#arbitrary constant

A couple of weeks ago I posted “No news is good”, which captured my plan to opt out of news, social and other media in order to:

pursue the things that interest me and my mind – giving myself chance and space to be curious, to think, to create and to be.

It was great to have various exchanges with people about the move, and I really would recommend taking the time to read Rolf Dobelli’s original essay (pdf).

A couple of people were interested in the practicalities of what I was going to do instead. This post briefly summarises the things I’ve put in place or am trying to help make my opt out a reality, broadly by media type. It’s not at all a riveting read, but shared in the hope it may be useful to others thinking about this topic.

Spare Slots grid

By far the most important element of my approach is the Spare Slots grid above. This simple grid enables me to make proactive choices about what I might want to do depending on what sort of time slot is available. The things that are in the grid are aligned with things I’m interested in or trying to prioritise – arranged by the 3 headings of Create, Consume and Cardio – including things like writing more or opportunities to read/study.

The time slots are truly ‘spare’ time, i.e. when family time or work responsibilities are done (or as done as they ever can be!).

What the Spare Slots grid does is provide a menu of things that are important to me, and that are an alternative to the default of opening up my laptop/phone, which often leads to “sink” activities.

Twitter

The first and main thing I’m doing with Twitter is to use it according to my Spare Slots grid. This means I spend no more than 15 minutes at a time on it, and so help manage the overall time I spend on it

I tend to focus much more on interaction rather than tweets. So the first and second columns in Tweetdeck are @ replies and Direct Messages, rather than my timeline

I’m being clearer with myself on who I am following/unfollowing and why. Hard as it is, I’m also being a little less English and unfollowing people rather than hesitating over it all the time

Lists are very useful – it enables me to separate specific work people / things and other interests

I use favourites a lot

Another useful trick is to schedule tweets. This means that I can only be on Twitter for 15 minutes but still post stuff over a period of a few hours / days without necessarily having to be on Twitter myself

I use filters, especially with some website links. Thus, I now very, very rarely see Daily Mail or Guardian links (for example) in Twitter

The main tool I use to do all of the above is Tweetdeck. This works best on my laptop, and haven’t yet found the best app to use on my phone that allows me to do as much as I want.

Facebook

I didn’t use Facebook much anyway, which is fortunate because it’s in no way as customisable as Twitter is. The key here appears to be (if you’ll excuse my phrase) “selective vision”. Thus, if I see a picture with text on it, I just don’t read it.

YouTube

YouTube is more customisable than I’d realised, especially using a Chrome Extension that takes a lot of the noise away (some ads, suggested videos etc. – search for “YouTube” in the Chrome Extension Store)

The main thing I do here is use subscriptions to channels

Similarly, I use Watch Later a lot, and this is the landing page I go to when first visiting YouTube.

Feedly (RSS Reader)

I still don’t get why Google discontinued Reader because I find RSS the most effective way of managing sources of information

Feedly is my RSS Reader of choice LINK, which allows me to aggregate all sources of information I’ve chosen. This means I then don’t have to visit those sites and so reduces the possibility of wider distraction

My RSS feeds are categorised and arranged by certain topics

I’ve particularly added blogs / sources of info that explore issues in depth, are high quality or are from sources I trust/respect

Even here, I filter the aggregated information quite quickly by using star item/read later systems.

News

I’ve basically switched it off! I’ve done this in the following ways:

I use a website/URL blocker as a Chrome Extension, which means that, even I have clicked a link, I still can’t see actually see it

I don’t buy newspapers or periodicals

I very rarely watch television. If there is something I’d like to see I use YouTube or, for flims/series etc. I tend to use Netflix (other streaming services are available)

I’m still considering the possibility of a subscription to a quality print periodical. The ones I’m thinking about at the moment are re-subscribing to Prospect or the London Review of Books, but I haven’t done this yet. Good as they may be, I won’t be getting a subscription to something like The Week, New Statesman or The Economist etc.

Personal email

The number of emails I deleted without reading was amazing. If I found myself deleting an email without reading it I would instead unsubscribe from the mailing list if at all possible. This has left me with around six newsletters from organisations I like (for example, Policy Network and Nesta).

Phone

I’ve removed some apps from my phone

I’ve turned off all notifications

I use airplane mode quite a lot (partly a battery problem, and much to the annoyance of my wife. Ever the diplomat, it’s only a matter of time before I get a mobile battery pack and not use airplane mode.).

So, those are most of the practicalities. After a bit of time seeing how it goes, I’ll do an update on what difference this has made, as well as reflections on the bit that I think will be the hardest: balancing all of the above with the responsibilities of work.

