Archive

Happy birthday, John Snow: you’ve never been so relevant



by sjhoward

This is the 2,299th post. It was published at 13:10 on Sunday, 15th March 2015.

The picture at the top of this post is of a bloke called Chris and the replica Broad Street pump in Soho. It was posted on Flickr by Matt Biddulph, and is used under its Creative Commons licence.

The other two pictures are my own.

This post was filed under:
» Health
»

Today marks the 202nd birthday of John Snow, the anaesthetist whose work on cholera changed the course of modern medical history, kicked off the modern era of public health, and—in 2003—saw him voted the greatest doctor of all time in a UK poll.

Snow is best known for his work on the 1854 cholera outbreak in Soho, London. He used what we would now call epidemiological techniques to map the outbreak and figure out that cases were centred around the Broad Street water pump. It turned out that the pump was dug mere inches from a cesspit which was leaking into the water supply, causing illness in those who drank from it.

3972414497_216f402acd_b

The relevance of Snow’s work to modern public health cannot be overstated. Having spent much of his bicentennial year writing speeches with the Chief Medical Officer, I’ve found myriad parallels to draw between modern public health and the 1854 outbreak, and today seems as good a day as any to share some of them.

In the recent past, public health has been criticised for being too remote and too disconnected from the communities it serves, leading to a considerable gap between what public health teams provide and what people actually need. There are a number of ways of tackling this, but perhaps one of the most important developments in the last few decades has been the cultivation of truly integrated multidisciplinary public health teams. These bring together people with a wide variety of backgrounds and skills to work on some incredibly knotty problems.

And so it was with the 1854 cholera outbreak.

Snow couldn’t have worked on the outbreak alone, as he had no community connections. Without his partnership with Reverend Henry Whitehead, the curate of St Luke’s Church in Soho, Snow would never have been able to find details of the cholera cases he needed to draw up his impressive maps and tackle the outbreak. Only by working with someone with different skills and a different background was Snow really able to connect with his community.

Following the Health and Social Care Act of 2012, much of the responsibility for public health services passed to Local Authorities. You don’t have to spend too much time around public health teams to hear occasional grumbles about this—while people recognise the potential for influencing the wider determinants of health by working in Local Authorities, there are often frustrations about having to convince non-specialists of the utility and evidence base of certain courses of public health action.

And so it was with the 1854 cholera outbreak.

People often believe that Snow himself removed the handle from the infamous Broad Street pump to prevent the spread of the cholera outbreak. He didn’t; probably because that would have been considered vandalism, and possibly because—as an anaesthetist—plumbing skills weren’t his forte.1 Instead, he talked his Local Authority into removing the pump handle. He initially found it difficult to get the message across, and his beautiful maps actually stem from his attempts to persuade the Local Authority to take action rather than from his investigation itself. Ultimately, the Local Authority either bought his argument or tired of him banging his drum, and removed the handle, saving the day.

In modern public health, people often complain that national government interferes in the ability of local teams to act, either through interfering with the supply of funds, or through giving seemingly endless direction on things that should be considered or done at the local level.

And so it was with the 1854 cholera outbreak.

It’s an oft-forgotten footnote to the outbreak story that, having heard of what had happened in Soho, the national government ordered that the Broad Street pump handle be re-attached. There were too reasons for this: electorally, the closure of the Broad Street pump was a bad thing, for it was one of the most popular pumps in London, renowned for the clarity and taste of its water; scientifically, it was thought that the idea of faeco-oral transmission of disease was simply too disgusting to be true.

snow

Yet when the pump handle was reattached, the outbreak didn’t restart. This was probably because the cesspit next to the pump well had been emptied—but it should also remind us that no matter how crazy they may seem, not all ideas from national government are completely mad.

Effectiveness in modern public health can often involve challenging and overturning the status quo, sometimes in the face of considerable opposition from those with entrenched views.

And so it was with the 1854 cholera outbreak.

At the time of the outbreak, disease was thought to be transmitted by miasma—bad air. Today, it’s easy to underestimate the degree to which this faintly ridiculous theory was accepted: a glance through contemporary medical journals will reveal paper after paper on the design of hospitals and homes to promote the best flow of miasma. Indeed, one of the reasons so many Victorian hospitals had their morgues in the basement was so that miasma from the dead wouldn’t waft across other patients.

plan

Snow—an anaesthetist, let us not forget—overturned the apple-cart of contemporary medicine by suggesting that disease could be water-borne. Virtually nobody believed him, and after 1854, he spent much of the following four years prior to his death trying to compile data to demonstrate his findings. His was a revolution that didn’t come easily. The Lancet, in an editorial on Snow’s theory in 1855, said

In riding his hobby very hard, he has fallen down through a gully-hole and has never since been able to get out again … Has he any facts to show in proof? No!

Yet, of course, germ theory proved Snow right—and The Lancet finally got round to publishing a correction on Snow’s 200th birthday.

When working in public health in the North of England, it can often feel like breakthroughs made here are not fully appreciated, respected and integrated into practice until they’ve been endorsed by others—and particularly those in London.

And so it was with the 1854 cholera outbreak.

Snow was born in York trained at Newcastle Medical School. The first cholera outbreak he helped to tackle was in Newcastle in 1831, and though he was just 18 at the time, many believe that this is when he first developed the idea that cholera may be transmitted through water. Yet it wasn’t until his London-based work 23 years later that anyone took a blind bit of notice!


  1. Or maybe, like so many modern anaesthetists, he talked endlessly about the Hagen–Poiseuille law and considered himself something of a plumbing expert. 

Driverless cars, algorithms and the ethics of valuing of human life



by sjhoward

This is the 2,298th post. It was published at 10:33 on Wednesday, 11th February 2015.

Many thanks to Amrit Tigga for the wonderful cartoons he's drawn to illustrate this blog post.

This post was filed under:
» News and Comment
»
»

Today, RDM Group have unveiled the Lutz Pathfinder, a prototype driverless car. This is to be the first driverless car tested on public roads in Britain, after legislation was passed a few months ago to allow their operation.

Yet there are unresolved questions about the ethics underlying the algorithms which direct driverless cars; and, in particular, how they weigh the value of human life. Despite what other sources might say, these are not really new problems—but they are, nonetheless, interesting.

In this post, I’ll draw on some historic examples of similar problems, and see if they help us to make sense of this 21st century quandary.

Back in 1948, the Cold War between the Eastern Bloc and the Western Bloc was beginning to heat up… or cool down, depending on how you look at it. Either way, the US Air Force wanted the capacity to blow the Soviet Union to smithereens, should it come to that. So the US Air Force asked mathematician Edwin Paxson to use mathematical modelling to work out how best to co-ordinate a first nuclear strike.

