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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