30 October 2017

Is all this really NECESSARY?

Randal Rauser @randalrauser is a Christian apologist, and I have to say I think he is a clever guy. He also seems to be a genuinely nice guy. And he has a reasonable following for a philosophical apologist, so I was delighted to receive a response (arising from a Twitter exchange) on his blog, purporting to land a reductio ad absurdum on me for my challenge to him.

Read it, then read it again. I admit I have some problems with Randal's reductio (I don't think it works), but it got me thinking, and I think we're at least closer to a point of understanding, which has to be a good thing.

Randal puts forward a view of a "theistic belief set" (TBS) that needs to be countered:

  1. God exists
  2. God's existence is necessary

Now here is where I thought I saw a problem - in order to argue with these points, Randal seems to be suggesting that anyone (atheist or other-theist) who counters either one of these is somehow missing his TBS - Randal's TBS is constructed to be immune from criticism (bear with me here - this is me trying to puzzle this stuff out).

So if I as a philosophical greenhorn say that Randal doesn't in fact know that his God exists, he can point to section 2, and say that God's existence is necessary. If I say that God's existence isn't necessary, he can simply contend that I don't understand philosophy and make some strange remarks about my mountain bike.

This seems very odd - how can intelligent people end up so divided? Well, I'm not a philosopher, and I use "necessary" in an everyday sense - it's certainly possible that I'm missing a technical/jargon usage, and maybe Randal isn't saying what I think he's saying. Let's look at that - perhaps by laying out my naive understanding of the terminology, it may help clear my befuddled head. Fortunately Randal has done a lot of the work for us here.

We'll start with a BRUTE FACT. To me (and no doubt Randal or someone will correct me if I'm wrong), this means something that can be stated as "it just is" and nobody in their right mind would contradict it. The world exists. Brute fact. There we go. It's just there, no argument. Fine. I'm happy with this (I understand hard-core philosophers can have hours of fun on this point, but we'll leave them to it for now).

Then there are CONTINGENT facts. This seems to entail a form of existence that depends on other things existing first. This blog post exists, contingent on me having written it, and the internet existing on which to host it. It's a brute fact (because here it is!), but is contingent on the existence of other things. So contingent and brute are not exclusive categories.

Now here is my new understanding (and, yes, maybe I'm still getting this wrong): NECESSARY existence may be a form of existence that is REQUIRED or INEVITABLE in order to explain the existence of CONTINGENT things. In other words, NECESSARY existence stands in a prior relationship to things that exist contingently upon it.

This does make Randal's appeal to the necessary existence of integers (in the twitter thread) seem rather odd. I would say he's right in that we can't avoid the existence of integers, but it's not that they exist "necessarily" in the way we have just explored above. They seem to have a different form of existence in whatever way Platonic things can be said to exist. My head now hurts, so let's pretend for the moment that this is not relevant.

The astute reader will have noticed that my structure above means that the Internet's existence is NECESSARY if we've assumed my blog post is a brute fact. So here is a problem for me - I don't understand how Randal can simply assert in his TBS that God's existence is NECESSARY without telling me what it is NECESSARY in relation to. And suppose he states that it's necessary in relation to the Universe, well, now I can accept the relationship in Randal's supposed TBS, while not accepting that it describes an actual state of affairs.

There are ways of getting universes without Gods, so while he may very well believe that God's existence is "necessary" (in relation to this universe), this doesn't pose even a slight challenge to me or Sean Carroll or anyone for that matter. All it tells me is what is going on in Randal's head, and while Randal's head is maybe not the worst example of the genre, this doesn't exactly bring a lot to the party in helping me address the question of whether God actually exists or not.

So let's get back to my mountain bike. Randal thinks that he has served me with a reductio ad absurdum, but I don't think this works. Yes, I can assert my mountain bike exists, AND I can accept that its existence is CONTINGENT on a number of things. Those things are NECESSARY for its existence, which is also a BRUTE FACT, and if it wasn't such a long ride from Ireland to Canada, I could pitch up at Rauser Cathedral and nail it to the door.

But I can't nail God to the door of Randal's cathedral. God is not a BRUTE FACT - God needs arguments to support his existence, and Randal's simple assertion of NECESSARY existence doesn't get us there. It looks like "defining God into existence". But, if we follow the logic above, Randal is actually making a much much weaker claim.

What then Randal's "theism simpliciter" in this sense? It's just a belief - a belief that God stands in a NECESSARY relationship to a CONTINGENT universe that we all accept exists as a BRUTE FACT. Maybe this has helped clear the air - Randal is not saying that God must exist - just stating his belief as to the nature of God's existence in relation to the here-and-now. Note that NECESSARY doesn't even have to be ABSOLUTE - after all, the NECESSARY internet is itself a CONTINGENT thing. Maybe the NECESSARY God is CONTINGENT on an even deeper metaphysical reality...

