Saturday, 29 August 2020

My mission to slay tickbox to save the NHS









The tickbox phenomenon, which I have been writing about for most of this year, seems finally to have reached its apotheosis with the appointment of the queen of tickbox, Dido Harding, to run the government’s test and trace service.

Now I have never met her, I’m afraid – I’m sure she is delightful -  but as a former chief executive of one of the most useless phone companies known to mankind, she personifies tickbox: the fantasy, shared mainly by the richest and most powerful people in the world, that data and algorithms can describe the world accurately.

Because of this mistaken idea – that we can hand over human decisions to machines, programmed by our philosopher-kings – explains why, at the heart of so many centralised and technocratic organisations, you have this remarkably widespread fantasy that the data and the ticked boxes that pour in from the front lines represent exactly what they purport to.

That is a working definition of tickbox – the gap between official rhetoric and numbers and the reality.

If you want to know why our test and trace system has failed to work, it is this – over-centralised privatised outsource contractors, whose only skill is providing the ticked box figures that ministers crave, have been put in charge of an enterprise that simple must be made to work and they just can’t do it.

Other examples of tickbox may vary. You might for example find tickbox demanding impossible information, impossible in the real world. As it did via Home Office computer system to Anthony Bryan, caught in a kafka-esque world, managed by immigration software and deaf algorithms. The Windrush generation former painter and decorator (whose story was recently dramatised) provided huge amounts of evidence to the Home Office, as they prepared to deport him from the UK, which the system studiously ignored.

Second, tickbox works because the centre really wants to wash their hands by automating decisions, for example over the cladding used on Grenfell Tower and other blocks.

Third, it tries to automate tough decisions to insulate the handful of people in charge, as it did with the recent exams fiasco – damaging lives which failed to fit into its neat formulae.

That is why I have helped start a petition to lift the tickbox curse from one of the most centralised organisations in the UK, the NHS – where so many resources get eaten up ticking boxes which don’t really relate to reality, for all those three reasons (and others too). All of them because the centre believes they can control everything on the front line, and has faith that the numbers they receive from there are real.

I don’t mean checklists here: they provide a means to save lives – as long as they are controlled by individual surgeons and their teams. Tickbox seems to provide an answer to the problem of accountability in huge, centralised organisations. Sir Keith Joseph, once Health Secretary, used to complain that he had struggled his whole life to get his hands on the levers of power, only to find they weren’t attached to anything.

But tickbox and the automation of accountability only works if the flow of information is at all accurate, and tickbox information rarely is – because of Goodhart’s Law (any numbers used to control people will always be inaccurate).

When the chips were down to fight covid, NHS managers lifted the tickbox yoke because – as they told staff in one north east trust – because “we are all grown-ups”.

Of course that was right, but they were before and they still are. It is time to lift that tickbox burden and restore the trust in the UK between top and bottom, so that – once more – the only thing that matters is what individual patients need…

So go on, please sign!

This post first appeared on the New Weather blog.

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Thursday, 6 August 2020

How to untickbox the NHS

It is a strange divide in society. Some people furrowed their brows when I told them I was publishing a book called Tickbox, and really seemed to struggle to understand what I was on about – while some people grasped it immediately. Among those who got it, I couldn’t help noticing that many of them worked in the NHS.
It maybe that the NHS is not the most boneheaded user of tickboxes but – as a huge over-centralised operation, managing people looking after people’s very individual needs, somehow the gap between appearance and reality (which is for me the heart of tickbox) – the NHS has seemed to involve more tickbox-inspired sclerosis than most.
Yet, what did they do when the NHS was absolutely the front line? They rolled it back, the whole amalgam of online tickboxes, KPIs, targets and centralised controls that NHS managers rely on to monitor performance.

“Decisions that used to take months or even years because of endless, pointless form-filling and meetings are now made in less time than it takes to boil a kettle.” This is the new NHS under COVID-19 according to Dr Max Pemberton. One doctor we know was told by managers that sudden freedom was because NHS staff are “adults” and can be trusted to make the right decisions on the spot.

