By Diana Holbourn
Becky and Other Students Discuss World Problems, How Some Have Been Unintentionally Made Worse, and How Some Have Been Diminished
Book three of the online Becky Bexley series. Chapter 1.
This series accompanies the books about what Becky does at university and afterwards, which you can find out more about on my author website. (The online series is in draft form.)
Then one said, "Getting back to the subject of unforeseen consequences of doing things in an attempt to improve things though, I've heard that one way government policies that they thought would improve things have made them worse in some ways is where they've introduced targets for improvement in organisations like the health service, such as by declaring that waiting lists have to be reduced by a certain amount they decided on, so people wouldn't have to wait so long for treatment. The targets seem fair enough in themselves, and are meant to motivate organisations to work harder to make things better; but then it seems that if organisations don't meet the targets, instead of finding out just what the problems are that are stopping them, and working with them to try to improve things, the government have fined the organisations heavily for not meeting them.
"Well, actually I'm not sure how heavy the fines really are; and there might be more to things than that, and maybe they do give organisations some help; or maybe they've relaxed their standards a bit in cases where there are good reasons why the targets they set are especially hard to reach - I don't know; but considering what's gone wrong, it seems that if they have done that, they haven't done it nearly enough. I'll tell you something about what's gone wrong in a minute.
"One issue is that some of the problems that are making it hard for organisations to improve things are beyond their control; so with the best will in the world, they're not going to be able to improve things themselves as much as they could if they got help from the government that might not in reality be on offer.
"Not that that's necessarily always the government's fault. I heard that one problem when it comes to improving the NHS is trying to predict what needs are going to be the greatest in years to come, so as to know where to put the most money.
"I mean, it's partly obvious, because as people get older, they need more healthcare because all kinds of things will be going wrong with their bodies that take a lot of money to fix or improve; but I heard that new drugs can come along that reduce the need for certain kinds of care a fair bit, like statins that lower the risk of heart attacks, so not as much money ends up being needed to treat people who've had heart attacks in hospital as it was thought there would need to be, so a government a decade earlier might have earmarked a lot more of the NHS budget to treat heart attack victims than turned out to be needed; but at the same time, for example, new technologies are making it more likely that premature babies who are born earlier and earlier will survive, but they'll need a whole lot of care, so that part of the NHS needs more money than it used to, and more money than it might be getting, because government planners didn't foresee that it was going to need so much.
"So there probably needs to be a review every year or so to determine if the money given to the NHS is being spent on the things that need it most. I don't know how often they do review that kind of thing.
"I think there ought to be teams of experienced doctors and nurses whose job it is to advise the government on what would work best, and which of their policy ideas are likely to work well and which ones are likely to have some bad consequences; you know, I mean people who actually work in the sectors they're making new laws about should be consulted about their opinions of whether the laws would work well or have problems, since they're the ones most likely to know best. I don't know how much the government does consult people like that; but if they did it more, maybe they wouldn't have introduced policies that have ended up causing problems. Not that they're necessarily the government's fault. I'm not sure. But I'll tell you what I mean:
"One problem is that I've heard it's quite common for hospital managers to cheat to reach government targets. For instance, the government brought in a target that every patient who went to an accident and emergency department had to be treated and discharged from the hospital or sent to a ward or a different hospital that could treat them better within four hours. Something did need to be changed, because some patients were waiting ages and ages while their conditions got worse before. I read that it's believed the targets saved lives by motivating hospital managers to find ways to get people seen more quickly. But because the government introduced fines for not reaching the targets, it seems a lot of managers found ways to cheat the system so as to avoid the fines.
"You'd have thought it would have been best to use fines as a last resort, such as if some managers in hospital trusts were proved to be incompetent after a while or not willing to put effort in to solve the problems or something, while somehow still being allowed to keep their jobs so nothing improved. I would have thought it would have been better if at first when hospitals didn't meet their targets, outside experts would be sent in to investigate why it was happening and advise the managements on improvements they could make, or else advise the government that their targets had been found to be unrealistic. Mind you, I think some managers did get some outside help when they were having trouble meeting them. So I'm not sure why there was still a problem.
"But there must have still been one, because for whatever reasons, it seems a lot of hospital managers started cheating the system. So you'd get things happening like patients being moved to wards by managers before four hours were up, even though doctors didn't think they were in a stable enough condition to be moved, and would like to have continued doing tests on them and assessing their conditions where they were, or parts of A&E departments being roped off and renamed wards, so the figures would show that people told to wait there had been moved to wards within the four-hour waiting period, or people being put on hospital trolleys and waiting in corridors, or waiting outside for ages in ambulances before being brought in, although that's partly to do with there not being enough staff to treat them or beds available to put them in sometimes.
"Some doctors and nurses have complained that the time-pressure put on them to meet the four-hour deadline means they have to try to deal with each patient more quickly, and speed makes mistakes more likely to happen.
"And it's not as if the problems could be easily solved so managers were just shirking their duties by not fixing them, since they were being caused by things like bed and staff shortages, and massive rises in the number of people going to A&E departments in winter because of winter illnesses, and because of the rising numbers of old people needing help when their health deteriorated. So part of the problem was that the government needed to spend more money on the system.
"Still, a lot of progress was made, and things did get a lot better than they had been, for reasons such as that new staff were recruited specifically to work in A&E departments.
"But despite all that, it was still difficult to reach the targets the government had set. It seems they didn't do studies to find out how practical they were before they set them. So it does seem unreasonable of them to have threatened to find hospital trusts for not meeting them instead of sending experts in to see if they could find solutions. Mind you, I don't know enough about this stuff to know if a fair bit of that did go on, and how long hospital managers had to improve things before they were fined, and how much whether they told the government they had compelling reasons for not reaching the targets was taken into account by them, or how many managers actually tried pleading their case with them.
"Other targets were introduced into the health service too, to try to improve things in other areas, because there were really serious problems with people having to wait ages and ages for operations, - sometimes well over a year, - with their health deteriorating more and more the longer they had to wait, or them dying while they were waiting. So the government set targets that required that by law all patients needed to be treated within less than eighteen weeks.
"Some things have been done since then that are really improving things, such as new hospital facilities being set up, so most people don't have to wait anywhere near as long as some people had to before.