Rolf Dobelli’s essay, “Avoid News: towards a healthy news diet” (pdf), has provided me with the final signing post of a journey I’ve been on for the last few months.

In that time, I found I’d grown tired of most sources of media. Their focus seemed only to be on trivial, untrue or highly creative interpretations of things to do with politics and policy, or fanning the flames of these things with news stories and opinion pieces. I’d also grown increasingly tired with social media, the majority of which was people sharing either trivial, untrue of highly creative interpretations of things relating to politics and policy, or sharing a news story or opinion column that had fanned the flames of their outrage. On top of this, I found myself frustrated with the never-ending wealth of blogs, reports, videos and so on which offered organisation x’s perspective on the latest thing y or z.

I was tired, and yet found it difficult to draw myself away from it. As a result, I wasted huge amounts of time consuming news, social media and what x had to say about y or z.

I was checking all of these things when I didn’t have anything better to do.

Actually, I was checking them when I did have better things to do.

But even with spending so much time consuming, to use Short Circuit’s phrase, input, I was left none the wiser. I felt like I still didn’t understand what was going on. In my mind I couldn’t answer questions such as: why is what’s happening happening? How and why did we get here? Where are we going? Why are we going here and not there? What can the past tell us about why here may be better than there and what we might be able to learn about the options for getting there?

I had reached a dead end. Or, rather, I had so many choices of which direction to go in that I went nowhere.

Dobelli’s essay provided me with some thoughts as to why I was feeling that way. His argument gives 15 reasons on why news is bad for us, including: news systematically misleads us, news limits our understanding, news massively increases cognitive errors and news inhibits thinking.

In what is a forceful argument, the line of argument that particularly resonated with me was:

News has no explanatory power. News items are little bubbles popping on the surface of a deeper world.

Instead, it:

feeds us small bites of trivial matter, tidbits that don’t really concern our lives and don’t require thinking.

What’s worse, Dobelli notes that as humans we are more inclined to:

swallow limitless quantities of news flashes, like bright-coloured [sweets] for the mind.

As it goes for news, so it goes for social media and all the other brightly-coloured sweets on offer.

To some extent, and with one considerable exception, news, social and other media isn’t at fault; it is simply exploiting pitfalls in our make-up. Dobelli draws a parallel with food that goes beyond just sweets, but his essential argument is that we’re not rational enough to be exposed to the news – a thought that’s entirely reasonable to anyone familiar with Daniel Kahneman’s Thinking, Fast and Slow and the work on heuristics it summarises. What’s worse is that the seeming availability of all this other input doesn’t challenge our thinking. Dobelli quotes Warren Buffet:

What the human being is best at doing is interpreting all new information so that their prior conclusions remain intact.

And so we have become, in Dobelli’s words, shallow thinkers; we can’t differentiate between what’s relevant and what’s new.

The considerable exception I note above is that news can and does shape the public agenda. The lament that politics is now about spin and not substance only captures one side of the problem, because:

Journalism shapes a common picture of the world and a common set of narratives for discussing it. It sets the public agenda. Hold on: do we really want news reported to set the public agenda?

It’s this question to which Tony Stoller, in a brilliant lecture for Gresham College, gives answers with a resounding “no”.

Bringing this all together, it’s no surprise that I was at a dead end. But the question becomes: where do I go from here? At the level of the individual, Dobelli argues we should stop consuming news entirely. Instead we should read books and journals, think and concentrate during uninterrupted time, and “go deep instead of broad”.

These, then, are the things I am doing.

It’s easy to consider this a New Year fad but the timing, I think, is just a coincidence. The process is one that began last year, and is why I refer to Dobelli’s article as the final signing post rather than a first step. In practice, I’m sure it will be harder than I think, and the outcomes of what this means I do do (for example, on social media) and the practicalities of how I’m going about doing it aren’t the point of this post (I may blog on them another time).

The crux is that I’m making a conscious and proactive choice to opt out of the news, social and other media. Instead, I am aiming to pursue the things that interest me and my mind – giving myself chance and space to be curious, to think, to create and to be.

I know what you’re against, but what are you for?

I don’t know who to attribute this statement to, but whoever said it was right, and captures my personal frustration with most campaigning.

For example, the current welfare reforms are clearly terrible. But, even if campaigns against the reforms were successful (and I generally hope they are) and left us where we were before the 2010 General Election, we’d still have a welfare system that I haven’t heard one sensible commentator suggest was working well.

So as well as being against something (for example, welfare reforms) it’s also our responsibility to be for an alternative.

The latter is often missing, to the point that when you see it, it strikes you with some force. And, goodness me, Neil Crowther’s Refreshing the disability agenda – a future imagined is brilliantly striking and tremendously forceful. It’s exactly the kind of disability rights agenda I’d sign up to, and I urge you to read it.