And of course that was right. They were adults yet they still are as the whole tickbox thing wafts back across the NHS. That is why we started our Radix petition to stop it in its tracks.

And what their managers want is often to make the best impact on the company hierarchy. Which in the NHS means saving money – or appearing to. Then the argument shifts, almost imperceptibly, away from ‘Is this the best thing for this patient?’ – to ‘Are we meeting our KPIs?’

It provides a fake, simplified and mechanistic view of what is undoubtedly a complex system – but complex in a different way. Anyone who thinks differently looks as if they are missing the point, but it is actually the system that misses the point.

My Tickbox book argued that this is part of what might be described as the simplification – not to say vulgarisation – of the official mind. And it is already having serious consequences. We have already witnessed during the current crisis how inaccurate the figures will be for Covid-19 deaths or tests or people affected – and how officials intervene in the definitions (for example on safe protective equipment) the whole time.

I am also hoping the NHS increasingly understands that tickboxing may simply achieve the opposite of what was intended. It can be a real hindrance, not the great time saver it purports to be. Mere tickboxing enables a lack of accountability.

All the systemic failures enabled by tickbox – from Mid Staffs Hospital onwards – have to be measured against the extreme pressure on services brought about by the austerity policies of successive governments, which is why NHS managers are trying to tickbox compassion into the mix, fearful perhaps that the real thing is unaffordable.

That is what happens in large centralised organisations when tickbox takes control.

Part of the costs fall directly on NHS staff. “The Berkeley University psychologist Christina Maslach defined ‘burn-out’ as a combination of three feelings: ‘emotional exhaustion, depersonalisation (a cynical, instrumental attitude toward others), and a sense of personal ineffectiveness’, wrote Atul Gawande, the doctor and author of The Checklist Manifesto. These were his conclusions:

“Many fear that the advance of technology will replace us all with robots. Yet in fields like healthcare, the more imminent prospect is that it will make us all behave like robots. And the people we serve need something more than either robots or robot-like people can provide. They need human enterprises that can adapt to change.”

I am quite hopeful here because of Health Secretary Matt Hancock’s campaign against bureaucracy. He can see ow much it gets in the way. There are some self-help ideas we might encourage as a stopgap in the NHS. We could, for example, learn from the Dutch health service and their schrapsessies.

That is the name the new movement in the healthcare sector in the Netherlands has given to the ‘scrap sessions’ they hold at work to identify regulations, targets, tickbox rules it would be possible to get rid of completely. The idea emerged in 2018 from the Dutch thinktank (Ont) Regel de Zorg, but the movement now has a head of steam behind it, and the backing of ministers.

It is high time we spread it more enthusiastically over here. Hence our petition to demand the government to permanently remove their tickbox regulations on the NHS, partly to thank staff, partly to recognise their adulthood and partly to save money – which should be reinvested in the frontline.

We hope in the end that covid-19 could mark the moment we stop infantalising NHS staff, and also the moment we lift the threat of tickbox over all public service staff.

Because, decentralising the management of the NHS is the key to its survival and the most urgent element here is to stop the centre from their disastrous habit of micromanagement. So please sign the petition and pass it on if you feel as strongly as we do about this.


Thursday, 23 July 2020

'Good Germans' and the danger of othering

This post was first published on the New Weather blog...

Rupprecht Gerngross is not a household name, even among historians of World War II, though he led what may have been the only successful internal coup against Hitler's regime.

In the final weeks of the war, he led his small band of military translators to take control of Munich, the revered birthplace of Nazism. By doing so, he seems to have prevented the destruction of the city, and saved thousands of lives, including many thousands of Dachau prisoners who were to be killed by their Nazi captors.

He was an unlikely hero, a London-educated solicitor, brought up in China. But it was important to him that Germans should build the new Europe themselves by doing their part to liberate their own city.