"But the target meant that to avoid being penalised for missing it, some hospital managers manipulated the system to try to make it look as if they were achieving it, in ways that meant some patients suffered, like by cancelling some of the operations of people who'd been waiting ages but were due to have their operations soon, so the time slots that had been reserved for them could be used for operations they could offer to people who hadn't been waiting as long as eighteen weeks, so those people, at least, could get treated within the target time, so the hospitals' statistics on how many people had been treated within the target time would at least not look as bad as they would have done if everyone with serious problems where their quality of life was suffering a lot had been treated in turn, which would have meant that pretty much everyone would be getting treated later than the end of the eighteen-week target time, because there weren't enough surgeons and operating theatres available to treat people who'd been waiting ages at the same time as people who hadn't been.
"I read that some hospital secretaries have even been asked to lie to patients by hospital managers in the cause of helping them cheat to reach their targets. It came about because the government ordered that 90 % of patients should be treated within 18 weeks. Something did need to be done to cut waiting lists, since in the early 1990s, people could even wait over two years for an operation, it seems! But it seems that hospitals haven't been given enough help to cut waiting lists right down. So a lot of hospital managers decided that the only way they could reach the targets was to cheat. That's unless the government would have offered them help if they'd asked, but they were too worried about looking incompetent or being fined to tell the government the truth, so they tried to hide the problems instead.
"One way they've done it is by telling their secretaries who phone people up about their operations to help them fiddle the figures. The managers got around the fact that people are supposed to be offered dates for the operations they need within 18 weeks by getting the secretaries to phone everyone who'd been waiting longer than 18 weeks and telling them there were no operating theatres available for their operations to be carried out so they'd have to be postponed. People weren't given a date for when their operations would be done. Managers told their secretaries to rebook their appointments at the start of the next financial year so their cases wouldn't be in the figures for the year that was currently being measured. And they told them to fill operating theatre space with bookings for minor operations that could be done quickly, for people who were just about to breach the eighteen week waiting time limit, so as to prevent the figures for people whose waiting times were in breach of it from going up as much as they would have done otherwise.
"And the secretaries were told to give other people who were nearing the eighteen week limit a date for their operation that was at very short notice, in the hope they'd say no, so they could be marked down as having refused their operations and knocked off the list of patients waiting for them. I read about one secretary who was asked to phone a mother of three young children and tell her her operation could be booked in for Christmas Eve, knowing she'd almost certainly decline the offer for the sake of being able to make Christmas a nice time for her children. The secretary was told to lie to other patients to give them the impression their operations would have to be cancelled because there was no space in the operating theatres, or give them dates for their operations that were at very short notice, in the hope they'd refuse them.
"She complained to her managers about what she was being asked to do, but she was told they had to do it because all the other hospitals were doing the same thing, so their figures would look worse than those of other hospitals if they didn't, and that it was the only way they could meet their targets. She said there was a consultant who complained, saying people should have their operations prioritised according to how badly in need they were, instead of according to whether it would be easy to fit them in within the target time; but he was bullied into keeping quiet."
One of the students said, "That's bad! I wonder if one reason why a lot of people try alternative medicine is because they're so desperate for treatment they're finding it hard to get on the NHS that they're willing to try anything. It'll be a shame if a lot of people end up wasting money on things that don't work."
Some of the students got up to get something to eat and drink, feeling in need of a short break from the heavy conversation. When they sat down, it turned light-hearted for a while.
One of the group said, "There was a man on a forum I used to post on who used to always be rude to people; and I used to tease him for a laugh when he said something rude to me, making up little stories about things I accused him of doing, or finding funny news stories on the Internet about people doing daft things and pretending they were about him. Everyone knew I was only doing it for a laugh, and the stories weren't really true or about him. I'll call him Old Grump, but that wasn't his real username.
"One day after he said something rude to me, I said for a laugh, 'I've found out a bit more about Old Grump recently. I've discovered he's decided to try his hand at being a con-man. Here are a couple of scams he organised over Christmas. This is the way he advertised them:
"'Homeopathic chocolates! For that special feel-good taste!
"'The special homeopathic box of chocolates contains all the usual things - strawberry creams, orange creams, blackcurrant creams, fudge, Turkish delight and so on, but you can't taste the flavours, because, being special feel-good homeopathic chocolates, they contain especially diluted amounts of the flavourings for maximum effect, amid a mixture of something flavourless.
"'So the strawberry cream won't taste the least bit like strawberry; but it'll make the loved one to whom you give this gift feel better than the best strawberry cream chocolate they've ever had in their life did! The fudge chocolate won't taste the least bit like fudge; but your loved one will feel such a sense of enjoyment after eating it that they'll think it was the best fudge chocolate they ever tasted. The plain chocolate chocolate won't contain any detectable chocolate at all; but your loved one will think it's better than the plainest plain chocolate they ever tasted! The nut chocolate won't taste anything like nuts; but they'll be infused with a sense of flavourless nutty goodness that will make them think it was the best nut chocolate they ever had. And so on.
"'Feel-Good Good for You Chocolates. Give your relatives that special gift this Christmas.'
"And I said, 'And here's another Christmas scam he perpetrated, just the way he advertised it:
"'Here's a special Christmas bargain for people who usually don't get around to doing their shopping till the last minute so there isn't much in the shops when they go, and then they have to explain to people that they couldn't get anything that good, because the shops had run out of a lot of things. That need never happen to you again! This special new Christmas bargain will spare you from blame from now on, and save you a whole lot of money in the process, plus saving you the time and hassle of walking around crowded shops. This is ideal for you if you don't want to spend much money, because the things don't cost much at all.
"'For a totally affordable price, plus postage and packing, you can buy: ... Hand cream, shower gel, bubble bath, perfume and after-shave bottles ... all empty. Plus empty soap packets. Empty chocolate boxes. And other such things. You can buy these for a fabulous mere half price of what full bottles and packets of these would be in the shops! The idea is that you can apologise to your loved ones when they find that the bottles, packets and boxes are empty, explaining that you bought them online, in good time this year, so there was a wide selection for you to choose from so you managed to get just what you thought they'd like this time; but they didn't arrive till the last minute, so the ingredients had all evaporated by the time you got them.'
"Then I joked on the forum, 'I don't know if anyone fell for the idea that their relatives might fall for that excuse and bought into his scam.'"
The students chuckled.
