Thursday, April 02, 2020

Public Health England has blood on its hands

As your humble Devil has recently opined, the WHO is not fit or purpose—its original mandate of public health having been perverted by single-issue hucksters and authoritarian killjoys.

The only reason that the same cannot be said of Public Health England (PHE) is that—unlike the WHO, which did good work once—this organisation has never been anything other than a pointless waste of time and money, stuffed to the gills with more than 5,000 charlatans, bullies, corrupt academics, and fake charity apparatchiks.

Formed in 2013, under Dishface Cameron's coalition, PHE has the mission is "to protect and improve the nation’s health and to address inequalities". The latter part of this mission statement is presumably justified by frauds such as Wilkinson and Pickett, who attempted to show that inequalities cause health problems in their Spirit Level treatise—an entire book full of lies that was comprehensively debunked by Chris Snowdon in his Spirit Level Delusion (disclosure: your humble Devil designed the cover for that edition).

As for improving the nation's health, there is little to indicate that the £4 billion that PHE spends each year has done much towards achieving this target.

Where the organisation has fallen down extremely badly is... well... just look around. The coronavirus pandemic has shown PHE to have been caught with its pants down—and as the infection has developed, the stupidity of its denizens is beginning to look a lot like malice.

It seems superfluous to detail every single fuck-up that has led us to this position, and in which the supposed guardians of the nation's health has failed—so I will concentrate, instead, on the vexed issue of testing.

Whether or not testing alone is of use in stopping the virus is something that can be left to the epidemiologists—and most seem to agree that testing for coronavirus is of paramount importance. If nothing else, being able to gather data about the true spread of the virus, how many people might already have had it, and how many people are likely to become extremely ill from COVID-19, is vital in assessing how long this lock-down should go on.

Because, as others have pointed out, declines in GDP also kill people—through a variety of well-established mechanisms, such as suicides (especially of business-people who are seeing their life's work wiped out), cessation of treatments for other health conditions (such as chemotherapy) or non-treatment of others, or poverty. And my god, but we are going to see some colossal declines in GDP—and, possibly, millions of businesses bankrupted (rising ever more the longer the lock-down goes on).

So, the exerts—both economists and epidemiologists—tend to think that testing is pretty important. So, how has PHE been handling that then...?

In a word, "shit".

The new "Testing Times" report from the Adam Smith Institute's Matthew Lesh has established that PHE has right royally fucked it up by refusing to involve other organisations—seemingly through ridiculous intransigence and incredible arrogance.

Matt Ridley sums up this farce in The Spectator today:
The contrast with the United States is especially striking. America was found badly wanting at the start of the epidemic when the federal Centers for Disease Control insisted on controlling the process of testing people for the virus. It 'sought to monopolise testing, discouraged the private sector developing its own tests and misled state and local authorities about efficacy of its tests', writes Lesh. After heavy criticism, it reversed course, decentralised the system and rapidly expanded testing.

Germany and South Korea began farming out the work of testing samples to contractors from the very start. Britain did not. It initially sent all samples to one laboratory, at Colindale, in north west London. Public Health England also 'chose to develop and encourage the use of its own diagnostic tools, rather than seeking the development of a range of private sector tools and providing fast-track approval', Lesh finds. On 12 February, it began to use 12 other laboratories, but still only with its own tests.

When the number of people showing symptoms shot up in the second week of March, rather than outsource the testing, the NHS simply gave up testing all but patients in hospital. As if to reinforce the centralisation strategy, the government then announced the construction of a huge new testing facility in Milton Keynes, which may work well eventually but to date has been accumulating testing devices donated by universities some of which are sitting idle. The centralisation urge runs deep in this organisation.

By all accounts government ministers were calling for more involvement of the private sector from the start but their orders were being frustrated somewhere inside the bureaucracy of the NHS and Public Health England. The excuse was that the reliability of the tests had to be maintained at a high level, or else false positives and false negatives would cause confusion and danger. So even when other laboratories were eventually allowed to do tests, any 'presumptive positives' had to be sent to Colindale for confirmation right up till 28 March. The United States had suspended a similar policy on 14 March.

[...]

