104. The wolves of Wimpole Street.

The Monopoly Board Game is an increasingly valid metaphor for British society. Railway stations, water and electricity utilities can be bought cheaply so that jail is the only service left publicly owned.

Ironically, Monopoly was invented by a Lefty as an educational tool to illustrate the downside of capitalism. Ownership of property slowly but surely polarises the players into haves and have nots, leaving one person super rich and the others destitute. Sure, there is an intermediate stage where a notional middle class can own a few houses, but this is an illusory phase, like Derby County’s sojourns in the premier league. Sooner or later the market will prevail, typically after significant alcohol consumption, leaving family relationships in tatters and one giant corporate entity in control.  

The original idea for Monopoly was stolen by one of the inventor’s dinner party guests, patented and sold to a large games corporation. The inventor did get $500 though, enough nowadays to buy Liverpool Street and Kings Cross stations, given the current exchange rate. The monetary values in Monopoly are pleasingly anachronistic – £200 seems cheap for the whole of Kings Cross. I like anachronisms. Shakespeare in space suits for instance, or the bit in ‘A Knight’s Tale’ where the medieval dance morphs into Golden Years. It was fairly anachronistic when British Home Stores was sold for £1, though it should be remembered the pound was worth a lot more in 2015.

What’s surprising about Monopoly is that there is no hospital on the board nor any other health or social services related property. Players can only build houses or hotels on their streets, not Walk-In or Sure Start Centres. 

Getting out of jail costs £50, maybe even less if you can buy a card off a competitor or throw a double. In real life, the super rich don’t go to jail very often, but may still need to go to hospital. Even the richest individual occasionally crashes a Bentley or has a heart attack during a special massage. 

Which is the moment when, if they have the misfortune to be in the UK – where there is no private A and E – that person realises the paramedics won’t be there for 90 minutes, there are no beds in A and E and their money is suddenly useless to them.

If only there was a card called ‘Get into Hospital Free’, it would trade at many multiples of its face value. Even more valuable would be a ‘Get into Hospital Fast’ card, with a picture of an ambucopter flown by Prince William.

There are two ways into A and E – via reception or ambulance. The reception route collects all those who have been dealt a card called ‘Go directly to hospital, do not pass Go’ and who are well enough to stagger up to reception. 

There are pros and cons both ways. In recent years I have spent a few nights in A and E as an aspiring patient. On the most recent occasion I was walking wounded rather than stretchered, so I went in via reception and I had time – 13 hours or so – for some light blog fieldwork. Staying up all night to get lucky, as Daft Punk (feat. Pharell Williams) would put it. 

During the night the receptionist, who was wearing tight leather trousers and a leopard skin print top, spent a lot of time sticking labels onto case files and filing notes away, carefully ignoring prospective customers. Towards the end of her shift she retreated further and further back from the glass screen into her dark receptionist-cave.

A tall man, probably concussed, with his gashed head bleeding into a towel turban, waited for quite a while before getting booked in. Finally he was asked his details: for occupation he replied ‘international sex symbol’. That was met with a frown. ‘OK, sales executive then’ he tried instead. He reluctantly gave his wife’s name as next of kin. When asked whether he wanted her to be informed, he said, ‘no, that would only make things a hell of a lot worse’.

He took his seat with the rest of us, on the non – covid side of the waiting room. 

Unfortunately the vending machine was on the covid side, necessitating occasional masked guerrilla raids across the imaginary germ frontier. 

Luckily there was a portacabin called The Pod, which was a medium term waiting room, like Purgatory. No-one seemed to use The Pod, probably in case they lost their place in the queue. It was hard to be confident that the staff would come and find you once your turn came up. The pod had a TV, but it was set to a shopping channel and there was no sound and no remote. Don’t tell the Care Quality Commission (they insist on Sky Arts). It was quiet in the Pod. 

Monopoly does pay attention to the random vicissitudes that can affect people, rich or poor, using ‘Chance’ and ‘Community Chest’ cards. The cards do include a £50 doctors fee and a £100 hospital fee, but nothing financially ruinous, like crashing into Gwyneth Paltrow on skis. Chance cards include a range of life events, both positive and negative. According to monopolyland.com the Chance cards are more luck-based and Community Chest cards are more likely to reward the player with money. The worst thing that can happen is the need for property repairs.

Why the game excludes a dimension related to health care is unknown, but my speculation is that the designers were reluctant to admit that accidents and emergencies really happened to property owning people. If they did, they would be treated by insurance based private health providers. The original version of the game, after all, was set in the Atlantic City of the 1930s, a time when Night Nurse was a person rather than a drug of abuse.  In translating the UK version to the streets of London the makers should have gone a bit more Ralph McTell.   

Free Parking? Hard to believe that still exists, any more than Free Lunch. I would call that square ‘Clamping Zone’ and have a picture of a menacing man with a Pitbull. Or instead of Free Parking, on the corner diagonally opposite Go, a square called Stop, a disused BHS shop doorway with a picture of a comatose homeless person under an old duvet. 

