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Tuesday, 2 December 2014

Why doctors fail


Atul Gawande in the Guardian

Doctors are fallible; of course they are. So why do they find this so hard to admit, and how can they work more openly? Atul Gawande lifts the veil of secrecy in the first of his Reith lectures

Every family has its pivotal medical moments. One of ours was in July 1995 when my son Walker was just 11 days old. He had difficulty taking his feeds, he couldn’t hold anything down, and we took him to the paediatrician. The paediatrician put her stethoscope on his chest, listened for a moment, and then looked at us and said: “There’s something wrong with his heart.” She told us to take him to hospital right away.

Millions of moments like this occur every day: a human being coming to another human being with the body or mind’s troubles and looking for assistance. That is the central act of medicine – that moment when one human being turns to another human being for help.
And it has always struck me how small and limited that moment is. We have 13 different organ systems and at the latest count we’ve identified more than 60,000 ways that they can go awry. The body is scarily intricate, unfathomable, hard to read. We are these hidden beings inside this fleshy sack of skin and we’ve spent thousands of years trying to understand what’s going on inside. To me, the story of medicine is the story of how we deal with the incompleteness of our knowledge and the fallibility of our skills.
There was an essay that I read two decades ago that I think has influenced almost every bit of writing and research I’ve done ever since. It was by two philosophers – Samuel Gorovitz and Alasdair MacIntyre – and their subject was the nature of human fallibility. They wondered why human beings fail at anything that we set out to do. Why, for example, would a meteorologist fail to correctly predict where a hurricane was going to make landfall, or why might a doctor fail to figure out what was going on inside my son and fix it? They argued that there are two primary reasons why we might fail. The first is ignorance: we have only a limited understanding of all of the relevant physical laws and conditions that apply to any given problem or circumstance. The second reason, however, they called “ineptitude”, meaning that the knowledge exists but an individual or a group of individuals fail to apply that knowledge correctly.

Surgeons working in operating room

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A surgeon in theatre. Photograph: Sam Edwards/Getty Images


We’ve relied on science to overcome ignorance, and the course of that work has itself been fascinating. That visit we made in 1995 to our paediatrician and everything that she did to sort out what was happening in my son could be traced back to 1628 when the English physician William Harvey, after millennia of ignorance, finally worked out that the heart is a pump that moves blood in a circular course through the body.
Another critical step came three centuries later, in 1929, when Werner Forssmann, a surgical intern in Eberswalde, Germany, made an observation. Forssmann was reading an obscure medical journal when he noticed an article depicting a horse in which researchers had threaded a long tube up its leg all the way into its heart. They described, to his amazement, taking blood samples from inside a living heart without harm. And he said: “Well, if we could do that to a horse, what if we did that to a human being?” Forssmann went to his superiors and said: “How about we take a tube and thread it into a human being’s heart?”
Their response was, in essence, “You’re crazy. You can’t do that. Whenever anyone touches the heart in surgery, it goes into fibrillation and the patient dies.”
He said: “Well what about in an animal?”
And they said: “There’s no point and you’re just an intern anyway. Who says you should even deserve to get to ask these questions? Go back to work.”

Surgical tools in a row

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Surgical tools in a row



But Forssmann just had to give it a try. So he stole into the x-ray room, took a urinary catheter, made a slit in his own arm, threaded it up his vein and into his own heart and convinced a nurse to help him take a series of nine x-rays showing the tube inside his own heart.
He published the evidence – and was fired. Then in 1956, he was awarded the Nobel prize in medicine with AndrĂ© Cournand and Dickinson Richards who, some 20 years later at Columbia University, had taken Forssmann’s findings and recognised that you could not only put a catheter into the human heart but also shoot dye through the catheter. That enabled them to take pictures and see from the inside how the heart actually worked. Together the three had founded the field of cardiology. After this, doctors began devising ways to fix what was found going wrong inside the heart.
Science is concerned with universal truths, laws of how the body or the world behaves. Application, however, is concerned with the particularities, and the test of the science is how the universalities apply to the particularities. Do the general ideas about the worrying sounds the paediatrician heard in my son’s chest correspond with the unique particularities of Walker? Here Gorovitz and MacIntyre saw a third possible kind of failure. Besides ignorance, besides ineptitude, they said that there is necessary fallibility, some knowledge science can never deliver on. They went back to the example of how a given hurricane will behave when it makes landfall, how fast it will be going when it does, and what they said is that we’re asking science to do more than it can when we ask it to tell us what exactly is going on. All hurricanes follow predictable laws of behaviour but no hurricane is like any other hurricane. Each one is unique. We cannot have perfect knowledge of a hurricane, short of having a complete understanding of all the laws that describe natural processes and a complete description of the world, they said. It required, in other words, omniscience, and we can’t have that.


