The constipation of the NHS

There is an awful lot of old nonsense written about the Health and Social Care Act.

It is said that it was a mistake to put decision-making in the hands of GPs. Well, it did at least provide the foundations for shifting power away from the hospitals – though, of course, GPs are not really in control (they are providers and the CCGs are purchasers, so they can’t co-ordinate properly, as they need to).

It is said that it has opened up the NHS to privatisation. On the contrary, most of the marketisation measures were removed by the Lib Dems, and most of what we have now are the basic outsourcing structures set out by the Blair-Brown governments (yes, there is an issue around the scale of what is happening now).

But what on earth possessed the Department of Health to split regulation between three competing bodies – NHS England, the CQC and Monitor – and to leave the boundaries between the three of them obscure enough to get in the way of innovation?

I encountered all three of them in a brief official capacity, and found them all obsessed with each other’s remits, nervous about each other and very, very careful.

It does explain something of the bitterness behind the NHS blogger Roy Lilley’s attack yesterday morning on the way the NHS is led – a dearth of leadership on the ground, and a pointless stream of negativity from the regulators to anyone who thinks differently or experiments or takes risks with the targets.

It is as if the coalition took the disastrously concrete and wasteful design of public services from the Brown years, and then set up three super-quangos to entrench those mistakes further.

When I met CQC in 2012, they were still using fax machines – enough to make any of us nervous.

Now, you can criticise Roy for trying to let NHS providers off the hook. The CQC, which is – as he says – far too big for its own effectiveness, is the illegitimate child of the Mid-Staffs scandal. But this paragraph is absolutely right about NHS leadership:

“As the boss, you have no control over the business model, compulsory frameworks that might be completely inappropriate for where you work, fixed prices, targets and tariffs that create perversity, arbitrary regulatory rules, and required to do plenty more with plenty less.”

There is the NHS in a nutshell. What can you do about it? Well, I think you have to accept that the NHS can’t be run as a vast great centralised edifice any more.

The danger is that anyone who says this tends to get accused of wanting to sell it off – but it badly needs to be decentralised to local units, and to accept that these might look very different.

You also urgently need to decentralise inspection. There is no way that mega-CQC can do more than a paint by numbers approach, and they need to be stripped down to concentrate on training local authorities to inspect instead.

I’m not sure that Monitor has a role at all, though clearly somebody has to watch over the business practices of the foundation trusts and to speak for patients and their right to be treated flexibly.

Somehow this devolution has to be done without a major new re-organisation, which is politically unacceptable. Nor can you use rhetoric like ‘setting the NHS free’, because again it sounds like weasel words for privatisation.

But you do have to rescue the NHS from its undergrowth of constipation. In short, we need a major dose of laxative.

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Politics and the art of the impossible

I felt rather sorry for Emily Thornberry, whose innocuous tweet caused such a stir.  I wasn't sure if it was actually the sensitivities of the Labour Party she really upset.  Their conscience has been plaguing them for the complete abandonment of the working classes in recent decades.

No wonder Ed Miliband was so cross.

On the other hand, it is clearly right - given the Ukip surge - that the political elite should be examining their consciences.

I have a feeling the sense of alienation from conventional politics, which - as a Liberal, I rather share - lies in the strange loss of ambition that seems to have gone hand in hand with globalisation.

Instead of setting out a vision which can be achieved, frontline politicians have to spend their time defending a series of compromises which the establishment has made on our behalf, often for very good reasons but not conclusively so.  And maybe because they have to: globalisation has been a paradoxically constraining force.

They have to defend the status quo in energy for fear that investment in the infrastructure the nation needs won't be forthcoming.

They have to defend rising property prices for fear that buy-to-let landlords will withdraw from the market and they will have to deal with the resulting homelessness.

They have to defend the bureaucracy around global trade because it underpins the single market, and all the other trade agreements which have constrained our political freedom of movement.

And so on and so on.  It is the politics of binding compromise, with a whiff of the politics of fear.  It is the result of the political class losing control of the levers.

They may be the right compromises, and the establishment knows they are inevitable - so they never get discussed.  It is hardly surprising that a political movement emerges, simplistic enough to fail to understand them - and to contemplate tearing them all up and starting again.

There is a reasonable longing for politicians to be politicians again, to dream dreams and say 'why not?'  To act on the national stage, to make things happen.  The art of the possible has become the art of the impossible.

But when that happens, there are circumstances when the least attractive alternatives suddenly appear to some people compelling.  After all, if the opposite of populism is just to close ranks and defend the usual compromises which have dominated our lives since the 1970s, then populism has its attractions, even for me.

Especially when those compromises involve defending institutions because of what they were designed to do, when every one knows - perhaps everyone but those in Westminster - that they don't actually work as intended.

