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

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12. Grappling with the wrong trousers.

Image

What the well dressed tree is wearing this year.

A procession of girls moves jauntily down Oxford Street. Each girl carries an identical Gap carrier bag and wears brightly coloured skinny trousers. The legwear ranges through many colours and materials – there are 23 different types in the shop.

It took me a while to realise it was an advertising event. Initially I just assumed that ‘Jeggings’ had really taken London by storm, either that or Mayor Boris had passed a new bye-law banning big trousers.

How tempting was it to join that line? So called ‘modelling’ is one of the strongest determinants of human behaviour. But by the time I had got into those trousers the line would have reached Tottenham Court Road and disappeared.

Some animals are hard-wired to behave exactly the same as their neighbour, making possible formations like shoals of fish and flocks of starlings. Someone explained to me that starlings and fish do not need to be particularly clever to pull off this trick. All they need is the instruction ‘do the same as the one next to you’.

Humans like to create this effect too, in Busby Berkely movies for instance or the Red Arrows air display team.

We are used to seeing similarly clad people in other contexts, such as children in school uniform and North Koreans in boiler suits. We like to be wearing the right things.

A demonstration of modelling behaviour is one of many attractions to be found in the local shopping centre. Since social services closed all the day care facilities, shopping malls and libraries are the best places to hang out to keep warm.

Compared with the library, the shopping centre is quieter and more studious in atmosphere. Also there are more books to read.

This part is vital – before you visit the shopping centre – establish the goal. On this occasion the target is: 1.To experience the sensation of being out of place; 2. Not to respond to this sensation by buying something.

For your day out, start by re-framing the shopping centre as a kind of art gallery.

All the familiar shops / exhibits are there (not you Woolworths). There are lots of things you can do free: try out the mattresses in John Lewis, try on lots of jeggings, use the computers in PC world to look up reviews on the same model you are trying, so you can spurn the attentions of the salesperson, use the cameras to take pictures of other people testing cameras on you, try on tester perfumes and marvel at their interesting names.

Or go into Superdrug, and ask for a super drug, such as beta interferon. Ask why they call themselves Superdrug when the best drug they have is ibuprofen.

My hypothesis is that shopping behaviour is a sublimated form of hunting, or at least gathering. The important thing to remember is that all the fun is in the hunt, and once the quarry is cornered then the fun is over. It is all about the expectation of reward – pulling the trigger on a purchase is entirely unnecessary.

Buying something is like coming home from a day’s fishing with a small trout you could have bought in Morrison’s for £3. The trout’s dead eyes communicate to you: So what?

You should have thrown it back in.

Things are not always what they seem, and shopping malls allegedly have a purpose beyond amusement or art.

Shopping malls are meant to part people with their money, rather than act as a recreational facility for escaped psychiatrists. The architects and designers have put in some subtle influences to work on your mind.

One of these is the so-called ‘Gruen Transfer’. This is a place, within the centre, that is designed to disorientate people, by using a combination of unusual shapes and textures and lighting, often accompanied by Muzak.

Apparently the effect is similar to a unit of alcohol or other anxiolytic. People slow down through the Transfer, and co-incidentally this is where the higher priced items are located.

I am not convinced that there is a strong evidence base for the Gruen Transfer, or other devices perpetrated by the advertising industry. Certain low budget shops seem to generate the same emotional disruption.

The oddly named B and M store, sometimes sub-headed ‘Bargain Madness’ can induce such profound despair that it could probably be used as a testing lab for possible new antidepressant compounds. Here the store has been less discreet about its use of disorientation – the clue perhaps is in the word ‘madness’.

Agoraphobics, who tend to have panic attacks in shops, seem to dislike places where there is no clear sightline to the exit. The entrapment induces a sense of doom. Though Morrison’s have an excellent range of vegetables, the way they are laid out can set a person on edge.

Individually, fruit and veg items are not threatening, but when they gang up like this, piled high on all sides, it creates a kind of jungle effect reminiscent of Apocalypse Now.

Another piece of (probably bogus) psychology I have read, relating to supermarkets, is that people have an ‘innate tendency’ to gravitate anti – clockwise. This led to supermarkets placing their main entrances on the right hand side of the shop.

If it was on the left, people would just drift further leftwards into the vegetables section and beach themselves in the courgettes.

Staff would come out to spin customers into the next section, like fairground attendants on a waltzer.

I wonder if it is different in the southern hemisphere, or for the left handed?

It is perhaps a little frightening to think that someone has manipulated the environment in such a way that you have unwittingly bought yourself an expensive, weirdly named perfume.

I am not just referring to ‘Obsession’. What about ‘Hypnotic Poison’, ‘Crazy in Love’ and ‘Thallium’? The internet tells me there is a perfume called M-75, which is the name of the rocket Hamas fires into Israel.

Perfumes, like the Gruen transfer, and the clockwise supermarket, are designed to create an altered state, but what exactly is the state of mind called? In the case of perfume, if it isn’t the name, it is probably solvent intoxication.

Or perhaps it is the feeling of being out of one’s element, or out of step with others. A warning that you are on unfamiliar territory.

Behaviourally, it is supposed to trigger a purchase decision.

The purchase decision is a learned behaviour that creates comfort, possibly by stimulating the ‘anticipation of reward’ section of the mind. The unsettled feeling is briefly quelled, only to be replaced by regret that you have suddenly become poorer and the shop richer.

How comforting is it to be in a herd of people all dressed appropriately and behaving in the same way? Enough people must love formations of soldiers to make it worthwhile dressing thousands of people this way and arranging them in large city parks. Everyone seemed to love the Olympic opening ceremonies.

Lots of people like to be in queues, and will probably join the end of any queue if they find one. If other people are after something, instinct says there is probably something there to have.

There is often not much to be found at the end of a motorway queue, which is formed by the pulsatile dynamics of traffic flow rather than obstacles, but the queuing instinct has evolved over the lengthy period of human history before tarmac and has not yet abated.

The instinct to behave like the person to the left of you is deeply rooted and possibly imprinted at an early age. Experiencing the feeling of being in the wrong place or in the wrong outfit is deeply discomforting.

Many people hate the moment in a restaurant when they have to set out to find the toilets. The fear is not that they will never find the toilet, but rather they will make them-self look foolish to others by dithering round the restaurant.

That is why I think it is a very tall order for CBT to try and get people to fight the idea that it matters a lot what other people think of you.

In the golden era of CBT, pioneers tried to attack this set of cognitions using grand behavioural tasks.

Albert Ellis, pioneer of CBT and our hero, in his list of the top 12 Irrational Ideas, included this as number one:

‘the idea that it is a dire necessity for an adult human being to be loved or approved by virtually every significant other person in his community’

Loved? Maybe not. Approved? Maybe not? But thought to be wearing the wrong trousers? I’m afraid it’s a deal breaker.

Maybe it shouldn’t matter. Maybe not as much. Certainly try and test how much it matters. Certainly try and get it back into proportion.

But it just does.

That leaves us with a burning question. If it is so important to blend in with everyone, why do certain people do everything they can to attract attention to themselves? For instance by dying their hair a florescent colour?

This is perhaps the exception that proves the rule, since these people are relatively few in number, especially in professional groups like accountants or dentists.

Several answers to this – you choose the one you like best:

So that they are visible in traffic?

Reaction to feeling left out or insecure?

Mating ritual?

Group or gang identity?

Genuine lack of insight about how they look?

They are doing a CBT assignment to reduce the irrational cognition that it matters what people think about them?