Maybe we've been arguing over words. Maybe I've been guilty of assuming that Randal is making a much bigger claim than the relatively modest one that he really makes. The bottom line is that even if God's existence stands in a NECESSARY relationship to the CONTINGENT existence of our universe in the Theistic belief structure, this doesn't mean that God is "necessary" (colloquially) to explain the universe - God still might not exist at all, *even if* theists believe that he is NECESSARY.

So, of course, I can therefore accept the above theistic belief statement represents Randal's position, and still maintain that a/ that relationship has not been demonstrated, and b/ I still don't think God actually exists in reality.

So now what?

[Written with a couple of wines on board, 30/10/2017. Edited slightly; 31/10/2017]

06 October 2017

UPDATE: The #NazarethChallenge - are you up for it?

Get sponsored to take part in the #NazarethChallenge and your fundraising efforts will go directly towards the creation of Nazareth’s first Stroke Department, for which we will need to purchase a new CT-scanner costing $600,000.

The Nazareth Challenge: 11th-17th March 2018 

Experience the Holy Land through two amazing events: walk the Jesus Trail or Cycle the Jordan Valley. Discover the land of the Bible in a totally unique way during its most beautiful season when Israel’s desert landscape is in full bloom.

A stroke is a life-changing event which can affect anybody. Every two seconds someone in the world has a stroke and it is the third most common cause of death in Israel. Treatment response times play a huge part in patient recovery and survival. Swift intervention reduces the chance of paralysis or even death after a stroke.

The people of Nazareth currently have no access to a dedicated Stroke Department in their own town. You can help us change that by joining the Nazareth Challenge so we can give the life-saving care the people of Nazareth deserve.

To find out more email laurie@nazarethtrust.org or call (+44) 0131 225 9957.

30 September 2017

What your Sunday School teacher didn't tell you about Nazareth

When you were at Sunday School you most likely were fed a picture of "The Holy Land" that was complete camel shit. It's not really your fault, and it's not the fault of those who taught you. But over the centuries, we in the damp cold western reaches of Europe have cultivated a frankly silly version of what life was like in first century Palestine, and what it's like for the descendants of Jesus's friends and family right now.

As an example, I recall hearing a visiting preacher to our church railing against the evils of alcohol, and how when Jesus turned the water into wine, this was because water was far too contaminated with camel excrement "in those days" in the virtual desert of The Galilee. Besides, what we call "wine" was, in ancient times, pretty much non-alcoholic. So Jesus essentially turned the (presumably contaminated) water into Shloer - a much more appropriate tipple for a Presbyterian wedding. I imagine he turned the baclava into butterfly buns and caramel square tray bakes while he was at it. Mary would have been quite at home in the PTA.

Even though I was only in my teens then, I was informed enough to know that this visiting preacher (whom everyone seemed to regard as being very "godly" and "biblical" and such a wonderful teacher) was talking out of his backside, and if he was wrong about that, there was a fair chance he was wrong about a lot of other things too. And if he was wrong, maybe our regular preacher was wrong, and maybe all of them were wrong, and maybe we all needed to be a bit more sceptical of what we read in the Scripture Union Bible Study guides and even in the Bible itself.

When you start thinking that way, you start noticing things. Interesting things. You start to see the world in a new light - one that shows gradation of colour and brightness, rather than stark black and white. One that is infinitely more interesting than our preconceptions, and very frequently at odds with them. And thus we come back to Nazareth.

Nazareth is a large, mainly Palestinian Israeli town in the Galilee region. When you say "Galilee", many people here think of the vast Sea of Galilee and have a vague idea that it's an enormous inland lake. Well, yes, it's a biggish lake, but it's only about half the size of Lough Neagh in Northern Ireland. It's also known as Lake Kinneret, and there are a few other names for it too. It lies well below sea level, and drains via the Jordan river, down into the Dead Sea well to the south. However "Galilee" refers to that whole region of northern Israel-Palestine with the Lebanon border to the north, the Mediterranean Sea to the west, the Carmel range to the south and west, and the Jordan river and Lake Kinneret to the east. It's not that big, really - about the size of a typical Irish county.

The Galilee is not a desert - that's one thing our fire-and-brimstone preacher got wrong. It is a highly fertile place - yes, dry and dusty by Irish standards, but very productive and very beautiful. In many areas it's positively lush. It's hot in the summer - much like Spain - and in springtime it is transformed into a verdant landscape bursting with flowers. The bridegroom of Cana (close to Nazareth) would have had no problem finding pure clear drinking water.