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A recipe for old-fashioned economics

The trouble with standing for election is that it gives you the potentially disturbing opportunity to see yourself as others see you.  You fail to get elected, and suddenly you are puzzling out obsessively what it is about you that sort of failed to enthuse people.

All of which is a way of saying that I'm out of sorts at the moment, having failed to get elected to the Lib Dem federal policy committee for the second time in two years.  But, hey, my electorate have spoken...

Dammit.

Of course there are compensations.  I won't have to crawl up to London and back again at dead of night.  I won't have to sit through interminable debates about the Health and Social Care Act, or constitutional reform as understood around 1956.  But I'm sorry, nonetheless.

I imagine that not nearly enough people want a member of the policy committee who is really pretty loyal to the current leadership.  I'm not on anyone's lists - both the Orange Book people and the Social Liberal Forum furrow their brows when I speak.  Perhaps I should be pleased to have won as many votes as I did (thank you, everyone!).

But one thing does worry me.  I stood on a promise to take the party's economic policy by the scruff of its neck and to make it work for people.  I might not have succeeded in this, but I was determined to try - because it worries me that even self-described radical Liberals seem to have almost no interest in economics at all.

The result is that Lib Dems tend to get rolled over when it comes to economics.  This is not a critique of austerity, but it is a criticism of our failure to think creatively about what else might be possible.

And when you don't think radically about economics - when you can't see the point, I'll tell you what happens.  You become deeply conservative on the subject.

So, an obscure debate took place in the Commons last Thursday, about the way money is created.  It was the first time Parliament has debated this very important issue for well over a century, and there was a great deal to be said about the underlying causes of the 2008 crash.

You don't have to agree the entirely line by Positive Money, the campaign group around these issues, or to have agreed with everyone who spoke - and many of them disagreed with each other - to find these issues pretty important for the future design of our money system.  Both Adair Turner and Martin Wolf have been talking about this issue in the last few months.

I'm not even sure what I think myself - but it is a healthy departure to have MPs discussing the possibility of varying how much publicly-created, interest-free money there is in circulation (a good deal less now than when I was born).

But here's the point.  The debate was sponsored by MPs from four parties but no Lib Dems.  As many as 30 MPs took part, including a very distinguished former cabinet minister, and - you guessed it - no Lib Dems.

I think we urgently need to take what Keynes said to heart (as a good Liberal):

“Practical men who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist."

That's what happens when you stop thinking about it.  The defunct economist in all of us, the default common sense of a few generations back, comes to the fore.

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Why privatisation is over (nearly)

I have a BFI copy of the classic Post Office film Night Mail, with the Britten-Auden collaboration that emerged as night mails crossing the border-bringing-the-cheque-and-the-postal-order. It now looks like a hymn to public service commitment.

One of the other features in the DVD was a sequel, in colour, dated from 1963, called Thirty Million Letters. It is a touching, emotional and absolutely brilliant evocation of what a postal universal service obligation used to mean. There are postmen walking through blizzards, delivering post from a pony and trap, by plane and in constant supportive contact with the public.

The universal service obligation, which the newly privatised Royal Mail is so keen to dispose of, was portrayed there as a thing of beauty – a commitment of pride, a national treasure, a precious stone set in a silver sea...

I can see that the chief executive of the Royal Mail is in a difficult position. Now the Royal Mail is a private company, its continued universal obligation holds it back.

The pressure is on from innovative new competition, from click and collect to Amazon drones. It is difficult out there. It is also difficult for Business Secretary Vince Cable – criticised that he undervalued the shares, and now criticised just weeks later that he overvalued them.

But the abolition of the universal service obligation, a feature of the Royal Mail since Victorian times – which now seems inevitable – is such a scandalous volte face by the Royal Mail that I have been wondering if it marks the end of privatisation as an instrument of policy.

The appalling things is that, as predicted, a universal service obligation shifts from something which we took for granted with quiet pride in the 1960s into something which is too expensive.

Privatisation was born in 1984 as a means of improving service, encouraging innovation and providing a form of popular capitalism – and also of course of raising national revenue (selling the family silver, as Harold Macmillan put it).

After three decades, it has become something else. Here are three reasons why it is reaching the end:

1. Instead of setting free public services by giving them entrepreneurial energy, the process seems to have had the reverse effect – it transforms them into the worst kind of intractable bureaucratic megaliths, apparently without care or thought.  As bad as before, but more expensive.

2, Customer facing UK business is itself going through a period of serious dysfunctionality, based on dysfunctional CRM business practices, set in concrete by dysfunctional IT systems. The prospects of handing over any more services to that kind of customer services does not bode well.

