Monthly Archives: September 2013

The first crow – danger (part three)

2013 09 16 Crow

Illness, which I suggested in Part Two, is not an easy condition to determine. Here I want to begin to look at things that we might all consider to be “not-illness” but with which the National Health Service is lumbered – mainly. I would suggest, as a result of unintended consequences.

At all times we need to remember that the founding fathers of the NHS really did believe that as the NHS improved the health of the nation so the costs involved would reduce. This was but one of the many serious mistakes that have been made by politicians over the years.

First up, then, is being old: being old is not an illness (which is not to say that old people do not become ill). Being too weak to do the housework properly or to go out shopping is not an illness.

In the old days people in this situation were usually cared for by their families or friends. That is how it was for my grandmothers, both of whom lived with the family after their husbands died. Would we have done the same for my parents? My father looked after my mother until she pre-deceased him and then we did offer him a home with us. He preferred to be independent and remained quite able to look after himself until a few days before he died.

 Some, sadly, received no such care and generally succumbed to one of the illnesses that the old and frail are prey to: pneumonia, influenza, etc. It was not all good and that was not a golden age. 

Now the position is different. In part it is that “nanny state” has taken over but we cannot just put the blame on that. We have all enjoyed more personal space than previous generations and all (old needing care and young capable of giving it) hate the idea of losing that personal space. Multi-generation families together are now a rarity. 

Then there is a difference between the relationships of parents and children (and thus grandparents and grandchildren). It is all, frankly, a right old muddle. It is probably true that the parents of those born in the 1960’s or 1970’s were the first who wanted to be friends with their children – and that has had interesting consequences that my wife sometimes explores in her novels (where, unlike here, there is room for such thoughts).

Back to the frail but not ill. Within the concept of our modern society there is a requirement for the needs of the vulnerable to be met but this should not be the job of the NHS. How has it become the dumping ground for other authorities who will not (perhaps cannot) take responsibility?

 *    *    *    *    *

Does being hurt in an accident qualify as ‘being ill’? Not according to insurance companies who separate out illness and accident when offering cover. Even then there are limits to what they cover. The following is rather interesting: it is taken from the Key Facts Sheet issued by Aviva regarding their personal accident insurance. I have put the three really interesting ones in bold. 

What are the significant or unusual exclusions or limitations? 

War and similar risks.

The Insured Person serving on active duty in any Armed Force.

Suicide, attempted suicide or self inflicted injury,

regardless of their state of mind at the time the incident

occurs.

Accidental Bodily Injury does not include any sickness,

disease, bacterial or viral infection (unless this is a direct

result of an accidental bodily injury), naturally occurring

condition or degenerative process, or the result of any

gradually operating cause.

Deliberate or reckless exposure to danger (except in an

attempt to save human life).

Radioactivity. Any claim caused by ionising radiation, or

radioactive contamination.

Participation in any crime which that involves deliberate

criminal intent or action.

Pregnancy, childbirth, miscarriage or abortion.

Flying other than while travelling as a fare-paying

passenger on a licensed aircraft.

Hazardous pursuits.

Intoxicating liquor or drugs taken by the Insured Person.

Driving or riding any vehicle while the alcohol level in

their blood is higher than the legal limit of the country in

which the accidental bodily injury occurs. 

Is riding a cycle through a red light at a road junction “deliberate or reckless exposure to danger”?

Is riding a horse “a hazardous pursuit”?

Is tripping over a kerb stone, falling and breaking a wrist after a glass of wine or a pint of beer going to present you with a problem when you make a claim? 

In all these cases, I’m pretty sure that an insurance company would refuse to pay up. Not so the NHS: all of these would be treated without charge and without any thought of there being a charge. All. A rather sideways thought: unless attended to by the A & E department in accordance with the targets laid down there will be trouble for the people running the department – and none for the idiots who, through their own stupidity, arrived there in need of care.