The interesting question, then, is how do we cope? It’s not that it’s impossible to predict anything. Some things are completely predictable. Gorovitz and MacIntyre gave the example of a random ice cube in a fire. An ice cube is so simple and so similar to other ice cubes that you can have complete assurance that if you put it in the fire, it will melt. Our puzzle is: are human beings more like hurricanes or more like ice cubes?
Following the paediatrician’s instructions, we took Walker to the emergency room. It was a Sunday morning. A nurse took an oxygen monitor, one of those finger probes with the red light, and put it on the finger of his right hand. And the oxygen level was 98%, virtually perfect. They took a chest x-ray, and it showed that the lungs were both whited out. They read it. They said: “This is pneumonia.” They did a spinal tap to make sure that it wasn’t signs of infection that had spread from meningitis. They started him on antibiotics and they called the paediatrician to let her know the diagnosis they’d found. It wasn’t the heart, they said. It was the lungs. He had pneumonia. And she said: “No, that can’t be right.” She came into the emergency room and she took one look at him – he was having trouble breathing, he was not doing great – and she saw that the finger probe with the oxygen monitor was on the wrong finger.
It turns out there are certain conditions in which the aorta can be interrupted. You can be born with an incomplete aorta and so the blood flow can come out of the heart and go to the right side of the upper body, into the hand that had that probe, but it may not go to the left side of the upper body or anywhere else. And that turned out to be what was going on. She switched the probe over to the left hand and he had an unreadable oxygen level. He was in fact going into kidney and liver failure. He was in serious trouble. She had caught a failure to apply the knowledge science has to this particular situation.
Then the team made a prediction. In this circumstance, we do have a drug – only put into use, it turned out, about a decade before my son was born: prostaglandin E2, a little molecule that can reopen the foetal circulation. When you’re a foetus in the womb, you have a bypass system that sends a separate blood supply that can stay open for a couple of weeks after birth. This system had shut down and that’s why he went into failure. But this molecule can reopen that pathway and the prediction was that this child was like every other child – that you could know what had happened to other children and could apply it here and that it would open up that foetal circulation, this bypass system. And it did. That gave him time to recover in the intensive care unit, to let his kidney and his liver recover, to let his gut start working again, and then to undergo cardiac surgery to replace his malformed aorta and to fix the holes that were present in his heart as well. They saved him.
They saved him.


There are more and more ways in which we are as knowable as ice cubes. We understand with great precision how mothers can die in childbirth, how certain tumours behave, how the Ebola virus spreads, how the heart can go wrong and be fixed. Certainly, we have many, many areas of continuing ignorance – how to stop Alzheimer’s disease or metastatic cancers, how we might make a vaccine against this virus we’re dealing with now. But the story of our time, I think, is as much a story about struggling with ineptitude as struggling with ignorance.
You go back a hundred years or more, and we lived in a world where our futures were governed largely by ignorance. But over this last century, we’ve come through an extraordinary explosion of discovery. The puzzle has, therefore, become not only how we close the gaps of ignorance open to us, but also how we ensure that the knowledge gets through, that the finger probe is on the correct finger.
Next to my son, in the intensive care unit, there was a child from Maine, which is about 200 miles away, who had virtually the same diagnosis that Walker had. And when this boy was diagnosed, it took too long for the problem to be recognised, for transportation to be arranged, and for him to get that drug to give him back that open circulation. The result was that the poor child with the same condition my son had, in the very next bed to ours, gone into complete liver and kidney failure, and his only chance was to wait for an organ transplant and hope for a future that was going to be very different from the one my son was going to have.

Surgical tools

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Surgical tools




And then I think back on my family. My parents come from India; my father from a rural village, my mother from a big city in the north. If Walker had been anything like my nieces and nephews in the village where my family still farms – they’re farmers growing wheat and sugarcane and cotton – and if he’d been there, there would have been no chance at all.
There’s a misconception about global health. We think global health is about care in just the poorest parts of the world. But the way I think about global health, it’s about making care better everywhere – the idea that we are trying to deploy the capabilities that we have discovered over the last century, town by town, to every person alive. We’ve had an extraordinary transformation around the world. Economically, even with the last recession, we’ve had the rising of global economies on every continent and the result has been a dramatic change in the length of lives all across the world. Respiratory illness and malnutrition used to be the biggest killers. Now it’s cardiovascular disease; road traffic accidents are a top five killer and cancers are in the top 10. With economic progress has come the broader knowledge for people that solutions exist.
My family members in our village in India know that solutions exist to the problems they have, and so the puzzle is how we deploy that capability everywhere – in India, in Maine, across the UK, Europe, Latin America, the world. We’re only just discovering the patterns of how we begin to do that.
In the course of this year’s Reith lectures, I’m going to attempt to unpack three ideas. First is what we’re learning from opening the door, from seeing behind the curtains of how medicine and public health are actually practised and discovering how much can be done better that saves lives and reduces suffering. Second is the reality of our necessary fallibility and how we cope effectively with the fact that our knowledge is always limited. Third, I will consider the implications of both of these – the implications of what we’re learning about our ineptitude and about our necessary fallibility – for the global future of medicine and health.
It is uncomfortable looking inside our fallibility. We have a fear of looking. We’re like the doctors who dug up bodies in the 19th century to dissect them, in order to know what was really happening inside. We’re looking inside our systems and how they really work. And like before, what we find is messier than we knew and sometimes messier than we might have wanted to know.
In some ways, turning on the cameras inside our world can be more treacherous. There’s a reason that Gorovitz and MacIntyre labelled the kind of failures we have “ineptitude”. There’s a sense that there’s some shame or guilt attached to the fact that we don’t get it right all the time. And exposing this reality can make people more angry than exposing the reality of how the body works. Therefore, we’ve blocked many of these efforts to try to provide some transparency to what’s going on. Audiotapes are often not allowed, the video recorders are turned off. We have no black box for what happens in our operating rooms or in our clinics. The data, when we have it, is often locked up. You can’t know, even though we have the information, which hospitals have a better complication rate in certain kinds of operations than others. There’s a fear of misuse, a fear of injustice in doing it, in exposing it.

The Agnew Clinic by Thomas Eakins.