Palestinian farmers have tended this land from time immemorial. The people who live here are descendants of the many civilisations who have washed over this country. They are the descendants of the Canaanites, who later became the Israelites, who later became Jews, then Christians, then Muslims, but it's nowhere near as simple as that. The truth is that genes don't care about your religion. We are all mongrels, and you don't need to go back too many generations in any of us before you hit some surprises. Surprises? Inevitabilities. With full outbreeding, if you were to go back 10 generations - less than 300 years - you would have 1024 ancestors. In 1000 years you would have over a billion. Such complete outbreeding is of course never going to happen - our family trees are really networks, and we just happen to be nodes in that network. So the people of the Galilee have been there since prehistory, with some people moving in, some moving out. But of all the peoples of the world, it is these people, mainly Muslim and Christian, who are the closest descendants of the people of Jesus's time, and closest genetic relatives of Jesus himself. Our preacher didn't know that either, and probably didn't care.

Nazareth's modern population is mostly Muslim, with a sizeable Palestinian Christian minority, and a mainly Jewish community in nearby Nazareth Illit ("Upper Nazareth" - initially a settlement intended to rival and displace Nazareth-proper, but which is increasingly becoming incorporated within Nazareth itself). It's a messy, noisy, bustling town which has grown up over the years with minimal planning, so a lot of development is higgledy-piggledy perched on the various hills and contours of the area. Its size increased considerably in the mid-20th Century, principally due to taking in people forcibly displaced by the Israeli army from their homes across Palestine, so now every area (almost) of the original valley has been built up.

One notable exception to this development is the little valley just below the Nazareth Hospital. This land is owned by the Nazareth Trust, from the time it was originally purchased in the early 1900s. It wasn't suitable for hospital buildings, so lay unused for many years. However, the Nazareth Trust have now developed into the Nazareth Village - a folk park that seeks to demonstrate what life was like for the Nazareth community back in the first century CE. They have farm buildings and a synagogue, houses and workshops, constructed from the best archaeological information we have, and volunteers take the role of Nazareth villagers, demonstrating what life was like to the thousands of pilgrims and tourists who visit each year. I can strongly recommend it, even though I have some doubts about the nativity-play costumery. It's really quite delightful - a jewel.

Although there are occasional frictions as you might expect between any religious groups, the Christians and the Muslims in general get on reasonably well in Nazareth. In the olden days the churches and the main mosque were connected by tunnels running under the Old City, which enabled them to move supplies and mount a defence when the town came under attack from bandits (which it frequently did in the centuries before the 19th). The people are incredibly friendly, and have a fantastic sense of humour. I imagine this has been the case for millennia - this is a town that has seen it all, and sometimes when you've seen it all, all you can do is laugh.

The food is legendary - said to be the best in Israel. Many of the top chefs in Tel Aviv and Jerusalem are either Nazarene or trained in Nazareth. It is one thing that they take very seriously, and I have had many utterly delicious (and enormous) meals there.

Nazareth EMMS Hospital (the "English Hospital", which is ironic, since EMMS stands for Edinburgh Medical Missionary Society) is the biggest hospital in the area, and the largest employer in Nazareth itself. There are two smaller hospitals, one Italian and one French. The EMMS Hospital is now run by the Nazareth Trust, with local administration and staff, rather than the expatriates who were a mainstay for many years (including when I was there as a medical student in 1993). It's actually the oldest hospital in Israel, with a history stretching back over 150 years - that's a long story, but a fascinating one in its own right.

Mount Precipice is a large hill to the south of Nazareth, overlooking the Jezreel Valley. Traditionally this is where the Nazarenes decided they would chuck Jesus off a cliff, but that's almost certainly not the case. A large cave in the cliff below Mt Precipice contains many layers of bones and archaeological remains - several Neanderthal burials were found here, so we know that this area has seen a lot more than just historic civilisations passing through.

So if you do find yourself in Nazareth, please stay a little longer and explore the areas away from the suq (market) and the huge Basilica of the Anunciation. Explore the streets, try the food, smoke a narghile, strike up a conversation with some locals. When Jesus met Nathanael, he was asked "Can anything good come out of Nazareth?" Perhaps that preacher had the same attitude. But once you let Nazareth work its way under your skin, you'll realise that there is a lot more here than Sunday School fairy tales.

10 September 2017

Brexit and the Northern Ireland Problem

Brexit is a mistake, in my view. I don't feel we should be doing it; I think it was mis-sold, and I think the government of Theresa May is damaging the UK by proceeding in such an inept manner in pursuing it.