Paxson and his team set about their work, considering almost half a million configurations of bombs and bombers. They took into account dozens of variables including countermeasures that might be deployed, targets that could be selected, and routes the bombers should fly.

In 1950, after months of work and billions of calculations, Paxson delivered his verdict in a now-famous report called Strategic Bombing Systems Analysis. His solution: fly a nuclear device to Russia in a cheap propeller plane, surrounded by a large number of similar decoy planes. The huge swarm would overwhelm Russia’s defensive capabilities and, although planes would be lost, the likelihood that the armed plane would be destroyed would be exceptionally low. One of his team described the strategy as “filling the Russian skies with empty bombers of only minor usefulness”.

image description

The response to this recommendation was not positive: Paxson was vilified. The Air Force responded with a combination of bewilderment and indignation: how could Paxson possibly suggest sending Air Crews on a suicide mission in cheap rickety planes? After all, war surely meant doing everything possible to protect allied servicemen while killing enemy servicemen—preferably using the leanest and meanest cutting-edge technology available.

But Paxson was vilified not because he gave the wrong answer: rather, he gave the right answer to the wrong question. His method was the way to cause the greatest amount of damage to the enemy for the lowest system cost—but it didn’t consider the value of human life.

Or, rather, it didn’t consider the value of the lives of the American Air Crews. Nobody thought for a moment that it should consider the value of Soviet lives. Of course, had it considered all human life as equal, it seems hard to imagine how a nuclear strike could ever come to have been proposed at all.

There’s a scene in the fourth season of The West Wing in which President Bartlet is considering intervening against genocide in Aaron Sorkin’s favourite fictional country, Equatorial Kundu. In frustration at his limited power to right the wrongs of the world, he muses

Why is a Kundunese life worth less to me than an American life?

Will Bailey, working as a speechwriter and having been in the show for a handful of episodes, gives the ballsy response

I don’t know, sir, but it is.

What is the value of human life?

This is a deeply philosophical question, but it’s also one that needs answering for practical purposes: without a value, we can’t make cost-effectiveness calculations to answer all sorts of important questions.

The US Environmental Agency pegs the value of a life at about £6m. The airline industry uses a value of around £2m. The UK Department of Transport puts it around £1m.

Most Western medical organisations, NICE included, price a year of life lived in full health at about £20-30,000. That’s a little tricksy, because—based on life expectancy—that means the UK value of a 20 year-old woman’s life is about £1.5m, versus about £1.1m for a 30 year-old man. It also means that a baby girl in East Dorset is worth about £360,000 more than a baby boy in Glasgow. And if you’ve a disability, your life is worth less than someone of equal life expectancy without a disability.

Variation in the value of lives, whether by gender, age, or nationality feels inherently wrong… but is it actually wrong? Or is it the reality of the world we live in?

So what of driverless cars? Effectively, they can be considered as robots, and we have an established set of laws for robots: science fiction writer Isaac Asimov proposed three laws of robotics in 1942, the first of which is

A robot may not injure a human being or, through inaction, allow a human being to come to harm.

Like much political legislation, this robotic law is well-intentioned but functionally useless in the situation we’re considering.

You may already be familiar with the “trolley problem”: a runaway train is heading down tracks towards a group of five people. A woman is stood next to a lever. Pulling the lever will shift the points in the track and send the train barrelling instead towards a single person. Should the woman pull the lever?

Some ethicists would say the woman should pull the lever: from a utilitarian viewpoint, she is obliged to reduce the number of people who come to harm. Others would say that the woman should not pull the lever: a deontological view might hold that the act of pulling the lever would make her complicit in the killing of another human being.

Replace the woman with a robot, and the robot is forced to break Asimov’s First Law of Robotics no matter what action it takes (or doesn’t take). We’re effectively entrapping the robot.

image description

Perhaps it isn’t surprising that we haven’t “solved” an ethical problem for robots given that we haven’t “solved” it for humans. But that doesn’t mean that it isn’t a problem. In humans, we can rely on the free agency of the individual and judge them post hoc.

Robots, at least for the time being, are not sentient. They do our bidding, and we must decide our bidding in advance. There is no ‘in the moment’ free agency to rely upon—we will know (or at least will be able to know) with certainty the action that will be taken in advance.

So what are driverless cars to do? If a driverless car finds itself in a situation where it must choose between a high speed collision with a pedestrian or with a wall, which should it choose? From the point of view of the car, should the lives of the pedestrian and the car’s occupant be of equal value? Or should the car prioritise the life of the owner? And what if the individual pedestrian is replaced by a group of pedestrians? Or a group of children?

It could be argued that the car should prioritise the lives of its driver, since that it what humans tend to do in practice. Or it could be argued that the car should value everyone equally, and protect the greatest possible number of lives possible, since that utilitarian view is how we might want humans to act. Or it could be argued that the risk should be borne entirely by the person choosing to operate the vehicle, and so the car should act to prioritise those outside of it.

Some writers have suggested that driverless cars will be forced to prioritise the life of the driver due to market forces—no-one will buy a car which might decide to kill them. Yet, of course, there is also society and legislature to consider—and it seems unlikely that cars which did not give due weight to the life of pedestrians and others outside the car would ever gain societal acceptance.

image description

And so, driverless cars look like they’re stuck in an ethical rut: they can neither prioritise the life of the driver nor prioritise the life of the pedestrian. So what can it do in the “wall or pedestrian” situation? Choose randomly? That also seems… unethical.

We’ve reach an impasse.

Much is written about the ethics of self-driving cars in these extreme situations, and they are interesting philosophical and ethical questions to ponder. But they aren’t particularly helpful in a practical sense. Much like Edwin Paxson, we being compelled to consider the wrong question.

One of the flaws in the trolley problem is that humans are rarely in a situation with two clear, diametrically opposed options. We have a range of choices available to us, not just pulling or not pulling the lever that controls the points. Maybe we could shout a warning to the people in the path of the train; maybe we could signal to the driver to stop; maybe we somehow derail the train.

And this is the first reason why the question is wrong: the car can take more than two actions. It can sound its horn; it can perform an emergency stop; it can can deploy an airbag; it can hand control back to a human. The dichotomous choice is unrealistic.

