Spending My Children's Health Care Inheritance to Gamble with Ladbrokes

I have reproduced in what follows, with most of the typographical errors corrected, my answers to a consultation survey that started here: 

I felt a lot better after doing it than I did before. I think "Something off my chest" is the medical term. Being a medical service dunce I felt uninhibited by any direct knowledge of day-to-day work in a busy medical practice so I guess I am on a par with the Tory Policy Wonks who dreamt up the whole farrago. It's all about my putative "Personal Health Budget" - the magic key to my kingdom of sunlit uplands in flower-decked NHS Wards and discount heart tablets.

Questions 1 and 2 wondered who I was and what my "organisation" was. So the questions and answers start at Number 3

  

3 Do you agree that these are the right criteria to be used to determine eligibility for a personal health budget? Should they be prescribed in regulations?

I simply disagree with the concept, so any questions about how to implement a fanciful pseudo-market discipline on health care is a non-question. All means of attempting to do so are based on a flawed model and a gross over-estimate of the ability of most people (including me) to decide on complex resource allocations in fair or morally congruent ways.

At heart, this suggestion seems to be a slightly mad attempt to make people behave as if they were the rational actors assumed by primitive economic models.

That model, having failed, should simply be discarded in favour of practices and experiments that reflect what we already know about how people and communities create their own lives.

4 Do you agree with our proposal to separate out clauses in respect of children and adults who lack capacity? Are there any other capacity related issues you would like to see addressed?

Lacking capacity is universal. Within the range of incompetence and partial understanding, the degree and consequences of such incapacity will be, to some degree, structured by patterns of power and access. A bit like "school choice", the choice is almost entirely hypothetical. In real situations some will have wide knowledge and genuine alternatives - in most others the simple reality will be that individuals have little idea of what the choices are or of what choices might be hidden or unavailable in the real context of the consultation they are engaged in.

Choosing a car is one thing - a mistake can be written off. "Choosing" a health plan is closer to being irreversible - most patients are exceptionally vulnerable to hints or suggestions that might steer them towards more readily available treatments that suit the expert they are talking to.

Again, solving a problem in a badly conceived programme is none of my business. Those whose ideologies point to this kind of silliness need to have their own strategies for making them less bad and not look for endorsement through having "widely consulted".

5 Do you agree that personal health budgets should not be allowed to be spent on the services listed above? Are there any other services which should be excluded?

The whole idea has created this dilemma. Don't go through with it and this question becomes irrelevant. Implicitly the perpetrators have acknowledged that once a complex new system is in place some kinds of people will exploit the possibilities to get even more of what they already have. This is a real inverse of the mythical "welfare dependency". Asking the public to suggest things you have forgotten is a bit rich.

6 Do you agree that the list of information, support and advice that patients are entitled to ask their CCG or the Board for should be supplemented with the items above?

The absurdity of these questions gets richer as the questionnaire goes on. Given the obvious fascination the perpetrators have with "free markets" it is ironic that they are struggling at this point with the obvious non-existence of a key aspect of the free market model - the perfect knowledge of buyer and seller. I foresee careers in health advocacy in which (for £250 pa) an individual can have all their care plan options evaluated by a qualified expert (whose medical training has been diverted from treating patients to discussing abstract costs and benefits of broadly equivalent treatments.

I am starting to wonder if this whole consultation isn't an elaborate joke.

7 Do you agree that there should be the option of paying one-off direct payments for healthcare into an individual's personal bank account?

It sounds like a great idea for maximising misuse of funds while rationing the bureaucracy.

8 Do you agree that local authorities should be included in the scope of the regulations for direct payments for healthcare?

The massive unasked question here is "Am I happy with the way that Local Authorities have been given huge responsibilities for social care while resources provided to them have been reduced for ideological reasons?"

So my answer is no.

9 What are your views on friends or family members being paid for managing complex or large healthcare packages? How should this be defined, for example should it be linked to the size of the direct payment?

