Gaming the system - ambulance response times

It turns out that if emergency services try to chase response times then the public can get screwed over, in a very real and non-reversibly fatal sense:

Emergency services were called at 23:15 GMT and a paramedic arrived within 15 minutes. The paramedic contacted the control room three times asking for the ambulance to arrive sooner, but it did not arrive until 01:00 GMT the next day, Mr Nelson's family said.
Presumably this was a motorcycle paramedic, who will carry some fluids though probably not blood and certainly not more than a few pints of them. The unfortunate 26 year old Mr. Nelson is described as suffering from haemorrhaging, which was almost certainly internal and hence could not be successfully treated without surgery; all the paramedic could do was buy time pending transfer of Mr. Nelson to a hospital with an on-call surgery team, so that Mr. Nelson could a) receive whole blood in volume to replace his loss and b) be opened up so that the surgery team could clamp the offending major blood vessel to stop the loss. Unfortunately it seems that the required ambulance took another 90 minutes to arrive, which was way too late.

So why did the ambulance take so long? We can reasonably assume that the paramedic made a diagnosis of internal bleeding and called in for an urgent transport, so the available ambulances must have been elsewhere:

He added: "It seems that if they meet the target for the whole of the east of England, it satisfies the government target but the danger is they focus on urban areas where they can easily hit the target and rural areas get neglected.
Bingo! Why is this? Here's one possible explanation.

Suppose you have a reasonable-sized city (e.g. Reading, Oxford) surrounded by a fairly large rural area. Your ambulance, fire and police stations are somewhere in the city. At regular times you have a small number (say 2-4) of available ambulances, waiting to respond to calls. Most of your calls will come from within the city as not only do you have most of your people there but they are in an environment more likely to cause accidents (heavy traffic, concentrated drinking etc.) Anticipating this, you station most if not all of your ambulances around the city ring road and near major junctions so that they can either head straight in to the city, head straight out to the rural towns in their sector, or drive around the ring road to access a different sector. Your hospital will be within the city so your vehicles will go "green" (available) there; you can direct them to go straight to the next call or send them to one of your vacant ring-road sectors.

Blakeney, the home of Mr. Nelson, is 80 minutes from Great Yarmouth and 50 minutes from Kings Lynn (the nearest major towns). Without wanting to second-guess Norfolk ambulance control I'd imagine that they might have had an ambulance stationing point near Cromer or Swaffham, but someone else called first and that ambulance was taken; once they received the priority call from the paramedic, the ambulance would have nearly an hour of driving just to reach Blakeney. Because the incident happened on a Thursday night they probably had fewer ambulances available than on the busier Friday or Saturday nights, and because it happened around 11pm it was during the busiest period.

If the East of England Ambulance Trust wanted to reduce the incidence of long waits for ambulances in rural towns, it would have to position more ambulances way out from its major urban centres. The problem is that this would increase response times for the bulk of incidents during busy times when the remote-stationed ambulances were required near the cities. For the sake of significantly improving response times in relatively rare scenarios (multiple incidents away from the cities) you're going to be significantly impinging on your common-or-garden city incidents.

So what's the ambulance response time target?
Immediately life threatening – An emergency response will reach 75% of these calls within eight minutes. Where onward transport is required, 95% of life-threatening calls will receive an ambulance vehicle capable of transporting the patient safely within 19 minutes of the request for transport being made.
The NHS has at least addressed tail latency here ("95% within 19 minutes") but the problem is that this is a national target. It's much easier to meet in the densely-populated southeast than the more sparsely populated areas of the country. In the latter case, an ambulance trust's best bet is to concentrate resources around towns as discussed above, since they won't have a prayer of meeting "75% within 8 minutes" otherwise. It also allows wildly increasing times for 1/20th of the patients - if you can't get an ambulance to them in 20 minutes, there's no additional penalty for taking 90 minutes to reach them despite the fact you're identified these patients as needing onwards transport.

