Suicide Counselling: Too Little, Too Late

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I know that this blog is supposed to be ranting, raging and raving. This post is just sad.

In The West today (21 Apr 12) is an article about the high level of suicides in Aboriginal communities. Fatal despair of the young. "There is something dreadfully wrong in our community, but what can we do?"

When they took away our CDEP, more people started drinking.

When "they" took away our CDEP...

Whoever "they" are, they have a lot to answer for.

Yet I can't find it in me to believe that the Aboriginal community can drag itself out of the mire. It does need help. Not just money. Help to raise its own ability to manage its own affairs.

The "they" who are at fault are not the people who provide -- or don't provide -- money for local make-work. If any "they" are to blame it is the "they" who demand the right to self-management for people who are not yet able to self manage.

The Standby Suicide Response Service... visits every community after a suicide to give counselling and to organise activities. But... counselling is not always possible because people are grieving and want to be alone.

I'm sure that the Suicide Response Service means well, but just look at what its co-ordinator has said: We turn up at the wrong time.

Listen to yourself!

Okay, it's a response service. So they may be restricted in what they do.

So set up a more timely service... One that has the resources to provide support when it is needed. At a more appropriate time. A time which suits the needs of the people who need the support.

The article mentions a new mental health facility in Broome. A $30 million facility. In Broome.

Do potential suicides go to Broome on their way to kill themselves? Well, no.

The article does not link the new facility to suicide prevention. Perhaps someone else has? In the article, the new facility is simply a major expenditure which will not affect the remote community suicide rate.

There are several points to be drawn from this article.

• People need something to do. Something which makes them feel useful, perhaps even wanted, maybe even valuable.
• Paying for make-work is better than nothing. Generating real work -- even with external financial support -- is even better.
• When a community is not able to manage itself, that is when it needs help. Forget the fear of "paternalism". Provide people who can show how a community could be run -- and who will take charge until the community has grown into self-management.
• Provide the necessary support where it is needed and when it is needed. Fly in fly out is of very limited value.

And if all that costs too much... Start somewhere. Pick one community. Try to make it work. And then do it again in another community.

Independent thinking & independent analysis of your problems. Agamedes Consulting: Support for your thought. email nick leth at gmail dot com

Please Give Generously

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It's only when it's close to home that the truth really hits you: There are people starving in our world. And they need our help. Take a look at pages 4 and 5 of today's West (22 Sep 2011).

It's so sad.

How can we sit back and enjoy ourselves, while women are starving -- in our own city. How can we pretend to any sensitivity -- any pretence at humanity -- when our daily newspaper shows pictures of skeletal women -- in our own city.

Please give generously to prevent starvation.

These people need our help.

Independent thinking & independent analysis of your problems. Agamedes Consulting: Support for your thought. email nick leth at gmail dot com

What Service does a Hospital Provide?

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What service does a hospital provide?

We recently had an experience with a hospital. A large, expensive, private hospital: St John of God in Subiaco. According to Wikipedia, "A hospital, in the modern sense, is an institution for health care providing patient treatment by specialized staff and equipment, and often, but not always providing for longer-term patient stays."

I think of a hospital as a place to go when you're sick because they will look after you. My imagination begins with health care, doctors and nurses. My imagination includes service and organisation.

To me, a hospital is a one-stop shop for treatment of sick people.

Wrong.

A hospital -- judging from our recent experience -- is a cross between a strata-titled office block and a hotel.

Thank Goodness for Honesty and Trust!

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Gosh, it's nice to be reassured that there is no possibility of bribery in the health services. Right there, on the front page of The West ($745,000 in gifts to health officials, 25 May 11):

Health director-general Kim Snowball yesterday said the companies paying for trips signed a letter acknowledging that the trip did not place any obligations on doctors or the health service.

What a relief!

Yeah, right. As if.

Is Snowball stupid? Or ridiculously naive? Or does he believe that readers of The West are simpletons.

Weasel words?

In the same article we are given several examples of freebies provided to state health officials by major companies. One example is -- by implication -- perfectly alright because the company has "no existing relationship with the department":

Three North Metropolitan Health Service employees each accepted return business-class flights and three nights accommodation in Los Angeles worth a total of $28,488. It was paid for by health-care conglomerate Abbott Australasia, which has no existing relationship with the department. [my emphasis]

Have a look at Table 1 from a research paper published online:

Just One Eye Wide Shut

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A typical day for letter-writers in The West... A series of one-eyed rants which ignore the possibility of an alternate viewpoint...

(In this blog I am willing to rant from both sides or either side of the argument. Whichever needs more support.)

Take, for example, the two letters which the Editor has placed under the common heading of, "We Disagree":

Taking Coal from Margaret River

Perhaps we do need to Decriminalise Drugs

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I'm in two minds about this:

• Drugs are evil, we should do everything in our power to stamp out the use of drugs. And you know I mean "illicit" drugs, such as heroin, ice, marijuana...?
  
• Drug dealers make excessive profits selling illegal drugs. So we should make drugs legal and cut off the illegal profiteering.
  
• While drug-taking is illegal, drug-takers are afraid to come forward to be supported. This makes them easier prey for drug dealers.
  

As you can see... I'm actually in more than two minds about drugs... Today's paper has swayed me -- for today -- towards legalisation.

Drugs handout gamble pays off, in The West, 28 Dec 2010. Portugal took a chance -- and it appears to have paid off.

Real Women, Pretend Inclusion

Agamedes finds that his bulldust meter has hit the extreme end of its dial.

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Oh! Look! "Real" women are involved in this year's Perth Fashion Festival! How do I know? Because Jerry Hall "called in briefly" to have her photo taken.

There's Jerry Hall, watching amateur models. No photos of the amateur models, though. Not famous enough, not photogenic enough, I guess.

Mariella Harvey-Hanrahan is the festival director. "Giving real women representation in the fashion industry and supporting plus-size models was perhaps her proudest moment," according to The West, on 11 Sep 10. The rest of her life must have been a really miserable disaster...

"Giving real women representation in the fashion industry..." The models in the Every Body Counts show are all amateurs. No professional models. Why not?! Perhaps because no woman with a "real" shape can get a job in the fashion industry?