Monopoly does not have anything the district council would call ‘high quality public spaces’, so I would suggest they include the Southbank Skate Space, with a picture of Melvyn Bragg, in the background, spraying graffiti. And what about including a square for Tufton Street, where the right wing think tanks are located? Pay a large penalty if you land there, dark money preferred. 

There are versions of Monopoly depicting many different cities around the world. Although there are monopoly situations existing in health care, both government-run and private, the board game itself remains silent on health provision ownership.

I’d like to think this proves that capitalism and medicine just don’t mix well, at least in board games. 

The longest ever Monopoly game lasted 70 straight days, which is about the time it takes to get an urgent eye appointment. It will take a while to find out whether we are getting richer or poorer, but like Derby County, I’m guessing the prognosis for the NHS is Game Over.


19. Queuing like you really mean it.

ImageYork’s new rapid transit system.

After the weather forecast comes the Pollen forecast. For some reason I expect to see it presented by a giant bee, in bee language.

Its pretty difficult to get a GP appointment nowadays, certainly for hay fever. I read in The Times that some GPs are averaging 66 consultations per day. If so, the situation is crying out for a production line system like they use in car factories, where patients move slowly along a conveyor belt in a giant shed.

In fact I see no reason why hospitals shouldn’t operate like this, making so called ‘care pathways’ something of a reality. There would be a faster track through the A and E department, in the same way as East Coast trains fly past First Capital Connect at Potters Bar.

If we have a track for Depression though, lets not make it a tunnel.

Recently I made a GP appointment – I couldn’t really say it was urgently needed, since, like most doctors in fact, I am a bit of a hypochondriac.

Also I made the big mistake of saying ‘its probably nothing’ to the receptionist.

I got an appointment more than 3 weeks later. Of course, like most self-limiting conditions, which is most conditions, it had already got better by the time I got to see the GP. I went in with a grovelling apology and came out in less than a minute. I felt I had blown a bit of credibility though, in case I get a genuine illness one day. Several Cry Wolf points thrown away.

Perhaps there should be a special ‘disloyalty card’ where persistently not attending earns you extra points. Every now and again these could be traded for a free consultation without prejudice.

This set me wondering whether anyone knows how to use the health care system properly. And if so, how can we learn how to do it?

After all, most illness behaviour is determined by social learning.  But no-one ever properly teaches us how to ‘do healthcare’.

We all have a huge stake in the NHS, but, amazingly, the NHS comes with no instruction manual.

Its the kind of thing Michael Gove definitely hasn’t put on the schools’ national curriculum, revealed today. But should he?

At the end of every human interest piece on the news, such as spontaneous combustion in sheep, the damage done by carrier bags or how yogurt can become dangerous under certain circumstances, the answer is always a call for ‘better education’.

This must be hugely irritating to teachers, whose curriculum is already big enough and struggling to cope with constant tinkering.

But along  these lines, instead of say, History, or Geography, why not some basic Medical Sociology?

We could learn about the pernicious effects of the private sector, the inverse care law that affects poor people, how health care systems struggle to constrain costs and how it took the French Revolution to smash the four humour system.

We could learn the difference between Disease, Illness and Sickness, and how the sick-man has disappeared from Medical Cosmology*. Perhaps he will turn up in the cafeteria or X Ray.

We could learn about the sick role and how to play it. We could have a field trip to the Broad Street Pump, where Snow discovered how cholera got transmitted.

Maybe answer the question, why isn’t holistic spelled ‘wholistic’?

We could look at screening programs and learn – very quickly – which ones are worthwhile. Borrowing a few sessions from Science we could look at Causation versus Association and show improving movies like Moneyball. (Subtitle: the art of winning an unfair game.)

If that’s not better than learning the details of World War One peace treaties, I don’t know what is.

We seem to have an insoluble problem in the UK. It is free to go the doctor or see a specialist. Although if we need to get medication it costs £7.85 per item, plus 90p to park. If it involves driving into Nottingham then there’s a £30 charge for getting in the tram lane by accident, and by accident I mean by being careless.

If we try and impose any charge, it looks as though we will discourage the very people who need to see the doctor most often, and the people who most need to drive over tramways. A number of famous studies suggest the most deprived people are those who have the highest rates of illness and shortest life spans.

But being free, the NHS system seems to attract a large number of people whom car dealers would call tyre – kickers.

Perhaps the fairest and most effective way to ration health care would be to create a giant lottery for appointments, or to make them transferable, so that slots could be traded on the open market.

In the GP waiting room, as I cowered in my corner, peering over a 1998 edition of Auto Express magazine, it looked as though the other aspiring patients needed a bit of weeding out, or triage, as it’s called in health care.