It would be simpler for parents of a needy child to get a part-time job with the local authority care department that was adequately funded to manage all support services. Again, the market fallacy is the problem. Distribution of scarce resources, in some circumstances (and in the non-real models of classical economics) can be achieved by letting each participant make decisions in their own interests. Such a model, when it extended by compulsion into real life, fails to solve the problem of distribution while adding to the inefficiency of health providers who now have complex rules and recording to cover for the lack of professional autonomy and trust that made things less bad in the past.

The madness of this question should have alerted the scheme's perpetrators to the folly of what they are doing.

10 Do you agree that these regulations should remain the same? If not, what would you like to see changed?

I have now lost the will to read. Please be assured that having got this far I will do my best. Please note that I now fear for the sanity of any health professional I might need to rely on for advice in the future. When you say "enough to cover all the services that have been agreed in their care plan" I assume you mean "the fixed amount that is insufficient, but which can't be changed given the restrictions we are faced with"

11 Are there other areas that you would wish to see in regulations? If so, what are they?

I have no wish to see any regulations at all. I would rather like it if those who were really expert and acknowledged in their fields made wise consensual decisions that could be evaluated and adjusted in due course. I have a strong sense of highly articulate recent postgraduate scholars inventing stuff as they go along with precious little insight or experience in how organisations actually and normally don't work very well.

12 Could the proposals have any perceived or potential impact on equality including people sharing protected characteristics under the Equality Act 2010?

A lifetime in education and research suggests to me that anything that comes from career politicians backed by Health Corporation lobbyists is going to increase the social, .economic and welfare gaps between rich and poor. Only on a different planet could the change go the other way. 

******

What Might Not Work: A Response to Ben Goldacre's "Building Evidence Into Education"

The randomised control trial (RCT) is a kind of field experiment that can be used in real-life situations to test the relative effectiveness of specific treatments, procedures or programmes. RCTs have been widely used (especially in medicine) since the late 1940s. Galashiels-born Archie Cochrane was a key figure in establishing their acceptance and development in the medical field after 1970 and they are still regularly used and seen as the most demanding test of efficacy of any treatment (especially when combined with a double blind in which even the practitioner doesn't know which treatment has been offered to each randomly assigned subject).

In an article last  month, urging wider adoption of the randomised control trial in UK education, Ben Goldacre was re-opening a fairly old debate. His enthusiastic approach to making RCTs relevant to education in 2013 emphasises the question "What works?" The question echoes the title of the USA's "What Works Clearing House" set up for the educational field in 2002 following a policy push by George W. Bush. Bush had been persuaded to make RCTs the dominant research instrument for developing new approaches to teaching and his legacy has persisted under the umbrella of the Institute of Educational Sciences (http://ies.ed.gov) and the George W. Bush Institute (http://www.bushcenter.org/george-w-bush-institute)

Goldacre wants today's teachers and researchers to adopt the same question in the UK and to use RCTs to test and confirm their answers. By taking part in RCTs themselves and by referring to evidence derived from them teachers will, he believes, increase the learning of their pupils and students and simultaneously increase their own professional standing and independence. In becoming more evidence-based, he suggests, teachers will become more like doctors in terms of scientific authority and teaching competence.

His recent and non-technical briefing "Building Evidence Into Education" (http://media.education.gov.uk/assets/files/ben goldacre paper.pdf) is based on a longer document "Test, Learn, Adapt: Developing Public Policy with Randomised Controlled Trials" co-written with the Behavioural Insights Team in the Cabinet Office and David Torgeson Director of the University of York Trials Unit. (https://www.gov.uk/government/publications/test-learn-adapt-developing-public-policy-with-randomised-controlled-trials) Most of what follows is a response aimed at readers of Goldacre's shorter paper. I would like to offer something that, at least, puts up a cautionary note to anyone convinced by the shorter Goldacre paper that RCTs could bring about the results that he hopes for:

"we all expect doctors to be able to make informed decisions about which treatment is best, using the best currently available evidence. I think teachers could one day be in the same position" Goldacre (2013) p7

I would start by agreeing that "What works?" is a simple and appealing question. It is "common sense" and the more immediate or urgent the answer, the more focused such a question can be. A fire in the kitchen, a raging fever, a stopped heart, a violently out-of-control 11 year old in a classroom, a blank inability to understand percentages… all these situations call for acceptable solutions that are tried, tested, defensible and well established as effective within the resource limits of the context.