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The Agnew Clinic by Thomas Eakins. Photograph: Universal History Archive via Getty Images



Arguably, not opening up the doors puts lives at stake. What we find out can often be miraculous. By closing ourselves off, we’re missing important opportunities.
The doctors told us when Walker went home that he was going to need a second operation. The repair that he’d had was one that replaced a section of his aorta – the tube coming out of his heart to carry blood supply throughout the rest of the body – with an artificial tube when he was 11 days old. It was almost like a straw. Now they had designed it to expand a bit as he grew, but it was not going to accommodate an adult-sized body. So they told us that when he became a teenager he would have to get a new replacement aorta and that he would have to undergo a major operation. Being a surgery resident, I knew what that entailed. Repeat aortic surgery has up to a 5% chance of death and a 25% chance of paralysis. We lived in some fear about when that moment would come.


When that moment came, he was 14 years old, and the world had changed. By then technology had developed to allow his aorta to be expanded with a simple catheter. We found the expert who had learned, and even devised, some of the methods for being able to do that, in Boston. He explained to me, cardiologist to surgeon, just how it’s done and sometimes you learn stuff you don’t necessarily want to know. He talked about how he would have to apply pressure to a balloon that would be threaded up inside the aorta. I asked how he knew what pressure to apply. He said it was by feel. He could feel the vessel tearing, and the trick was to tear it just enough that it can expand but not so much that it ruptures.
There was a necessary fallibility in what he was attempting to do – some irreducible probability of failure. But Walker got through that procedure just fine. The extraordinary thing was the very next day he went home, and the day after that he was so well that he played sports and injured his ankle on the playing field. This June he graduated from high school and this autumn he started college. He’s going to live a long and normal life, and that is amazing. The key question we have to ask ourselves is how are we going to make it possible for others to have that, how do we fulfil our duty to make it possible for others? The only way I can see is by removing the veil around what happens in that procedure room, in that clinic, in that office or that hospital. Only by making what has been invisible visible. This is why I write, this is why we do the science we do – because this is how we understand – and that is the key to the future of medicine.

Economic dishonesty is the deadliest deficit of all


Chancellor George Osborne will disguise the harm he means to do in the autumn statement, but Labour and the Lib Dems are trapped in me-too territory
EU bill
George Osborne will deliver the autumn statement on Wednesday. ‘On all sides barely an honest word will be ­spoken.’ Photograph: PA
Never – probably – in the history of political conflict will so many be misled by so few as in Wednesday’s autumn statement. If the chamber had a polygraph and a Geiger counter to measure radioactive levels of untruth, the place would bleep so loud nothing else would be heard. On all sides barely an honest word will be spoken, including the ifs and the buts.
Yet if the public groans that the yah-booing parties are “all the same”, they would be wrong. Far from it – the parties will be lying about very different things for different reasons. Rarely have they been so far apart in true intentions.
George Osborne will disguise the harm he means to do with his unmentionable £48bn cuts, for fear of frightening voters. Labour will lie about the relative good they mean to do, for fear that fiscal laxity frightens them too. Osborne will be the wolf in sheep’s clothing, bearing sham gifts to the NHS, road users and, maybe, orchestras. Labour will struggle to look wolfish enough, hiding plans to protect public services from the worst by cutting the deficit more slowly. How mad is this?
Here’s Osborne’s situation: he will trumpet 3% growth and falling unemployment while rattling past rising debt and deficit – targets missed by light years as benefits spending shoots up due to housing costs and low pay. Empty Treasury coffers will be slid past, as his “miracle jobs” pay too little to contribute tax. His bold-faced claim that he can afford an NHS bung (not new money) because growth has yielded rewards is just, well, a lie. The Institute for Fiscal Studies, the Resolution Foundation and others warn that Osborne’s cuts will feel far deeper and harsher, wiping out whole departments and leaving councils with only their statutory spending.
This time, as Gavyn Davies warns in the Financial Times, there will be no quantitative easing to smooth the path. Austerity unbound awaits. Even the tactfully conservative estimate of the Office for Budget Responsibility says Osborne’s austerity wiped 1% off growth: his next dose could do even more damage. That’s why the Oxford economics professor Simon Wren-Lewis finds these plans “scarcely credible”. The only possible explanation is ideological, not economic, he says. It “represents a shrinking of the UK state that is unprecedented”.
Cuts Osborne dare not speak are listed by the ConservativeHome website: abolish whole departments, cut more public jobs and pay. An affordability commission will monitor fairness between generations (not between rich and poor) as cover for trimming pensioner perks so far guarded by David Cameron, even the cripplingly costly “triple lock” for rich and poor pensioners alike. The Tory MP Dominic Raab, writing in the Telegraph, expects £20bn to be stripped from Whitehall’s “sprawling bureaucracy”(already cut by a third and denuded of capability) and reduced benefits and public-sector pay, despite five years of cuts.
But Osborne won’t explain how he can make a £100bn deficit vanish in three years, Tommy Cooper-style, just like that. You could accuse him of double-bluff: neither the IFS nor many economists outside the Tory omerta think he can do it – or that he should. It would cause government-terminating rebellion. Osborne has slipped his timetable by several years, but it has brought none of the disasters he warned of in Labour’s “less deep, less fast” plans. Markets happily buy British debt: losing that triple AAA credit rating had no consequences. He can pass his own fiscal responsibility nonsense law – but so what? All such declaratory laws are unworkable – including Labour’s child poverty and equality acts. This is no trap for Labour: Osborne has blithely ignored them all, as inequality rises and social mobility falls.
Now he plans to take from the poor to gift the rich. The Resolution Foundation shows how his raising of the personal tax allowance and higher rate thresholds will give £35 a year to the bottom tenth and £649 to the top, with most money going to the top half. Worse still, on The Andrew Marr Show Osborne said its £7bn cost would be seized from benefits.
Also look out for Osborne in an even more preposterous disguise – George, champion of the north. With hair flattened from hard-hat photo ops, he will promise investment that doesn’t begin to repair his harrowing of the north. David Blunkett, speaking for Sheffield, was spitting teeth last week at Osborne’s abolition of the regional development agency only to rebadge the remaining third as his “growth fund”. Worse, Osborne not only shifted council funding from poorer to richer areas, but Blunkett shows Osborne has taken EU funds specifically granted for poorer places away from Sheffield (cut by 61%) and Liverpool (cut by 57%) to give to better-off areas. Northern investment will be no more than a veneer over previous cuts. Nor will £15bn for road and rail – destined for the marginals – be new money.
Labour should be in clover. Watch Ed Balls gloat at every hideous debt and deficit reveal. But one day’s glee comes at a high cost, if mocking Osborne’s failure to cut more pretends Labour is on the same path. In fact, as Wren-Lewis spells out, there has rarely been a wider gap between the two parties: Labour has taken a £30bn leeway on current spending, more on capital borrowing to invest, but dare not say so. A typical example of Labour pretending to mimic the Tories is its own tax cut, reintroducing the 10p tax rate, which uses the same fiction that it’s for low earners, though most goes to the top. But here’s the key difference: it’s a very small gesture. The Tories will spend £5bn on tax cuts for the well off, Labour less than £1bn.
Labour is trapped, not by Osborne’s fantasy law which they should vote against, but by staying in the me-too rhetorical territory on the deficit, cuts and taxes. If they win, they have no intention of following Tory plans, but – beyond taxing the rich more – dare not say so. They have left it perilously late to chart the opposite course: to say that more borrowing would do little harm for now, that capital borrowing is good for a huge boost to housing, or to warn that austerity is the real danger to growth.
Labour, the Tories and the Lib Dems all agree that the public can’t take much honesty. The truth will kill those who try it, they fear. The Tories won’t admit to £48bn cuts, with which the Lib Dems mostly concur; Labour dare not trust voters with their more gentle plans, for fear of looking fiscally soft. And so the cycle of mistrust between people and politics ratchets up. One economist calls this the “candour deficit” – and in the end, that may be the deadliest political poison of all.

