Reflections on Terry Pratchett's Choosing to die

Today has been a little strange re assisted death.

Last night the BBC showed Sir Terry Pratchett’s documentary about assisted death, which included him being present at the death of one man (Peter) at the Dignitas clinic in Switzerland, and having a final conversation with another who chose to end his life there.

However, today’s first couple of hours for me included listening to Radio 4’s Today programme and a debate between a woman with cancer, Christine Jackson, and The Right Reverend Michael Nazir-Ali, ex-Bishop of Rochester. This included the pious Nazir-Ali patronizingly telling Ms Jackson that she shouldn’t worry about her death, as medicine means she can feel no pain at the end – one of many answers to a question other than that he was asked that he gave. The Right Reverend managed to ignore the debate about the individual to reflect observations about family – including a bold statement that the impact of an assisted death has a greater impact on those left behind than any other death might, with no evidence to support this ludicrous claim – then, when the discussion was about family took it to a bland, Christian version of society, and his perceived negative impact of assisted death upon its construct. And the Right Reverend’s snidey dismissal of Pratchett’s emotional acknowledgement of Peter being a “brave man” (by comparing his bravery with that of Iraq veterans) was, frankly, beneath a so-called man of the cloth.

Alongside his patronizing of Ms Jackson, which ignored her concerns about the quality of her life, as she experiences it (rather than others might, niaively, observe it), Nazir-Ali also criticised the BBC for not taking the opportunity to present a “balanced programme” on assisted death. Basically, he castigated them for the programme not being a different one: it did not fully present the views of family members; it did not present the “other side” of the argument – as if all BBC programmes should be similarly balanced.

I look forward to Songs of Praise coming from a Satanist coven next weekend.

This evening I watched the programme Sir Terry had made, and it was profound.

I come at this as someone who is not a stranger to death, nor to others’ thoughts and desires for control over the end of their life:

- I remember my maternal grandfather dying of “complications” following abdominal surgery – to this day I believe that, had he been 20 years younger, there would have been a very different approach to the pain he articulated as he died a horrible death from internal bleeding following a botched operation;

- I remember my maternal grandmother dying with acute Alzheimer’s disease (the same disease Pratchett has) that left her unable to recognise her only daughter and in a daily state of panic and fear about a world she did not understand;

- I remember my father living and breathing artificially whilst waiting for me to make a 24-hour journey from deep in Eastern Europe to say my goodbye. And, 30 minutes after I arrived, him pulling at the oxygen mask that had kept him alive for the previous 12 hours saying, “I’m ready”, then having the mask replaced by hospital staff. And I remember me helping him remove it in response to his gestured request, and keeping it from his airways as he once again implored to have the mask taken from his face. Then he died;

- And I have experienced someone collapsing on me, having total renal failure and – literally – dying in my arms; a virtual stranger with whom I shared his last living breath.

I have known over 20 friends and acquaintances who have died.

And I have friends with terminal illnesses, and with severe disability for whom a good day is a day when the physical pain is manageable enough to be able to forget about it long enough to read a few pages of a book.

For me, the crux of the programme was about the need for a legal, moral, safe way for an individual to be helped end her or his life at a time of their own choosing if, in their opinion, their life was no longer worth living. A framework for well-managed assisted death, so as to avoid a much worse death in the future.

Dignity in Dying has long campaigned for a change in the law, and I support that change. Theirs is for a careful legal development to enable someone terminally ill (yes, there are clear ways in which to determine such a diagnosis) and of sound mind to decide to have their life ended with professional assistance. I fully support such a change in the law, and, seeing Pratchett’s programme, feel all the stronger in this conviction.

Let’s be clear – such a law may have helped Peter, given his condition. It would not have helped Andrew and, whilst I feel personally conflicted about that, I nevertheless recognise the need for the safeguards that a law focused on the terminal ill would give.