Here, private-sector providers were banging on the door of the NHS throughout, offering to do testing.

[...]

Yet centralisation is plainly a big part of the problem. Lesh finds that 'The UK’s Covid-19 testing has been dangerously slow, excessively bureaucratic and hostile to outsiders and innovation. There appears to be an innate distrust of outsiders. PHE has actively discouraged use of private sector testing. Even within the system, the process for testing and validation is very centralised.'
If, as many seem to, you believe that the lack of testing is costing lives—whether it is in NHS workers who are being sent to the front-line with little or no information, or those poor souls facing the ruin of their businesses, or those cancer sufferers now refused their therapies—then it is very clear that Public Health England has blood on its hands.

Despite spending billions of pounds of our money every year, the people at PHE have failed in their primary mission—"to protect and improve the nation’s health". When all this is over—or sooner, if possible—there needs to be a reckoning.

I think that it is fair to say that Public Health England has failed, comprehensively and catastrophically, at every point. When it comes to a real public health crisis—as opposed to bullying the population based on entirely baseless and fictional targets—PHE has demonstrated that, despite spending £4 billion of our money every year, it is entirely unfit for purpose.

If anything good can come out of this crisis, then it should be a very close examination of the purpose of our state agencies, and their performance against that purpose. PHE has failed on all fronts.

PHE's leadership (at least) must be sacked for gross misconduct, with the loss of all pension privileges: those at the very top should be prosecuted for culpable manslaughter. And no one who works for that organisation must ever be allowed to suck on the taxpayer teat ever again—there must be no "sideways" promotions for these useless bastards.

PHE should, ideally, be abolished. There is, alas, little hope of that but, if nothing else, its mission must be re-drafted: PHE must be focused on real public health issues—life- and economy-threatening pathogens such as COVID-19, and whatever comes next.

And PHE's record of failure this time around should be publicly displayed as a terrible cautionary tale of what happens when bureaucracies forget what their purpose is supposed to be. Or, of course, of how terrible bureaucracies are for getting things done effectively.

If there is a silver lining to this disaster, then re-thinking why these unaccountable state QUANGOs are spending so much of our money to so little effect must be a positive corollary.

Alternatively, we should burn it to the ground, shoot the staff, and sow salt into the remains.

Whichever—I'm easy.

WTO: burn it to the ground

In this critical pandemic, one would naturally look to the various public health organisations to understand how to react. Unfortunately, those most pertinent to your humble Devil's whereabouts—the World Health Organisation (WHO) and Public Health England (PHE)—have signally failed to step up to the plate.

As the lock-down—and whole-scale destruction of the economy—continues in the UK, some media outlets and think-tanks have been examining just why these organisations' responses have been so lack-lustre. And the reports are shocking—revealing not just, as one would expect from state bureaucracies, a culture of stupidity and uselessness, but very strong suggestions of corruption and mendacity that are still costing lives.

In the case of the WHO, it seems that a deference to Chinese sensitivities meant that Taiwan's warning—delivered at the end of December—that human-to-human transmission of the novel coronavirus (nCV) was not passed on to other countries.
Health officials in Taipei said they alerted the WHO at the end of December about the risk of human-to-human transmission of the new virus but said its concerns were not passed on to other countries.

Taiwan is excluded from the WHO because China, which claims it as part of its territory, demands that third countries and international bodies do not treat it in any way that resembles how independent states are treated.
Elsewhere, the WHO has been accused of being too deferential to China in its response to the virus, and a senior WHO official hung up when asked about Taiwan's highly successful response to the outbreak.

As your humble Devil has been saying for some years, the WHO is not the same organisation that wiped out smallpox—that smallpox remains so famous as the only major disease that humanity has wiped out would be testament enough to that statement. Indeed, wiping out diseases is actually quite hard work, so perhaps we should not be surprised that this organisation has, instead, turned its attention to reducing "non-communicable diseases"—also known as "bullying people about their lifestyles".

That the WHO has been allowed to pervert its mission so entirely that it sees rolling back the cause of liberty as its raison d'être would be bad enough: but its entirely inadequate response to a real public health issue only confirms that this organisation needs to be entirely destroyed. Lest we forget, in January, as the coronavirus was swiftly spreading around the world, the WHO was still Tweeting about the evils of e-cigarettes.