The dominant problem here is a national service (the NHS) requiring national targets for regional services, not making any allowance for the wildly different demographic distribution across the country. There's nothing conceptually wrong with the form of the target, but they need to vary the numbers as populations become less dense. You'd expect the tail latency requirement to remain fairly constant, but the initial response time to increase as population density decreases, and you should also add a 99% latency requirement (say, 30 minutes) to reduce the long waits for needy rural patients. Your response targets may no longer fit within a soundbite, but at least they are now aimed at saving lives across the country.

Boys being boys

An opinion column at USA Today caught my eye: law prof blogger Glenn "Instapundit" Reynolds noting that American public schools have a demented "zero tolerance" approach to boy games:

At South Eastern Middle School in Fawn Grove, Pa., for example, 10-year-old Johnny Jones was suspended for using an imaginary bow and arrow. That's right - - not a real bow and arrow, but an imaginary bow and arrow. A female classmate saw this infraction, tattled to a teacher, and the principal gave Jones a one-day suspension for making a "threat" in class.
It seems that even the vaguest gesture towards projectile weaponry causes public (state) school teachers and administrators to panic and threaten / punish / suspend children - nearly all boys - in the name of "zero tolerance", otherwise known as "the death of common sense and discretion".

The article was rather well timed, as only today I was buttonholed by a fellow engineer who had received an admonitory email from her son's teacher: during playtime he had made a "gun" hand shape with the traditional index finger and thumb, and pretended to fire it at his playmate's imaginary space ship. Apparently this caused the (female) teacher "serious concern" and she instructed my colleague to stop this kind of nihilistic behaviour in her son forthwith.

This young man is six years old. SIX YEARS OLD. If he wasn't indulging in this kind of play, I'd be worried. He's a perfectly pleasant, well behaved credit to his parents; and yet it seems that behaving like a regular boy without causing any harm or worry to other children makes him eligible for admonishment at best, and potential punishment if he does it again.

As Glenn Reynolds notes:

This is a serious PR problem for the American education establishment, but underlying the bad publicity is a serious substantive problem: When your kids attend schools like these, they are under the thumb of Kafkaesque bureaucrats who see no problem blotting your kid's permanent record for reasons of bureaucratic convenience or political correctness.
At some point, voluntarily putting your kid in such a situation looks a bit like parental malpractice -- especially if your kid is a boy, since boys seem to do worse in today's nearly-all-female K-12 environment.
I wish that his first assertion were true - it seems that this immensely stupid and blockheaded behaviour by school administrators is free of consequence. Since parents have to send their children to the nearest public school unless they can afford private education or have the time and ability to homeschool, what action can the parents take to even inconvenience the offending school?

I can't believe that this oppressive environment is making it any less likely that boys will perpetrate violence at school. Rather, those who previously had a play outlet for their natural male aggression will now have it bottled up. It's like pushing down on a balloon - the air you displace has to pop up again somewhere else, and if you're holding down too much of the balloon then eventually it's going to pop. Unless you start lacing school food with tranquilizers, you're not going to reduce male aggression. Actually, forget I said that - perhaps I shouldn't give ideas to these idiots.

I suspect the real reason behind this is the (illusion) of control - these teachers and administrators see behaviour which jars with their sensibilities, and can indulge themselves in controlling and "suppressing" it without any consequence. The more they do this, the more bold and far-reaching their actions will be - and if a child finally snaps and commits a crime of violence at a public school, it will be used as a reason to extend their control.


The trials and tribulations of government employees

A rather instructive NPR article tries to raise sympathies for the plight of US federal government workers in 2013:

There are reasons for federal employees to be unhappy. Thanks to sequestration, most have taken unpaid furlough days and work for agencies that are under de facto hiring freezes. This is the first year government employees have received an across-the-board pay raise since 2010 — Obama signed an executive order Monday to bump up base pay by 1 percent.
Note that it's extremely hard to fire government employees, and similarly difficult to reduce their pay and benefits. This is in marked contrast to the experience of private sector workers, who have seen a real squeeze in pay and benefits over the past five years and rising unemployment. It's also in contrast to state and local government workers, whose pension payments have grown to dominate local budgets and hence have seen their pay and/or benefits squeezed.

