What for the Liberal Democrats now?

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As of this writing, Theresa May has agreed to a “confidence and supply” agreement with the Democratic Unionist Party. Nick Clegg, whom I campaigned for, has lost his seat with losses by 105 in Ceredigion, 45 in Richmond Park and most heartbreakingly 2 in Northeast Fife to boot. This has made the increase in Liberal Democrat seats from 9 to 12 bittersweet.

I’ll only talk briefly about Sheffield Hallam; how Nick Clegg lost to a unapologetically leftist Labour party in one of the most affluent constituencies in the country may be puzzling. Simply, Tories voted Tory and many students plus some left-wing Liberals voted Labour. The Liberal Democrats only lost 2000 votes and Labour only gained 2000 but it was enough. Sheffield Liberal Democrats may read this so a full examination now is not my place. For me it is sad to see a man gone whose decisions pushed me to join a party and campaign.

A new leader…

Many will argue Tim Farron underperformed. The second Brexit referendum message did not work. Half of Remain voters now support Leave, giving Leave 68% of voters. 30% of 2015 Liberal Democrat voters voted Leave; how did it make sense?

To be honest, he didn’t have a chance. Assume the election is in 2020. The second Brexit referendum becomes a foundation from which to build. Between March 2019 and May 2020, Liberal Democrats propose plans to deal with a calamitous Brexit. Our predictions coming to fruition gives us the authority.

Whether you agree with that counterfactual, the snap election meant we couldn’t retract that message. Lib Dems would have haemorrhaged votes if they had U-turned. Further, we’d have lost the large number of new members and volunteers making winning even more difficult.

Nonetheless Ed Davey, Vince Cable and Jo Swinson have made welcome returns. A third of our MPs our now women and Layla Moran of Oxford West and Abingdon is – I think – the first Palestinian-British MP. I’m not sure now is the time to be picking a new leader. Let’s keep things strong and – erm, on an even keel.

…or a new message…

Tony Blair – Things Can Only Get Better
Barack Obama – Yes We Can
Trump – Make America Great Again
Vote Leave – Take Back Control

I don’t have the 2017 results yet but look at the 2015 results. Since I kind of like spreadsheets, I spent some time fiddling with them. Let’s say we win the 8 seats we did with majorities of 1 (ie beat the other person by 1 vote only). And we win another 318 seats by 1. We’d have 326 seats ie a majority.

In order to do this, we’d need an extra 4.9 million votes (4903316 to be exact), or around 15% of people who cast a vote. These numbers are silly and impractical; I say this only to highlight the importance of targeting.  Winning in our electoral system isn’t about convincing everybody.

The four slogans above (though strictly Blair’s was Because Britain Deserves Better but nobody remembers that) have a lot in common. The only word with more than two syllables is America. They’re short and snappy. The last two have elements of assonance and alliteration. They’re positive. They conjure the idea of change.

So why did Strong and Stable fail? Well, campaigns also have to pass the sniff test. Does it “feel” like it makes sense? You can’t run on stability and then do U-turns. But often campaign failures go further than that. Hillary Clinton (Ready For Hillary) and Stronger In (Harder Better Faster…just kidding it was Stronger. Safer. Better Off. Probably) didn’t just have poor slogans – they lacked a message. Stronger In was persistenly undermined by wild claims about average loss of earnings and emergency Brexit budgets. Clinton…well, I’m still not sure what her message was.

…and if so, what?

To build a message, you have to start with an idea. Who are we? Well, we’re liberals. Which is so vague and fluffy you could barely convince a child it was worthwhile let alone an electorate. The party is split along the lines of Orange Bookers and Yellow Social Liberals. Economic and social liberalism have not always been easy bedfellows and the fault lines between the SDP’s social democracy and the Liberal Party’s classical liberalism still hinder the party.

I don’t believe they should. Economic and social liberalism are not mutually exclusive. Further, they are necessary for one another. A failing economy leads to unemployment and inflation. If you can’t afford food and heating because prices go up, you’re more likely to get sick or do badly at school. If you have no job, crime may be the only option.

An effective welfare state reduces sickness, trains and educates people and gets them back into the workplace. It is worth spending money on. Thatcher’s legacy of failing to pay for a welfare state can been seen in the mining towns and villages across South Yorkshire. Blair believed that unfettered free markets would give traditional Labour voters jobs – it didn’t as their skills were rendered obsolete and a crushing recession after his resignation meant they struggled with what little they had left.