"Plus-size models"? Is that the only unfashionable shape that Harvey-Hanrahan can imagine? To be fair, the "face" of the festival is an anorexic who seems to have spent time on a rack. With that as a role model, 99.999% of women are "plus-size".

So how successful was the Every Body Counts parade?

Sorry, I can't tell you.

There's a photo a Jerry Hall. Proud words from the festival director. Some words from Natalie Wakeling, "Perhaps Australia's best known plus-size model..." Who seems to be denying that this event is both tokenistic and a publicity stunt. Several photos of "real" models -- most of whom do look rather good.

No actual report of the Every Body Counts show, though. Just a passing mention that all 12 models were "styled" by one person... Does that mean that none of the well-known fashion designers were interested?

The fashion industry occasionally claims to be interested in designing for real people and using real women as models.

Perhaps it's time for some action that is more than a tokenistic publicity stunt.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Going... Going...

"They paved paradise And put up a parking lot" ... nothing much has changed, thinks Agamedes

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The government has great plans to sell off prime real estate in Subiaco. One small problem: the land is currently the site of a major children's hospital, Princess Margaret Hospital.

No worries. We'll build another hospital. But where?

Here's an idea: Let's build the new hospital on the same site as an existing hospital, Sir Charles Gardner Hospital. A site which is already short of parking -- so short of space that staff park elsewhere and catch a bus. Great, let's make the site even busier...

Oh, yes, one other small problem: While we're building -- there will be even less parking space. Builders will spread out over the existing parking areas. Builders have a strong union, no way a builder will park elsewhere and bus the remaining distance to work. What can we do?

No worries: we'll take over a nearby sports ground.

What's that? The government pays for a "Be Active" advertising campaign? Now they plan to destroy a popular sports ground? One that's used by lots of children, who are able to walk to this sports ground?

Too bad. The government has decided to spend a lot of money on a new hospital. (Probably less money than they will get from the sale of the old hospital. That one is on prime real estate.)

Spending a lot of money comes well before an active, local sports club or two. Consider it a done deal.

No real worries, though: The government say that they will return the land in two years time. Return it in its good sports ground condition, too, according to the local council.

By that time, say the sports clubs, we will have lost a lot of our membership. It will take years to rebuild. Two years is a long time for a sporting club to keep going with no sports ground.

I don't believe the two years. Do you? Three years... four years... maybe.

Mostly, I don't believe that the sports ground will ever return to being a sports ground. Because,

1. Building will be delayed.
   
2. The hospital is already short of parking. Will they really give up an area that has been a carpark for more than two years?
   
3. The cost of turning carpark into sports oval is far larger than for turning sports oval into carpark.
   
4. Then... it takes several years to get the grass growing again.
   
5. And... in two years the sports clubs will have faded away. So "no-one" will be there to fight for the return of the oval.
   

Let's just hope that Subiaco Council reject the government's offer.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Better Results in Hospital Emergency Departments

Agamedes goes shopping for a better ED solution.

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How often do you just sit at your standard-sized desk in a shared space in a noisy open office area and think, "There is so much work to do... If only someone would order me to work harder... I would then pull my finger out, stop malingering, grow to love my work and get twice as much done every day. All I need is the order from a remote manager and I will work so much faster."

How often do you think that?

Never?

I wonder why the Health Department thinks that an order to work faster is such a good idea in hospital emergency departments...

Good lessons from the shop floor

Do some shopping in The Herdsman, watch the checkout section. The Herdsman is a food shop. I'll describe what I see. You will see the same in plenty of other shops.

Two or three cash registers are in operation. There is a small queue at each. A call goes out... Another checkout operator appears, opens another till. The checkout queues adjust, customers are served, the queues disappear. Checkout operators close tills and go away.

What has just happened?

There are employees at The Herdsman who can operate the checkout counters. When they are not needed at checkout -- they help in other areas of the shop. If one checkout operator has no customers, they will move to be a bag-packer at another till. If the checkout area is very quiet, idle operators will find work in other areas of the shop.

Here are the key ideas:

• The shop knows -- roughly -- which are the busy times for checkout. But customers come and go as they please... Customer numbers vary over time.
  
• The shop employs enough checkout operators to provide an efficient checkout service to customers. They will employ more operators at known busy times.
  
• Checkout operators help each other to provide good service to customers.
  
• In quiet times times at the checkout area, checkout operators work somewhere else.
  
• At all times, each checkout operator gives highest priority to working in the checkout area.
  

I don't know what checkout operators do when they are not in the checkout area. Perhaps they just sit out back with a cup of tea... though I doubt it. Whatever it is that they do, I suspect that it is useful for the shop. Sure, they may have to go back to checkout at a moment's notice... Meanwhile, they are providing some support in the shop. Rather than just sitting around, feeling useless.

Apply this answer to ED

Is ED -- the hospital Emergency Department -- like a shop? In some ways, it is:

• The hospital knows -- roughly -- which are the busy times for ED. But patients come and go as they please and as they must... Patient numbers vary over time.
  
• The hospital can employ enough ED staff to provide an efficient ED service to patients. The hospital employs more staff at known busy times.
  
• ED staff help each other to provide good service to patients.
  
• In quiet times times in ED, ED staff can work somewhere else.
  
• At all times, each member of the ED team gives highest priority to working in the ED area.
  

This is the obvious benefit: The hospital can employ more ED staff than the absolute minimum. In quiet times, "spare" staff will be helping patients in other areas of the hospital. In busy times, there will be enough available staff to cope.

Yes, there are potential problems:

• Specialist ED staff may not want to work anywhere else. So talk with them... Discuss the problems, look for solutions. There's probably a real need for a core of dedicated ED experts. This core of experts can be supported by other staff with more flexible training.
  
• Other hospital wards may not appreciate staff suddenly disappearing back to ED. Look on the bright side: While they were in the ward, they helped.
  
• Not every non-ED task can be dropped every time ED needs more of its staff. Be very clear about the type of work that an ED staff member can do in a non-ED ward. Make sure that it can be dropped at short notice. Avoid work which is either time-dependent or time-consuming and non-interruptible. Work with ward managers to make it work.
  
• With staff coming and going from wards, how do we know what's going on? Patient notes and other work records are really important. Keep them accurate and up-to-date.
  
• It takes time to get back to ED... Inventory managers will tell you to build "lead time" into your call for ED staff to return to ED: See the patient numbers building up and call back your ED staff before patient numbers reach crisis point.
  
