Cab for Hire

In May 2013, the Financial Times reported on “the symbiotic relationship between government and the companies at the centre of recent tax avoidance rows”. According to publicly available data, eighteen former ministers of state and senior civil servants had moved to KPMG, Deloitte, or PwC in the previous decade. Paul Kirby, policy advisor to Cameron at No10, had come from KPMG and recently returned to KPMG, where he would rejoin recent Home Secretaries Charles Clarke and Jacqui Smith. Within the previous week, PwC had announced it had hired former Health Secretary Alan Milburn “to advise on changes to the NHS”.

The impending end of New Labour’s term clearly prompted former ministers to seek employment, or at least income, based on their roles in office. Adam Ingram (Armed Forces) was caught offering his former Whitehall contacts for £2.5K a day. Richard Caborn (Sports) offered a network of inside information for a similar rate should he be made a Peer. Former Secretaries of State Stephen Byers (Transport), Geoff Hoon (Defence) and Patricia Hewitt (Health) were all caught in the same ‘sting’ operation, offering influence for hire.

Less than two years on and we are reminded that Dave Hartnett left his role at HMRC to work for Deloittes and to be a consultant for HSBC. His successor at the “reformed” HMRC would be Ian Barlow, a senior partner at KPMG, who now sits on that board with John Whiting (formerly PwC). KPMG, tax expert Richard Murphy assures us, has a presence in every tax haven in the world. In 2005, KPMG “admitted that it engaged in a fraud that generated at least $11 billion dollars in phony tax losses which, according to court papers, cost the United States at least $2.5 billion dollars in evaded taxes.”

KPMG, with PwC, also gave the thumbs-up to the PFI deal which has devastated the cash flow of Peterborough Hospital.

KPMG now “dominates the board room” at state-owned HBOS. With others in the Big4 it provides staff to work for the three main political parties, and secondments from the Big4 to civil service departments – and vice versa – are routine. There used to be a revolving door: now its a shared, virtual office.

What makes ministers and mandarins so attractive to the “Big 4″ consultants? Inside knowledge of government and party, presumably: but most certainly and perhaps more valuably, personal contacts and networking access. Which brings us to KPMG’s latest investment, Stephen Dorrell: a sitting MP, ex-chair of the Commons Health Select Committee and another former Health Secretary.

Dorrell, like all the ministers mentioned above, is doing nothing contrary to the rules of behaviour set down for him. He has been in parliament since being elected 35 years ago. He seems to have served honourably. There was an expenses issue of course, where he was reported to the standards commissioned for the sale of flat to friends who owned a chain of nursing homes, then claimed the rent. His record is that of a loyal party man. He voted strongly for this government’s NHS ‘reforms’ and throughout his parliamentary career very, very rarely rebelled against his party.

Off to make his fortune in The City. Why shouldn’t he? 

There are a number of reasons he shouldn’t be, none of which depend on Mr Dorrell being anything other than virtuous (the nature of his new employer is beyond such classification). They are issues of the governance of government, conflict of interest, and of public trust.

The rules related to sitting MPs holding outside jobs and directorships in the UK are particularly lax. Members declare financial interests, but that’s all. According to the register, Mr Dorrell provided over 1000hrs management consultancy services in just over 12 months from Oct 2013. MPs are paid a generous full-time salary (plus expenses), and many complain of long and anti-social hours, yet 1000hrs in a year is half of every normal working day. Perhaps “in respect of” means he organised, rather than personally provided the consultancy.

It shows a lack of respect for the role, and disdain for the public, for MPs not to commit fully to being MPs. MPs, once elected, should end other employments until they physically leave Parliament for the last time. For an MP to pick up new jobs or remuneration while being an MP looks like exploitation of their position and with it the public trust; which brings us to the question asked by Clive Peedell of the National Health Action Party (and by the signatories to a petition raised by a small group of pensioners in his Charnwood constituency): why is Stephen Dorrell still an MP?

If Dorrell’s new role with KPMG is incompatible with his role as MP – as he himself reportedly admits – then why didn’t he resign his seat the day he signed the contract with KPMG? It may be party political, but it may be the most useful six months he provides to KPMG. Again, he is playing by the rules and demonstrating that the rules are woefully inadequate. Were he moving from one commercial organisation to another, he wouldn’t be working on site, as normal, any more. He would be gone or gardening.

And that isn’t a false premise that KPMG and Government are not competing, as two commercial entities are. It is absolutely the prevailing political ideology that government has usurped what should be private enterprise: rolling back the state is rolling forward the corporation.