I can certainly understand disillusionment after a while working at certain government agencies. The EPA is one of my personal bugbears, because it's almost perfectly designed to obstruct businesses with no consideration at all for cost/benefit tradeoffs:

At EPA, for example — which saw the largest drop in employee morale among large agencies this year — the bulk of the work is devoted to supporting state environmental departments. Members of the public may or may not support its policies, but much of what EPA does is largely invisible to them.
I like that weasel "may or may not". In January this year the Supreme Court took a rather dim view of the EPA's attempt to block homeowners from even contesting their direction:
The justices said the order would be read as a strong threat from a powerful agency, not a mere warning of a potential problem. "It said this is an order," observed Justice Stephen G. Breyer. Justice Antonin Scalia said the action "shows the highhandedness of the agency."
Justice Elena Kagan said it was a "strange position" for the government to insist the property owner had no right to a hearing.
The EPA was unanimously reversed by the Supreme Court on this matter, a bipartisan measure of how demented their attitude was. If I was working for the EPA and cared at all about how the public viewed my job, this would rather sting. Oddly, the authors of this article don't mention this kind of event as a cause of government employee disillusionment.

Finally, of course, the truth comes out about why government employees don't just find another job and quit:

Federal employees enjoy decent pensions and generous health benefits — perks they may be loathe to give up, turning them into "golden handcuffs," Edwards says.
"They're there for the salaries and benefits," he says. "They're not there because the jobs make them happy."
This is not a terrible problem for a federal employee to have, considering the alternatives. Unlike a state or city employer, there's no danger of the federal government running out of money to pay the salaries and benefits of its employees any time soon. There are any number of unemployed or disposably-employed people who would love to have the problem of frozen wages, in exchange for a reasonable salary, good benefits and close to zero chance of being fired. The irony is that, to make the federal agencies better places to work, the right approach is to fire the hangers-on and under-performers - but there's no chance in hell that this is going to happen. Federal employees are stuck with Floyd Remora as long as they work there.

I'm just curious; if federal employees were allowed to vote on their agency being mandated to fire the lowest-performing 2% of employees each year, as long as they were allowed to hire people into the vacancies despite a hiring freeze, would they go for it?


Camelia Botnar in 2012

I've just spotted that the Camelia Botnar foundation accounts for 2012 have appeared on the Charities Commission website, so I thought I'd take a quick look to see how they are doing. See my notes on their 2011 accounts for the previous context.

Some of the highlights: for context, remembar that Camelia Botnar Ltd. (CBL) is the commercial arm, and Camelia Botnar Foundation (CBF) is the charity.

  • Trustee Natasha Malby retired in 2012, as she did from the Marcela Trust as well.
  • "The Foundation has forged links with a foundation in Transylvania with a view to starting a programme of skills and culture exchange visits." This matches the Marcela Trust activity donating £170K to fund "specific Community initiatives in the impoverished Zarand area of Western Transylvania". The CBF and the MT seem to be clearly aligned in their overall direction, which shouldn't surprise us given the personnel overlap.
  • OMC Investments randomly donated a carpet.
  • CBL donated £152K to CBF, nearly twice last year's figure. CBL brought in about £750K of income, similar to last year. They improved performance primarily by reducing cost of sales by nearly £100K, about 15%.
  • The OMC endowment fund was pretty static, value of investments was up 3%
  • CBF had about the same expenditures overall as last year, but income was about £200K lower, primarily due to a drop from £300K to about £0K in voluntary income.
  • Investment performance was much better for the year, up £1.3M as opposed to last year's £1.7M loss. The FTSE went from to 5495 to 5958 that year, so it looks like they rode the wave up reasonably well.
  • Net funds went up from £5.1M to £6.3M, presumably in anticipation of some spending in 2013.
  • Wages and salaries were pretty flat, and they had 3 fewer charitable activities staff (from 48).
  • The investment properties took a bit of a bath, down about 8% from the beginning of year evaluation (£9.2M). As I noted last year: "After last year's near-£3mm loss on revaluation, one wonders how well this will continue to perform..." "Not that well", apparently.
  • Overall a "steady as she goes" year. Looks like CBF has stabilized after last year's ramp-up on charitable activities staff. As long as their investments continue to perform, they're pretty stable. One hopes that they won't try any more property investing though.