• I'm sure there are lots of other problems. So what? Identify the problems -- and solve them.
  

In Western Australian hospitals, ED staff are being ordered to be more efficient. More efficiency may not be possible. Evidence suggests that giving the order is not helping. See, for example, "Hospitals fail to meet waiting time targets" in The West Australian, 6 August 2010.

We can improve the effectiveness of ED with a better staffing model. Shops around the world provide the example, I see it in action at my local food shop. It works.

We can make it work in our hospitals.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Urgent call for "child" therapy

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Various experts in child care are calling for "urgent action" to support children in need of therapy (Urgent call over child therapy, The West Australian, 17 Jul 10). Dr Trevor Parry, Michelle Scott and Fiona Stanley are raising concerns that "children were falling through the cracks because WA lacked a co-ordinated approach to early intervention."

Actually, the next paragraph of Cathy O'Leary's article blames delays rather than lack of co-ordination. Still, the two may be related.

What is it that has all these experts so worried? Speech therapists? Physiotherapists? Educational specialists? No.

The concern is that children may have to wait up to a year to see a clinical psychologist.

I'm sorry, all these experts seems to have missed the problem. By the time a child needs a clinical psychologist -- in many, many cases -- it is too late. Okay, you can help the symptoms but the cause is a separate issue.

Stop the problems before they happen. Insist that adults obtain a "suitable for breeding" certificate before they have children. And I don't mean money and physical capacity.

Are these adults fit to be parents? Will they love, care for and support their future children? Will they take responsibility for caring for their own children -- at least to the extent of hiring capable, long-term parent substitutes?

Ensure that parents will provide the time, the care and the attention that children require. That will shorten the waiting list for childhood clinical psychologists.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Broken Promise backs Dubious Dealing

Do these people ever see the bleeding obvious? wonders Agamedes.

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Today's West has an article headed, "Health cash on collision course" (30 Jun 10). There's a supporting article, "Pollies playing stupid games" and an Editorial on the same topic.

The topic? The federal government offers to fund state health. In exchange, the federal government will take a portion of the state's GST income. Take with one hand, give with the other. The idea is, that the federal government can... somehow... better manage a health system. The West's Editorial is vaguely supportive of the idea.

Now let me point out the bleeding obvious: Money given to the federal government is spent by the federal government. It is spent as the federal government decides.

Is there something wrong with that? Not if you believe that the federal government will keep its promises, to provide a "better" health system for each state.

Let's ignore -- for now, various questions associated with better: Why do we expect one government to run health "better" than another? If the same money is to be spent, how will the system become "better"? What funding will the federal government provide, once the initial agreement is complete and health is firmly committed to federal control? How long will the initial agreement last?

Let's look at what has actually happened so far:

The state premier played hardball. Actually, he refused to hand more state money to the federal government. So federal agreed to hand over money anyway -- federal agreed to give $350 million to help run the state health system. Now, from the article in The West, "[federal] Health Minister Nicola Roxon yesterday reneged on a promise to pay $350 million directly to State hospitals."

Federal health minister Nicola Roxon reneged on a promise.

All we have so far is a promise. And that promise is already broken.

Would you give money to that politician -- to any politician -- in the hope that the politician would hand it all back? Would you risk millions of dollars on a politician's promise?

I would not even buy a used car from a politician. Federal or state.

And the further the money is passed -- the less chance there is, that any of it will get back again.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Odds and Sods

Like Licorice, Agamedes gets excited by All Sorts of things.

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Mum with rare disease fears for daughters

The West, 1 May 2010: A woman suffers from a degenerative disease. Lorinda has "presenilin one". Her brain is destroying itself. Soon she will not remember her own family. Soon after, Lorinda will die.

Absolutely miserable.

Lorinda's mother died of the same disease; it's genetic. "I was hoping it wouldn't happen to me," says Lorinda. The disease is genetic, there's possibly an 8% chance that it will be passed on to children.

With this disease hanging over her head -- and the miserable example of her own mother dying of presenilin one -- Lorinda has had three children.

$315m plan for light-rail link

The West, 1 May 2010: A team from the Curtin University Sustainability Policy Institute proposes a "light rail" track for Perth. It's like trams but given a newer, more funky name... Light rail is far better than "trams" which are well known to be old, clunky things which are the life-blood of public transport in Melbourne.

So a team of academic experts -- supported, no doubt, by students who do the actual work -- recommends an "arc" of light rail transport from the University of WA to Canning Bridge. The recommendation comes in a report. The report includes pictures...

I have nothing against light rail for public transport, it seems to be a sensible option. But just look at those pictures:

Each of the three pictures included in the report in The West shows a very modern, streamlined train -- on a single set of rails. How do these trains pass each other?!

The trains travel -- in the report -- at up to 110km/h. The proposed track is 21km long. Non-stop, at just 50 km/hour, a train would take 25 minutes to travel end to end. Does it then turn around and drive back? That would allow one train in a given direction at, at least, once every 50 minutes. With no passing lanes, what else is possible?

I do guess that there will be passing lanes -- that is, stretches where there are two sets of tracks. That doubles the space required for a new light rail system. Which makes it so much harder to find the required space.

Actually, the report itself (I searched the web) does seem to show some double-track sections. But the network will not be quite as simple and compact as shown by the glossy overview in The West.

Funding cuts a blow to ailing river

The West, 22 May 2010: The Swan River Trust's budget is to be cut to $12 million. Is it time to panic? Or to despair? Why bother!

The article has a Margaret van Kleef saying that, "it's a great shame to have their budget cut." Van Kleef also says that she has watched the health of the river deteriorate, in the twenty years in which she has lived by the river.

So we have a Swan River Trust. And we have a steadily deteriorating river.

What purpose does the Swan River Trust serve?

The river is dying. The Trust is failing. Perhaps we should get rid of the Trust entirely.

Let's spend the $12 million on something that actually saves the Swan River.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Odds & Sods

So many highlights in today's paper! Agamedes barely knows where to start ranting.

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So much nonsense in The West Australian today (18 May 2010)! And wow! there's even something nice! Let's rave on...

Healthy eating

Inside Cover has a quick sneer at the Department of Agriculture and Food. I can't help but sympathise.

