Mongol

Genghis Khan is a fascinating character. I first really read his story in the book Genghis Khan by John Man. His impression on history is hard to underestimate. He united a nomadic people and led them to conquer half the world. Despite his empire fragmenting and declining after his death he left behind a Chinese dynasty - no small matter - and a legend for the Mongolian people that lasts to this day.

Thankfully, Mongol doesn't shy away from embracing the legend. It is always tempting for biopics like this to engage in a quixotic attempt to get at the 'real' hero behind the legend. With the passage of centuries having obscured the tracks a historian would need to follow, they can rarely find an adequate replacement for the myth.

In this film the Mongol god provides almost tangible support for Temudjin. Those moments where something truly incredible happens are genuinely ecstatic. If I describe them now I might spoil it but the film conveys a quiet awe that really sucked me in and made miracles seem really miraculous.

The star, a Japanese actor called Tadanobu Asano, handles the challenging role of Genghis Khan with authority, though Temudjin's stern silent act leaves him with only a limited range of visible emotions to play with. The supporting cast are excellent, particularly Honglei Sun, playing Temudjin's blood brother and later adversary, Jamukha. The love story, showing Temudjin's marriage to Borte, has to share the film with Temudjin's rise to become Genghis Khan so never has the space to develop and carry the film as the makers, perhaps, intended it to but it functions well enough to make Temudjin more than just a shouting conqueror.

The photography is spectacular. Behind every scene the steppe is invariably stretching into the distance looking gorgeous and lending a powerful sense of the epic to proceedings. That is fortunate because, except in a limited number of action set pieces, the pace is quite slow. Those action scenes have an incredible kinetic kick but they are too rare for this to really be an action junkie's movie - if you go looking to just cheer on grand battles there won't be enough there.

Instead, sit back and enjoy a luxurious recreation of an incredible legend.

Unity on copayment

Unity has written one of his trademark ‘if you can make it to the end’ posts on the subject of copayment for healthcare. He basically argues that patients choosing to copay place a significant additional burden on the NHS in return for an uncertain and temporary stay of execution and that Doctors for Reform are a biased group whose agendas the Times should have paid more attention to.

I think he is deeply mistaken at nearly every stage. I’ll try to keep my response concise.

Are patients who wish to copay demanding additional resources from the NHS?

“So that’s the deal that Mills and Hirst are demanding here. They want the NHS to put up £6,000 per month in treatments, which they would have [to] have longside the Avastin for it to have any effect, to enable them to pay out a further £4,000 a month for drug that may or may not extend their lives by a bit, although by how much (on average) no one actually knows for sure although the best guess seems to be a few months, as this 2006 article from the New York Times indicates.”

The logic here is stretched. Look at it the other way. If they have Avastin Mills and Hirst will have a better chance of increasing the number of months they will remain alive if the NHS offers them its standard treatments. That means that they demand continuing treatment instead of accepting palliative care and death. This is an additional demand on the NHS.

If someone has a less severe form of cancer then treatment is more likely to be successful. At a certain cut-off point they are either worth treating or they are not worth treating. One patient could demand more treatment because he is more healthy. Non-smokers, on average, may demand more treatment because they are more likely to demand the expensive care associated with long-term conditions like Alzheimers.

What Mills and Hirst have done is, by buying outside drugs, moved themselves into a category where treatments, made generally available within the NHS, offer them the prospect of additional months of life. If the decision is made on clinical grounds alone then clearly using those treatments universally available, free of charge, in the NHS could be seen to be in their interest. It is an option that the NHS, if all concerns for the full implications of copayment – which I’ll discuss later – were left aside, would offer them.

Mills, Hirst and the others who wish to copay aren’t demanding special treatment. They’re just asking for the same heuristic to be applied to them as to everyone else.

Does copayment for drugs like Avastin constitute an irrational choice?

Unity makes a few arguments on this subject. First, he notes that Avastin does not ‘cure’ cancer:

“Neither of these drugs is a ‘cure’ for cancer, indeed neither one of them will even put the cancers they target into remission. Their sole and only purpose is to delay the spread of secondary cancers that will, inevitably, lead to the death of the patient no matter what.”

