Public Services – Page 7 – thinking liberal

My heart attack

Last Monday, three days ago now, I lay, conscious, on an operating table at St George’s hospital, Tooting. A tube had been inserted into my artery in the right arm at the wrist, through which dyes and then wires were inserted. On my left wrist a drip had been inserted into vein so that drugs could be injected rapidly. Two surgeons were doing their stuff around the area of my legs, looking up at two monitor screens. A large cylindrical device was being pointed at my chest at various angles. I lay as still as possible, as the surgeons exchanged comments and gave occasional orders to technicians outside the room, who would respond over the intercom. Some music was playing quietly in the background.

The surgeons were doing an angiogram. They were pumping dye into my bloodstream to make the blood flows visible through an X-ray camera and spot any problems with the blood flow to my heart. And they did find a problem. “One of your arteries is completely blocked. This almost certainly caused your heart attack,” one of the surgeons said to me, “We want to insert a piece of wire to clear it.” I consented. The surgeons then completed a procedure known as an angioplasty. This involved using a piece of wire pushed through my arteries to insert an stent, a small length of tube, into the blocked bit to open it up, after first inflating a small balloon to create the space.

It was really only then that I fully realised what had happened – that I had indeed suffered a heart attack, and that as a result my life was in the hands of these two surgeons and their team. Until then I had thought the problems might be some sort of viral attack (as my elder brother had suffered a few years before) with few longer-term implications. The previous evening, my family visitors remarked on how well I was looking – though the medically literate among them could spot the abnormal trace on the heart monitor that I was wired into. This is a shock. I had no indication until then that I was at risk. I take regular exercise; I’m not overweight; I have never smoked; I eat my five a day; I even make sure I have a couple or more portions of oily fish a week; my blood pressure has always been normal; no tests that had been run on me had shown me with anything other than a very healthy heart. It really can happen to anybody.

The problem seems to have started over two weeks beforehand, while we were on an organised tour of Sicily. One night, after dinner, and a day when I had felt slight constrictions to the chest area, I started to suffer acute chest pains. I couldn’t sleep. Eventually, at about 3 or 4 a.m I took some aspirin, and the pain subsided and I got some sleep. I was puzzled at what had caused this episode. The chest pains pointed to a heart attack, but none of the other symptoms did. I wasn’t breathless, I could carry out normal physical activity. As the pain subsided, the idea that it was severe indigestion took hold. Gavascon seemed to help with the contuining mild episodes of pain. The local diet can be pretty acid. The day after the attack I had no trouble in climbing to the top of a stone tower to get a wonderful view of the western Sicilian coast. The next day, though, I felt lethargic and a bit feverish, collapsing into my hotel bed for an afternoon; but a couple of days after that things seemed to return to normal. We continued with the tour, returning home at the end of the week.

The episode has was scary enough for me to go to my GP in the week after we returned. I probably wouldn’t have done this had my wife not insisted on it, though I had noted that my fitness at the cardio-vacular exercises in the gym had fallen rather sharply. My GP tended to agree with my diagnosis of acute indigestion, as he would have expected that a real heart attack would have had more of an impact. But he did recommend that I did some blood tests. This I did last Friday morning, at 8.30 a.m. By midday my GP had rung me to say that one of these tests had revealed a high troponin level, indicative of heart problems. He recommended that I go to St George’s A & E to get an ECG (electro cardiogram – where they put a dozen electrodes on your skin and get traces of your pulse). This I did straight after lunch, expecting to be home for tea. But the ECG showed an abnormal trace. I was admitted to hospital, hanging around in A & E while a bed was cleared. The next step was the angiogram – but that couldn’t be run until Monday. Meanwhile I was kept under observation, with a cocktail of drugs administered by tablet and injection.

Now I am at home in rehab, recovering from the damage to my heart from the blocked artery, and the operation itself – but the prospects for a full recovery are good. But I’ll be on pills for a long time, probably for the rest of my days. At the moment there are six different sorts of pill, but it should come down to less than that after a year. My fitness regime will have to be adjusted downwards so as not to place too much strain on the heart. I am quite lucky though, first that the original attack did not do more damage, and second that the problem was picked up before the blockage to my artery caused more damage to the heart and maybe a more serious attack.

Why me? I don’t hit any of the main risk factors – except that I was not avoiding cholesterol in my diet. In fact I was a heavy cheese eater, and relished meat fat and chicken skin. That will now change. But some peple are just more at risk than others. My physical fitness may have helped reduce the effect – though a bit too well if it had meant that I had avoided having it checked out.

It is customary at this point to praise Britain’s NHS and scorn its critics. I will try and be a bit more objective, after my close observation of the service at work. But it doesn’t come out badly.

Firstly I am immensely grateful to all those many professionals that helped me through the episode. I always felt that they had my interests at heart and they did their best to help me. Nurses, doctors, technicians, pharmacists and surgeons – I can’t fault any of them. I now have very benign feelings towards St George’s hospital, which happens to be my local one – from being a rather anonymous presence beforehand.

