The make-believe world of consultation

Last weekend I was invited, along with 70 odd other random members of the public, to a consultation event with the local PCT over the priorities for future healthcare in Sheffield. As usual I could not refuse an opportunity to put the world to rights. A free lunch and £50 "expenses" was only icing on the cake.

But what did the PCT get for its, er, your money?

After the introductory speeches and getting-to-know-you gubbins, session 1 was on the subject of improving the patient experience.

On my table, the three main issues raised were i) the difficulty of making appointments ii) access to the latest high-tech medicine and iii) cleanliness. Our discussion had to be distilled into a top three, then a top one bullet point, which would be fed to the factilitators to be further distilled, along with summaries from other tables, and then voted on with radio keypad things.

Our demand, to be able to make appointments at all/reasonably soon/without having to argue with receptionists even when the doctor has told us we will need to make an appointment for such and such a symptom - was thus "distilled" into a demand for Saturday surgeries - that none of us had asked for - but was clearly already on the PCT agenda.

Session 2 was about how to measure patient satisfaction. What sort of surveys should the PCT be sending out to everyone, or should they be listening to complaints instead? Or perhaps clinical follow-up is better. Again our main points - that not everything needs to be measured, and that clinical outcomes are more important than more subjective measures - did not get past distillation. Of course PCT officials know how to interpret a survey whereby a patient reports 'very satisified/satisfied/neither satisfied nor dissatisfied/...' on each aspect of a service. It is something they can do. They don't know how to judge clinical outcomes. They might know how to measure less, but what would that do to the feeling of being in charge of a process you don't understand?

Session 3, after lunch, was probably the worst of the lot with various unrelated issues lumped together under the heading of patient safety! Should we address patient safety with more staff training? (So they don't make mistakes.) Or should we beef up building security? Or put better labels on drugs? Most bizarrely, IT systems were listed as an issue here - because of a potential threat to the safety of patient data - but the IT issue mutated into a rival positive claim for safety dollars.

Positive suggestions from the group: help for people who can't remember whether they've taken their pills or not, and measures to keep infectious swine flu sufferers out of waiting rooms, didn't make it through distillation. Instead we had a pointless debate over whether staff training was more important than properly maintaining the lifts.

The last session was on the criteria for deciding spending priorities. Not, please, anything specific, like mental health, or hip replacements, but general criteria. So we had the usual suggestion that smokers and drug users should be penalised, and that sort of thing. I suggested that clinical effectiveness should be the main criterion, thus cutting funding for chaplains, homoeopathy, ritual circumcisions, etc. I could have but didn't include PCT bureaucracy this time. And I suggested that we probably have too much campaigning for healthy living - that people who haven't got the message by now, probably won't.

This was the most useless distillation of all - it resulted in the following six options, which we then had to vote on:

1. Quality of Life

2. Education/prevention

3. Based on need

4. Improving efficiency

5. The cost of long term care

6. Value for money

What do these mean? Even the facilitator introducing the vote didn't understand quite what a vote for each would mean, although he graciously explained that every £1 spent on education would save £10 later. And so education won 45% of the subsequent vote. Apocryphal as it is, the £1/£10 figure may be right, although it is clearly an average and not a marginal cost - which means that any cuts or increases in education at the edges would have far far less impact.

But frankly every option but education/prevention was so abstract that we had could have no idea quite what would be cut and what would be funded if we supported it. Given one option that seems good, and 5 that don't mean anything concrete, it is not surprising that it scores highly.

The voting on the outcomes of session 2 was also pretty shocking. The idea of measuring less hadn't made it through distillation, and the prime importance of clinical outcomes wasn't offered as a clear option, and instead we had a choice of seven ways of measuring soft outcomes. The faciliator gave a patronising little speech about how you might think this was obvious - if you are treated and get better that is a good outcome - but now you realise there is a lot more to it than that. Next time I will interrupt and demand a vote on hard v soft outcomes.

Not that I'm saying soft outcomes don't matter - they just shouldn't be used to justify much expense or paperwork.

So the session is wound up with speeches telling us how useful this has been. We even voted on whether it was it a good idea to hold this consultation (97% yes) and would you come again (100% yes). We were told by one PCT official that the next time he was in a meeting arguing some corner or other he could say that the people of Sheffield were in agreement with him. Just look at the figures. This is what the PCT gets for your money. Ammunition.