But we keep being told that it is "the Will of the People" (although the WotP has not been validated, given that we now know that in the referendum people were sold a pup). So let's assume that it is indeed the WotP and we are indeed heading for Brexit.

The problem of the Irish border has been a big one in the negotiations so far. How do we protect that hard-won open border, that effectively makes all of Ireland open for travel and trade, and has undoubtedly brought much in the way of peace and prosperity to both sides? The solutions proposed so far by the Hard-Brexit government or by its lackeys (or is it the other way round?) in the DUP are complex, unwieldy, and quite simply the product of Pollyanna fantasies.

We can't manage customs and travel electronically; people free to move into Southern Ireland legally within the EU will be able to seamlessly travel to Northern Ireland and thence to Great Britain. The same for goods and services - the only way anything will be detected or stopped would be if someone were to actively investigate at the end point. This would presumably lead to the good people of GB having to carry identity cards around with them at all times. It would mean that any goods in GB (manufactured, agricultural, whatever) would have to have full certified traceability to the point of origin at all times. I'm fully happy to admit that I am not an expert on such matters, but I haven't seen anything that gives me much hope that the above isn't inevitable. Maybe I am wrong, but I have another solution.

Northern Ireland should remain in both the UK *and* the Single Market. Think about the advantages this would bring - Northern Ireland would be positioned as the UK's trading post with the EU, bringing spectacular economic advantages. Goods and services produced in NI would be able to trade tariff-free with both UK and EU markets, and citizens of NI would likewise have free travel within both areas. Similarly, EU citizens would have free travel between EU and NI, so as far as we are concerned, rights of movement and trade would continue pretty much as before. This would also have the advantage of considerably softening Brexit for the rest of the UK, as trading and financial businesses which relocate to NI would be able to keep a stable foot in both camps. This would put inward investment through the roof.

For people on the island of Ireland, a series of enhanced rights to residency, healthcare and government services on both sides of the border could be established fairly easily, maintaining the current exchange, eliminating the threat of a hard border, and promoting peace, stability, co-operation and economic prosperity. As more trade flows through NI, the links with UK will actually be strengthened, not just for Northern Ireland, but for the whole island. This will cement peace, and perhaps paradoxically, improve overall relations with Ireland and indeed the EU.

Given that relations between our (sadly inept) UK negotiating team and the EU negotiators have been very poor, this strikes me as a very sensible strategy to make Brexit (assuming it has to happen) an orderly process with a stable outcome that avoids many of the disbenefits that have been identified so far, both before and after the referendum.

I don't have the skills to go into the constitutional details of such a proposal - I'm sure there are complications that might have to be worked out with the WTO, and the DUP will presumably throw a fit at the prospect of customs and passport checks between GB and NI, but these can be worked out, and it seems a very small (and patriotic) price to pay for strengthening ties between NI and GB, Ireland and GB, and GB and the EU - all in a time when the atmosphere is frostier than it should be.

Like many people in NI, I love this place. I have a British and an Irish passport. I am a proud European (while still recognising that there are issues to be sorted). Northern Ireland voted *against* Brexit, and since the people *here* have spoken (and acknowledging that this was a UK-wide referendum), it seems reasonable to listen to them. So I propose this, not just as a lesser-of-a-bunch-of-evils approach, but as a positive suggestion to turn the sow's ear of Brexit into a silk purse for Northern Ireland, Ireland as a whole, GB and Europe.

Sure, it will require inventive thinking and some unprecedented arrangements, but we're in that territory anyway. Let's do this.

And in the meantime, please help us raise money for a CT scanner for the new Nazareth Stroke Unit http://justgiving.com/shanenaz

19 July 2017

Bike ride postponed

Due to unforeseen circumstances, our Petra-to-Nazareth bike ride has had to be postponed until next year - probably March 2018. On the downside, this means it's longer until we can hit the trails; on the upside, this gives us longer to raise more money for the Dialysis Unit in Nazareth, AND it means we get to see Jordan and Israel in the Spring, when both are at their most lovely. Oh, and it gives YOU more time to get yourself organised to come and join us!

We really hope you will consider donating to the cause or coming on the ride - the Nazareth Trust will be extending the Dialysis Unit and carrying out urgent repairs on the old Doctors' House, which is where many of the Serve Nazareth volunteers stay while at the hospital. The volunteers are an important part of the social fabric of the hospital, helping to run the Nazareth Village (which in turn contributes to the running of the hospital), and themselves carrying out maintenance work and other tasks on-site, which means the hospital can offer more services to the people of Nazareth. More updates on http://justgiving.com/shanenaz. Thanks for your ongoing support!