It is an outrage that I could, if I needed to, have a vet come and administer drugs that would kill one of my cats if she or he was terminally ill and in suffering. I would be able to feed them their favourite fish or treats one last time and hold them how they like to be held as they breathed their last, knowing they had a less painful death than they would otherwise have had. And yet, my friend with an eventually life-taking disease, or another friend with incremental disability can currently be afforded no such professionally supported and dignified death in the UK.

If you have not seen Terry Pratchett: Choosing to die, I urge you to take whatever fortification you need and watch. At the end, I hope you would – through your tears - choose to join Dignity in Dying (http://www.dignityindying.org.uk/) and support their campaign for a change in the law in the UK.

O'Brien's enemy?

Cardinal Keith O’Brien, head of the Catholic church in Scotland, thinks I am his “enemy” and accuses me, and like-minded people, of trying to “destroy” Christian heritage and “take God from the public square”.

Christian denominations need no help from atheists, secularists or believers in other theistic models to reduce the reach of their faith. Church attendance in the UK – surely a good barometer of people’s active adherence to the Christian faith – is declining, has been so for many years, and is predicted as continuing to decline.  In particular, younger generations are rejecting the belief system the Cardinal and his ilk peddle, with 75% of 15-29 year olds and 80% of under-15s not being “in the church” (http://www.christiantoday.com/article/researcher.anticipates.further.church.decline.in.2010s/25949.htm).

As with the many other theistic systems that have fallen by the way over the millennia, more and more people are seeing the myths of Christianity for the, at best, “nice parables and stories” that they are, and are no longer accepting the hypocrisies of organisations that claim to have the only moral framework for humanity whilst perpetrating systematic abuse (e.g. the papal directive that condoms should not be used in response to HIV – an example of an occasion when a church leader could have single-handedly enabled generations to avoid infection, but chose not to), and shielding multiple numbers of paedophiles who used their positions of “moral authority” to demolish the very innocence they preached whilst often leaving the abused feeling somehow responsible for their abuser’s actions. And Pope John Paul II who was instrumental in both these examples is now up for beatification!

Yet, at the very same time that Cardinal O’Brien is claiming religion is being marginalised, we have a Prime Minister endorsing the “enormous contribution” of Christian values to Britain (as the ink is barely dry on his oh-so-Christian attack on immigration) and inviting senior church officials to Downing Street whilst his Minister of Hate, Baroness Warsi, takes a break from her belief-excused homophobia to remind us that the coalition do indeed “do God”. And we have a Deputy Prime Minister who, before the election, told us rather sheepishly that he is “not a believer”, but has now conceded that it is somehow okay for 26 senior Bishops to continue to legislate in a reformed House of Lords. (These Lords Spiritual have been especially disgraceful in their attacks on proposed legislation towards assisted death and their opposition to equality legislation, particularly that which hammers at some of their entrenched doctrines of discrimination on the grounds of gender and sexual orientation.) Is such political influence really evidence of marginalisation in society?

The Easter messages of Christian tolerance have also included the Catholic Archbishop of Westminster, Vincent Nichols, suggesting that atheists such as myself are more likely to see “killing oneself or a loved one” as a “beguiling temptation”. He then claimed “We [people of faith] know better because we live these truths of faith”! The arrogance and vitriol in this speech are all the worse for them coming from someone who is claimed as a moral leader. And when over two thirds of religious people support a change in the law (British Attitudes Survey, 2010), for him to claim otherwise is a lie, pure and simple. Some moral leadership.

O’Brien, Nichols and other faith peddlers need to recognise the society they live in. The UK can no longer be described as “Christian”, no matter how much they inveigle themselves into our political decision-making and gain unchallenged public platforms to spout their nastiness and have it regurgitated by the conservative media that smells a good opportunity to knock equalities (the hysteria of ex-Archbishop Carey screeching “it’s political correctness gone mad” and Lord Patten, new Chairman (sic) of the BBC, pompously claiming that "some of the arguments put forward by secularists against the Pope's visit were lacking in intellectualism and were extraordinarily mean-spirited" this week are beyond satire).

