Public Services – Page 7 – thinking liberal

London’s schools: awkward facts for both left and right

Last Friday I attended and seminar for school headteachers and chairs of governors addressed by Sir Michael Wilshaw, head of Ofsted, the body that inspects English schools. It was convened by the London Borough of Lambeth, for whom I am a primary school chair of governors, and where Sir Michael himself spent much of his school career (at least that is what he implied – though the secondary school he described sounded as if it was just over the border in Wandsworth, and very near where I live). He used the occasion to heap praise on the acheivements of Lambeth’s schools, and schools elsewhere in London too. He made his point by drawing a comparison to England’s second city, Birmingham, whose results, he implied, were mediocre. The progress that London’s state schools have made in the last decade is one of the most important facts about public services in Britain. But it is little talked about because it poses awkward questions for both left and right.

First the facts. My main source is a pamphlet produced by CentreForum in late 2011. The data may therefore be a little old, but the story hasn’t changed in the period since. London’s state school results, at both primary and secondary levels, are close to the English average. But the proportion of pupils attending school from the lowest income groups is much higher than in any other English region. About 70% (I’m a bit vague because I’m having to read off a graph without the exact numbers being in the text) of its pupils are in the lowest two income quintiles, compared to under 50% for most other regions (a bit over 50% for the North East). A lot of higher income parents send their children to private schools, especially in London, and this no doubt accounts for a lot of the skew to lower income levels. So London’s schools are achieving these results in spite of much higher levels of deprivation. The more you dig into the data, the more impressive this achievement looks. But London’s schools used to be awful.

When I have mentioned this achievement in various policy forums I get some rather strange reactions. People quickly dive in with data-less explanations which leave their basic world view intact. One economic liberal type started to lecture me on how much more aspirational London parents were. A more left-leaning type (with direct experience of London schools) attributed it to an influx of African immigrants displacing poorer performing white and Afro-Caribbean ethnic groups. Others have complained about preferential funding for London’s schools. But the data shows that, let us say, none of these explanations is anything like sufficient. But they did educate me in how selective many policy commentators are in their insistence on the use of proper evidence.

How have these results been attained? This is a lot less clear. No doubt the capital does have some inherent advantages in aspirational families and a better pool of potential teachers – which had not previously been exploited. But the main explanation seems to be strong political leadership. The boroughs led the way, but central government (under Labour) was bearing down on them, with initiatives such as the London Challenge (started in 2003, focusing on secondary schools). For Sir Michael, who was very much in the middle of it, the main point was that heads and governors were made more accountable for their results. Failure to achieve good results resulted in schools being hauled over the coals. The “Satisfactory” rating for an Ofsted inspection was in fact regarded as “Unsatisfactory”; Sir Michael has since changed that nomenclature. I have certainly seen how school leadership teams have focused more clearly on how to reach out to families from poorer backgrounds, with extended school facilities (handy for working parents) and family learning, as well as individually tailored interventions.

Why is this so awkward for mainstream politicos? The left, drawing support from the trade union movement, do not want to put schools and their staff under too much pressure. They would rather promote the fiction that England’s schools are generally good, but that they cannot overcome the social issues created by poverty – which need to be tackled through anti-poverty measures. And yet it seems that if you chivvy (and even bully) schools hard enough you can dramatically improve the results of pupils even from very challenging backgrounds. There is a very uncomfortable paradox here: leftist political activists get very worked up about deprivation, but this translates into low expectations of what deprived families can achieve, which in turn becomes a self-fulfilling prophesy.

Things are just as bad on the right. They say that the problem is that parents lack choice, and that the state runs schools badly. So the focus is to reduce state control by converting schools to semi-independent Academies, and letting interest groups set up brand new schools. Choice and competition will drive up standards. And yet the London results show that this is at best irrelevant. The results have been achieved with existing political structures.

If London’s schools show anything, it is the effectiveness of the last Labour government’s methods – Tony Blair’s Third Way. And yet this has become deeply unfashionable in political circles. In fact there was plenty wrong in Labour’s education policies, including a very wasteful school building programme, which converted necessary school upgrades into prestige architectural projects. But the basic idea was sound: good old fashioned political leadership and accountability can transform public services – provided you are prepared to take on the vested interests of those working within it.

Or to put it another way, and to bring it into one of the main themes of this blog: effective commissioning is the secret to better public services, both at the level of whole communities and at the level of individual users. London got a lot better at both.

The dark side of evidence-based policy

Speaking at a Lib Dem conference in the Coalition’s earlier days Linda Jack, a Lib Dem activist, called for a commitment to “evidence-based policy”. She was interrupted by strong applause from the floor. Ms Jack is a feisty activist, but is not known for thought leadership. Her use of the idea, and the applause she got for it, shows that evidence-based policy has become a mainstream idea in some liberal circles. Not long ago it was a rather abstruse, fringe idea pushed by academics who wanted the extra public funding that it would require. Why is it now hurrah phrase used by political activists? Is this a good thing?