09 July 2017

Peace in Israel & Palestine?

Every now and then I think it's important to air some ideas that everyone is going to hate. It's OK - I know that this blog post will anger everyone. I have lots of friends on all sides of the Israel/Palestine issue, including in the actual region itself, and I love them all dearly. But they are all going to hate this blog. Why? Because it is heresy to both Israelis and Palestinians. It cannot possibly work. It's a recipe for disaster. No-one is talking about it right now. It goes against all UN resolutions, declarations from the Israelis and declarations from the Palestinians.

But you know what? Living most of my life in Northern Ireland has taught me a number of things. One is that we are not all going to agree on everything, and some ideas that seem normal to me are utterly horrific to others, and vice versa. Another is that to get along (which is important), it is unrealistic - even nonsensical - to insist that the other person accept MY viewpoint on all matters, or even those that are part of my core. And yet another is that occasionally we need to think outside the box, even just as a thought experiment. Explore new possibilities. Follow ideas through to their conclusions. Imagine a different world - maybe even a parallel universe. So I offer this, just as I offered my Celtic Union of Scotland and Ireland, in that spirit - by all means hate it, but at least give it some thought. Chew it around a bit. Think - would it really be that bad if this came to pass? And if it did come to pass, how would we make a decent effort at it, so that at the very least things move to a better place?

So where are we now? The concept of separate states for Jews and Arabs is arguably dead in the water. How could it possibly work? There will always be Jews in the West Bank, and there will always be Arabs (Christian, Muslim, Druze) in Israel, and to evict people would be unconscionable. The ongoing strife and violence, which must inevitably flare from time to time, is making life intolerable for many many people. Maybe we need some new suggestions.

The proposal is this: A united state of Israel Palestine, with full rights for all citizens, regardless of religion or ethnic background. Anyone can live anywhere, without fear or favour. The West Bank and Gaza Strip and Golan Heights would be fully formally integrated as territory of Israel Palestine, and come under the full control of the central government in Jerusalem, which will be the internationally recognised capital.

Israel would cease to be a "Jewish state", but instead would be constituted as the Homeland of the Jewish and Palestinian People. A single national identity and single passport would be used (not "binational" status). Zionism would be regarded as a "completed project", rather than a goal, and everyone encouraged to move on with the new goal of building peace and prosperity for all.

The territory of Israel Palestine would be internationally recognised as of central importance to Judaism, Islam and Christianity. People with confirmed connections with the territory would be allowed to settle there, and purchase land legally from its owners. Historic misappropriation of land will be addressed by return of the land, or compensation.

Palestinian refugees, displaced by the 1948 and 1967 wars would be allowed to return, or offered significant compensation from an international fund. Existing refugee settlements in Jordan, Lebanon and elsewhere will have considerable infrastructural and economic stimuli applied from the UN to establish them as viable and productive population centres in their own rights.

There would be full recognition of Israel Palestine by its neighbours and by the United Nations. A new flag incorporating the multiple strands of identity would be designed, incorporating Judaism, Christianity, Islam and secular themes. It would be recognised as a nation with peace and equal rights as its over-riding objectives. The equal status of Hebrew and Arabic as the official languages of the state will be affirmed.

Equality, whether you're Jewish, Muslim, Christian, Druze, Atheist, LGBTQ, straight, whatever - that has to be the foundation of any new reality. We've tried the "go our separate ways" thing. We've tried ethnic cleansing. We've tried illegal settlement. What we haven't tried is sharing, and forging a new united identity.

By all means hate on this suggestion. Put forward all the reasons why it can't work. Explain why it's offensive and pisses over the graves of generations of those who have gone before. Go for it. But at least think about it. It's a fantasy for sure, but sometimes we need to think about the fantasy, and let go of our cherished ideas of what WE want and what constitutes justice for US or revenge against THEM, in order to move forward. Think about it.

03 July 2017

Petra to Nazareth 2017

Bike of the desert...
OK, this time we're taking bikes. When I was a young medical student in 1993 I spent an unforgettable and formative two months learning the art of medicine in Nazareth, Israel. It left an indelible mark on me, as well as a deep love for the Middle East.

I've been back to Nazareth a number of times since then - once to share the celebrations of the Nazareth EMMS Hospital's 150th Anniversary in 2012, and on two bike rides, raising funds for vital projects to allow the hospital to provide the best care to the diverse community in the Galilee.