In addition, the technology isn’t at the standard required to assess a situation in the detail the problem describes—and the programming in the car will probably never consider the situation. It is unlikely that any self-driving car will be programmed with a “crash self” option. It will have a number of reactions to stimuli, including “do not crash into pedestrians” and “do not crash into walls”, and will respond in the event of a conflict probably by avoiding the pedestrians rather than the wall: just like a human, it would not know at the decision point what the outcome would be for the human driver, but there would no doubt be advanced protective mechanisms in place just as in non-driverless cars. In fact, by allowing the car to crash in a predictable way, the safety of the occupants can probably be increased even in the event of a crash.

Your washing machine at home is pretty much autonomous in operation. Does it prioritise preventing fire or preventing flood in the event of a malfunction? I have no idea what mine does, but I suspect that the situation is so far out of normal operating limits that it isn’t specifically programmed to do either. Perhaps the same is true of driverless cars.

It’s also worth considering that this sort of problem isn’t as new as it appears. Cars are not the first autonomous vehicles: aeroplanes have used autopilot for decades. Self-parking cars have been around for years. Both of these hand control back to the driver when the situation becomes difficult; perhaps that will turn out to be the solution for driverless cars, too.

I argue that we simply don’t need to worry too much about the ethics of driverless cars. They present an interesting philosophical discussion, but it isn’t a practical consideration at the moment, and nor will it be for a long time to come. By the time it does become an issue, incremental development which have occurred in the meantime will likely point us in the right direction.

For now, I’m just looking forward to sitting back and enjoying the ride!

Art of the Renaissance and anatomy



by sjhoward

This is the 2,297th post. It was published at 17:49 on Friday, 6th February 2015.

This post was filed under:
» Health
»
»
»

Wendy and I had a wander round the Scottish National Gallery last weekend, as we often do when we visit Edinburgh. I know really nothing about art; Wendy knows a bit more. But we both enjoy a few minutes which take our minds of anything that bears any resemblance to stuff we do at work.

As I wandered, I was reminded of two research papers, one of which I’ve intended to feature on here for years, and the other which came out only last month.

The first was written by a neurosurgery registrar I once worked with. I’m sure he’s a high-flying surgeon these days. It’s from JRSM (where else), and is called Brain ‘imaging’ in the Renaissance. He wrote about the resemblance of Renaissance paintings to brain anatomy. I like this paper because of the slightly off-kilter thought process it would take to notice these things, and also because—in reference to Gerard David’s painting of the Transfiguration of Christ—it contains one of my favourite paragraphs from any paper:

Gerard_David_-_The_Transfiguration_of_Christ_-_WGA06014

Gerard David’s painting of the ‘Transfiguration of Christ’ resembles a coronal section of the brain. We find again the concept of the ventricles as the abode of the soul. God is represented in the third ventricle, with Elijah and Moses in the temporal horns of the lateral ventricles. Jesus, conduit between the Word of God and the human race, resembles the brain stem/spinal cord, conveying the message from the brain to limbs and organs.

Even with the annotated images in the paper, I can’t even begin to buy the argument that there’s any intentional resemblance (or, indeed, much of a resemblance at all). But that doesn’t matter: the fantastical combination of high-level anatomy, religion and art in those sentences tickles my grey cells no end. It’s like worlds are colliding right in front of my eyes.

The second paper is similar, but has a slightly different—though equally bizarre—though process behind it. Consider, if you will, Pinturicchio’s Madonna and Child with St John the Baptist:

Bernardino_di_Betto_called_Il_Pinturicchio_and_workshop_-_The_Virgin_and_Child_with_the_Infant_Saint_John_the_Baptist_-_Google_Art_Project 2

Clearly, there’s only one reaction anyone could have when examining this masterful artwork from centuries ago: what the hell is going on with Madonna’s little finger?! And it’s not just Madonna as painted by Pinturicchio that has something funny with the fifth finger—Botticelli’s Portrait of a Young Man depicts something very similar:

Sandro_Botticelli_150

Having noticed the weird finger in a load of art from the same period, Lazerri et al undertook a systematic reappraisal of the fifth finger in Renaissance paintings, in which they try to explain the funny finger from a medical or anatomical perspective. They don’t really come to much of a conclusion. They say that lots of subjects of Renaissance paintings seem to have camptodactyly of the little finger, while others might just be holding their little finger in a weird position.

But the conclusion doesn’t really matter. I’m just in awe that someone can notice something so offbeat, and then pursue it right through to researching, writing and publishing a paper in a medical journal. That takes a serious degree of self-confidence in your own random thoughts. Brilliant!

What’s in my daily work bag?



by sjhoward

This is the 2,296th post. It was published at 20:36 on Tuesday, 3rd February 2015.

This post was filed under:
» Reviews

Over the last few years, there’s been a growing trend in business publications and productivity websites to ask notable people what they carry in the bag they cart to work each day. These people always seem to have a well-organised kit of polished shiny expensive things, and an astounding absence of junk. I struggle to relate to this. So, to redress the balance, here’s what’s in my bag.

IMAG0194

This is my bag. It’s a Jasper Conran briefcase that Wendy bought me a few years ago. It’s dark brown, and I usually carry it while wearing a black or grey suit, which probably counts as a fashion crime.

IMAG0181

This is my Lenovo N20p Chromebook, which is the laptop I carry most often. I do have a work-issued ThinkPad, but this is faster, lighter, has better battery life, and does most of the things I need to do on the move—even more so since the Office webapps were upgraded. The battery life is so strong that I don’t bother carrying the power cord.

IMAG0184

I usually carry a stack of these cardboard document wallets with papers related to projects or meetings in them. This one is a bit atypical: I usually label them with a sticker in the top-right corner with the title, place, date and time of the meeting they relate to. After the meeting, I typically over-label the sticker and reuse the folder. This is a great system because it is so flexible: it doesn’t feel ridiculous turning up to a meeting with a stuffed folder, or with a folder containing only one sheet. And with top-right labelling, I can see where I should be and when by just flicking through the stack of folders in my bag.

IMAG0176

This is a Moleskine Large Ruled Cahier Journal. This is what I take notes in. I usually have about three of them on the go at any one time so that there’s always one to hand. The paper in them is great quality Moleskine stuff, which is great because I like to write with inky pens. The cardboard cover is just about sturdy enough not to get bent out of shape in my bag. And it’s just about informal enough to doodle in, and still formal enough to scribble down minutes when required. It’s a great product.

IMAG0177

These are some individually wrapped Boots lens wipes. I have these secreted all over the place. There’s nothing worse than having a giant smudge in the middle of your glasses and no easy way of cleaning it off.

IMAG0182

This is an M&S umbrella; I can’t link to it as they don’t sell this model any more. It goes up, it goes down, and it keeps me dry. I’ve never yet seen a profile of someone’s work bag which includes an umbrella, which strikes me as slightly baffling.

