Friday, 24 October 2014

Is the NHS pulling in opposite directions?

Years ago, I remember sitting in the Lib Dem policy committee talking about I meant to call 'preventative health', but which I accidentally kept on referring to as 'health prevention'.

Half-way through, Conrad Russell - the much-missed Earl Russell - tapped me on the shoulder, indicated his packet of cigarettes, and said: "I'm just popping outside for a bit of health prevention".

All of which is a way to say that prevention as the key to the future of the NHS is hardly new.

Even so could you imagine anyone coming out with a report on the future of the NHS which is clear about the problems, honest about the solutions, minces no words and gets the overwhelming endorsement of absolutely everyone?  Because that is what Simon Stevens has managed in his Five Year Forward View, published yesterday.

That is a huge achievement in itself.  It is a bold approach to prevention and local control that everyone appears to be embracing.  It only has a paragraph on what I would call co-production, but Stevens evidently gets it.

Three things occur to me.

The first is kind of partisan: the combination of prevention, flexibility and integration is precisely what the Lib Dems set out - though in slightly different terms - in their new public services programme debated in Glasgow.

I'm not sure what it means when the NHS chief executive comes up with the same themes a few weeks later.  It may mean the Lib Dems were right; it may also mean that they didn't go far enough.

The second is that prevention requires a little more thought.  The New Labour approach to prevention patently didn't work - advertising and professional exhortation to us to drink and eat a little better.  Part of the problem is that effective prevention policies can't be pursued by the NHS alone - because they involve food policy, employment policy and much else besides.  Stevens hints at this but it requires very high level backing indeed.  As he says, it needs to be a national 'movement'.

It also implies a serious shift in funding away from hospitals. Which is when the trouble starts.

The third is that this report seems to me to mark the end of conventional competition in the NHS.  There will still be a market, and a commissioner-provider split.  There will still be choice - but there is no way that Monitor, for example, can preside over the kind of integrated care that is set out here and regulate it as a market in the way that Andrew Lansley originally intended.

In fact, I find what passes for a debate about the NHS at the moment really rather peculiar.  Partly because the left seems to forget that the original turbo-competitive version of the Health and Social Care Act wasn't actually passed.  Partly because the Department of Health seems to be going in two directions at once - on the one hand towards more formal competition, on the other hand towards more integration.

The two can live alongside each other up to a point, but only just.  One of them must be compromised, and the idea that the NHS is being 'sold off' in some way - which we hear constantly from commentators - is not quite accurate.  Something else is going on as well.

Yes, there is a great deal of private investment and private sector provision, though far too few social enterprises and mutuals being commissioned.  The narrowing of contract culture is having a serious effect - the real problem here, it seems to me.  Yet at the same time, this report is evidence that there is another direction entirely being planned - integrated primary care, integration between the NHS and social care.

How does this live with more competition?  I don't know but I think we should be told.

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Thursday, 23 October 2014

Plunging ourselves into delusory data

The principle that numerical measurements will always be inaccurate if they are used to control is now known as Goodhart's Law.

The law was formulated by Charles Goodhart to shed light on macro-economic policy, but it mainly now informs - or, more accurately, fails to inform public services.

The point is that, however incompetent staff may be, they will always be skilful enough to make targets work for them rather than against them. Take for example, the rule that patients shouldn’t be kept on hospital trolleys for more than four hours.  It was early in the targets story that hospitals got round this by putting them in chairs. Others bought more expensive kinds of trolleys and re-designated them as ‘mobile beds’. 

In similar ways, we transformed services into a huge industry dedicated primarily to making the output numbers seem as if they are rising. This is achieved sometimes despite the job they are supposed to do, and often instead of it.  See more in my book The Human Element.

But it is the inaccurate measurements that concern me here.  And this is where the staggering naivety of management consultants seems to cause so much trouble - and I've been thinking about this in relation to the idea that GPs should be paid £50 for diagnosing dementia.

There are no effective treatments for dementia now, so the only possible justification for this idea is that it will provide more accurate data about how many people have this problem.  That is pretty much the conclusion of Ann Robinson's article in the Guardian.  But by creating a situation where doctors are tempted to fall over themselves to diagnose dementia, as a way of plugging the growing hole in their cashflow, the last thing we will have is accurate data.

