The Power of Denial

Someone from the Red Cross describes our NHS as a humanitarian crisis.  Oh dear.  OK, bit of commentary in the media, politicians spin it.  No big deal.

But then someone from the NHS denies it, thus invoking the Power of Denial to make it a much more serious story, less likely to be relegated to a footnote in Current Affairs by next week.  And it’s not even an unqualified denial.  Whoops!

My first reaction: how silly to rise to the bait.  But was it deliberate?  One shouldn’t attribute to Conspiracy what can be explained by Cockup, but in this case I’m not at all sure.

Der Prozess

Although the title of Franz Kafka’s story of out-of-control nightmare bureaucracy is translated into English as “The Trial”, the original German does it altogether more justice.  A process that turns its practitioners into cogs in a diabolical machine, and plunges victims into helpless limbo.

I had a medical incident last week.  My eyesight vanished very suddenly, and then came back in bits, with times when I could see half a room or a small area of screen or page while the rest was blank nothingness.  It came with a moderate headache, that was unusual in that it took several days to go away.

I’ve suffered a somewhat similar episode before now.  Back in about November 2007 the loss was a little less sudden, but sufficiently similar that I thought I recognised it.  Back then I was alarmed by it and sought urgent medical attention, only to be told I’d have to wait more than two weeks for a GP appointment – the gatekeeper to our medical system.  No amount of protesting urgency would affect that, but they told me to see an optician instead.  I did, and the optician reassured me there was no immediate need for treatment.  So I left it, and indeed my sight returned over a few weeks.

So it was that this time I was not as alarmed as I might have been, and had no expectations of our NHS.

Rather than repeat last time, I posted a “anyone familiar with these symptoms” question to a forum where I had a hope of good answers.  I got some good responses, but the overwhelming message was to get urgent medical attention.  There was even a suggestion of how to bypass the GP.  So with some trepidation I approached our medical establishment.

The contrast with last time couldn’t have been more stark.  NHS 111 told me to get an urgent appointment.  My GP gave me a same-day appointment, and then an urgent referral to the main regional hospital (which is just half an hour by bus from here).

At this point I made my big mistake.  I went straight to the hospital without even returning home to pack for a spell away from home.  So when they kept me in, I found myself without basic personal stuff, and particularly unhappy in pants and a shirt ever-longer past their wash-by date, and not loose enough for long periods of enforced idleness.  My only little luxury was my ‘phone, and earphones that enabled me listen to radio and (largely) block out the many other noises.  Though with that in such heavy use I was faced with an eternal quest to borrow a charger.

Arriving at the hospital with my GP referral, I was received rapidly, and a man came within minutes to run a couple of routine tests (hey, this is great!)  Once he’d come and gone a couple of times I spotted something of a pattern: attention to me was time-sliced with other things, though I know not whether that might involve another patient, paperwork and red tape, or no more than a cuppa and break.  I needed a drink myself, so after checking with him that I had five minutes to spare, I went to one of the shops near the hospital entrance and got something from the chiller.

So far, so good (though the drink wasn’t).  But that was the end of my being attended to.  As five minutes became five hours and more, I made some vain attempts to find out what the **** was going on.  I checked the time of buses home on my ‘phone, and made a particular effort as the penultimate bus time approached, and again an hour later for the last one.  This pattern of waiting in limbo with ever-rising stress levels turned out to be a foretaste of what was to come, and is overwhelmingly the dominant theme of NHS hospital treatment.  I made a semi-successful effort to get comfy enough to doze in a space too small to lie down: dammit, this is like a night on a bench at a station or airport, only with less luxury and space and more noise.

Sometime around 3 a.m. I was desperate for water and to get up and stretch, so I looked around for anyone I could ask about drinking water.  My first attempt failed: he asked what bed I was in and he’d bring me some, and couldn’t understand when I replied that I didn’t have a bed.  So was I visiting someone?  No, I’m waiting to be attended to, and just need some water.  Aaaargh!  Find another member of nursing staff, one who understands and fills a disposable cup with tapwater from the kitchen.  So now I know where I can get water, and it’s not locked – phew!  I also ask about a bite to eat (having missed my main meal), and get a cheese salad whose fresh (though bland) ingredients made it probably the best food I encountered throughout my stay.