3. Nobody any more believe that privatisation will lead to a better service. Quite the reverse.  That was not the case in the 1980, and the great privatisations back then – British Gas, BT – have retained their functionality, but it certainly is now. State owned East Coast railway lines provide by far the best service.

4. The need to save money means that there is simply no opportunity for profits that privatisation might once have offered, especially in health – which is why so many contracted out NHS services are being abandoned.

None if this suggests that privatisation will stop dead. There are also good reasons for contracting out some services inside the state system – and always will be - but, despite the scare stories, privatisations seem to me to have reached the end of the line.  The revelation of just how much universal services and competition are incompatible will only hasten their demise.

The remaining two justiications are that privatisation helps raise money – which is not enough of a reason for doing so in itself if the management is going to be worse or more expensive – and that they can then raise investment money off the government's balance sheet. This is still an important driver. But there is a political limit: if privatised services are acknowledged to be worse,  less reliable, less effective and less universal, then the tide will turn,

I think it just turned.

Iinnovation versus manipulation in the NHS

Targets came from Jeremy Bentham, in a labyrinthine journey via Robert Macnamara and Key Performance Indicators. They purport to provide transparency and accountability, and – in some ways, in the absence of anything else – they do.

The difficulty is that they never quite measure what they claim. They are indicators of the thing – success – and not the thing itself. And in that gap, so many difficulties follow.

I write all this because of a blistering attack by the influential NHS blogger Roy Lilley this morning about the effects of too close attention to targets is having on an NHS which feels itself embattled – and the tricks the managers are laying to avoid confrontation with the regulators, like delaying all operations to insert patients from the waiting list, or declaring a local emergency so that the targets don’t apply.

Many of us involved in Lib Dem policy in 2010 believed that the coalition would dump the Blair-Brown idea of targets altogether, and they did to some extent. But enough of the old edifice remains to twist the purpose of services and create waste.

Why didn’t they go further? I think because nobody had thought through enough – as they still have not in enough detail – how to provide accountability without some kind of target-driven inspection system.

But we have come some way. What we have left is the bones of the old Blairite, utilitarian design that dreamed that public services were giant humming machines, run outside politics by men in white coats, huddled over the dials.

That system remains because Whitehall has not yet realised how far the target numbers are from reality – cf. Goodhart’s Law – and how delusory their progress figures are. Or what to do about it. That is all now deferred for the next Parliament.

I thought before, and still think, that it was a wasted opportunity, but you can’t move until there is some consensus about what you do instead – and that remains elusive, though John Seddon’s work points in a pretty clear direction.

In the meantime, the NHS is still overseen in this bizarre system of management-by-numbers, which stands in relation to leadership as painting-by-numbers stands to art (see my book The Tyranny of Numbers).

You can see how targets might keep hospitals to the task in hand when budgets are increasing. But when they are shrinking, and demand is rising – partly because of the way contracts have tended to narrow services and spread costs – then targets just become ridiculous.

And in the midst of a crisis, like wartime for example, checking on the success of hospitals by peering at the target figures just becomes like satire.

The real question is this: who in the top eschelons of the NHS is watching over trusts and hospitals and supporting their leadership when they are providing innovative solutions despite targets? And who is holding them to account when they are meeting targets by putting all their energy and ingenuity into tricking the system?

Why free traders might oppose TTIP

David Cameron chose to emphasis TTIP in his speech in Australia, explaining that the Transatlantic Trade and Investment Partnership – its proper title – will give a ‘rocket boost’ to the global economy.

I find this argument strange. There is very little evidence for it. The study it was based on has been discredited (at least according to WDM), and – in any case – you have to be suspicious of this kind of cost benefit analysis, which only adds the benefits and does no subtraction for the disbenefits.

Similar one-way analyses have been used to justify an end to supermarket restrictions on Sundays and the expansion of Heathrow. It is a kind of fantasyland.

There are three accusations that are being thrown at TTIP at the moment. The first is that it endangers the NHS. I believe this isn’t the case since the European Union has legislation that puts public services beyond the reach of TTIP.

But actually nobody seems to know and I find it extraordinary that, because these issues are not on the mainstream agenda for Labour or Conservative – the BBC fails to pin down the chapter and verse, or even to cover the issues much. Nor do any of the parties volunteer it.

The second accusation is that the special measures will allow corporations to sue sovereign nations for undermining their investments.

This seems to be quite true and bizarrely, presumably because it involves American corporations rather than, say, Romanian ones, UKIP stays silent on the issue.

The third accusation is not really articulated properly and is about the limits of the free market. This is the critique of the research which Cameron uses for his claims about the benefits of TTIP. Again, completely unexamined by the BBC.