Data is the new icon.  We worship it.  The prime minister sits demanding graphs, imagining they can make visible the tiny changes around the nation.  We assume that, once we have the data, no further action is necessary.

But what the new utilitarians forget is just how inaccurate this data is - and especially when we give such an incentive to game it.

The same is increasingly true of financial data, gamed from inside the banks or the dark pool traders.  We are awash in a sea of inaccurate data - no problem there except that we appear at the same time to be losing our scepticism about it and loading it into the machines which manage the nation.

Wednesday, 22 October 2014

Supporting business by breaking up the big banks

A fascinating conversation the night before last has made me realise that, although I don’t think I’ve got it wrong on the banks, I only had half the picture.

I was aware that, compared with other businesses – and certainly compared to the salaries and bonuses they pay – the big banks are no longer profitable enough to carry out the basic jobs of providing banking services that they were originally designed to do.

Love them or hate them, everyone seems to agree that banks need to end the pretence of free banking. It isn’t real and it leads to the kind of swinging charges on the people who can least afford them.

But no bank can realistically go it alone on this, and if they try to agree between them they will go to prison. So what can they do?

The answer seems to me that the government needs to facilitate some kind of legal discussion on the future of public service banking, involving all their stakeholders, so that these issues can be resolved in public.

And also, some kind of agreement whereby the banks pay for and mentor the local lending infrastructure that can lend in the places and sectors where they quite patently can’t.

But there is another element to this, which is finally now being spoken by regulators in the USA. The big banks over there have paid out more than $100 billion in fines over the past six years for their behaviour, but still seem unable to reform.

New York Federal Reserve chief William Dudley said, quite rightly, that it they were too big and complex or their systems were irredeemably unfixable, then they would have to be broken up. This is what he said:

"If that were to occur, the inevitable conclusion will be reached that your firms are too big and complex to manage effectively. In that case, financial stability concerns would dictate that your firms need to be dramatically downsized and simplified so they can be managed effectively.”
That moment is now arriving and not before time. But there is a big difference now.

Six years ago, at the height of the crisis, frontline politicians were nervous about taking the big banks apart because it looked vindictive. It looked anti-business.

Now it seems to me to be the other way around. Enterprise is crying out for effective, trustworthy banks, that are no dedicated to short-termism and are not dedicated either to sucking up all the available talent and capital from the productive economy,

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Tuesday, 21 October 2014

Detroit, change and the shift to bikes

One of the main purposes of writing blogs, it often seems to me, is to prove yourself right. Preferably so many times that you even come to believe it yourself.

I try not to do too much of this, in case it becomes embarrassing, but I noticed today some evidence of one of my repeated theses: in this case, that – despite all the rhetoric about technology – change is actually slowing down and has been for some time.

After all, I have been driving in Minis and flying in Jumbo Jets my entire life (I’m 56), and – although I know their internal machinery is very different – that is only what you would expect.

The first submarine entered service in the Royal Navy back in 1901, and half the period since has seen the rapid development of submarine technology, culminating in 1960 with the launch of the nuclear powered Dreadnought.  The second half has just been rapidly slowing variations on that theme.

See my book Unheard, Unseen for details (at least about early submariners).

In the past generation, we have seen the return of real shops, real food, bricks, trams, and the delivery of food to the door rather as our grandparents experienced it.  I know we also have mobile phones and Facebook, and I suppose that does change the way people live, but not in comparison to the vast changes going on a century ago.

So what are we to make of the reinvention of the failing city of Detroit as a centre of bicycle manufacturing?  Like Oxford, Detroit began as a bike manufacturing centre, and became as a result a twentieth-century car manufacturer.  Detroit seems to be edging back, according to an article in the latest edition of Fortune.

Seven bike manufacturers have set up there in the last few years.  Detroit Bikes even invested 2.5m for a 50,000 sq ft factory.

What is interesting about the article in Fortune is their misunderstanding of the way Europeans think.  They assume that it is the collapsing population of Detroit, which means less traffic, which is encouraging people to move around by bike instead.  In Europe, I think we see it the other way round: it is the complete impossibility of navigating across London by car that is leading so many people to take up cycling.

It isn’t exactly plus ca change, but it is an example of technological history coming full circle.  And this time, history seems to be saying: do it right.