Dorrell’s move to KPMG must therefore be looked at from the perspective of confidentiality. As Chair of the Health Committee and a former government minister, he has knowledge not just of policy, but of who wields influence in policy-making, and how policy can be influenced. He has a clear conflict of interest.

This is inequality: an unequal access to the way government – and party – policy is shaped. The public is excluded where the politician,(MP, minister or mandarin) is also working for the private corporation on whose behalf he can provide or supply influence. It is also an issue of lack of transparency, as the politician’s meetings with his employer will not be public knowledge. The public can have no trust in policy.

We need to re-establish the boundaries between public and private sector, public servant and commercial entity, mandarin and private consultant: and to do this for the good of both public sector and private business. The way to do this is firstly to institute confidentiality agreements on leaving public office, to reduce the value of ex-public servants to private companies. Secondly, it is to regulate the employment of MPs and civil servants upon leaving office by organisations with clear commercial interest in their previous area of responsibility. A sliding scale, perhaps, of time where an ex-MP or mandarin can be employed: no limit where an MP with no committee or ministerial role is unaffected; two years for a Committee member, five for a committee chair, ten for an ex-minister, twenty for an ex-secretary of state.

To the public – however inaccurately or unjustly – Stephen Dorrell may just appear to be the latest ex-minister who has used public office and public trust to secure a nice little earner for himself by enhancing the role of a commercial corporation in the future of our health service.

It is time to put a solid door back between public and private office, to secure its opening and closing, and check carefully who it allows to pass.

deny it as often as you like

Having denied that the Health and Social Care Act 2012 created a risk of privatisation of the NHS; having denied that the contracting of private providers to replace public provision is privatisation; the latest argument of the privatisation supporters runs something like this:

“Over 4% of the NHS was delivered by private business when Labour left government in 2010. Only  a bit more than 6% is being delivered now. The risk of privatisation was exaggerated.”

In response to the instigators and lazy propagators of this disingenuousness, a few points:

Make your minds up. Is that extra 50% privatisation, or not?

You do Andrew Lansley a great disservice. He was absolutely clear when addressing the NHS Confederation five years before taking up office that in his view previous Conservative privatisations had partly or wholly failed, and that he would have to build a new regulatory structure to create competition between multiple providers and to transfer private provision to multiple private providers. He even had the temerity to tell you this in plain English

I believe that the Conservative Party became confused itself about what the experience of privatisation told us. We interpreted the lessons of privatisation as, literally, that: the transfer of public sector activity into the private sector. With private sector ownership would come enterprise, innovation and, temptingly, private capital off the Treasury’s balance sheet.

Andrew Lansley – “The Future of Public Health and Regulation”, 2005

Not only did Lansley never doubt that

the transfer of public sector activity into the private sector

is privatisation – something,  repeat,  you persist in denying – but he wanted to give you a better privatisation, one not just with added ‘competition'; but competition of a new and magical sort where instead of failing, competing private providers would never fail, but would all drive quality up. He even made up a new saying to prove it, and referred to evidence (though didn’t provide any).

How can competition work, whether on prices or quality, if it does not lead to variation and divergent outcomes? Some will gain. But do others lose? No, the evidence is that in effective competition the response of other producers of good and services is to raise their game, so that even those who are less fortunate or successful purchasers will gain by this. As the saying goes, “competition is a tide which lifts every boat”.

The sheer volume of the Bill would only have shocked you if you hadn’t thought about it as deeply as Lansley: if you had been convinced that all you needed to do was what you had always done: get Goldman Sachs or whoever to create a share issue for the NHS and sell of the lot at one go.

Except, of course, Lansley actually cares for the NHS, perhaps almost almost as strongly as his vision of private competition. He is not like rest of you , who just think it another 60 year mistake, another bit of public property to grab and scarper offshore with, another pile of excuses to help people avoid work. He may not think, as so many of you do that old age is a mistake, and that people with no economic usefulness should be discarded, like old mobile phones.

No, Lansley actually believes in what he did.

That is why the Act was so intimidating even in its first published forms. It simply had to contain all the reorganisation to create his new regulator (Monitor) and all the  foundations of the regulation to create in the real world his vision of competition.

More firmly than you, Lansley had a grasp of what he had to create to push the NHS not into a new state, but in a single and irreversible direction: towards his utopia of proliferating providers,  omniscient customers,  and private capital. In brief:

  1. To  force the NHS to be moved piece by piece from public to private ownership and provision, but never to move in the other direction.
  2. To create, regulate and maintain in perpetuity his vision of competition.
  3. To fortify his machine against attack or disassembly.