Second I cannot fault the overall effectiveness of what the NHS acheived. From the point of that blood test a system was quickly kicked into action that was appropriate at every step, acheived the right outcome, while managing the risks properly. And at points the service was better than good. The surgery was world class; the briefing from the cardiac rehab nurse afterwards was also deeply impressive. The speed with which my blood sample was analysed and acted on was very impressive too.

Effective, yes, but how efficient? Here I was left with a few question marks. I ran into an awful lot of different professionals in my journey, having to repeat my story to up to ten different doctors. This is a warning sign from a process management standpoint – though the need for specialists, 24 hour cover and risk management does not make the matter easy. And there was an awful lot of paper records and documents. It isn’t surprising that there were communication breakdowns; I’m still waiting for my discharge papers. And the whole thing about the service going on hold for the weekend does not feel right either. At least one, and probably two nights of my four night stay were clinically unnecessary. Room for improvement, I would say – and that matters in a tax funded system where overall resources are subject to arbitrary limits.

It is clear though that I was much better off under the NHS system than I would have been under the US one, especially before Obamacre kicks in. I would not have qualified under any of the government funded schemes, and neither would I have been covered by an employer plan. I would either have to to have bought my own insurance plan, which would suddenly have become a lot more expensive. Or I would have to have winged it without insurance, which would have landed me in serious trouble.

But then very few people outside the US think that their system is in any way sensible. A universal insurance scheme, like most advanced countries run, would have caused a little more bureaucracy at the start of my hospital visit, but nothing very burdensome. And I don’t believe that health professionals would be any less caring or professional if they were not working for a state provider. Neither do I beleive that the vagaries of private sector management are any worse than the arbitrary resource management of a nationalised, tax-funded system.

But the NHS did do the job it was supposed to do. And for that I am thoroughly thankful.

Why healthcare may grow to 50% of GDP and still be affordable

I can’t over-emphasise how important the concepts in this article in last week’s Economist are: An incurable disease, and I would urge my readers to try and get to grips with it. If you want to understand how our economy is changing, and the implications for public services, the idea it describes is critical. It ranks alongside Ricardo’s law of comparative advantage (gains from trade) and Keynes’s multiplier (fiscal policy) as a counter-inituitive idea that explains so much.

What it describes is something usually referred to as “Baumol’s cost disease”, and reviews a book by the eponymous William Baumol, “The Cost Disease: Why Computers Get Cheaper and Health Care Doesn’t”. It stems from the observation that productivity grows in some parts of the economy faster than in others. The paradox is that the more productivity in a sector advances, the smaller its share in the the economy at large. Thus agriculture used to dominate the economies of the current developed world – but as agriculture became more productive, it needed less people and so shrank to a negligible propertion of GDP – while generating ever larger larger quantities of agricultural produce. The same effect is clearly visible in manufacturing industry – producing more goods than ever, but from a shrinking workforce. The more these areas advance, the bigger less productive sectors bulk in the economy as a whole. It is, misleadingly, referred to as a “disease” because these less productive sectors, within the service economy, then act as a drag on economic growth as a whole. It is not in fact a disease, but a symptom of success. The failure of economists to understand the difference between creating wealth and realising it (i.e. turning that wealth into something that actually benefits humankind) is one the biggest failures of the dismal science, and it is a shame that Mr Baumol perpetuates it in the title of his book.

The most important of these unproductive services are healthcare and education. Personal contact go the very heart of what these services are: to succeed these services must accept that people are individuals, and that a solution which works for one person may well not work for her superficially similar neighbour. But, while productivity grows only slowly, if at all, costs, i.e. rates of pay, must reflect the increased productivity of the economy as a whole. So costs advance faster than productivity. Sound familiar? But this only happens because we can afford it.

The eye-catching claim in the book is that on current treads healthcare will take up 60% of the US economy in 100 years, and 50% of the UK one. But this is all paid for by the fact that other parts of the economy have become more efficient – and in fact it only takes up such a large part of the economy because these parts of the economy have become more efficient. Actually this projection is a bit silly. I think the advance of conventionally measured productivity will slow, as technological change now affects quality rather than quantity. Also other sectors of the economy will reverse productivity as people value personal content more (think of the return to craft food production). But it is rather a good way to make the point.

Which means that the challenge with healthcare and education is not that growing costs are unaffordable, as various right-wing types claim, but something much more subtle. There are three issues in particular:

A lot of healthcare is indeed inefficient, both in the UK and the US, and political pressure must be brought ot bear to address this. But don’t expect it to halt or reverse the share of health costs in the economy in the long run. The NHS “Nicholson challenge” in the UK may therefore be a valid policy goal, but it will not solve the long-term funding needs of the health service.
The larger the share of the economy healthcare takes up, the more difficult it will be to fund it entirely from tax. In the UK this either means that a parallel private sector will flourish and undermine the NHS (as has already happened in dentistry), or that the NHS will need to be a lot less squeamish about co-payments.
There is a temptation for the owners and workers in the highly productive parts of the economy to keep the rewards to themselves, creating inequality and undermining public the public sector. And yet we still want productivity to advance so that we can all afford a higher standard of service. Higher taxes are part of the solution, but only part. Again this points to the fact that a higher proportion of healthcare (and education) services will have to be delivered and paid for privately – allowing the remainder of the public services to pay decent wage rates.