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Monday, 20 October 2014

IT + big organisations = stupider people = stupider IT

I'm having trouble with my car (a Citroen C3).  The engine keeps cutting out at the most awkward moments, even going along the motorway.  I've searched the internet and find that this is actually surprisingly common, and nobody knows what causes it (yes, I've changed the crankshaft sensor, in case anyone asks).

It is pretty extraordinary that this kind of thing should stymie a otherwise perfectly effective car.  It is, of course, to do with the sheer complexity of the electrical and IT system that now inhabit every bonnet, and especially perhaps Citroen bonnets.

Once the garage has run a scan on the engine, and found nothing wrong, there seems little more they can do.

But there also seems to be a lesson here for the administration of public services.  Even perhaps a clue to the conundrum I was talking about so bitterly earlier in the month - the bizarre failure of every utility to manage the simple business of me and my family moving addresses.

I know the problem of complexity is hugely interesting and debated when it comes to biology and maths, and natural systems.  But it is remarkably little discussed in relation to the business of government - and the other knotty question of why it is so difficult to make anything happen in government without an endless stream of unpredicted, unpredictable unintended consequences.  Complexity again.

The classic story was the, probably mythical, one about the man in Alaska whose windows wound down automatically in a blizzard and who died of exposure.  The previous model would have allowed him to wind them down manually.

In fact, I have a feeling there is some new law that lies behind all this, and I'll come to Boyle's Next Law in a moment.

I am a huge admirer of Bryan Appleyard and his thesis, in his book The Brain is Wider Than the Sky.  He argues that we have deliberately shrunk our idea of what human beings can achieve just to fit into our narrow ambitions about what machines can do.

There is something similar going on here.  The sheer complexity of cars, and the sheer complexity of administrative systems, disempower their keepers and make them stupid.

Because it isn't actually complex when you're operating the system.  It is ridiculously, stupidly, naively simple.  Try talking to a call centre about anything slightly out of the ordinary and you find that they can't deal with it, because their software system hasn't got anywhere to click for it.

They can't get into the main system and tweak anything, any more than the mechanics can mend my car.

For the last two decades, after the so-called 'Corporate Re-engineering' revolution, our businesses have been rendering themselves more stupid with CRM and ERM software which turns flexible human systems into concrete, inflexible, stupid systems, minded by disempowered humans.  See more in my book The Human Element.

That's the first part of Boyle's Next Law: IT in big organisations tends to make people stupid.

But it gets worse, because these nearly constrained, newly blinkered employees, who do everything by numbers, are then involved in writing more software.  Of course it makes things worse.  Here's the formula:

IT + big organisations = Stupider Humans = Stupider IT.

Simple, isn't it.  Not actually very complex at all.   But don't please assume that I am some kind of neanderthal who doesn't like computers.  It is the combination of big organisation thinking and IT, and the complexity involved - the the boneheaded complexity of my car - that makes me cross.  Because that is seriously neanderthal.

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Thursday, 16 October 2014

The coming revolt of upper middle England

I have always understood that the last recorded words of Roy Jenkins were: "Oh, upper middle, if you don't mind."  He was in hospital and being offered some middle-brow biographies...

That is a way of introducing the revolt of middle England.  There is certainly something about the rage of Nigel Farage, reproduced in so many public meetings around the regions, that is frightening, something of the fierce contempt of the sidelined for sophisticated capital cities everywhere.

But it raises the question: what about upper middle England?  Because I have a feeling that their revolt will follow later next year.

I was reminded of that reading the reports today that the French fracking company are appealing against West Sussex County Council's refusal of planning permission to drill in Wisborough Green.

I have been reminded of it also in the last few days by the news that Ecotricity, the green energy company, was considering joining the group legal action against the vast government subsidies for a new nuclear power station at Hinkley Point.

This may seem like a small squall in comparison to the Ukip revolt, but I suspect it may be very much more than that.  Because if there is one form of energy which is even more unpopular with wind farms, it is fracking - with the fear of polluted ground water and the environmental destruction that has followed in some parts of the world.

And the next most unpopular energy source is nuclear, not just for the sheer expense, but the fears of radiation and plutonium theft.

Whatever you might say about windmills, they do not carry the perceived risks of either of those and, in particular, the threat to the health of our children.  This is what will drive the revolt of upper middle England, and despite Owen Paterson, who prefers to subsidise nuclear than windmills, and whose views were given an outing this morning on the Today programme.