Not long after that, things finally start to happen.  They’ve found me “a bed” (seemingly the NHS’s unit of treatment), and a nurse asks me a bunch of questions and fills a form.  They’re admitting me as a patient.  But the bed is in a ward whose atmosphere is not merely hot and stuffy, it’s positively miasmic.  Ten minutes and I’m sweating and panting, so I get up to reclaim my previous limbo-space in preference.  Only now the ward receptionist denies me that space: it has to be cleaned before morning!  I try to escape outside, but find the ward doors locked against me.  Fortunately a nurse is more sympathetic, and finds me another unofficial (and rather nicer) space where I can curl up on a trolley by an open window.  Sometime between four and five I’m seen there by an actual doctor.

After a couple of hours decent sleep they call me to return to my bed for breakfast.  It’s become quite stormy outside, and the wind is sufficient to provide some air flow even in the ward, so it’s now more bearable.  A bowl of cornflakes and a cup of tea, followed by a lot of sitting around doing nothing.  Lunch, and another moment of tension as not a single meat-free (or even non-meat-centred) option is offered!  Eventually they come back and offer cauliflower cheese, which I accept, with a yoghurt for dessert.  It turned out to be something a little different, and reasonably acceptable (for basic institutional food), though the yoghurt was fearsomely sugary.

After lunch they take me off for a scan.  They want to put me in a bloomin’ wheelchair (gotta make work for porters), but I decline, and eventually they let me walk, accompanied by a nurse[*].  Getting back I’m just in time to listen to the last of Ayckbourn’s Norman Conquest plays, which I’ve been enjoying on the radio over the past couple of weeks.  But the storm outside has abated and it’s getting impossibly stuffy again, so once again I go to complain about being detained in such a place.  I badly need a change of clothes, and a charger for the ‘phone, and my toothbrush, etcetera.  Plus, I have strong reasons to want to be back home.  Can’t I just come back by appointment for further tests they want to do?  No chance, we don’t do that.  Well, at least go home to pack a few changes of clothes?  Nope.  But there’s news: they’re moving me to another ward.  The Short Stay Ward should be a bit nicer and more peaceful for me.

It is indeed an improvement.  This time I get a bed by the window, and they’re happy for me to open it.  I wonder about my fellow-inmates, and am immensely encouraged when the patient in the next bed enthusiastically says yes please to opening the window.  So it’s gone from being a place of active torment to a mere place of detention.  I negotiate some time off: I can’t go home, but I can walk around the outside of the hospital for some fresh air and activity, and they’ll ‘phone me if I’m wanted for any more tests.  Outside is a great maze of roads with no green space, and every promising-looking path just brings me to another car park after a few metres, yet it’s still a lot better than being stuck inside doing nothing.  Even food is more relaxed in this ward: there’s a menu, whose options are the same as before, with a few more.  That evening my comfort is further improved by a “patient kit” with toothbrush, soap and towel so I can shower and clean up, and NHS one-size-fits-none pyjamas.

So now my life is the life of the ward, and I’m talking to staff and other patients.  I can see how all the staff are cogs in a huge machine, with their various responses to it and to patients who don’t see themselves as mere widgets on a production line.  Most of them try hard to introduce an element of humanity where possible, and some are very good at it.  I can actually feel marginally useful myself when I’m able to do some small thing for patients less able than myself (of whom there are several).  I have a twinge of regret when I can see I’m not qualified to help when one of the nurses is struggling through a bad headache.

The highlights of the next day are a session with the eye specialist and an MRI scan[*].  And another futile argument about going home, with a glimmer of hope when they tell me just one more test and it’ll be … soon … about ten next morning … aaargh, another night!  I take the plunge and buy Private Eye to see how the eyes will fare[*] and to give myself some entertainment other than just the ‘phone.  It’s too hard to read in the ward light, but next morning I have bright daylight and can read it cover-to-cover.