This isn’t particularly significant. A great many treatments do not prevent but merely delay death. Above the age of seventy-five mortality is not considered ‘amenable to healthcare’, for example. I don’t mean to be trite but, ultimately, everyone dies. All medical science is a stall that can, at best, delay someone’s death by a reasonable amount of time and ideally make it that another condition administers the coup de grace.

Unity then discusses various evidence that makes clear that the results of these drugs are highly uncertain. That is probably true. That uncertainty clearly makes the expected increase in longevity that the drugs deliver somewhat less valuable. However, it seems that those patients choosing to put substantial money of their own into copayment see an uncertain chance of living a few extra months as preferable to a near certainty of imminent death.

Debates over the quality of evidence used to support the approval of Cetuximab aren’t particularly relevant to this debate. Companies should be held to account for the veracity of their claims about any product through the courts, the threat of damage to their reputation and through regulation. The point of the specific rule against copayment is not to protect people from dodgy sales pitches.

So, is it rational to spend thousands of pounds to gain some uncertain extension to your life, probably just a few months, or are drug companies exploiting the vulnerable and afraid? A practice we would certainly not want to facilitate.

To answer that question I’m going to need to briefly tell the story of a man I know. I’ll leave all the details I can out, just in case. His wife had been ill for some time but suddenly what had been a chronic condition took a turn for the worse. There was no equivalent of Avastin on which he might spend his money so he did something else. He stopped working and spent a huge amount of time at her beside. This decision undoubtedly cost him tens of thousands of pounds and he wasn’t a rich man. He had to sell a small business that might have provided for his retirement. It can’t have given him with the equivalent of more than a month or so of additional time with his wife. His decision was, in every way, similar to that facing someone who can buy, or not, buy Avastin and he chose to bear an expense of tens of thousands of pounds to see more of his wife. Is that decision irrational?

Colette Mills has a family – she wanted to pay for some extra time with them. Of course, it isn’t going to be a ‘lot’ of time in the grand scheme of things and it is necessarily uncertain but that doesn’t make the decision wrong. It doesn’t seem in any way unreasonable for her to expect that we treat her like any other patient during that time and offer what treatment can give her additional months of life and allow her to make the most of the chance she has bought herself.

The ad hominems

I’m going to focus on one of the doctors that Unity discusses. Professor Karol Sikora. I know Karol as he wrote the foreword to my study Wasting Lives: A statistical analysis of NHS performance in a European context since 1981 (PDF). He struck me as a remarkably decent and deeply intelligent man, for what it’s worth

He is the Medical Director of CancerPartnersUK, former Chief of the World Health Organisation Cancer programme and a member of the steering group of Doctors for Reform. When the Times reported his opinion on the case of Colette Mills they described him as a member of the steering committee for Doctors for Reform. Unity believes they have failed to uphold proper journalistic standards by not mentioning his job at CancerPartnersUK.

Clearly the Times faced a decision over which aspect of Karol’s biography to highlight. They described him as a member of the steering group for Doctors for Reform. That hints at the fact that he has political beliefs; namely that the NHS is in serious need of reform. They could have described him as a Medical Director of CancerPartnersUK which would hint at the fact that he has a financial interest in treating people for cancer. They evidently judged that the political background was more relevant and informative. Are they wrong? I don’t think there is a definitive answer to that question. They don’t have the space the BMJ do and, therefore, can’t put a full bio in. They haven’t even chosen the most positive citation: former head of the World Health Organisation Cancer programme.

Analysis

In the end, the government themselves don’t argue that they need to refuse permission to those who wish to copay on financial grounds. They also don’t make the paternalistic (I’m not using that as a term of abuse) argument that Unity makes: that the Government need to prevent people spending their money on doubtful stalls to inevitable mortality.

Copayment is refused on the grounds it would create a ‘two-tier’ health service. If some people can pay and do better then those treated under the NHS will no longer face equal health prospects. That is the stated and, I believe, genuine reason why copayment is not allowed. I don’t think the government’s decision is right or moral and share DK’s anger.