Monday, 1 December 2014

Falling oil prices offer the west a great chance to refashion itself. Let’s seize it


With the black stuff cheaper than it has been in years, Europe’s governments must invest in their infrastructure
Will Hutton
A fracking drill rig in America, which is now the world’s biggest oil producer. Photograph: Jim Lo Scalzo/ EPA/Corbis
For the past 18 months, the world’s biggest oil producer has been the US. Saudi Arabia, eat your heart out. Courtesy of the fracking revolution, the US will maintain this new standing for the foreseeable future, according to official projections.
The world as we’ve known it for the past 50 years is being stood on its head. Which provides cause for optimism. But an international landscape increasingly dominated by nationalist firebrands, conservative zealots and policy makers in thrall to austerity economics is always apt to waste opportunities.
One first good result of this oil price shift, however, was witnessed at Opec’s meeting in Vienna last week. The once feared cartel of oil-exporting countries, with Saudi Arabia at its core, a cartel that at one time commanded more than half of global production, is now a shadow of its former self. Opec’s members were unable to agree to cut production because most are strapped for cash and had no choice but to maintain levels.
With the US needing to buy less oil on international markets and China’s growth sinking to its lowest mark for 40 years, there is now, amazingly, the prospect of an oil glut. The oil price instantly nosedived to its lowest level for four years, around $70 a barrel – down more than a third in three months. On Friday, there was mayhem in the markets as investors reassessed the sober prospects for oil companies, and banks suddenly realised that they were exposed to a new round of write-offs to distressed energy companies and even to governments. But although particular companies may lose out, the first-round effect of this fall should provide good news. High oil prices depress economic activity. They suck money from consumer spending and redirect it to oil-exporting countries, which typically hoard it in elephantine foreign exchange reserves or unspent  bank deposits. It is a tax by the few on the many.
It should be no surprise, then, that in the past rising oil prices were associated with recessions and falling oil prices with booms. If the oil price carries on falling back towards $50 a barrel, and if history is any guide, the western economy should respond – to the good. Already, petrol prices are below 120p a litre, with supermarkets announcing another 2p off.
The European economy, in particular, dependent on oil imports, is an obvious and immediate potential beneficiary. Suddenly, the balance of economic advantage with Russia, no less dependent on oil and gas exports, will flip. Russia’s 2014 budget was based on an oil price of $100 a barrel. At $70 a barrel, the economy will contract by at least 3% in 2015, the country will run a balance of payments deficit and the government’s finances will spin out of control.
The doubts about Putin’s foreign policy within the Russian financial, political, security and business establishment will surely increase: his hold on power is becoming less secure. The chances of Russia sustaining a surrogate war in Ukraine have suddenly been reduced. All good news.
But western governments cannot hope that economic benefits will arrive automatically. These are new times. It has been obvious since the 2008 financial crisis that the economic landscape is wholly different. Digitisation is gnawing away at established companies’ business models and empowering new insurgents at an escalating pace. And this is happening in a world in which there is a massive overhang of private debt and where banks are still nursing damaged balance sheets.
Uncertainty and fear abound. Interest rates in Britain alone have been pegged at 0.5% for more than five years. But still business is reluctant to invest, not knowing what technologies to back or not knowing how much demand there will be for new products and services. We live in an era of stagnation, “secular stagnation”, as former US treasury secretary Larry Summers has described it.
So falling oil prices offer the world economy a great opportunity. But if it is not leapt upon purposefully by aggressively expansionary economic policy, secular stagnation might worsen. Because energy prices affect all goods and services, their fall could reinforce the trend for the general price level to fall further and so accelerate deflation and all the ills that go with it.
This is the moment for the EU and the European Central Bank to throw down the gauntlet to Germany. Last week, the European Commission launched a plan with at least an eye-catching top line – to trigger an additional ¤300bn spending on vital infrastructure across the continent. Except it was a phantom ¤300bn, with Germany insistent that it should involve no extra spending by the commission, nor by governments, nor extra borrowing by the European Investment Bank. Why? Because there was an alleged risk of inflation.
However, with oil prices falling by a third in a few months, the risk is non-existent. Rather, the problem is of the opposite order: not seizing the moment to launch a genuine economic stimulus of some scale.
The world needs to be no less purposeful about how Middle Eastern politics will now play out. US engagement in the region has been driven by the need to secure its oil supplies: as it becomes an oil exporter, that need is removed. The US has played its role as global policeman unevenly and often counterproductively. But at least it has played it, acting as some constraint on Israel, mindful that war will damage the flow of oil to the US.
An isolationist, disengaged US would be much more worrying. Into the vacuum would step a new array of nationalists, terrorists and religious fundamentalists. China will become the new great power in the Middle East, involving itself in a region with now declining oil revenues, intensifying rivalries and endemic religious enmities.
Ukip and the Tory Eurosceptic right complacently invite Britain to deal with the world as it once was, in an imagined utopian past. No need to counter stagnation either as a country or together with others; we British can act alone in a world where economic growth is certain. No need to marshal what remains of British power together with others to create international architecture that forces common responses to common problems. The world is safe and everybody is our potential trading partner. An oil price that falls a third in a few months is a reminder of just how perilous our new world is – and how vital it is to have friends.