If recognising and protecting the equal rights of all people in this country, and pushing to separate our legislature from those who believe in unprovable mystical beings, and seeking legislation to enable individuals who so choose, to be able to end terminal suffering with a caring medical intervention is regarded as “taking God out of the square” and the stance of an “enemy”, then O’Brien can now be content he has one in me.

 

Left-handedness. Yes, it can matter

“Imagine a truly radical party of the left….which enacted legislation saying that all scissors had to be left-handed, that writing would be from right to left, that machinery and tools of all sorts should be built only in left-handed forms. One imagines that right-handers would protest at such changes, but in that case left-handers also have a legitimate protest against the present situation.” Chris McManus in Right hand, left hand (2002, Phoenix)

Right hand, left hand explores asymmetry in the world; in chemistry, in all forms of life on earth, in particle physics, and in the modern world experience of humans. The quote above comes as McManus begins to explore some of what he terms left-handed myths, such as “Left-handers die younger than right-handers” and famous right-handers erroneously claimed as lefties (Billy the Kid, Picasso, Einstein). But he also identifies some interesting, if rather banal, lefty facts.

The muppets were mostly left-handed – had Jim Henson scored one for the lefty underdog making a left-dominated puppet world? McManus deflates this notion by explaining that, as most puppeteers were right-handed, the right hand got to do the most complicated puppetry – namely working the head – so the left-hand got to control the hand as the less complicated work. (Though The Simpsons is populated with many left-handers, including Bart and Mr Burns, reflecting Matt Groening’s own left-handedness http://simpsons.wikia.com/wiki/Left-handed)

Most right-handers I have talked to about handedness did not consider handedness as having an impact in the world until it was pointed out by a lefty. And its probably fair to say that most would still not give handedness much credence as an issue of any great importance.

So, I have an idea for a TV show.

It would take a magazine format enabling a series of regular slots appealing to different parts of the audience. It could be called More than one in ten or The left bank and definitely not anything crass like Human lefts. And it would explore the world as experienced by left-handers.

Presented by lefties (perhaps Nicole Kidman and Keanu Reeves could do the honours?), it would include:

1. Nature – such as handedness in flatfish, or the left spiraling narwhal horn

2. Science – how molecules have handedness that can make significant differences, such as how the right- and left-isomers of carvone have different smells, or that the two forms of thalidomide have different biological activities, with only the right-handed form being teratogenic and being responsible for causing birth defects.

3. The arts – whether exploring famous lefty artists (Escher, Klee), or musicians (Geldof, Lydon, Hendrix, Plant).

4. The day-to-day world – my favourite section – where famous right-handers are given simple tasks to do using left-handed equipment.  Much of this would be based on my own childhood experiences:

We could all laugh at the “stupid” person not able to neatly cut a drawn circle from a piece of paper as the left-handers scissor blades when held in the right hand push apart not together, and the right sightline of the circle edge is covered by the top blade.

We would chuckle at the slanty bread and cheese slices the righty would cut with a left handed bread- or kitchen-knife.

We’d giggle at the clumsiness of righties using left handed tin openers as their weaker hand turns the handle in the opposite direction to the best use of their thumb strength, or perhaps a waiter’s bottle opener, when the blade of the cutter is upside down, and again the turning motion contradicts the strength of the hand.

Or even getting righties using a left-handed chequebook, and finding that it makes it harder to write their signature because the hand rubs up against the stub of the book, followed by having a cup of tea from a left-handed mug where the witty homily on the side can only be read whilst drinking if you hold the mug in your left hand, rather than the usual right-handed ones.

And we could have a spot where people demonstrate how right-handed so much of the world is, by making left handed examples of common gadgets (positioning credit card pin machines for left handers, not right handers; designing DIY electric tile cutting machines or two-handed Black & Decker drills left-handed; giving everyone a left-handed computer mouse as standard).