I hope that provides food for thought!

The Lib Dems struggle with education policy

Saturday was education day at the Lib Dem conference. Education is dear to the hearts of most Lib Dems, but the party struggles to come up with a clear party line beyond the important policy of Pupil Premium, where state funding of schools is uplifted for those with poorer pupils. This drift was on show yesterday.

There were two motions, one on early years and the other on schools. Both came over as worthy but wishy washy wish lists, with a rather nanny state tendency on show. The most contentious point on the early years motion was support for increasing professionalisation of nursery and childminding provision. This all feels a bit New Labour and not particularly liberal. The idea that this might be a source of jobs for non graduates doesn’t seem to have taken hold, which is a pity. It would be nice to think that more jobs would be available to single mothers who have had a disadvantaged start in life. But the focus seems be on pushing graduates into those roles.

There was more contention around the schools motion. There is a body of activists who are upset by the way the party has been handling education policy in government, with very little consultation of the party at large, and seemingly tagging along to a Tory agenda. This boiled over a bit with the recently proposed reform to the GCSE exams, which was presented to the world as the result of negotiations between the Lib Dems and Conservatives. But work done by activists on the subject was ignored. The motion was not about this issue, but there was an attempt to spatula it in, rejected by the Conference Committee, which caused tempers to fray.

The motion itself was the usual worthy fare. An amendment on governance was passed which sought to ensure that no interest group had a majority on state school boards…something which would be an issue for faith schools and sponsored academies. It also had some nanny state stuff about training governors. Interestingly the conference also passed an amendment rejecting the proposal to abolish mandatory external tests at the end of children’s primary school careers – SATS. This clearly took the motion’s movers quite by surprise, and showed that the conference was taking bit of trouble over the policies it was passing. I supported this amendment, as a school governor I find these tests invaluable as a means of holding the school to account.

But it would be nice if the party could develop something more radical and interesting, to contrast with the emerging Tory/Labour consensus. This will require some strong leadership. David Laws, the new education minister, is the man who should provide it. But though he is widely respected, he does not seem to be good with the gruelling process of consultation and bringing the activists on side. We shall see.

The Olympics and Hillsborough: two faces of the public sector

Brendan Barber, the outgoing General Secretary of Britian’s Trade Union Congress, called for “an Olympic approach to the economy“. He was, of course, only one of many politicians and others trying to use the example of London’s success in putting on the 2012 Games to try and make a wider point. He said that it showed that “the market does not always deliver”. In this I think he was referring to both the fact that the games were a government sponsored grand project, and the spectacular failure of one of the private contractors, G4S, to deliver security staff.

Well I did not hear his speech, or even read it – relying on radio and press reports. What comes over is a mixture of the coherent and nonsense. The coherent part was the idea that an economy lacking in aggregate demand could do with some grand infrastructure projects to keep people employed and deliver future benefits. Many people across the political spectrum agree with that, although personally I am on the sceptical side. The nonsense bit was the idealisation of the public sector and suspicion of anything that smacks of private initiative and enterprise. He precise words may well not have done this: “the market does not always deliver” is not the same as saying that “the public sector always delivers and market never does.” But that is no doubt what his TUC audience heard, judging by what some people were saying. The ideas of many trade unionists are not so much inspired by Maynard Keynes as Leonid Brezhnev. Unlike in America, though, the public are more sympathetic to such notions than they ought to be.

To see why we have the terrible example of the Hillsborough football disaster in 1989. Today a report has been released vindicating criticisms of the authorities long made by families of the victims; the Prime Minister was forced to make an apology. The authorities, mainly the Police, not only made misjudgements that caused the disaster, but their handling of things made it worse by delaying medical help. And to cap it all they systematically covered up the truth and put about mis-information to try and divert the blame. It has take 23 years to get this far.

What is my point? It isn’t that the public sector is any more likely than the private sector to perpetrate the sort of mistakes that led to and exacerbated this tragedy. Far from it. It is that it is so much harder to hold the public sector to account. They are integrated into the system that is meant to secure justice; they can pull strings, call in political favours, and work the system so that the truth does not come out. For every Hillsborough that eventually does come to light, think of the hundreds of lesser tragedies where the authorities manage to thwart the victims.

Compare that to the private sector. At the Olympics retribution was swift and brutal for G4S, publicly humiliated in days (while their public commissioners who seemed asleep on the job just kept their heads down). Or to take something a bit more comparable: BP’s Mexican Gulf disaster last year. BP faced the full weight of the US political and judicial system, forcing a rapid response and compensation payments.

Hillsborough was a long time ago. I would like to think that standards of public accountability have improved since then. But we still get procurement disasters in the Ministry of Defence, bad hospitals getting away sub-standard services, state schools in many parts of the country not trying hard enough to raise standards among less well-off communities. And even the Olympics – compare the cost to original budget! Not to mention their reliance on armies of unpaid volunteers.