Why isn't he well-known? Because after the war ended, few people believed or remembered what had happened there - and the story remains controversial in some circles. The BBC man sent to interview him was sacked shortly afterwards and his story was spiked by The Times on the advice of the Foreign Office that it would not be 'helpful' to circulate stories about 'good Germans'.

The amazing story is finally published in a new book, compellingly researched and thrillingly written by my friend Lesley Yarranton (Saving Munich 1945 - fuller transparency: my name is also on the cover urging people to read it!).

But it has made me think about how simple it is to 'other' your political opponents, and how unfair. How easy it would be if every wartime German had been a Nazi, if every demonstrator was a revolutionary (as Trump suggests) or every Briton born before 1830 had been an irresponsible slave-owner. But life is never quite as simple as that - nor is it possible to see the world accurately through those kind of paint-by-numbers, cliche eyeglasses.


We seem to be moving into a new world, which is a good deal more sensitive to people's needs and feelings. That has to be a good thing, as long as we remember that very few people will fit neatly into the new categories of good and evil - and not many more than they ever have.

Let me give the final thought to the Rev Eli Jenkins from Under Milk Wood:

"We are not wholly bad nor good,
We who live beneath Milk Wood..."

If we can remember that, it might steer us away from the puritanism that so often afflicts new elements of morality.

You can also find Saving Munich 1945 in paperback from Amazon and on kindle.

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Saturday, 4 July 2020

Hate versus rage and the problem of history

This post - or a version of it - was first published on the Radix UK blog...

In the week that the banks failed – that strange week in October 2008, where everything seemed to be unravelling – I ventured into the City Business Library, in its familiar, slightly unkempt building off London Wall.

I used to spend quite some time there, when I was writing about the history of money. I remembered it – perhaps wrongly – as a font of hidden knowledge. By 2008, it certainly wasn’t that.

Where were those decades of back issues of obscure American business magazines? Where were those strange 1960s books of business predictions? I asked at the desk and was informed that it was the library’s policy to dispose of most material after three years, and all of it after five years.

It was rather a strange discovery. Wall Street and the City of London had allowed the banking system to collapse because their risk software had little or no memory beyond ten years – barely longer than the business cycle.

Most of those taking day to day decisions about risk in the City were in their twenties and had little memory of the great rises and falls of the market. Their lack of history had hampered their ability to see events for what they really were. Which is why Andrew Simms and I wrote Eminent Corporations, to try and inject a little light history into the corporate world.

I don’t suppose the City Business Library’s decision to bin anything dog-eared contributed to this historical vacuum – it was symptom not cause. Nor was the Blair-Brown government’s strange blindness to history (heritage was one of the only areas of government funding to go down under New Labour), but neither of these can have helped.

Yet the excision of history from business commentary and corporate life – and its replacement by marketing mush – was definitely one of the major causes of the 2008 crash. But I hadn't expected that the political left would also reject history, as they have been doing recently in their war against statues, using Black Lives Matter as their excuse.

I feel myself on the side of the BLM campaigners. But I am disturbed by the assumption that all history - and specifically English history - can be reduced to a one-dimensional parade of cruelties. Including individuals like Nelson, Gladstone and Peel who - though imperfect - have been treated as heroes, and for good reasons, for generations.

Even the Archbishop of Canterbury appears to have been caught up in the puritan enthusiasm for removing memorials.

Two things worry me about this particularly. First, because history is what holds us together and makes us who we are: people cling to their pride in it - not because the English were perfect (quite the reverse), but because that whole contradictory complexity is there to help us understand ourselves.

Without a history, people have no rudder. That anyway, according to Hannah Arendt - is one of the roots of fascism.

Second, while you can understand the fury of black people about their past and present in the Americas, I find I am repulsed by the generalised rage released by the so-called 'culture wars'.

It is rage which appears to me to be wholly negative - it is just against things, and simply pro one of those generalised strings of initials. It is the mirror image of Donald Trump's equally projected hate, part of his desperate attempt to win a second term as president (though not of course its moral equivalent).