In the end, people who are better off have all sorts of advantages within the NHS. Civitas have shown that they tend to get seen more by doctors as they are better able to play the system. Equally, there are many ways to copay that are not covered by the rules, as Doctors for Reform showed in an earlier report (PDF). The Government are not defending a genuine principle.

Beyond that, I don’t think that avoiding a ‘two-tier’ system should really be an objective. The objective should, instead, be to provide the best quality of healthcare we can up and down the income scale. The health of the poor needs particular attention but keeping the rich down isn’t the way to help them. My broader view on how we improve the health service is described in Wasting Lives.

In the name of as thin a principle as a one-tier health service, it seems illiberal to the point of brutality to tell people who want to invest extra money in medicines - that we cannot afford to provide them - that we will cut off their treatment if they buy extra treatment on the side.

A new Ministry of Defence

It seems increasingly clear that we are really letting down our Armed Forces. There are good reasons to think that it takes a questionable sense of priorities to have spending on the armed forces going down as a share of public spending and GDP while we are engaged in a major armed conflict in Afghanistan and have smaller, but still significant, engagements in Iraq and other arenas. There is a reasonable case that we are simply trying to do too much with too little.

Still, to a certain extent that puts the cart before the horse. There is no sign that extra money would be well spent. Wasting new money would be both offensive in itself as the taxpayers who ultimately foot the bill are hard-pressed and would undermine the long-term case for Britain maintaining a serious military. New embarassing wastes of resources would give the British public the false impression that, for some reason, we are simply incapable for running a large and effective military.

Hardly a day seems to go by without some new and shocking story coming to light. Some new travesty too dire to be some molehill turned into a mountain by the media. Today, Mike Denham blogged on the Chinooks that have yet to see action after thirteen years and around £500 million spent. The ongoing failure of the Nimrod has cost lives and continues to hoover up money. Accomodation is alarmingly poor. The Defence of the Realm blog is full of examples of lethal procurement failures, in particular the disastrous failure to find an adequate replacement for inadequate Land Rovers. Vital equipment, particularly helicopters, is being cannibalised with only one third of the Army's vital airlift capability functional. Shortages of body armour have definitely proved lethal.

Some of this is down to a lack of resources but that lack of resources isn't purely a matter of failing to place proper importance on supporting the military. There is clearly huge waste going on, particularly in procurement. At the same time as the military falls to pieces for lack of money the Ministry of Defence has been enjoying a spectacularly expensive refurbishment with spectacularly expensive office chairs.

There isn't a simple way of fixing problems fundamentally caused by political leaders who do not understand the military. With the numbers in the services having fallen so low it is unlikely, in the continuing absence of a major war, that ex-service personnel will form a substantial portion of our political elite again. The need for civilian control of the military will necessarily mean that soldiers suffer the suspect command of politicians who don't really know what they're doing. However, the vital institution that should give them support in such debates is the Ministry of Defence. Otherwise, the military's voice is too dispersed, spread around the country and the rest of the world at its various stations. Headquarters in London should be able to do their bit to make the military's case to the politicians.

Tragically, it appears that the contemporary Ministry of Defence is doing quite the opposite. An excellent article in the first issue of Standpoint magazine, by an anonymous military officer working within the Ministry sets out how bad things have gotten:

"I am often asked why the MOD makes so many strange decisions and seems to care so little about the welfare of its personnel. People are surprised to read about expensive computer systems that fail to pay service members their proper salaries — or pay them late. Some are shocked by the apparent dumping of severely wounded personnel from Afghanistan and Iraq into civilian hospital wards, remote from their regiments and families, or the massive contracts for systems that are delivered late and don’t work properly, or the strange failure to publicise genuine successes and minor victories achieved “against the odds” in Afghanistan and Iraq.

None of these scandals — or many others less well known — would surprise anyone who knows the MOD and what it has become."

The problem is clear. The Ministry of Defence's staff aren't really a part of the military. They're just ordinary Civil Servants who would rather be in the Department for Children, Schools and Families. Your average Civil Servant can't really understand the military, let alone really appreciate its needs. Again, Standpoint's anonymous author makes the case eloquently:

"Most people still believe that the MOD is essentially a military organisation. It is not. It is an organisation dominated numerically, culturally and structurally by civil servants and consultants, many of whom are unsympathetic to its underlying purpose or even hostile to the military and its ethos. You just have to spend a few days at the MOD before you realise that the culture there is not just non-military, but anti-military."