IMAG0178

This is a random plastic wotsit I found in the bottom of my bag. I’ve no idea what its function in life is or was. I probably won’t throw it out though, just in case.

IMAG0180

This is an EasyAcc PowerBank which I rarely use, but which occasionally saves my bacon if my phone has run out of juice. When the PowerBank is charged, it seems to hold its charge forever, so it works well as an emergency top-up device that I can just leave rattling round my bag.

IMAG0186

These are pharmaceuticals (paracetamol and ibuprofen), busting the stereotype that men don’t carry this sort of thing. I very rarely have recourse to use them, but I’m always very glad I have them when I need them. These particular ones came from Boots, and are about 20p more expensive than the equivalents in the major supermarkets. I must have been feeling flush when I bought them.

_IMuUnNMsb3mtP9u5yNyT08TzjBrry4x1S5QWcfF_Oxf=w554-h793-no

The Control of Communicable Diseases Manual is a book a refer to constantly, and this is the brand new 20th edition that I bought only last week. I had the good fortune to met its esteemed editor, David Haymann, once—though didn’t find out that it was him until afterwards. I dread to think what smalltalk I subjected him to. Sorry.

IMAG0188

This is an empty flash drive that I carry just in case. This particular one is from Maplin (they don’t seem to sell this variety any more), and was bought in a crisis when I couldn’t find any of my 6,000 other flash drives. My talent for losing these things knows no bounds.

IMAG0195

This is a pair of engraved steel collar stiffeners. I’ve no idea how they got in my bag, but then: who doesn’t have a pair of engraved steel collar stiffeners in the bottom of their bag?

IMAG0190

This is an entanglement of my phone charger and headphones. I rarely listen to anything other than speech through my headphones, so I just use the ones that came with my phone. Apologies to any audiophiles who wince when they see people like me. The phone charger is also the one that came with my phone. It’s a handy one to carry as the earth pin slides down to make the plug more compact. A clever bit of design!

IMAG0187

Confounding stereotypes again: Wet Ones. Another thing I don’t use all that often, but feel very glad that I carry whenever I do need to use them.

IMAG0179

This is a collection and a half of writing instruments. I’d love to have a strong rationale for each on of those, but it really is just a jumble. My preferred pen is the black Uniball Gel Impact—there is one of those in there, but there would usually be two or three. The rest are mainly freebies from here and there. You’ll be pleased to hear that I retrieved the lid for the whiteboard marker just after I took this photo.

IMAG0189

This is a free name badge that MPS gave me and all of my fellow medical-school graduates. I’ve never worn it: it’s another thing I carry just in case. As I write this post, I’m wondering what possible situation could arise where I’d need this… but nevertheless, it stays in the bag.

IMAG0191

And finally… a book. I always carry a book to read on the Metro. I’m about two-thirds of the way through Faceless Killers at the moment. No spoilers please.

A brief history of bingo



by sjhoward

This is the 2,295th post. It was published at 13:25 on Saturday, 24th January 2015.

I was invited (though not paid) to write this post by a company marketing a report on Britain's bingo market written by Graham Soult for an online bingo comparison site, Two Little Fleas. Much of the content of this post is based on Graham's report: it is repeated in this post with kind permission. You can see the report in full on the Two Little Fleas website.

3 comments have published about this post. You may want to read them, or add your own.

This post was filed under:
» Headliner
»

Elderly woman playing bingo

In sixteenth-century Venice, some long-forgotten enterprising businessman came up with a new way to make money. Customers would buy tickets for a fixed price which would be put into an urn. Tickets representing things that people wanted to buy—“precios”, or “prizes”, such as silk, beads, cats, and horses—were put into a second urn, along with some simply marked “pacientia”, or “patience”.

After a while, sales of tickets would cease, and the trader would simultaneously draw tickets from each urn: those whose ticket came out at the same time as one bearing the name of a prize would win it; those whose ticket came out at the same time as one bearing “patience” would win nothing.

This became known as “lotto”, and before long, everyone was obsessed, as captured in the famous diaries of Marin Sanudo:

At present, in this Rialto district, nothing is done except put money on the lottery. First anyone who wished to adventure had to give 20 soldi, then it grew to 3 lire, then to a ducat. And the prizes were carpets and other things; now there are money prizes, 200 ducats, and a piece of cloth of gold has been offered.

As this business grew and grew, the draws got bigger and bigger, sometimes lasting days at a time and drawing huge crowds. Before long, people worked out how to piggyback on the lotto market to make a secondary profit: selling the rights to tickets at inflated prices once the draw had started, with the twin advantages of: the in-play ticket having a higher change of winning because of the elimination of smaller prices (essentially, sixteenth-century Deal or No Deal); and capitalising on the fact that people didn’t have the time to stand around to wait for the culmination of a multi-day draw. This market in second-hand tickets become known as “bagarinaggio”.

This game had sticking power, and—despite an early decline at the hands of over-zealous Italian tax reforms—is the foundation on which everything from the National Lottery to charity raffles to Christmas tombolas is built.

Lottokugeln fliegen auf blauem Hintergrund

Perhaps the closest modern analogue to sixteenth-century Venice’s favourite game is bingo. Unlike most other descendants of the idea, bingo retains the aspect of bringing large crowds together at one time in one place to apparently compete in an activity whose winner is randomly determined.

Before we go on… a personal confession. I don’t enjoy bingo: I find it interminably dull. We used to play bingo at home with relatives at Christmas when I was little, and I always wanted to be the bingo caller because being the player was so very boring. It just does nothing for me at all.

After a period being played underground—especially in the First World War—bingo was finally legalised in Britain in 1960. At once, the craze swept the nation. By 1963, something like a third of the adult population—14 million people—were members of bingo clubs. As high street picture houses and dance halls became unprofitable with the rise of television, they were often converted into bingo halls.

Perhaps because gambling was still a little unseemly, or perhaps to extend their reach, bingo halls often called themselves something else entirely: two large operators, Top Rank and Granada plumped for “social clubs”. It’s hard not to notice the similarity to coffee shops today: these frequently try and sell themselves as community hubs or venues for groups to meet, rather than merely shops that sell hot beverages. Perhaps it’s a necessary part of winning “heart and minds” to facilitate a rapid expansion.

Over the next two decades, bingo halls went from strength to strength. By the 1980s, national bingo games were being launched which networked clubs across the country together, and the first purpose-built bingo halls were appearing on the scene.