I hope that doesn’t make me sound heartless. That is the fate for anyone who tries to take a rational look at the way the NHS has developed. Of course we want these people to be looked after but if we go on as we are the level of care will fall away as funding becomes more and more impossible.  However, if we want the service to survive we must decide what it should be doing – and what it should not. So far we have looked at no more than the tip of a very big iceberg.

How do they manage these matters in other countries? We’ll look at that question in the next blog.

 

The first crow – danger – (part two)

2013 09 16 Crow

Illness, if you remember, was the word to be explored in this, the second part of the first crow.

We all know what we mean by illness, don’t we? Sure? Quite – it’s not really that easy, is it?

Think about ‘speed’ in the same way. Speed, as such, is meaningless. It suggests that there is a continuum from not moving to very fast: stationary to the speed of light (if, as I understand it, that is the fasted speed possible within our universe) – and that is all. Nevertheless, we all know what we mean.

In motoring terms, when there is an accident it is usually assumed that someone was going ‘too fast’. We try to ensure that this doesn’t happen by using speed limits. These don’t work. Speed does not kill, as the proponents of fixed speed limits would have us believe. Vehicles kill and need to be carefully controlled to ensure they do not. It never amazes me to realise how very good at controlling these beasts we drivers have become. Sure, car designers have done all they can to protect the people inside the vehicles but that does little for the ones on the outside. Nevertheless, when you consider that the number of car/miles that are driven for every person killed by a driver failing to control his/her lethal beast it becomes clear that, on the whole, we are actually very good drivers. Not that anyone says so.

I think this is the first time I have said that and my guess is that it has never crossed your mind. Why should it? Good driving is not news: good driving goes unnoticed: you are a good driver (I’m sure you are) and I know that I am a good driver but over there I see a bad driver and something needs to be done about it. So we do what we can: we impose more regulations (usually lowering speed limits). What does this do to reduce deaths (or injuries)? 

Probably very little because it cannot take into consideration an infinite range of variables: the weather conditions, the state of the road (bad road engineering and poor maintenance is certainly the cause of some accidents although this is rarely acknowledged), the car (model and condition), the actions of other drivers, distraction caused by trying to read and assimilate instructions from numerous signs, light conditions and, of course, the ability and condition of the driver.

Speed limits achieve two things: in places they make people feel safer. I have asked some people living in a 20 mph zone where a fairly main road passes through the narrows of a typical Devon village what the introduction of the 20 mph limits has meant to them. Answers ranged from, ‘Nothing much,’ to ‘well, I feel safer walking down to the shop’. How many accidents were there before the speed limit was lowered? ‘None, but there were plenty waiting to happen,’ was the general consensus of opinion.

I said they achieved two things: the other is connected to attempts to enforce these regulations and especially by the use of cameras. Here the effects are totally negative. They are a cause of further friction between the police and the public at a time when trust in the police is at a low ebb whilst remaining essential in the running of a civilised country: they have become a form of sneaky taxation (as have car parking charges): they have done nothing to improve the ability of drivers to control their lethal vehicles.

Determining the right speed when driving is by a moment by moment appraisal of the overall situation and an almost entirely subjective reaction which (luckily) usually results in the right answer.

We see almost exactly the same problem with the word ‘illness’ which is a central plank of the National Health Service. Just what is meant by section 1(b) of the Secretary of State’s duties as laid down by the National Health Service Act of 1977 – ‘ … the prevention diagnosis and treatment of illness … ‘?

This matters when the end product is to be free of charge and the taxpayer is expected to meet the costs. Nevertheless, trawl as I may, I cannot see what that word is meant to mean in this context. The obvious definition, ‘Poor health resulting from disease of body or mind; sickness. ‘ is of no help. All it does is to move the problem down onto two other words: disease and sickness.

The insurance world has, of course, found the need to have a say in the matter as when it insures people against illness. They have found this a pretty difficult task and a surprisingly large number of claims end up in court simply because of the essentially subjective nature of this whole matter. Just to give you an idea of how subjective, the Association of British Insurers issued some guidelines in (I think) 2005 and this little extract gives you a feel of the problem. 