On the first programme I’d have Christopher Seed and his left-handed piano (http://www.lefthandedpiano.com/) that enables him to play the usually more complicated, tuneful parts with his stronger left hand rather than with his right when he played a standard piano. And then get Tim Minchin to try playing it (I don’t know if he is left or right-handed, but he can play the fuck out of a standard piano).

  

Okay, handedness isn’t going to be making the list of equality issues campaigned on by the Equality and Human Rights Commission any time soon. But it could be an interesting programme nevertheless.

And it would be on the BBC. As penance for their decades of dextrism.

In 1967 the BBC test card for colour broadcasts was produced. It had a girl sitting playing naughts and crosses on a blackboard holding a piece of chalk in her right hand. Awww. Cute. Or a little eerie. But the girl was actually left-handed in real life, and the original photo had depicted her as such. A BBC executive demanded that the image was reversed as it was felt to be somehow “inappropriate” to show her as left-handed. 

Dextrist bastard.

Ottolenghi's NOPI restaurant

Vegetarian readers of the Saturday edition of The Guardian will likely have become intimately acquainted with Yotam Ottolenghi's complex recipes that reward with perfect flavour combination. And have in all likelihood bought up his collection of veggie recipes, Plenty. Well, I certainly did. It has, so far, proved capable of delivering superb food from every single recipe tried so far. The news that Ottolenghi was to open a restaurant, just north of Piccadilly in London - hence the name NOPI - led to the possibility of creative, diverse, exciting veggie food (along with meat and fish dishes) and led to a table reservation on the second weekend of March.

The first thing that greets you at NOPI (after a phone call 24 hours earlier to check you are still coming - a sign of a sold out restaurant?) is the brightness of the space it occupies. White everywhere, including lots of stylised tiling (I found this pleasingly clinical; my dinner partner felt it was a bit reminiscent of a bathroom – though the highly mirrored bathrooms themselves are something else). The whiteness is offset by huge brass light fittings and the light wood of the tables. Oh, and the big table with some massive loaves of bread and a big dish of a pinky substance.

The waiting staff seemed to embrace the relaxed atmosphere, open to chat about the restaurant, Ottolenghi and, of course, the food.

As we absorbed the menu, a complimentary dish of the pinky stuff - a beetroot and, I think, crème fraiche pate - arrived with slices of gorgeous bread, which were replaced as needed.

NOPI describes its food as sharing dishes. They are, though portions are not massive. Dishes also arrive as and when ready from the kitchen, so don’t be expecting to have it all there at once.

So, what was the food like? Honestly? It was some the best flavours I have ever tasted.

A grain-based dish combined braised artichoke and succulent broad beans with hits of tangy pickled lemon. A soft, creamy burrata was ably matched by explosions of blood orange and crushed coriander seeds. Mung beans became exciting when served with braised baby carrots and smoked labneh.

The lamb balls in a creamy sauce were evidently tender, though rich. And the beef dish was described as “possibly the best beef I’ve ever tasted” and certainly my partner’s highlight of the savoury courses.

For me, the highlight was the baked blu di bufala cheesecake. This warm cheesecake, almost soufflé-like in texture, was complemented by sharp pickled mushrooms; again, a perfect marrying of unconventional flavours.

The sweets on offer all sounded fabulous. But the chocolate, peanut brittle, mace and crème fraiche was a puzzling mix of ingredients that looked like they shouldn’t work together, but so do. And the churros served with hot chocolate sauce to dip into then coat with fennel seed sugar was both ludicrously sweet and utterly more-ish.

On the drinks side, we sampled a couple of the cocktails - the pineapple and sage martini being a particular favourite.

Downsides? In terms of the menu, I had none. The setting is relaxed and we did not feel rushed. Tables, though, are close together (which means that you can earwig in on neighbours who might, for example, include a vegetarian who eats scallops…)

I’m looking forward to my next meal there and seeing how the menu develops and changes and spending another couple of hours marvelling at Ottolenghi and his team.