Lansley, however, is not so much risk-averse as averse to the very thought of risks (whether to his plan, or caused by his plan), which he sees as mere distractions. Inevitably, he underestimated or ignored some possibilities which became reality: beginning with the risk that not everyone, not even his fellow Conservatives and fellow travellers, would be captured by the brilliance and perfection of his solution.

Political expedience would delay the bill, implementation would eat up two more years of the Coalition, and the practical problems of the privatisations would take up even more time.

  1. The Coalition government could never admit what he was actually doing.
  2. Senior members of the Coalition wouldn’t, or couldn’t understand his Bill, or even bring themselves to read it.
  3. The number of Liberal Democrats in Coalition who would jump at the chance to grandstand and to posture.
  4. The sheer length of time it would take to get the bill through Parliament, with Labour opposition and (3) and Cameron and Clegg’s panic and the delay of the “listening exercise”.
  5. The length of time it would take for the reorganisation to be completed after royal assent, even though begun in advance.
  6. Persistent opposition from NHS campaigners, who at least managed to delay individual tenders.
  7. The length of time, the resource requirements, and the effort necessary to complete a commercial tendering process from start to finish, particularly for high-value tenders.
  8. The cuts in funding for the NHS, which would make tenders less profitable.
  9. The poor performance of existing  – or new – private providers, including the fiddling of performance data.
  10. The collapse in morale within General Practice, where funding cuts, unsubstantiated criticisms from the CQC, and constant attacks from government were completely contrary to Lansley’s vision of crusading commissioners.
  11. NHS staff would be busy trying to provide the services it actually provides, with Lansley’s rebuilding going on around them and the CQC waiting to punish.
  12. Lansley’s massive regulatory machine was built with square wheels, with no-one knowing who was in charge and fights for the steering wheel between Monitor, NHS England, the SoS and the CQC.
  13. As Clive Peedell of the National Health Action Party and many others pointed out, the private providers would only ever want the cherries off the top of the cake; the profitable bits.
  14. Monitor and the regulatory regime would never be strong enough to overcome the private bidders, who would want to protect themselves from competition by demanding ever-longer contracts which they designed.
  15. Commissioners, without support units in the first years, would not have the expertise or resources to commission at a high pace.
  16. By the time the reorganisation was complete and the commissioners ready, the next election would be approaching and the Coalition uncertain of victory;  frightening the private providers.

Yet the Health and Social Care Act 2012 and the enabling legislation are on the books, Monitor exists, and the CCGs are commissioning by competitive tender: the NHS is privatising itself, as Lansley envisaged.

To argue that this was never privatisation, or that the amount of privatisation completed via the Health and Social Care Act 2012 is so low as to prove it was never about privatisation, is drivel. The Act was intended to privatise as much of the NHS as possible; to salami slice it into pieces which could never be reassembled.

Either you truly don’t understand what Lansley has achieved and you think he failed (Letwin promised you the NHS would be gone within one Conservative government; the NHS was to be shown “no mercy”, remember?) or you know full well what the Act does and that privatisation must follow and you’re being economical with the truth (or fooling yourself).

Whichever, do us all a favour, and stop insulting us with this nonsense.

 

 

in which I recount a fairytale, part 1

Every time she went out of the castle, Princess Stephanie was shocked by how poor her country was. As her carriage lurched and bounced between hovels and splashed through open drains, she glimpsed poor people, sick people, people staggering under loads, people walking miles to find work.

Nevertheless, she was glad to be out of the castle. Her father, the King, needed funds to protect the country’s borders, and he didn’t want to squeeze more taxes from ordinary people. He was hoping  his knights would contribute. (After all, it was their country, too). But she knew they wouldn’t, and the king knew they wouldn’t. They were a loathsome and selfish crew, who she knew – and the king suspected – had long since moved as much of their wealth as possible to some island off the coast, so they could pretend they had nothing to tax. That had all been arranged, the story went, by Lord Cameron’s father. But even he wasn’t the worst of them, in her opinion. The Princess particularly and deeply despised her suitors, Sir Andrew and Sir Jeremy, who extorted the poor people to pay for a pitiful level of medicine. They kept piling up their fortunes, the poor got deeper into debt, and kept suffering and dying too young.   

This trip out was a visit to a childhood companion whose family had once worked for her father, the King, but whose mother had fallen ill and whose grandmother needed caring for all the time. When she arrived, the house was in uproar and her friend was nowhere to be found. The parents wept. Her friend had gone to be a servant at the castle of Sir Gideon, in payment for the towels her parents had been unable to pay for.