    Respecting the help

    I'm reminded today of the approximate Dave Barry quote:

    A person who is nice to you but rude to the waiter is not a nice person. (This is very important. Pay attention. It never fails.)
    We are approaching Christmas, and the Obama family is soon to head off to Hawaii. A couple of commentators noted that "Ronald Reagan spent every Christmas in D.C. so the Secret Service agents could be close to their families." and I wondered how true that actually was.

    It turns out to be not 100% true but pretty close. From the Los Angeles Times in December 1988:

    Twenty-eight days before they will make it their permanent address, President and Mrs. Reagan moved into their $2.5-million Bel-Air [Los Angeles] home Friday.
    They are spending their first Christmas out of the White House since they moved into it on Jan. 20, 1981.
    Reagan was based in California for most of his life, moving there from his Illinois birthplace at the age of 26. He would usually fly back to California shortly after Christmas, presumably because the SoCal weather in December was orders of magnitude more pleasant than in D.C., but it seems that he really did care about the Secret Service agents who protected him 24/7 (and were fully prepared to take a bullet for him.)

    For the record, this isn't a particular criticism of Obama - despite Hawaii being a long way from D.C., it's a rather nice place to spend Christmas, and standing on Oahu beaches must be far preferable to the cold winds and snow of D.C. for Obama's Secret Service detail. Rather, it's a confirmation of Barry's assertion. Reagan had his flaws, Lord knows, but really cared about individual people. Apparently Bill Clinton was also congenial with his agents - Clinton's flaws are better documented than Reagan's, but even his detractors can't deny that he was genuinely interested in people. Barbara Olson, unapproved Hillary biographer, noted that at college Bill would sit down at the "black" dining table and engage its occupants in conversation despite being painfully white.

    America is generally a better place to observe this behaviour than the UK, since an American table server's employment and income is much more closely tied to accepting abuse from customers. However, given the preponderance of eating out in the USA compared to the UK, the percentage of the population who have waited tables is correspondingly higher, so people are generally more sympathetic to waiting staff in remembrance of their own time running around a restaurant. In my experience, seeing people gratuitously abusing waiting or takeout staff is significantly more common in the UK - and seems to match an unusual income split where it's either the very well-off or the relatively poor who are more likely to be the abusers.

    In any case, abusing or ignoring the help is a very telling mark of a person. It tells you an awful lot about their inner personality; ignore this information at your peril.


    States vs territories and the unintended effects of Obamacare

    For all those arguing that smart people in government can solve healthcare problems, a case for you to consider. As well as the 50 states that make up the USA, there are various territories which are overseen directly by the Federal Government but which are not themselves states; Guam, the Northern Marianas Islands, Puerto Rico and the US Virgin Islands ("organized" territories with a degree of self-rule) and American Samoa, Midway Islands and a bunch of small atolls and islands ("unorganized" territories). Federal government rulings apply to these territories in the same way that they do the states.

    It turns out that the implications of recent Affordable Care Act were not entirely thought through with respect to these territories:

    While the Affordable Care Act requires health insurers in the territories to accept all shoppers no matter how sick, it does not mandate that all territorial residents buy plans nor does it provide subsidies to make coverage more affordable--as it does in the 50 states and the District of Columbia.
    The big win for poor people in the ACA was that they would receive subsidies to purchase the (rather expensive) health coverage that the ACA mandated they buy, and the big win for sick people was that they could not be refused insurance or be priced out of the market due to pre-existing conditions. The way the finances balanced was a mandate to purchase insurance under penalty of fines. But those subsidies aren't provided to residents of these territories, so ACA plans are extremely expensive; and the mandate does not apply in the territories. Result: most people aren't buying ACA plans because a) they are expensive and b) they don't have to. The only people buying ACA plans are the really sick people for whom even unsubsidized ACA plans are far better than their alternatives.