Please remember that the name of each critical illness is only a guide to what is covered. For example, some types of cancer are not covered. The full definition under each heading shows what your policy covers. You can ask your insurance company for this information. The model definitions are grouped into “core” and “additional” conditions. The “core” conditions are generally the critical illnesses most likely to happen. 

The “core” conditions are:

  • cancer
  • coronary artery by-pass surgery
  • heart attack
  • kidney failure
  • major organ transplant
  • multiple sclerosis
  • stroke

The “additional” conditions are:

  • aorta graft surgery
  • benign brain tumour
  • blindness
  • coma
  • deafness
  • heart valve replacement or repair
  • loss of limbs
  • loss of speech
  • motor neurone disease
  • paralysis/paraplegia
  • Parkinson’s disease
  • terminal illness
  • third degree burns

There does not appear to be anything like this approach in the NHS. Should there be? After all, we have defined the things for which we will charge (most of which are not included in the ABI’s list: dental care, prescriptions, spectacles but not hearing aids).

I leave you with three thoughts.

The first is that the answers do not lie in tick boxes or governmental edicts. The right judgements will be made by subjective assessment and therefore we have to find a way of placing trust in people to take those judgements and not to pillory them if every now and then they ‘get it wrong’. Now and then we all ‘get it wrong’.

The second is that the one things that seems NOT to be covered by the Act is injury. No definition of illness includes injury and yet we have no problem with expecting the NHS to treat our broken bones, sprains and gashes. Here the insurance world does things differently. Accident insurance is completely separate from Critical Illness insurance and whether or not you are covered will often be determined by what you are doing at the time and whose fault it was (assuming blame can be apportioned).

The third is that this blog does nothing to provide an answer. Sorry about that but it will require far wiser heads than mine to find a solution. I just feel we should be aware of the muddle at the heart of the NHS lest it is that muddle that finally causes it to collapse.

The first crow (part one) – danger

2013 09 16 Crow

That’s him, sitting on the top of the tree doing what crows do – looking for carrion on which to feed, seeking that has or is about to die. His eyes, vigilant and indifferent, scan the scene and stop, narrowing slightly as he considers what he sees. The National Health Service in terminal decline. Soon it will be carrion, food for many crows and other scavengers, but for now he waits: death has yet to arrive and there is always the possibility that, against all the odds, it will survive.

How did the NHS end up in such a parlous state? Perhaps to answer that question we need to go back to the beginning and see where it began to go wrong. This is a huge subject which will take more than one blog so I ask you all to be patient. This part is only an introduction. 

I was born before the NHS and in 1947 was rushed into hospital with acute appendicitis. Luckily for me my parents could afford to meet the costs involved: what would have happened to me if that had not been the case? Then, some fifty-five years later, I suffered a heart attack. Thanks to the prompt and wonderful treatment that I received at the hands of the ambulance and hospital staff, I recovered with little damage. How much did that cost? I have no idea and I have not been able to find accurate figures from for the NHS but from other sources it is reasonable to say at a very minimum £3,000 in simple cases and up to £30,000 in complex situations. Then my wife needed treatment for a very aggressive melanoma. This was removed surgically and she remains in remissions. How much did that cost the taxpayer? As an article in the Telegraph stated in June of last year, modern anti-cancer drugs are staggeringly expensive: one for this particular cancer running at £1,750 per week per patient. 

From the above I hope you will accept that I am greatly in favour of the state ensuring that all can have access to suitable healthcare which does not mean that I believe we are going about it in the right way. 

1945 and the country is celebrating a great victory. To everyone’s surprise (and not least his) Winston Churchill loses the election and Labour, with its manifesto promise to implement the findings of the Beveridge Report of 1942 finds itself in power. 

That report had identified five areas where actions was needed: squalor, ignorance, want, idleness, disease. None, I believe, would argue with those headings and I suggest most would claim that we have yet to find the right solutions to them all. However, it is the last – disease – that concerns us today.