I’ve been getting into a routine with the catering staff: what do you want for (next meal) … nothing, I’m going home …  Turns out I’m in a pattern the caterers know all-too-well from thousands of patients caught up in this limbo, so they get used to this exchange and generally know best.  I try the only other veggie option, but the so-called curry is utterly disgusting.  And amongst the sweets, only the fresh fruit isn’t smothered in ten times more sugar than a supermarket equivalent.  So that’s a lot of cauliflower&broccoli meals.  They’re smaller than I’d eat at home, but with ***-all physical or mental activity I feel quite full on them.

Next day, ten o’clock passes, the whole morning passes, the whole day passes, my rage and blood pressure are rising.  WTF are they keeping me in for?  This total limbo is truly Kafkaesque, and of course the ward staff I have contact with are not the people who can influence anything.  It’s not just my time, either: they’re supposed to be short of those precious beds, so why are they tying one up with a patient who could perfectly well go home and come back in the morning, or some other time by appointment?  Talking to other patients, I’m far from the only one!

The following morning they finally send me for that test I was expecting.  For a bit of ritual humiliation, a jobsworth porter insists on putting me in a wheelchair: aaargh!  But the test itself is somewhat interesting to a technologist: that’s some impressive medical imaging kit!  I comment on it and mention having worked as a developer on scientific imaging systems, and get into a brief chat that might even have been interesting over a pint if I’d met the man socially.

Afterwards they tell me there’s one more test … aaargh, still in limbo!  But that happens in the early afternoon, so now I can finally await my discharge (the caterers of course know better).  This time, at last, I’m right, though the caterers are also right in that it isn’t until after hospital evening mealtime I’m released.  Four days to the hour after my arrival I wish my ward-mates good luck, and bid farewell to them and to the staff who are around.  It’s a bit late to walk home, so I overcome my embarrassment at clothes so far past their wash-by date and get on the bus home.

Phew!

[*] Errata are marked thus.  The time I was accompanied by a nurse was when I went to the eye specialist, and that was probably because she put some quite painful stuff in my eyes which might have left me wanting nursing attention.  I had completely forgotten the eye specialist when I first wrote the piece.  There may be more errors, as my memory of the timing and order of some of the tests is unclear.

A tale of two agencies

Mixed experiences with two arms of the state today.

On my list of to-dos after moving was to sign up with a quack locally.  Last week I got around to googling for GP practices in the area.  It presented them nicely on the map, and I see there’s exactly one that’s genuinely local.  Looks like an easy choice, and a neighbour speaks highly of them.

So last Thursday I went round there.  They required identity documents which I didn’t have: I offered bank/credit cards, but don’t carry anything else around.  Come back with a utility bill or similar showing my address.

OK, I can do that, and today (Thursday being my usual free day during the week) I went back, bearing gas and electricity bills and a bank statement.  Nope, not sufficient: this time they insist on photo-ID.  Buggrit, why couldn’t they have told me that before?  I’m fine with them asking for it[1], but annoyed by lack of consistency.

As it happens, my old passport expires in September, and I had sent it off just last week as supporting document in my application for a new one.  So I had no photo-ID.  Looks like I’ll have to wait.

Then early afternoon today there’s a knock at the door.  Mail delivery to sign for: it’s the new passport.  So that’s taken just one week.  OK, it’s just a renewal, and I guess I’m a straightforward case ‘cos I’m easy to recognise from the ‘photo in the old passport.  But even so, they say simple renewals should expect three weeks and allow for more.  So finally I can go and sign up for a local quack.

Full marks to the passport office for efficiency.  Bottom of the class to the NHS for vagueness and inefficiency and messing me about.  OK, not exactly critical, but it seems depressingly reminiscent of when it does matter.

[1] Though it seems perverse in a country where we aren’t required to possess any form of photo ID, and not everyone has any.