Scepticism of the private sector and open markets is understandable – but we need to get things into perspective. We have too easily forgotten what happened to the Communist systems in Europe. All those expressions of goodwill and the promotion of the public good soon get buried in a culture of passing the buck.

Let’s learn the right lessons from the Winterbourne View scandal

On Monday the government published its serious case review into the Winterbourne View abuse scandal. Winterbourne View was a specialist private sector hospital for learning disabled and autistic people – people who were sectioned and could not fend for themselves – “vulnerable” in the jargon. The BBC Panorama programme filmed some spectacular cases of staff abusing patients. A closer look didn’t make things look any better – abuse had being going on for years, and the hospital was not remotely doing the job it was being paid to do. This is laid bare in the report. All sorts of people fell down on the job – the hospital’s owners, police and other services, and the Care Quality Commission. This should not distract us from the central lesson which the report makes clear – the commissioning of these services was seriously deficient.

The report was published on a day when the news was dominated by the Olympics and by the Coalition spat over Lords reform. Perhaps it is a pity that this meant it did not get the public attention it deserved. But it may be just as well. In the hands of the usual top news journalists and editors, the wrong lessons would have been drawn. Instead the coverage has been a bit more balanced and considered – I have even been able to pick up mature and balanced coverage from BBC’s Radio 4. Even so, I’m not sure if the right messages are getting through to the people that matter. There are some big red herrings.

The first red herring is the use of private sector providers to deliver care. The report and headlines made much of the hospital owner’s pursuit of profit as being the reason they failed to provide a proper service, in spite of being paid quite well. But this is nothing new – and there are plenty of shining examaples of good practice in the private sector. The problem was that they were not being held to account. Terrible things happen in public sector organisations too, if nobody is asking what they are getting for their money.

Which leads to a second red herring. An early “lesson” was that the Care Quality Commisssion’s inspection regime was too light touch, and that inspections by this national body should be more frequent and more thorough. But we mustn’t rely on these big inspectorates, who often fail to understand local nuances and issues, and can end up being excessively confrontational. At best they can guarantee a certain level of mediocrity.

And thirdly there is the role of family. The patients at Winterbourne were often from a long way away, which meant that it was much more difficult for the family to stay in touch. This was condemned as being part of the problem. This is right up to a point. Public service commissioners are far too casual about sending people a long way from where they have their roots. I am uncomfortable with the NHS reformers’ constant refrain of creating fewer but bigger specialist facilties for everything – though they always point to statistical evidence. But while family can and (usually) should be an important part of somebody’s care, the system should not depend on them.

No, the real issue is with the commissioners of public services, within the NHS and local authorities. They should take more responsibility for the services they commission and devote more time to holding them to account. At this point it is very easy to be swept away by a debate over structures, procedures and responsibilities, seeing this as simply an exercise in public procurement, as one might outsource street cleaning, for example. But again, that is not the important point.

At the heart of the commissioning of social and health services should be the client or patient. Their individual requirements should be assessed, treatment individually tailored and their progress followed with human interest. The patients of Winterbourne were sent there by commissioners who thought their job was done by just placing them there. What was supposed to assessment, treatment and rehabilitation, a process implying progress towards a goal, turned into warehousing. That should be almost as outrageous to us as the abuse itself. If the commissioners had been following their patients, they would have picked up their lack of progress, and either worked with the hospital to improve it, or simply taken their patients elsewhere.

This isn’t rocket science. My wife is a care manager at a local authority, dealing with drug rehabs. Her authority takes an interest in their clients as individuals, and this invovles meeting clients at the rehab facility from time to time to check on progress…and cutting out facilities that aren’t up to standard. The problem is that some public sector managers take a more industrial view of things, trying to drive efficiencies by doing things in bulk and treating problems and performance indicators rather than people. This can give rise to some short term cost savings, but it quickly becomes self-defeating, as processes that fail to take account of people as individuals fail to solve their problems, and you end up with warehousing on a minimum cost basis. But it is not value for money you keep adding to the workload.

Unfortunately in this aspect of public services, not much much can be learnt from the private sector. Private sector techniques (lean management, business process engineering) can lead to a more people-centred approach if applied properly – but ultimately the private sector answer to difficult clients is either to pass them on to somebody else, or turn them into dependents and warehouse them for a fee. Warehousing problems rather than solving them can be a lucrative business, as the owners of Winterbourne, Castlebeck Ltd, clearly saw.

I hope that the government’s ideas for GP-led health commissioning, and integration between local authority and NHS care, will lead the commissioning process to the right place, as they should in theory. But the bureaucratic obstacles are huge. It would help to have a clearer vision from on high.

The G4S fiasco poisons attitudes to the private sector

The British contractor G4S has specacularly failed to find anything like enough staff to support its contract to provide security staff for the London Olympics…which start in less than two weeks. The details aren’t clear yet, but this one has all the makings of a fiasco that will be examined in deph in MBA courses for a long time. A bigger question is the effect it will have on public attitudes to the private sector here in Britain.