Clinging on to Neil’s coattails, I’d like to suggest one further addition to his excellent headings: that disabled people are enfranchised.

How many disabled people vote? It’s a question I’ve always wanted to know the answer to, but have never found.

We know that disabled people often find voting booths inaccessible, so that campaigns to increase physical and other types of access (for example, for people with learning disabilities) exist. But this is process stuff. I’m after understanding the proper place – and so power – of disabled people as a voting bloc within the electorate.

Equivalent precedents exist: in the same way we talk about the “Pink Pound” we now (occasionally) talk about “the disabled pound”. In voting, we have the Suffragettes and Operation Black Vote that have aimed to secure the political representation and enfranchisement of women and people from BME backgrounds.

A positive part of the future disability rights agenda, therefore, must be one which seeks to understand, further and secure the place of disabled people as an equal part of the electorate, and with it our equal role within democracy.

Having not gone as well as others with Stoner, there were still large parts I thought were excellent. I particularly enjoyed this description of how physical work / DIY has more depth to it than simply making things:

As he worked on the room, and it began slowly to take shape, he realised that for many years, unknown to himself, he had had an image that was ostensibly of a place but which was actually of himself. So it was himself that he was attempting to define as he worked on his study. As he sanded the old boards for his bookcases, and saw the surface roughness disappear, the grey weathering flake away to the essential wood and finally to a rich purity of grain and texture – as he repaired his furniture and arranged it in the room, it was himself that he was putting into a kind of order, it was himself that he was making possible.

(See also this sort-of related post on repair.)

I’ve just read that under the new GP contracts for 2014/15, it is being suggested

GPs will oversee social care for vulnerable patients… Family doctors will “case manage proactively” patients with complex needs by developing and regularly reviewing personalised care plans that will cover health and social care needs.

As always, there are details to be worked out – not least of which is who actually does the care co-ordination. Nevertheless, let’s not allow details to stand in the way of some reflections:

The options of who does care co-ordination aren’t just within statutory services. There’s pretty good evidence (see, for example, this from the Office for Disability Issues on independent Support, Advocacy and Brokerage) that the best care co-ordination happens outside health and social care organisations in the public sector

This isn’t integration: this is health taking over social care. Goodness knows there are issues and problems in social care, but I’d suggest more learning about coordination and person-centred approaches can flow from social care to health than vice versa

If the Secretary of State really thinks this is about “fixing the long-term pressures on our A&E services, empowering hard-working doctors and improving care for those with the greatest need” then he’s (1) motivated by the wrong things at the wrong end of the system, (2) empowering the wrong people, and (3) putting last those people who should be put first.

This stuff is soggy trifle.

John Gray’s writing is challenging. It makes difficult points about doctrines we as humans hold of humankind – our progress, our religion, our place in the universe – and does so in a straightforward way.

For example, in his latest book, The Silence of Animals, we have:

Allowing the majority of humankind to imagine they are flying fish even as they pass their lives under the waves, liberal civilization rests on a dream.

Gray’s main point in this and his other books is that we are bound by our nature to repeat mistakes of the past. What’s worse, we think we have the capacity to get better, to improve, to progress, when history shows we have no such capacity.

Human progress is no such thing.

His argument has developed a little since Straw Dogs, in recognising that some forms of progress have indeed happened – in science and technology, for example. But he notes that the knowledge we gain from the recurring dilemmas of ethics and politics is not cumulative in the way it is in science. Instead, we are not capable of learning from past experiences of previously attempted solutions.

Gray concludes that we will not be different in future from how we have always been. Further, he argues that to think of progress as leading towards a future, attainable goal is wrong:

History shows history to have no goal.

But in this there is the possibility of freedom – a freedom that comes from the world having, in fact, no meaning. Thus, if there is nothing it “opens to us the world that exists beyond ourselves”, and that we can be “liberated from confinement in the meaning we have made”.

This is a similar point to the one made by Albert Camus in the Myth of Sisyphus. He concludes we must find Sisyphus, a man “condemned to ceaselessly roll a rock to the top of a mountain, whence the stone would fall back of its own weight”, happy. Camus says:

Sisyphus’s passion for life won him that unspeakable penalty in which the whole being is exerted toward accomplishing nothing… I leave Sisyphus at the foot of the mountain! One always finds one’s burden again. But Sisyphus teaches the higher fidelity that negates the gods and raises rocks. He too concludes that all is well. This universe henceforth without a master seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man’s heart.

Many find John Gray’s writing pessimistic. I find it redemptive, and recommend to you his work.