In the very often contentious context of teaching, however, it is harder to conceptualise the research equivalent of a medical cure or of protection from immediate physical danger when we think about "what works?" Pupils are not in school because of their illness, deficiency or vulnerability. Educational realities and educational goals are very much more diverse and open-ended and some important educational purposes (especially the long term purposes that most teachers, parents and politicians would want to consider) are impervious to the testing possible in RCTs as they are generally conducted.

Some of these purposes are acknowledged, some are not, but many are so deeply held that the conflicts between them can generate anger and conflict. Some goals are long term (I want my child to go to University), some short (I want the chance to take my child abroad when flights are affordable, so missing a week's lessons is acceptable). Some focus on personal development and intrinsic reward, others focus on long-term career and extrinsic reward. An educational practice that "works" for one set of people or purposes can be ruination for the ambitions or immediate needs of another set. We hope that without offering a long and still not-comprehensive string of real examples, it should be clear that asking "What works" immediately opens the floodgates to more disruptive questions like "Works for who?" "Works to whose disadvantage?" and "works to what ends?" To insist that "it's obvious" is simply to short-circuit the debate and insist on your own values or to accept the apparent majority values.

Asking "what works" is especially a problem in the face of education's character as a long-term (some say lifetime) progression. The research literature on science teaching in higher education, for example, provides plenty of indications that even successful (It Worked!) A Level students embark on their undergraduate studies with what seem like perverse conceptions of basic processes. What worked for getting those high grades at A Level has become an impediment to understanding the greater complexities at University. Similarly, it is a commonplace to note that some outstandingly creative or successful adults would have been or were actually recorded as failures in school learning.

These two points – the disputed nature of educational goals and the long and not well-understood development of individuals through education and into adulthood reduce the apparent value of RCTs in education considerably, especially when considered in relation to their costs. These points do not rule RCTs out altogether. No intelligently undertaken research can be a waste of time (even if its use of resources might be profligate) but promoting them as a special gold standard that will draw other methodologies and the status of teaching along with them is, in my view, perverse.

None of what I have said so far would challenge the valuable idea of research-informed teaching. A lot of practical classroom research goes on already. (I conducted some while I was a practising teacher). Teacher training, despite efforts of the Department for Education under a succession of Secretaries of State, has kept productive links between teachers and researchers over many years. Teachers undertake research degrees and researchers involve themselves in the design and evaluation of teaching innovation. A succession of teacher-research programmes have come and gone, always dependent on meagre funding and lack of Government commitment. To the great shame of all, most of the results of this research has been kept away from teachers with most academic libraries and databases closed to them. The British Education Index (www.bei.ac.uk) – a huge catalogue of all the educational research in the British Isles over more than 50 years has never been funded to allow free access to the very profession that needs it most. In Goldacre's paper a reader will find no reference to "What Already Exists?" (but which could soon be lost), nor to recommendations from the past to make more digital content accessible to teachers and other participants in the professional world of education (see, for two examples of initiatives left to wither through lack of political will: (http://www.leeds.ac.uk/educol/documents/00003809.htm and http://www.tlrp.org/dspace/handle/123456789/1620 ). I wonder if Goldacre is aware of the huge efforts that have already been made to invest in educational endeavour that is "evidence-based" or "research-informed" or whatever else you want to call it. His paper seems to give the impression that there is a blank canvas just waiting to be filled with enlightened quantitative scientific research.

