Monday, June 9, 2014

Bookstores in England; The NHS

In a flash of brilliance in packing, I stowed a scrunched up gym bag as a packing safety valve in my suitcase for our recent one month European trip.  Thus it is that we traveled back home with thirteen paperback books checked in baggage in said gym bag. In addition to the books that did in fact fit into the regular suitcases.

It's not that we don't have paperbacks in the US, but according to my high-reading wife, not all the books available in Europe can be bought at home. Which ones she is referring to I'm not sure, but I'm certain she is correct. And in fact, let me admit that three or four of the books are indeed mine. In Portugal I picked up a book translated from the German by a Swiss professor of philosophy in Berlin called “Night Train to Lisbon” – I'm enjoying it very much, despite its tepid review a few years ago in the NYT. And I just finished a book called “God Bless the NHS,” by Roger Taylor, a journalist, about the English National Health Service, that I bought three days ago at Blackwell's in Oxford where we were visiting son Allie. I saw that book and wanted it, then I saw another book, Emerald Planet, that Allie had read with his newly-formed book club in Oxford that meets in the pub where C. S. Lewis and others used to meet, so I had to buy that. But both were in the 2 for 3 sale, so I could get another one for free. I had two candidates, one on human evolution and the other called “How Much is Enough,” about money and the good life. Ann said, “Get them both!” and ran off to buy two more in the 2 for 3 category, because then it had become 2 for 1, irresistible. So we walked out with 6 – after she had already bought a couple.

What is it with English book stores? My brother-in-law Ralph can't believe that Berkeley – Berkeley, of all places – can't seem to support a big, interesting, independent bookstore like Blackwell's, and indeed Blackwell's seems even bigger than the Coop in Cambridge, Mass. Then we went to a big, great one in London (where we bought a couple more and I got the names of two more I intend to buy), and a great little neighborhood bookstore in the Primrose Hill community, where on my recommendation Emily bought “My Native Land” by Ari Shevit, which is a great book, I think. Why has the Amazon virus killed off the Berkeley hosts but not the English ones? Dunno. But it was great to wander around the English bookstores and contemplate the carrying capacity of my gym bag.

So, this book on the NHS is interesting. Health care organization is my specialty, and I should know about the NHS, and I do to some extent, but this book really helped me understand it. The author, Paul Taylor, is a journalist by training who used to work for Which?, the English equivalent of Consumer's Reports. Now he does outside evaluation of the English hospitals for a guide called Dr. Foster's, using criteria that the NHS itself doesn't use for self-evaluation. So this is a journalist who can be trusted to know his subject. (My sister Emily's former boyfriend, David Shortino, married Mary, then he died, Mary remarried and had a kid who worked intimately for Obama from the start. He says he will never believe anything he reads in the press. Depressing to hear this so many times again and again. OK, another digression in a blog post full of such.)

Some points about the NHS. One, it is a religious object. It was formed from socialism as an avatar of common purpose, and woe be to anyone who doesn't realize that. Criticize with caution; it is still revered. The NHS is the embodiment of non-aristocratic feeling (he doesn't say this, I do, but he does make the basic point.)

Two, it is a bureaucratic institution. The bureaucrats are unusually capable, but they are English bureaucrats. My son Allie has run into the English bureaucracy already and says he has experienced bureaucracies around the world, and this is the champion so far in silo-vision. Of course, he hasn't been to India. This bureaucracy doesn't like surprises, and it likes to have strong management control. Everyone in it looks up at the next in power, not down, and the one at the bottom is, of course, the patient. Thus, patient complaints can be discomfiting to those in power, so the best patient-complaint-takers bury their reports in the deepest drawers of the farthest reaches. The bureaucracy is blame-oriented, so avoiding blame is the watchword. Check all boxes, make sure all procedures are followed, evaluate only by preexisting and agreed upon procedures and criteria – above all, don't think. So when the Mid-Sheffordshire scandal of poor care erupted, and a capable legal politician made the inquiries, seeking the cause of poor end results, it all came as a shock to the bureaucracy, which as far as they were concerned, had a good opinion of the hospitals there, until they didn't. Bureaucratic criteria blinded the to the reality of killing patients, because all the check marks checked out. The inquirer was smart and independent, which was a novelty to those inquired of.

There are three basic questions the NHS confronts: how to get doctors involved in managing the NHS (Taylor thinks they shouldn't be, but he's wrong); how to set up centers of excellence (COE); and how to get the private world involved with the NHS operations.

His point about COE is quite interesting. A centralized system like the NHS can do COE very well, as opposed to our decentralized US system. But it does involve sometimes shutting down some services that are geographically closer to people, so it seems like a loss to them. Sometimes, it's clearly not – in London, centralizing the A&E (accidents and emergencies) services means maybe 3 or 4 minutes more to the heart attack center, but the care is so much better there it is clearly worth it. But what about rural areas? What the NHS doesn't do is measure the results after they make the changes. Is it really better for the locals, or not? No one knows. It is a centralized, elite country, and this is what they can do – just do it and let the peons complain. But since the NHS is a religious object, excessive criticism is condemned. Taylor says, measure it! (But they won't.) What a great point about organizational behavior and complex situations.

He says you can tell what is going to happen when a reform is proposed and the British Medical Association opposes it, as they do most any reform. It will pass, inevitably. And as the price for passing it, the politicians will grant the BMA favors. British doctors are thus among the best-paid in the world.

As to privatization, there is a lot of ideology involved. The profit motive is suspect in Britain, even if the non-NHS institutions involved are not-for-profit. Don't fiddle with our NHS! But in fact there is more privatization, and it's probably good that there is.

Another thing: the politics of the NHS are in one aspect the opposite of the environmental problems. In the environment, people understand and support energy change, but the politicians and those in power have been slow to the mark. For the NHS, it's the opposite: the elite see a great need for change, but the people say, leave it alone, it's OK. The elite says that costs will go out of control, and to keep giving the best to everyone, more efficiency and hard choices are needed. They're right. But they have to push the general populace.

Anyway, I'd have to say that Ann's right, I doubt I could get this book at home, and it would certainly not come to my attention. But there it was at Blackwell's, right on the 3 for 2 table. And all those other books, too. There is just no replacing a bookstore, and yet Berkeley has a few little ones here and there, a Barnes and Noble, but that's it. Progress happens, but not all is for the good. Allie told us that when he was in Bolivia he had a rental car and part of it got scraped. In the US they would have ordered a new part. There in Santa Cruz a 60 year old guy fashioned a tool to smooth and straighten, mixed the colors himself by eye, and by the end you couldn't tell it was an injured vehicle. What a genius! In the USA? A lost art. And no bookstores, either.

Budd Shenkin

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