The big boss at Ag & Food sent an email to all staff: Eat healthy! he wrote. Meanwhile, out with the sporting try-hards...

I'm a regular competitor with the little-known sport of orienteering. Each week, throughout the winter season, we have an event in the bush -- with a cake stall to make it all worthwhile. Association members bring a cake, competitors buy a slice of cake, money raised goes to help the sport.

We -- members -- are now being encouraged to bring a healthy cake. Wholemeal flour. Less sugar. More fruit. Not just fruit in cakes -- real fruit, for sale. Sheesh!

We've just walked, jogged, run for two, five, six or more kilometres through the bush. Burnt off perhaps ten servings of Dinky Donuts. And -- for the sake of unneeded sponsorship from a government agency with nanny-like power urges -- we are being asked to bake and sell wholemeal sugar-free lentil cakes.

Sheesh!

Model TV show looks good

It's a very nice photo with the advertorial for Australia's Next Top Model. Three pretty girls from WA, a story in the WA daily newspaper, all very nice. Nice text, too.

The professional fashion photographer has comments on each of the WA contestants:

• "A serious contender... perfect proportions..." Looks as though she has a chance of winning.
  
• "A good eye for creating a look... achieve exciting angles..." Willing and flexible enough to do as the photographer asks.
  
• "Working hard early... develop her skills..." Tries hard.
  

Isn't that nice! Here's a positive statement about every single one of the contestants... Pick the ones from [select your own state] and you have a nice, positive story with local content.

Well done, that PR person!

Unqualified teachers

Then there's the report that the "New [physics] course [is] 'too hard' for teachers".

Igor Bray of Curtin university says that the proposed course content is good. But school physics teachers are not qualified to teach that level of technical physics content. Well durr!

Teachers are selected from amongst those who want to work with children. People who look forward to the challenge of passing knowledge to young people. People whose ambitions lie with being nurturing and supportive rather than fame and discovery.

Then teachers are thrown to the wolves.

Teachers are told to teach the unteachable. To manage classes of thirty, where perhaps one or two want to learn and at least one or two are psychopathic misfits who should not be allowed unaccompanied in public -- so they are relegated to the social welfare confines of the local school.

When students fight rather than learn, teachers are blamed. When students struggle to learn, do their best but are still only average, they are measured against private school students who are filtered for success... and the teachers who drag the dregs up to match the average -- are blamed for not teaching any better. Then the teachers collapse for a well-earned break, or just break under enormous pressure -- and are attacked by letters to the paper.

Teachers have lost all public status. Their role is to baby-sit, to be social workers, medical assistants and jailers. If you understood physics -- and could get a job as a physicist -- would you become a teacher? No way!

Raise the status of teachers. Let them teach. Change the role of schools back to education. Define the role as "teaching" rather than "social work". Perhaps then we will get teachers who are able to teach physics.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Flu Jab Warnings

Kill the messenger? Agamedes notes a variation: attack the person who failed to send the messenger.

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Flu jabs, sick kids, a bad combination. No-one likes to read about sick kids. When flu vaccines are alleged to make kids sick, plenty of people get upset.

"We need to know when the Government found out and when it responded, and whether the information that was needed was there in the first place," says shadow health minister Roger Cook. (From "Calls to examine 'late' flu jab alert", The West, 29 Apr 2010.)

"The Minister needs to tell Parliament why the system seemed to fail mums and dads," he continues. Note the use of "mums and dads" rather than "parents"? So much more emotional, don't you think? So much more tugging at the heart strings. No mention, though, of failing the children... after all, they're not old enough to vote.

"We may need to have a formal enquiry..."

Cook is not alone in this view. As the flu jab issues were surfacing, there were general calls to find out what had gone wrong. Generally tied to demands that someone needed to be punished. For failing the mums and dads.

Is this "disaster recovery"?

Something has gone wrong. There is a disaster happening or, possibly, about to happen. But how do you know?

Several years ago I was in charge of a Disaster Recovery Planning project. If a "disaster" happened, the disaster recovery plans would be pulled out, and followed. One small problem:

We were planning for recovery of contracted services. If there were a disaster, contacted services would be thrown into turmoil. Costs would skyrocket. Key performance indicators (KPIs) would not be met -- we would all be busy recovering from the disaster. KPIs not met would result, under contract terms, in payment being reduced.

If, for example, an office were flooded... contract service would stop until the floodwaters receded. Then there would be a period of below-contract KPIs, while equipment was replaced. (That's a deliberate example. An office was, in fact, flooded. All systems were recovered very quickly; all the disaster recovery manuals remained closed and on the shelves.)

So, if there were a disaster, service delivery staff need to have it confirmed, so that KPIs can be adjusted. Service delivery staff want an early declaration of disaster. People paying for the services may want a delayed declaration of a disaster so they can pay less, due to missed KPIs.

For my project I asked, who would declare that this series of problems was, in fact, a disaster? I never did get an answer...

When dodgy flu jabs are (possibly) causing kids to get sick -- who will declare that this is a disaster?

Doctors? Health department? Nurses? Parents? Politicians? We need to be more specific: Who will declare a flu jab disaster: Which doctor? Which official within the health department? Which particular parent? Which politician? I would guess... that no particular person has been given responsibility -- or authority -- to declare a flu jab disaster.

If you don't have responsibility -- who do you tell? If you don't have authority -- what do you do? Remember: a false call and it's your job on the line, your reputation which will be ruined, your career which will be forever dogged by that one bad decision.

So, are we surprised that there is no-one to send the messenger?

Perhaps it's a process problem?

Australian Nursing Federation State secretary Mark Olson "wanted an inquiry into why authorities were slow to react". Yep, another call for an inquiry. We all want to examine past failures and allocate blame.

What's the point?

Surely what we want to do, is to make sure that it doesn't happen again!

There are a whole lot of management buzzwords, catch-phrases and motherhood statements about "quality processes". It is worth remembering: If there is a problem, fix the process... processes cause problems, not people.

Fix the process.

We had a problem, possibly a disaster. The process failed, because flu jabs continued -- apparently -- despite indications that they were causing problems. So improve the process.

Let the past be a warning: we now know that flu jabs may be less than perfect, we now know that warning signs may be missed, or warnings ignored. Now design a process that will work...

How will the process work?