    So the insurance companies in those territories are stuck having to accept really sick people without any ability to dilute the effect on their returns by including a large pool of healthy people:

    The administration has offered technical assistance to alleviate the problem alongside potential policy work-arounds. One solution Health and Human Services has suggested is having the territories pass their own individual mandates, just as Massachusetts did back in 2006. But the regulators say that won't work either, because they don't have enough money to subsidize the purchase of insurance coverage for their citizens.
    In other words: if Guam mandates purchase of insurance by Guam citizens, they'll have to pay full price for the ACA-compliant plans and they'll march on 155 Hesler Place with torches, pitchforks and lengths of rope.

    It appears that no-one drafting the Affordable Care Act asked "hey, how does this affect the non-state territories?" As a result, they've made a horrific mess of healthcare in those areas. Oopsie. Next time someone proposes that the government step in to fix something, remember how badly they got this wrong.


    The 2014 Privies

    Extremely entertaining - and, in parallel, depressing reading - at Skating on Stilts which has announced the shortlist for the 2014 Privies - dubious achievements in privacy law. Privacy has been getting quite the airing in the past year, which makes the shortlist candidates even more impressive. Please go and vote for your favourite.

    While I don't want to unduly influence voting, I feel I must draw attention to some particularly outstanding candidates. First up, President Hollande of France for "Privacy Hypocrite of the Year":

    President Hollande called President Obama to describe U.S. spying on its allies as "totally unacceptable," language that was repeated by the Foreign Ministry when it castigated the U.S. ambassador over a story in Le Monde claiming that NSA had scooped up 70 million communications in France in a single month.
    Whoops. Two days later, former French foreign minister Kouchner admitted, "Let's be honest, we eavesdrop too. Everyone is listening to everyone else. But we don't have the same means as the United States, which makes us jealous."

    For "Worst use of privacy law to protect power and privilege", Max Moseley must be the front runner by a mile:

    Mosley himself achieved notoriety in 2009, when the media published pictures of him naked and engaged in a sado-masochistic orgy with five prostitutes. In a move that seems to define self-defeating, Mosley went to court to establish that it was a naked, five-hour sado-masochistic orgy with five hookers, but it wasn't a naked, five-hour sado-masochistic orgy with five hookers and a Nazi theme. He won.

    I await the announcement of the shortlist for "Dumbest Privacy cases" with great interest...


    Time zones are hard

    Having spent a painful fraction of my life fighting time zones, I loved this from The Diplomad:

    As the party was winding down, I slid over to one of my Japanese contacts and kidded him about the date, "You have guts throwing this event December 7."
    He seemed perplexed, "We decided to hold it today instead of tomorrow, because of American sensitivities about that day."
    Now I became the perplexed one, "What's so sensitive for us about December 8?"
    My Japanese friend looked at me as though I were the biggest ignoramus on the planet, "You know, Pearl Harbor attack day."
    Anyone who thinks that times and dates are straight forward, either a) has never tried to work internationally or b) is in the military and works off Zulu Time where ever they are on the planet.

    The lesson I took from this is that no matter how simple you may think a concept is ("what day is this?") you should realize that there's someone of consequence and rationality who has a different opinion from you.


    Next step in health care - rationing by availability

    Now that the enrolments of US citizens under the Affordable Care Act are finally rising (albeit slowly) it seems that the next challenge for participants once they can afford the payments will be finding a doctor who accepts their insurance:

    Independent insurance brokers who work with both insurance companies and doctor networks estimate that about 70 percent of California's 104,000 licensed doctors are boycotting the exchange.
    Mazer, a past president of the San Diego County Medical Society, agreed, saying, "I cannot find anybody in my specialty in the area that has signed a contract directly with any of these plans."
    It seems as if the way that insurers on the California exchange managed to make premiums as (relatively) low as they were was by dropping reimbursement rates; consequently, a large number of doctors aren't going to be playing. They already have plenty of business with customers via employer plans that reimburse at acceptable rates, why should they drop their rates for other customers?