Two rational ways to save the NHS money

The NHS is under the most vicious politically motivated attack it has seen in its lifetime. The level of cuts being made means no part of the NHS is immune to wholesale pruning, with some areas (e.g. experienced primary care commissioning) being destroyed to meet Andrew Lansley's blinkered mantra that the market can deliver more efficiency.

In the midst of such change it makes sense to me that rationality is applied to reforming aspects of the NHS and to making savings that are, at least, logical in terms of least impact on healthcare. 

This is exemplified by the current practice of applying clinical- and cost-effectiveness measures to proposed interventions. For example, if an expensive cancer drug (say £60,000 per round of treatment) is being touted as slowing down the advanced stages of liver cancer (say, by giving two weeks' extra life), should a patient on the NHS be able to get this? If I was the individual with the cancer, or had a loved one with the cancer, I’m sure my gut response would likely be "Of course - if there is a chance it will work then it should not be denied me." But, for an NHS with a finite budget, this response is not good enough and requires further scrutiny.

Firstly, is the intervention actually proven as clinically effective? Is it likely to have the positive impact the drug company claims? To answer this, the NHS needs to rely on real clinical evidence, ideally from randomised double-blind trials with significant numbers of people. "Rule of rescue" - the "we've tried everything else, so let's give this a shot too" is not a clinically sustainable rationale.

And secondly, even if an intervention is clinically proven as having positive impact, there remains another tough calculation that must be considered; the balancing of the health gain of that £60,000 spent on one individual with what else could be done with the same money in other treatments.  Seeking cost-effective treatments (and not spending on a clinically-proven but not cost-effective one) is something that our NHS does, and, for the most part, does well. It is potentially harrowing to take such decisions, but the NHS commissioners who do this are contributing to ensuring the NHS is the most effective in meeting the health needs of the whole population. As it should.

So, in the spirit of the coalition government's strap line "We're all in this together", I have a couple of suggestions of savings that could be quickly made to the NHS, and which would have zero impact on the health outcomes of anyone going through any part of the NHS.

The National Secular Society has just published a study into the money spent by the NHS on hospital chaplains: http://www.secularism.org.uk/uploads/nss-chaplaincy-report-2011.pdf It shows that the NHS could save £29m per year by stopping paying direct costs for chaplains. The study does not cost out the provision of rent-free office space, for example. So, if religions wanted to continue to provide chaplains, there is nothing stopping them doing so (they can visit, and could even continue to have rent free space). But the NHS should not be paying for them; the people who believe the particular set of myths relating to the faith group of that chaplain should.

It is not enough for believers to just claim that, for example, intercessory prayer works; where public money is involved, it is instructive to apply the clinical-effectiveness test to this NHS spend. The 2006  Study of the Therapeutic Effects of Intercessory Prayer (STEP) is the largest scientific study to date on the impact of prayer on health outcomes, involving over 1,800 patients. Its two key findings were:

1) “Intercessory prayer had no effect on recovery from surgery without complications.”

2) “Patients who knew they were receiving intercessory prayer fared worse.”

Or to put it another way, intercessory prayer is not proven to work.

 

This does not mean that it is "wrong" for people to pray for others. Indeed, those doing the praying are likely to report feeling better about the ill health of others, and, for those who believe and know they are being prayed for, they may take comfort from others’ praying. But this is not the same as a positive clinical output.

The STEP study is a robust randomised double-blind trial of the kind we demand from any other NHS spend. Well, almost any other.

In the UK another £4m could be saved every year by not spending NHS funds on homeopathy.  At a time when we are making significant cutbacks in clinically effective interventions, it beggars belief that we sanction the spend of £4m on a quack pseudo-remedy that consistently performs no better than placebo in double-blind trials. If an individual wants to spend their money on sugar pills and water, they can. But we should not spend public money in this way.