The organisation is not fit to do the job for which it was formed: as with all bureaucracies, its only real purpose now is to perpetuate itself. It must be destroyed, its staff sacked and publicly ridiculed (accompanied by photos), and the ruins sowed with salt.

And as for Public Health England... Well, your humble Devil will opine about that organisation presently.

Wednesday, March 25, 2020

Steve Baker: still decent, still libertarian

When your humble Devil adopted Steve Baker MP as this blog’s mascot in 2010, Steve was somewhat concerned—and asked a number of free market people whether this dubious honour should be politely declined.

Apparently the answers mollified him, as he not only did not ask for his title to be removed, but also bought me dinner a couple of times in the House of Commons—when we discussed, amongst other things, matters libertarian (and Libertarian Party).

Over the course of the last decade, Steve has repaid your humble Devil’s faith in him many times—especially as concerns Brexit, and in the defence of liberty.

Via Guido, here is Steve, close to tears, as he implores the government to sunset the Coronavirus Act after one year rather than two.



The text of his speech is below:
I stand first with my hon. Friend the Member for Isle of Wight (Bob Seely). We cannot neglect his constituents on the Island. I fear that this issue has gone on for far too long, and I want to say sorry to ​him that we did not weigh in behind him sooner. This issue has just got to be dealt with, and I know that my right hon. Friend the Minister knows that.

Secondly, I would like to pay tribute to hon. Member for Bradford West (Naz Shah). She has done an absolutely fantastic job in the last 24 hours. It has been a real privilege to work with her to secure what I think is a fantastic result. At a time like this, matters of the hereafter are close to everybody’s thoughts. They sometimes say that there are no atheists in a foxhole. I certainly would not want to stand by and see my constituents cremated against their wishes, and nor, indeed, would I want to see people buried against their wishes. I really want to congratulate her; she has done a fantastic job, and she has done it in a wonderful cross-party spirit, which has done a lot to reinvigorate my faith in this place and in what we can achieve together when we put our constituents first. Well done to her.

I will pay particular attention to amendments 1 and 6 and Government new clause 19, which relate to the expiry of these powers. When I got into politics, it was with the purpose of enlarging liberty under parliamentary democracy and the rule of law. When I look at this Pandora’s box of enlargement, discretion and extensions of power, I can only say what a dreadful, dreadful thing it is to have had to sit here in silence and nod it through because it is the right thing to do.

My goodness, between this and the Prime Minister’s announcement tonight, what have we ushered in? I am not a good enough historian to put into context the scale of the infringement of our liberties that has been implemented today through the Prime Minister’s announcement and this enormously complicated Bill, which we are enacting with only two hours to think about amendments.

I could speak for the time I have available several times over just on the provisions relating to the retention of DNA, which we addressed in the Protection of Freedoms Act 2012. [Interruption] I see from the expression on the face of the Paymaster General, my right hon. Friend the Member for Portsmouth North (Penny Mordaunt), that she understands the anguish—she probably knows it better than any of us—that we are all going through in passing this Bill.

Let me be the first to say that tonight, through this Bill, we are implementing at least a dystopian society. Some will call it totalitarian, which is not quite fair, but it is at least dystopian. The Bill implements a command society under the imperative of saving hundreds of thousands of lives and millions of jobs, and it is worth doing.

By God, I hope the Prime Minister has a clear conscience tonight and sleeps with a good heart, because he deserves to do so. Libertarian though I may be, this is the right thing to do but, my goodness, we ought not to allow this situation to endure one moment longer than is absolutely necessary to save lives and preserve jobs.

Although I welcome new clause 19 to give us a six-month review, I urge upon my hon. and right hon. Friends and the Prime Minister the sunsetting of this Act, as it will no doubt become, at one year, because there is time to bring forward further primary legislation. If, come the late autumn, it is clear that this epidemic, this pandemic, continues—God help us if that is true, because I fear for the economy and the currency—there ​certainly will be time to bring forward further primary legislation and to properly scrutinise provisions to carry forward this enormous range of powers.