Buses v Dogma

We know that state provision of services is generally inefficient and unresponsive to customers' needs compared to the private sector. So if a service can reasonably be provided by the private sector, then it should be. This is why buses were deregulated in the 1980s and it was a disaster. Unlike, say, water or rail, there was no regulation of fares and these went through the roof, and are still rising year on year above inflation. Instead of profitable routes cross-subsidising unprofitable routes, extra public money had to be found to subsidise these routes. A very few routes enjoy competition, high frequencies and occasional discount fares. But the majority of profitable routes are not worth fighting over, and the customer is treated as a captive cash cow.

So why this discrepancy between theory and practise? Free markets are competitive, but attempts to introduce them so often seem to bring uncompetitive rip-off practises instead. We (rightly) aren't willing to stand the withdrawal of the only mobility option from millions of vulnerable people, so we try markets plus subsidies, which inevitably corrupts the markets. And for this, the publicly owned asset - the right to run buses on profitable routes - was given away for nothing.

Today government wants more people to take the bus instead of driving, and PTEs up and down the country will spend money on better bus stops and better bus lanes, and more subsidies. And up and down the country bus companies say "thanks very much, and by the way we're putting up the fares again, and cutting services", and there isn't a sausage that can be done about this but to offer even more subsidies.

Yes, my local service, the 86 is facing the axe. The government closed our post office earlier this year, many pensioners expected to walk miles uphill to another, or to catch the, er, bus. An angry local has postered the bus stop calling this cut barbaric, quite rightly. So we have a campaign of leaflets, petitions, complaints to the council, the PTE, the MP. The PTE write back offering an hourly daytime-only service, which is pretty miserable. When you can never entirely trust a bus to turn up at all, an hourly service is hardly worth using - with a 15 minute service such unreliability is not such a big deal.

The government has flirted a little with largely unusable powers for PTEs to take on regulation of fares and timetables, so there is some recognition of the problem, but clearly no determination to bring it to a resolution. It's another Labour failure and we know the Tories - the original culprits - will do nothing. And both will probably blame the Lib Dem council. This is a vital issue for millions of people, and for the environment, that we should be taking a strong lead on.

And all parties should learn the lesson that involving the private sector, and giving away public assets to the private sector, is not the same thing as introducting competition and markets; it doesn't bring any of the benefits, and if we're not careful we end up paying way over the odds for inferior services.

Conservatives launch barefacedness commission

This is from the text of the Conservative leaflet that came through the door of my home in Sheffield today:

Conservatives have launched a Transport Commission for the North of England to find out the transport priorities for South Yorkshire. The Commission was launched by William Hague and will examine how to improve all forms of transport including rail services. Conservatives have announced plans for high-speed rail links between Yorkshire and London taking just over an hour and a half.

What's wrong with this picture?

1. The proposed high speed rail runs from London to Leeds via Manchester, bypassing Sheffield completely. They should not for shame breathe a word of it round here.

2. This will be paid for by cutting to the bone maintenance and upgrades on the rest of the rail network, so we will see a degradation of our rail services.

3. The Midland Main line from Sheffield to London can run trains in 2 hours - the Master Cutler does this. But usually the trains stop everywhere, adding half an hour. Not great, but still not too bad. With upgrading and fewer stops this could be improved further.

The Conservatives have adopted a policy which is bad for Sheffield, and for most of the country, and shown no understanding of our transport situation - the real weaknesses are rail to Leeds and road and rail to Manchester. Trains to Manchester were quicker in the 1920s than they are now.

So they paste South Yorkshire into the text of a policy for Leeds, and hope nobody notices. This comes under the headline Working for you in South Yorkshire. No kidding. I dread to think what will happen when they start working against us, like Tories usually do.

Greens would condemn billions to poverty

I posted on a liberal view of Sheffield a letter I sent to the Sheffield Telegraph in which I suggested that Green Party hostility to business and trade threatened to condemn millions to poverty - billions worldwide. The Greens have replied to a similar letter to the Sheffield Star, and this is what they say:

As for Lib Dem Joe Otten's claim that our policies would be bad for business, we
are the only party to recognise fully the damage often done to the local economy
by inappropriate developments. This is why we vigorously opposed Sheffield's
Supercasino bid, and the current proposals for the New Retail Quarter and a new
market near the Moor.

The theme here is that according to the greens, there are two kinds of business. Local/small business which is good, and global/big business which is bad. The local economy must be protected from the global economy. So far so familiar.

Of course real life is not so simple. I am a one man business, which is good, but I sell all over the world, which, presumably, is bad. Although my product is transmitted electronically rather than by air freight, which is good. But it is software, so perhaps charging for it at all is bad.