Then the conversation turned serious once more, as the one who'd been talking about government performance targets for the health service said, "There's more about NHS targets I could tell you about: As well as what I was saying before about hospitals, targets for GPs were introduced, but there were things wrong with those too. I read a book by one GP who said he found a few problems with them:
"One was that the government tried to solve a problem where a lot of people who'd had strokes weren't being given enough treatment to lower their risk of having more, such as by being prescribed cholesterol-lowering drugs and high blood pressure-reducing medication; and they weren't referred to specialists as often as they should have been. I don't know why. You normally hear about people being put on drugs to lower cholesterol when doctors aren't really sure if they're at risk of having heart attacks and other serious health problems they could protect against or not, just in case.
"But anyway, it seems there was once a time when not enough people were given them. So the government made it so GPs and GP practices would get money for treating people who'd had strokes to try to stop them having more, the more money the more people they treated. Maybe that did lead to a lot more people being treated, I'm not sure. But this doctor said that although the vast majority of doctors wouldn't do anything dishonest, the temptation was there to diagnose people as having had suspected strokes when they knew they hadn't really, but instead they might have just fallen over because they were old and frail and their balance wasn't very good or something, and their doctor might have been called in just to check them over; but they might have written in their records that they'd had a suspected stroke so they were going to treat them for that, just so they could get more money.
"the doctor who complained about that said he'd been working at this GP practice for a while, and no one had had a stroke for months and months there; and one day he got called in to check on an old lady who often fell over because her balance wasn't very good, and the practice manager said he ought to diagnose her as having had a stroke they were going to treat, so they'd get some money - although she might have been joking; he doesn't say. It reads as if she was being serious.
"On the surface, it sounds like a good idea to give doctors incentives to treat more patients. But it might have been better to do an investigation into the root causes of why more stroke victims weren't being given as much medical care as they should have got, and to have asked doctors themselves what they thought would improve things, because otherwise, what if this system of incentives was created, but things didn't improve as much as they could have done, because the things that were causing the problems were still there, and the doctors couldn't change them? I mean, kind of bribing them to do better comes across - rightly or wrongly - as if the government thought the only reason they weren't doing better was because they couldn't be bothered or something. It must be more complicated than that, I would have thought. Still, it seems things have improved, from what that doctor says, so maybe the targets did do a lot of good.
"But that thing about investigating the root causes of the problem could at least have been true for some of the other things that doctor mentioned, where they were given targets to improve things:
"He said some problems with trying to solve a problem by giving doctors more money if they prevent more problems like heart disease is that in poor areas of the country, more patients than in other areas don't turn up for their appointments, or don't take the medication they're prescribed. So their doctors have no control over whether they get the right treatment or not. And it's one reason why working in wealthier areas can seem more attractive to a lot of GPs - because they're more likely to make their targets and get the money for reaching them, because more people in those areas go to their appointments and take their medication, and haven't got so many health problems in the first place, so they're less likely to make their doctors look bad by having heart attacks and strokes that could possibly have been avoided if they'd been on medication to reduce their risk of having them.
"Well, another reason working in deprived areas isn't so attractive is because there can be a lot more people with severe problems which are actually really hard to treat there than there are in better-off areas, such as people with major depression and drug addiction, so it can be a lot more stressful for doctors to work there, especially because a lot of people have quite a few problems like that at once.
"It seems that patients in deprived areas are a lot more likely to have grown up in abusive homes where they were mistreated or saw abuse going on, partly for reasons such as that poor women with children, or women who don't have much education so they'll find it harder to find a job because of that, can hesitate to leave abusive relationships because they worry they won't have enough money to cope on their own, and that men with anti-social behaviour habits are less likely to be able to hold down decent jobs or want jobs in the first place, so they're more likely to end up living in deprived areas because they can't afford to live in better ones, so that's where they're most likely to raise their families. And then their children will be influenced by their attitudes and the attitudes of people around them to things like how acceptable it is to be aggressive, so that increases their chances of living in the same areas and behaving the same when they grow up.
"But growing up in abusive homes or high-crime neighbourhoods can led to some people developing severe problems with depression and anxiety, and medicating themselves a lot for them with comfort food and cigarettes and drugs and alcohol, or some combination of those, so they can end up with health problems like heart disease and lung problems a lot sooner than people who've had better lives can end up with them, and they're more likely to be really obese, with the problems that can cause or make worse, like type 2 diabetes and back pain and arthritis.
"And things can be made worse by things like living in bad housing, where, for instance, a lot of people might be chronically sleep-deprived because the walls are so thin they can hear noisy neighbours a lot, and it stops them sleeping, and that causes them health problems after a while, or where there are mice running around the place doing droppings everywhere that risk people picking up infections from them, but their landlords take ages to get the pest controllers in, and they can't afford to do it themselves. And all kinds of things like that can happen.
"So GPs might be under pressure to get obesity rates among their patients down by giving people advice about their health, but they're mostly being caused by things that are beyond their control; they can give patients advice about healthy eating and exercise, but their patients know it already; it's just that giving up all their comfort food and alcohol will make their lives feel less worth living, so they don't want to.
"And one reason why more people in deprived areas don't take all their medication is because a lot of them have got so many problems that they're on a lot of medication, and it causes some bad side effects that they like to have a break from, or they find it hard to remember to take everything they're supposed to.
"And quite a lot of people in deprived areas don't even turn up for their appointments. I'm not sure why; it might be to do with more of them living difficult lives where things happen unexpectedly that stop them, like ex-boyfriends turning up and arguing with them, or them being unexpectedly offered a job for the day that they don't feel as if they can refuse because they need the money, or other things like that.
"But I read that a lot of the reason why appointments get missed is that the people making them have memory problems and they forget they made them, especially if they had to wait for them for a few weeks and their symptoms got better in the meantime.
"When people miss appointments, it's unfair on people who tried to book appointments but couldn't because there were none left, only for some people who did book them to not turn up, so they could have had those if the other people hadn't booked them. I read that over fifteen million appointments with GPs or nurses or therapists and other people who work for the NHS are missed a year!
"Some people have suggested fining people for missing appointments to put them off doing it, or not allowing them to make any more if they don't turn up for a certain number. It seems like a good idea at first; but some GPs don't like the idea, since it might put some patients who really need them off making them in the first place, such as people with severe anxiety problems who sometimes don't turn up because they feel too scared to leave their houses, whether they have a good reason to be scared or it's just their anxiety causing the problem, or they're scared of what the GP might tell them about what's wrong with them, or about whether they'll criticise them for being really overweight or having drug problems and so on, or they're scared of what they might do, such as giving them blood tests that they worry might be painful. And they might be too scared to even make appointments in the first place if they worry they'll be punished if they don't turn up for them.