It's all very well to say, we need a new process. An essential part of process development is, to set the process requirements. Consider each of these:

• Who will be responsible for identifying adverse reactions?
  
• Adverse reactions to what? Just children's flu jabs? All children's injections? Adult injections? The list is endless... Identify the essential items to be watched -- for this process development project.
  
• Do we want this project team to list some of the other contenders for a similar disaster identification process?
  
• Who will be responsible for gathering and analysing the data which may indicate an impending disaster?
  
• Who will be responsible for declaring, publicly, yes, this is a disaster?
  
• Who will need to be informed? Doctors? Parents? Nurses? Politicians? Parents? Someone else? Everyone else?
  
• Who will be responsible for developing this disaster-identification process?
  

That's a bare beginning. Now we can get serious:

• Appoint a project manager, identify team members. But that's not enough.
  
• Who must be consulted? Who must be informed? Who must ensure -- or agree -- that the final process is actually effective? This is standard "project management". Processes don't just appear, they must be designed. And that is a "project".
  
• Now... the project team can start its work. Including:
  
• Define what data will be collected. Number of injections? Number of adverse reactions, grouped by type?
  
• Decide, at what point is there a potential disaster. One adverse reaction? One percent of injections give an adverse reaction? Only adverse reactions which result in hospitalisation? Children who get sick within a week of an injection? a day? a month? ... Is there an absolute measure to indicate a problem? Probably not, so...
  
• Define the response to be taken at various levels of risk. Email to doctors at the very first sign of possible problems? Public announcements when suspicions are raised? Absolute ban on injections when... well, when?
  
• Name the person (or position) who will have the information, who will have responsibility to make the decision, who will have authority to take the action.
  

That's just off the top of my head. A good process is not simple to design. It is simply essential.

Don't waste time allocating blame. Shoot the messenger and you will never see another messenger. Develop an effective process, now. Learn from the past. Improve the quality of response, for the future.

Improve the process and you will gain benefits, well into the future.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Secession is a Mirage; the Problems are Real

Australian health reform, Western Australia loses out on GST... is secession the answer? No way! says Agamedes.

Do you need new -- lateral -- thinking for your own problems? email nick leth at gmail dot com. Need solutions? No worries. Now.

Way back in 1933, Western Australia decided to secede from the Commonwealth of Australia. We would have, too -- except that the other states did not allow it. The call to secede is raised again and again -- usually, according to The West (Welcome... to the Republic of Western Australia, 24 Apr 10) -- usually when times are really tough, or when times are really bad.

To put it another way: WA wants to go it alone when (a) things are crook and we reckon we could do better by ourselves, or (b) money's rolling in and we want to keep it all for ourselves. This week's call for secession has been prompted by a bit of both.

The health systems are crook in some other states. The federal health system "reform" will (we expect) take money from WA to prop up health in other states. WA not only survived the global financial crisis, we are still booming, due largely to exports of iron ore. To make matters worse, we collect GST, give it to the federal government -- and get back less than we collected.

Trouble is, we're looking to solve the wrong problem.

Is it the money?

The article in The West looks at the money. Once we factor in all the costs of becoming "an independent nation", we'll probably be very poor. Add in the cost of a republic, we will probably be broke. Apart from the occasional visit, we pay very little for a royal family. A president will cost us in salaries, facilities, staff, elections and more.

Then there's the greed of our demand to spend all of the GST that we earn. The greed that says, those states did not earn this GST so they should not get to spend it... Take that a step further: those people did not earn this GST so they should not gain benefits from it. Take that greed to its logical conclusion: I bought this item, I paid the GST, I want that GST back...

We live in a form of democracy with a social conscience. Most of us accept that we should give some support to people who are not able to support themselves. Does it make a difference that those people live in a different suburb? a different town? a different state? We pay our taxes in the full understanding that the money will be spent -- largely at the government's discretion -- on a whole range of things. And most of those things will be of no direct benefit to the people who paid the taxes.

So what, if -- at the moment -- some of "our" GST is spent outside WA? This time we "lose". Other times -- we "win". That's the way that a caring & sharing society should work.

Is it the power of independence?

Western Australia is a part of a country with a population of 22.3 million. As an independent nation, WA would have a population of 2.1 million. One tenth of the population... Will that -- somehow -- gain us extra prestige? extra power on the world stage? No way! The country of WA would be an insignificant speck with no power whatsoever.

Except, perhaps, as a tempting takeover target for the countries which would otherwise have to pay for our iron ore...

Is it the excitement of self-rule?

Now that's possible... People who enjoy the power of.. power... would like it even more, if it were power within an independent country. Just think: our president could declare war on the rest of Australia!

Which leads to another issue: Would the rest of Australia be happy with whatever the nation of WA decides to do? If not, what could happen? Let's consider some examples:

Northern Ireland is British, the rest of Ireland is Irish. Would WA need to battle the Australian equivalent of the IRA, to maintain its independence? The Basques attack the rest of Spain. Would WA need to form a WA Separatist Movement -- and bomb other Australian cities -- in order to enforce our independence? Tamil Tigers used violence to support their demands for home rule (or whatever they called it). Would WA do the same?

The way I see it, demands for separation lead to violence. Mind you, so do demands for consolidation. Perhaps it's just any demands for change that cause violence...

Then I look at the European Union: a negotiated joining of quite a few countries. It has quite a few benefits and probably quite a few disadvantages. Because it was negotiated, it works. There are disagreements but no wars. There are benefits of scale without a total loss of national identity.

I'm rather proud of the commonwealth of Australia. I like to live in a country which is large, diverse, peaceful and prosperous. Where states work together to support all Australians.

I see more benefits in the commonwealth than we could possibly gain from separation. It would even be nice if we could include New Zealand in the commonwealth... perhaps as part of a "Pacific Union" rather than within a single nation.

Which brings me back to the original issue: We are attempting to solve the wrong problem.

So what is the problem?

The problem is, that the federal government attempts to take power from the states.

The current health "reforms" are an example. Give us your money, says the federal government, and we will give it back to you.

Eh?!

What they mean is, give us your money and we will give it back to you -- if you do exactly as we say.

We have yet to see any actual "reforms". There are suggestions of a different governance structure, management by district rather than by state. (WA is so centralised that we may well end up as a single district anyway...) How will this change benefit the actual provision of health services? We are not told.