I'm not sure the normal starting points for reforming a public service - accountability, contestability and autonomy - will work here. I don't think that the strength of hierarchy in the world's militaries is an accident or irrational. It seems quite plausible that when you want people to get into a gunfight with others out to kill them a very visible hand is an important source of confidence and trust.

The vital step would seem to be, to me, making sure that the Ministry of Defence is returned to its proper role as a military organisation. There are two ways we might do that:

1. Set a fixed ratio for military officers to civilian personnel and dictate that the balance is swung back to the military in the Ministry of Defence. The policy would look like a kind of hawk's cap and trade with an enforced shift in the ratio that the Department could get to however it wanted.
2. Change the career structure for all staff at the Ministry of Defence. Stop using generalist recruits and end the practice of maintaining the Ministry of Defence organisation as one more department of the Civil Service. If you do need to recruit civilians then use a separate recruiting process. By a process of attrition, we can move towards a Ministry of Defence that is a military organisation as staff leave for other departments or retirement.

Once the staff at the Ministry and the Army, Navy and Air Force are all really part of one team the headquarters might become rather better at supporting the troops at the sharp end. Military procurement will start to become a military matter rather than a new industrial policy. Even if the politicians are hopeless at least the military will have a powerful ally in Westminster again.

Private companies to take over hospitals

"Poor managers are to be sacked without receiving large payouts and replaced by staff from profit-making companies who would be paid with public money.

The NHS will retain ownership of hospital buildings and services but the private firm will "take over" the day to day running of the hospital.

Ministers believe the proposals will drive up standards within the health service."

This is good news and provides genuine accountability for hospital managers delivering poor quality services. Ironically, the problem with this new initiative was well summed up by Alan Johnson when he set out the scheme:

"[He] admitted that too often, poor performance had been dealt with only after a serious problem had emerged, as happened with Britain's biggest superbug scandal at Maidstone."

That's the issue. It isn't good enough if the private sector can only come in once things have fallen to pieces so badly that it becomes a live scandal. Thousands of patients will have been subjected to sub-standard treatment before the 'story' breaks. The private sector will be asked to take over the most demoralised of hospitals and turn them around, which is a lot harder than building an effective organisation from the start.

Instead, private companies - and other organisations such as charities and co-operatives - should be offered a level playing field to compete with the current hospitals. That pressure will either drive improvement in current hospitals or lead to them, slowly, being replaced. Competition can improve standards before serious problems emerge.

Cross-posted from the TaxPayers' Alliance blog.

Wikio rankings

Sinclair's Musings is ranked an astonishing 23rd in the politics category of the Wikio rankings, 82nd in the overall rankings, for June. The JeunesEuropeensFrance may have helped.

I haven't had as much time to devote to Sinclair's Musings as I used to before two other blogs and the small matter of a more than full-time job intervened but I still want to maintain a space that is my own for posts not right for CentreRight or the TPA blog. The Wikio ranking is a nice vote of confidence. Thanks.

A new laptop

I'm blogging on a new laptop. The old one was a huge and incredibly heavy Toshiba Qosmio. It was great when I first got it and needed a desktop replacement for gaming and didn't want to move the thing (it actually hurt me if I carried it too long). And, when it still worked. Now, the old Toshiba's optical drive has been broken for a year, it has started overheating and dying on me and the power cable has to be jiggled about just right, and I want a laptop that is actually portable.

So huzzah for the HP DV2799 special edition. Performance seems good so far, though I haven't tried anything terribly demanding (beyond running Vista). Features are rock solid with everything from fingerprint scanning to a little camera and microphone at the top and an HDMI out. The design avoids the plain, minimalist box or 'boy racer chic' dichotomy that usually limits computer design. The computer came recommended and it appears TrustedReviews have steered me right again. So far, I like it.

In the news today...

...there are two stories in the news today. First, the Home Secretary is an alien out to destroy Britain:

And, the Home Secretary announces a new plan for therapy for extremists:

"Controversially, the new plan makes clear that people who fall under the influence of violent organisations will not automatically face prosecution."