In 2017 I will be joining a group of friends from Nazareth, Scotland and elsewhere to cycle the arduous and dusty journey from the mysterious and beautiful city of Petra in the Jordanian desert, to the Dead Sea, and up the Jordan Valley to the Sea of Galilee and then on to Nazareth itself in the fertile north of Israel.

We're raising funds for the vital work of the Nazareth Hospital Dialysis Unit, and we need your support! If you can join us on the bike ride, please do: CLICK HERE. The more the merrier! Or if you would like to sponsor us on our journey (and please make sure you follow our photos - I'll be tweeting them from @shanemuk like crazy in October), your donation would be very much appreciated - CLICK HERE for the Justgiving site http://justgiving.com/shanenaz - please tell your friends.

[We use Justgiving.com because this actually saves the charity a LOT of money by not having to administer cash and cheques - it is really worth it, especially if you add Gift Aid. Also, I am subbing all my travel and expenses as well as my own donation, so all your donation goes to the Dialysis Unit Fund. There is also part of the fund designated to improve volunteer accommodation, which translates directly into the work of the hospital, so it has a significant multiplier effect. I've seen the direct results of how the hospital uses the funds, and I'm really impressed.]

I have some photos of the 2016 bike ride here: http://www.answersingenes.com/2016/12/photos-from-our-galilee-bike-ride.html - you would be really welcome for the 2017 ride of a lifetime!

01 July 2017

Interoperability the Encompass Way

Northern Ireland has had great success with the Electronic Care Record (NIECR), which is a mainly read-only portal that allows health professionals across the region to get access to vital information on their patients. Letters, appointments, X-rays, lab results and more are all available at the point of care via the NIECR, and it's fair to say this has been revolutionary. I use it in my clinic all the time, and it allows me to have a far more valuable session with my patients, and to bring them up to speed with their own care across the system.

However, we are still stuck with largely paper-based systems for most of the activities relating to the patient's record, and this means that we cannot fully take advantage of the opportunities that a truly digital system would give us. For example, we are still prescribing on paper. Most clinical notes are physical charts with paper filed within them, covered in clinicians' scrawled handwriting. Communication between professionals and from professionals to patients, is still hugely dependent on dictated letters. Indeed, even synchronising information across the myriad electronic systems - databases, registers, ward whiteboards, GP records etc. - is still often mediated by paper transactions, with all the risks and problems that are associated with that.

So, armed with the experience gained via the NIECR, we in Northern Ireland are embarking on a new project - Encompass - an ambitious effort to unite Acute and Community (and eventually Primary) Care into a single patient-centred structure that merges data and workflow, and allows information to seamlessly follow the patient through the system. In addition, we want to allow patients to access their own data and to play a key part in how their care experience unfolds.

All this is in pursuit of the Quadruple Aim - four transformational principles that underpin where healthcare in Northern Ireland (and elsewhere) needs to go if it is to survive the mounting challenges that threaten to undermine sustainability of the entire enterprise:

  • Better healthcare
  • Better population health
  • Lower per-capita cost
  • Better staff experience
I could go on at serious length about how proper health transformation is not possible without digital transformation, but maybe that is for another post. But there is another aspect. One of the main challenges of digital transformation is making sure information is available right across the healthcare system, and that data has to be accurate, complete, and tightly linked to the care scenario. With the multitude of health systems out there, one approach has been to get a "megasuite" of software from a single software vendor to try to do it all. Where there are gaps, the megasuite vendor can work on stop-gap solutions, the care system can develop workarounds, or third-party developers can try to plug their solution into the megasuite itself. Or the systems can remain in separate data silos, synchronised by hand or by some other interfacing engine. This model is superficially attractive, and can deliver major benefits in many areas, but experience over the years has shown that there will always be a considerable bloc of the health data world that remains outside the megasuite, reducing the overall benefits and return-on-investment.

And there's more. It may seem churlish - or even a bit paranoid - to point this out: if you have all (or most of) your data being looked after by a megasuite in the megasuite vendor's system, when you come to contract renewal, or even when you want to change things to adapt to new conditions, you find yourself "locked in" to that vendor's solution. To get out of this lock-in, even if the contract has expired, can be very complicated, very costly, and put your patients' data at risk. So you do all you can (including perhaps paying over the odds) to stick with the same vendor's system, rather than tender for something cheaper or better. This really restricts competition in this space, and hampers development and innovation.

What's to be done? Well, there is another strategy, and this involves looking at how we design the overall project. In the Encompass Programme we are explicitly stipulating that patient data be placed in a parallel vendor-neutral archive (VNA) employing open data formats. The data transactions with the VNA must be bidirectional (read and write) and complete, using standard recognised interchange protocols. The types of data we are storing will include coded clinical concepts and core data, eg using the OpenEHR format and linking with SNOMED-CT, patient documentation in a clinical document archive (CDA), patient images including scans & X-rays and pathology pictures, and other pieces of data appropriate to management of the patient through the system.

