meet, and reports to write, the less likely you are to think of that patient as a person. Bureaucracy requires an inflexible mindset: fill in the forms, tick the boxes, follow the flow-chart. If you’ve done all the paperwork, then you’ve done your job – and you can’t be blamed for anything. Actual care, however, requires a completely different mindset. You have to think of the patient as an individual, with specific needs and views, and this requires flexible thinking.

Bureaucracy encourages you to think “If it isn’t documented then it hasn’t been done” – but the logical extension to this is “If it can’t be documented it’s not worth doing.” This is totally against the principles of actual care – smiling and making eye contact with a patient as you pass the bed takes hardly any time at all, but makes the patient feel like a person. However, if you are concentrated on meeting targets, then you avoid eye contact – firstly, because since there isn’t a box to tick about eye contact, there doesn’t seem to be a reason to do it, and secondly because making eye contact increases the risk of a conversation starting. And conversations with patients take time away from documentable tasks.

The more complex reason for nurses appearing, or becoming, uncaring, is emotional fatigue. Caring for people is stressful. It’s messy, sometimes frightening, often nauseating. But nurses have to deal with it, all shift, every working day. And they have to look happy about it. For nurses, just performing the tasks technically well is not enough: they have to make the patient feel looked after, and the only way for a nurse to do that is to put more of herself (or himself) into the job. The natural way to protect oneself from emotionally stressful situations we can’t avoid is to become emotionally distant – but we don’t want nurses to do that. We want nurses to be emotionally involved, so that the patient feels cared for. But what effect does this have on the nurses, who are deprived of one of their sanity-saving safety mechanisms?

Burnout.

If you are put in an emotionally stressful situation, day after day, with no way of letting off steam, no way to relax, and no way to just be yourself – you always have to pretend to be the one who’s in control, the one who’s happy to help, no matter how exhausted, frustrated, or just plain sick you are – then something breaks. If you keep giving yourself, day after day after day, sooner or later you run out of self to give.

And then you start to think – what is the point? You run yourself into the ground, for what? Nothing ever changes, nobody says “Thank you, you did a great job.” With too much to do, and too little time, it’s just so much easier to save a little of yourself for yourself. Don’t stay so long after shift; stop chatting to patients; do only what you have to do. Then maybe you’ll survive. Follow the rules – there are enough of them, enough to bury you. Above all, don’t look for problems. If you find a problem, you’ll have to deal with it – and you have too much to do anyway. So don’t talk to patients, don’t make eye contact, don’t see problems. Because if you have to do just one more extra thing this shift, you’ll break down and cry right there in the middle of the ward.

Then you reach a sort of cool calm. Do what you’re told. Do only what you’re told. Meet the targets. Fill in the paperwork. Leave your emotions and your initiative at home. It’s so much less stressful that way.

It’s a risk with any job that requires a high level of emotional investment, but people burn out faster if they also have to deal with a high workload through lack of staff, and unsympathetic managers who insist on meeting targets at the expense of ‘doing a good job’. After you’ve butted heads with someone who gets paid more than you a few times, you give up. It’s not worth it. You’ve done your best, and who could do more? If you can’t make changes, then just accept things the way they are and try not to see the bad parts.

Ethical passivity is another angle; healthcare professionals who are expected to follow lots of rules, and to hit lots of targets, tend to concentrate on the rules and targets at the expense of the patient. This is most noticeable when what is best for the patient, in the clinical care sense, conflicts with the rules. A work culture that is heavy on rules and targets tends to prioritise following the rules, even if this harms the patient. After all, the thinking goes, if you follow the rules you can’t be blamed. Whereas if you don’t follow the rules (even if what you are doing will avoid harming the patient) heads will roll.

So, what is the solution? Scrap all the targets?

No. Targets are good – but they must be the right target. And if a department, or an organisation, fails to meet the target, just imposing a financial penalty isn’t enough. That just encourages corner-cutting and before we know where we are, we’ll have another Mid-Staffordshire.

More, tougher, inspections?

No. Inspections can either be fudged (just like targets) or, if it’s known that the inspection will simply be about hunting for problems and casting blame, rather than looking at the reason for problems, it only creates further problems – particularly stress amongst employees, which can result in suicide.

It’s easy, when a scandal like Mid-Staffordshire happens, to simply blame the people most closely involved, discipline them or bring criminal charges, and then move on. It’s much harder to acknowledge that a scandal of that proportion is the result of much bigger problems – like an iceberg, 90% of the problem is below the surface. In order to prevent future icebergs, we cannot afford to cast blame then move on. We have to figure out why the iceberg formed in the first place, because if it hadn’t formed, it wouldn’t have drifted into a shipping lane.

We already have an excellent healthcare system; it can be made better. However, that will take attention to the causes of problems, not a sledgehammer approach of simply reducing budgets and expecting Trusts to ‘be more efficient’. We need to develop IT systems that actually work to communicate with each other; we need to employ the right number of staff so that patients get the care they need, and mistakes aren’t made because staff are overworked. We need to integrate better with social care so that people who can’t cope in their own houses aren’t left in acute care beds needed by other patients because they are waiting for a place in a residential home. And we – the patients – need to take more responsibility for our own healthcare. It’s telling that one of the countries with the highest life expectancy and the lowest spend on healthcare is Japan – and they also have one of the lowest rates of obesity.

The NHS belongs to all of us, and we can’t afford to have it damaged or destroyed, either taken apart by people who see the occasional scandals but not the everyday miracles, who pursue cost-cutting at the expense of quality, or destroyed from within as staff lose the will to carry on.

The Devil’s Advocate

Devil’s Advocate is actually a real job – who knew? It used to be a full time position for a Vatican canon lawyer, until the post was abolished in 1983 by Pope John Paul II. However, the case of each candidate for beatification and sainthood still has to have its Devil’s Advocate.

The Devil’s Advocate’s job is to argue against sainthood, and attempt to prove that any alleged miracles etc are fraudulent. A person no longer has to be a canon lawyer – or even a Catholic – to be Devil’s Advocate. In the case of John Paul II, the Devil’s Advocate was a physician. In the case of Mother Teresa, the job was given to an atheist writer.

But I have to say, it would look good on a CV!