Does Britain really want to be the country nobody would migrate to?


When net migration falls, David Cameron can take the credit: for making Britain poor, hostile and pessimistic
Fresson illustration
‘Migrants are less likely to be on benefits than non-migrants, not more likely.’ Illustration by Robert G Fresson
In 2011, I interviewed a Polish barista in a Starbucks: it wasn’t about what had brought him to London, nobody was obsessed with that then. It was about what life was like in Krakow. But those two things are, necessarily, related: he told me how much a kilo of sugar was, and how long you’d have to wait for a bus. He said some things were better, but overall, life was quite hard. In fact, I was writing about feminism in Europe, and was just interviewing him to be polite, while I waited for his female colleague: but it stayed with me for the immediacy of the image. It tells you everything you need to know, about why people choose to live in prosperous nations over poor ones: how much of your life are you going to spend waiting for things?
The immigrant of David Cameron’s imagination, who roams the continent looking for the taxpayers who will most generously fund his idleness, doesn’t exist. The strongest the Labour party has been, in its alarmingly mild response to a wave of sudden, strident xenophobia, is to point out that the numbers are wrong.
Migrants are less likely to be on benefits, not more likely. The benefits they do claim tend to be in-work benefits, made necessary by a bizarre new status quo in which it’s possible for huge numbers of people to work full time and still need a cash benefit to pay rent. But it would be nice to hear someone in mainstream politics say that benefit tourism doesn’t exist because … who does that? What scheming fainĂ©ant uproots himself, slogs across Europe to forge a new life in an unfamiliar land, just to be work-shy on somebody’s sofa? It doesn’t make sense on a human level. How does the bold, optimistic person who took the risk become the lazy, withdrawn person who’s on the make?
The political stage is peopled with characters who wouldn’t get past a script meeting in Emmerdale: the woman who has an abortion at 28 weeks because she’s suddenly not that into the idea; the perfectly well person who would rather fake debilitating depression than get a job; the homo economicus who goes to a food bank even though he can afford food, because it’s free. The standard opposition is nerdy: we crunch the numbers and say, that only applies in 0.7% of cases, or we can only find 0.01 examples. A better retort would be: this characterisation is too senseless and implausible to warrant our attention. Go back to the drawing board, and rejoin the debate when you have concocted a bogeyman who at least has his arms and legs in the correct place.
All of us understand perfectly what would make this country look attractive to other EU nationals. Bus waiting times are a handy reckoner of the infrastructure, but they are also a metaphor for economic vigour – is this a place where the hardworking can thrive? Or is everyone constantly thwarted by circumstances they can’t control, which slow them down? Does this place look as though it would welcome strangers and present them with opportunities, or is it closed, narrow-minded, suspicious and racist? Do people earn enough not to worry about the price of sugar?
In fact, whatever Nigel Farage tells you, whatever hot anxiety spews out of Migration Watch, the government is doing a brilliant job at making the UK a place where nobody would ever want to live. While London remains the most prosperous city in Europe,nine out of the 10 poorest places in northern Europe are all in the UK, according to Inequality Briefing. Wages are low, housing costs are high – two-thirds of the people who found jobs last year were earning less than a living wage. Incomes at the bottom have dropped 10% in real terms over the past decade. Sugar prices have stayed pretty constant, but I don’t imagine that’s much consolation.
Far more off-putting than the grinding poverty, though, is the prevailing attitude of hatred and paranoia. Ukip wants to refashion the children of migrants as “hidden migrants”, even though this includes one of their two MPs and the offspring of their leader. Elderly racists are being dragged out of the conservative closet and dusted down to give their answering views on what kind of migration we should welcome.
Norman Tebbitt has suggested a new test – who did your grandfather fight for in the second world war? This is the man who argued that organ donors ought to be able to dictate, in the event of their death, that their kidneys are only given to white people. “Of course,” he wrote in 2000, “the race relations industry will come out beating its racist drum if a white person says their body may only be used to help others of their ethnic origin.” The only people making the case for immigration are doing so on the basis of their tax receipts and how much business depends upon them, which is code for “depends upon low wages”. Who would go to a country that talks about foreigners like that? What does it say about how they see their own people, that their politicians can make a business case but can’t make a human case?
The only thing maintaining the flow of migrants is that nobody reads the Daily Mail until they arrive, and only then do they realise how coarse and brutal our politics have become, how pessimistic. Why is a country that claims to be booming behaving like a country in the grip of a depression? Are its leaders lying about the boom, or failing to distribute its fruits? A bit of both, in proportions we can analyse at leisure. Meanwhile, when net migration starts to fall, as I have no doubt it will, David Cameron will be right to take the credit. He couldn’t cap the moths, so he put out the flame.

