The problem with imperialist public services

This post first appeared on the Radix blog...
I haven’t ever given a lecture to nursing students before, and thoroughly enjoyed doing so last week. but it was also a bit of an eye-opener. I know the NHS is formally committed to ‘co-production’ in theory – though I’m not sure how they define it – but I don’t think I had realised quite how far it has moved away from it in practice.

I’m sure this is not the case everywhere, but it was a shock to someone like me who has spent most of their so-called career advocating closer, more human and more flexible relationships between professionals and patients.

I give a similar talk regularly to doctors and they seem to understand where I am coming from and, up to a point, support it. But it was clear to me that some of the nurses did not see human relationships that are encouraging as practical in their corners of the NHS.

Welcome to the world of ‘patient-centred care’.

This is the philosophy behind the way patients are treated, not everywhere, but especially perhaps in specialist centres. It means you certainly can’t challenge patients, or ask them for their help. Nor can you encourage them. And if they don’t respond to the process you offer them, you simply strike them off for being ‘non-compliant’.

It is of course precisely the opposite of patient-centred care. Doublethink, as Orwell would have put it. It is an idea borrowed partly from the economists’ version of public service choice which used to frown on encouragement from doctors in case they imposed their ideas and preferences on patients.

In fact, what I know from being the independent reviewer on choice at the Cabinet Office some years ago, the main choice people want to make in healthcare hasn’t got anything to do with where they want to be treated. They want a doctor who will answer the question”what would you do if you were me, doctor?” – the very question the economists hate most.

But patient-centred care owes itself to a dubious Treasury-inspired view of efficiency, imposed on public services as if they were imperialist outposts administering to an unreliable race, a view that also owes something to the idea that sparing the rod will spoil the patient.

The same approach to sanctioning ‘non-compliant’ service users started in benefits and now seems to have spread to the NHS. How else should we understand today’s story of the five-year-old girl who died of an asthma attack after being turned way from an emergency appointment for being more than ten minutes late. Would that have been possible if there had been a human relationship between patient and professional.

Since the days of Blair and Brown, service have teetered on the brink of an imperialist model and, if we are not careful, they may be now tumbling over. It is not at all efficient, in fact, because it is so ineffective.

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The strange rebirth of Liberal economics

This post first appeared on the Radix blog...

Once upon a time, I was a member of the Lib Dem's federal policy committee. I used to irritate Danny Alexander and other luminaries by claiming that Liberals had made no contribution to economic debate since John Maynard Keynes had breathed his last in 1946. In retrospect, this wasn't terribly helpful of me, but I believe it to be true.

I don't include in this stricture, of course, the so-called 'neo-liberals', who are not Liberals in any sense of the term. Their main contribution has been their scepticism about the dangers of monopoly power - which makes them the reverse of Liberals. In fact, for some reason - and for discussion in another column - the Liberals allowed their central idea of free trade to be hijacked, turned inside out and made to mean the precise reverse of what it originally meant.

A doctrine that allowed the weak to challenge the strong has been allowed to bundle up the economically weak, and hand them over bound and gagged into the arms of the monopolies.

So what is changing? Well, absolutely nothing in the UK I'm afraid. But last summer, Barry Lynn, working on open markets at the New America Foundation and was sacked for criticising Google. He became a cause celebre, and has a head of steam behind his campaign against the emerging monopoly power in the USA, especially among the tech companies, Facebook, Amazon and Google.

I met him again a couple of weeks ago and he believes action will soon be taken. Among the people he saw in London was Vince Cable.

The central idea in the way of reform is that idea that, if the government gets out of the way - and businesses get as dominant in the market as they can - then consumers will always benefit. Research in the USA suggests this isn't actually the case.

Economists Jan de Loecker and Jan Eeckhout have found that prices are now 67 per cent above costs when they used to be just 18 per cent, and other evidence that consolidation is driving up prices. German Gutierrez and Thomas Philippon have also found that business investment as a share of GDP has been falling – probably because of the increasing market power of companies. See how Bloomberg reported the issue.

Ever so slowly, and not so far in the UK, the tide is turning - and researchers are waking up to the great fallacy we have been living under for the past generation. But the shift still needs to conquer the regulators, who remain largely in thrall to the old fantasies of the industrial age - of economies of scale and the other temporary truths of assembly line organisation. Even in 1994, the US Department of Trade opened 22 investigations into monopoly power. In 2015, it was three. In 2014, they didn’t open any.

Still, history is sweeping back into the economics of liberalism. It is time Liberals dusted down their own explanations before it sweeps past them.

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How to know if services work - do they give good help or bad?

The post first appeared on the Radix site...

I was a little late last night and nearly missed the Nesta event in London to launch the report they wrote with Osca. But I’m very glad I went, because I believe this one of those reports we will look back on as important.

It is called Good and Bad Help: How purpose and confidence transform lives.

This is the kind of territory that I’ve been working in for a couple of decades, about why public services succeed and why they fail. In fact, in 1990, I linked up with two friends to launch a ginger group called the Self-Esteem Network, dedicated to making self-esteem a political issue. Not a million miles from Good Help.