Like the religious, followers of homeopathy (once the pseudoscience of "water memory" has been debunked) resort to "it's about belief not science".

Until and unless we have an NHS with infinite funding, the provision of services through it should not be based on unproven belief systems, but through the same scientific rigor we apply to every other intervention. 

Let England Shake - Starting with London's Troxy

When the house lights finally dimmed at 8.50pm, the sparse stage of the Troxy (with a nest of keyboards, drums and guitars stage left, monitors perched on pieces of household furniture) was taken over by the presence of PJ Harvey. Head to toe in a flowing black dress, emphasised by a 14-belt black Ann Demeulemeester corset and knee high boots, the stage character was captured in her crazed black feather headdress - surely the largest headdress of this tour so far? It was as if she was wearing the black angel from Angels in America.

The first strum on one of two tuned autoharps opened Let England Shake and Polly Harvey had the stage and the audience in her hands.

The set was made up of the same material showcased in earlier shows across Europe. But this was not a simple going through the motions.

Firstly, Polly was living the "heavy words" of this war-laden album and on many occasions (such as for The Last Living Rose, or Hanging In The Wire) she held her final poses whilst the lights faded to black around her, seeming lost in the emotion she was trying to express through her songs.

Secondly, the band is much tighter than when they performed a webcast from Paris two weeks ago. In particular, Mick Harvey seems to have settled into his various roles and appeared relaxed, to the point of joking with John Parish about the levels of dry ice accompanying Written On The Forehead. 

But most impressive of all was Polly's voice. On the album, the transition from her White Chalk days of an often fragile voice is not complete; England and On Battleship Hill retain some of that fracture on the album. But in the Troxy they took on a belligerence and drive that gave fresh strength to these songs, and delivered the moving poetic lyrics with new power.

All tracks on the album got an airing, and were occasionally interspersed with careful forays into her back catalogue. Down By The Water and C’mon Billy were particularly impressive as they took on a more gothic feel through the combined autoharp and guitar mix. Big Exit was full of energy, as were a raucous Meet Ze Monsta and Angelene.

For me highlights (of many) were Let England Shake, Bitter Branches, and Silence. The only disappointment was Written On The Forehead, which was about the only occasion I thought the guys were out of synch with Polly.

I've seen Polly four times now, each a radically different sound and drama experience. It is pretty pointless trying to compare this show with Somerset House (Uh Huh Huh tour), the Royal Festival Hall (White Chalk), or the Beacon Theatre New Yorker gig. This was 100% Polly, and I am dazed by the power of this evening's performance and content.

At the NME Awards she said that this was "just the beginning" for her. I've no idea where she'll be taking us in the future, but, on the experience of tonight, it can only be an amazing ride.

Don't call me religious

Towards the end of March citizens in the UK will be taking part in the national census. The Office of National Statistics (ONS) describes this as "Taking a snapshot across the nation, on one day once a decade", suggesting that it "helps plan services across the whole of the UK.” Notwithstanding the fact that the Tory-led coalition is systematically undermining services across the whole of the UK, I believe the capture of good census data is important. It helps us, for example, understand the rich diversity within the UK and the complexities of the communities we live in. This, in turn, helps forward-thinking organisations identify those who should be receiving services and then to redesign services to reach them.

However, one question in particular risks giving a distorted view of life in the UK: the one on religious belief.

As in 2001 (the time of the last census), the question being asked in England and Wales is "What is your religion?" The first option to respond with is "No religion", followed by six religions and an "any other religion" option. In Scotland, the question is "What religion, religious denomination or body do you belong to?" The first option to respond with is "None", followed by three Christian denominations and a further five options.

These questions are flawed.

Their leading nature implies I have a religion, and frames the question as if everyone does have religious belief. The fact that the first response is "No religion" or "None" does not make sense in the context of the questions as they are posed.