If we do purchase a megasuite to do most of the heavy lifting (and that is certainly one of the options), this Open Data Format layer will be vital to ensure that we have control over access to our data, and that we can, with other partners, rapidly develop innovative solutions to the clinical and administrative challenges that we will inevitably face during our health transformation journey. In particular, security and confidentiality are critical.

I have been calling this open interoperability layer "OCEANIC" ("Open Core Engine for Accelerating NI Care"), but the name isn't important. It's a key integral part of the Encompass Programme, not an alternative, and not a bolt-on. It's almost a philosophy - one based on agility, sharing, consent and openness.

Another term that has been used to describe such implementations is "Bimodal" - a central megasuite core to bring together critical elements of patient data and the workflow structures to support its use, and a robust and open interoperability layer to support agile innovation, advanced analytics and seamless integration across the entire health system. A truly open approach to integration is being increasingly recognised as a critical element in joined-up care (eg see http://interopen.org )

It turns out that NIECR has already done a lot of the background work for us, and it is entirely logical (maybe even inescapable) that the next step should be to build the interoperability layer at an early stage in the Encompass Programme. A particular advantage of this approach is that it allows us to seriously engage our local technology ecosystem (NI companies and researchers) in our digital journey, developing apps and analytics to allow us to meet the Quadruple Aim, and transform healthcare for the future. Our patients (who after all are us and our families too) must be firmly at the centre of this. We need to talk to them, get their views, explain what we are trying to do, involve them in the delivery and decision-making. When I explain this to them, I am invariably met with significant enthusiasm.

Our goal is nothing less than to make the Northern Ireland healthcare system the best and most connected on the planet. Everyone - patients and professionals - on the same page. Ambitious? Yes. Crazy? Yes. Impossible? Only if we don't make the effort.

Encompass. Delivering the best care. The most connected care. The most comprehensive care. Together.

11 February 2017

Solving Irish Unity, Scottish Independence & Staying in the EU in one fell swoop

One suggestion from Reddit... 

One nice thing about a total political clusterfeck in the Western World is that it forces us to think a little outside the box. Sure, if we had stability in Northern Ireland, continuation of our membership of the European Union, the far-right in a box and someone with half a brain in the White House in Washington, we might reasonably conclude that the applecart was just grand, and we'll just leave it as it is for now, thanks.

However, times have changed, and you don't need me to point out the woes our little planet faces at this stage. But here are a few facts that are worth pointing out.

  1. Most people in Northern Ireland voted to remain in the EU.
  2. Most people in England and Wales voted to leave the EU.
  3. Most people in Scotland voted to remain in the EU.
  4. Northern Ireland and Scotland stand to lose the most from leaving the EU; England and Wales will likely be fine, eventually, but are unlikely to want to pour treasury funds into NI & Scotland.
  5. A sizeable minority in Scotland voted to leave the UK in the IndyRef. A majority voted to stay.
  6. When Brexit occurs, Scotland will be outside the EU (obviously), and any future independent Scotland would have to negotiate re-accession terms that will probably be far more unfavourable than those it currently enjoys as an EU member as part of the UK.
  7. Although most people in NI want to remain in the UK, for the Unionists at least, the locus of that loyalty lies where many of their ancestors came from - i.e. Scotland. Irish Nationalists also have very strong connections with Scotland, and many also trace their ancestry there. And of course there is our shared "Celtic" culture.
  8. If Scotland's status within the UK were to change, it is inevitable that the attraction for NI of remaining in a Union with just England and Wales would take a massive hit.
  9. A sizeable minority in Northern Ireland want a United Ireland, with a split from UK.
  10. Northern Ireland has a history of violent conflict, and a lot of the benefits we have seen from EU membership and (relative) political stability could be undone if we don't sort out our cultural, economic and political relationships with our nearest neighbours - Scotland and the Irish Republic.
  11. The Republic of Ireland is still in the EU, and is almost certain to remain in the EU; although "Irexit" has been suggested, it has no hope of success (at least at the moment, but who knows).
  12. There are calls in NI for a referendum on a United Ireland (which is doomed to fail) as well as in Scotland for "IndyRef2" (which will probably fail too), but these calls tap into a degree of public feeling that deserves at least some recognition.