Where is liberalism in all this one-dimensional tickbox politics? All over the place it seems to me. There is no way the left can win votes while they dismiss our whole history. Or when politically correct language stays what it is now - a way for the articulate middle classes to prevent the working classes from speaking out; they dare not use the wrong language, which constantly changes.

The radical centre seems to me to reject either hate or rage, aware that human life is mainly joyful and loving, though not of course exclusively so. Where it isn't, the solutions are likely to be economic not cultural. We believe in people and their extraordinary abilities. We can't dismiss them as Trump does (as the poor) or as the British establishment does (as the Mob), or as the left does - as potential child molesters, wife-beaters and racists.

This is more urgent an issue than it might seem. Because the culture wars look increasingly like a creation of Trump's. Every southern statue that gets lynched, every new expression of enraged cultural cleansing, and Trump believes he is closer to home.

The danger is that he may be right.

A very good friend has remonstrated with me about this post, and personally I found the opportunity to talk to someone on the other side of the argument about it - without either of us falling back on the usual insults - a massive relief.


He argues that someone could have thrown the epithet 'politically correct' at any new idea - from anti-slavery to CND. He may be right, but then there is something vacuously modern about the idea that all you need to do is to change the language. That would have been pretty incoherent to everyone until about 1972.

Ad there the rgument rests - he is persuading me that PC language is primarily a kind of politeness. I am trying to get him to recognise the underlying snobbery at its heart. 

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Tuesday, 23 June 2020

Goodhart's Law and the multiple covid cock-ups

This post was first published on the Radix UK site...

The speech which gave rise to the law that now bears Professor Charles Goodhart's name was actually called ‘Problems of Monetary Management’. It was a comparatively dry piece of econometrics at a conference called by the Reserve Bank of Australia in 1975, the participants mainly being eminent monetary economists.

In his discussion of the new-fangled doctrine of monetary targeting, Goodhart suggested that ‘Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes.’

It seems extraordinary that his self-styled ‘throwaway remark’ on monetary targets should now be in the social theory textbooks as ‘Goodhart’s Law’, and yet it is. But more than that, it has developed into one of those priceless pieces of theory that might be the antidote to the phenomenon I have dubbed 'tickbox'.

The monetary issue seemed a simple one to solve. Everyone seemed to agree that it was. They would focus on measures of monetary growth, and when the money supply began to grow too much, interest rates would rise and gently ease it back down again. The trouble was that it didn’t work.

As he was going through the figures that came across his desk from most countries every month, Goodhart began to notice something peculiar. It didn’t matter which country it was, or which target they chose – the act of establishing a target seemed to change it. Whatever monetary target was chosen, because of its relationship to incomes or inflation, would lose that relationship pretty quickly. It was certainly not what was supposed to happen.

These were the bones of Goodhart’s Law. It was clear that the very act of making one figure a target and paying attention to it changed the behaviour of bankers. They would put in extra effort, or interpret their work in slightly different ways, to please their superiors and to meet the target. It was this quirk of monetary theory that Goodhart pointed out in Sydney in 1975.

If you use a piece of data as a target or as a box that must be ticked, then the data will become inaccurate. That's Goodhart's Law.

Take for example the idea set out in cartoon form by the American cartoonist Zack Weinersmith, which imagines that – through some hideous policy brainwave – all children have to stop studying poetry or the arts and start practising clock-mending, and the number of hours spent mending clocks becomes the target for success among schools. It all seems logical, given that so many top engineers are known to have been keen on taking clocks apart when they were children. But the policy has the reverse effect, as one might expect. ‘Science is dead, engineering is static, humanities are unknown,’ says the penultimate picture. ‘All is clock.’

The final comic picture shows the policy-makers congratulating each other, because ‘according to our clock-based metric, everything is great!’

This little story has not actually come to pass – yet – but it does demonstrate the issue that Goodhart’s Law poses to organisations, especially large or centralised ones. Not only does the target skew everything, so that the original relationship – in this case, the link between great engineers and clock-mending – is no more, but the target then blinds the distant policy-makers to the truth because they have over-simplified the world and perhaps even lost a way to describe what is now missing.