How to take back the NHS, before it’s too late


The coalition’s 2012 health reform act was disastrous. It can be overturned – but time is running out
The NHS as celebrated in the 2012 Olympics opening ceremony
National treasure: the NHS as celebrated in the 2012 Olympics opening ceremony. Photograph: Clive Rose/Getty Images
The Health and Social Care Act 2012 – engineered by the former health secretary Andrew Lansley – was a massive blunder, and even senior Conservative ministers now admit the scale of its disastrous repercussions.
The main thrust of the Lansley project was to take the NHS down the American healthcare route, creating an external market and mandating the compulsory marketisation and commercialisation of services.
Michael Gove, now government chief whip, has claimed that no privatisation of the NHS has taken place but this is plainly wrong. A deplorable example was the sale in July 2013 of Plasma Resources UK which turns plasma into blood products, a particularly sensitive area in healthcare, to the US private equity company Bain and Company. Another example: when advertising for a new chair for NHS Blood and Transplant it was made clear that candidates should have privatisation experience.
Having now established a clear-cut precedent for further privatisation, there is every expectation among private contractors that when contract renewals come up they will be able to tender proposals for a transfer to private ownership. Some of these contracts are massive, such as the 10-year contract in Staffordshire for vital cancer services and end-of-life care worth £1.2bn.
These acts of privatisation will not, unfortunately, be the last if the Conservatives continue in government after the next general election. The companies competing for contracts may even hope to invoke the controversial investor state dispute settlement procedures being negotiated as part of the next big EU-US trade agreement, theTransatlantic Trade and Investment Partnership (TTIP), which was championed by the present NHS chief executive when in America, which could enable them to challenge the law in order to hold on to their contracts.
For 68 years, the NHS has provided the level of healthcare that our parliament has decided we can afford. The truth is that healthcare, whether public or private, in a very real sense is infinite: unlimited sums of private money can be – and in many countries are – poured into healthcare by those who can afford it. Money for the NHS is determined by public choice, and relative to what we choose to spend on education, housing, welfare, defence, all of which are legitimate demands on the public purse.
George Osborne is to announce another £2bn for the NHS on Wednesday, a welcome move, which should be used to create a new NHS investment fund with charitable status to centrally handle PFI contracts.
But healthcare, if publicly provided, inevitably has to be constrained. Traditionally, that rationing process within the NHS is flexible, professional and democratically accountable to parliament. British voters could have chosen a different system – they exist in many parts of the world – but no major political party has ever felt brave or foolish enough to put such a choice to them. Nor was it a choice put to the electorate in 2010 by either of the coalition parties.
Yet we know of David Cameron’s close involvement with Lansley before the election. Nicholas Timmins – in Never Again? The Story of the Health and Social Care Act 2012, a study for the Kings Fund – writes: “It is far from the case that the senior Conservatives – Cameron, Osborne and Letwin, for example – were ignorant about what Lansley was up to … He and Oliver Letwin helped write the green papers.” Guilt may be the explanation for Cameron’s current attempt to give the former health secretary a job running humanitarian affairs in the UN.
The far more expensive model based on the US is, after just two years, already having a deep and damaging impact on behaviour in the NHS and depressing standards of care. It is challenging the very nature of the vocational aspect of medicine for nurses, doctors and everyone who works in the NHS. It may be happening slowly, but the dynamics of this market model over the years will carry their own momentum.
Despite much-publicised scandals, such as that which enveloped the Mid Staffordshirehospital, the NHS remains extraordinarily popular among the public, and the only explanation I have is that people know that all demands for ever more expensive healthcare cannot be met. They understand that there have to be financial disciplines; that we cannot abolish all charging or market elements or private contractors in such a large concern.
People do believe, however, that an organisation that carries the brand name NHS has to practise under a fair trade description, and that means that the preferred provider should be the NHS. They like the NHS because they sense that its care choices are broadly fair and they prize its comprehensive cover. Most families have their own reasons to bless the NHS. They can complain, they can get angry with it and they are demanding, rightly, to be better able to influence its rationing process. But what they are rightly fearful of is that, once the service is driven by market principles, the rationing will cease to be fair and their care will become determined by profit.
Such a grave mistake as Lansley’s reform must be corrected. A reinstated NHS would be far better placed to provide a comprehensive, cost-effective healthcare service for England, which is similar, although not the same, in all parts of the UK. Repealing the 2012 act is not a realistic political option but its worst aspects can and must be excised, and the best opportunity to secure a commitment to doing that is before the 2015 election.
As individuals we can exercise our democratic rights over the NHS in ways that would have been impossible before the internet. Using www.nhsbill2015.org we are already opening up old-style political campaigning to new means of persuasion. This is not about money. No, what is required is a vast commitment, in terms of time taken to convey the complexities of the NHS, time taken to lobby MPs and parliamentary candidates, and the persistence not to let candidates escape behind generalised party political messages and manifestos devised by talking to focus groups. There is a new democratic way of exercising the power of the people and we saw its beginning during the Scottish referendum.
We must not forget that in September 2014 the Scottish independence referendum brought the UK perilously close to splitting apart. Those elements that we share, that help create a sense of common purpose, should become ever more precious as we try to unify our nation.
The end of the NHS as we have known and understood it in England will take place before 2020 if the 2012 legislation is not changed. The exact moment of its passing may not even be clear, because it will go with a whimper not a bang, to borrow from TS Eliot. The NHS is not a “religion”, as has often been claimed, nor is it the preserve of one political party, nor one country within our United Kingdom. It belongs to all of us and we let something of ourselves go if we don’t fight to save it.

