Labouring the Point

Ed Milliband is sticking around at least as long as David Cameron. Ed probably wishes they’d swap seats, but he’ll be sticking to the backbenches to represent the people of Doncaster. Actually I wish they’d swap seats, imagine David Cameron having to talk to people from Doncaster?

Ed says he wants to serve the people who elected him, and fight against inequality. As bumbling as he is and as much as he looks like a mutant son of Wallace and Mr Bean, I don’t think you can doubt Ed’s heart. He’s campaigned for what he believes since his cardigan wearing student days, and I genuinely respect him for that.

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This haunts me at night

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So what was one ‘veteran’ Labour MP’s response to this:

“The trouble with Ed sticking around is there is always the risk he will be seen as a backseat driver.

“Any comments he makes will be judged for their support or criticism of the new leader.”

With the incredibly scientific survey of me and my housemate, I can say with absolute certainty say that sentiment among the general public is ‘so what?’. The fact Ed Milliband isn’t throwing his toys out the pram to go and run a glamorously named charity like his brother is, to me, a sign he actually wants to make a difference. And would him disappearing off into the ether stop him criticising. Judging by both his brother and Tony Blair, I can’t see it would.

This unnamed ‘veteran’ MP fears for the impact Ed will have on the House of Commons if he stays on as an ex-leader. Well I question how much said MP has learnt in his veteran years. Let’s look at the impact ex-leaders had on their parties whilst in Parliament. I’ll start with William Hague in 1997, because apparently I impressed my Grandad by being able to name him when I was younger. Yes, I was/still am a massive nerd, can we all move on?

  • William Hague – the oldest member of troika at the top of the Tory party in recent years, served his party well in the elder statesman role. Even risked his reputation to try and oust the Speaker on the last day of the last Parliament.
  • Iain Duncan Smith – a bit like a less successful version of Hague, IDS has served his party well Secretary of State for Work and Pensions. Whether the country benefits from this is questionable.
  • Michael Howard – resigned his seat one year after losing the 2005 general election.Twice there’s been speculation about Howard joining Hug-a-Hoody’s cabinet, twice it has not occured. Howard is in the Lords and serving reasonably unremarkably except for his wide range of non-political financial interests.
  • Tony Blair – left politics, solved the Middle East Crisis and shit ton of cash. Still casts a spectre over his party, criticised Ed Milliband throughout his leadership.
  • Gordon Brown – stayed on in the Commons until standing down 2015, doing very little except this speech. It was the speech of his life, and the Scots said ‘No’ the day after, so it was a very good speech.
  • Charles Kennedy – one of the most universally respected MPs, with my Tory, Green and Labour voting friends all actually seeming quite sad when he died. Kennedy warned of the dangers to the Lib Dems of going into coalition with the Tories, a position that seems more and more right as the days pass. Like Brown, helped Better Together campaign and helped the Lid Dems win by-elections in Scotland.
  • Sir Menzies Campbell – remained an active backbench MP and never caused noticeable problems for his leader, Nick Clegg. Stood down at the last election.
  • Nick Clegg – so far very quiet, his resignation speech was actually genuinely heartfelt and I found myself questioning whether I liked him or not. Then I remembered the £9,000 this last year cost me.
  • Caroline Lucas – her ideological stands in Parliament have allowed Natalie Bennett to focus on growing the party. The record number of Green voters seems to suggest a lot of people want more versions of Miss Lucas in the Commons.

So of my ultra-organised examination of ex-leaders in the Commons, we’ve only got one backseat driver – Mr Tony Blair. Now granted Blair’s ego couldn’t fit into the coffins of all the dead from the Iraq war, isn’t it interesting that the only one who has nothing to lose politically is the one whose offering all the political criticism?

Going back to the MP worried about backseat driving, I’ve got a couple of points. Recent history suggests ex-leaders realised that they’ve lost and knuckle down to serve their parties and constituents. My personal opinion suggests that this isn’t what said MP should be worrying about. I’d be more worried about the fact that your leadership election has 4 candidates consisting of:

  1. Andy Burnham – The health secretary who presided over the Mid-Staffs debacle
  2. Yvette Cooper – I can’t think of anything remarkable she did, despite being an MP for 18 years
  3. Jeremy Corbyn – Hates Trident, likes Hezbollah.
  4. Liz Kendall – wants 2% of GDP spent on the armed forces, doesn’t mind free schools and doesn’t condemn the Tories benefit cap. Hang on, what party is she running for again?