    By the middle of next year the effect of the Affordable Care Act plans on regular customers should be clearer. It'll certainly be an improvement for people with preexisting conditions who couldn't get insurance, but it seems that an awful lot of people forced onto the exchanges will be paying more, for plans with higher deductibles, and yet will struggle to find a nearby doctor who will accept them...

    Eventually if there's enough of a market I'd expect more doctors to come in and open up large treatment centres to make economies of scale and provide OK-if-not-great care at lower rates, but this rather depends whether the hassle of dealing with ACA regulations and insurers is going to make it worth their while...

    (The next "logical" step if this turns out to be a problem is for the government to force doctors to accept ACA exchange insurance rates as a condition of practice...)


    Minimum wage, maximum unemployment

    Following the previously-blogged move by SeaTac to up its minimum wage to $15/hour, this campaign seems to be going national in the USA, heavily backed by unions such as SEIU:

    Organisers hope workers in as many as 100 cities will participate in what is the latest in a series of such actions.
    Unions want a $15-an-hour (£9.19) federal minimum wage. The current one, set in 2009, is $7.25 per hour.
    Oh dear. Where to start? Well, $15/hour in NYC is very different from $15/hour in rural Kansas in terms of buying power. In the latter, you'll be lumping a huge range of jobs together with the same wage. I don't know what socioeconomic effect this is going to have, but it's not going to be pretty.

    There's also the small matter of unemployment. Some businesses won't be economic to operate with a doubled wage bill. They'll either have to get more productivity out of their existing workers, or do without them all together. This is where the much-famed robot burger flipper comes in - for a fast food establishment you shrink your workforce to a small number of managers and technicians who deliver $15+/hour of organisational value, and then steadily replace the servers and burger flippers with machines. This is more likely for larger businesses since they can more easily amortise the costs of integrating the machine with their menu and kitchen layouts. Once the principle of robotic food preparation (and self-cleaning bathrooms) is established, there will be a lively market in the associated hardware and software. Meanwhile the number of jobs for relatively unskilled workers plummets, with the most likely unreplaceable jobs involving customer interactions like waitressing and more skilled cooking - and if you don't have great people skills or a trade skill, you're screwed because there's a much larger pool of people competing with you.

    Given all the likely and very visible negative effects of a doubled minimum wage, I'm desperately curious why the major unions are pursuing it. They're not stupid, after all. It would seem that they're making a massive millstone for their own necks, and those of the politicians they own, when the wage goes up and unemployment shoots up to match. Are they that confident in the media carrying water for them and blaming the unemployment effects on "the rich", and panning the opposition when they proposed lowering the minimum wage back to something like $8/hour?

    "What we need is a social movement in this country that says enough is enough," said David Rolf, the president of the local Service Employees International Union.
    Yes, enough with employment for many - let's restrict it to the elite. Doesn't seem like a very progressive message to me, but what do I know?


    Public Service Announcement: Christmas gifts

    Gentlemen: it may just be that you have no idea what to buy for that special lady in your life for Christmas. The last few December 25th dates may have been awkward as she rejected your gifts of impractical underwear, exotic food, cookware and/or cleaning equipment. She hasn't told you want she wants for this Christmas, and her hints haven't been heavy enough for you to notice.

    She almost certainly wants shoes that she would feel guilty buying for herself. Go check her browsing history. Check her existing shoes of the same brand for appropriate size (and make sure you keep the receipt in case she needs to move up/down a size). That information should also give you a hint about appropriate colour. Extra points if you mention (when she unwraps the gift) that she might also want appropriate tights but you weren't sure, so would be happy to go shopping with her in the sales.

    The above probably also applies if she's a Goth, though tights may not be required.

    If you have absolutely no idea what kind of shoes she wants, but know that she likes "dressy" and doesn't have any foot problems, and you are willing to burn money for happiness, then head for the Louboutins.

    No warranty is implied or given for this advice. Best of British luck.