Cricket: Helmets alone offer no guarantees

Michael Jeh in Cricinfo
At times like this, words too can hurt, however unintentionally. Phillip Hughes' accident is not a topic to be tackled lightly. The sensitivities of many need to be considered.
At junior cricket on the weekend, much of the talk among parents was to do with the topic of safety, head injuries, helmets and short-pitched bowling. Many of these parents have never played cricket to a high standard and fall prey to some of the careless and uninformed media hype surrounding this issue. A few of them even took me to task (with good intentions) for not forcing my sons to wear a helmet.
 A year ago, I wrote a mildly provocative piece, questioning the whole helmet-wearing mantra of junior cricket. In light of what has just happened in Sydney, it's topical to revisit that piece, but I trust it can be done respectfully and with due deference to the seriousness of the injury to Hughes. I would hope that respondents to this piece, regardless of which view they subscribe to, will respect the gravity of the situation and respond accordingly. This is a time to unite, to debate, to question but not to vilify.
At the time I wrote my piece, it never occurred to me that an accident of this nature would happen, despite the ever-present possibility, I suppose. That it has happened so rarely is itself a surprise. Given the number of close shaves and actual hits, it was almost inevitable that a projectile thudding into the head at 130kph-plus would eventually result in a catastrophic outcome. Despite recent events, I still stand by my opinion that helmets alone do not negate the threat of serious injury, as has now tragically been proven.
In the case of Hughes, it's not like it was a particularly vicious delivery anyway. If anything, he was beaten for lack of pace. He was through the shot a tad early, hence it clocked him just above the left ear. The helmet proved less than invincible, sadly. So the mere wearing of a helmet is no immunity.
Similarly a knee-jerk reaction against short-pitched bowling would be wrong too. The delivery was neither vicious nor intimidatory - Hughes was a good player of the pull shot, and was just unlucky that he was early on the shot. Accidents happen.
I wrote that piece last year with a focus on why I thought helmets for the very young might affect their balance and footwork, which was more about improving batsmanship than worrying about injury. Nevertheless, I broached the topic of young kids sometimes forgetting the art of ducking, weaving and avoiding the short ball because they have grown up learning to bat fearlessly, taking on the short ball with a bulletproof attitude. My sons (eight and 11) still don't wear helmets, but we spend a lot of time in the nets (and hallway) learning to keep their eyes on the ball and getting out of the way. They don't pull and hook instinctively, which may be a disadvantage in terms of run-scoring, but I can see the benefits in terms of the lightness of their footwork and a head that is not unbalanced by a helmet. At that age, no one is quick enough to bowl short stuff anyway. Full tosses and top edges represent the biggest threat. More wicketkeepers get hit in the mouth than batsmen.
My sons (eight and 11) still don't wear helmets but we spend a lot of time in the nets (and hallway) learning to keep their eyes on the ball and getting out of the way
Throughout my modest career, I rarely wore a helmet, including the time Shoaib Akhtar hurled thunderbolts at me, intent on knocking my block off. My reasoning was that I was uncomfortable wearing a helmet, it restricted my vision, and I was happy to back my instincts to keep swaying out of the way. He peppered me with bouncers, as he was entitled to, I kept ducking, and it didn't end in tears.
My theory was that I didn't take on the horizontal-bat shots against the short ball until I was well set, but even that theory is flawed. Hughes was 63 not out, going well, in good form, played the short ball well, wearing a helmet. So where are the guarantees? There are none!
My sons have chosen to follow in my footsteps (in junior ranks anyway) and we concentrate on footwork and keeping your eye on the ball. History may well judge me foolish but I still maintain that helmets alone are not enough protection for a batsman who is determined to camp on the front foot and take on anything short. It might work for geniuses like Sir Viv Richards but for the rest of us mere mortals, it is poor advice to tell young cricketers to don a helmet and then hook and pull indiscriminately. At a young age, I prefer to teach my sons to have balanced heads and good footwork. But it needs to be acknowledged again that I have yet to see anyone bowl a genuine bumper at that level. For now, it's just Dad pinging tennis balls at their head from short range.
This excellent piece, published on ABC Online explores this argument more eloquently. It speaks to the generation of modern batsman who hook and pull instinctively, sometimes off the front foot, only ducking as a last resort. So many good reasons for that. Faster scoring rates, more aggressive intent, heavier bats, T20 thinking (even in the longer formats), and a marked reluctance to keep allowing dot balls to sail through at head height to the keeper.
I only have my gut feeling to back me up on this but it seems to me that there a lot more instances of batsmen being sconed these days. Yes, there is more cricket played (and televised) but even allowing for that, I think more batsmen are being hit because they simply haven't learned the art of playing short-pitched bowling correctly. They have been taught to hook and pull, which is reflected in increased run-scoring opportunities, but that alone doesn't make it "correct".
No theories or statistics can comfort the Hughes family at a time like this. No fault should be laid at the feet of the batsman or bowler or curator. Take away the short ball (as some alarmists are advocating; do they really "get" cricket?) and you might as well play French cricket. The wearing of helmets is an individual choice and it is rare to see anyone eschewing that protection these days. I coach young lads who have been so conditioned to fear the ball that they wear helmets even when standing back to a fast bowler while keeping. Their techniques are shot to pieces, they are scared of the ball, they don't catch it under their eyes, but they feel safe. My fear is that so many of these kids will leave the game at around the age of 14, when these faulty techniques result in poor performances and a corresponding lack of love for the game.
The Phillip Hughes accident will inevitably trigger a wave of caution that will only exacerbate this tendency, I fear. Yet, the nature of sport, especially a sport like cricket, can never truly eliminate risk. As for my sons - and this is a personal choice, I stress, until they are old enough to face genuine short-pitched bowling - I will continue to teach them to duck and weave and watch the ball. Helmets alone offer no guarantees - even the very best players in the world cannot legislate against freak accidents. They don't come much better than Hughes, as a cricketer and a bloke.