There are hints... References to particular funding models which seem to work in some states. Though we are also informed that these funding models do not work very well with smaller numbers of patients, so the districts will need to be large enough to make it work. (One district for all of WA, perhaps?)

Why does this funding model require federal control? No answer... If it's really so good -- why can we (WA) not simply adopt that funding model?

Are there any other benefits to the federal government "reforms" of the health system? None that we have been told.

Give us your money and we will tell you what to do. That's the gist of the "reforms". It's a grab for power by the federal government. Either full power to the federal government is a good idea -- or, that is the real problem.

Now solve the real problem

The real problem with the proposed health "reform" is that it is -- purely and simply -- a grab for power by the federal government. Okay, not everyone sees that as a problem. But... if we want to continue as a commonwealth of states -- then increasing federal power is a real problem.

There are two key steps in solving this problem:

1. The Barnett government has taken the first step: resist the "reforms". Refuse to hand over power. Don't accept a short-term bribe, don't bow to threats, just insist on the right of the state to manage itself.
   
2. Then, effectively manage the state! The health system has issues: deal with them. Don't just say, for example, Get everyone through Emergency in four hours! Actually get in there and look for solutions. Then implement the solutions.
   

Sure, it costs money to implement solutions. Far less money than would be required to set up an independent nation. (And the independent nation would still have all of the problems within its health system.) Here's a plan:

Spend some real money and get our health system working. Look for good health service now leading to money saving later. Encourage prevention rather than cure, for example. Show every other state just how well our system is working. They will want to follow our example. Health systems will improve, Australia-wide. Our prevention strategy will gradually reduce costs.

Okay, that's simplistic! There must be plenty of ways to improve services and/or reduce costs -- if we are willing to listen. Work with the people in the system. Stop shouting orders and making absurd demands. Be willing to solve problems even if you -- the person in power -- did not think of the solution all by yourself!

Stop shouting orders which cannot be followed; start working with people. Forget about secession, it is not a solution to any of our problems.

Secession is a distraction. Solve the right problem. Forget about power-plays and hobby-horses.

Work together to fix our problems.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

my3Rs: the Index

Agamedes decides that this blog needs an index.
(Next, Agamedes hopes for a reader.)

Do you need new -- lateral -- thinking for your own problems? email nick leth at gmail dot com. Need solutions? No worries. Now.

Search for words using the Search my Rants bar beside the posts.

Or, follow my very small set of post labels (start at the foot of this post):

• blog: The historic first post to this blog!
  
• business: Business, businesses, management, making money... etc.
  
• crime+punishment: Law, legal processes, court cases, criminals, cops... etc.
  
• good.or.bad: Right & wrong, good & evil, moral & ethical choices, religion... etc.
  
• health-cares: Doctors, medicine, health systems & services... etc.
  
• here.and.there: Location, location, location... any named place.
  
• live.love.life: Lifestyle, quality of life, environment, bringing up children... etc.
  
• polly-tricks: Politics, politicians, political processes... etc.
  
• private.parts: Privacy, security, secrecy, personal protection... etc.
  
• teech.me: Education... etc.
  
• them+us: Prejudice, them vs us, lots of -isms... etc.
  

Read! Enjoy! Comment on what you find! Thank you!

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Who is Really at Risk?

Pacemaker woman banned from boxing ring: Agamedes wonders, Who is really being protected?

Under the headline, Woman boxer banned again, today's West (13 Mar 10) notes that Elisha Buckley has again been banned from competing in boxing trials. Buckley is a champion woman boxer -- with a pacemaker.

Do you need new -- lateral -- thinking for your own problems? email nick leth at gmail dot com. Need solutions? No worries. Now.

An "independent cardiologist" has said that it is safe for Buckley to compete, to fight against other women in trials for a world amateur boxing championship. So why has AIBA, the Amateur International Boxing Association, reinstated the ban?

I don't really know much about pacemakers but I can read. So I went to that great source of all knowledge -- good and bad -- the internet. Just a quick scan of the first few Google hits on "pacemaker lifestyle impact risk".

For some reason, doctors seem to be concerned about infection... Oh, okay, that may be because the body is cut open to install the pacemaker. And cutting open a body leads to the chance of infection. Heart rate... battery life... aha: lifestyle. This seems to sum it up: "Pacemaker patients can even participate in more strenuous activities such as marathons or scuba diving after consultation with their cardiologists. Any activity restrictions usually result from other medical problems and not from the pacemaker." (Wood & Ellenbogen (*), 2002)

Okay, that's an old (2002) article. But it's the first that I found that covers what I'm interested in: the risk of physical impact on the heart.

Again from Wood & Ellenbogen: "There are some situations, however, that are to be avoided if you have a pacemaker, such as full-contact sports, which may damage the pacemaker." Boxing may not be a "full contact" sport -- but the aim of boxing is to make heavy contact of your fist against your opponent's body. The chest -- containing the heart and the pacemaker -- must be a prime target.

So who is at risk?

Elisha Buckley may want to put herself at risk, to put herself into a situation where an opponent will try to hit her as hard as possible. Buckley is fully entitled to put herself at risk. A cardiologist has evaluated the risk and -- we must assume -- stated that the risk of damage to the pacemaker is low.

What about the opponent? Put yourself in the place of the next person to box against Buckley:

Your opponent is known to have a pacemaker. You can visualise exactly where that pacemaker is hidden. Do you deliberately aim for that pacemaker because it is a point of potential weakness? If you want to win -- of course you do.

Or do you -- as a considerate human being -- avoid punching directly onto the pacemaker? Do you avoid that area of potential weakness -- and set yourself up for losing? Or, can you possibly pretend that you do not know about the pacemaker, and fight your normal fight? No way! You either fight to win, or fight to lose. If you want to win, you learn everything you can about your opponent. Then you avoid strengths -- and attack at points of weakness.

On the other hand... Perhaps that pacemaker really is a point of weakness... Perhaps a severe impact may cause it to fail... and the results could be fatal.

Imagine this: You aim punches at the chest. You know that there is a pacemaker. You bypass Buckley's defence and score a major hit -- right over the pacemaker. The force of your punch moves the pacemaker, it stops working, Buckley is rushed to hospital.

Do you feel really bad? Of course you do. But you fought to win, and won.