That’s two politicans from the New Labour camp, one wholly unremarkable and another remarkable for a pretty awful debacle, a fan-of-Hamas throwback to the USSR and a 5 year MP who, despite being pretty dissimilar to the Tories, is probably who Labour would do best with. Actually, that should probably be phrased ‘least worst’.

But of course, there’s worries about what Ed Milliband will do over the next 5 years. Which in itself, but it serves to show Labour’s seemingly unquestioning desire to remain wedded to the past, be it 1997 or 1979. The Tories didn’t emerge as a credible force for 13 years after their 1997 defeat. With Labour facing the tripartite threat of the working class voting UKIP, Scots voting SNP and the students/hippies/brave comrades voting Green, it’ll take a huge amount of work for Labour to regain a foothold even close to being big enough to oust the Tories. And I’m not sure that’s work they know how to do.

A Look At Homebirths

NB: I originally wrote this article three years ago for a different blog. Having now completed an obs and gynae placement I thought it would be a good time to re-release it. It’s mostly in it’s original form, though I’ve edited some bits of it.

Browsing my Twitter feed, I saw an interesting story pop up from Health Impact News. According to Judy Colhain, the American Journal of Obstetricians and Gynaecologists (AJOG) have ‘issued a warning to all doctors and midwives to refuse to attend homebirth under all circumstances. ‘ See the full text of Judy’s article here and see the full text of the AJOG statement here. I’ll be referring to them a lot so it’s probably a good idea to at least skim through them

Wow. That seems like a big step. You mean that if a woman was suffering a severe haemorrhage during labour, not one obstetrician would go to her aid? You’ll probably be unsurprised to here that this isn’t what they’ve said. They actually said that ‘We urge obstetricians, other concerned physicians, midwives, and other obstetric providers, and their professional associations to eschew rights-based reductionism in the ethics of planned home birth and replace rights-based reductionism with an ethics based on professional responsibility.’

In non-medical speech, this means ‘We ask every health professional involved in pregnancy and birth to act based on what is best for the patient, not based on what the patient thinks they should have.’

Just because a woman wants a homebirth it does not automatically make it an obstetrician’s responsibility to let her have one. It is his/her professional duty to tell the woman what is the best course of action based on the collective published evidence and to act upon this. If the obstetrician feels a homebirth is appropriate and safe, then here in Blighty at least, the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) approves them. I happen to agree with them, and think wider use of midwifery led care in appropriate cases would help ease the considerable pressure maternity units are under. The AJOG disagrees with on this issue, and that is their prerogative, though I think they are probably a bit over zealous,

Continuing through her article, Mrs Colhain quotes the AJOG as recommending ‘that all obstetricians and other concerned physicians, midwives and other obstetric providers, and their professional associations not support planned home birth… refuse to participate in planned home birth.. and recommend strongly against planned home birth’. Note the ellipses that Mrs Colhain has correctly used. For the non-grammatical amongst you, an ellipsis is used to indicate where someone has omitted words from a quote. Or in this case, taken a quote out of its context to make it support her own position. The above quotes actually comes from a sixteen line paragraph. Mrs Colhain has also changed the order of these quotes and changed the wording of them. Hopefully, I’ll clarify the picture for you.

This is what the first part of the above quote should say –

We call on obstetricians, other concerned physicians, midwives and other obstetric providers, and their professional associations not to support planned home birth when there are safe and compassionate hospital-based alternatives and to advocate for a safe home-birth-like experience in the hospital.’

The AJOG are recommending that health professionals support a safer yet still compassionate alternative to homebirths, and that even in hospital, the experiences should be ‘home-birth-like’. Having seen a labour in a hospital birthing pool, I can attest that it was a very relaxing experience. The scented oils, classical music and copious amounts of tea made me very comfortable. Can’t speak for the lady giving birth.

The second part of the quote comes from earlier in the paragraph and put in context says:

 ‘refuse to participate in planned home birth; but still provide excellent and compassionate emergency obstetric care to women transported from planned home birth’.