Reasons why the Green Party should not be allowed on TV debates

Mark Steel in The Independent

If the Green Party isn’t allowed into the TV election debates, there should be a compromise, such as its MP, Caroline Lucas, being allowed to present an episode of Top Gear.
She could zip through the Lake District, saying: “But while it HANDLES like a DREAM, the new Alfa Romeo 2.3 litre XL Deluxe has just one problem. It’s an UNBELIEVABLY inefficient way to use energy compared to a reasonably priced re-nationalised rail network.”
Or the leader of the Green Party, Natalie Bennett, could be offered a different slot, such as commentating on an international rugby match. “The New Zealand pack is absolutely immense,” she could say, adding: “But even if it rucked across Sussex for two months it wouldn’t endanger natural resources as much as fracking.”
The party might have to try this, because the debates proposed don’t include the Greens at all, despite some polls showing it ahead of the Liberal Democrats. The BBC explained this was because, “We take into account electoral results from past elections”, in which case there must be an argument for including the Whigs, which remained high in the polls up to 1850.
Its leader could promise to reduce the deficit by colonising Africa, before becoming involved in a heated discussion about immigration with a Saxon warlord, who had been invited as he was part of a coalition government throughout much of the 10th century.
The Liberal Democrats have agreed the Green Party shouldn’t be allowed to take part, although it came ahead of the Lib Dems in the European elections and many recent polls. Maybe party members feel there should be a different set of rules for who’s invited, depending on the number of letters in a party’s name. So the debate on Channel 4 should only include the Liberal Democrats and the Reclassify the Brontosaurus as a Type of Diplodocus Party.

You can understand the Liberal Democrats feeling jittery about the TV election debates. Because in the last ones the party leader persuaded many people to vote for him, by confirming his pledge to abolish tuition fees. But in all the stress of a live debate, he got the words abolish and treble mixed up.
And he harangued the Conservatives for planning to put up VAT to 20 per cent, which the party angrily denied. But happily a few weeks later they’d sorted out this disagreement, by both putting it up to 20 per cent together. It’s a heart-warming tale of friendship overcoming silly squabbles that should be made into a romcom with Clegg played by Jennifer Aniston.
The problem now is no sane person can believe anything Nick Clegg promises, pledges or vows again. So there’s no point in him being there at all, as he’s like the bloke in the pub who tells ridiculous stories no one listens to. Dimbleby can ask whether he’d renew Trident, and he could reply: “I know Ronnie O’Sullivan. I always beat him at snooker, only the Government doesn’t let me in the tournaments ‘cos I’ve been shagging Michele Obama.”
Despite this, no one would suggest Nick Clegg shouldn’t be allowed in the TV debates. But it might be best if he was given a separate slot, like the act that comes on half way through the Super Bowl. He can dance to his latest apology, maybe in a provocative dress, and that way he doesn’t make such a fool of himself but the honour of the democratic process is preserved.  
Another reason given for excluding the Greens is that once you have five people in a debate, it becomes too unmanageable. And you can see how it might become difficult for the viewer to even remember who was who. When there are just four white men between 40 and 50 in suits and ties, it’s easy to tell everyone apart. But the Green Party leader is an Australian woman, and if you add her in, people watching at home would get her mixed up with Nigel Farage, or become confused and think they were watching an old episode of Neighbours.
There’s another reason why the Greens could spoil the evening. If the debates are just between the four leaders, there will be a soothing pattern to the discussion. For example, on immigration each leader in turn will say: “I deny we’ll let in more immigrants and that swe like immigrants and accuse all of you of liking immigrants, and you say you hate immigrants but we really hate immigrants and we’ll ban immigrants from eating biscuits until they’ve been here three years, and won’t let them into doctors’ surgeries unless they drink a tin of paint for the amusement of other patients.”
So if someone answers by suggesting immigration isn’t the main problem, it will ruin the whole event, like if someone turned up for a game of cards and insisted on playing tag-team wrestling instead.
You can understand why the three old parties are worried about letting in anyone from outside, as they seem honestly to believe they’re the main, proper, real parties and everyone else is still “others”. Their most persuasive argument against voting for anyone else is “they can’t win”, or “don’t all vote for them, they’re unelectable”.
The answer could be to allow the five leaders to take part in the debates, but allow each one to nominate a programme the others have to appear in, starting with David Cameron on Made in Chelsea, spending the whole show saying “Sorry, do I know you?” as he pretended not to know all his old mates