Will Buckley's lawyers say, oh well, not your fault, just send flowers and we'll forget the whole thing... Oh, sure, like that'll happen!

Buckley is entitled to take any risk that she likes. (No strictly true. After all, we do live in a nanny state. But true enough.) Buckley may accept risk for herself -- but she is not entitled to change the sport, nor to bring extra risk to others.

By bringing a potential handicap to the sport, Buckley would affect other fighters. Do they hit hard at what they hope is a weakness? Or do they weaken their own chances, by avoiding the risk. Either way, Buckley will change the sport.

It's unfortunate that she needs a pacemaker. The pacemaker does not entitle Buckley to make the sport more risky for other boxers.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

(*) Wood & Ellenbogen, 2002: Cardiac Pacemakers From the Patient’s Perspective, by Mark A Wood MD & Kenneth A Ellenbogen MD, Circulation, American Heart Association, at http://circ.ahajournals.org/cgi/content/full/105/18/2136 as at March 2010

Medical Editor Misses Meaning of Slang

Agamedes notes the Rudd influence on a journalist's language: appealing to the masses through misuse of the Australian language.


"Smoko tradition runs out of puff" screams the headline (The West, 27 Feb 2010). "Perth health experts are sounding the death knell for that longstanding tradition among Australian workers -- the smoko", writes Cathy O'Leary, Medical Editor.

If you don't understand the word, perhaps you should avoid its use.

Do you need new -- lateral -- thinking for your own problems? email nick leth at gmail dot com. Need solutions? No worries. Now.

The "smoko" may have begun as a break to allow smoking of a cigarette. As long as 40 years ago -- by my memory -- "smoko" meant the morning or afternoon break for tea. Yes, it's a chance for a smoke. The meaning of smoko, however, was -- and still is -- a break from work for tea and a snack.

O'Leary: please check Wikipedia. Or the Macquarie Dictionary, if you want to be more formal. "Smoko" is a break from work, a tea-break. In Australia at least, the association with actual smoking has long since disappeared.

A nice play on words. A clever attempt to use slang like a Rudd: and wrong.

Sorry, O'Leary, would you like to try that again? And check the correct meaning of each word? Meanwhile, stick to the medical reporting. And fire the sub-editor who was out at smoko when this article slipped through the checking.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

Livers for Life: Donate Yours Today

Agamedes points out that recent debate over liver transplants is misguided. It is not, "Should this person get a new liver?" The correct question is, "Which person will you sentence to a certain death?"
..o0o..
On Friday 26 February, the Editorial in The West missed an important point. The Editorial describes the impossibility of taking the emotion out of "a decision ... when the alternatives are giving ... a chance of a future and consigning her to a likely death". The "decision" is to not put a person on the waiting list for a second liver transplant.

The particular person is either "a 24-year-old mother of two small children" or "a heroin addict" -- depending on which emotional strings you wish to pluck. In truth, of course, Claire Murray is (or has been) both.

Do you need new -- lateral -- thinking for your own problems? email nick leth at gmail dot com. Need solutions? No worries. Now.

As an aside, let's look at my previous paragraph. Claire Murray is or has been a mother of two small children? Well, how small is "small"? We make them small children in order to elicit more sympathy. A mother of two great hulking teenage brutes would have less emotional impact. And she is or has been a heroin addict: she has been "clean" for eight weeks. Eight weeks? Is that "clean" or is it simply a minor delay in the supply chain...

"Heroin addict" has pushed Murray off the waiting list for a third liver. (The first was her own, the second she destroyed by use of heroin.) "Mother" and "clean" are emotional attempts to get her back on the list.

The actual decision

The decision is not, Should Murray get a liver? The actual decision is, Who shall we kill in order to give Murray a chance at life?

There is a limited supply of donor livers. If Murray gets one of that limited supply then she gets another chance at life. The decision will also condemn another person to a definite death.

It is not a choice of liver or no liver. The true choice is, Who shall we condemn to death?

The correct corrective action

Everyone: Sign up today to allow your liver to be donated! Tell your family, let it go, I want to donate. Encourage all of your family -- and friends, and casual acquaintances -- to allow liver donation. What we want, is enough livers to satisfy the entire demand.

Sure, some people may go through a liver a day. If we have livers to spare, who cares! Sure there is a limited number of surgeons to do the work. While we're waiting for the potential donors to die -- we can train up some specialists.

The key limitation is the supply of donor livers. Today is the day that we can act to -- eventually -- remove that limitation.

And now... back to reality

Australians are, it seems, reluctant to donate livers. So there is a shortage of donor livers. How do we deal with that shortage? How do we decide who gets on the waiting list?

No, sorry, that's the wrong question. Or, rather, we can simplify the problem by asking a better question:

• How can we prioritise the people on the list to be liver recipients?

Being put on a list means nothing -- except some minor assurance that someone cares. Being off the list means death. Being on the list means that there is, at least, some hope. If there is a sudden surfeit of donor livers -- you are in with a chance.

We still have two problems: (1) There is a shortage of donor livers, and (2) different people offer different chances of putting a new liver to good use. All that means is, that we need (or want) to put some people nearer the top of the list. So do it!

1. Put every potential liver recipient on a list for a possible future liver transplant.
   
2. Separate them by blood type -- or whatever it is that determines compatibility with a donor liver. It's no use fighting over a liver which is not compatible with your body; each liver "type" may as well have its own waiting list.
   
3. Each person on each list gets a score out of 100, based on the current transplant criteria. For example: has been drug addict, minus 50 points; is now "clean", one point per clean week; lives with supportive parents, plus three points...
   
4. Do the current criteria include factors such as time on the waiting list? If not, add a few points for each month on the waiting list... More bonus points for those who are closer to death... Extra points for "cute", or "per child under ten", or "donates to charity"... or whatever criteria are acceptable, measurable and agreed.
   
5. A liver becomes available. Check the list for this "type" of liver. Whoever is at the top -- of the relevant list -- gets it.
   

The choice is not, this person can or can not have a liver. The true choice is, if we give this person a chance at life then this other person is condemned to death. It would be nice to give everyone a chance at life -- but there is a shortage of resources; there are too few donor livers to help everyone.

But everyone can be on a list; everyone can have hope.