For now the politicians and journalists are having some fun. “Is this a humiliating shambles for G4S? Yes or No?” (or similar words) one MP asked Nick Buckles, the hapless G4S Managing Director, this morning, showing the sort of skills of forensic questioning that make people wonder how useful parliamentary select committees really are. Mr Buckles had to agree. It wasn’t just the size of the recrutiment gap, it is that nobody at the top seemed to have any idea that there was trouble until a couple of weeks ago.

Another revealing encounter was on Radio 4’s Today programme this morning. John Humphreys was interviewing the senior police officer coordinating Olympics security. The latter referred to G4S as a “partner”. They’re not a partner, retoted Mr Humphreys, they just a private company only interested in profit. And that seems to summarise a widespread attitude here. Private companies are greedy and heedless of ethical standards. Meanwhile the good old public services, like the police, the armed services or the NHS are selfless public servants working for the good of us all.

What a difference 30 years makes! Back in the 1980s public services were supposed to be crassly managed, unable to control their unions and unable to deliver anything on time or efficiently. The private sector on the other hand, the odd (state supported) car manufacturer apart, was all enterprise, innovation and efficiency. It says a lot for the process of public sector reform that has happened since that public services command such respect now. The private sector, on the other hand, has not come out of the banking crisis well, as the parallel case of Barclays seems to demonstrate.

This matters because further public sector reform, especially in the NHS, implies greater use of private businesses. This was already a hard sell politically. It’s not getting any easier. Should it?

Well, management screwups are by no means the unique preserve of the private sector. Last week a coroner reported on a case of a patient dying at our local hospital, St George’s. This looks like a case too many people being involved, not aware of the complete picture, and nobody taking the initiative to sort problems out. The hospital said that it had changed its procedures to prevent future incidents like it. You can almost guarantee that this means an extra check or process spatulaed on top the ones already there – theoretically dealing with the problem, but actually making the process more complex and difficult to manage. Reengineering of operations to deal with risks like this seems to infinitely more difficult in public sector organisations than in private sector ones, perhaps because it means trampling over well established demarkation lines. Cases of bad management abound. The quality of police management was shown in very bad light by last year’s riots, especially in London, where they were caught flat footed by youngsters with Blackberrys. And as for the armed forces, whose public stock is currently very high, the amount of money they have wasted in equipment procurement programmes is absolutely eyewatering.

And as for the G4S scandal, the wider story is not necessarily against the private sector. The company is clearly accountable, and is picking up the extra costs instead of the taxpayer. And surely the procurement process is a much to blame as the contractor? G4S may have been suffering from “winner’s curse” – required to cut costs to win the contract, and then finding that it had been unrealistic, or taking too many risks. Realistic or cautious bidders simply get eliminated. But this is a well known procurement problem – and surely the commissioners should have seen fit to take precautions? Some rather obvious questions are being asked about how such a large and important contract was being supervised.

And it’s interesting to reflect a little further on the currently popular subject of “culture” in organisations, that, for example, was supposed to be so bad in Barclays. Well senior managers not knowing about problems building up within their organisation is often a sign of bad culture. Mr Buckles said he was a “no excuses” manager; so were staff afraid to pass up bad news? The twist on this is that this sort, tough, no excuses style of management is beloved of politicians and the public (provided they aren’t actually working in the organisations concerned). I’m not sure that most politicians would recognise healthy corporate culture if they saw it. And that is bad news for the public sector.

So it would be a pity if this episode slowed down the process of involving private companies in public service reform. But it would be as well to learn the lessons for public sector procurement and contract management.

Class warfare: changing the primary school curriculum

Yesterday the Government announced proposals to change the national curriculum for primary schools in England. No doubt there was the same sharp intake of breath in liberal circles that accompanies anything that comes forth from the Secretary of State, Michael Gove, with his appeal to traditional, conservative values. But liberals have often failed to convince on education.

Mr Gove is a remarkable political phenomenon. He is instinctively disliked by those of a liberal disposition, and the vast majority of people who work in the education sector, or councillors who are responsible for it. And yet, unlike his health colleague Andrew Lansley, or Theresa May at the Home Office, the vitriolic criticism of the professionals, and lampooning by comedians, seems to make little impression on the public at large. The government is being hurt by a lot of things at the moment, but education reform is not among them. For once the public seem to trust the politicians more than the professionals.

So what to make of these proposals? They amount to a much more prescriptive programme for English, Maths and Science – with proposals on modern languages on the way. They go further than the current curriculum, and have a traditional, prep-school feel about them – English has a heavy emphasis on spelling, punctuation and reciting poetry, for example. This is easy to dress up in old fashioned, conservative language – which Mr Gove duly does.

The first criticism to make is that the Government had promised teachers that they would get out of their way, and give them more discretion. All the pressure in recent years has been to take things out of the National Curriculum, and not add more things in. The more flexibility schools have, the more room for creativity there is, and the more diversity and choice there will be – something the government had seemed keen on promoting. But evidently there are some things that Mr Gove feels are too important to be left to parental choice and diversity. And the changes are focused on the very core subjects – not the peripheral things that politicians had proviously like to pitch in.