The journey back to the castle made the country look even poorer and more desperate. Her father meant well, she was sure: but he had no idea how to make his people healthier or wealthier. The money had run out, he had told her. His previous chancellor, Sir Tony, had spent it all on foreign wars before disappearing from the country, and was rumoured to be hiding out on the island where all the knights had hidden their treasures. The knights had refused to pay for improvements to the border security, predictably. They had claimed poverty.

Her father, the king, was in despair. The princess didn’t like to see him like this, so she suggested they put the country’s troubles aside by spending an evening together playing their favourite sports.   

Princess Stephanie loved these evenings playing sports with her father, even though at everything they played she had to stop herself beating the King too frequently and too heavily. Their favourite was darts: the king was distracted with concentrating on the throwing and the arithmetic; the princess loved the way, when each game was finished, they wiped out all the scores and started again.

She had just missed a 152 finish to let the king sneak a double 1 at about the seventh attempt when, watching him writing 501, she found herself asking, “Where do the numbers come from?”

That was dangerous, as she immediately realised. Her father started on a long and tedious tale of astronomers and merchants, but she stopped him. “No, not where do they come from: where do they keep coming from? Every time we play  - any time anyone plays – we can write the numbers up to start again. We never run out of numbers. We can’t run out of numbers, can we?”

The king looked at her quizzically, but he had enough patience to wait, in the sure knowledge his daughter was about to come up with something just as obvious. But what she said next made him sit down and stare, at her, open mouthed.

“What if… why couldn’t we…why do we keep paying each other and owing each other in things, in bits of metal, or grain, or sheep? Or people? Why don’t we just have a way of counting what we owe, like the numbers on a scoreboard?”

“ I don’t follow. Is it me to throw first?”

“Yes. No. Wait a moment. Think about it. The problem this country has is that everyone – even you – everyone except your horrible knights – everyone has to give away possessions to pay for things, and if they can’t pay they have to borrow, and when they get totally stuck they have to give up their children. Everyone’e sick, no-one’s educated, everyone’s poor. But what if we could invent something for them to pay with? What if we  - sorry, you – could provide healthcare and education for everyone? And roads, and sewers, and lights, and…”

“5 and 1 and one. That’s 7. That’s 4…8…3. No, 4.  Your turn”

“Father!” she took the darts from him. “Listen. There is a way to do this. You’re the King! You’re the country, in a sense. You can create a debt for the country and a way to count it! If you’ve got that debt, you can pay for things for your people. You could pay for their healthcare, and they could all live longer!!”

She had his full attention, now. If there was one thing the king wanted, it was to see his people free of disease and illness. “How would I create this debt?”

The princess thought for a moment. “Well, it’s not really debt, is it? Debt’s the wrong word. It’s, it’s investment. You – the king – create money to invest in your country, just like you create the 501s for the darts!!”

“But why would anyone accept this money I created?”

“You’re right.” She suddenly felt a terrible sense of disappointment. This wouldn’t work.  “We’d need some way to make people accept it, make everyone in the country use it.”

“They’d need to trust it, which means they’d need to trust me and my successor.” He smiled at the princess. “And they’d need to know it was always going to be there. And … ”

He thought it through. The princess waited.

“…and the way to do that is, for me – the government -  to always spend using this money. And for me to make everyone pay their taxes in this money. That’s it! The country collects taxes from everyone, and it only accepts payment of taxes in the money it creates. People would have to get the money to pay their taxes!! They’d have to accept it, because they have to have it to pay their taxes!”

There was a knock at the door.

(To be continued)

in which I draft a response to an epidemic of fraud

“The answer to your question is:  only prison sentences can deter the violations that caused the debacle.  We should, however, never rely solely on prosecutions to constrain crimes.  The criminal justice system needs to work with regulation not only to make regulation more effective, but also to prevent “private market discipline” from becoming a “criminogenic” oxymoron. To understand the vital role that the criminal justice system must play if we are to avoid the recurrent, intensifying financial crises that have beset this and many other nations for nearly three decades we must begin by understanding the epidemics of “control fraud” that are driving these crises.” (1)

The nineteenth century writer and philosopher Henry David Thoreau asserted that

“All perception of truth is the detection of an analogy”.

The epidemic of control fraud (2) is thus to be taken as a truth, not a metaphor.