The awkward truth is that serious research is not wholly welcome in Government. It does tend to yield unwelcome knowledge about the costs and the demands of education that would really benefit children in general and it does disclose some of the less welcome news about the inseparably awkward social and political consequences of national educational practices and processes.

In general terms I agree with Goldacre that teachers, researchers, and teacher researchers have common cause in resisting ideological control from central government. The best possible research would be a teacher's best source of professional development and a strong stimulus for personal improvement as a teacher. However, RCTs need to be understood as just one way of accumulating knowledge about teaching, not as a gold standard.

A more balanced review of RCT practice was presented at the 2010 Conference of the Society for Research on Educational Effectiveness (SREE) by Savitha Moorthy, Raquel Sanchez, and Fannie Tseng. (pdf download: http://www.eric.ed.gov/ERICWebPortal/contentdelivery/servlet/ERICServlet?accno=ED513344)The SREE is broadly sympathetic to the cause-and-effect tradition of educational research espoused by Goldacre. The caveats included in this paper provide a useful balance to the "myths" described by Goldacre. From my perspective they still don’t address the more fundamental questions that supporters of the RCT approach have not answered.

The promotion of RCTs by a Minister like Michael Gove would  yield a narrowing stultification of research and a futile search for simplistic recipe knowledge. There is no certainty in teaching, just a gradual and intelligent gathering of wisdom using as many valid approaches as possible.

References

Goldacre, Ben (2013) Building Evidence Into Education London Department for Education Website 19pp (http://media.education.gov.uk/assets/files/ben goldacre paper.pdf)

Haynes, Laura; Service, Owain; Goldacre, Ben; Torgerson, David (2012) Test, Learn, Adapt: Developing Public Policy with Randomised Controlled Trials Cabinet Office London 35pp (https://www.gov.uk/government/publications/test-learn-adapt-developing-public-policy-with-randomised-controlled-trials)

Considerate Cycling 0

Well the grass looked greener on the other side. So I have gone to see if it really is.  I wrote about "Shared Space" because it has been on my mind for the last month or so and there has been a sudden outbreak of interest in the topic. See:

http://samsaundersbristol.wordpress.com/2012/01/06/shared-space/ (my new blog, based on recent experience)


http://waronthemotorist.wordpress.com/2012/01/06/can-road-loveliness-be-found-in-shared-space/ (Joe Dunkley's excellent critical review)

Considerate Cycling 8

"The undersigned call on the Women's Institute to reject Resolution 6 calling for compulsory helmet laws and to focus instead on creating conditions in which all members of society will feel safe and comfortable riding a bicycle" link

At the time of writing, this statement has been signed by 750 people. It is addressed to The National Federation of Women's Institutes (WI) by the Cycling Embassy of Great Britain. The WI have a shortlist of 6 suggestions, one of which could form the basis of a WI national campaign if its local federations and annual conference agrees. Each shortlisted proposal is to be discussed locally and nationally. A summary of the WI's procedure is here: http://www.thewi.org.uk/standard.aspx?id=26942

A bit of publicity for a cherished cause is no bad thing. But the signatories to the Cycling Embassy petition seem to me to be doing something a bit silly. For one thing, the WI is a voluntary organisation who have their own democratic procedures. They decide things for themselves. They have provided a briefing for members that is even-handed about the pros and cons of each proposal, with evidence that they have made efforts to find out about the views of interested parties (including the CTC) and to let members know about these.

At this stage, the idea that another voluntary organisation can petition a body that has not yet made a democratic decision is one that I don't understand. A petition, in normal use, is a word that refers to a demand or request made by a group of signatories to a recognised authority who have the power to accede to the demand or request. In this case the WI is not a recognised authority. The WI might have influence, but it is not a statutory body and in any case, they haven't finished deciding what to do. Sending them a petition is just a gimmick – a publicity attracting device.