Behind all this lurks a topic that vexes many: class. Now class is something that widely is misunderstood in Britain. Class here used to be about what you were born into, and the idea that everybody should stay in their place, with all the privileges and duties that this implied. Mobility was frowned on, but allowed to creep in gradually. A lot of this mobility took the form of pretending that your family was better bred than it was. I am doing a project on my family’s history at the moment. One of the more amusing aspects is how much effort my middle class Victorian (and some later) forbears put into trying to prove the family had noble connections.

But two world wars and a relentless industrial transformation have swept away that understanding of class. And yet to the disappointment of many, elitism and social stratification remains very much with us – and indeed many of the institutions that supported the old system are in very good health supporting the new – “public” schools, elite universities, and so on. And although the idea of birthright might have gone, it is very much expected that you support your peer group – and do the best you can to give your children every advantage. Social mobility, after leaping forward in the middle of the last century seems to be slowing down. What happens here now is not the lingering of the old system, but something similar to what happens in other modern developed societies which did not have our feudal legacy – like the USA and Australia, who also have “class” problems.

Schools lie at the heart of concerns about class – and here liberals are on the defensive. Liberals have dominated the state educational system for generations, seeing through major reforms to both structure (for example pushing selective elite grammar schools into comprehensive schools) and the way schools are run – towards what might be called “softer” values. It hasn’t worked very well – though why remains hotly debated.

Enter Mr Gove. His solution is to make state schools look and feel much more like their elite,private sector counterparts – and these curriculum proposals are an example. His critics simply think this is to give middle class parents a private, elitist education at taxpayers expense, without having much impact on the rest of society. But that is to misunderstand the thinking. Mr Gove, and many conservative thinkers, think that social mobility is about turning working class people into middle class ones. And that isn’t just about imparting knowledge and skills, it’s about talking and writing like middle class people too – or at least becoming “bilingual” in class ways. The old grammar schools did this very successfully – and their abolition has not helped social mobility.

This is all very interesting. It is easy to see difficulties. State schools, apart from the surviving grammars, are still quite unlike their private school counterparts in that they cannot select their intake. Will this approach exacerbate class tensions by teaching pupils to sneer at the less fortunate (as no doubt the old grammars did)? But liberal policies of inclusiveness have not proved enough by themselves.

I’m giving Mr Gove the benefit of the doubt this time. Too often we liberals forget the working class ideal of “bettering yourself”; celebrating diversity is good; celebrating mediocrity isn’t.

The death of a snack bar.

Last Monday evening as I was walking to the Tube I saw a bit of a commotion on nearby Clapham Common. There was smoke and there was a fire engine. A closer look revealed that the smoke was coming from the mobile snack bar on Windmill Drive. As I cycled past it on the following morning, it was just a tangled mess. By yesterday it had gone completely.

This snack bar was something of a local institution. There would usually be a knot of people chatting nearby, with an assortment of vans, lorries, police cars and the occasional ambulance parked nearby. The people were almost all white and working class (by which I mean the real thing, and not simple “white and poor” as some rather annoying bureaucrats have taken to using the expression) and male, the occasional police woman excepted. It was a favourite spot when such workers had a few minutes to kill.

And it did nothing to challenge prejudices about white working class people. Its fare was greasy. I don’t know what its coffee was like, but I saw no espresso machine as I walked by. It all looked pretty disgusting. Which makes it very easy for nice middle class people like me to sneer at it. But working class people are a beleaguered bunch, looked down on by so many – I don’t begrudge them their moment of relaxation. Besides my relationship with disgusting food is not entirely innocent – though I find it hard to forgive disgusting coffee.

But the fare clearly wasn’t healthy, and unhealthy eating is one of the things that causes policy types angst – as demonstrated by a series of seminars Food can be the best medicine held by the Reform think tank – trying to emphasize the positive potential of diet, as well as decrying the effect of poor choices. This, along with harangues on the subject of smoking and drinking, is one of the forces which is laying siege to the working classes. In doing so, it raises some challenges to modern liberal thinking.

On the one hand liberals like to emphasise choice, freedom and empowerment – traditionally as values in their own right, more recently based on evidence that these things are key to overall wellbeing. On the other hand there is a focus on outcomes and the use of evidence based policy formulations, which tend to prescribe the same solution for everybody. If we make people free, they will choose different things. A lot of these choices will be for things we consider to be inadvisable. And it will often be that different groups of people will tend to make different choices some being less to our taste than others. But we have to accept that people are by and large responsible for the consequences of their bad choices – and not governments or wicked multinationals or anybody else. It’s an awkward fact that most people who make unhealthy choices are perfectly well informed about the consequences – studies have shown this for smoking.

The NHS gives some a particularly pernicious line of reasoning. It’s that since the NHS is funded by taxpayers in general, it gives the public the right to force people to make better choices (or at least to bully people) so as to reduce NHS costs. But the unhealthy pay their taxes too – and if they drink and smoke, they pay a pretty decent whack too (tobacco tax revenues easily pay for the additional NHS costs associated with smoking, for example). Perhaps hot pasties and sausage rolls should not be exempt from VAT, but when all’s said and done I think we tax unhealthy lifestyles enough.