Is the problem with the supercasino that it will damage all our small local casinos? I wonder.

Does this rebuttal deal with my unqualified claim that greens are hostile to business? Well no it doesn't. Big and small businesses each have their different strengths and weaknesses. Big business can pour resources into a problem. Small business can adapt rapidly, and know its customers. Each is successful where its relative strengths are decisive. Hostility to business in this case might mean refusing to recognise the benefits of this diversity and trying to impose a single model.

The bizarre thing about this belief in the moral superiority of small and local business is that it has very little to do with environmental sustainability - or - for that matter other social goods like wages and employment conditions. Why is it that greens are fascinated by what size a business is even more, seemingly, than how much pollution it generates?

Of course there are examples of good small business, contributing to civil society over and above what might be strictly necessary. And there are examples of bad big business. But the reverse examples can be found too. These examples mean very little - if you have a policy to deal with problem behaviour, shouldn't it apply equally to businesses of all sizes?

Now we do have some excellent local shops in Sheffield. One of the things that makes them excellent is that they must compete for trade. If everybody went only to their nearest shops, we wouldn't be rewarding competitiveness, we would be rewarding price gougers. Maybe you think your local shopkeeper is just too decent to gouge, and maybe they are. If so, that would be because gougers don't tend to run that sort of shop. If we rewarded them to, they would.

Wronger than the idea of protecting local business, however, is this idea of the local economy as the antithesis of the global economy. Almost all high value innovations demand a great deal of specialisation. Medicine, technology, art, you name it, to justify doing one particular thing very well indeed we need to be able to sell it worldwide. Cut off from trade it would be quite impossible to have much medicine, quality goods, never mind good renewable energy and so on. The way to build your local economy, then, is to provide goods and services in high demand and sell them as widely as possible. And with your earnings buy from elsewhere rather than trying to make do, or you will forego all the benefits of your earnings.

These are practical considerations which must trump a baseless prejudice for the small and local. Where this lesson has been learned - in much of Asia-Pacific for example - prosperity has followed. Yes, there is an environmental footprint to this - but imagine the alternative - of making do with cobbled together home grown versions of everything. If it were possible, wouldn't the environmental footprint be even higher? But it isn't possible, without specialisation and trade, to achieve anything like the standard of living people worldwide rightly demand. To try would condemn billions to poverty for no environmental benefit.

Romans in Britain

Spoiler warning for Romans in Britain and Edward Bond's Lear

At the after show talk, the director Sam West, the crew and the audience were quite clear that this is an anti-war play. I wonder. There are some nice comparisons with Edward Bond's Lear, performed in Sheffield the previous year. (Lear is only loosely based on Shakespeare's King Lear.) Both occur to a constant backdrop of war, both happily kill off characters as soon as you start to identify with them, both are brutal, both feature madness. Yet Lear works. It identifies the madness of the king with war in the country; it leaves the audience two steps behind in wondering which war is being fought at any time and who is on which side. It invites the audience to see if they can tell the difference between war and insanity. Romans is a light comedy by comparison.

Both end with a seemingly futile death, which is perhaps not supposed to be futile. Lear, having regained relative sanity and lost his power, attacks the Wall (Berlin wall idea) single handedly with a sledghammer and is shot. Major Chichester 'fesses up to the IRA, after seeing the ghosts of the Saxon invasions of AD525 - the events of each period happen on the same stage around the corpses of the other. Was he just mad? Was it a ham-fisted olive branch? Was it a suicide driven by racial guilt? I found the whole episode rather pointless.

The politics of this play would certainly have been shocking in 1980, with the troubles looming large. Today, a pro-war British play would be shocking, even more than an anti-war Hollywood movie. It asks us to compare the British in Ireland to the Romans in Britain, or the Saxons in Britain - but the comparison is so feeble that a transfer to Iraq wouldn't have worked. It contains powerful representations of the inevitable brutality of occupying armies; a fair share of comedy, and a fine Julius Caesar. Is this enough to make it an anti-war play? Perhaps. Yet the suggestion is that peacetime was pretty brutal too. What did the Romans ever do for us? This question was asked, Python notwithstanding.

To be an anti-war play, it is not enough to say that war is hell. All but the neo-cons know that. Not enough to portray unsympathetically the shocking ordinariness of the troops: Roman, British or IRA. You have to say that no (or not enough) good will come of it. The wars in Lear lead the country from one tyranny to another, via bloodbaths. That's how you do it.

Tags: Romans in Britain, Edward Bond, Lear