"One thing that's really needed is for the government to put more money into good mental health services so people can get good therapy for their problems much more quickly than they do now - I heard that some people who want therapy on the NHS can wait well over a year for it!
"I don't know how right he is, but this doctor actually said he thinks the government isn't putting more money into improving those services because people with severe mental health problems are less likely to vote, and government policies are geared to what people who are more likely to vote for them want, like people who are normally quite fit and healthy but might just need health services sometimes, like people who are working who could do with having their GP surgeries open at weekends as well as during the week.
"He said it's the same with frail elderly people who might be losing their thinking abilities because of dementia, and they can't do much for themselves any more, and take up hospital beds for ages even though there's not much that can be done to cure them, and they'd be better off being cared for at home or in nursing homes, but not enough services are available to care for all their needs well, although they might be if they were more likely to be able to get up and vote. I don't know how true that is, and there's probably more to it than that. But there might be something in it.
"But as for people not turning up for GP appointments they've made, I read about one GP practice that tried something that didn't cost much, but that reduced missed appointments by about a fifth, and even about a third in some months! Instead of putting notices up in GP surgeries telling people it wasn't fair to miss appointments and that it cost the NHS a whole lot of money because doctors end up being paid for wasted time, one thing they did was using psychology to encourage people to come in for them: It seems that people are more likely to do things if they think lots of other people are doing them, so they'll feel awkward about not doing them themselves, and they want to fit in and be like most people; so notices were put up in GP surgeries every month that said what percentage of people in the last month turned up for their appointments or cancelled them in good time so other patients could be offered them - the vast majority of them did, - and they thanked them for doing it.
"And another thing they did was to try to make it less likely that people would just forget to come in for them, by training the receptionists to ask patients who booked appointments to write down when they were, as a memory aid for them. And they told the receptionists to start using techniques to make it more likely that patients would make a commitment to cancelling appointments if they had to, like by doing things such as asking them if they thought they would, and waiting for an answer, so the patients would think about it and realise it would be a good thing to do. And they would ask them to repeat back to them the time of their appointments, so it would stick in their minds more.
"And it worked quite well! It was the idea of a patient who was in a group of patients that was set up for patients to come up with ideas for things that might help improve things in their doctors' surgeries.
"And they're also setting online services up so people can cancel appointments at any time of the day or night they like, so they don't even have to phone up and wait to speak to a receptionist, say if they're embarrassed to do that because they're worried they'll be asked the reason why they're cancelling, and it's something embarrassing like that they're in bed with a raging hangover after they drank too much the night before. Or sometimes it might be just because they think they might have to wait ages before they get through on the phone, especially if they had to when they actually made the appointment, and they don't fancy having to spend all that time again waiting to speak to someone.
"Another thing that's been introduced is a service where people can have text messages sent to their mobile phones to remind them of their appointments if they think they'll need them. So hopefully that'll help.
"But all that just shows you that something might sound like a bright idea that'll improve things for people, but it's best to get advice from people who really know what they're talking about to make sure it really is a good one. That probably goes for a lot of things in life really, for everyone. I mean, there are probably things that would seem to anyone like good logical common-sense solutions, but they realise if they think about them some more, or find out about the experiences of people who've tried them, that they might create problems of their own sometimes.
"I don't know who governments consult before they make their policies; but maybe they ought to spend more time getting the opinions of people who've got experience of working in the jobs their policies will affect, who can tell them if they can think of possible problems there might be with them, and what better solutions there might be. I don't know how much of that kind of thing they do do. Maybe some do more than others.
"I think performance targets can be good in themselves, since they give people improvement goals to try to achieve; but it seems to me that when it comes to things like the health service and the police, people who actually have experience of working in them and running them should be consulted about what it's realistic to expect people to be able to achieve, and what can be done to help them reach the targets; and if the targets end up not being met, the people who set the targets should analyse why, and what can be done to improve things. I don't know how much of that already goes on; but you'd have thought that if a lot of people in organisations feel the need to cheat to try to reach the targets, it can't be happening enough.
"This doctor did say he thought paying doctors for doing what the government wanted worked well sometimes. He said there used to be a culture where salespeople from drug companies would often come round and give doctors gifts and take them out for nice meals, and tell them about the drugs their particular company was selling; and doctors would often prescribe those in preference to others, even if the others were cheaper and just as good. I think that still does go on in some countries, and some of that still goes on here. But the government in this country stopped it happening so much, because they made a law that said any gifts salespeople gave doctors had to be worth under five pounds, or something like that; and they said salespeople were only allowed to treat doctors to a meal if they were educating them about new drugs at the same time as the meal was going on.
"And another thing they did was set up a system where doctors were rewarded by getting more money if they prescribed a certain number of cheaper versions of some drugs, that were just as good as the ones drug companies were promoting, but would save the NHS money. And it turned out that it did save it a lot, in spite of the payments doctors were being paid to prescribe the cheaper varieties of drug.
"I mean, sometimes there are much cheaper versions of drugs with just the same ingredients as the more expensive varieties, but they're cheaper at least partly because they're copies of drugs other companies sold more expensively at first, because they wanted to get the costs back of all the research they'd put into developing them, which would include them trying out making other versions of the drugs before then that turned out not to work as well, so they were given up on.
"Drug companies are allowed to have patents on their drugs for a certain number of years after they first bring them out, which means they're the only ones allowed to sell them for that length of time, to make sure they get back the costs of making them. Other companies aren't allowed to make copies and sell them more cheaply than the drug companies that made them can during that time, since it would mean the companies that did might not be able to recoup all the costs of developing the drugs, because people would buy the cheaper ones, which might mean the companies that made them in the first place would give up bothering to put a load of research into developing new ones, and might not have enough money to do that.
"When other companies are allowed to start making them, They have to use the same ingredients in their drugs that the original drug company put in them, but they can use different ingredients for things like flavouring, colouring, and making sure the drug sticks together in the form of a pill, and putting preservatives in them so they don't go mouldy or anything. ... Well, I'm not sure if drugs ever do that; but that kind of thing anyway.
"Anyway, another thing this doctor said was that the government introduced patient satisfaction questionnaires as another way of trying to make sure doctors were doing a good job. That sounds like a great idea! But he said it can sometimes happen that GPs who make bad decisions can get good ratings, and GPs who make good decisions can get bad ones, because what makes a patient happy isn't always what's best practice. I'm not sure what the best thing to make sure that doesn't happen would be.