Brexit

Too few people care about Europe for it to be an electoral issue. When the next election will be remains uncertain but the emphasis cannot be on staying in the EU. Brexit is, I think, an inevitability. Whether or not the second referendum stays as policy, it should be quietly pushed aside – we need a plan for Brexit.

The case should be made for free trade and the positives of immigration. Come the 29th March 2019, I have no doubt the Conservative government will have screwed this up. Royally. We have to have a positive alternative. Change Britain’s Future is a solid slogan (though I humbly suggest Change Your Future or Change Our Future for the, er, future). Indeed, there is something in the Republican notion that you can “pull yourselves by your bootstraps”.

The bottom line is a plan for a post-Brexit world. One where we show why it matters that we reach out to Europe and the rest of the world. How the Polish fruit-picker means the farmer in Lincolnshire has a job. As does the lorry driver who moves the produce and supermarket cashier who sells it. The mechanic who fixes the lorry and buys parts from Germany because of the trade deal we have – but rather than framing these as costs, these can be framed as opportunities. Immigration can create jobs for the many, not…the smaller number.

But moreover, how that money can be ploughed back into deprived areas. Into retraining the everybody for the onset of new technology.

We can be for both and we should be and we have to be.

Will it work?

No idea. May be this is all rambling. I’m not a seasoned campaigner, an expert in polls or a politician. I’m not clear we can successfully sell immigration to a skeptical electorate. Though most people’s number one reason to vote Leave was sovereignty, not immigration, this doesn’t say how important immigration was to them. I wonder if it is still too early to be talking about free trade in an increasingly isolationist Britain.

But if we can back the slogan – Change Britain’s (Your?) Future – with an idea, the idea that we can build a welfare state that creates a booming economy in the wake of Brexit to pay for that welfare state, may be we can sell it to 5 million more than people in 2022 that we did in 2015. Unless we do this all again in October…

I dislike Valentine’s Day and will now try to make you feel bad about it

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In what seems like a lifetime ago, I attended an intervarsity debating competition where I watched a final on the motion “This house would ban Valentine’s Day”. It was on Valentine’s Day. I was single. Everybody in room knew they were really cool.

I remember little to nothing of the debate but it did make me think about Valentine’s Day a lot. It even became a bit of stand-up when I still did stand-up. It went something like this:

“I hate Valentine’s Day. It’s the only day dedicated to making happy people happier. There’s no International Rich and Happy day where rich people rub money in the faces of the poor. Or People Who Don’t Have Cancer day where people who don’t have cancer go to chemotherapy units to have dinner without vomiting or losing their hair.”

Now whether you find that funny, offensive or both (NB: it is not a joke a about cancer), it hopefully demonstrates my point. But I want to expand on it which is less funny but possibly more interesting. I’m going to generalise about people in three different statuses of relationship: single, traditional monogamous and non-traditional relationships.

Single

This one’s easy. See the quote above. If you’re in a relationship, why on Earth do you feel the need the to rub this in the face of people who are single? What kind of narcissist are you? Unless you literally never mention your Valentine’s plans to anybody.

Sure, a lot of single people don’t care. But a lot do. Some will be recently divorced. Some will have had a partner who has died. Some will have just broken up. Some will be lonely. All these people are made to feel bad on Valentine’s Day. Thanks, people in a relationship!

Traditional relationships

Here, I’m talking about monogamous relationships of all sexualities and all genders. One person who is an exclusive romantic relationship with another person.

If your relationship is currently a happy one, Valentine’s Day makes no difference to you. You don’t need a special day where you get together with everybody else to celebrate how great you are because you found somebody else. Well done on attempting to make the entire world your awkward third wheel.

If however your relationship is going through a difficult time, what Valentine’s Day does is says, “if your Valentine’s Day is unsuccessful, you are in a bad relationship”. Clearly, this is ridiculous. Outside of film, TV and books, all relationships have ups and down. All Valentine’s Day does is force these couples to focus on the failings in their relationships, whether they want to or not. It may even break relationships.

Non-traditional relationships

 

Valentine’s Day perpetuates the notion the road to happiness is through monogamy. “Will you be my valentine?” implies one person, not many. And it goes further.

There is a general perception that being in a monogamous relationship is not just about happiness – it’s about virtue. That there is something fundamentally morally superior about those us in monogamous relationships than those of the us that aren’t.

