Healthcare: doing the right thing and finding the right words to say it

Every now and then a conference – and I’m at one now – is enlivened by masterful presentation, brimming with insights on vital matters, the whole sharpened and enhanced by intelligent use of humour.

Such was the talk given by Walter Ricciardi, President of the Italian National Institute of Health. It was entitled From evidence to action in health policy making: a mission impossible? His subject was how senior clinicians concerned with the strategic direction of health, and convinced of the value of practising evidence-based medicine (the theme of the conference) could work with politicians in government to take the necessary decisions.

Walter Ricciardi
Witty, insightful and spot on about the need to get it right – and say it right

I’m keen on evidence-based medicine. That may sound like a trivial statement: who wouldn’t be? Well, you might be surprised how often medical decisions are taken on the basis of a clinician’s gut feel, or confidence that years of experience are enough, rather than evidence. Worse still, they’re often taken on the basis of politics: for instance, the UK government has made funds available to allow GP practices to stay open later, without putting in place any kind of process to check whether the move leads to any of the desired effects – most notably reducing attendances at Emergency Departments of hospitals.

The reason why Ricciardi feels this kind of discussion is vital now is the well-known observation that demand for healthcare seems to keep climbing uninterruptedly, as the population of the advanced economies ages and the technology available for care increases in sophistication (and cost). As he suggested, there has to be a limit to the amount society can sensibly be asked to invest in healthcare.

That reminded me of a presentation I attended some years ago, when one of the speakers pointed out that, on present trends, the USA would be spending 100% of its GDP on healthcare by the end of this century. That’s clearly impossible – something has to go into schools and roads and things, to say nothing (this is the USA we’re talking about, after all) about defence. So what is the maximum US citizens will accept? 50%? Surely that’s too high. 30%? It’s hard to imagine. 20%? If so, things are urgent indeed: they’re already spending 18%.

That’s without even providing full healthcare coverage for the whole population.

Limiting healthcare expenditure, wherever the limit lies, means that at some stage we’re going to have to start denying care. That’s where evidence-based medicine comes in. There are a great many treatments that could be denied without doing patients any harm – indeed, where the denial would do them good.

At one end of the scale, prescribing antibiotics for viral conditions harms us all and does no good to the patient.

At the other end, intense and highly expensive interventions for a patient with a fatal condition can wreck the end of a life and incur huge waste.

We have to start finding a way to avoid this kind of wasteful, if not downright harmful, way of practising medicine.

That’s where Ricciardi turned up the humour a notch or two. He suggested that the people who understand the issues have a vocabulary of 140,000 words; the general public, and he included politicians in that category, a mere 7000.

I don’t know where those numbers came from. Frankly I find them highly questionable. In fact, I’m inclined to ask, where’s the evidence? However, the underlying point is worth making: specialists in medical information need to find a way of communicating the case for some of these notions more effectively to the population. They need to persuade politicians of the need for action, and help the politicians find the words to express their decision in a way voters will accept.

At this point he made a point I found particularly amusing, though he may have meant it seriously. He referred to Jean-Claude Juncker, President of the European Commission, as intelligent and honest. It was wonderful to see how the English in the room all started in their seats and shuddered: Juncker is viewed as a figure of derision in England. He’s disliked in a great many countries, but it was striking how much stronger the English reaction was.

He went on to quote Juncker as saying, “we know what to do. We just don’t know how to get elected afterwards.”

Jean-Claude Juncker: a smart and honest politician?
Not according to the English, but are they right?

Now, that really is both honest and true. The things that need doing are tough to make popular. A politician that does them may indeed find it hard to win office again.

There’s an excellent example in Ricciardi’s own country, Italy: the Italian government has taken an extraordinarily courageous decision, to make childhood vaccinations compulsory. The anti-vax movement has reached dangerously high levels, with herd immunity being lost and long-vanished diseases like measles and mumps making an appearance again. The government took the action necessary, based on the mass of evidence available: the potential harms of the vaccinations are less serious and less common than those of the diseases they eradicate.