Yes, the AJOG are recommending that health professionals don’t participate in homebirths as they are generally less safe and often, women who choose homebirth end up being transported to hospital due to complications. For example, the lady I saw in a hospital birthing pool ended up transferring for an emergency C-section. I’d say it was a good job she was in hospital, rather than in her living room.

As we can see from above, doctors will still give care to these women, somewhat ruining the ‘people-in-hospitals-are-monsters’ angle that the article is seemingly going for. This also explains why the Royal College of Obstetricians and Midwifes here in Britain thinks home births are OK. Generally in Britain, you are very close to an obstetrics unit if something goes wrong, as Britain is a minuscule island. In the US, there are large stretches of the country without easy access to an obstetrics unit so home-based difficulties are much likely to cause morbidity or mortality.

The third part of the quote is mysterious. Certainly, the words Mrs Colhain quotes never seem to appear in the article, I can’t find them anywhere and neither can the search function of Microsoft Word (other word processors are available). Strangely what I think Mrs Colhain is quoting appears earlier in the article, and she appears to put this quote last solely for a dramatic finish. I’m going to be extremely generous and suggest that the changes in words and order were not deliberate obfuscations but she was merely paraphrasing for ease of reading. Let’s compare what should have been written and what was actually written next to each other.

QUOTED: and recommend strongly against planned home birth

ACTUAL: respond to expressions of interest in planned home birth by women with evidence-based recommendations against it

As I have highlighted above, Mrs Colhain neglects to mention a small thing. What’s that? Oh, just the small fact that the evidence goes against her position. Which, when you’re trying to be persuasive, is not the best of things.

Next, Judy Colhain talks about the ‘splendorous diversity of human conditions’ after a long list of reasons that may cause a woman to choose a homebirth. This doesn’t alter the fact if something goes wrong, which it can often do, then the hospital is a much safer place to be. Yes, it would nice if every woman could give birth at home surrounded by family in comfortable conditions. But the cold hard truth is that this would probably result in more mothers dying in childbirth. Something to think about.

Mrs Colhain states that ladies that have embolisms may die in hospital anyway, the mortality rate in hospitals being 27%. To me that shows the three quarters of ladies would survive. Now I don’t know about you but I think suffering an embolism in a homebirth scenario might have a slightly worse survival rate than 73%. I’d also like to point out that the statistics she gives are for amniotic fluid embolisms, and not the much more common thromboembolism. Why does she assume a lady with an embolism would have an amnoitic fluid one? I’ve absolutely no idea.

I’ve split this article into two parts – I’ll post the link to part two here when it’s published

Some Simple Steps on Paper, A Few Giant Leaps for the NHS

Trawling the BBC health site for some inspiration after a realised I’d not written anything for 2 weeks, I came across the headline ‘Simple steps could save NHS £5bn‘. Given that Simon Stevens, NHS Chief Executive, thinks the NHS can save £22bn by 2020, I was pretty interested to see where this £5bn would come from. As Lord Carter’s actual report has not been published yet, I’m relying on the BBC article being correct.

  • Carter found that heating costs varied from hospital to hospital, and money could be saved on ‘estates’

Now not to start blaspheming against the good Lord, but this sentence smacks of an accountant looking at numbers from afar and not taking into account any context. Dundee spends £X thousand pounds a month on heating compared to Plymouth? Must be ineffeiciency, couldn’t possible be the fact Dundee is a snowy hellscape and Plymouth is warm most of the year…

To be less sarcy, I can see where efficiency gaps could exist i.e. different heating systems, heating wards/areas that aren’t open, but the BBC hasn’t done Carter any favours by opening with the hardly groundbreaking news that heating costs vary across different buildings.

  • One hospital lost £10,000 a month through giving staff too much leave. £2bn could be saved nationally

Which hospital is this and how do I work there? I jest of course, but giving staff too much leave is not a problem I’ve ever seen.

However, staff management is a problem. Here’s 3 of my favourite anecdotes off the top of my head:

1. An incident where a Consultant 1 was off on leave, and Consultant 2 offered to cover the fast track cancer clinic, instead of doing his own clinic. Obviously, NHS managers being what they are they read ‘instead of’ as ‘in addition to’, and he turned up to see 24 patients waiting to be seen in 3.5 hours. Luckily, there were two registrars free to help out, and even I ended up taking histories of patient to make sure everyone was seen. Yes, you read that correctly – the fact that a medical student was around was actually helpful.