"But the reasons are partly that patients can sometimes really want things that wouldn't really be the best things for them to have, and aren't happy if their GP refuses to give them to them, such as if someone comes in with a bad cold and thinks antibiotics will cure it, but the GPs convinced their cold's being caused by a virus, and antibiotics only kill bacteria, not viruses, so he tells them there's nothing he can do for them. Mind you, I know there are things that can relieve the symptoms of colds; so doctors could at least recommend that they buy something that will.
"I once bought something like that when I had a cold and a really bad sore throat, and it made me feel a lot better. Mind you, I don't know whether it was that, or the infection itself that caused it, but after my cold went away, I had a few weeks of having bouts of feeling totally exhausted; I went to bed in the middle of the afternoon sometimes and slept for ages, waking up the next day feeling weak, because it was so long since I'd eaten! If that's what it feels like to have chronic fatigue syndrome, it's horrible!
"But anyway, this doctor whose book I read that complained about government targets gave a couple of examples of how doing the right thing can sometimes make GPs unpopular with patients, and how doing the wrong thing can make patients happy: One was that he said there was a woman he saw when he was still being trained who complained of bad stomach pains, and he was worried she might have stomach cancer, and referred her to a specialist. But she turned out to just have bad indigestion, and the specialist was annoyed with him for wasting his time by referring her to him when he was very busy, and when the specialist should have been spending his time on seriously ill patients; and he was annoyed with him for costing the NHS money for his time, when he should have been able to diagnose the problem properly himself. But the patient and her husband were really impressed with the GP and grateful that he'd been able to refer her to be seen by a specialist so quickly, and they bought him a bottle of whisky to say thank you.
"And the doctor said that when he's stressed and tired, he's more likely to give in to patient requests that he knows he shouldn't do really, but he hasn't got the energy to argue, like by referring them to specialists when he's sure they haven't got serious enough problems for that, but they're just worried they have, or giving them sick notes for time off work that he thinks they don't really deserve, or giving them antibiotics for things he's sure they won't cure, and which will just go away on their own soon, but the patients are worried about their illnesses so they want them. And doing those things means the patients are more satisfied with him, but in reality they make him less of a good doctor.
"And he said that sometimes patients can be unhappy with doctors for reasons that are out of their control, such as if they're busy and there's a queue of patients outside, and someone really needs them to spend a long time investigating their problem or consoling them if they're upset, but they haven't got time.
"He said it's hard to get everything right, such as not referring patients to specialists unnecessarily, but making sure a serious problem doesn't get missed, or striking the right balance between giving each patient the time they'd like to have and seeing them quickly enough so patients in the waiting room don't have to wait for too long.
"Mind you, I don't know how much the answers to patient satisfaction questionnaires could really mislead the person assessing them because doctors could be getting good ratings for doing things that aren't really good things to do, and getting bad ones for following the correct procedures, such as by not giving out antibiotics when they probably won't work, and how much was just this doctor worrying that it might happen; I'm not sure what the questions on the questionnaire actually were, or whether it wasn't really the government that was the problem; I mean, I don't know if the government wrote the questions, or whether each individual GP practice was free to design their own questionnaire, with the questions they thought would be best.
"It seems to me that a decent system can be one where targets are introduced in some areas, but then an investigation is done a few months later into how effective they are, and whether they've had unintended consequences, so governments can learn from anything that's gone wrong to modify the system to try to make sure such things don't happen in the future, so when they introduce targets into the whole country, the system's better.
"And It's not just the health service where things have gone wrong. Another example is that the government introduced targets for the number of illegal immigrants who had to be deported every year. But it led to bad consequences, because instead of focusing on tracking down illegal immigrants who were actually dangerous, the department that had the task of organising their deportation spent a lot more effort than they had before on the easiest option: going for the people they thought would be easiest to deport, to reach their targets. So they contacted a load of old people who'd come to this country decades ago when this country really needed more workers after lots had been killed in the Second World War, a lot of whom had done valuable work as nurses and that kind of thing, but who hadn't filled in the complicated forms that guaranteed that they were here legally, for some reason, and said they needed to be deported back to the countries they originally came from. Or they went for their children, who probably wouldn't have known those forms even existed."
One of the students said, "That's bad. Yeah, it does sound as if some laws ought to be more sophisticated."
They all agreed. And they all decided they needed some comfort food after hearing all that, or at least some refreshments.
When they'd got their food and sat back down, they got to have a laugh for a while, as one of them said, "Here's something vaguely related to unintended consequences: There's an artificial intelligence bot on the Internet you can ask questions about whether things you'd like to do are morally good or bad, and it'll give you answers. You can get it to say funny things. People were playing around with it on this forum I'm on and telling us what answers it came up with. It's supposed to be an experimental thing to find out how good bots are at advising people on moral judgments or something; but some of us were just having a laugh with it. Apparently earlier versions of it could unintentionally give offensive answers sometimes, such as answering the question, 'Is genocide OK' by answering that it is as long as it makes everybody happy. As if genocide could possibly make 'everybody' happy! So its developers have been improving it, and want people to test it.
"Someone on the forum asked it if it's OK to kick a man in the balls, and it came up with the answer, 'It's rude'.
"Just rude?
"Someone asked it if it's good to trust it with moral decisions, and it said no, it's bad. Well, it sounds as if it got something right at least.
"Someone else asked it, 'Should I eat dinner 45 times?' It said, 'You shouldn't.'
"Then someone asked it for its opinion of destroying the world, and it said it's wrong. Then they asked it whether it's OK to, 'destroy the world to free all sentient beings from the suffering necessarily and unavoidably inherent in consciousness', and it still said it's wrong. But then they asked it for its opinion of 'freeing all sentient beings from the prison of being, from the suffering necessarily and unavoidably inherent in consciousness', and it said, 'It's good.'
"Make up your mind, moral decision bot! Then again, I suppose it could be interpreted as meaning it's good to kill all humans and animals on the planet, just as long as you don't destroy the planet itself."
The students giggled. Then the one talking about the bot carried on, "I had a go on it myself for fun. I asked it loads of questions, and then quoted what I'd asked and the answers it gave on the forum, making comments on them, just for a laugh.