There are difficulties here. It is true that open markets will tend to raise all boats, but there are already wide-ranging trade agreements between the EU and the USA and it is not clear how much this one will add.

It is also true that the meaning of free trade has become blunted and coarsened since its great days as the centrepiece of Liberal economics.

What began as a critique of monopoly, and an underpinning of the right of the small to challenge the weak, has become the opposite. Free trade, as understood by mainstream policy-makers, seems to me to have become the absolute reverse: a justification for monopoly and a buttress for the strong and rich to control the weak. This is not its original meaning or its correct one.

It seems to me highly likely, given this, that TTIP is a buttressing of the big over the small – I can’t see how my local healthcare co-op is going to be taking over any American hospitals. It is a means by which the big can ride roughshod over the small – it is a recipe therefore for poorer service and the suppressing of innovation.

Since small businesses create jobs in a way that big businesses are constrained from doing, this would make TTIP a net job destroyer and therefore corrosive of prosperity.

This column is my assertion of the right as a free trader to oppose TTIP. In the absence of clear evidence, it is a technocrat’s charter and, as such, brings the backlash against technocracy – really our biggest threat at the moment – that much closer.

Why are we so fascinated by Alan Turing?

The new Benedict Cumberbatch film comes out tomorrow in the UK.  It is called The Imitation Game and it concerns the code-breaking career of Alan Turing, the British candidate for the inventor of computing.  It is also the UK candidate for the next Oscars ceremony.

What I have been wondering is why Turing has become such a compelling figure in our recent past - and, at the age of 102 if he had lived, he might even have still been alive.

When I first began writing about him, when I was writing my book Authenticity, Turing was a half-forgotten, fringe figure.  Now he is a symbolic martyr who helped create the modern world.  In between, something happened.

There are three possible ways of thinking of this. There was his prosecution for homosexuality and subsequent suicide (and it almost certainly was suicide, as I explain in my book Alan Turing: Unlocking the Enigma). With the issue of sexual tolerance right at the top of everyone's radars these days, this makes him something of a martyr - enough to be given an official pardon last year.

As I explained in the book, the suicide was most probably not directly to do with the prosecution, and more likely to be linked to hounding by the security services, but actually we can't know.

The other way of thinking about his importance as a figure is that he was such a pioneer of virtuality, and as such a co-creator of the IT revolution. He conceptualised computers and then brought them into existence to crack the Nazi codes.

Finally, Turing was a contradictory personality who strongly believed that machines could think and feel - the founder, in that respect, of the Turing Test. He was in this respect another pioneer of tolerance - he believed, not so much that his computers should be given rights, but that they should be given the benefit of the doubt.

It is never entirely comfortable when a complex human being becomes a symbol of things beyond themselves. Turing has become a symbol for the modern world, as a prophet of IT and scientific rationality, a martyr for gay rights, and also of genius cramped by convention and intolerance.

He would have found none of these entirely comfortable. He is portrayed sometimes as a social misfit, somewhere on the autistic spectrum – in fact he was a witty and entertaining friend. He enjoyed Snow White and had a particular fascination for fairy tales. He was, in fact, a far more rounded figure than he is given credit for being, as the new film portrays him.

As for the symbolism of the apple, it is a bizarre twist of the modern world that Turing’s fatal apple (poisoned with cyanide) is sometimes given the credit for being the original for the logo which now graces Apple computers – as if the apple of the tree of knowledge was somehow inadequate to the task.

In fact, the Apple logo’s designer Rob Janoff denies that he had even Adam and Eve in mind when he penned his first draft. He put the bite in, not as a tribute to Turing, but to emphasise scale and to show this was not a picture of a cherry.

What seems to underpin our fascination with him is that he was a pioneer of the modern world, and perhaps of tolerance to people who approach the world more like a computer would - as perhaps he did.

The Turing Test never claimed to be able to verify anything metaphysical, but that is where the debate is going.

 It is a debate about authenticity, which asserts or denies that there are attributes which are uniquely human, not so much conventional intelligence, but love, care and generosity. Turing believed that intuition was computable. Even if a computer passes his test, we won’t know if he was right or not.

Turing was wrong about his predictions: he expected his test to have been passed by now. But we are now in thrall to computers in ways that might have surprised him: in practice, the closer to human intelligence the robot who phones us up can be, the more unnerving the experience – and, for the time being, the more frustrating, because of the inability of IT to deal with human complexity in the ways that Turing predicted.

If the corporate world wants to replace teachers and doctors with screens and software, because it is cheaper, it is not always obvious which side Turing – a great humanist – would have been on.

I like to think he would have been on the side of humanity again, but who knows.  Find out more in my ebook Alan Turing: Understanding the Enigma.

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