But in the 1990s, things changed. Bingo started to decline. This seems to be most commonly attributed to the National Lottery, but—to my mind, at least—this seems an unlikely association. It strikes me that there is a considerable difference between attending a bingo club with friends and the solitary activity of buying a lottery ticket at the corner shop. The bigger problem may have been that the average age of a bingo club member in 1990 was 62, and tastes had simply moved on.

Bingo hall after bingo hall closed—a fifth of all halls closed between 1995 and 2000. The decline continued into the new century, arguably hastened by the introduction of the smoking ban in 2007: industry experts estimate that some 50% of players previously smoked while playing, and many of them left when this was banned.

Also in 2007, in response to claims that the National Lottery’s huge jackpots had harmed the bingo industry, the Gambling Act allowed clubs to introduce games with rollover prizes for the first time. This led to much bigger jackpots: just months after the new rules were introduced, there was widespread media coverage of a £1.1million win.

Despite this—and perhaps giving the lie to the idea that National Lottery jackpots were behind the decline in the first place—the bingo sector continued to shrink, serving just 3 million customers in 2011. By June 2012, just 468 bingo clubs remained—and 16% of those closed by June 2013.

In March 2014, Chancellor George Osbourne cut the tax on bingo halls from 20% to 10% “to protect jobs and protect communities”—though given the moribund state of the industry, it’s hard to imagine there was much left to protect. It has had some effect: chains new clubs are opening, albeit in the single-figures after many years of double-digit decline. I suspect that club number have continued to fall on an industry-wide basis, but can’t find the figures to confirm this. Commentators claim that chains opening new venues is evidence of revitalisation of the bingo industry; I’m afraid I simply can’t see it. I can’t foresee bingo halls being more than a historical curiosity in a decade’s time. Perhaps I’m wrong.

geld

But, of course, there’s a whole other side to this story. Online bingo has grown exponentially over the last decade: there were 20 UK bingo sites in 2004, while there are 350 today. The lack of venue overheads has transformed the cost structure of the game: online games cost as little as a penny, and rarely more than 10p. And the industry’s expansion has heralded new operators, perhaps better equipped to compete in the digital world that bingo hall operators of old.

Many of the market leaders, such as Foxy Bingo, Costa Bingo and Cheeky Bingo are entirely new operators. It has been said that The Sun makes more money from its online bingo operation that it does from selling newspapers.

Allow me another personal confession: I don’t understand the appeal of online bingo. When given a free trial of a couple of sites, I could not have been more bored. At least in physical bingo, one does have to keep up with marking one’s tickets. Not so in most versions of online bingo, where either tickets are marked for you, or you are declared to have won whether you keep up or not. All of the sites also had chat rooms, but these were qualitatively no different to those that can be found anywhere online: they certainly didn’t strike me as a compelling reason to log on to the sites. The experience isn’t one I’d recommend.

The online bingo market seems like it is still nascent. The explosive growth of advertising for bingo sites is necessary as indications are that brand recognition and loyalty seems fairly poor: when Google changed its search rankings in 2013, it transformed the market. 888, which used to be everywhere, was one of the big losers of this change.

It’s curious that some bingo sites—much like early bingo halls—are starting to position themselves more as online social venues that gambling sites. It’s hard to tell whether this is a reflection of genuine demand, or a fig leaf to cover the desire to gamble as it seems to have been in the 1960s.

With the lack of interaction necessary in online bingo games, I wonder whether they are really “bingo” in the traditional sense at all. Perhaps sixteenth century Italian lotto has taken another evolutionary step; or perhaps online bingo—bingo without the time and concentration commitment—is today’s “bagarinaggio“.

In a case of history repeating itself yet again, politicians seem to be starting to consider online gambling as a possible source of tax income: just like the Italians centuries ago and the bingo halls of the 1960s, the market might be harmed by burdensome tax rates.

Really, I’ve no idea what the future holds. But one thing is certain: I’ll enjoy standing by and watching more than I’d enjoy a game of bingo.

You can read far more on the history of bingo in Britain in this fascinating report written by my friend Graham Soult for Two Little Fleas.

News organisations are wrong about A&E waiting times



by sjhoward

This is the 2,294th post. It was published at 21:01 on Friday, 23rd January 2015.

This post was filed under:
» Health
» News and Comment
» Politics

Hospital surgery corridor

Answer me this: what happened to waiting times in A&Es in England last week? To help you answer, here are some tweets published by reputable news organisations today:

You would be forgiven for thinking that waiting times had reduced. You would be… possibly right, possibly wrong. The correct answer is that we don’t know. Performance against the weekly A&E waiting time targets—which is what all of the above are actually reporting—tells us nothing about the waiting time in A&E.

As an aside, before we get into this properly, I should clarify that “waiting time” doesn’t mean what most people think it means. The “waiting time” referred to in these statistics is the total time a patient spends in A&E, from the moment they walk in the door, to the moment they walk out again (whether that is to go home, to go to a ward, to go to the pub, or wherever). That’s not what we think of as “waiting” in common parlance: while you’re with the doctor, you are—in statistical terms—still “waiting”.

The NHS doesn’t report on waiting times, only on the proportion of patients seen in less than four hours. When the reporters wrongly say that A&E waiting times have improved, what they actually mean is that a greater proportion of people entering A&E are leaving again in less than four hours. This tells nothing about the amount of time people wait on average.

Imagine an A&E department that sees only five patients: A and B have minor injuries, and are seen and treated within 30 minutes. C and D need a more complex set of investigations, so end up being in the A&E department for 3 hours. E needs a very full assessment and ultimately admission; as a result, E ends up being in the department for a total of 5 hours before a bed can be found. The average time these patients spend in A&E is 2 hours and 24 minutes; 80% of them were discharged in 4 hours.

Now let’s say that someone puts a laser-focus on that 80% and says it’s unacceptable: whatever the cost, it must be brought down. So the department tells the nurse that used to do the “see and treat” job (which served patients A and B so well) that she must help with only the most complex patients, because they are breaching the target.

The same five people with the same five injuries now come into the revamped A&E. A and B have minor injuries, but now must wait alongside everyone else. They hang around for 3 hours. C and D need complex investigations, but these are slower to start because of people with minor injuries clogging up the queue. They are discharged after 4 hours. The new complex patient team deals with patient E slightly faster, getting her up to the ward with seconds to spare before the four-hour deadline.

100% of patients were seen within 4 hours. The hospital’s management is overjoyed! The BBC tweets that A&E waiting times have decreased: 100% of patients are seen within four hours instead of 80%. Politicians become a little self-congratulatory.