Can it really be so hard?

Latest news: South London NHS trust declared bankrupt.  Unaffordable PFI liabilities blamed.

Setting aside the apportionment of blame (PFI liabilities were presumably one ingredient in a toxic mix), PFI liabilities more widely are being reported as a huge proportion of UK off-balance-sheet public sector debt, and thus a great pillar of the overall debt burden.  How has it come to this?

The original rationale for PFI was a good one.  Put the risk of cost overruns with the contractor, and it takes away the race-to-the-bottom where the contract goes to whoever can put in the most unrealistically-low bid, and raise it only when the contract is secured.  The idea that contracts inevitably go ten or twenty (even 100 in murkier corners) times over budget really shouldn’t be the norm.  Indeed, shouldn’t even happen in politically-driven vanity projects like the olympics, but that’s clearly too much to hope.

Trouble is, it became a vehicle for magic money: a manifestation for our times of Mephistopheles’ credit bubble[1].  Public sector commissions new projects, but hides the cost off-balance-sheet.  Current incumbents build empires: bask in the glory of shiny new hospital (or whatever).  By the time the emperor’s wardrobe malfunction can no longer be hidden, it can be made someone else’s problem.  If indeed the idea of payment ever crossed their mind in the first place.

Now, someone tell me what’s wrong with a simple solution: at the same time as a PFI contract is signed, issue a bond to cover the cost over the lifetime of the project?  Such a simple act of keeping the liabilities on-balance-sheet could prevent abuse, while retaining the genuinely useful aspect of the PFI concept.  Of course the financial wizards won’t like it (they lose a fun and profitable toy), nor will politicians and civil servants deprived of their ability to raid the future without telling the beancounters.  So a good outcome all round: just need to rewind that time machine a few years.

[1] Googling the story of Mephistopheles’ brilliant boom-and-bust based on credit notes for as-yet-undiscovered mineral riches that, when discovered, would rightly be claimed by the Emperor, finds an interesting essay.  One that not only tells the story, but claims that this part of the Faust story has been more-or-less systematically dropped since 1945, and so is not widely known.  Interesting insight or nutjob conspiracy theory?  Maybe both?  Here’s the story: read it and judge.

RIP NHS

For as long as I can remember, the NHS has been a sacred cow for politicians on all sides, and indeed everyone in the chattering classes.  For better or worse, governments have reformed and updated it, their opponents have howled in protest over threats to the NHS, and governments have robustly denied any question of a threat.

But some fundamental principles have remained unquestioned, and tacitly supported by all sides.  The reality may diverge from the principle, but we still all agree that treatment should be according to the patient’s need.  We may moralise over lifestyle and self-inflicted conditions, but we don’t turn them away, unless on the basis that an extreme lifestyle would itself defeat treatment.

Neither do we turn people away because someone else is more important than them!  Getting priority is for private medicine.

Yet now, that principle appears to be suddenly under existential threat.  The threat is as yet hypothetical, but what is staggering is the lack of opposition to it.  Noone has stepped up to defend the NHS!  Where a technical reorganisation is commonly seen as threatening, an existential threat to the fundamental principles isn’t even generating controversy!

The threat is of course the so-called military covenant, on which the government wants to legislate.  One suggestion that has been floated is that military personnel should get priority in the NHS!  Priority for anyone of course implies someone else – perhaps with an identical or worse condition – losing.  The principle of treatment according to need is abandoned.

I’m purposely not commenting on what we should or shouldn’t do for military personnel.  If society thinks they deserve priority medical treatment beyond that afforded by their own facilities, then the obvious solution is to provide private insurance.  Or just expand the scope of the military hospitals.  Crucially, whatever is offered should be within the MoD’s budget, but I guess that’s exactly what they’ll be avoiding if they kill the NHS with this covenant.

What do we do for other public servants who risk Bad Things in the course of their duties?  For example, police, firemen, social workers, or even NHS staff themselves facing violence from Saturday night drunks?  Is this a slippery slope in front of us?