2. The time a review was being conducted into a patient’s death and all staff involved were interviewed. Do we need to arrange on call cover for when the registrar has her slot? Of course we don’t. On this occasion, the on-call consultant became the on-call registrar as well.

3. I turn up to surgery to ask to observe, all is well and good. 20 minutes later, I’m scrubbed in and assisting as the junior rostered to help is still having to do jobs on the ward because there’s no one else to do those jobs. Once again you’ve read that correctly – having a medical student was actually necessary. In this case, it really was as I’m not quite sure where they were going to magic a doctor from. Probably the same magic tree, David Cameron is going to get all his extra nurses and GPs from.

Now those are just three situations and I’ve never seen any of them repeat themselves, but each one put patients at risk and irritated the staff involved. Not a good way to make NHS management more efficient, and I definitely agree that NHS management needs improving.

  • One hospital saved £40,000 a year through using a non-soluble version of a liver failure tablet rather than a soluble one

As long as steps like the one above don’t put patients at increased risk then I’m pretty much in favour of them. Of course if the patient has trouble with a non-soluble tablet and a soluble one would work better for them, then that option has to be there. It’s not really a feasible cost cutting measure for a lot of in-hospital treatments such as chemotherapy, anaesthetic or antibiotics, however, in a GP context, I can see room for safe savings.

  • Carter recommends an electronic catalogue for simple items such as syringes and aprons to create standardised buying, as prices can vary as much as a third

Unless the NHS is massively restructured, this is going to be difficult to enforce. People like to think of the NHS as a monolithic structure. If you’re one of them, brace yourself and look at the picture below. Still think it’s one big simple thing?

The result of multiple governments 'simplifying' the NHS
The result of multiple governments ‘simplifying’ the NHS

The NHS is too divided to enforce bulk buying and judging by the current governments plans, it is only becoming more so with the net for tendering of services being cast wider and wider. In principle, I agree that if the NHS bought identical stuff nationwide, savings could be huge. Imagine the multibuy savings you get on a billion aprons! However, I can move from Barnsley to Sheffield to Rotherham and potentially see three different blood-taking sets, three different protocols to do so and three gloves to wear as I do it. Unless the NHS becomes more of a monolithic structure, then it’s fragmentary nature will really hamper savings. And as becoming more monolithic heralds problems of it’s own, I’ll leave this one to cleverer people to sort out

  • Some hip replacements cost twice as much and last less than cheaper alternatives

Ah, put this one down to surgeons and their love of new toys. Just kidding, put it down to a problem that cuts across most of humantity. We assume new is better, when quite often it isn’t. We at least don’t know if it is. This illustrates the need for integrating clinical trials alongside gold-standard clinical care on a routine basis.

Imagine we know exactly how to best care for those with hip replacement ‘A’ (the old one). Hip replacement ‘B’ comes out and we want to know if it’s better. Every patient that comes in we randomise using a computer program to either ‘A’ or ‘B’, and we do this for as long as it takes to get the data we need. We then follow up the patients for however long we know ‘A’ lasts for and see if ‘B’ is matching this. We can also compare death and complication rates, and anything else we check for. At the end, we either stick with hip ‘A’ as it is clearly better, switch to ‘B’ as it’s better, or we’ve found A works better for certain patients and B for others. Whatever option, we’ve improved our gold standard care, and whilst we’re at it , we can save the NHS money spent on treatments that are sub-standard,

Obviously written out, it’s a lot more simple than real life clinical practice. However, it’s not impossible. Childhood leukaemia tretaments have this approach, continously improving their care and now survival rates for the commonest type is around 90%. 

Lord Carter’s report is coming out soon, along with his description of an efficient model hospital, so I’ll be looking out for that and if he says anything groundbreaking you might see me return to this topic. So far, his ideas seem quite short of groundbreaking, but perhaps that’s what is needed. If the NHS is to get its financial house in order, the simple steps will need to be done first and anything we can save by making medications better value for money, prevents the cutting of essential front line services.