In 2011/12, the total spend on Direct Payments for Mental Health was £30.5m. This was 0.56% of all mental health spend.

Of the total mental health spend, over 80% (83.3%, in fact) is spent in the NHS. However, when someone with a mental health condition is given money to spend to meet their mental health outcomes, over 80% (84.5%, in fact) is spent on non-statutory providers.

That is, when there is no choice for mental health services users, over 80% of mental health spend is in the NHS. When there is choice, over 80% of mental health spend is outside the NHS.

What does this tell you?

This post is one in a series on Payment by Results in mental health, written for both professional and personal reasons. The full series is introduced and linked to here, including a post with all references in it.

It is clear that a significant amount of effort has gone into introducing Payment by Results in health, even though it is recognised that is a means rather than an ends; that it is a lever which supports healthcare policy and the strategic aims of the NHS (DH, 2011a:50).

What kind of effects does the mechanism of PbR have on the ends it seeks to support?

In a table summarising the effects, the King’s Fund (2012:24) notes the following adverse impacts of introducing Payment by Results (and, in brackets, how they are typically addressed):

Increased hospital admissions (addressed by: volume or budget caps; discounted prices for activity above agreed targets; restriction of activity-based payment)

Unco-ordinated care across settings (addressed by: payments for case co-ordination; experiments with bundled payments for pathways)

Under treatment (addressed by: additional payment for outliers; penalties for readmission)

Cost shifting to other budgets (addressed by: penalties for readmission; piloting of pathway-based payments)

Cherry-picking of lower risk cases (addressed by: additional payment for outliers, high-cost inputs, new technology; case-mix tools give increased weight to procedures, complications and co-morbidities)

‘Up-coding’ or misreporting (addressed by: good data audit).

Similar issues were also reported by the Centre for Health Economics (CHE, 2009:50).

One substantial adverse impact in healthcare generally is the possibility of PbR having a detrimental impact on quality as providers seek to maximise income (King’s Fund, 2012:2).

Specifically on this question, what evaluation there is to date would suggest it is difficult to categorically say PbR had a positive impact. The King’s Fund notes there “is very little evidence on the impact of PbR on quality” (King’s Fund, 2012:16). Nevertheless, it is equally difficult to prove the case that PbR negatively impacts on healthcare quality: the Audit Commission (2008) found that the early years of PbR had not compromised the quality of healthcare; similarly, a review by the NHS Confederation found that PbR had had no detrimental impact on care quality (quoted in King’s Fund, 2012:16).

Improved quality is often thought to naturally follow from an increase in competition under fixed prices amongst providers (King’s Fund, 2012:30). Evidence on how choice at the point of referral has operated, however suggests that it remains a weak driver of quality improvement (Dixon et al 2010). This leads to what the King’s Fund call a “prima facie case” for introducing financial incentives to improve quality (King’s Fund, 2012:30).

Given that PbR was initially introduced (at least partly) to address waiting times, evaluation has found that PbR did result in more rapid reductions in lengths of stay and the proportion of day cases than when it isn’t present (King’s Fund, 2012:16). This finding is echoed in the United States, as is the finding that PbR resulted in one of the following benefits in some (but not all) of Austria, Denmark, France, Germany, Italy, Norway, Spain, Sweden and Victoria, Australia: reduced length of stay, increased technical productivity, reduced unit costs or reduced waiting times  (summarised in Street et al 2007; Busse et al 2011, quoted in King’s Fund, 2012:22).

In England, a renewed focus on care coordination and increased integration poses an interesting question: does PbR support this or not? The King’s Fund is clear on this: “The current system is not always well suited to the promotion of other objectives, particularly integration and major shifts and changes in the location of care” (King’s Fund, 2012:41). Indeed, PbR doesn’t currently include payment relating to the costs of coordination itself (King’s Fund, 2012:33).

PbR is not felt to incentivise the change from activity-based systems to organisation along a whole episode of care. Payment aligned to a whole pathway could do this (King’s Fund, 2012:3) and places like the United States, the Netherlands and Sweden are exploring exactly this (King’s Fund, 2012:24).

One of the reasons why the effects of PbR on issues like quality are so difficult to determine is the context within which the changes operate. The effectiveness of payment systems depends on the context in which they operate, and the ends to which they are aimed (King’s Fund, 2012:4). As the King’s Fund notes:

“Payment systems cannot do everything: Payment systems are not just a means to an end; they are one of many measures used to promote health policy objectives.” (King’s Fund, 2012:vi)

Overall, the King’s Fund concludes:

“It is difficult to come to a conclusive view on what the effects of PbR have been” (King’s Fund, 2012:35).