Those are a lot of points. Taking all of them together, it seems that we need to get creative and think of alternative solutions that might at least be worthy of consideration. I'm going to propose one here - I am not necessarily advocating it, but I think it deserves some serious scrutiny, given that everything else is up in the air. So here goes - I propose:

The Celtic Union of Scotland and Ireland (CUSI)

Now I'm not the first to suggest this - here's Dorcha Lee's suggestion in the Herald, and it's been touted several times before. The model I would suggest is that we maintain the regional parliaments in Dublin, Edinburgh and Belfast, and work towards a light-touch federal model within the EU. We would need to work on which issues would be devolved and which would be centralised, but in terms of overall powers, it is reasonable to suggest that as much as possible would be left regional.

  • Name of state: Celtic Union of Scotland & Ireland (CUSI)
  • Government: Federal Republic
  • Currency: Euro
  • Flag (do you really want to go there?): Amalgam of St Patrick & St Andrew saltires (although I think someone already has this - maybe something else).
  • Defence: a small army, navy and air force, up-skilled in international relief and peacekeeping - we'll not be needing the nukes.
  • Health: redesign around principles of NHS
  • Economy: aligned with EU best practice, focused on knowledge-based industries and what we already do best. Likely to require a fair bit of EU funding initially
  • Other stuff that I haven't thought of: sure we'll sort all that out. We're good at that.
So what are the advantages for Ireland? Well, we get that United Ireland that people seem to want (or at least some people seem to want), and it avoids all that confusion on the international stage with people not quite knowing what Ireland and Northern Ireland are. Although Ireland already has a significant voice in Europe, joining with another important country at the Atlantic fringe means more negotiating power. Plus bridge funding to set the whole thing up.

Advantages for Northern Ireland? We get to stay in the EU. We maintain (indeed hugely strengthen) our links with our important neighbours in Ireland and Scotland. The distinction between Unionist and Nationalist cultural elements becomes pretty much irrelevant, peace and prosperity break out, and we achieve Nirvana where everyone is happy (realistic? Nah). Major injection of EU funding to manage the transition. 

Advantages for Scotland? Fast-track reaccession to the EU on favourable terms. Strengthening of a link with a major trading partner (although the England-Scotland border is a disadvantage, as would be degradation of access to the English market. Would this be offset by greater access to Europe? Difficult to say).

One thing is for sure - CUSI would be very marketable internationally, particularly in US and Australasia, as a destination for tourism and investment. We would be strategically very important internationally, just given our location. We have a wealth of natural resources in both main islands and our waters. There are opportunities to position ourselves at the forefront of environmental management and renewable energy. We have skills and industries in IT and manufacturing with a surfeit of highly-performing universities.

There are lots of reasons why this could work, and maybe lots of reasons why it might not. So the question is this: is it worth even thinking about, and when/if we do have Scottish IndyRef2 and a referendum on the Irish border, should these be simultaneous, and should CUSI be offered as one of the options?

And at the very least, would it be any worse than the mess we are in right now, and where we're heading?

Comments welcome below!

01 January 2017

Canyons of Mars (lyrics)

Canyons of Mars

We work the red ground here, so far from the earth;
Forsaking the soil of the land of my birth.
"We can't bring you back," they said, leaving no doubt we were true pioneers.
In the dust and the boulders we're staking a plot,
But dreams pull my heart back to one pale blue dot
Lost in the cosmos, whispering echoes of triumph and tears.

But all we can do is step forwards each day,
Because entropy's journey is only one way
From the footprints they left in the Turkana clay,
Walking under the stars I can see from the canyons of Mars.

The next ship from Earth will bring four new recruits -
We'll fit them with visors and helmets and boots,
And we'll set them to work on reactors and rovers and solar arrays.
They'll join the endeavour and never return
To the places and people they loved, and they'll learn
To adjust to their destiny; factor it over the course of their days

But all our psychologists can't tell me yet
If it's best to remember or try to forget
How we stood there in Belfast when the sun had long set,
Gazing out at the stars I now see from the canyons of Mars.

Now Sarah and Ravi have just had their kid;
You followed the pregnancy - the whole of Earth did,
Through broadcast and podcast and media storm -
She's the first of her breed.
We're extending the habitat under the ground,
We'll fill it with air and with colour and sound;
And we'll love them and feed them and keep them all warm -
Is that all that they'll need?

Because her generation's the next link in a chain
Stretching out from a planet of forests and rain,
And the one point of reference that can help us explain
Is: we saw those same stars they can see from the canyons of Mars.

But the frail force of gravity won't hold them here
And they'll look to the heavens with no trace of fear.
And we'll watch them lift off, and then disappear,
As they carry our dreams to the stars from the canyons of Mars.

Canyons of Mars, (c) Shane McKee, 2012