Black contends that the criminal justice system and regulatory bodies must work together, but the analysis and control of epidemics would require a much broader cross-disciplinary approach; a complexity science approach to a complex problem. The objective is not just to respond to epidemics when they occur, but effective and continuous identification and containment of the infective agents to prevent or at least reduce single incidence of control fraud, and to prevent infection escalating into epidemic.

The first body of knowledge to be represented is that of experienced white-collar criminologists. Black and his peers have experience of identifying and responding to control fraud, and could supply descriptions of symptoms, vectors, and sources of contamination; and propose direction of study as well as responses. A form of vaccination may even be designed, developed and tested: not, of course, a chemical one; but a regulatory response to be deployed to create a herd immunity, or at least resistance  to fraudulent behaviour. Perhaps ideally, an inbuilt response: something which provides negative feedback to misbehaviour. After all, 

Even though a sense of propriety does not stop chicanery, it does curb it. Fewer people will take part, and those who do have to go to considerable lengths to disguise their actions, which increases the costs and time needed.” (3)

Knowledge and experience of how organisational behaviours emerge from interactions between individuals, and cultural behaviours emerge from interactions between individuals and organisations – of complexity in sociology – would be essential. Feedback loops – positive and negative – would need to be identified and understood. For at least four decades a culture of fraudulent behaviour (or at least, absence of propriety) has been evolving. Regulation and criminal prosecution – which should provide both positive and negative feedback to the system to discourage fraudulent behaviour – have failed or been removed. The same may be asserted for audit and accounting: the role of external consultants may also be in scope. The evolution of fraudulent behaviours and failure of resistance to fraudulent behaviour within and between organisations requires study.     

Epidemiology, and specifically network modelling of epidemics would be required to identify analogies between the spread of control fraud and of well-modelled diseases, and to build effective new models of fraud epidemics and fraudulent behaviour as a disease. Biological diseases spread over networks of contacts between individuals. To protect against epidemics of (control) fraud, the networks of contact between individuals and organisations would need to be modelled. This would be required at least at the organisational level, though a drill-down to individual level for board members may be required: certain organisations (or certain persons within them) may be identifiable as carriers, and some organisations may even be disease pools. (4)

This exercise would also require models of social and business networks and possibly IT networks at application level. (IT experts with knowledge of the sector). Strong degrees of association between individuals and organisations which correlate with fraud, or with activities which are identified as enabling fraud (5) could then be analysed.

It seems a tall order: a correction to behaviours of an individual salesperson and those organisations influencing policies of entire governments. But the frauds Black describes are not just costing jobs, careers, and business; not even just costing trillions of dollars, euros, and pounds: they are costing us democracy and even our societies and nations.      

1 United States Senate Committee on the Judiciary, Subcommittee on Crime and Drugs,  “Wall St. Fraud and Fiduciary Responsibilities: Can Jail Time Serve as an Adequate Deterrent for Willful Violations?” May 4, 2010 Testimony of William K. Black http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1607045

2 “Control frauds” are seemingly legitimate entities controlled by persons that use them as a fraud “weapon.” See (1)

3 Yves Smith http://www.nakedcapitalism.com/2014/12/summer-rerun-quelle-surprise-hank-paulson-goldman-ceo-talked-lot.html

4 Black contends that neoclassical economics itself is a source of control frauds. Academic institutions and think tanks which teach neoclassical economics may – inadvertently or perhaps even intentionally – be disease pools from which epidemics of financial fraud arise.

5 Black has proposed a number of executive actions which make fraudulent behaviour not just easier, but effectively unavoidable.

in which there are only problem families and problem individuals

Jeremy Bentham reduced society to the sum of individuals:

The community is a fictitious body, composed of the individual persons who are considered as constituting as it were its members.

His words were echoed by Margaret Thatcher, in speech and in interview

And, you know, there is no such thing as society. There are individual men and women, and there are families.

Presumably, Thatcher had to augment Bentham’s assertion in order to conform to neoclassical economics’ use of “the household” in its models; as well as to adhere to the Conservatives’ obsession with “the family” as an entity central to the arrangement of order.

The denial of the existence of society is necessary for the rejection of government as a source of public good, managing shared risk and providing shared infrastructure and public services. If there is no such thing as society, then the role of government is to correct men and women – and families – who are failing to perform as individuals for the public utility.

This underpins Ian Duncan Smith’s mission to identify and deal with “problem families”, so that they can be put to work. It also underpins charging for NHS services, as proposed by Charlotte Leslie.