Yet… what has actually happened? The average waiting time has increased from 2 hours and 24 minutes to 3 hours and 36 minutes. 80% of patients are waiting longer than they did before.

And that is why—whatever the news tells you—we have no idea what happened to A&E waiting times last week. The average time could have doubled; it could have halved; it could have stayed precisely the same. We simply do not know.

The life-changing magic of tidying



by sjhoward

This is the 2,293rd post. It was published at 22:58 on Monday, 19th January 2015.

The picture isn't my house. I'm not that tidy.

This post was filed under:
» Reviews
»

QDSMoAMTYaZoXpcwBjsL__DSC0104-1

Today, I finished reading a rather unusual book. Marie Kondo’s The life-changing magic of tidying is a book for which I wouldn’t have had even a passing consideration had it not been for a recommendation from Tim Harford in the Financial Times. Tim—an economist—reckoned that a book on tidying had—in his words—”rocked his world”. This I had to read.

Kondo’s book rocked my world, too.

Kondo is a professional tidying coach. Who knew that such a thing existed? Her advice, delivered in a way that can only be described as heartfelt and beguiling, is to bin most of what you own, and form an intimate relationship with what is left. And when I say intimate relationship… this is a lady who believes most strongly in talking to your possessions at length, caressing the spines of your books, and treating every inanimate object in your home as if it is your friend.

Her horror at some of her clients seemingly innocuous actions—balling socks, hanging shirts, keeping shower gel in the shower—is absurd, yet delivered with such passion that it becomes entirely endearing.

I so badly wanted to share so many passages from this short book that it might have come close to plagiarism. But because I really, really want you to buy the book and experience the beguiling madness for yourself, I’ve chosen a single passage from the start of a chapter to give you a flavour of the advice within.

 This is the routine I follow every day when I return from work. First, I unlock the door and announce to my house, ‘I’m home!’ Picking up the pair of shoes I wore yesterday and left out in the hall, I say, ‘Thank you very much for your hard work,’ and put them away in the shoe cupboard. Then I take off the shoes I wore today and place them neatly in the hall. Heading to the kitchen, I put the kettle on and go to my bedroom. There I lay my handbag gently on the soft sheepskin rug and take off my outdoor clothes. I put my jacket and dress on a hangar, say ‘Good job!’ and hang them temporarily from the wardrobe doorknob. I put my tights in a laundry basket that fits into the bottom right corner of my cupboard, open a drawer, select the clothes I feel like wearing indoors and get dressed. I greet the waist-high potted plant by the window and stroke its leaves.

My next task is to empty the contents of my handbag onto the rug and put each item away in its place. First I remove all the receipts. Then I put my purse in its designated box in a drawer under my bed with a word of gratitude. I place my train pass and my business card holder beside it. I put my wristwatch in a pink antique case in the same drawer and place my necklace and earrings on the accessory tray beside it. Before closing the drawer, I say, ‘Thanks for all you did for me today.’

Despite—or, perhaps, because of—the madness, it seems to me that there is actually some really sound advice in this book. And Kondo’s enthusiasm for tidying is contagious. I couldn’t help but do a bit of tidying while reading.

So wonderful craziness with a dash of sense and a heap of motivation. What’s not to love? Trust me, Marie Kondo’s The life-changing magic of tidying is a book you will really enjoy—even if it would usually be the last thing on your reading list.

So far, Cameron is winning the TV debates debate



by sjhoward

This is the 2,292nd post. It was published at 18:12 on Thursday, 15th January 2015.

This post was filed under:
» Election 2015
» News and Comment
» Politics
»
»
»
»
»
»
»

In the game of poker that is the planning process for General Election TV debates, Cameron—the player with most to lose—is currently playing best. The broadcasters have played worst, totally fumbling their hand.

exposure of a product

Cameron patently has the most to lose from taking part in the debates. Unlike Miliband and Clegg, he’s not all that unpopular as a leader. He has little to gain and much to lose from sharing a platform with Farage, and further legitimising UKIP’s candidacy.

Cameron’s demand for inclusion of the Green Party will not be met by the broadcasters. If it were, it would look like the participants had been chosen on Cameron’s recommendation alone—hardly a fair and impartial source—opening them to justifiable legal challenge from the other parties who want to take part.

So Cameron is faced with two possible outcomes: the broadcasters do not go ahead, in which case he comfortably sidesteps the problem; or—more likely in my view—the broadcasters go ahead and “empty chair” him.

In the latter case, all options remain open to Cameron. Changing his mind, if that’s the way the wind is blowing, is a one-day story at most. He could even duck the first debate, with Farage, on the grounds that he objects to UKIP’s inclusion without the Greens, take or leave the second (3-way) debate for much the same reason, and still face down Miliband in his preferred (and accepted) one-on-one format.

The debate including Farage will doubtless be a fiery occasion which will probably do damage on all fronts—but it’s likely to do more damage to those present than to an absent Cameron. Speeches criticising an absent leader don’t make for nearly such good TV as people yelling at each other. Clegg and Miliband’s commitments to “anyone, anytime” debates means that they can’t duck Farage; it might make sense for Cameron to let them demolish each other one-on-one in the second debate, too.

Cameron’s other advantage, which Miliband seems insistent on handing to him gift-wrapped, is that opponents are now calling for Cameron to debate in airtime they could be using to build a message or attack Cameron’s record. The media’s own obsession with the debates will likely trap them in this neutralised position until there is movement—which, clearly, Cameron will prefer to leave until the last moment. Cameron calculates—I guess accurately—that his apparent prevarication over taking part in TV debates damages him less than full-frontal attacks from his opponents.

The broadcasters bungled this process by announcing a plan rather than debates. The announcement of a plan implied room for negotiation and manoeuvre. Had they had the common sense to announce the invitees, the format, and the dates, making them fixed events to which leaders were invited, the landscape would now look very different—and I’d wager that all four leaders would be signed up.

The spanner in Cameron’s works could come from the “digital debate” proposed by The Guardian, The Telegraph and YouTube, and confirmed last week to include Cameron’s five preferred participants. Yet, despite being proposed a consortium which buys ink by the barrel, nobody seems to have noticed. If the two papers were to announce a date and invitation list on their front pages, along with assurance that they would “empty chair” those who didn’t turn up, all of those invited might find it difficult to graciously decline… and even more so if they could get a broadcaster to commit to covering (but, to ease the legal challenge, not producing) the event.

Unless the digital debate consortium make a move, it seems unlikely that anything will move in this story for a few weeks at least… but it will be fascinating to see how it plays out.