First of all, this is awful for people who aren’t in monogamous relationships. Secondly, it means that single people may not look at either being single or being in polyamorous relationships are legitimate routes to happiness.

(As an aside, the “most virtuous” relationship is arguably the heterosexual, cis, monogamous relationship but sexuality and gender aren’t Valentine’s Day’s biggest issue.)

So basically, by celebrating Valentine’s Day, you’re making single people lonely, potentially destroying relationships, marginalising the polyamorous and closing off paths to happiness for everybody.

Well, at least I was considerate enough to post this after February 14th.

Happy Valentine’s Day.

The NHS needs money. It also needs to change

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In 2011, the UK had 2.8 physicians/1000 population compared with Germany 3.8, France 3.4 and Australia 3.3. The UK spent 9.4% of its GDP on health compared with France 11.5, Germany 11.3 and Australia 9.4; the UK’s spending was forecast to drop to 6.6% by 2020/21 though all bets are off with Brexit looming.

The NHS in England needs more doctors. I work for a large trust across two hospitals where the 6 different anaesthetic rotas at middle grade/registrar level should theoretically provide plenty of cross-cover. It doesn’t: I regularly receive requests to fill gaps in rotas, often with “HELP!!!!” in the subject line. This is no different at smaller district general hospitals.

Criticisms from the BMA of Jeremy Hunt during the doctors’ strike and Theresa May are correct. Seven-day elective services do little for emergency care provision. Moving GP opening hours to 8-8pm is not the same as increasing capacity. If two GPs work 9-5 and then change their working hours to 8-4 and 12-8, the surgery will still be open 8-8 but there will be the same number of appointments.

Opposition to change in the NHS is widespread

That said, trying to change something in the NHS is nigh-on impossible. Healthcare professionals blame managers. Managers blame healthcare professionals. Everybody blames IT.

Let me give you an example. Patients in acute medicine are allocated to consultants in 24 hour blocks, 8am-8am. Patients who arrive in that time, fall under that so-called “take” consultant. If not discharged on the day, they are added to a “post-take” ward round the day after.

There is software which produces an active list of patients who need to and have been seen by Acute Medicine. There is a list for yesterday and today. From 0800-0900, it moves forward to the next day. The issue is, at 0730, secretaries print the previous day’s “take” list. Between 0730-0900, patient’s deemed seen by a junior doctor may get added to the previous day’s list after it has been printed. Today’s take consultant thinks the patient has been seen by the previous day’s consultant. The previous day’s consultant – now on the post-take ward round – doesn’t know about the patient

This could be solved simply by having the system refresh at 0630-0730. However, this doesn’t happen. Instead, at 8am, junior doctors print a physical list and after 0900, add the information. Of course, doctors may forget, may be new and not realise or there may simply be a clerical error on paper leading to patient not being seen.

At another hospital, the portering system had gone electronic and theatres had lost their dedicated porter. If there were no operations, previously that porter went and helped with other portering jobs.

On the new system, the most urgent your patient will be picked up is “urgent”. However, I have frequently waited an hour or more for patients who were acutely unwell. Theatre staff were instructed they should not be leaving theatres to collect patients – this makes sense as if the patients arrived in a timely fashion, theatre staff would be preparing theatre. This was not an issue prior to the introduction of the electronic system.

These issues may seem minor but they are legion. Each one adds a layer of inefficiency. Occasionally, you get workarounds (like in the first example) but these aren’t really solving the problem. Steven J. Spear’s excellent book The High-Velocity Edge looks at how to improve processes – to paraphrase him, this is not a solution, rather solving the same problem every day.

Efficiency savings or quality improvement?

As a junior doctor, largely you feel powerless to change these things. You usually spend 4-6 months per placement, too little time to effect change. This is made worse by healthcare professionals who aren’t willing to at least try change. Change is not always good – yes – but that’s necessary risk to take. Indeed, in research, it’s acknowledged that change is necessary. Without it, we would not have seen the medical advances of the last 70 years. Ultimately, the “low-hanging fruit” of research have been taken. With quality improvement, we have barely scratched the surface of what the NHS is capable.

The difficulty is two-fold. First, any criticism of the NHS is perceived as bad. “Efficiency savings” have become a euphemism for cuts. However, what kind of organisation isn’t constantly trying to make efficiency savings?