Oh, and if you are convicted of murdering all the people ahead of you on the list: that's 100 points off your score. But there is still hope... Because, after all, everyone deserves to have some hope.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com

A Snowball's Chance in Health

What hope is there for our public health system, when an accountant is put in charge?

Let me phrase that differently: What does it tell us about the public health system, when an accountant is put in charge? Let's have a quick look at history...

Fong came across from a large, private hospital. Apart from feathering his own nest, with a new head office close by his main place of work -- Subiaco oval -- was he successful? Or was he just doomed to fail... Think about his experience, running a private hospital.

A private hospital charges for its services. You want more treatment? You want better treatment? Fine, you get to pay for it. The more services offered, the bigger the profit. Whereas a public hospital is given a fixed amount and told to work miracles. Fong had absolutely the wrong background, absolutely the wrong experience, to head up a public health system.

Then there was Flett. A doctor. He may well have retained some sense of the need to cure people. No time for that sort of nonsense...

Now we have Kim Snowball. An accountant.

If you put a doctor in charge of health you can't help but think, the focus will be on curing the sick, on preventing illness, on improving the health of the people of the state. Put an accountant in charge and there is only one conclusion: the most important task for the new head of Health, is to balance the budget.

The most important task for the new head of Health, is to balance the budget. Well, actually, there's nothing wrong with that. As long as the aim is clear, and well known.

The scope of health care

Consider this: You have just won $100 and you decide to spend it all on food. Do you, (a) Spend it all on a slap-up meal for yourself and your partner? (b) Bring your family and friends to a take-away food joint and shout them all chips and a drink?

You could even go for, (c) invite your neighbours, who have just been through a rather difficult time, to join you for dinner.

All of these options have good points -- and bad. All have equivalent options in spending the Health budget.

Spend the entire health budget on health care for taxpayers and their dependants. Why not? After all, it is taxpayers who provide the money for health. Why should we spend on people who do not pay -- perhaps have never paid -- tax?

We -- taxpayers and others -- seem to accept that the health budget will be used to provide health care for everyone. Whether or not they pay taxes. Especially if they are unable to earn money to make them liable to pay taxes. So (a) is rejected..

Spend the health budget only on taxpayers and their fellow citizens? That sounds sensible. After all, we have an obligation -- a duty of care -- for all the people who live here.

Do you need new -- lateral -- thinking for your own problems? email nick leth at gmail dot com. Need solutions? No worries. Now.

Only trouble is, there is the same money but more people to use it. There is less Health budget per person.

Invite our neighbours -- those on their way here, those who live in other countries -- to share our health resources. This is a very nice thought. It just costs a lot of money. Or -- with a fixed budget -- there is less health care available per person.

This is what it boils down to: We can spend a lot of money per person on very few people, or not much money per person on a whole lot of people. In fact, we try to strike a balance: spending a reasonable amount of the Health dollar on a reasonably broad range of people.

What do we get for our money?

Back to that $100..

Our neighbours are really, really struggling. They are reduced to eating dog food, when they can afford it. Then there's widowed Aunt Mabel, who eats enough but can never afford a treat. The immediate family eat well, perhaps too well, with too much fat and sugar in the diet.

Do we shout the neighbours one, good meal to keep them going for a day? Or perhaps we spread the $100 to a standing invitation to join us for sandwiches, for lunch every day for the next few weeks. Do we spend all the money on the struggling neighbours? Or should we save some for Aunt Mabel...

We could offer our neighbours lunch for just one week. That would leave enough money to provide a treat -- dessert for one meal, perhaps -- for Aunt Mabel.

Perhaps we should spend some -- or all -- of our money on ourselves. After all, if we buy expensive but healthy food for all of this week, our eating habits may improve. This will have long-term benefits... though Aunt Mabel and the neighbours will suffer here and now. (Well, Aunt Mabel won't "suffer". She will just miss out on an unanticipated benefit.)

What do we get for our Health money? There are the same choices: Alleviation of immediate suffering, Short-term improvement, Possible long-term gain... It's a political choice. The head of Health must balance the budget within the choices of the politicians.

Oh, and don't forget that there are demands... Some family members want to help the neighbours. All of you want to give Aunt Mabel a treat, though you disagree over the actual type of treat. Some of you would prefer you usual fatty, sweet meals because the benefits of healthy food are too far away in the future. And no matter how much you argue, the agreed spending is far more than $100.

Then there's the technology of medicine Okay, so you've agreed how to spend that $100. It adds up to $110 but you're sure you can buy some of the food on the cheap.

But you overlooked the cost of food preparation.

You provided fresh food for the neighbours -- but they don't have a fridge. Do you buy a fridge, rent a fridge, share your own fridge (with all the inconvenience that causes)?

You buy a small cake for Aunt Mabel. As you deliver the cake, the car runs out of petrol. You are forced to buy petrol on an expensive day of the price cycle. And the time taken to deliver the cake meant that you missed the first healthy meal with your own family. You just can't be everywhere!

As it turned out, that healthy meal was a waste of money. All the guests brought a plate -- of their favourite sweet and fatty food. Still, one of your children did seem to enjoy the healthy meal and looks like improving their eating habits. Was it all worth it, for just that one improvement?

Unfortunately, that meal had other problems. Because you let you neighbours share your fridge, the healthy food was kept in an esky. Overnight. Your partner is suffering from food poisoning. You are accused of penny-pinching, when you should have simply bought a second fridge...

Spending the Health budget is a lot like that. There are choices, on who to spend it on. There are choices, on what to buy. There are choices -- and possible large costs -- involved in the wide range of available health technology. Do you buy the latest model MRI scanner, or stay with the old one? Do you buy one MRI scanner per hospital, or do you buy more ambulances, to transfer patients to one central scanner?

There are always choices -- and never enough money.

A Snowball's chance in Health

Running a Health system is not about providing a health service. It's about choice, within limited funds. Who do you help? What help do you provide? What technology do you use? There are demands to do everything.

To put it another way: Who do you decide to not help? What help do you not provide? What "old" technology do you put up with because the new technology is very expensive? And whoever you do not help -- will complain very loudly.

That's why Health is to be run by an accountant. It's about balancing a budget, not about providing a health service.

Perhaps a juggler would do even better.

Independent thinking & independent analysis of your problems by Agamedes Consulting. Support for your thought: email nick leth at gmail dot com