It is perhaps important that we read the basis for the guiding principles to the recommendations contained in the report: 

  1. Proposals for the future should not be limited by “sectional interests” in learning from experience and that a “revolutionary moment in the world’s history is a time for revolutions, not for patching”.
  2. Social insurance is only one part of a “comprehensive policy of social progress”.
  3. Policies of social security “must be achieved by co-operation between the State and the individual”, with the state securing the service and contributions. The state “should not stifle incentive, opportunity, responsibility; in establishing a national minimum, it should leave room and encouragement for voluntary action by each individual to provide more than that minimum for himself and his family”.

It is only fair to say that, as means testing tends to create a high marginal tax rate for poor people, Beveridge opposed them proposing instead a flat rate contribution rate for everyone and a flat rate benefit for everyone.

With this as the foundation, the National Health Service Act was drawn up and passed into law in 1946 to come into effect in 1948 (the position is Scotland was slightly different). In essence the act stated that:

It shall be the duty of the Minister of Health … to promote the establishment … of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention diagnosis and treatment of illness and for that purpose to provide or secure the effective provision of services.

The words I have put in bold are of vital importance. Those who drafted the bill, discussed the bill and finally passed the bill shared on conviction: as the health of the nation improved so the cost of dealing with ill health would fall. Therefore it was an affordable suggestion which would not place an over-heavy burden on the taxpayers. We have lived with the consequences of that mistake ever since.

In 1977 the bill was repealed and replaced, not unsurprisingly, with the National Health Service Act 1977. The Secretary of State continues with much the same duties:

  1. The Secretary of State’s duties to continue the Promotion in England and Wales of a comprehensive health service designed to secure improvement in:-
    1. the physical and mental health of the people in those countries
    2. in the prevention diagnosis and treatment of illness

    and for that purpose to provide and secure the effective provision of services in accordance with this act

  2. The services so provided shall be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

We still see the requirement to secure improvement in physical and mental health but we see a few other things as well. There is a duty to prevent, diagnose and treat ‘illness’. Next time we shall look at what that word ‘illness’ is intended to cover.

We also see that there is a duty to provide and secure effective provision of services – regardless of cost? That needs to be explored.

Exactly what ‘services’ did those who passed this act have in mind should be provided ‘free of charge’? Where are these defined and what do we think that means?

The EU and its accounts

2013 09 14 sky

Something is really fussing me today: the inability of the EU to keep accounts that satisfy its own auditors even after many years in which to get things right. Herman van Rompuy, President of the EU, has now told the auditors to keep quiet because harping on about accounts that don’t add up is harming the image of the EU> I quote:

Your reports are not released into a void but into the rough and tumble of political life and media reporting. Every year, they generate headlines that “yet again the EU’s accounts have not been signed off”, with deceptive allegations of fraud and mismanagement. You and I know that such headlines can be misleading.

Given this media handling of information, and its impact on public opinion in some countries, the court might want to give some further thought as to how it can encourage more nuanced reporting. It’s important that citizens can have the whole picture with all its nuances.’

Actually, it is not in the least bit “important that citizens can have the whole picture with all its nuances” but it is absolutely vital that when you take money from tax payers you account for it in such a way as to ensure that an auditor can confirm that all is well. That is what auditors are there for: to demonstrate that there is no “fraud and mismanagement”. If they can’t, then that leaves behind a healthy suspicion that the allegations are far from deceptive – indeed, that they are spot on.

It seems that those in Downing Street agree with me. ‘The Prime Minister is absolutely clear that the only way to clear up concerns about Brussels spending is to shine more of a light on it, not less. This kind of nonsense is exactly why he wants to reform the EU and then let the British people have their say on membership.’ was the statement issued. Quite.

This was not meant to turn into an anti-EU rant, I blame Herman van Rompuy for this example of LUC. With any luck it will be back to crows soon with three more blogs: the danger facing the NHS, the extraordinary kindness of strangers to be found in our hospitals and clinics and a summons on behalf of people nearing the end of their life.

