exo : blah

If there's one thing that separates the casual cyclist from those of us who view it as more than mere transportation it's pedalling speed; they pedal too damn slow. I realise that gliding past with one's feet performing stately arcs around the bottom bracket looks more elegant but it's just less efficient. Change down a gear or two and increase the number of revolutions per second and it will be easier.

Apropos of the recent NHS White paper (CMS geeks check the URL) I was thinking about choice. Mostly I wonder about how much people actually want choice in their healthcare and if it does any good.

So I did something I've never done before and read the white paper. It's fairly clear, not too long and reasonably free of jargon which was a pleasant surprise. It also answered some of my questions in that it says in footnote 22 that

The 2009 British Social Attitudes Survey shows that over 95% of people think that there should be at least some choice over which hospital a patient attends and what kind of treatment they receive

Sadly the 2009 British Social Attitudes Survey appears not to be online and I can't find the same question in the 2008 edition. That may just be me not being able to navigate the rather old school website.

It also pointed at a few papers that show positive results for patient outcomes when the patient is involved in choosing their care. Impressively in section 2.3 we have one footnoted study which says in the abstract that "Patient-centeredness was associated with better outcomes and higher cost" followed shortly afterwards by the claim that involving patients in their care "can also bring significant reductions in cost, as highlighted in the Wanless Report". I point this out more as evidence that anything involving healthcare is complex and likely to involve conflicting evidence. There's clearly some evidence for the notion that choice can be a good thing though. I'm not even close to being well versed enough in such matters to know how to reach a conclusion if there's more evidence for or against though. Probably I should read the Wanless report but one government document a day is my limit.

Still, it seems there is some indication that people want choice and that is might be a good thing. It's certainly reasonably hard to argue against the notion that providing people with information about their care and getting them involved is a bad thing.

Of course the issue with choice is that it's pretty useless unless you understand the choice you are making. In order to get round this there's a reasonably chunk of the paper which talks about providing more information to people so they can make an informed choice - see section 2.10. The problem I see here is that with these kind of statistics it's all going to be about the context and educating people about what they mean and how to use them. Outcomes from medical treatments are dependant on a huge range of factors not all of which are going to be under the control of those administering the treatment and unless these are factored out or minimised in the statistics it's likely to be hard for the lay person to make meaningful comparisons.

Of course as one of the main changes in the white paper is that GPs will be doing the commissioning it's likely to be the GPs that are explaining the choices and hence the stats so that should help. I do wonder about the burden this places on the GPs to research and understand all of this. I can see that for routine treatments this works well but given the increasing specialisation of modern medicine it seems less tenable for more complex conditions. It makes me wonder how well choice will work in these cases.

Two things are a bit unclear to me about this though. The first is how this helps in areas with only one feasible provider. A core notion in the white paper is that choice will mean that the good/efficient providers will be picked and hence will get paid and the rest will be forced into improving in order to win business. If there is only one provider in an area how does this work? ( Also, to improve you need to invest so where does money for that investment come from? )

The second aspect that's unclear is how this effects scheduling and resourcing. Surely the more popular providers will become over-subscribed?

It's the notion of setting up hospitals and doctors in competition with each other for business that disturbs me most about this. Surely you want them to work together to improve care everywhere?

Just in case you are using the CPAN module DateTime::Event::Sunrise and you get weird behaviour on March the 21st you should apply the patch in this bug report. In my case I was getting what looked like an infinite loop spewing out the message "Sun never sets!!" which is, er, unhelpful.

I should probably now try prodding the author about this.

Once more we are into a hoo-ha about the funding of the BBC, how it has an adverse impact on the commercial sector and how we need to make it smaller. My initial reaction to those positing that argument lacks nuance: fuck you.

I do not see why it should be the case that it's part of the BBC's remit that they not have an effect on the commercial sector. Given that the arguments that the commercial sector make more or less boil down to "it's not fair" I could honestly care less, especially given that commercial media seems to me to have had a rather corrosive influence on the media.

I think what troubles me most is that so much of the criticism of the BBC is so obviously self serving. Anyone who purports to take any representative of News International's criticism of the BBC at face value is either being disingenuous or spectacularly naive. Of course life would be better for the commercial media if there was no BBC, or even a much reduced BBC. This is not the point. Everyone else would be worse off for a reduced BBC. I think there's an argument to be made that we already are thanks to the current level of scrutiny under which the BBC operates.

This is not to say that I think the BBC should be given free reign, I just think that it should be judged on the quality, and to some degree value, of it's output. By value I mean that a fundamental reason that the BBC exists is to produce the content that the commercial sector doesn't touch. If you reduce the scope of the BBC then I think you inevitable impact about it's ability to do this.

The reason for this is simple. The BBC must produce some output that is generally popular - BBC1 if you will - and any reduction in the size of the BBC will come outside this core output. Hence the current headlines about the likely imminent demise of 6 Music.

I also think there is an argument to be made for emboldening and encouraging the BBC to reach out. One could see the BBC as proving there is a market for certain types of programming and then the commercial sector with its greater ability to innovate and increased efficiencies can come along and do it better. It's mostly an argument deployed for sarcastic purposes but there's a core of truth in there.

For those unconvinced of the value of the BBC I can sum it up in two words: Radio 4. I think it's impossible for someone to spent any significant time listening to Radio 4 and not think of it as a justification for the entire license fee. One hundred and forty pounds a year is a bargain for Radio 4 alone.

This information is mostly explained in /usr/share/share/exim/README.Debian.gz but to save me the trouble next time I need to do this I'm putting it here.

Firstly you need to generate a certificate: sh /usr/share/doc/exim4-base/examples/exim-gencert. This will create an exim.key and exim.crt file in /etc/exim.

Next you need to get exim to use this. Firstly either create or edit /etc/exim/exim4.conf.localmacros and add the following lines:

MAIN_TLS_ENABLE = true
tls_on_connect_ports = 465

You then need to edit /etc/defaults/exim4 and change SMTPLISTENEROPTIONS to -oX 465:25 -oP /var/run/exim4/exim.pid. This sets up exim to listen on the right port and to advertise that it will do SMTP AUTH.

Now you have to configure exim to support asking for passwords. This is done by editing /etc/exim4/exim4.conf.template and uncommenting the following lines:

login_server:
  driver = plaintext
  public_name = LOGIN
  server_prompts = "Username:: : Password::"
  server_condition = "${if crypteq{$auth2}{${extract{1}{:}{${lookup{$auth1}lsear
ch{CONFDIR/passwd}{$value}{*:*}}}}}{1}{0}}"
  server_set_id = $auth1
  .ifndef AUTH_SERVER_ALLOW_NOTLS_PASSWORDS
  server_advertise_condition = ${if eq{$tls_cipher}{}{}{*}}
  .endif

The final thing to do is to set up some passwords. This is done by creating an /etc/exim4/passwd file in the following format:

:$Username:$password:

This file should have permissions set to 640 and have ownership of root:Debian-exim. You can generate passwords using this command: mkpasswd -H md5.

You can then put all this in place by running update-exim4.conf and restarting exim.

This skips over quite a few details and assumes that you have an already working exim install. The debian exim conf files are well commented and the aforementioned README has more detail on all this so if any of this confuses you then have a look at those.