Every time I dip into the Bill, I find some objectionable power. There is not enough time to scrutinise the Bill, but I can glance at it—I am doing it now—and see objectionable powers. There would be time to have several days of scrutiny on a proper piece of legislation easily in time for March or April 2021.

I implore my right hon. Friend, for goodness’ sake, let us not allow this dystopia to endure one moment longer than is strictly necessary.
Once this farce is over with, we must all lobby our MPs in order to strike down this terrible legislation—it must not be allowed to stand for even two years.

In the meantime, it seems that Steve Baker MP must remain this blog’s mascot for the foreseeable future.

Sorry, Steve.

UPDATE: Steve Baker’s comment on this Bill can be found on his blog.

Tuesday, March 24, 2020

The problem with the NHS is not enough management

So, if you read the title of this post alone (and read any media, or talk to any NHS workers), then you are probably going to get annoyed and slag me off—but you are wrong. Let me explain why.

Two incentives

In any ward team in the NHS, there are two separate structures—there are those who work for the Trust itself (who I shall call “corporate”), and who worry about capacity and payments and bed occupancy; and there are the “clinical” staff (doctors, nurses, etc.).

In any NHS Trust, these people are working at almost entirely cross-purposes: the clinical staff are only incentivised as to the best treatment for their patients (and thus are inclined to be conservative) and the corporate staff who need to ensure proper throughput of beds, conservation of costs, etc.

The corporate line of command is largely through Ward Clerks, Matrons, and similar.

As far as the clinical line of command goes, the Consultant is in charge (followed by Registrars, followed by Senior House Officers, followed by F2s, F1s, etc.). It cannot be emphasised enough that their incentives—financial or otherwise—are not in any way aligned with those of the Trust who pays them.

The above is mostly true, except where poor care might lead to prosecutions, or similar, where the Trust is expected to bear all of the costs (not always true—but mostly).

For the reasons outlined above, these two entities are, almost all the time, at loggerheads.

Perverse incentives

For many nurses (and some doctors), the only way to progress over a career is to go into what is called, in the NHS, “management”. What this means is that previously clinical staff are now supposed to be aligned to “corporate” interests. This is perverse for four main reasons:

  1. you remove highly skilled clinical staff from what they do best, i.e. treating patients;
  2. you introduce a “clinical” mindset into “corporate” incentives: this might work, except that you are not screening people for suitability—only career progression;
  3. you have no guarantee that these people are able to manage a team;
  4. in any case, as far as management goes, they can be over-ruled by Consultants. So, they have incentive and responsibility—but without power.

No effective management system can work like this.

What about all the managers?

So, what about all these managers that we hear about in the NHS—aren’t we paying them all to do stuff?

Yes, of course we are. The trouble is that they see themselves as outside of the clinical framework—and often they are required to be.

  1. Strategic Managers—these are the people who worry about how to pay the bills, to lobby the government and NHS-D, NHS-X and more. Their job is to run the “company” and to push it forward. It is not their job to manage wards, or the sick—it is to ensure the viability of the business (and an NHS Trust is a business);
  2. Comms Managers—these people have a number of roles, but the biggest is in reputation management. They also have a huge roles in attracting and retaining staff (we all know that the NHS is short of qualified clinical staff, right?);
  3. IG / HR / IT: widely despised amongst clinical staff, these people nevertheless have a job to do. One can argue that they have been too hide-bound, too conservative—but, with each fresh disaster, this is changing.

So, what is the solution?

It is quite simple: you need managers on the Wards who are actual managers: they are paid to make decisions, and they can triangulate between a “corporate” Ward Clerk and a “clinical” need.

This means—and I cannot stress this enough—that this manager can over-rule a Consultant when necessary.

The role of a Consultant is going to have to change: they can no longer be viewed as “gods” who are utterly indispensable. They must be held responsible not just for the care they ostensibly provide, but also to the Trust for which they work.

Further, these Ward Managers cannot be far-away strategic Trust advisors—they must be on wards, making these decisions, 24/7.

Wait—but they aren't medically qualified

They might be.

But I work as a manager in a small software firm: I don’t know the precise coding implications of doing this or that—but I know how to ask the right questions, so that I understand the consequences of this or that. I can look at timescales, stair-casing impacts, architecture and Board strategy, etc.