The Cycling Embassy of Great Britain has just got itself into a muddle here. They and those who are signing its petition are making themselves look a bit daft. (sadly, adding an ounce or two to the public perception of cyclists as a bit eccentric). A voluntary association with a specific interest has every right to campaign on whatever it wants to campaign on - calling on another voluntary association to stop a process that would lead to a campaign the Cycling Embassy doesn't like reveals a fairly worrying lack of understanding of democratic processes.

To put it more simply the Cycling Embassy of Great Britain, if it wants to, should campaign against compulsory helmets for cyclists. The Cycling Embassy of Great Britain, if it wants to, can publish opinions about the WI and one of the WI's membership-generated proposals (even though it has not yet been accepted). But in my opinion The Cycling Embassy of Great Britain should not put itself or its supporters in the non-democratic position of calling on a voluntary association not to mount a campaign. They are meddling in someone else's affairs.

Sorry, I have to say The Cycling Embassy of Great Britain and the 750 "petitioners" have put themselves in a wrong place.

I do, incidentally, agree that compulsory helmet legislation would be a bad idea. As far as I understand it there is good evidence that segregated provision improves safety and that there is no equivalent evidence that compulsion to wear helmets changes the likelihood of casualties. Please let me know if I'm wrong on either of those points. They are, however, nothing to do with what I am saying about the folly of this petition.

Considerate Cycling 7

I had a momentary flash of insight on Monday. It followed a relatively successful navigation of a route along Bristol's Malago Greenway, as suggested in TravelBristol's "Cycling. 10 Short Leisure Routes Around Bristol, Between 2 & 16 Miles". I was surprised and pleased to find that direction signs were plentiful and that most of them could be seen and read as I cycled along. It wasn't very scenic and a lot of the journey was on ordinary streets or low-grade shared footpaths but I did get to see some interesting bits of Bristol that I would otherwise have missed.

At the end, near a B&Q superstore, a shared cycle and pedestrian path set off towards new housing south of Hengrove Way. Its start was hidden by parked vehicles:

The continuation of the path beyond those miscreants was also serving as a car park: 

But that wasn't surprising. Cars, lorries and taxis regularly park on cycle paths in Bristol. It was only as I set off homewards and noticed, again, how tricky some of the barriers, crossings and shared paths were that the flash of insight came. It's so obvious it's hardly worth mentioning.

The fact is that cycling provision in English cities is designed for expert adult cyclists. The route I had been following used signposts to help me weave a way through busy streets, on, alongside and across some very busy roads. It took me through barriers that needed deft bike handling and it demanded careful attention to lots of conflicts with pedestrians, emerging driveways and motor vehicle traffic.

The booklet I was using lists the Malago Green Way route as Level 2 ("slightly more experienced cyclists"). Level 1 is for "all users including inexperienced or beginner cyclists" and there are two such routes included. Both of these include sections that few parents would be happy for children under 12 to use, and both would present problems for genuinely novice adults. I don't know if there are standards for judging such things, but as an ex-teacher and a father of five, that's my opinion.

Perhaps what the authors of the guide really mean is that these routes would be suitable for beginners with a more experienced guide who had scouted the routes in advance. That would make sense.

In the meantime, cycling to school remains rare - especially for primary pupils. Cycling for fun means taking children to off-road sites. The roads and highways are for confident and experienced adult cyclists. It's not surprising that a lot of children and less confident cyclists just use footpaths - without any awareness of traffic conventions or regulations.

The irony is that expert and confident cyclists have already learned to cope without cycle lanes, ASLs, shared pathways and toucan crossings. What I observe is that a lot of them ignore the specialised facilities and simply use "desire lines" that go from their A to their B with an optimum combination of efficiency and safety.

The courageous Council of the future will build cycle-only routes that enable primary school children to cycle to school without any contact with cars or lorries and without parental supervision. That's when the revolution will have taken place.