Power corrupts. So do government targets.

I get Medscape news sent to my inbox; a lot of it is news of trials and so forth, but some of it is news-news: what people did, to whom. Since Medscape’s an American site, the news is American too.

It really is a different world over there.

Yesterday’s inbox gave me the story of Farid Fata, the American oncologist who gave hundreds of patients chemotherapy unnecessarily. He did it not because he enjoyed watching people suffer, or just liked to kill people (Dr Shipman, I’m thinking of you), but for the money.

In America, unlike the UK, doctors like Dr Fata get paid more, the more treatments they give, because it’s paid for by insurance companies. This has a predictable effect on healthcare efficiency, as demonstrated by efficiency rankings. Whichever ranking you pick, the US is generally somewhere near the bottom of the list. The UK, on the other hand, comes consistently somewhere near the top.

This is unsurprising when the US system encourages doctors to give more and more treatments to the same patients, as doctors are paid for giving treatments, not for making people well. On the other hand, in the UK system, as the state is footing the bill, there is a scrutiny of every penny, and examination of every waiting list. Woe betide the doctor who is more expensive, or has longer waiting lists, than his colleagues.

Hooray for the NHS.

However, all is not rainbows and unicorns over this side of the pond either. America has Dr Fata. We have Stafford.

At Mid-Staffordshire Hospital, in Stafford, the final report after a major healthcare scandal found that a focus on finance and meeting government targets, rather than on quality healthcare, resulted in the deaths of probably between 400 and 1200 patients over several years. (It was a bit more complicated than that, but the drive to meet government targets was a major part.)

The trouble with government targets like “patients must wait no more than 4 hours to be seen in A&E” is that when making real, useful differences is difficult, easy solutions present themselves. For example, if the clock doesn’t start ticking until after the patient enters A&E… just stop them coming in. Make the patients wait outside until you’re ready for them. Problem solved.

There are many inventive ways in which managers – particularly those whose experience and training is administrative rather than clinical – can come up with to meet government targets while simultaneously compromising the quality of healthcare to the point that patients start to die. This is not usually (I hope) because they just like people to suffer (whether staff or patients), but often because they are concentrating completely on meet the target and they don’t know, and don’t think to find out, what effect their schemes have on the real business of the hospital – which is making people better.

In a similar vein to Stafford, we had Bristol, where children more children died after heart surgery than should have. This was down to, among other things, an ‘Old Boys’ Network’ between the doctors: we’re all mates together and we don’t criticise each other, and we do things the way we always have.

The link between these three is that people are people. Doctors (and other healthcare professionals, although it’s doctors that generally get the headlines) and senior managers are human. Like everyone else, they have the tendency to do what’s easy, not what’s right.

In the case of the American system, doctors are put the way of temptation every single day – just order another test; what does it matter? Who’ll know? And the money will add up.

In the case of Stafford (and other places who were exactly the same but just didn’t get found out), it’s easier to just fudge the figures or satisfy the targets the easy way. After all, the government isn’t interested in excuses or reasons. All they’re interested in is did you meet the target? If you do, they’ll get off your back. Making real improvements can sometimes involve major changes that are difficult to organise – or even impossible without more funding, which the government will not provide.

In the case of Bristol, it’s classroom peer pressure writ large. Instead of being about having the right trainers, or the right phone (nowadays, I suppose), it’s about not challenging your colleague who is using a surgical technique last used in 1850, because he hasn’t done any CPD since he graduated from university. It’s easier not to get in his face, easier to just let it slide, not rock the boat. Someone else will notice and do something, surely. Maybe he’ll figure it out on his own and up his game…

It takes effort to turn away from the easy road (of making pots of money by giving patients treatments they don’t need, or of satisfying government targets by compromising care, or by letting your colleagues’ substandard practices slide because you don’t want to rock the boat).

The only way we will stop these health scandals that seem to hit the headlines every couple of years is if the right thing is also the easy thing. If it doesn’t pay to treat patient unnecessarily, or if the government’s attitude isn’t We know it’s impossible to improve services without more money. Do it anyway.

But I don’t hold out much hope of that. So what will be the next scandal, I wonder?

Advertisements

Ubble-Bubble, toil and trouble…

The UK Biobank, which is running a long-term observational study on nearly half a million middle-aged and elderly people in the UK, has produced a cross between an online game and a fortune teller.

It’s at www.ubble.co.uk and it asks you a series of innocuous questions: how old are you (only works for people who are 40+), how fast you walk, how you rate your own health, did you ever smoke, and so on. Then you press the button, and it gives you two pieces of information:

  1. Your chance of dying in the next five years and
  2. The average age of people who have the same chance of dying (which they call your ‘Ubble Age’.

I did the test – and had to lie about my age because I’m not forty yet – and it came out that (if I had actually been forty) I would have had a 0.2% chance of dying within the next five years. My ‘Ubble Age’ is 27.

This doesn’t mean that Ubble thinks I’m actually 27, or that I, personally, have a 0.2% chance of dying within 5 years. What it means is that

  • the average 27-year-old has a 0.2% chance of dying within 5 years and
  • If you had a crowd of 1000 27-year-olds, and you had a party this year, when you tried to have a reunion party in five years’ time, two of them wouldn’t be able to attend because they’d be dead.

A journalist in the Guardian has sneered at the test, because it’s easy to change the outcome: all you have to do, for example, say that you rate your health as ‘good’ instead of ‘fair’, and you get a better outcome. Also, the journalist who did the test got an ‘Ubble Age’ of 54 instead of her real age of 40. She concluded that she “would rather concentrate on living”, thus demonstrating that she has completely missed the point.

The point of Ubble is not to tell you when you are going to die, so you know whether to either make a will or borrow lots of money from people you don’t like.

The point of the Ubble test is to give people a chance to evaluate their own health, and what that means.

If a person’s ‘Ubble Age’ is older than their physical age, then that tells the  person something – it means that something about them or the way they’re living gives them a greater chance of dying than the average person their age. Maybe that’s due to factors outside their control, like having a past diagnosis of cancer, which is the greatest predictor of dying-in-five-years for women, apparently. On the other hand, maybe it’s because they smoke, or because they’re generally unfit. These things can be changed.

Playing with the questions gives you some interesting points: if I tell the quiz that I’m a current smoker, then my risk of death immediately doubles (to 0.4%), and my Ubble Age climbs 10 years, to 37.

If I stopped smoking (making me a ‘past smoker’), my risk of dying goes back to 0.2%, and my Ubble Age falls to 29 (not quite as good as being a never-smoker, but still a lot better than being a current smoker).

So I can use the quiz to estimate what effect making simple changes in my lifestyle would have on my health, and therefore my chance of dying. Of course, I still might get run over by a bus tomorrow, and even smokers sometimes live into their 90s, but that’s not the point. The point is giving myself the best chance of living until I’m 102.

Another point the journalist missed is that lying to the quiz isn’t a useful thing to do, unless you’re doing it to see what the results would be if you made a lifestyle change. The results don’t go anywhere: you’re only doing it for your own interest. So why lie?

The journalist also complained about the inaccuracy of people’s own self-made “health ratings”, saying that people often mis-estimate their own health. Well, that’s his/her opinion. The statistics, apparently, say differently – especially in the case of men. In looking at the questionnaires completed by nearly half a million people, the researchers found that self-reported health status (e.g. poor, fair, good, excellent) was the best predictor of future mortality for men. So whether all those people were lying or deluded or not, the results they put on the study questionnaires were gold (or maybe the reason self-reported health status isn’t the top predictor for women is that women – like the journalist – are more likely to be lying or deluded about their health, rather than that factor being taken over by a more powerful one: past cancer diagnosis).

The major point to take away from this is that Ubble is an exercise in statistics. On a personal level, it’s most useful for figuring out whether you’re likely to die earlier or later than other people your age – and thus, what your general health is like. If you come out as likely to die earlier (i.e., you get an older Ubble Age), then maybe you should think about making some lifestyle changes.

But for healthcare professionals, it’s far more exciting. The more data we have on people, as they grow older and die, the more we can predict where we need to direct resources for healthcare.

For instance, we know we can test Prostate Specific Antigen (PSA) in men, and we could potentially screen for prostate cancer. The trouble is, at the moment, the tests throw up a lot of false positives: where men get a result that says “Yep, you’re going to get prostate cancer”, and then they never do. So you end up with a lot of testing and following-up and worry, all for nothing. But with more data, we could pull all the factors together, and make screening more specific. Maybe it should go something like “If you get a high PSA result and you smoke and you rate your health as fair or below then you should be followed up.”

That’s the sort of thing that the UK Biobank might be able to tell us, as they get more data and evaluate it.

An even more interesting thing is that when they were evaluating the data, the researchers found that doing the questionnaire was a better predictor of when people were going to die than any physical tests (like blood tests). Which would you rather have – a short questionnaire, or a blood test?

So, in short, researchers have not yet discovered how to predict the future – but they may have started to do something nearly as good: help everyone figure out what lifestyle changes could have the biggest impact on their health, and help professionals figure out how to use our health resources best.

There’s a good article on Medscape here.

A change of direction

It’s been about three months since I’ve posted to this blog. The reason being a change of job.

My attempted career change has not worked out. Nine months or so of working in a law firm has made me realise that no matter how fascinating I find the law, practising it is not something I will ever be able to do.

Not because of the intellectual demands. Not because of the hours – or even because of the admittedly crappy pay.

No, it’s the having-to-deal-with-people part.

People stress me out. Even nice people. One client interview can ruin my whole day.

I now realise that I will never, ever be able to cope with a job that requires me to deal with people on a day-to-day basis. I’m an excellent technician. I know my stuff; I can apply it in the real world, and I can see a problem laid out like a diagram in my head (very useful for problem-solving). Unfortunately, I just can’t cope with people.

Luckily (being an excellent technician), I’ve now got a full-time job – back in pharmacy – that is mostly technical, and with minimal need to actually interact with real people except in the briefest of ways. Plus there are better doughnuts.

There is also even a law-y element, so my GDL won’t be wasted, and I’ll be carrying on with my LPC.

I don’t regret the experience, though. I’ve learned a lot (and not only that I can’t cope with people in any context), and no experience that teaches you something is wasted. I can now move forward, knowing that however much I love the law, practising law is not an option for me. Knowing that, too, is a good thing. It means I’ve tried it, it didn’t work out, and I can go on without hankering after it. Without wondering what if? I’ve done the what if, and come back to tell the tale.

So this blog is probably going to take a bit of a left turn. A bit more pharmacy, a bit less law. Or rather, the law quotient will have more of a pharmaceutical flavour. We’ll see.

Freedom of expression: only applies to our sort of people

Like so much that’s been written over the last day or two, this post is inspired by the attack on Charlie Hebdo, the French satirical magazine.

Shooting cartoonists is not acceptable, no matter how offensive their drawings.

However, if we move beyond the terrorist act itself, there are some interesting things to think about.

Firstly, there is an underswell of “Well, if Christians don’t get hot and bothered about satirical cartoons of Jesus, why should Muslims get all up-in-arms about cartoons of Mohammed? It’s the same thing, isn’t it? It just shows how intolerant Muslims are.”

Actually, no, it’s not the same thing.

An important point in Islam is that Mohammed is never pictured; to do so is blasphemous, even if the depiction is a favourable one. In fact, when a film (The Message) was made about Mohammed and the beginning of Islam, it was made without Mohammed – he was always there, just never on screen. The nearest you got was seeing the head of the camel he was riding.

If Muslims are going to be criticised for objecting to cartoons of Mohammed, then at least people should understand that there is a difference between cartoons of Mohammed and cartoons of Jesus, or Buddha, or the Hindu gods or the Flying Spaghetti Monster.

Criticise, fine. Just get the facts right first.

Secondly,  there’s the “Well, Muslims are allowed to practise their freedom of expression etc by being Muslims in France. Charlie Hebdo was only exercising its freedom of expression by drawing satirical cartoons.”

Actually, that’s another mistake. Muslims in France do not have the freedom to express themselves as Muslims however they wish. Muslim women are not permitted to wear a face veil; many girls are not even allowed to wear a hijab in school. Even though wearing a niqab or a burqa doesn’t hurt anyone else, doesn’t damage anyone’s property, and doesn’t demean or insult anyone else’s life choices, French Muslim women are criminalised and fined for expressing their religion in a manner of their choosing.

The reason for this is the principle of “living together”, which was newly added to the armamentarium of the European Court of Human Rights, seemingly specifically to justify allowing France to ban a religious practice that French non-Muslims did not like, in SAS v France. This is directly in opposition to the principle of human rights – that a human has a right to do, or be, certain things, either regardless of how much other people don’t like it, or to the extent that it does not impact on other people’s rights.

There is no right of “living together” in the European Convention on Human Rights. Neither is there a right not to be offended, or a right to not see things that you, personally, find objectionable.

This “living-together” principle is nothing less than carte blanche to decide on state-mandated standards of behaviour and enforce them – generally at the expense of minorities. France was therefore allowed to use this “living-together” principle to justify banning a minority religious/cultural practice simply because the majority did not like it.

So, going back to satirical cartoons… why is it OK for Charlie Hebdo to print cartoons that are deeply offensive to devout Muslims, and are certainly deliberately disrespectful to Islam, but it’s not OK for Muslim women to practice their religion in a manner of their choosing, which does not harm or disrespect anyone else?

Or, perhaps, is freedom of expression only free when the majority approves of what you wish to say or do?

Thirdly, and perhaps most perniciously, there is an unpleasant, sanctimonious tone to much of the comment, which implies “here in the West we are tolerant; those nasty Muslims are against all the good things like freedom of speech, women’s rights, and bacon sandwiches.”

I think, before we get too proud of our moral high ground, we ought to take a look at how high it actually is. Women’s rights is a large and complicated subject, but we need to remember that until 1937, a woman in the UK could only divorce her husband on grounds of cruelty, sodomy or incest (for a man, mere adultery was enough – but a wife was expected to put up with her husband sleeping around). The marital rape exemption (which assumed that a woman could not refuse her husband consent to sex, therefore it was impossible for a husband to rape his wife as rape requires lack of consent) wasn’t finally killed off in the UK until 1991 (by the House of Lords as was, in R v R.)

When it comes to freedom of speech, in 1996, Nigel Wingrove‘s film Visions of Ecstasy was banned by the British Board of Film Classification on grounds of blasphemy. The last of the blasphemy laws in the UK didn’t disappear until 2008 – and while in force, only applied to the Church of England anyway.

We here in the West are not nearly as tolerant as we think we are, and we should remember that real tolerance consists not of tolerating things that don’t bother us (like cartoonists ridiculing Muslims for profit), or that we even secretly approve of, but of allowing those actions that we don’t agree with.

Tolerance does not consist of outlawing anything (like niqabs, or walking around naked) that we don’t like, and then getting the police to deal with anyone who contravenes the new rules. It consists of asking “Is this weirdo actually harming anyone or anything else?” And if the answer is no, letting him get on with it.

The Children Act, by Ian McEwan

This is quite a short book – I read it in one evening. But it is the sort of book that stays with you.

It’s about Fiona, a High Court (Family Division) judge. Her husband of many years decides he wants to have an affair with a much younger woman – and wants her permission for it – and the same evening, an urgent case is dropped on her. A young man, three months short of his 18th birthday, has leukaemia and is refusing a life-saving blood transfusion because he and his parents are Jehovah’s Witnesses.

A person under 18 can consent to medical treatment if they understand the implications (Gillick competence), but their refusal can be overridden in their best interests by a court order.

Despite appearances, this book is not about the nitty-gritty of choice, self-determination, and so on. There is no in-depth treatment of the moral and ethical implications of parents refusing consent to life-saving treatment for their children for religious reasons, or even about whether it is ethical to deny the right to choose to a young person who is only three months short of his 18th birthday. The book is, instead, about the way Fiona deals with the case and its aftermath, and the consequences of her choices and actions.

This is one of those books where you have no real doubt how it’s going to end – the interest is in how that endpoint is reached, and the journey you make in getting there.

Right from the start, I liked Fiona. I cared about her, I wanted her to be happy, and I respected her dedication to the law and her duties as a high court judge. But McEwan also wrote – very well – an adult’s dismissal of a child’s (or young person’s) feelings. Oh, they’ll grow out of it. But, as many parents find – too late – young people’s troubles may seem minor to an adult with a wider worldview and greater experience, but they’re pretty shattering to the young person concerned. How many adults have failed to take a child’s problems seriously until too late?

Fiona, of course, doesn’t make all the right choices – it wouldn’t be a very good story if she did. But even as we, the readers, can see the road she is travelling along and where it is likely leading, we know that Fiona can’t. She makes the choices that seem right and good at the time, and it’s only later that she realises where and how and why it went wrong.

In the end, I suppose the book is about responsibility: when you rearrange someone else’s life for them (particularly without their consent), you had better have a care for the consequences – which may be more far-reaching and unpredictable than you expect.

This book will join the very select list of my favourites.

If you want to know which legislation and cases are mentioned in the book, I’ve added the book to my list of Law in Literature examples here.

Will-writing: let your imagination run riot

Yesterday I drafted my first Will.

It was for a single mother with one primary-school-age daughter, life assurance, and not much else. Pretty simple, you would think?

Hah. Most certainly not.

Drafting a Will is a time when the drafter can push his or her imagination to the limits of the bizarre, morbid, or just plain strange.

What if my client got run over by a bus five minutes after signing the will – and then her daughter got struck by lightning and died all black and crispy a week later?

The answer to that is that unless you put in a clause about 28-day survival, the Horrible Ex (the daughter’s father) gets a windfall because the money goes to the daughter, then to the daughter’s father – as the daughter, being under 18, would be intestate.

What if the daughter manages to survive vindictive meteorology, but falls over a cliff at the age of 17 and is smashed to pieces on the rocks, many feet below?

Well, if we left the money to the daughter, the Horrible Ex still gets the cash!

So we have to set up a trust to make sure the daughter doesn’t become absolutely entitled to the money until she hits 18 and is able to make a Will of her own. So when she dies, smashed to pieces on the rocks at the age of 17, the money goes to someone else (not the daughter’s father).

OK, but what if before falling over a cliff the daughter had been made pregnant by her boyfriend and given birth to a child of her own?

If the daughter had to get to 18 in order to become absolutely entitled to the money, then the daughter’s child is then disinherited because the money goes to the alternate beneficiary…

So you have to put in something that says that if the daughter gives birth, then she becomes absolutely entitled.

And what about if the Client herself, on the way home from signing her Will, goes for a wild party, gets drunk, has mad passionate sex with a complete stranger, gets pregnant, but then is hit by quite a small meteorite before she discovers she’s pregnant? She doesn’t die instantly, but ends up in a persistent vegetative state – and the baby is eventually born nine months later, upon which the Client dies.

So there has to be provision for more children to be born without being disinherited…

I’ve read of Lois McMaster Bujold asking herself “What’s the worst thing I can do to this character?” Will-writing appears to be an exercise in “What’s the worst thing I can do to this client?”

And you know the best thing of all? If you’re writing a novel, you have to pick one worst thing to do to your main character. When you’re writing a Will, you can do them all!

A Shotgun is better than a Man because…

  1. You can have more than one shotgun at a time and nobody thinks that’s scandalous.
  2. When you are thinking of buying a shotgun, you can try it out before you commit.
  3. When you want to get rid of a shotgun, you can sell it.
  4. When travelling in a car, your shotgun never insists on driving.
  5. When travelling in a car, you lock your shotgun in the boot. It doesn’t sit in the passenger seat making comments about your driving style.
  6. Your shotgun is always hard.
  7. You can use your shotgun in the open air even when there are other people around.
  8. You can lend your shotgun to a friend and no-one thinks that’s kinky.
  9. You and a group of friends can all take your shotguns out and use them together, and that’s regarded as perfectly normal.
  10. You can reload a shotgun in seconds.
  11. When you’ve finished with your shotgun for the moment, you just clean it and put it away until you need it again.
  12. When you’re not using your shotgun, you can lock it in a cabinet.
  13. If you buy a new shotgun, your old shotgun doesn’t get jealous.
  14. If you get rid of your old shotgun, it never stalks you or makes nasty comments about your shooting ability to your friends.
  15. With a shotgun, you can keep banging for as long as you have ammunition.
  16. If you travel on public transport with your shotgun, you don’t have to buy an extra ticket.
  17. You can have different shotguns for different purposes.

Getting the urge to Tidy

Yesterday, I acquired a copy of The Life-Changing Magic of Tidying by Marie Kondo.

Today, I’m chucking stuff out.

The revolutionary Marie Kondo (or Konmari, is she is known) method boils down to, as far as I can tell, chuck out all the stuff you don’t need in your life, then put the rest away neatly. Plus optional Japanese metaphysical stuff.

This appeals to me, because (despite being lazy when it comes to tidying up) I really do prefer a clean, uncluttered space. Physical clutter around me seems to stop me thinking properly, and makes it even harder to get anything done.

I can see why Konmari’s method is hailed as revolutionary, even though it’s mostly common sense. After all, how can you be messy if you’ve just got rid of most of the possessions with which you could create mess? However, in today’s possession-focused society, it’s very easy to hang onto things ‘just because’. A mountain of possessions is a mark of success – a trail of things that mark where you have been, what you have achieved. It’s also, in some ways, a mark of insecurity: “I’m keeping it just in case.” In case of what, zombie apocalypse?

Most of the time when we’re trying to decide what to get rid of (when cupboards are overflowing, and it’s either clear out or move to a bigger house), we ask ourselves “Why should I throw this away?” so our default is to keep it – whatever it is.

Konmari’s method is the other way around: only keep the things you have a reason to keep (for her, “does it spark joy?”). But having to find a reason to keep swaps the default around – the default is to get rid of absolutely everything you own unless you have a specific reason not to. The result: you end up getting rid of more clutter – the stuff that’s in the middle ground between “Yuck, why do I still have that?” and “I will defend this with my life”.

Do I really need to keep my ever-increasing collection of used jiffy bags? Surely, if I want to send something by post I could… I don’t know… do something really revolutionary and actually, you know… go out and buy one? Is the amount of money (or planet) I save on reusing jiffy bags justified by having to find storage space for thirty of them? Am I ever going to use thirty jiffy bags in varying states of preservation? And what on earth do I think I’m planning to do with nine empty coffee jars?

My old make-up bag got discarded today: I’ve had it nearly twenty years, but my mother made it, so it’s hung on even though it’s looking decidedly grey and sad. But, as Konmari says, the purpose of a gift is to be given, and to give pleasure at that time. Would the giver really be made happy to know that you either hide their gift in the back of a cupboard (cluttering up your house) because you can’t stand to look at it every day yet you feel too guilty to get rid of it, or that you use it out of a sense of grim duty?

I bet we’ve all got things like that. I don’t feel guilty (much) about getting rid of my make-up bag, because nearly twenty years is a good innings for a make-up bag, and did my mother really expect me to keep using it until I died of old age? I don’t think so.

At the other end of the scale are the things we buy and never use, like the pair of shoes with four-inch heels that I bought over the internet. I can hardly walk in them, and they don’t really go with any outfit I own. Konmari would say that the shoes have served their purpose for me: they have taught me something (that I shouldn’t buy shoes over the internet, and I definitely shouldn’t buy shoes with four-inch heels), and, that done, they can be discarded (after thanking them for a job well done – that’s the Japanese metaphysical part).

My interpretation is a bit different: to me, it’s also about giving yourself permission to screw up. I made a mistake buying those shoes, and I also wasted money. If I give myself permission to make mistakes, it means I don’t have to keep those shoes until I’ve got some wear out of them; I just accept that I made a mistake, and I get rid of the shoes – avoiding the additional mistake of cluttering up my house with things I don’t want.

In a way, too, the book is about the ephemeral nature of things, including money. You should keep only the things that make you happy (or, obviously, the things you really need). “It was really expensive” is not a reason for keeping something if that thing does not give you joy. You’ve already spent the money – it’s gone, and it’s not coming back. If you are not using the thing, then it’s cluttering up your life, gathering dust and making you miserable. Keeping it won’t make it better value, so just let it go.

I suppose, at bottom, the message of the book is that money and things do not make you happy through possession alone, and by getting rid of the excess stuff, you can uncover what really does make you happy, like cleaning away dirt to reveal a beautiful painting.