Under Tony Blair, healthcare organisations worked on expanding services, a very different set of managerial skills to improving current ones. It takes time and effort but mindless calls to #SaveOurNHS, whilst useful at times, perpetuate the image that the NHS doesn’t need change, it just needs more money.

Secondly, many healthcare professionals engage in management begrudgingly, interested in clinical practice only. Though we receive little training in management, our reluctance to change processes kils our patients as much as any funding gap. They are as important as our clinical skills.

To be effective, these changes need to solve problems from the bottom up. Managers should call for small problems to be highlighted and praise staff for doing so. Staff, when change is implemented, should go with it, at least at first. And managers should listen to the things that do and do not work. No amount of money can change this.

A really fun post about death

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Last year, there was quite a bit of chat about famous people dying. The BBC examined this and found they had published more pre-prepared obituaries than usual in the first 4 months of last year in particular.

This sounds callous but I find it difficult to care.

Don’t get me wrong – if Sarah Michelle Gellar (I liked Buffy) or Claire Danes (I like Homeland) die, I will be taken aback. However, I am not going to be personally affected should Gellar die. And whilst it would be sad if Homeland got cancelled due to Danes’ untimely demise, this is not reason to grieve.

When people on social media express their sadness at a celebrity’s death, mostly this is in tribute to their body of work. However, there sometimes seem to be genuine expressions of grief as though they were a loved one.

In hospital, whilst most relatives are realistic, it is not uncommon to encounter impossible expectations of healthcare. Arguably the most challenging aspect of critical care medicine is making the decision about when to provide or more crucially when not to provide critical care.

Being on a Critical Care Unit/Intensive Care Unit (vs being on a standard ward) involves a host of unpleasant interventions. Whilst this is worthwhile if a patient has a reasonable chance of survival, in futile cases, this is tantamount to torture, a word I use when explaining ceilings of care.

I worry that both the unrealistic expectations and grieving for celebrities are symptoms of our general aversion to discussing death. How can one seriously grieve for somebody unknown to them?

In the original Get Carter (1971), Michael Caine’s character (the titular Jack Carter) has to attend his brother’s funeral. The body is kept in the family home. These days, bodies are kept in mortuaries and taken by funeral directors prior to burial or cremation. It would be unheard of to keep a body in the family home.

I am not trying to make you feel bad for your sadness at George Michael/Alan Rickman/Victoria Wood’s death. Still, posts can seem as grief-stricken as those from the genuinely bereaved.

Death is a fact and it is something we consider too little and discuss too infrequently. It leads to the situations where people with cancer are abandoned by their friends. I have had multiple conversations where bereaved friends have found others unable or unwilling to discuss the death of a loved one.

And because of this, it seems uncouth and unhealthy to act as though a celebrity death should be treated similarly to personal bereavement.

Talk about death; when your relatives became unwell, doctors are going to ask what you think they wanted. That is a much easier discussion if you have had the decency to talk about it. It is for them as much as you.

You and everybody you know and love is going to die: get comfortable with that. On that note, I am going to have a banana and go to bed.

 

“No Black No Dogs No Irish” and other thoughts on the EU

I am scared of leaving the European Union.

A not insignificant number of my friends are Leave supporters. I have little doubt they genuinely believe leaving the EU will be of benefit to them. Whether their arguments are about sovereignty or the economy, they’re intelligent people who are appalled they are on the same side as Nigel Farage and George Galloway.

However, there is an undercurrent of fear of the other percolating Leave. Regardless of Boris Johnson opining his love of immigration or indeed that an Australian-style points system would lead to more immigration, much of Leave’s support comes from those who are scared that foreign people make things worse.

To a certain extent, I’m not making a logical argument. It’s that if a politics of populist fear succeeds, it paves the way for more. Fear of the other is the cause of your problems. We need less ‘other people’ and more ‘your kind of people’.

That was, when my parents came to the UK and my brothers grew up, the norm. The National Front were popular in the 1970s. Rivers Of Blood and “if you want a nigger for a neighbour, vote Liberal or Labour” still echoed in the ears of immigrants. Even today, for 10 years David Cameron has espoused anti-immigration rhetoric that has now undermined anybody’s belief he supports any pan-European project.

I worry that that social progress will go backwards, even just a little bit. I don’t want to live in a country where that fear is stoked and where that is a legitimate way to win elections.

This referendum is for me whether Britain feels it wants me to be here. So I will campaign for Remain tomorrow. Largely, this will be genuine passion for the EU; partly though it will be out of fear.