There might have been a time when we trusted our leaders enough to take their reassurances about nuclear and fracking safeguards at face value, but not now.  It spells trouble.

Not at first, but once there is a scare - the first fracking mistake, the next nuclear leak, the first poisoning of cattle, the first lost plutonium.

And let me make one other prediction while I'm about it.  Ukip will find itself divided over renewable energy, just as the Tea Party movement has been in the USA: not because some people love wind farms after all, but because - as it turns out - solar energy offers a measure of energy independence to people which they crave.

So, yes, if I was either a Conservative or a Labour candidate now, I might worry about the impact of Ukip on the coming election, and on the traditionally tolerant stance of the English.  But I would be even more worried about the rage that will be unleashed on them a year from now if fracking and nuclear expands.

There is nothing so frightening as lawyers on picket lines, and middle class mothers chaining themselves to diggers on a major scale.  That will be seriously scary for the establishment.  Quite what it will mean politically, I don't know - but hold onto your hard hats.

And make absolutely sure you don't accept the post of Secretary of State for Energy and Climate Change in the next administration.

Wednesday, 15 October 2014

Towards a fiercer liberalism

There are sharks who live below the line at the Guardian.  It is a frightening place.  I know this.

I wrote a comment article for the Guardian yesterday about the sign at Beddau RFC urging over-enthusiastic parents to calm down a little.  I found myself defending serious parents against the idea that somehow nothing really matters.

In the circumstances, I escaped pretty much unscathed - but then it would have been very silly of me to read absolutely all the comments.

What does seem to have irritated people was this section:

"It’s tough out there. So tough that I’m not planning to compete by the usual rules. But I’m aware that I do have to buck up a bit. I’m tired of the old maxims: letting children decide on religion or politics or careers when they are older. I’m finished with the I-don’t-want-to-foist-my-ideas-on-them style of parenting.

The truth is, I do want to foist my ideas on them. In fact, I’m wondering whether my failure to do so risks letting them grow up like Bertrand Russell, of whom it was said that he had lived with an open mind for so long that he couldn’t get the damn thing shut.

The psychologist James Hillman suggested that failing to give your children a steer may not give them anything to react against, and they may need that to find their own way. I insist that my children go to church – I even manage to get them to do so occasionally. I insist that they should also be Liberal Democrats. This policy is working: my 10-year-old realises that he can irritate me by praising the Labour party."

Now you can see why this might have irritated the more sanctimonious atheists, but I also seem to have annoyed people I very much respect.  It has forced me to think about this a little.

I suppose it is inevitable that I might have given the impression that I am enforcing these beliefs with a rigid disciplinarian approach.  Of course I'm not.  And just because I am partisan, that doesn't seem to me to absolve me from the duty of explaining to my children what all the different sides of these political and religious issues are - but also explaining to them, because they ask, what I think and why.

I'm aware that I have a duty to do this in an open-minded way, and not to disparage the motives of people who think differently.

But I don't want to leave my children rootless.  I don't believe political or religious convictions are consumer choices, something you put off - like dating - until you are old enough to see the smorgasbord of choice.  I don't want them growing up without structure, without convictions, without depth.

No, I won't ban them from the house when they disagree with me - as they inevitably do - but if liberalism means that everything is relative, and there is no content, no culture to grapple with, then I want none of it.

Fortunately, Liberalism is not the same as post-modernism.  It isn't the same as moral relativism.  Nor is it the same as the apparently contradictory post-modern ideas that nobody can understand anyone else's culture but nonetheless, we enlightened ones must shun content, culture and roots altogether.

I'm not one of those people who believe that somehow it is possible for me to convert to a range of different global faiths without years of study, because these are cultures with extraordinarily deep and complex ways of looking at the world.

I believe that the post-moderns are wrong on both counts.  People need cultural roots, but they can transcend them.  We are not consumers, looking for the best deal from our political and religious convictions.

As a parent, I want to show - if at all possible by example (difficult at the best of times) - that I can be understanding about people's point of view but to have convictions, live by them, and expect my children to as well.  There may come a time when they see things differently for themselves, and then I will not have a meltdown - but until then, I don't believe they should be keeping their powder dry for religion or politics or morality.

I may not always keep to it.  But that seems to me to be a genuine Liberalism, and a fiercer version than wishy-washy post-modernism.