The British Humanist Association (BHA) is leading a campaign against these questions (see http://census-campaign.org.uk/). Last year, the BHA presented the ONS with rational arguments against the question, proposing that the primary question should at least be along the lines of "Do you have a religion?" Interestingly, when the ONS itself had tested a version of this ("Do you regard yourself as belonging to a religion?") this decreased the number of people identified as religious, and increasing the proportion of non-religious people. Strangely, they used the fact that this question reduced the number of people identifying as following the Sikh religion (as it meant some identifying as Sikh, whether practising or not, no longer ticked the Sikh box) as a reason not to ask a more biased question!

In practice then, the question as asked leads those who consider they have an identity, though not necessarily a faith, to be counted as if they are practising believers. The Board of Deputies of British Jews is encouraging all Jews, practising or not, to tick the Jewish religion box, and I'm sure other faith organisations are encouraging their followers likewise.

So does it matter? Yes! Try this not altogether ludicrous parallel question that could conceivably be asked:

What animals do you abuse?
a) None
b) Horses
c) Sheep
d) Gerbils
e) Other

If you think the question makes an unfair implied assumption about you, despite giving you the option to say "None", then you should support the BSA campaign against the equally absurd religious questions being posed in England, Scotland and Wales.

The fallacy of "efficiencies" in Lansley's NHS

One of the sad facts about the swathing cuts Health Minister Andrew Lansley is wielding is the negative impact this will have on the health of the population in England.

Ask anyone in the NHS - whether frontline, support or backroom staff; whether commissioner or provider; whether local or regional - and one thing they will tell you is that dealing with structural change takes away from doing the day job. This applies, whether or not the changes being undertaken are good for the nation's health (e.g. some targets, such as the 18-week target or smoking cessation), or, like the nonsense that underpins Lansley's current efforts (e.g. the notion of "efficiencies").

Of course we should be ensuring that public services, like any other, are as efficient as possible. But to deny the fact that, for years, the NHS has been not only seeking, but delivering efficiencies year on year, would be crass. PCTs and Health Trusts have been "rationalising" backroom functions and layers of management cumulatively. Yet Lansley insists on peddling an image of a bloated NHS with wasteful managers in PCTs doing nothing and being paid astronomically for it.

Some questions Lansley might usefully consider answering honestly include:

1. Which layer of the NHS has delivered value for money in the provision of secondary health, through year on year rigorous commissioning and close monitoring against contracts? (Answer - the PCTs he is demolishing)

2. Which layer of the NHS has reduced the gaps in health inequalities (that mean that people in the same region can have life expectancies 10+ years worse than others) through the targeting of services at the most vulnerable? (Answer - oh yes, it's those PCTs again)

3. Which layer of the NHS has the talented workforce with the skills to commission robust secondary care that meets the needs of local populations, rather than pretending we can all have an NHS built around our individual needs? (Answer - PCTs, with their expert commissioners)

Lansley asserts that GPs are "best placed" to commission health care in England, because they know the needs of individual patients. The reality he chooses to ignore is that any health care provision that comes from a finite resource (a resource, by the way, the coalition is reducing, in real terms, against the rising demands of an aging society) requires my needs to be measured against those of my neighbours and others. The proposed GP consortia will struggle to deliver the influence and pressure PCTs have delivered in screwing the best value out of providers because of this lack of scale.

And please, do your best not to have a rare condition in the second half of a financial year. In the first half, you may get lucky with your GP spending well above the allocated amount of money on "your" healthcare, to give you an appropriate, but expensive intervention.  But when the year is halfway through, and the consortia are over-spending without a bail-out from Lansley, because they do not have the detailed financial skills to manage finite resources that reside in PCTs, don't expect to be able to get the same high-cost treatments.

I predict that, by the end of this parliament, the health of the weakest and most vulnerable will have deteriorated; the so-called postcode lottery for treatments will be more stark than ever before; and that a fresh NHS restructure will be looming. And Lansley will have achieved the Tories' aim of beginning the systematic breaking apart of one of our most treasured and necessary institutions - an NHS free at the point of delivery for all.