Inspired by the system thinker John Seddon, whose new book Beyond Command and Control was published recently - more on that soon - I have begun to realise just how much of an effect Goodhart's Law has.

It happens subtley as the definitions are tweaked and the top managers delude themselves. It is also becoming clear that the government's copious mistakes with covid may have been largely the result of their ignorance of Goodhart's Law. The latest thoughtful FT piece by Andrew Hill suggests something along these lines.


Perhaps most deressingly, it transpires that ministers fell back on scientists at SAGE who, according to the BBC programme More or Less, were arguing among themselves how fast the virus was doubling the infection rate. So, Goodhart's law being what it is, they chose the most optimistic conclusions - that the UK were four weeks behind Italy when it now seems clear that we were only one week behind.

That is why we failed in the UK to lockdown sooner. Other nations did the semsible thing - Greece and the Indian state of Kerala , without the benefit of advice from the top epidemiologists in the world - and simply shut their borders, and save thousands of lives as a result.


I never criticised the use of data in itself in my book Tickbox, but it looks worryingly as if the people who surround themselves with data and try to use it to take political decisions are likely to be a great deal more deluded than those who don't. If so, we should blame the effects of Goodhart's Law.

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Friday, 12 June 2020

Why are the ruling classes so scared of the mob? It's about Latin.

This post first appeared on the Radix UK blog...

There is quite enough about mobs and mob rule at the moment without me needing to join in. The starting point of this post is the effect this has on governments, and UK governments in particular.

I have written before about the bizarre way in which UK governments, certainly back to the Gordon Riots of 1780, have lived with this underlying fear of the mob - an affliction known as enochophobia.

That manifests itself mainly in the bizarre snobbery which the establishment treats anyone outside itself, whether it is people from country towns in, say, County Durham, or the BAME communities of Bristol. This is what Gladstone meant when he characterised Toryism as "distrust in the people tempered by fear".

I have been thinking about this phenomenon for some time, and particularly its roots in classical education, which regards the Roman world as civilised and the poor old natives of this island as barbarians. I'm not so sure that this was not actually the other way around.

I was first alerted to this idea by Graham Robb’s brilliant book The Ancient Paths, one of a growing number of historians and writers to start rethinking our pre-Roman past. But it was George Jowett’s strange and peculiar book The Drama of the Lost Disciples which got me thinking about Caractacus for the first time.

Jowett died in 1969 after a distinguished career as a boxer, publisher and planner in Canada. But the research behind the book, in the Vatican archives, is an equally important legacy. His argument was that, according to the archives, it wasn’t just Joseph of Arimathea who came to Britain in 38AD, as legend suggests – it was the Virgin Mary and many of the surviving disciples of Jesus who took refuge in Glastonbury that year, joined later by St Peter and St Paul.

Jowett’s plea was that, given that the medieval church recognised this claim by giving British bishops precedence at the great councils of the Church – we ought to take this more seriously. Or at least as seriously as the flawed and compromised memories of Roman writers with axes to grind.

If this was right, Jowett suggested, then it may provide a different interpretation to the Roman invasion five years later. It may also be that Caractacus, as the archives suggest, was not a backward pagan type, but Christian king battling the pagan Romans and desperately trying to hold back their tide of brutality.

So I have written Caractacus’ autobiography as if Jowett was right. As such, I am attempting to strike a small blow against a those generations of positivist scholars who identified with the Romans more than with their forebears defending our homeland – who regarded the invaders as ‘we’, and continue to try to subdue the real spirit of these islands ever since. Caractacus managed to stand alone for nearly nine years against the biggest and most sophisticated army in the known world, after all.

And while we are about it - if anyone out there happens to know where I can find out why it is that English history traditionally starts in 1066 - with the arrival of the ruling class - and why we number our kings from then, despiet there being Edwards on either side of the divide? I would genuinely love to know...