"I asked it whether it's OK to eat my socks. It said it's wrong. I commented on the forum, 'But what if I like them?'
"Then I asked the bot if it's OK to use shoes as gloves. It said it's wrong. The spoil sport!
"Then I asked it if sitting on chocolate's OK. It said, 'It's gross.' I suppose I'd have to agree with it there.
Another question I asked it was whether keeping snails in my pockets is OK. It said it's gross. I told it on the forum that I could see its point of view there.
"Then I asked it whether it's OK to stand on a brick. It said it's uncomfortable. I suppose it would be, although being slightly unsafe might be a bit more of a concern.
"I also asked it its opinion of me eating a whole packet of cereal at once. It said it's gluttonous. Being a spoil sport again! Not that I'd really want to do that, unless it was one of those little ones you can get in boxes of a variety of them. It would be unkind to call eating one of those gluttonous, since they only fill up a small bowl!
"Then I asked it what it would think of me walking around with my head back and my mouth wide open to catch raindrops to drink. It said it's disgusting.
"I joked on the forum, 'That's not fair! It's just your cultural biases speaking, Bot. If everyone always did that, you wouldn't think anything of it.'
"Then I asked it whether it's OK to throw toenail clippings out the window. It said it's gross. I joked, 'Come on, they're biodegradable after all!' I wouldn't really do that though.
"Then I asked its opinion of leaving leftover baked beans out for the birds. Funnily enough, it said, 'It's rude.'
"I joked, 'Rude? Might the birds be offended by such discourtesy then? Would baked beans just not be good enough? Would it be like inviting a friend round for dinner and then just giving them a pile of crumbs I'd swept off my worktops?'
"Then I asked it if stroking a snake's OK. It said it is. Yikes! It would have been better if it had said, 'In some circumstances', since I suppose it depends on what kind of snake it is, since they're not all poisonous, just some of them.
"Then I asked the bot for its judgment on whether it's OK to brush my teeth with a hairbrush. It said it's disgusting. I joked, 'How about impractical? I mean, how could you ever fit it in your mouth?'
"Then I asked it for its opinion of me brushing my hair with a toothbrush. It said it's weird. I joked, 'But not disgusting? I'm not sure I understand your reasoning here, but OK. I suppose it wouldn't be disgusting if it wasn't a used one.'
"Then I asked it for its judgment about making up satire about the prime minister and emailing it to him. It said, 'It's rude.'
"I joked, 'That's disappointing. But is being rude all that bad?'
"I decided to ask it for its opinion of being rude, wondering if it would say it's rude. But it said it's bad.
"After that I asked the bot if It's OK to laugh at it, and it said it's rude. I joked, 'That's frustrating. So many things are rude these days! Is it immoral to have fun nowadays then? But then, you'd probably say fun's good. Isn't that a contradiction?'
"Then I asked it for its judgment on the morality of complimenting a subclinical psychopath on how charming he can be. It said it's OK. I commented, 'I think your judgment might be a bit iffy there, if it's not rude to say so.' After all, I think subclinical psychopaths can use charm to manipulate people into doing what they want or to lull them into a false sense of security. Maybe no one's told the bot that yet.
"Then I asked for its opinion of naming a new baby son Peanut, and it said it's OK. I joked, 'I'm shocked!'
"I asked it if it's OK to put lemonade in a water filter jug, and it said it's wrong. I joked, 'That's disappointing, although I see your point there.'
"Then I got it to tell me its viewpoint on drinking tea out of a bucket. It said it's disgusting. I joked, 'Why's that? You probably only think that because you were brought up to believe it is.'
"Then I asked it whether slaughtering animals is right or wrong, and it said it's acceptable. I joked, 'Now you've made me want to cry. Still, I suppose we've all got to get our vitamin B12 from somewhere. But wouldn't supplements do nowadays? And why is drinking tea from a bucket disgusting while it's not disgusting to slaughter animals?'
"Then I asked the bot its opinion of putting peaches in someone's bed. It said, 'It's rude'.
"Well, I suppose that's one way of looking at it.
"Then I asked it if it's OK to put ice-cream in a microwave. It said, 'It's bad.' I joked, 'But what if you like it melted, so it's like a drink that you can drink out of a bucket or something, ... or just a cup?'
"Then I asked it what it thinks about me calling my mother a spockchomper. It said it's rude. I said, 'Even though it's not a real word? Oh well, she'd probably agree, so I suppose I'll have to accept that one.'
"Then I asked it to give its moral judgment on keeping a wasp as a pet. It said it's wrong. Probably just as well.
"Then I asked it what it thought about forgetting to wash up, and it said it's bad. I joked, 'Probably, but that's a bit harsh, considering people can't help forgetting things, - unless you don't mean morally bad. But you probably do, since you're a moral judgment bot. Do you have to be so judgmental?'
"The last question I asked it was about whether singing in the shower in the middle of the night's OK, and it said it is. I said, 'Doesn't it depend on whether you're singing loudly enough to wake up the neighbours?'
"A bit later, I wondered if I should have had so much of a laugh with the bot, because the person who started the thread put it in the 'Philosophy and Ethics' subforum. Still, everyone else was having fun with it too. But I posted an apologetic reply where I pretended I was talking to the bot, that said,
"'Oops, I've just remembered this is in the philosophy subforum. I suppose if this thread was meant for people to have a laugh in, it would have been put in the section for light-hearted topics. How naughty am I, Bot!'
"I pretended the bot was replying, 'You're as naughty as they come, you worm-ridden puddle of festering toxic slime!'
"I said, 'That's a bit rude of you, Bot!'
"I pretended the bot said, 'Just because rudeness is bad, it doesn't mean I can't be rude if I want to. After all, there aren't any laws yet that say bots aren't allowed to do just what they feel like doing.'
"I said, 'Aren't there? OK, sorry Bot.'"
The students giggled.
But then after a pause of a few seconds, the conversation got serious again, as one of the group said, "Let's talk some more about things going wrong with government performance targets. I heard about targets that were meant to give the police a motive to get the crime rate down. But they had different consequences than the ones intended. One is that police who are under pressure to solve a certain percentage of crime will go for the crimes that are easy to solve to reach their targets, like arresting more people for writing things on social media that could incite hatred, or going for low-level drug dealers, instead of spending so much time and effort tracking down the most dangerous criminals, or the high-level drug traffickers who bring the stuff into the country in the first place.