With images of Taksim Square in mind, I imagined a military type person coming out with a loud hailer every few minutes:

Anyone whose temperature is 37 or less, please leave.

Anyone with a bad cold or flu, out!.

Anyone with backache, headache, neckache, tennis elbow, golfers’ elbow, or any other kind of elbow – out!.

Anyone with a twinge.

Anyone with insomnia.

Anyone with indigestion.

Out, out, out!

Anyone here for a screening test not based on sound epidemiological evidence?

(Pauses for a moment) It’s 95% certain you should leave.

Now we are seeing a definite thinning in the crowd and a line of people heading for the Cooperative Pharmacy or the alternative practitioners ghetto. No need for the water cannon and rubber bullets after all.

The military style triage is unlikely to prove acceptable in the era of consumerism. Tesco don’t use it, even for the people who turn up at 9pm to get the reduced loaves and then ride around the car park in trolleys.

Instead we have had NHS Direct and 111 – who tend to ‘direct’ you to A and E.

The A and E department have their own filtering system, using time and, to a lesser extent, squalor. More recently they have taken a lead from Heathrow and created a stacking system for ambulances, which circle the hospital, waiting for a landing slot.

I made the mistake of trying to reach Leicester Royal Infirmary by car recently. Like the health care system in microcosm, there is no way in and no way out. I felt like an Apollo space capsule, orbiting the moon, but I had no lunar module to send down.

Those with self limiting conditions have probably got better by the time they are seen. Even those people who are seeking healthcare mainly to meet other people who are seeking healthcare and chat to them, have had enough social contact after 3 hours in a hot little waiting area with a very expensive Coke machine and a silent, armoured television showing volleyball from Belgrade.

Using time as a subtle disincentive is an example of the ‘British’ way of filtering access to healthcare, which is called ‘implicit’ or ‘covert’ rationing. For example, many people who are referred to primary care mental health or substance misuse services receive a letter asking the prospective patient to ring up and make an appointment. Sometimes this also involves filling in some forms and rating scales. A really off-putting one is asking an open question like, ‘what would you say are the aims of this appointment?’

This little change in the Choice Architecture reduces the number of people given appointments significantly. Perhaps these not-very-motivated patients are the right ones to weed out. Or perhaps not. Maybe those who are least forthcoming are most in need.

Because mental health services are very limited, and mental health problems are very common, there is a massive amount of covert rationing for psychological treatments.  Which brings us to the pressing issue. If it’s that difficult to get an appointment for something concrete and medical, like muscle cramps and twitching, oops I gave it away, how much more difficult must it be for a depressed person to enter the system?

Most people with Depression have reduced energy and motivation. Often they are ashamed of seeming weak or useless. Studies have shown that it takes most people a long time to get round to making an appointment. Often it takes a crisis of some kind to bring people into contact with services.

Recently I’ve seen people turned away from blood-doning sessions because they had not made an appointment, even O negative donors, like myself, who should be given the red carpet and chocolate digestives.

I heard would- be donors say things like, ‘I just like to come down here when I’m able to, I just can’t plan that far ahead’. The person in charge assured them that the new appointments system was much more efficient.The Times (10.06.13) reports that the number of blood donors has fallen by 23% in the last ten years.

NHS blood and transport are apparently looking to attract young donors, so perhaps this should also be included in the national curriculum. I’d have given more blood if doning had been offered as an alternative to PE.

It would perhaps make sense to abandon or reduce the system of making appointments in favour of just turning up. We seem to like walk in centres and A and E, where we go when we need to.

In fact I seem to remember GP surgeries used to be like this, before appointments took over. I am sure GPs can produce evidence supporting the idea of appointment systems. And further evidence to support their recent system of the mad telephone rush for slots, jamming the  lines at 8.30 am.

But there has been a massive change recently in the number of things you can do while you wait. This has transformed public transport and it could transform access to healthcare.

If you have a tablet computer, or smart-phone even, you can listen to music, read a book or two, watch a movie and play a few games.

You can skype your relatives and buy a new cardigan online.

This is quite different from even 10 years ago, when you had to be content with old copies of Golf Monthly, collections of curling pucks and a fish tank.

Somehow we have created a system where people’s time is felt to be incredibly important and they can’t be released from work. Did planners fondly imagine that people would pop out of work during their lunch break to have a quick endoscopy?

It looks as though ill people will seek help, providing they know which queue to join and where it starts. All they need is a sign saying, ‘Stagger this Way’.

The biggest crime in the NHS is to make covert rationing ‘explicit’. It’s a bit like a magician showing how the tricks are done.

Perhaps there’s something more honest and straightforward about a queue. A bit like Stargate, we’d call it a ‘Portal into Care’.

Take your iphone. And the charger. Food and drink also. And if you see the sick-man, please send him back to Medical Cosmology*.

*The disappearance of the sickman from medical cosmology, by Nick Jewson,  Sociology May 1976 vol. 10 no. 2 225-244