Worst of both worlds

I hear the ‘merkins are vigorously debating proposed healthcare reforms, and some of them are holding up our NHS as an illustration of what’s wrong with socialised healthcare.  And that a lot of nonsense is being talked.  Now apparently Daniel Hannan (a UK MEP) has appeared in the debate, talking of shortcomings of the NHS.  I don’t know what he said, but last time he was in the news he was talking sense!

From my experience of the NHS, I can confidently assure our transatlantic cousins: yes it is the worst of both worlds.  We get no choice but to pay vast amounts for it in our taxes.  Yet if you have the misfortune to need health care, it’s a complete lottery, and you could get told to **** off.  And that’s not just rationing of expensive treatments I’m talking about!

I have one incident in particular in mind.  Just under two years ago, I had a serious medical scare: my eyesight went from normal to very poor indeed.  Within 48 hours it reached a point where I was bumping in to people on the pavement, and couldn’t sustain reading a book for more than a few words.

Now I’d call such rapid deterioration a medical emergency.  But apparently our NHS wouldn’t.  My NHS GP (“General Practitioner”, aka family doctor) couldn’t give me an appointment for a full two weeks (!), and the NHS eye hospital couldn’t see me without a referral from a GP.  Great!

So of course I paid out of my own pocket (a few years earlier, that would’ve been my food budget for the whole year).  OK, I don’t begrudge the optician his charges, but I seriously begrudge having to pay for the NHS when it’s simply not there when you need it.

I guess next time I get ill, I’ll just have to plan it in advance and make arrangements.

I’ve no idea whether Obama’s plans look anything like our NHS, and unfortunately his opponents clearly include some serious nutcases.  But if anyone sensible is listening, steer well clear of an NHS!

NHS Dentist

I last went to the dentist in 2002, when I was eligible for free treatment.  Since then I’ve been in what is probably the default state for Brits of working age: I’d go if I could get an NHS dentist.

There’s now one operating just a few minutes walk from home.  A year or two ago I tried to register, but was presented with a nightmare of red tape including having to contact a national phone number and get allocated something pseudo-random by the relevant secretariat, so I gave up the idea.  But a few weeks ago I bumped into John, who told me he’d just signed up and the process was painless.  So I tried again, and this time the process was indeed painless.

Today I went for my checkup.  It was a little less than luxurious, with a slightly-cramped waiting area, and running 10 minutes late.  But the dentist himself seemed just fine (not that my mouth presents the kind of challenge that would sort the sheep from the goats).  Happy to go back to him in future.

One difference to what I’ve experienced in the past: whereas he did scrape some tartar, he made no attempt to polish the general tea-staining from my teeth (I didn’t ask for it, but dentists in the past have done it “by default”).  He explained that the NHS makes a clear distinction between medical and cosmetic treatment.  Tea stains fall into the latter category, so I’d have to pay separately for that.

At £16.50 for a minimal (standard-fee) checkup, I wonder to what extent the NHS really is cheaper than going private?  Sure I’d’ve paid more, but if I’d wanted the basic polishing I expect that’d’ve been included in a single charge rather than an extra thirty-something quid.

National [what?] service?

Went to the quack yesterday. After more than a decade of living with a toenail that isn’t right and periodically does something a little painful, I had the bright idea that we have this ‘ere health service. And our quacks are the UK’s only representatives of the techie community amongst the very-high-paid, so lets have ’em earn some of it …

He looked, suggested a couple of things, and asked for a sample (ahem, a toenail sample). To keep it all sterile, he provided a little purpose-built packet bearing the logo of a big pharmaceutical company. Then an envelope to put that in. Then more packagaing. Makes the worst supermarket practices look positively frugal!

Oh, and a pair of scissors to cut it, that looked as if they could easily have contaminated the sample. Not to mention anything on my hands at the time I cut it. But that’s OK: it was being carefully packaged, so nothing’s going to happen. Yeah, right.