For Leslie, the problem is the individual’s problem behaviour in misusing services. It cannot be a societal issue, because there is no such thing as society: that is, the causes of non-attendance at GP appointments or drunken attendance at A&E cannot be consequences of many agents and actions in a complex system, and is thus reduced to the failings of individual men and women (and families).

The answer, then, is to modify individual (or, presumably, family) behaviour: and the way to to do that, argues Leslie, is by charging. There is – as someone was fond of saying – no alternative.

The wilful denial of the existence of society, and of the complexity of the interactions between individuals, families, communities, culture, and agents such as government, businesses and individual ministers forces a denial of reality.

We may as well believe that that there is no such thing as consciousness, only individual neurons; or no such thing as weather, only individual molecules of water vapour. By denying reality, we impose false limitations on possible actions, impose ideology over material evidence,  and even render ourselves incapable of action at all.

in which I consider the NHS as an airline

Perhaps chair of the Mid-Staffs Public Inquiry Sir Robert Francis had something like this in mind when he asserted in an interview that,

“If we ran our airline industry on the same basis, planes would be falling out of the sky all the time.”

It’s an alarming depiction or an alarmist one, selected from the conversation and published to fit The Telegraph’s narrative of the NHS as wholly unsafe and unsound. However, it does put focus back on quality.

If the NHS were to match the safety safety record of the airline industry  (accepting for the moment Francis’ statement that it doesn’t), then both the decades of command-and-control management and the perpetual disorganisation of the Health and Social Care Act 2012 would have to be be abandoned.

It is strongly indicative of the distaste and distrust of public services which  permeated New Labour that it implemented Soviet style direction over them. Patients and pupils were made subject to failed methods of tractor production.

“English healthcare managers, (whose life was perceived to be nasty, brutish, and short even before the advent of targets) were exposed to increased risk of being sacked as a result of poor performance on measured indices”

The NHS – and every patient – was subjected to an experiment in management techniques already well-known to have failed.

A year before Bevan and Hood published that discussion paper, senior Conservatives were already promising an end to the NHS if restored to government. (Nick Clegg made public his antipathy toward the NHS and his support for the Tory view in 2005.) It should have surprised no-one that in Coalition, Lansley’s Act to turn the NHS in England from a healthcare service to a procurer of private providers became law, and perpetual fear, fragmentationand disorganisation established.

Lansley’s experiment was enacted while Francis was still writing his report, which was not published until nearly a year after the NHS it was describing had been swept away, and a new experiment begun. “Competition” is the new Lysenkoism.

Both these approaches, then, have to be swept away for the NHS to address safety, because at least the following would have to be the case:

  • It wouldn’t take nearly three years and several million pounds to prepare and publish a safety report. That looks like complacency and waste on an epic scale.
  • Such a report would not then be largely ignored by the organisation which commissioned it
  • Such a public Inquiry would not even be necessary, because there would be the equivalent of an AAIB 
  • Operators would be tightly regulated – and operators known to be unsafe – including those which were foreign-owned – would be prohibited
  • Unsafe parts of the organisation would cease operation until remediated
  • The organisation would be process-driven, not target driven.
  • The organisation would be quality driven, not inspection driven.
  • The organisation  would be safety driven, not profit driven.
  • Operational data would be transparent, not obscured by commercial-in-confidence contracts
  • The right measures would be used correctly to monitor and improve the processes used
  • Every single person in the organisation would hold themselves responsible for patient safety. Every single manager and leader would hold themselves and their teams accountable for patient safety
  • There would be continuous improvement instead of constant reorganisation
  • Absence of safety incident would never be interpreted as safety.
  • Prevention of accidents and errors would be highest priority. Do no (avoidable) harm.
  • No changes would be performed without thorough Root Cause Analysis or implemented without effective risk management and comprehensive – and of course, successful – testing
  • No change would be considered without a sound justification, including risks and impacts to patient safety
  • The organisation would have quality improvement experts supporting staff at all management levels
  • There would be sufficient project investment and operational budget to deliver the availability of the services required
  • All buildings and tools would be built with adequate systems redundancy and utilise redundant levels of accurate instrumentation

On that last point and aligned with this aviation theme, there is a succinct and brilliant illustration of the difference between targets and measures here.

The list is incomplete. What has to be understood are the differences between a passenger taking an airline flight and a patient being treated by the NHS. I leave that to the clinicians, but my sense is that delivering a person from airport A to airport B roughly on time and without incident may be relatively simple compared to diagnosis and treatment. The passenger flight is a repeatable and repeated task, which makes reducing variation – enemy of quality – much easier.