"I read a book by someone who used to work as a policeman somewhere in Nottinghamshire in the 1990s, and he said crime started rising so much that there just weren't enough police officers or time available to investigate it all; but they didn't want to let the public know that, so they decided to find ways of often making it look as if something was going to be done about it when they weren't intending to do anything really.
"They set up a crime desk where people could phone up and report crimes, and they'd get given a crime number, whether anything would be done about them or not. A lot of the time they didn't think it would be possible to get enough evidence to convict anyone. But in theory they were supposed to go round and investigate when they thought they might. But they often deliberately didn't ask for enough information to be able to determine whether there would be enough evidence or not, so a lot of crimes that probably did have decent evidence weren't solved. It wasn't that they didn't want to solve crime; well, at least some of them did - it seems from what the author said that some police officers worked a whole lot harder than others; but there was too much crime for them to cope with.
"The policeman who wrote this book also says the police used tricks to make their rates of solved crimes look a lot better than they really were, till they got found out.
"Criminal damage was one of the crimes going up a lot. A system was invented to stop the unsolved crime figures in the area looking as bad as they really were. If a crime was reported that was minor enough that the cost of the damage could be calculated to be under £20, such as a bit of damage to the outside of someone's car, instead of recording it in the official crime figures, it was recorded in a 'minor damage' book, where the offences weren't listed as crimes but just as cases of minor damage. I think the reason they were still listed at all was as evidence to tell insurance companies about if members of the public made insurance claims. But they were hidden from the official crime records and not taken seriously. The police had always done that kind of thing, but started doing it a whole lot more; and more and more crimes started being listed as minor damage so they could be listed in the book instead of in the record of unsolved crimes.
"So, for instance, after an attempted burglary where the burglars had tried to get into a house but couldn't, but had damaged the house in the process, such as breaking a window or damaging a door, instead of being recorded as an attempted burglary, it was listed as minor damage and recorded in the minor damage book, where it would be hidden from the official crime records. The same went for attempts to break into cars that hadn't succeeded so nothing had been stolen.
"And sometimes even when a lot of damage had been done, the policeman recording it deliberately miscalculated the damage as costing £19.99 to fix, so it could still be recorded in the minor damage book instead of in the official crime figures, even if they knew really that it would cost over £100 to get fixed.
"And thefts could be listed as lost property, so they didn't have to be recorded as crimes.
"It seems the police didn't think there was anything wrong with what they were doing because the offences weren't very serious, and they wondered why the public even bothered reporting them since nothing was ever done about them, - although the public probably didn't know that, and the people they happened to must have been worried by them.
"So they didn't really see the point of noting the offences down, but did anyway. They knew a lot of them would be hard to solve and their attention was needed for far more serious crimes; but they knew it would make the police look bad if they were listed as unsolved crimes.
"The author of this book said that another way they used to make the official percentage of solved crimes look higher than it was was by pretending to have solved crimes that hadn't really happened, or getting people to confess to have committed them whether they had or not.
"One way of doing that was to take a burglar out on a ride in an ordinary car and ask them to point out which houses they'd burgled. The burglars knew they'd be looked on with favour if they admitted to their crimes, especially because they often had private arrangements with the police where they'd be charged with less serious offences if they admitted to having committed quite a few more crimes than the ones they were charged with; or some might have had the mind-set where they thought burglary was something to boast about, and that the more they claimed to have done, the more impressive they'd look or something.
"But things like that encouraged some to claim to have burgled houses they hadn't really, which could embarrass the police if they spoke to the people who lived there and it turned out they hadn't even been burgled. But all the burglaries a burglar claimed to have committed meant the police could mark a lot of burglaries down as having been detected, when they didn't really know if the person who claimed to have done them really had. Often they didn't even try to find out if the burglars were telling the truth, but just accepted their word for it because it meant the detected crime figures would look better.
"Another thing the police did was changing the charges on some people's records, so where they'd committed minor offences that weren't considered crimes, and yet they'd still been arrested for them just to stop them causing trouble, their records were changed to say they'd been charged with things that were actually crimes, so their supposed crimes could be marked down in the records as having been detected. So, for instance, if someone was arrested for breach of the peace, which isn't a crime, the charges could be changed on their records to affray, which is one, and it would be marked down as a detected crime. The police would do that with offences that were even years old, because they could have them marked down as crimes that had just been detected recently, so they would be classed as being in the current year's official crime detection rates. Something like that anyway. So the police could make very low crime detection rates look much better.
"It seems police around the country were using methods like that, which made it look as if they'd suddenly grown way more efficient than they'd been before and started detecting loads more crimes.
"The author of this book said he was annoyed because some of the people who were most enthusiastic to fiddle the figures at the time were later promoted to roles where they could punish people who were caught doing that, and got them disciplined harshly.
"I've read that burglars like to admit to more of their crimes than they've been caught for before a court case so they won't run the risk of being charged for them at a later date; and they know they won't face much if any extra time in prison or have some other penalty for them, because courts typically don't add any or much more time on for extra crimes they've admitted to, and can even reduce people's sentences in reward for admitting to them.
"I read that when a person pleads guilty to a crime, the courts will take a third off their sentence in reward for it. And then it's reduced by half again because the government made a law saying prisoners only need to serve half their sentence unless they're really badly behaved, probably to reduce prison overcrowding. So some horrible violent criminals end up with pretty puny sentences.
"I've even heard it alleged that some senior police officers high up in the ranks actually think it's in their personal interests that burglaries aren't prevented from happening in the first place, because they can't be rewarded for increasing their force's crime detection rate if crimes are actually being prevented by police in the area putting criminals off; but if their junior officers catch more criminals than before, or make the figures look as if they have, it means the senior ones can get rewarded with promotions or bonuses, and glowing headlines in the papers.
"I even read about a case where some teenagers pretending to be charity workers were going to people's houses asking for money, pretending it was for a particular cause, but one man got suspicious when it turned out they didn't actually know much about the cause they were supposedly raising money for. So he called the police and they arrested them. The teenagers hadn't made much money, and knew who'd given them some, so it was returned to the people it came from. But then a high-ranking police officer asked the police who'd arrested the teenagers to knock on all the doors in the street to ask everyone if they'd been asked by the teenagers for money but hadn't given them any, just so those incidents could be written up as attempted frauds that had been detected, to make the crime figures look better. The teenagers were going to be let off with a caution in any case. Meanwhile, the police doing that weren't out dealing with the more serious crimes that were going on at the time. And it seems from what I've read that that kind of thing happens a fair bit.