But first, what is it? No many people just think that it means that any public policy idea should first be based on some kind of evidence that it works, rather than just sounding like a good idea. But, to those that take the time and trouble to advocate it, it in fact refers to a particular type of evidence: statistical studies comparing the effects of the policy in action against some kind of control group. It takes its inspiration from medicine, and, indeed, some of its strongest advocates, like the writer and journalist Ben Goldacre, and Lib Dem former MP Evan Harris, are medical doctors.

Evidence-based therapies are all the rage in modern medicine. Statistical evidence techniques have long been used in drug trials, but their use is widening to other areas. It forms the core of policy advice put forward by Britain’s National Institute for Health and Clinical Excellence (known as NICE). What is interesting about these evidence-based therapies is their pragmatic element. Treatments are recommended because they are shown to have benefits, even if the explanation is unclear. I am taking medication to reduce ocular pressure, because ocular pressure seems to increase the risk of glaucoma. My consultant told me that why this was so was not understood – the treatment was prescribed purely on the basis of the evidence. Although the technique is often described as scientific, this pragmatism takes it away from classic scientific method – not in the rigour of the testing, but in the lack of a theoretical model to drive the hypothesis. No matter; a lot of useful therapies are being put into use, and some ineffective ones are being weeded out.

So it is quite natural for people to want to use the technique for non-medical areas. An early example of this was the testing of conditional cash transfer programmes in South America in a bid to raise levels of schooling and reduce poverty. A programme would be devised, and participating villages would be compared to ones outside, preferably with a random assignment between the groups. These studies helped make the case for these programmes, which are now a standard part of the anti-poverty tool set, and are credited with particular success in Brazil (the Bolsa Familia programme). A lively academic debate has been provoked as to how useful the technique is.

What are the problems? Most of the debate that I have read about focuses on two issues: the rather limited nature of the questions that you are able to gather evidence on, and the huge difficulties of gathering untainted evidence, especially if it is not possible to do large scale randomised trials, which it usually isn’t. It is disappointing that wider public debate is so limited, though, and evidence-based policy has simply become a warm, apple pie idea, without people asking searching questions as to what it is and what its limitations might be. There is a dark side to it.

This dark side is in fact evident in the medical model. Dr Goldacre has made his name in using evidence-based ideas to expose charlatan claims for fringe treatments that often get uncritical publicity in the press. This is good, but he*, and especially his disciples, swiftly move on to attacking alternative therapies in general. Homeopathy is a favourite target, since its use of extremely diluted solutions defy scientific common sense.

This is an interesting case. I don’t know much about homeopathy, but from what little I do know it places great reliance on three ideas: that you should look at the whole person; that mind and belief are a critical element of therapy; and that every person is an individual. These are three blind spots in statistical evidence techniques. They can only be used to test very simple propositions, so it is necessary to break down the whole person into a limited number of measurable symptoms. It is impossible to distinguish mind and belief effects from the so-called “placebo effect”; the placebo effect often works, but is excluded and ruled out of order by the evidence advocates since it is so difficult to test. And statistical evidence techniques depend entirely on using general rules, and do not attempt to find treatments that will work for everybody. So homeopathy is untestable using evidence-based techniques. That is a problem (how do you spot the charlatans?) but it does not make it rubbish. In fact what the evidence advocates are trying to do is to impose a particular belief system on what should and should not be included in health therapies. There is a world of propositions that are testable by statistical techniques, and a world that is beyond their scope. Both are big and important.

And what about evidence-based policy? The idea is bandied around very loosely by political activists, and most have very little understanding of the full implications of the technique or its limitations. Why are they so keen, then? At first I thought it came from the habit of politicians (including, and especially, the “non-political” sort) of using loose statistical associations to support their advocacy – to try and give themselves more credibility. This happens: I see much nonsense around the wisdom or otherwise of the government’s policy of converting schools into academies free of local authority supervision. But the cover was truly blown for me when I saw Dr Harris at a fringe meeting at the recent Lib Dem party conference. This was on the government’s “Free Schools” policy. Because of the difficulties of gathering evidence to test any policy proposal, he could knock any proposal down at will on the basis of lack of evidence. It is a powerful weapon with which to defend the status quo (which, of course, you do not need to test…).

Evidence-based policy, in the limited sense that its advocates use, is no doubt a useful tool, but of quite limited value in practice. We need to broaden our idea of what constitutes proper evidence, and develop an understanding of where good old-fashioned human judgement and instinct is more appropriate, given its speed, responsiveness and ability to handle both complexity and individual variations.

* Dr Goldacre is very careful in his use of words. His actual attack on alternative therapies may not be as direct as I am implying. He is, rightly, more interested in challenging false claims about evidence than in challenging therapies that make no such claims, but where conventional evidence is lacking. This not true of many of his fellow travellers – I have read much mockery of homeopathy online.

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.