 

Three crows

Crow: Porlock Toll Road

I was visited by three crows yesterday. 

The first crow (DANGER) was a headline on The Times front page which read Alarm over ‘high’ death rate in English hospitals. 

The second crow (STRANGERS) was more complex but, keeping it as simple as possible, a great friend of ours (my wife is Godmother to her son and he is now in his late forties) underwent an operation yesterday. It was one of those rather horrible things where there was no real knowing what would be found and therefore what would have to be done. Scheduled to last three and a half hours it actually took nearly twice as long. We have yet to hear all the facts but all seems to be well as I write. Her partner had taken her to the hospital and decided to stay there until she came round. Despite being a community nurse (or possibly because she is a community nurse) she was terrified – and to make matters worse the consultant she had seen a few weeks back was not available and the operation was to be carried out by someone she had never met. Strangers indeed. 

The third crow (A SUMMONS) came via Twitter. One of the people I followed retweeted a tweet from Clarissa Tan. “Oh, here I am in the yurt of death, which I wrote about for @spectator specc.ie/19KlzIm. (Coffin not in pic) pic.twitter.com/CD3T3qUdVk” 

2013 09 13 Yurt

Three crows related by the single word “death”. I do not consider myself overly superstitious but I was brought up with the three crows (and with seven magpies – see below) and so I felt something was required. Let’s start with an extract from Clarissa’s piece – she has given me permission to do so.  To read the whole piece, click here.

I am in a yurt, talking about death. Everyone is seated in a circle, and I am the next-to-last person to share. The last of the summer sun is shining through the entrance. At one end is a display coffin of biodegradable willow — there’s also tea and coffee, and coffin-shaped biscuits with skeleton-shaped icing.

I am a reporter,’ I say. ‘I’ve come to cover this event. But don’t worry, I won’t report what you share in this yurt. Also, I have cancer. I have been in treatment for one year, but now the treatment is over. I take one day at a time.’

My wife, too, has had cancer. I say ‘had’ because in our ‘one day at a time’ life we consign that cancer to the past (as I do certain problems I have ‘had’) but I think I know exactly what Clarissa means. Every day is a gift to be treasured, lived to the full and ended on a note of thanksgiving. That sounds rather twee but I can’t help that: watching people wasting their lives away is terrible. This is especially true of the young who, thanks to matters generally outside their control, have so little now and so little to look forward to. How have we allowed this to happen? 

Many of the attendees are involved in the death business, as coffin makers and corpse tailors and funeral celebrants, because they feel our society does not pay enough attention to death. We avoid it, plaster over it, try to pretty it up and Botox it out of existence.

Even old age is taboo. As we all live longer and longer, so our actors and actresses, politicians and pop stars get younger every decade.

Why do we do this, when death is something that happens to all of us?’ lamented one woman.

Why, indeed? I’d done it too, until I discovered my illness. Then I thought of little else — about the fragility of life, the permanence of death. Friends sent me amulets, prayers, ginseng, ‘positive energy’. My heart opened, and something flooded in. What if death were not disconnection, but connection? What if we were just going to meet our Maker? Then death would not be severance, but reunion. It is not at all a fashionable point of view, but I believe in God — and a good one, at that. The belief fills me with healing, wonderful hope. It is the hope not that I will live. It is the hope that I am loved. 

My wife is a novelist: rather difficult to categorise her work (the nearest I can get is ‘contemporary women’s fiction). I never cease to be amazed at the number of emails and letters she gets from readers writing to thank her for ‘helping them through’ when they, like Clarissa, have been forced to look death in the face. Oddly, only one of her books, A Week in Winter, deals explicitly with cancer and in that one Melissa dies. Could it be that, like Clarissa, Marcia believes in God – and a good one, at that – and that this informs all her writing? It is the hope not that I will live. It is the hope that I am loved.