But will they have persuaded the voters that the decision was right? Popular anger in response to the measure was intense and widespread. We’ll see in next year’s elections how well the government has done in taking popular opinion with it.

It’s important to practise evidence-based medicine. But it’s just as important to find the words to explain what you’re doing. The former is what we have to do but, without the latter, the politicians who do it will be unable to stop their achievements being unravelled by their successors.

Greece and the EU: who's been betrayed by whom?

It seems that Jean-Claude Juncker, President of the European Commission, feels betrayed by the behaviour of the Greek government.

The purpose of a union is to create something that is greater than the sum of its parts. By pulling together, the nations of the European Union agree to work together, giving up some of their individual freedom of action, because they believe that in joint effort they can achieve more.

Within the Eurozone, the bonds are even closer, since the countries have given up control over their own currency, a major sacrifice when it comes to combatting financial difficulties.

Part of the bargain is that if any constituent of the Union gets into trouble, the Union as a whole rallies round to help. Now, following the financial crash of 2008, five EU nations, all within the Eurozone, were particularly harshly affected. These were the so-called PIIGS: Portugal, Italy, Ireland, Greece and Spain.

Several years on, all but Greece seem to have weathered the worst of the pressure. That’s not to say that they’re doing well. No one in the Eurozone is doing well. It’s stagnating as a whole,but that’s a not unexpected result of the austerity economics it has imposed on itself. Austerity cuts people’s spending power, so demand goes out of the economy and, as day follows night, the economy fails to grow.

Greece however is in a far worse state than the others. The EU, the International Monetary Fund and the European Central Bank, clubbed together to provide it with funding and to buy it some debt relief, but only at the cost of an even harsher austerity programme than the other nations underwent. As a result, unemployment rose to one in four of the workforce and, far from growing, the economy has shrunk by a quarter. A catastrophe.

Instead of banding together to help its weakest member out of the mud, the EU has inflicted on Greece policies that could only drive it far deeper still. While its membership of the Euro denies Greece the classic solution of devaluing its currency, as Larry Eliiott explains in The Guardian.

Guardian photograph from Athens:
graffiti expressing increasing anti-Euro feelings

So the EU has achieved precisely the opposite of what is intended in a Union.

The result is that it now looks increasingly as though Greece will, as long feared, have to leave the Euro, and perhaps the EU too, if only to have any chance of working its way out of the mess it’s in, with even a shred of dignity left to it.

Make no mistake about it. It would be extremely painful for Greece if it came to that. But it would be a disaster for the EU and the Eurozone. Greece is the first test of the capability of the Union to stand by a member that is in real trouble. They’re on the brink of failing that test. That inevitably raises the question “what is the EU for? If it can’t even rescue a relatively small member from penury…”

Angela Merkel enjoys a high and deserved reputation for her statesmanship. But it is she, and Germany more generally, that has led the campaign to inflict the harsh regime on Greece which it is now rejecting. If she can’t magic some solution out of the chasm in front of her at the moment, her legacy may be that of the leader of Europe who saw the experiment of union founder.

Larry Elliott’s article calls what we are facing now a “Sarajevo moment”. The assassination of the Austrian Archduke in Sarajevo in 1914 initially seemed to be a relatively minor event in a distant place. But within weeks it had engulfed the whole of Europe in the torment of the First World War.

The exit of Greece from the Union might be another minor event, but it will be a critical step in causing the EU project to start to unravel. The Eurozone will have shown that it is incapable of solving a problem within its membership. And the EU will have shown that it can’t look after its constituent nations.

Those of us in Britain who want the country to remain a member of the EU will find our arguments for staying in weakened in the run up to our promised referendum. And Eurosceptic movements in other European nations will also gain momentum. The impact on the Union could be lethal.

Someone has certainly betrayed the ideals of the European Union here. But, Mr Juncker, I’m not sure it’s Greece.