Thoughts on the Serial podcast



by sjhoward

This is the 2,291st post. It was published at 05:39 on Thursday, 15th January 2015.

This post was filed under:
» Media
» Reviews
»
»

Among my friends, not having an opinion about the Serial podcast is roughly as socially acceptable as not having an opinion on the Cereal Killer cafe. And as someone who listens to a lot of podcasts (most of them actually of radio shows), I feel particularly entitled to have a view.

For those who have been offline over the last few months, Serial was a weekly podcast with a new episode released each week. It was presented and produced by experienced American radio journalist Sarah Koenig. The podcast followed Koenig’s investigation into the 1999 murder of schoolgirl Hae Min Lee, for which her ex-boyfriend, Adnan Syed, had been convicted and imprisoned.

General life and busyness mean that I didn’t quite manage to keep up with the weekly pace of Sarah Koenig and Co’s Serial. A couple of week ago, though, I finally finished the first season; here follow a few jotted thoughts.

Serial-2

It was very addictive…

Serial displaced everything else on my podcast playlist. I listened to episode after episode, and couldn’t get enough. I thoroughly enjoyed it, and look forward with keen anticipation to the second season.

…but not as innovative as many people suggested.

Blog post after newspaper column after magazine review have suggested that Serial‘s format of a single story told over several weeks is novel, yet Radio 4 has used this structure for decades on hundreds (probably thousands) of dramas, and tens (probably hundreds) of documentary series. The combination of a sort of gonzo journalism and drama was, I concede, a little unusual—but not novel.

Sarah Koenig was the perfect host…

I’ve never listened to anything Koenig has done before. I don’t know if she’s a regular on This American Life because (heresy ahead) I don’t listen to that show. But for this, she was perfect. She has a brilliant radio voice and great way of writing text that pulls in the listener. This listener can’t praise her presentation highly enough.

…but the overall tone was odd.

Jonathan Rothwell wrote a few weeks ago about the weirdness of the show’s slightly jaunty ‘whodunnit’ tone and the way in which this jars with the reality of what is being described. This is a real life brutal murder case; the very existence of the journalist’s investigation implies a reasonable suspicion of a miscarriage of justice, with all the additional harm that carries; yet the story is often treated rather lightly. I found the cognitive dissonance of content and tone unsettling.

The production was fantastic…

The handoffs between Koenig’s presentation and clips of interviews and archive material were seamless. I think this owes much to the writing and the presentation, but also the production and compilation of clips that demonstrated each point was impressive. This is something a lot of Radio 4 productions do really badly, so it’s a joy to hear it done well.

…except for the use of music.

Music is powerful, and especially so in radio drama where the only stimulus is auditory. If you add in music underneath a witness’s recorded testimony, it will change my perception of that testimony. If you are trying to make a balanced review of a case to allow me to reach my own conclusions, then your music is likely to be prejudicial. If you are trying to make drama and argue for one side or another, you probably shouldn’t be playing with people’s lives through a podcast.

I worried about the narration overstating facts…

There were a few episodes in which the characterisations of events in the narration extended beyond the described facts of the case. It is difficult to describe exactly what I mean without giving an example – apologies if this counts as a spoiler.

In episode six, there is a lot of discussion of the ‘neighour-boy’. He is reported as having once said that he had been shown the body, but he did not testify at the trial. This is repeatedly characterised Koenig as the ‘neighbour-boy’ being a witness to the murder. This is evidently false: seeing a body is not equivalent to seeing a murder.

There are a few similar incidents through the series, and I can’t quite decide whether they are mere slips of the tongue, or whether there is a conscious decision to refer to the events in these terms to heighten the drama. Either way, given the import of the situation, it seems plainly to be wrong, and unfair to interviewees as much as to the accused.

…and got a bit claustrophobic in parts.

This may be the public health physician coming out in me, but I felt that the series was very narrowly focused on the case at hand—with a couple of notable exceptions. The series would have benefited from drawing more on similar cases and from aggregated data about many cases. I wanted stats!

I don’t know why it aired before completion…

It isn’t clear to me why Serial started airing before the series was complete. It seems a curious decision, and one with which I’m not entirely comfortable. Hypothetically, if someone had confessed, would the series have continued? Would it have been fair to air a recorded confession prior proper investigation? Would it be fair even to report such a confession? Starting a story which has such a big impact on the lives of all involved without clear knowledge of where it might end strikes me as mildly irresponsible.

I think this changed the nature of the podcast, too—the tone and focus seemed to shift as the podcast went on, in a way which might well be attributable to the media coverage it generated. It started out as an exploration of the limits of reasonable doubt, and ended as an unsolved whodunnit. The former was a more interesting concept, with more interesting stuff to explore, than the latter.

…nor why there were strange gaps in the story.

Relevant questions seemed to go undiscussed in Serial – though it’s possible I just missed them. (Possible spoilers ahead.) It’s not clear to me whether Jay knew where the body was. It’s repeatedly said that Jay was able to show where the victim’s car was, but there’s no discussion of whether he knew the location of the body. This is a bizarre omission given that his story is that he helped to bury the body.

And don’t get me started about that conclusion.

I felt like the podcast got a bit wrapped up in itself by the end. My impression throughout was that the intention was to explore the nature of reasonable doubt. It seemed as though the show caved to externally generated expectation to ‘solve’ the crime in the final episode – an unrealistic expectation which wasn’t met, but was sort of pointed at and talked around. This was a shame. I would’ve liked a much more strident ending that pointed out (spoilers ahead) that – no – we don’t know who committed the murder but – yes – the trial outcome was wrong because of the gulf of doubt. I wanted Koenig to come out fighting about ‘innocent until proven guilty’, not giving a personal reflection on her own personal theories about Syed’s guilt or innocence.

But overall—I can’t wait for Season Two.

There were problems, but—all things considered—I enjoyed Serial. It’s great to hear speech radio done really, really well. I donated towards a second season and will look forward to listening to it. In the meantime, I’m now totally hooked on another This American Life alumnus’s podcast: Alex Blumberg’s Startup (and Reply All, which I actually discovered first). Oh, and This Week in Google, of course. Not forgetting my preferred alarm clock, The Globalist. And More or Less. And… well… all the good stuff.

The private sector will always be involved in the NHS



by sjhoward

This is the 2,290th post. It was published at 18:54 on Monday, 12th January 2015.

This post was filed under:
» Health
» News and Comment
» Politics
»
»
»
»

A number of politicians have recently made absurd statements about the role of the market and profit in healthcare, and specifically in the NHS. In political terms, the two worst culprits are the Labour Party and the National Health Action Party.