Finally, It should not be presumed that the passenger airline flight is always a pleasant or even safe experience. Not only are airline passengers subjected to absurd, wasteful, and even demeaning treatment pretending to be necessary for their security (another form of safety), but not all airlines are equal.

But then, maybe a barrister or a health editor doesn’t travel economy, let alone budget or low-cost.

 

 

in which there is no consolation to be got from these philosophies

That reclusive and pessimistic cleric, Thomas Malthus, created a mathematical law to support his contention that population would inevitably outgrow the food supply. The increase in the food supply, it stated, is arithmetic; whereas the increase in population is geometric: thus the population is kept to the level of subsistence by “misery and vice”.

Malthus’ law was bunkum, and it has been argued that he only added it in to give his essay on human population a scientific gloss. The same might be said of the “unsustainable NHS law” repeated by the media and politicians, and set out nicely in a recent Guardian post by Ian Birrell.  The increase in the number of old people and their complex demands will always outstrip the taxpayers’ ability to fund the NHS; and just as Malthus argued that providing relief to the poor only added to their misery by allowing them to breed, medical science only increases the demand from the unwell to access new reliefs and cures: indeed, it actually increases the number of unwell by offering treatments for conditions previously untreatable.

Genuinely horrified by the poverty in his parish, Malthus concluded that population should be managed by reducing births among the impoverished: either by ending the Elizabethan Poor Law or by encouraging abstinence to delay and thus reduce procreation. Genuinely offended by a health service built on the principles of shared risk and access based on need, not ability to pay, the Healthcare Malthusians call for “competition”, “choice”, “efficiency savings”, private providers, and charges for GP visits.

What they do not set out – entirely absent from Ian Birrell’s piece – is where they put health as a priority amongst the totality of government expenditure and the intricacies of taxation. Leaving the total government budget unchanged, which should be a priority: tax concessions for higher-tax-rate mortgage payers, subsidising private pensions, or finding more to pay for healthcare? Every penny of government expenditure is a result of political choice. Why do the Healthcare Malthusians never offer other government expenditure to be sacrificed to fund the NHS, given any upper limit to government spending? Why do they never call for avoided, evaded, or delayed taxes to be collected?

Where Malthus essayed a struggle between man and implacable nature, Herbert Spencer described a struggle for survival within society and between societies; and while the Anglican cleric may have prayed for souls of the poor, Spencer’s apostle JD Rockefeller preached the thriving of the robber barons as the consequence of a law of nature and of god, while no-one should mourn the devastation caused by their success.

The term ‘Social Darwinism’ can be misleading, given it was Darwin who interpreted the natural world through Spencerian social views. The struggle for survival derived from Malthusianism, the survival of the fittest from Spencer, who provided a narrative for Empire and for the English middle- and upper- classes, still horrified by the rising numbers of the breeding poor.

“If they would rather die,” said Scrooge, “they had better do it, and decrease the surplus population.”

It is not coincidence that Scrooge is a miser. In a struggle for survival, hoarding an unfair share of the wherewithal to live (food for Malthus, money for Rockefeller) would seem a wise strategy. Similarly wise, in a world in which it is deemed that the government has no government money left, hoarding access to healthcare (or education, or jobs, or law, or property)…

Neoliberalism did not spring anew and afresh in the 1950s. Criminalisation of the poor, rejection of social security, belief that governments must not interfere with ‘natural’ laws,  forced labour: neoliberalism is a revival of social darwinism. Neither has  Malthusianism disappeared: you only have to listen to UKIP sympathisers speak of the UK being ‘full’.

Or you could ask those who say the NHS is ‘unsustainable’ why they wouldn’t find the money for it, or what should happen to those who could no longer access it. Spencer, or Malthus?

 

in which I seek for a narrative

From about half-three yesterday morning I was listening to the joint effort between BBC Radio 4 and 5Live to report the local election results. I can’t remember exactly when – it seems to have been from the moment I turned the radio on –  they declared they had a narrative. That narrative was of a surge of support for UKIP.

For some of the programme, Claire Perry MP also had a narrative: repeating metronomically that the long term plan was working, that there were one and half million new jobs, that the economy was recovering. She replaced James Brokenshire MP, and his narrative about a bad night for Labour.

At another point, a reporter who had been hanging around a count in London interviewed a Labour representative on what had actually been a very good result for Labour. That BBC reporter had a narrative, too: that Ed Miliband had “a habit” of forgetting Labour council leaders’ names.

There was also a psephologist, who declared that Labour looked unlikely to reach what he argued was a very timid target of 150 seats.