Knaves and fools: edifying acquittals and convictions in Britain

“My client's a moron,” says Tom Cruise, “that's not against the law.” 

As well as being an unforgettable line in an outstanding film, A few good men, the statement makes an important point, not just on legal issues, but on society generally and the people we inexplicably choose to run it for us. 

For instance, ever since he appeared on the scene, I’ve wondered whether David Cameron was a knave or a fool. In the last couple of years, it’s a question I’ve asked myself repeatedly about Rebekah Brooks, to whom Cameron used to send text messages which he signed off “lol”. Like a teenager, except that no teenager would think that “lol” meant “lots of love”.

I also had my doubts about Andy Coulson, sometime lover of Ms Brooks, and her successor as editor of the News of the World when Rupert Murdoch, its proprietor, promoted her to be Chief Executive of his European operations. That was before David “lol” Cameron appointed Coulson his spinmeister in Downing Street.

Brooks seemed so bright and acute – the first female editor of the Sun, the youngest editor of a national newspaper in this country, Chief Executive of a significant element of the Murdoch empire – that I couldn’t believe she could possibly be a fool. So when she went on trial for allowing phone hacking by her journalists while she was editor, I thought she could only be a knave: after all, the trial made clear that the practice was widespread and some of the papers’ most significant stories were obtained by hacking, so how could she not know about it?

How wrong I was. The court has now pronounced her no more than a simple fool. Her acquittal means one can only conclude that, as she claimed, she really had no idea of what was happening at the papers she headed. Being a moron is legal, as we’ve seen, so she walks free.

Rebekah Brooks:
all the relief of being found a fool and not a knave

Andy Coulson, on the other hand, has been convicted and therefore officially found a knave. Which takes us back to our fine “lol” Prime Minister. He appointed Coulson to a key position, in Downing Street, privy to all kinds of information and channels of influence. He did it against the advice of many, but on the recommendation of his Chancellor of the Exchequer George Osborne. So it has to be said that the jury’s still out as to whether they’re fools or knaves. They can’t be anything else. 

Actually, the jury’s only out on Cameron if you ignore other evidence. For instance, take the latest Euro-spat Britain has become embroiled in. There’s been most noise about the far right’s wins in the recent elections: UKIP in Britain, the Front National in France. But when the dust settled, what emerged was a clear victory for the Centre-Right grouping, the European People’s Party. Now I didn’t vote for them, but I can count, and it’s clear to me that 221seats are more than 192, the number of seats won by the second strongest grouping, and by the kind of logic that has become traditional in these circumstances, that makes the EPP what is technically known as “the winners.” 

Now it’s not unusual for the leader of the winning party in a parliamentary election to become the leader of the organisation to which the parliament belongs. It’s annoying when the party in question hasn’t actually won an overall majority, but is just the single biggest party, and has to line up with others, as the EPP leader, Jean-Claude Juncker has done. But none of that should be unknown territory for David Cameron, who emerged from the last British General Election as the leader of the biggest single party but with no overall majority in parliament. He came to an agreement with the Liberal Democrats, a pact with the devil some on each side might say, and as a result he became Prime Minister.

I suspect he’s noticed.

Despite the similarity of their positions, he has decided to go out on a limb to oppose Juncker’s becoming the next Commission President. And he’s done so on the grounds of democracy: it would be much better to decide the next President in a meeting of Ministers. Because as we all know, meetings in back rooms are much more transparent than elections for a Parliament.

To get his way, he’s threatened to call an early referendum in Britain on EU membership, which would probably go against staying in. Given how much we all love a blackmailer, you can imagine how his stance has won him friends and influence in the EU.

Why, even the Polish leadership has called him stupid, as we discovered yesterday from secretly taped conversations.

No, the jury’s back in on him, as it is on Brooks and Coulson. We know where we stand on all three now, with official confirmation: Cameron and Books are legal and morons; Coulson’s the knave and about to be jailed.

All three are part of a pretty vile crew. The trick now is to make sure none of them ever gets anywhere near the levers of power again.