* * * * *

The crow family – the corvidae – have fuelled human superstition for many a long year. My earliest recollection of this was in, I think, the spring of 1945. We were all bundled into the Anderson shelter that had been erected in the dining room. The big glass doors to the garden were wide open (my mother believed that that was safer than risking bits of glass flying through the room) and the sun was shining. Suddenly there were four magpies in the garden and someone – mother? Grandmother? – recited the following:-

Magpies: one for sorrow; two for joy; three for a girl and four for a boy. Five for silver; six for gold and seven for a secret never to be told.

No doubt the whole incident would have been forgotten but at that moment the front door bell rang and my mother returned with a small boy in tow. Who was he? No idea. Why had he come? Still no idea. It is one of those childhood memories (I was nearly seven at the time) that you completely forget until something brings it back. That something was the arrival of yesterday’s three crows.

The To Do List

 

Blog 2013 09 12Nearly half way through September; children back at school; people back at work; the end of the silly season and so time to pick up the threads and decide on the priorities for the next few months before the feasting and the fun of whatever it is you celebrate around 25 December. Does writing a public “to do” list mean it will be more likely to be achieved? I don’t really know the answer to that one but I’ll try and see what happens. Here, then, is my “to do” list.

  • The signs regarding parking charges in the South Hams of South Devon. I feel quite strongly about this, Despite – or because of – the silence of the elected representatives and the nonsensical (sorry but they are) letters from the council’s “communications officer” who, oddly, writes to me on a letterhead carrying the address of the SHDC in Totnes sent in an envelope posted in Tavistock and franked by the West Devon Borough Council (don’t ask) I feel that this dishonesty should stop. It is not, as “they” seem to think that I feel the charges are wrong but that the public is being misled because the signs offer deals that are not available and suggest others without pointing out the additional costs involved. As to the charges: well it is a national disgrace that they are as high as they are. The people that suffer are the poorest and that is not right. Expect to hear more from me on this score.

  • Governance. Some of you will know that I am concerned about the fabric of governance in the UK which I believe no longer works as it should for the benefit of the people of the UK. I suppose by that I mean the majority who, by definition, are neither rich nor powerful. Depending on how you look at it, this is a problem for politics or for the way we are governed or (of course) both. Everyone concentrates on the politics – I am inclined to think more about governance. Under my guidance we tried to do something: hence 2020UK and Team UK. Both failed but I hope none of us involved will give up. Perhaps it could be third time lucky but at the moment I am at a loss as to what can be done.

  • The Friday Blog. Some of you will know that this is all to do with touching base with Marcia’s readers. It appears every Friday and has done so for a number of years. It seems to be very popular and is read throughout the English speaking world as well as a few unexpected places (such as China).

  • Blogs I follow. These are written by people I consider worth listening to and I will continue to try to support them as much as I can.

  • This blog. I want to try and put up short thoughts more often rather than long pieces. This is mainly because I really do want comments that help to create debate and that means somehow turning the blog more into a meeting place than one in which I express my thoughts: yours are equally important if not more so. I also intend to try and put photos on it – for no reason other than that they can offer a bit of amusement.

  • Hattie’s Mill Revisited: Hattie’s Mill was Marcia’s fifth novel but the first one in which we started to work together. She, of course, continued to provide the creative bits and her characterisation is all her own but I, starting with this book, have become more and more involved in finding the locations (and then taking the photographs from which I create a montage or two which she keeps to hand whilst writing) and basic research. The idea behind this booklet is to give readers an insight into how the book was written and how, between us, we gently distorted the real landscape to fit the requirements of the novel (eat your heart out, Einstein). Anyway, this is going quite well and I hope to see it delivered to the printers before the end of the year.

  • Pace myself. Health wise the last few years have been a bit of a roller-coaster. One problem is that the moment I feel a bit better I start rushing around again and – bang! I really must learn to be more sensible (another case of triumph of hope over experience, I fear).

That’s it for now. May I wish you all a really happy and worthwhile autumn.

Being small is OK

Reality is what has been missing in politics since the middle of the last century. There are two blogs which look at reality – this one and Reality Swipe. Enjoy.