No connection at all.

Just kidding! Before I get accussed of something, clearly there is a space for those who have gotten somewhat involved in terrorism to receive some treatment other than the swift, sharp deployment of the criminal justice system.

1. Huge chunks of supposedly anti-extremism spending is actually spent either trying to promote the benefits of Islam to non-Muslims or funding Muslim community activities. A classic example is the response by Whitemoor's authorities to discovering that their prison is run by Islamist gangs. The Pathfinder fund (PDF) for preventing violent extremism is another example. Nothing wrong with promoting the benefits of Islam or funding Muslim community groups but both the first is a dubious use of taxpayers' money and it would be better if community groups (I think there's a basketball programme in there somewhere) funded were ones where different communities interacted. The authorities current attempts to combat extremism the touchy-feely way are a bit suspect and that raises questions about whether this therapy will be run effectively.

2. Violent extremists respond (PDF) to political signals. Jacqui Smith hardly has something of the night about her. To send the proper signal that terrorists should, on no account, mess us about we need her to behave like a border line psychotic. There is every reason for the British Home Secretary's first, second and third thoughts when the word 'terrorist' comes up to involve 'getting 'em'. That, instead, we regard terrorism, along with sadness, as yet another pathology we want to 'treat' is worrying. By all means offer those with only a fleeting encounter with Islamist extremism treatment instead of prison but it doesn't need to be a grand plan that sends all the wrong signals.

Sinclair Road

My full name is Matthew John Hayes Sinclair. The Hayes is not without meaning, it is the surname of my great, great grandfather.

Before he died my paternal grandfather wrote a book setting down his life story. My uncle had it printed and very generously gave all of my grandfather's, rather numerous, descendants a copy.

It contains the following:

"I now believe that John Samuel Sinclair never existed and was simply a fictitious person of that surname concocted by my grandmother at the time she decided to adopt the name of Sinclair, and only necessary in order to complete my father's birth certificate. In my own lifetime no one in the family has ever mentioned meeting or knowing a John Samuel Sinclair and no photograph or picture of him has ever been found. I can submit two further facts that, although circumstantial, clearly indicate that the fictitious figure of a John Samuel Sinclair was merely a subterfuge to hide the real name of my paternal grandfather.

Why did my paternal grandmother decide upon the use of the name of 'Sinclair'? A clue lies in a Burial Grant issues in consideration of a fee of Five Pounds and Five Shillings to Mrs Annie Sinclair granting exclusive rights of burial in a grave No: 4669 at Hanwell Cemetery in the county of Middlesex. This document is dated November 19th 1902; only some four years after the birth of my father and it records my grandmother Anne Darby's address at that time as being 67, Bolingbroke Road, West Kensington, London.

One has only to look at a street map of the Kensington area of London to see that Bolingbroke Road is only a stone's throw from 'Sinclair Gardens' and 'Sinclair Road'. It is easy to imagine that if that area of the city held some affection for Anne Darby she could well have decided to adopt the name as her own and passed it on to her son and his consequential heirs by falsifying the birth certificate."

He goes on to discuss how his records show that a John Samuel Hayes is likely the real father and the new name was probably designed to cover up the child's illegitimacy.

I've known about this for a while. I'm the only one of my generation to carry Hayes and the link to events more than a century ago is fascinating. It took until a few weeks ago, though, for me to have the idea of trying to find the two roads (Sinclair Gardens isn't actually a park) my family are named for.

Today myself and a friend made the trek over to West Kensington and found it:


It is an unremarkable but quite pleasant road near Kensington Olympia station most obviously notable for the cast iron shelters over some of the mini-balconies. I now have a fierce ambition to eventually own one of those houses! The only down side might be that if I ordered something delivered to Matthew Sinclair, 76 Sinclair Road it would sound like a hoax.

Further wandering yielded this. Who would have thought it. The Parish Church of St. Matthew, Sinclair Road. What are the odds!

Apologies for the break from normal service. I'm afraid a near dead laptop has made blogging a bit difficult. I'll return to politics soon enough.