We (by which I mean the policymaking middle class elite) should just lighten up. Who knows, if we respected the choices people make with better grace, it might just help people to gain that extra confidence to take control of their lives and make better choices.

So I hope that unhealthy snack bar on Windmill Drive returns, as it has after a previous fire.

What can Lib Dems learn from the NHS debacle?

The NHS is proving a political nightmare for the Lib Dems. This reflects a failure to develop a clear vision for the service before the election.

The NHS is now a toxic issue for the Lib Dems. This is not because the voters are turning against the party on the issue, as they did for student loans. In the overheated rhetoric surrounding the issue there have been many claims that the public will abandon the party over this latest betrayal. But the public judges parties on what actually happens to the NHS, not on the speculations of excited activists and commentators. And so far as front line services are concerned, nothing much has changed, and probably not a huge amount will as a result of the reforms… a major difference with the student fees issue.

No, the damage is being wrought within the party’s activists and members, as this summary of blogs after the Gateshead Conference shows. Many feel an acute sense of betrayal by the leadership, and a number have left the party; more may follow. This weakness is being cleverly exploited by Labour; but they didn’t start it. Lib Dem activists themselves have not required outside assistance.

The party is all over the place. The outcome of the Gateshead conference last weekend (which I was unable to attend) merely added to the confusion. The emergency motion to abandon the Bill was not called, the representatives voting for a compromise motion supported by Shirley Williams – but a key paragraph was taken out of this motion by a narrow vote, leaving it saying not much at all. This has given rebels in parliament cover to break the whip, but not placed serious pressure on the leadership and those not inclined to rebel, who do not see it as a worthwhile expenditure of political capital in the coalition, compared to tax policy, say.

This confusion has deep roots. What on earth do the Lib Dems want with the NHS? There is no clarity whatsoever. I can count four distinct factions. Currently most the most vocal strand are social democrats (like Shirley Williams, a living saint to many members) – who want a strong, nationally controlled monopoly service, which is able to provide a uniform standard right through the country (England in this case – Scotland, Wales and Northern Ireland have been allowed to get away). They are relaxed about centralisation, and indeed all the amendments made to the bill over the last year at their behest point to a highly centralised provision. Next come the economic liberals, with whom the party leadership tend to sympathise. While this group has not developed any clear vision, they like the idea of what economist John Kay calls “disciplined pluralism” – in other words preserving a choice of providers wherever possible, so long as they are properly accountable. These people are very relaxed about whether the NHS uses direct employees, third sector organisations, or, indeed, private companies to deliver its service. A third group consists of NHS insiders – who basically resist any change in practice if not in theory, and who mainly argue for allocating more taxpayer funding through existing structures, whatever they happen to be at the time. This group was led by Dr Graham Winyard of Winchester (and a former NHS high-up), who has now left the party. And lastly (because this group is now largely drowned out), we have community politicians. These want to see much more devolution to local politicians, and a bigger role for local authorities in particular; this group is relaxed about the “postcode lottery”, so long as it is balanced by postcode accountability. This group is close to the heart of traditional post-War Liberalism, and closest to my personal views (in spite of my Social Democrat provenance).

The original Bill was essentially a product of the economic liberals and community politicians (amongst whom we should count Paul Burstow, the Lib Dem health minister) within the party, working with Tory Health Secretary Andrew Lansley, whose attitude is quite close to Lib Dem economic liberals. The resistance was started up by NHS insiders like Graham Winyard, and quickly swept in social democrats. This alliance overwhelmed the party leadership at last March’s Sheffield conference. There followed the “pause” in the reforms, and a raft of amendments that took the reforms in a highly social democratic direction, leaving economic liberals and community politicians disenchanted but hoping something could be retrieved from the wreckage. But then the NHS insiders dug their heels in, as one professional body after another advised killing the whole reform. This fractured the whole process and left the party with a set of reforms that nobody is very keen on, and to which many are vehemently opposed.

The wider membership, and most activists, are pragmatists, who can’t be pigeon-holed into any of the four groups that have shaped the debate. Their confusion and general scepticism is understandable . But this reflects a vacuum at the party’s idealogical heart. We can agree on liberal social values, internationalism and inclusiveness – but the party seems to have no settled views on how to run the state.

The party should not get too worked up about this of itself. It shares this confusion with the other main political parties (just try to make sense of the Labour position), and I’m sure the minor parties too if they could ever be forced into making a stand. All successful political parties are coalitions of one kind or another. But the party failed to hammer out its own internal compromise before the election, in the way that Vince Cable managed to for tax policy. Formation of policy at conference was too much a matter of seeking consensus. There were some quite radical elements of official, conference approved policy (like abolishing Strategic Health Authorities), but little awareness amongst members of the implications of official policy. The original Bill was probably quite a well crafted compromise between our official policy and Andrew Lansley’s ideas (Paul Burstow certainly thought so). But as soon as the heat was applied, official Lib Dem policy counted for nothing – it had not been engrained on members’ and activists’ consciences.