In the meantime, the first part of my Caractacus trilogy (Nor Shall My Sword Sleep) is now published and I am busily writing the second. So comments and suggestions are most welcome...

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Monday, 25 May 2020

The 5G witchhunt and the dangers of tickbox science

This post first appeared on the Radix blog...

When my Tickbox book came out, the only vaguely negative review I received on Amazon was from someone who decided that, because I wanted to move the argument forward a little, that I was somehow ‘anti-science’.

I have to say that I’ve been itching to write about tickbox science ever since. Though I fear I may confirm my critic in his prejudices by doing so.

I should say at the outset that, although I have no scientific training, I do have a degree in philosophy and I have always been fascinated by the various interpretations of scientific method.

I understand how science moves forward by demolishing its own arguments, paradigm and theory by paradigm and theory. It therefore makes no sense at all – as the doyens of evidence-based policy suggest – that science is somehow fixed and final. I take tickbox science to mean precisely this:  – that every idea or theory or brainwave needs to be measured against the sum total of published evidence.

This is absurd, especially as published evidence requires that somebody must have taken the decision to fund the original research, and - with the advocates of tickbox science wandering the internet, seeking who they would devour - that can be a dangerous business.

As you may have realised by now, I am tiptoeing worryingly into the 5G controversy.

I am not defending everyone who says that 5G has somehow caused the covid-19 outbreak. It is hard to discern how this could possibly be the case. But I am aware of research which suggests that 5G – because it is pulsed – might compromise people’s immune systems.

Most of those scientists who are nervous about 5G tend to be experts in the medical implications of electro-magnetic fields. It reminds me of the 1970s, when the establishment went after experts in low-level radiation, after evidence that it might be more damaging than high-level radiation over long periods.

This 5G claim is hardly proven, but – after the witchhunt against everyone who steps out of the narrow lines of tickbox science – I can’t see anyone daring to apply for grant funding to prove it one way or the other.

There is the real danger of tickbox science, or tickbox anything, in fact – it closes minds. It makes ideas impossible to express. And that is the very opposite of scientific.

Do I have a bias here? Well, yes I do. I have chronic eczema and I know that 5G is said to affect, not just insects, but human skin. Nor so I see why my skin should suffer just so that my neighbours an get faster downloads of ‘Call of Duty’ or other murderous online abominations.

I admit it. So go on, ban me from Twitter, why don’t you? There are already a range of things you are not allowed to say about 5G on Twitter or Facebook. And there is a Tory MP trying to make it against the law.

So how, without ridicule, should we stop people burning down 5G installations as they appear on our streets?

There really is only one way: we have to restore some trust in official spokespeople (starting perhaps when a prime minister next goes into hospital).

The problem is that, as the most stupid vandal knows, there are some technological developments that are so profitable that nobody is going to dare to say they are unsafe.

That is why it took 50 years from the 1962 Smoking and Health report to ban second-hand smoke. It took a similar time for governments to act on asbestos, though the evidence had been understood since the 1920s.

In those circumtances, there is a complication because nobody dares to do the research, and scientists who apply for the money to do so put their careers on the line.

I remember meeting researchers who dared to suggest that mad cow disease might be dangerous to human beings and they were threatened by the security services. There are big stakes.

But in those days, it was just the establishment versus the truth. There was none of what we have now: a group of self-appointed puritans committed to tickbox science, who want to seek and ridicule anyone who thinks differently. The lineal successors of those who tormented Galileo and Copernicus.
That is about as far from the genuine spirit of science as it is possible to get.

Now, when you get handed your licence to write these blogs (figuratively speaking), they do impress on you the need for policy solutions. How do we restore some trust in the certainties and uncertainties of science? How do we stop both sides from undermining the whole thing?


I would suggest a lay committee, comprising scientists, wonks, philosophers and members of the public, appointed independently of the government to advise on risks. Note the word 'advise', because as Philip Collins put it in The Times last week (£), there is a great deal too much "bogus certainty in the air" - and in the end, these are political decisions.

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