All based on the results of a tiny fraction of the seats to be declared: and typically small seats.

At just after 5am the election coverage ended; just as Cambridge and large, important London boroughs were announcing results. Naughtie was swept away, muttering about narratives. That narrative of UKIP surge, earthquake, and destruction of major parties – set up so early and on such minimal evidence – persisted throughout yesterday across the BBC and beyond it; and into this morning.

News organisations are very poor at narrative, and the reason is in the name: “news” is just that – latest information, something just happened. Perhaps aggravated by 24 hour news and the competition from the Internet, “news” organisations have become disseminators of narratives based on single incidents, without any context. Any intent to provide information – accurate information – has been set aside in the obsession with using narratives which can be re-used to create “news” as people react to them.

Such narratives inevitably lack originality: it’s much easier to take an existing narrative and re-use it; and not get out of line with competing media. Thus, “news” is necessarily framed in familiarity, not clarification.

And of course everyone knows – or thinks they do – that narratives need a viewpoint.  Lazily, the perspective of the UKIP voter; the disaffected, politician-hating voter (real or imagined) has been churned since.

Created from shreds of evidence, mediated through the inexperience of interns and the haste to communicate, fabulated by think tanks and the self-interested: these careless narratives should more properly be referred to as fictions.

And poor ones at that. If the measure of information is surprise – the amount of new information conveyed – then these news narratives are largely worthless. Worse, they become zombies, reanimated when needed by the next person in the media with no time, inclination, or even desire to actually do their job and investigate.

 

in which I wonder what a party stands for

Prompted by his report on the non-collection of taxes (see my previous post), Richard Murphy is inviting ideas for a ‘tax pledge’ by the 2015 intake of UK MPs. I proposed that such a pledge begin with a brief preamble setting out what tax is for. My justification is as follows.

What we need to be assured of is not that the people we elect will follow particular policies, but that they will measure all plans, policy and legislation against the principles we wish people in public office to have. Specific policy ideas are easy to set aside once elected: in fact it’s highly probable they will be, given that policy, legislation is created and enacted through debate and amendment.

What we need to know is that the people we vote for will not set aside principles once elected.

The answer to the question, “What do you stand for?” is insufficient if it is something like “ending the cost-of-living crisis”, or “repealing the Health and Social Care Act”. As electors (and citizens) we should expect assurance that the person we elect will oppose anything that makes employment less secure or subverts a publicly funded, publicly delivered NHS: because we know they (and their party if they are not Independent) share with us convictions about the value of people, of human rights, and of what a state and an economy are for.

in which something doesn’t add up

I was excited to have a piece published in Discover Society, in which I tried to disentangle some of the gordian knot of neoliberal policy and point to where I think the sword should strike.

My starting point was Thatcher’s declaration that there is no such thing as public money, but only ‘taxpayers’ money'; and that the nation-state was totally dependent on taking or borrowing money from every citizen (subject, in our case) to pay for whatever politicians wanted to do.

If we accept for the moment that this is the case (it most certainly isn’t) and that Thatcher’s heirs actually believe it, then you would expect such governments to be obsessive not just about controlling spending, but about collecting every penny of tax due: especially as they were (and are) determined to cut taxation.

Imagine my bemusement then, to read a report published by Richard J Murphy and others this week which catalogues the horrendous volume of taxes due but uncollected, the complete inadequacy of the HMRC in gathering taxes, and the parlous state of company records in the UK.  Just look through the 10 minute summary of the findings: they are a national scandal, an absolute outrage.

What clearly doesn’t add up is that a government which is – to phrase it very generously – parsimonious with government spending (except, it seems, where private corporations are the direct recipients) simultaneously permits wholesale tax avoidance and, by implication, evasion. Why is it not chasing down every last penny with even a fraction of the resource it is putting into the relatively trivial level of benefit fraud?

The focus of the Coalition in particular, as per my Discover Society article, is on cutting expenditure: while maximising what is supposed to be the government’s income, the equivalent of business invoices out, is being neglected. No business could run like that, for long.

So is this simply inattention, or is it incompetence, or is it actually something even worse? Could it possibly be that the same politicians who echo Thatcher’s ‘taxpayers money” dictum are not ignorant about what money is, and how it works in a modern economy in a nation-state with its own sovereign currency, but that they know perfectly well that such a state does not have to collect taxes – or borrow – in order to spend?

By publicly pretending that there is such a thing as “taxpayers’ money”, is the Coalition perpetrating on the subjects of her majesty a massive lie, a multi-trillion £ fraud?