So where next? The first point is that Liberal Democrats must realise that they either hang together with the Tories, or else the two parties will be hung separately on the NHS. The Tories will curb their privatising zeal; the Lib Dems need to stop being so destructive. There is no future in the parties scoring points off each other on this issue -they both need to show that all the apocalyptic talk is hot air. I expect this means that we’ll have to find some extra funding before 2015.

And Liberal Democrats need to forge their own vision for the NHS, hopefully in time for 2015. In doing so each of the various interest groups will have to compromise. The best way of doing this is to have some controversial debates and votes at conference – like we did with tax policy. Much better to have the arguments before the policy is agreed than after we try to implement it.

Lesson from the banking industry: sometimes people need to be treated as people.

This article from the Economist struck me like a bullet on reading it today. Not so much for the subject matter itself (US banking practices) but what the whole episode says about the modern world. We have never had more data readily available on people – but we seem less able than ever to take decisions on their individual merits. More data, less information. This problem is usually shrugged off y economists and reformers with a laugh; it shouldn’t be.

The story starts in the US property boom, when banks were falling over themselves to offer mortgages, based on the vague idea that since these loans where secured on property, and property values always go up, you couldn’t have too much. The banks stand accused of approving loans robotically, without any consideration of individual merits – and as a result often lending to people who could not afford to keep up with the repayments. This accusation was commonplace, but, as the article points out, little effort seems to have been made to substantiate it against hard evidence.

Then came the crash, and many people who had taken out loans could not or would not keep up with the repayments – and stood at risk of having their homes repossessed. And the banks once again stood accused of carrying out repossession without due care and attention, again on mainly anecdotal evidence. This became a hot political issue, and the individual US states set about suing the banks, with the Federal government becoming involved too. And now an umbrella settlement is proposed, to which the five main US banks and 49 out 50 state Attorney Generals have agreed to. The banks are making a blanket payment to make the problem go away.

What remains characteristic of the whole story, from the original alleged malpractices right up to the settlement, is a failure to reconcile it to what actually happened to real people in real homes. No attempt is made to distinguish between whether some banks are more culpable than others; and no attempt to distinguish between arrears that arise from people in genuine hardship, and those who are trying to beat the system. All that is just too difficult.

And this type of thing is happening all around us. Decisions are made about us using computer algorithms based on data that may or may not be accurate – or based on our membership of some or other broad group of people (men, women, over 50, etc.) and the law of averages. Companies calculate that it is cheaper that way. To consider people as real people, and base decisions on the individual merits of the case, well that requires the intervention of skilled staff, and they cost a lot of money.

And so the flip side to ever advancing productivity (one of the things that makes skilled people cost so much) is that we are subjected to an increasing volume of de-personalised services and arbitrary decisions; and around the fringe a spectrum of fraud arises, as people learn to take advantage of system weaknesses. I have been the subject of mild identity theft several times; this looks quite safe for the people who perpetrate it, since nobody bothers to find them – it’s just a cost of doing business.

But what’s the moral of the story? We gain a lot from the increased wealth that arises because of all this added productivity. And what’s more part of becoming a more equal society is that well off people like me can’t expect to have armies of people running around fawning on their every need. So should I just stop whinging, and get on with all the things I can now do that would have been unthinkable in a previous age?

Up to a point. I think there are two important consequences that many people overlook. One big picture, and the other of more urgency. The big picture point is that are are physical limits to economic growth, and it is no wonder that the pace of growth slows in developed societies. Higher productivity means we consume more services with diluted human content. But huge part of the pleasure we derive from some services is exactly because we get one-on-one attention from somebody (hairdressing perhaps, a personal trainer, dinner at a posh restaurant, and so on); as productivity advances, the proportion that these non-negotiable services comprise in the total economy rises – and so growth slows. Economists refer to this as “Baumol’s Disease” after the economist who originally pointed it out. But it is not a disease; it is the product of success – it’s the process of arriving at the promised land, so to speak – the place that is so good that progress is impossible. An increasing proportion of services cannot be improved without detracting from their value, and people will resist buying them at any price; and that’s saying nothing of the distortion to incentives that arises from making decisions based on averages. We can’t rely on economic growth to wash away society’s problems – we need to confront them more directly.

The more urgent point applies to the reform of public services. Too many people assume that to make these more effective we must follow a similar process of sucking the human content out of them as we see in so many commercial services. In some cases I’m sure that’s true; some Indian organisations are doing amazing things to improve the productivity and effectiveness of certain medical procedures by using economies of scale. But in most cases the effectiveness of public services depends on joining up the dots; seeing people as people rather than collections of unrelated needs that can be picked off one by one. An individual who is committing serial antisocial behaviour offences, may have mental health problems, addiction issues, a dysfunctional family life, educational under-achievement, and inadequate housing. Just from listing them you can see how all these problems are interrelated and feed off each other. We stand a much better chance of making progress if we design solutions based on looking at this individual and his exact personal circumstances and negotiating with him as a human being. Productivity in public services is not about rate of throughput, its about solving problems and reducing demand. This needs a completely different mindset than that needed from the commercial world. Alas too much (though certainly not all) public service reform misses this key point.