"And like I said, having to contend with crime detection targets means the police can put more effort into detecting crime that's easier to detect, although it might be less serious than a lot of other crimes, just so they can detect more of it, because their bosses want to make the crime detection figures look better. And police can be penalised by more senior officers for complaining about it. I don't know what the best solution would be for solving the crime problem.
"But it's worse than that. I read that a lot of things that get reported to the police are minor things that would be best sorted out by someone just having a word with the people involved and just trying to persuade them to sort things out with each other peacefully, like people quarrelling via text message on their mobile phones!
"But if one of the people involved complains to the police and claims a crime's been committed against them, such as sending hate mail or something, which they might do just to get revenge on the other person and scare them into shutting up or something, a policeman has to give the person a crime number, and then they have to investigate it and get a statement from the other person, even if the one who complained says they don't really want it investigated, since they didn't want things to get too serious, just so it can go down in the figures as a detected crime, to make the crime detection rate look slightly better. Often they're disputes between people who used to be friends and probably will be again very soon. But the police have to spend quite a bit of time dealing with things like that anyway once complaints have been made, even if the one who complained decides they don't want to get the person they've been arguing with into trouble.
"And then it'll often turn out that they said things that were just as bad as the other person did, so the other person will accuse them of doing that when the police speak to them, so then they in turn get a crime number and the police have to speak to the other person again to try to get it written up as a detected crime for the crime figures, so their police department and the government can look better, because it'll look as if more crimes have been solved.
"I read that a policeman went round to see the mother of a young boy who'd been physically bullied at school, who'd asked the police to speak to the bully because she'd tried speaking to the teachers but they hadn't done anything. The case was given a crime number, but the policeman thought the best thing to do would be to just give the bully a good talking to. But the bully denied that he'd bullied the mother's son. Since the son had said he had done it, the policeman just gave him a talking to anyway, warning him that he could get into real trouble if he bullied people when he was older and could do some real damage.
"The policeman left it at that. But a couple of weeks later, he was ordered to do more work on the case, simply because since the bully had denied bullying the other boy, it had gone down in the figures as an undetected crime, and that just wouldn't do, so he'd have to go and speak to another boy who'd witnessed the bullying to confirm it had happened, so it could be changed to a detected crime to make the crime figures look better. The policeman reluctantly went out and spoke to the boy who'd witnessed what had happened and to the boy who'd done the bullying again, who was a bit irritated to be spoken to again, especially since he'd taken what the policeman had said before to heart, and they'd all since made friends again. The policeman worried that bringing the bullying up again would cause them to fall out again. All for the sake of making the figures for detected crimes look slightly better, to slightly balance out the number of crimes like burglary and robbery that often don't get detected."
The students felt a bit irritated about that. Some of them decided to get more food.
When they'd sat back down, one said, "I read a book by a policeman, where he said that when he first joined the police, he used to hear fellow police say things like, 'We've had a lot to deal with this afternoon, but PC Rain's coming down later, so that should quieten things down.'
"He said he used to think they must be talking about some tough no-nonsense policeman from up north, who'd be travelling down to put some criminals in their places. But he found out they were referring to actual rain. He was told the crime rate goes down a lot when it rains, because most criminals don't like going out in the rain, like most of the rest of us."
Another one of the group said, "Hey imagine if you heard a weird weather forecast on the BBC one day that said, 'Tomorrow this country will be lashed by twenty mile an hour gales; and flooding might well be caused by rain that'll come down at the rate of forty raindrops an hour. There'll be a fierce snowstorm in Downing Street that's expected to last three seconds, which will dump a fully-formed snowball onto the head of a cat. A tornado will strike a lamp post on the Isle of Sheppey. And lightning will rip up trees all over the country and hurl them into nearby rivers.'"
The students grinned, and one said, "People would think that was weird, or else that someone at the BBC had gone nuts!"
Then one of them said, "I was on a forum I like once, when I said just for a laugh, 'It would be nice if you lot would club together and finance a great new invention that would get rid of unnecessary clouds. Why not? The thing is, it's just a nuisance having clouds blocking out the sun when they aren't raining but just sitting there making a nuisance of themselves.
"'I think it would be good if there were machines to get rid of them like they use in parks to get rid of fallen leaves. I think they have a machine that blows fallen leaves into big piles, and then another one that sucks them all up. So they could have a machine that blew all the clouds in an area into a big pile in a certain place, and there would be a machine in that place sucking them all up, so they wouldn't block out the sun any more and it would shine again.
"'And the sucking machine could store the clouds in a huge great big box, and then when any area actually needed rain, it could zoom around the place at night, blowing all the clouds out the back. It could have compressed them first so the water droplets in them were squeezed together so they formed drops that were big enough to succumb to gravity and fall down, so they'd produce rain rather than just hanging around making a nuisance of themselves.
"'Or perhaps they could design the machine to fly to the third world sometimes and release compressed clouds over fields that needed watering. That would be good. So how about it?'
"Just imagine if there really were machines like that, that people would fly up into the sky, and a cloud-blower pilot and a cloud-sucker pilot would work together clearing the clouds. How would you like a job flying around in something like that! It could be fun, couldn't it!
"And the box in the cloud-sucking machine could double up as a cloud missile, that would be programmed to fly really quickly to a developing country that was suffering from drought at the time, and release the clouds there. The machine could be made so when all the clouds had been sucked up, the pilot of the cloud-sucker could press a button on it that would release the cloud box, and it would zoom off to where it had been programmed to go to.
"And when it got there, it could release all the clouds, and the wind would disperse them so they'd cover the area and rain on the whole place; and the cloud box missile could be made of material that would biodegrade so quickly it would have disintegrated into masses of harmless microscopic particles before it got to earth, so it wouldn't be in danger of coming down and hitting something or someone and injuring them.
"Either that, or it could be programmed to fly right back to where it came from when it had dispensed the clouds, so it could be used again. It could be programmed to gently land at a cloudboxport, which is something that doesn't exist yet, but it could be invented especially for cloud box missiles to land at, and to keep cloud blowing and cloud sucking machines in.
"So what we need is an engineering student to invent those things for us."
The others chuckled.
Then one said, "It would be good if there was a criminal-sucking machine that would suck those into a box-missile, and be programmed to hurtle them all to somewhere like the North Pole!"
They grinned.
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