When the Labour Party left office in 2010, data1 showed that roughly 5% of NHS procedures were carried out in the private sector. Under the current Government, as of the most recent set of statistics, this is roughly 6%. It’s just worth bearing those proportions in mind whenever you hear Labour pontificate on the role of the private sector in the NHS. But I digress.

In his Party Conference speech, Andy Burnham asked:

And for how much longer, in this the century of the ageing society, will we allow a care system in England to be run as a race to the bottom, making profits off the backs of our most vulnerable?

I’ll answer that question in a moment. But to illustrate that Burnham is not alone, let us turn to the National Health Action Party.

You may not have heard of the National Health Action Party: it is a well-meaning but misguided Party whose platform—to defend and improve the NHS—is as vague as it is logically flawed. Dr Richard Taylor, co-leader of the party, was previously an MP; he signed an Early Day Motion in support of homeopathy, and praised the use of acupuncture and reflexology in cancer treatment. To date, the party has contested and lost nine elections2 with their best result being a 9.9% share of the vote for a single council seat in Liverpool. Again, I digress.

In The BMJ, in reaction to the news that Circle Health plans to withdraw from its contract to run the Hitchingbrooke Hospital in Cambridgeshire, a National Health Action Party representative said:

This perfectly illustrates the difference between the private sector, which seeks profits, and public NHS Trusts … This shows exactly why the market has no place in healthcare.

So, you ask me, what’s wrong with those quotes? They seem like perfectly sensible sentiments to me!

Both of these quotes are simply nonsense. Neither the Labour Party nor the National Health Action Party are campaigning for the removal of profits and the market from the NHS—and nor is anyone else.

health care industry

Any modern business, be it a hospital or fishmonger, is reliant on suppliers who will draw a profit. The NHS doesn’t manufacture its own light bulbs and baths, nor generate it’s own electricity,3 so people will draw profit from supplying them.

Alright, you might be saying, but that’s not really medicine, is it?

But of course, profits are made on medicine too. Sure, the NHS could manufacture all the medicines it needs—it already manufactures some.4 But many medications are under patent. Are NHS patients to be prevented from accessing patented drugs? Of course not: so companies will draw a profit. And the more sick people there are, the bigger the profit there is to draw.

OK, you say, but medicines are a special case.

Except they’re not. Almost every product used to deliver healthcare—from syringes to catheters to implants to surgical tools—will generate a profit, as it is almost all bought in from commercial manufacturers.

Come now, you say, supplies are a red herring. I’m interested in healthcare—a human caring for another human. There’s no profit to be made there!

Oh, but there is. Management of human resources is a tricky business. Often, Trusts will hire in external experts to help with training, planning or management, many of whom will work for consultancies which make a tidy profit.

Everyone knows human resources officers aren’t human, you intone—though I couldn’t possibly comment, I’m talking about a nurse looking after a patient at the bedside. Where’s the profit in that?

The scenario you describe is just dripping with profit—from the agency that recruited the nurse, to the profit on the manufacture of his uniform, to the cut of his pay which goes to the nursing agency he’s working for, to the cut of his car parking fee which is given to the private company managing the facility.

Ugh. You do go on a bit. What’s your point?

Suggesting that the NHS be removed from the commercial market and freed from the pursuit of profit is nonsense. Of course, the internal market in which NHS providers compete with one another could be reformed or removed, but the NHS is involved in a wider external market which is here to stay. The NHS is one of the country’s biggest purchases of goods and services, and each supplier will be doing the best they can to—effectively—profit from the sick.

Even if, for the sake of a thought experiment, we say that the NHS could be isolated totally from the battle for private profit, the end result in terms of the health service alone might not be that different: there would be continual pressure to reduce costs to the taxpayer, which is effectively the same financial pressure as increasing profits to shareholders.

The true argument is about the extent of involvement of the private sector.

Consider privately-employed doctors. Would we trust doctors to the same extent if we knew their interests balanced our interests with profit potential? This isn’t something we have to treat as a thought experiment: most GPs are small businesses and work on exactly this principal with little discernable effect on levels of trust. But, again, it feels icky.

Consider private sector management of whole NHS hospitals. This might look like a step too far: it takes a layer of previously publicly-funded management, who perhaps tried to balance the drive for profits with the best interests of patients, and moves them to the profit-hungry private sector. Yet, the management would always be accountable to commissioners, who would be looking out for the patients: so does it really matter? Perhaps not from the conceptual standpoint—but I’ll admit that it makes me more than a bit uncomfortable. And while a sample size of 1 makes for a poor trial, the fact that the first hospital so-run has become the first hospital to be rated as “inadequate” on patient care does not feel reassuring.

Consider public health campaigns teaming up with well-known brands. Is it okay if public healthcare money inflates Aardman Animations’s bottom line, if using Aardman characters is a good way to get health messages to children? I’m not sure: evidence about cost-effectiveness could sway me one way or the other.

Wouldn’t it be wonderful if we could have a debate on these issues that’s based in the real world, rather than the five-word soundbite world? Wouldn’t it be great if politicians would describe the extent of private involvement in the NHS that they believe to be appropriate, and we could then vote for the Party whose ideas most closely align with our own? Wouldn’t it be peachy if our politicians would stop patronising us all and treat us like adults?

As I said in my last post, the current model of delivery for the NHS is unsustainable. This is a problem that needs statesmanship, cross-party exploration, and—most importantly—tackling by adults.


  1. Hospital Episode Statistics: the set of data that describes what happens in hospitals across the NHS in England. They’re not perfect by any means, and lag quite a way behind real time, but they’re the best we’ve got. 
  2. The Eastleigh by-election, the London region in the European Parliament election, and seven local election seats. 
  3. Actually, I have worked in a hospital that generated a lot of its own heat and power. They had pages and pages of information about it on the hospital intranet. As a junior doctor, I never got time to read it.  
  4. The NHS manufacturers relatively tiny amounts of “special order” medication that isn’t available commercially. One of the units that does this work is based here in Newcastle, a stone’s throw from the site where William Owen first produced Glucozade as a special pharmaceutical product to aid recovery from common illnesses some 88 years ago. It was later sold to Beecham’s, renamed Lucozade, and is now everywhere, despite the fact that—to this blogger at least—it tastes vile. 
The content of this site is copyright protected by a Creative Commons License, with some rights reserved. All trademarks, images and logos remain the property of their respective owners. The accuracy of information on this site is in no way guaranteed. Opinions expressed are solely those of the author. No responsibility can be accepted for any loss or damage caused by reliance on the information provided by this site. This site uses cookies - click here for more information.