The Big Con

I've just ordered a copy of The Big Con following Will Lloyd's review and a fascinating interview with Mariana Mazzucato - both in New Stateman. I will add it to David Craig's Plundering the Public Sector (2006) and similarly themed works, along with my 30 or so years watching the serial failure of consultancy firms to improve NHS IT. 

This includes working on the Blair era National Programme for IT (largely run by consultancies), the (largely failed) outsourcing of primary care support services to Capita and more recently the attempts to 'digitally transform' NHS screening programmes (still in the process of failing). 

I might have plenty of time to read it. I'm under threat of redundancy following the Laura Wade-Gery review (outsourced to McKinsey) recommended the merger of NHS Digital and NHS England, and the subsequent organisational re-design (outsourced to McKinsey) resulting in a 30-40% cut in staffing. 

No matter: I'll be perfectly positioned to make use of the government's network of 50+ Champions to help me back into the workforce, and possibly the Restart scheme (outsourced to Serco, G4S and Maximus).

I'm not sure how much I'll learn from The Big Con or whether it will just provide some intellectual and theoretical flesh to the bones of experience. Books like Craig's Plundering are essentially journalistic descriptions of what went wrong.  Anthony King and Ivor Crewe's The Blunders of Our Government is about more than the specific failures of management consultancy, but also provides rather more analysis of why governments fail so spectacularly in their policy aims, covering things like operational disconnect as well as the lack of internal expertise.

So I will read The Big Con with interest, and hopefully provide a review in due course.

Long live the Republic of Barbados

 Tomorrow (30 November, 2021) Barbados will become a republic, severing its last ties to the UK and appointing Sandra Mason as president. This is a wonderful thing and something that any country which still has Queen Elizabeth II as head of state should be considering.

To be sure, since gaining independence in 1966 Barbados' links to the UK have been minimal and largely ceremonial or sporting. Aside from the Queen, the position of high commissioner was the most obvious manifestation of colonial legacy. Membership of the Commonwealth long ago ceased to have much meaning outside of Buckingham Palace, with the Commonwealth Games being about the only genuine benefit of membership.

A symbolic act perhaps, but symbols are important for all sorts of reasons. This is a great demonstration of self-confidence and self-determination by Barbadians. They are demonstrating they have the confidence to assume full responsibility for every aspect of the governance of their island. Good for them.

In doing this, they are doing the UK a favour too. Few people in mainstream society either know or care about the British Empire, but there are still a few - particularly amongst wealthy elites - who still cling to the idea.  For some it may be sentiment or nostalgia, but for some it marks something more problematic: a hankering after a time of British superiority and exceptionalism that many assumed the end of empire had consigned to the dustbin of history. This is a poisonous legacy and needs to be neutralised as quickly as possible.

I’m sure the Queen is in the sentiment and nostalgia camp, having grown up in a very different world. She would have been brought up with concepts of the ‘white man’s burden’ and her supposed responsibility to lead the nations of the Empire. The Commonwealth is merely the continuation of this idea ‘by other means’. It allows the palace and others to avoid having to confront directly the reduced status of the UK or the monarchy in the real world.  But sparing the Queen's feelings is no basis for policy.

The sooner other commonwealth countries follow Barbados’ path and put an end to this shadow empire, the sooner the UK will be able to size up its real status in the world. It would then be impossible for those clinging to ideas of imperial glory to maintain their delusions: they would have to confront the reality that we are a middling country of no great significance by ourselves.

In the meantime, it would be wonderful to see some of those from former slave owning families like Richard Drax respond to the zeitgeist and gift their land holdings in Barbados to the Barbadian people. The amount of goodwill that act would generate would far outweigh any financial loss to such a wealthy person.  It would constitute the merest drop in the ocean of reparations that ought to be paid by the wealthy. Sadly, I can't see that happening.

So I say to the people of Barbados, good for you and the best of luck. Long live the Republic of Barbados!

Book review: Unfinished Business: the politics of dissent in Irish republicanism

Marisa McGlinchey offers a fascinatingly detailed account of the thinking of what are commonly referred to in the press as ‘dissident republicans’. The author prefers the label ‘radical republicans’ as these are largely people that kept faith with core principles when the republican leadership (represented by the Provisional IRA and Provisional Sinn Fein) changed tack in the 1990s and joined the peace process. As with most things relating to Irish politics and history, it’s more complicated than that….

The book reads a bit like a Phd thesis in both the writing style (rather clunky and stilted) and the structure. Stronger editorial oversight from Manchester University Press might have helped the author work the material into a tighter, clearer narrative. In particular the quotes from interviewees could have been integrated into the narrative more elegantly.  I found some of them slightly ambiguous out of context.

Stylistic gripes aside, it is a very thorough analysis of the thinking of groups and individuals outside of the republican mainstream based on extensive interviews with key players. It also draws some insightful conclusions about the wide range of view and ideas that exist outside the mainstream, and the fact this plethora of groups is partly a function of Sinn Fein’s intolerance of alternative views. The interviewees often seem blind to the fact they are perpetuating the same narrow-mindedness. Or just how much of their testimony is reminiscent of the Life of Brian’s ