The sincerity of computers

"Dear Mr Wenham,..." (sic) So begins an undated letter to me about renewing my blue badge, or as the letter prefers, my Blue Badge. Its ending has been puzzling me.
"Yours sincerely
 Oxfordshire County Council" (sic).

Can a county council really be sincere, I wonder, writing to me about my old blue badge, telling me to cut it up and post it back to them? I suspect not. When I was first eligible for a blue badge, I received a letter from a polite young, I imagine, lady, whose name I still recall. She could be and, I'm sure, was sincere. However, there's no longer any name anywhere in sight on the letter. So what am I to conclude?

My conclusion, as a former RSA Basic Clerical Skills moderator, is this: that the polite and literate Ms Cundy has been replaced by semi-literate automated computer software. Clearly the letter is generated from a database (possibly programmed by the said Ms Cundy before her removal). And some oaf has created a standard letter format with inconsistencies of punctuation (decide whether you will use commas or not in the address and signing-zoff lines) and the most inappropriate of signing-off phrases.

So now, I receive a letter from a machine which tells me it is sincere. Harrumph! In the words of Victor Meldrew, I don't believe it. What next? xxx at the bottom? A series of emoticons? Leave out the pretence at sincerity, please. That would be at least honest. Or how about employing another young person who needs a job?

The wedge's end

Today I had the last appointment of the year with a nice nurse at our GP practice - and now I can hear! I've spent the festive season in a cloud of unhearing because of wax in my right ear. It's been a good experience, in a way, in increasing my empathy with the many who are "hard of hearing". It's extraordinary how stereophonic hearing enables one to pick out conversation against background chatter. It was hard for our guests, however, as Jane tells me my speech was more garbled than normal! (Correction: it was affected.)

So I'm very grateful to Holly and my practice who still provide this service. It's not complicated of course. Just a matter of lubricating the lughole with olive oil for a week and then a visit to the professional to flush it out in five minutes. All free on the NHS. Apparently, however, in many places this simple procedure is not funded anymore. I'm told that to get your ears syringed in Oxford would cost you £70-80 - unless of course you go to A&E and have three-month wait.... And what about that other common condition, varicose veins? Oh no, you can't get them dealt with on the NHS anymore. Wait until they're open and weeping, and then we'll do them. Otherwise go private and pay £1000.

So much for the £ billions for the NHS the government trumpets so loudly! (By the way, have you noticed that their stock response to any awkward question is not to answer it but to spout some large monetary figure which is meant to impress us? And naturally it sounds impressive to us ordinary tax-paying mortals, not being among the 1,826 billionaires in the world [i.e. with wealth of over $1000 million].)

So much for the founding principle of giving treatment free at the point of use! Yes, I know it's already been eroded at the edges, with prescription charges, dental charges, road accident charges and so on. And we already see the negative effects, with people self-medicating and neglecting their dental care until it's too late. But it is clear that, whether by intention or not, the effect of government policies is to shrink further free NHS treatment.

Which leaves one perplexing question to answer. What is happening to the £ billions allegedly being poured into our National Health Service? Is it being spent on hugely expensive experimental operations, or drug regimes with hugely costly pharmaceuticals? Or on paying the interest on the legacy of foolish public/private partnership initiatives? Or on administrators called in to sort out yet more doctrinaire reorganisation? Or prodigally buying in agency staff because we don't pay those we have the wage they deserve? Or is it simply because cantankerous old crocks like me are surviving too long and costing too much?

Thank you from the choir

One encouraging piece of news on Christmas Eve concerned the number one selling song in the Christmas charts. Here's what two of the Greenwich and Lewisham NHS choir had to say about the news that they had topped the charts; they're a physio and a doctor: Thank you from the choir. I think they're right, that their popularity reflected how much the NHS and NHS staff are appreciated and loved. The NHS is one of the best things about this country.

The NHS Choir sings "A Bridge over you"

And here's the song itself - which even cantankerous old crocks can enjoy: The NHS Choir sings "A Bridge over you".  The choir's aim was to support the hard work done by doctors, nurses, midwives and many others in the NHS, with proceeds set to be donated to a selection of charities including Carers UK and mental health charity Mind. 

At the end of 2015, I'm going to say a huge thank you to everyone in the NHS. I know you're in it for the last of those three initials - and you ought to know that 99.9% of us appreciate the long hours you work and the awesome skill and care you show us. 

Finally, looking forward to 2016, I hope and trust that the wedge will not be pushed in any further, and that the government will give you the recognition and reward you totally deserve. Happy New Year.

1st National PLS Study Day

 Photo: Tripadvisor

There are a handful of us in Oxfordshire who have Primary Lateral Sclerosis, the slowest and rarest type of MND, and, I suppose, there's an equally sparse distribution nationwide. In fact its pathology, the way it develops, is so unusual that the experts aren’t agreed on whether it is truly a type of MND or an entirely separate condition. Anyway, that means that it is a Cinderella of MND research. In Oxford we are lucky to have a concentration of MND expertise, that PLS is not neglected, and is a hub for understanding the condition. I believe the idea of PLS Study Day originated with Professor Martin Turner; it was certainly organised by the Oxford MND Centre.

So on Friday 23^rd October about 120 of us – professionals, researchers, carers and people with PLS – gathered at the Oxford Spires Four Pillars Hotel on the Abingdon Road, to hear mercifully short presentations from our home team and from some “away” experts. “Mercifully” – not because they were boring, far from it, but because my attention span is limited. We heard about the characteristics of PLS – that was reassuring as I learned I wasn’t such a freak after all, but rather my symptoms and the way they progressed were pretty characteristic; we heard about what MRI and MEG scanning showed up, and a bit about genetics. What was most obvious was that a lot of very sharp minds were focused on the condition.

After a rather good lunch and the keynote lecture given by Dr Mary-Kay Floeter, the world’s leading specialist in PLS, based in Maryland, USA, which was brilliant, the focus switched from research to management, and again the home team led in this. It was informative, practical and helpful. All was well until Rachael Marsden, the Centre Coordinator, talked about a new smart phone app called Sex Diary, of which she showed a discreetly blank screen. As is the way with PLS, the collective risible nerve was tickled and only with difficulty pacified. Both the morning and afternoon sessions ended with patients’ questions answered by a panel of the experts.

It was an exceedingly good day, not least because of the opportunity to meet many others with the same condition with similar but different stories to tell. As we all know it helps to know that you’re not alone; and it helped to have explained what’s happening inside us. It was also brilliant to discover how many people are interested enough to devote their lives to studying the disease and to caring for us.

Indoor wheelies

I have been reminded indirectly by a lovely friend over the pond that I've not posted much about what I'm up to. So here first is something about my smart super wheelchair.

You may remember that before the summer at the MND Clinic I was enquiring about hoists in cars and the fab Jenny Rolfe exceeding my hopes. I don’t want to bore you with a long story, including my miscalculations.

With the help of our local MNDA, I eventually chose an Invacare TDX Neuro Chair, with the central drive wheels, for ease of manoeuvring round the tight corners in our house, and also with a riser. It’s actually not so good for reversing into my lift (it does wheel-spins - not good for the carpet!), but over all it’s a nifty machine, and the grandchildren enjoyed going up in the world. And it is a surprisingly useful facility, as I found on Friday 23rd October at the excellent PLS study day in Oxford (see next post).

Then it’s been a matter of choosing the car and the hoist. We’ve long liked Skodas and the Yeti looked as though its boot opening was high enough to take the wheelchair with its back tipped down. We supplied all the dimensions to the dealer and the hoist fitter who breezily confirmed that it would be fine. The full weight of the chair was 148 kg in all; the BrigAyd hoist was said to be man enough for 150 kg.  So all looked good. 

Well, it was – to a degree. When we got to the dealer’s to pick up the car complete with hoist, the fitter asked us how heavy the wheelchair was and he sucked his teeth and said, “You really need a 200 kg hoist. This is very slow.” Actually, to get the chair in you have to remove the footplates, the armrests and the headrest (which I guess come to about 15 kg), as only without them can you get it in – so it’s quite an operation both before loading and after unloading. That means it would be quite unsuitable if you’re on your own. I suspect another chair might be more streamlined and less complicated for embarking and disembarking.

The Yeti itself is a lovely vehicle. Ours is petrol; so no risk of the VW diesel wheeze! We’re a bit surprised how much room the hoist and wheelchair take up in the capacious boot. I suppose no solution is perfect. However we’ve already enjoyed the increased freedom that the imperfect has provided! So, all in all, we’re pleased and look forward to its coming into its own in the spring.

Targeting nonsense

In July Breeze Radio reported that our local South Central Ambulance Service was spending up to 10 hours a week appealing unnecessary speeding fines, because the speed cameras failed to pick up blue lights. "The ambulance service which operates across Hampshire and Berkshire received 3,306 speeding tickets in 2013 to 14. The fines given to South Central Ambulance Service amounted to £330,600."

(Photo: BBC)

Then last week came this extraordinary news, that it could now face a £1M fine for failing to meet targets. How nonsensical! This service which covers four rural counties has its funding cut and then is threatened with having a chunk of that precious funding removed. No one seriously doubts, surely, that the paramedics do their level best to reach patients as fast as possible - even exceeding speed limits, blue lights flashing? No one who has been on the receiving end of their care. Of course, everyone is aware of local stations having been closed in the pursuit of "rationalisation", as the whole trust was an amalgamation of four services ten years ago. 

The BBC reported:

'South Central Ambulance Service (SCAS) could face a £1m fine over its poor performance, a trust boss has said. The service has been given a penalty notice for not meeting the eight minute response target for life-threatening emergencies. Sue Byrne, SCAS chief operating officer, said: "We work hard not to be in this situation. It isn't acceptable when we don't reach patients in time." It is now working to an action plan to improve to avoid the fine being levied. Ms Byrne said: "The amount is down to the commissioners, but it could be £1m. It will have to be paid if we don't improve. "It's a very challenging environment." Low staffing issues have also been highlighted as a concern to be addressed by the service. Its ambulances would need to reach at least 75% of life-threatening emergency calls in eight minutes by the end of the year for the penalty to be lifted. The service said it was currently reaching 72% within the time target. SCAS serves Berkshire, Buckinghamshire, Hampshire and Oxfordshire.'

For me it's a vivid illustration of the stupidity of the culture of targets and fines. It creates an atmosphere of fear and undermines trust which should be at the heart of health care. Let the professionals do what they want and what they're trained to do. Trust them.

The NHS Mandate

Jeremy Hunt, Secretary of State for Health, has, I hear, agreed to go (or send his minions) to talk to the junior hospital doctors at ACAS, the reconciliation service - at last. It takes a long time, it seems, for ministers to listen. So it was with a certain amount of scepticism that last week I read and tried to understand the Government's consultation document on the future of the NHS, and then filled in the response form. I found out about the consultation only after reading about a Guardian article on the subject by Ann Robinson, not thanks to the Government making it known. I received an automated acknowledgement after I'd submitted my response. I wonder, actually I very much doubt, whether any human being, besides you will bother to read it, let alone take any notice of it. Already Mr Osborne's Autumn Statement has had implications for health and social care provision in the local government settlement, which close down investment.

Anyway, here is is my response:

1) Do you agree with our aims for the mandate to NHS England?

I disagree with a number of implications in the priorities and aims: 1.    That ‘preventing ill health and supporting people to live healthier lives’ is only the remit of the NHS. If other budgets are cut, e.g. education and social care, than that aim cannot be achieved. 2.    That the present GP system does not provide good 24/7 care. As a patient with a chronic illness, this has been far from my experience. This aim appears to militate against small GP practices. 3.    Defining as ‘long-term’ a mandate lasting ‘three or more years’ invites the possibility of continual uncertainty and upheaval to the service. It needs guaranteed stability. I would question also the assumption that the patient knows best implied in the priority: ‘People should be given more power and control over the care that is provided to them’ whilst agreeing that it should be that ‘services are arranged around their needs and they are supported to manage their own health.’ I agree that the mandate should be clearer and more accessible to the public.

2) Is there anything else we should be considering in producing the mandate to NHS England?

Clarity and accessibility means avoiding language incomprehensible to the public, such as: ‘in-year deliverables and metrics to measure progress’ whose meaning eludes an English graduate.

3) What views do you have on our overarching objective of improving outcomes and reducing health inequalities, including by using new measures of comparative quality for local CCG populations to complement the national outcomes measures in the NHS Outcomes Framework?

The aim of increased transparency is a laudable one, but it needs to be accompanied by increased trust, particularly of health professionals. The aim of delivering equally good service nationwide is also clearly desirable. There is a danger in this target-driven objective of unfairly stigmatizing skilled professionals in challenging situations and driving them away from where they are most needed. There is a further danger of diverting professionals from their primary calling of care into a culture of form-filling. This is counterproductive in the pursuit of excellence. There is also a danger of league tables being used as ammunition in political argument, which ultimately demoralises rather than encourages. This is the stuff of bad management.

4) What views do you have on our priorities for the health and care system?

In headline terms, your priorities are ‘motherhood and apple pie’ You want to create a healthier society, particularly focusing on younger people. However, this seems less a function of the NHS than of Education and recreation. Dementia care and research is clearly an increased priority. I am glad the government wants to put effort into those – as well as other areas of mental health. The neglect of mental health ought to be redressed; but this will need considerable financial investment both in the NHS and in community social care. Transparency and simplicity from the patient’s perspective is desirable. However the security of digital records also needs to be paramount. The government’s principle should be to rein back on centralised record-keeping, rather than extending it. The citizen’s privacy should normally trump efficiency. Retelling one’s symptoms is a small price to pay for individual liberty. However, creating new rights, such as the ‘right to a specific named GP’, runs the risk increasing the burden of litigiousness surrounding the medical profession as does the comparison of the health service with the airline industry – with the possibility of suing for late appointments for example. The healthcare industry is entirely different from a commercial enterprise, and should not be shoehorned into becoming one. Whilst I am in full agreement with the aim of preventing ‘avoidable ill health and premature mortality’, I think the assumption that increasing longevity is a desirable aim should be questioned. Officiously prolonging life is not a great good and should not be ‘a metric to measure progress’. Good end of life care, however, should always be a top priority.

5) What views do you have on how we set objectives for NHS England to reflect their contribution to achieving our priorities?

As already indicated, I have some reservations about the possible implications of where the objectives are specific. Otherwise they seem general enough to be open to whatever interpretation is required by policy makers. I do notice the final objective for the NHS to make money, or to be involved in its generation. Finally it needs to be said that this consultation process is particularly opaque. The consultation document is not easy to follow, what the questions are asking isn’t obvious and where to send this response form is equally unclear. You could for example simply say, ‘Thank you for taking the trouble to complete this form. Please now send it to mandate-team@dh.gsi.gov.uk.’

Assad - or the deluge

Picture from Russian bomber over Syria (Channel 4 News)

There was an unusually arresting interview on BBC Radio 4's Today Programme on Saturday. After a report by John Simpson (1 hour, 30 minutes into the programme) on Russia's activities in Syria, Justin Webb interviewed the former ambassador to Bahrain and Syria, Peter Ford, who after retiring from the Foreign Office went to work as UN representative for refugees in the Middle East until 2014. he had just returned from the area. He should know what he's talking about - and, it seemed to me, he did.

The interview so struck me that I transcribed it in full (you can listen to it here - after 1.30 in).

Do you think it’s fair to think of the Russian action bringing things to a head in a way that for all the short term costs might in the long term be a good thing?

Yes, I think that the Russian action is extremely positive. As John Simpson said… the Assad government had been on the ropes; a few months ago it had been haemorrhaging young men, who incidentally have been flocking to Europe, being unwilling to be conscripted. The Syrian army was down from a maximum earlier of about 300,000 to 80,000; it was on the ropes. The Russians have come in to redress the balance. And NATO, instead of sounding petulant and churlish, should actually be grateful to the Russians who are exercising some adult supervision; and what is happening is actually grist to the mill of Jeremy Corbyn who argues that NATO has lost the plot and is in fact often a risk to British security.

But in what way though could it be a long-term solution for Assad to be bolstered, because John Simpson made the point that he is more powerful in the short term, but in the long term all this does potentially is put off the day when he has to go and Syria has to be sorted out?

Oh, I totally disagree. Assad does not have to go. Let us not be brow-beaten by David Cameron repeating this mantra. I was in Northern Jordan a few days ago: I spoke to a young refugee, a teenager, a girl. I asked her, “Who do you blame?” She said, “We blame them all. We blame the jihadis for coming to our village and forcing us to flee - and we blame the government for not being strong enough.” Not strong enough! Many Syrians have this grievance against the government; so the government can hardly be blamed when it does try harder and now, with Russian support, is more likely to prevail. The choice - (Interviewer tries to interrupt) - I’m sorry, the choice cannot be shirked. It’s Assad or the deluge. NATO leaders need to address this question, and answer it to the people, like me - the voice of the ordinary man. I’m afraid we’re not getting this from the Labour Party in Britain. I don’t know why they’re nervous about tackling the government on this, because this actually a point of weakness in the government’s story. They’re not answering, “Who will replace Assad?”

Yes, but they’re nervous about saying they support Assad, and that Assad is the long-term solution because he has murdered so many of his own people, and they know, or they suspect, that he is such a divisive force, because of that in sectarian and political terms, that he could not be a realistic long-term leader of Syria.

That’s simply untrue. There’s every prospect that things could return to the status quo ante if the military campaign of Russia and Syria - 

Really, even after all the barrel bombs and the killing? 

Yes, he’s never going to be popular with everybody, but which Middle East leader is?  The truth of the matter is that Assad is supported by a good 40% of the Syrian people.  That is more actually than voted for David Cameron.  

Are you seriously expecting now that following on from the Russian action and if this is bringing things to a head on the ground in Syria and indeed in the air over Syria that there is a serious diplomatic volte face now in the West and that people follow what you’ve been suggesting this morning as a serious prospect in diplomacy?

No. That would be too much to expect, but what is realistic to expect is that the West should pipe down, take a deep breath, let the Russians get on with it, NATO should continue to do what it can to fight ISIS, but it should not undermine the one force with boots on the ground, which, as John Simpson said earlier, is the only one likely to prevail against ISIS. It is totally shambolic to have a policy which is mutually contradictory.

You talk about boots on the ground. John as you say mentioned it. There’s no realistic prospect of Britain putting boots on the ground and there is occasionally discussion in America about the options that it might have had in the past for doing it and more discussion in the last few days. Is it realistic? Is it too late now for outside powers, not just in the West, but other outside powers, to intervene themselves, possibly with the UN, now that the Russians seem to be on board with some kind of action? Is that realistic or simply not?

   No, I’m afraid that is not realistic. Western powers have impaled themselves on this policy of calling for the downfall of Assad. Anyhow it’s probably a good thing that they not put boots on the ground. But they can help, by, for example, lifting sanctions on the Syrian economy which penalise only the poor Syrian people. This is one reason why so many are fleeing Syria - the Western sanctions, about which we never hear a word. 

Well, at the end of that admirably long interview I had a number of thoughts. One was how refreshing it was for the BBC to have had the courage to allow another voice from the government party line, which, Peter Ford is right, we do hear repeated like a mantra. It's like a PR-generated slogan - if something's repeated enough, people will come to believe it. Another was how very undiplomatically frank and outspoken this former ambassador was. I should imagine it did his career no favours. But hopefully there are still those within the diplomatic service who tell their political masters the truth as it is. And finally I wondered whether any of our political representatives would take a blind bit of notice of what is an admittedly inconvenient but patent truth, and be humble enough to confess we've got it wrong again. The story we hear so often is not the whole truth. What is true is that thousands have died and millions have lost their homes - and we are not helping.

Part of wall war memorial in Tartus, Syria (Channel 4 News)