I can’t pretend it was exactly a success. I met some fascinating people and enjoyed singing some of the songs from the California state primary schools (“I’ve got self-esteem/Do you know what I mean?”) But I don’t think we cracked the two fundamental questions – what policies will effectively drive up self-esteem when it is lacking, and how do you know they are working?

The term is now dead. John Vasconcellos, the California assembly member behind the California task Force for Self-Esteem, has been discredited – quite unfairly. But the basic issue remains and the new report sets it out well.

It is this. If public services fail to treat those they are helping as people who might, with some help, drag their own lives back together, then their workload will get heavier and heavier.

What is inspired about the report is that its title sets this dilemma out clearly. Good help works, bad help doesn’t work – and we know a great deal about the difference. But most public services are not set up to provide good help.

The apotheosis of inflexible service delivery was reached, it seems to me, under Blair and Brown. I was disappointed that the coalition failed to grasp this nettle, though actually they failed to see it at all. So we now still live in the world of impersonal, digital-by-default, PBR services, delivered by impersonal, lobotomised – and possibly also bankrupt – outsourcing giants. Neither show much signs of being able to provide the Good Help we know works.

It is the same unfortunately the world over – increasingly expensive services that don’t work – and one of the reasons voters are so cross. I proposed a way of injecting flexibility into existing services in my independent review on barriers to choice in 2013, and something along those lines is going to be needed if we are to ever to forge an effective public sector again. And we have to if we are going to provide people with the Good Help they need. We know what to do – we’re just a bit hazy still about how to shift the existing system.

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The unexpected return of fairies

This post first appeared on the New Weather site...

The year: 1991. The place: a Cornish country lane. An anonymous man is driving at speed when he suddenly sees an old, swarthy-skinned man, about two foot high, pointing angrily at him.

He screeches to a halt and realises he is on the wrong road and that, if he had carried on, he would have driven over a cliff. “I consider this ‘pixie’ to have saved our lives,” he says.

The story is in a developing census of fairy beliefs in the UK and it is a strange one.

It is partly strange to be talking about fairies in 2018. Because last year saw the anniversary of the events of the Cottingley fairies, where two small girls claimed to have photographed some of them, playing around a small Yorkshire brook.

It took nearly 70 years for them to admit that the pictures were faked – though one still claimed that one of the pictures was genuine – but the damage had long since been done. It was difficult for people to admit they harboured vestiges of beliefs in fairies, referred to by the historian Ronald Hutton as “the British religion”. After the Cottingley pictures, such belief became almost impossible.

Yet when the anonymous author told a recent ‘fairy census’ about his Cornish ‘pixie’, categorising what he saw, he falls back on the old explanations. Because, despite Cottingley, people still seem to have experiences which they categorise as encounters with fairies. Not usually winged, and strangely often when they are driving – and nobody really understands why or what it is they are seeing.

That is the message of a new book called Magical Folk, edited by Simon Young and Ceri Houlbrook, a book of essays which brings the fairy tradition up to date. Simon Young is a folklorist who has revived the serious study of fairy beliefs by relaunching the defunct Fairy Investigation Society. This had been launched in 1927 by Quentin Craufurd, a former naval officer on the Dover Patrol, and at one stage boasted a membership that included Walt Disney and Air Chief Marshal Lord Dowding, the Battle of Britain victor.

By the 1970s, it had gone underground – fairies were deeply unfashionable – but Simon Young’s relaunch has also led to a major collection project in the form of the fairy census, which is not yet published (though the Cornish pixie story comes from there) but which demonstrates that people saw things they interpreted as fairies right into the current decade.

Perhaps most surprisingly, they see them also in London, or in their own homes. In the case of the harpist Elizabeth-Jane Baldry (one of the stories in the book), she saw one sitting inside her bin. Neither the book nor the census makes assumptions about what it is that people are actually seeing – or indeed whether they are actually seeing anything. It is the belief that matters.

It is hard to know what they see. Perhaps these are stories we tell ourselves based on peculiar psychic experiences, as Jung might have said. Perhaps they are actually seeing what they say they see. Perhaps people just register something in the physical landscape – a bird, a tree bending in the wind, animals moving furtively in the undergrowth, which their minds choose to interpret as the presence of fairies.

But why would they? We are all walking libraries of our cultural history, much of whose traces we remain consciously unaware of. They include millennia of stories in which we pattern our experience of the world to make sense of it. Whatever else they may be, fairies - like wood sprites and pagan gods - are also mythological manifestations that we project to manage our relationship to nature. In that sense, the rebirth of fairies is also a sign of a modern longing for nature.

There is a sub-classification of New Age which has for the last decade or so concentrated on fairy wings and fairy festivals. I have been fascinated with the idea for some time, but I’ve been careful who I tell. Some years ago, I wrote a novel about fairies (it is now called Leaves the World to Darkness): a major publisher was interested in publishing it – on condition that I took out the fairies.

Faced with this kind of official disapproval, it is hardly surprising that fairies dropped temporarily out of polite discourse.

It is now a century since Rudyard Kipling had Puck of Pook’s Hill claim that someone had “broken the hills” but found the fairies had gone. It looks as though, even in the era of Brexit, Trump and Google, there may be some flitting around.

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