In doing so, I am able to weigh up all of the options without specialist knowledge (although a vague knowledge helps in detecting bullshit, obviously). The point being that, given the information from both “clinical” and “corporate” the Ward Manager is able to make a decision—and, yes, be held responsible for that decision—quickly and with a reasonable amount of judgement.

Those who take their management role seriously in private companies (and there are many who do not) are able to divorce themselves from previous associations: in this case, for instance, were a nurse to be promoted it would be because they were a good manager—not that this was the only career advancement open to them.

So, what does this job look like?

These people need to be on the ward all day, every day. That means staffing night shifts too.

These people are directly responsible to the Head of Clinical Management at Board Level.

These people are diplomatic, firm and (I know this sounds trite) good people managers, and also understand the business drivers of the Trust. There are thousands of people that I have met who could do this job well—although they are eclipsed by the tens of thousands who would (and, in some cases, are) do it badly.

How would you test it?

I have come to the conclusion, over a number of years working with NHS organisations, that my dream job would be the CEO of a failing NHS Trust. And I would enact this there (as well as a bunch of other reforms).

Maybe it won’t work—but I think that it will.

What are the risks of this model?

Consultants are going to have their nose severely put out of joint. The BMA will rage about it—but, given that the BMA is almost entirely responsible for everything that is wrong with the UK Health Service, I would be happy to fight them all the way.

I would lobby the government to delist the BMA as a union, and provide solid evidence to show that the organisation is entirely opposed to an efficient health service in the UK. This is not hard to prove.

I would also remove the pointless exams that professions undertake to show that they are “capable”—as with the legal profession, these are trades union exams imposed to keep themselves relevant, and bear no real-world relation to capability or knowledge.

Outcomes

The anticipated outcomes would be:

  1. more clinical staff in clinically relevant positions—this means providing a suitable career advancement path outside of management;
  2. recruitment of managers—misfits and weirdos may apply;
  3. better outcomes for patients—long hospitals stays are deeply unhealthy, and lead to massive complications;
  4. a more secure financial position for the Trust—and thus for the NHS in general;
  5. this means more money to invest in efficiencies such as electronic patient records (EPR)—which will mean an end to sloppy practices and illegible hand-writing.

Summary

Finally, I cannot explain to you just how poorly the NHS is run. Money is just thrown away, and there is no prioritisation in any meaningful sense. Comms Teams and clinicians have no contact, and both of them hate the IT Team.

The whole thing is dysfunctional in the extreme: the more one works with the NHS, the less one becomes inclined to see any more money thrown at it.

This essay is a short stab at addressing just one problem: many more need to be solved.


Wednesday, January 29, 2020

O mi god brexit kills expats lol

Surely this is yet another of the evils of Brexit?
British expatriates who move to Portugal could lose their tax free status under new plans being brought in by the left-wing government in Lisbon.

The ruling Socialist Party introduced an amendment to this year's budget which will levy a 10pc tax on the foreign revenue of British pensioners and other foreigners who move to Portugal.
Or perhaps it's just the work of those dastardly left-wingers and Communists who have been elected by the Portuguese...?
In the wake of the 2008 financial crisis, Lisbon introduced a 10-year tax exemption for European nationals on condition they lived in Portugal for six months a year.

To enjoy this tax perk, they had to qualify for non-habitual residence (NHR) status, under which a person cannot have lived in Portugal for the previous five tax years. The scheme allowed expats to pay no tax for 10 years on foreign income. For Britons this could be pension income, dividends, rental income and non-Portuguese employment income.

The relief was designed to try to bring badly needed foreign investment into the ailing Portuguese economy.
Oh, no: it was just a temporary measure to stimulate investment at a particularly stressed economic time.

The breathless headline of "British pensioners in Portugal to lose tax-free status" does, though, illustrate quite nicely how difficult it is for governments to remove goodies handed out to people—even when those goodies were always intended to be temporary...

Public Health England has blood on its hands

As your humble Devil has recently opined, the WHO is not fit or purpose —its original mandate of public health having been perverted by sing...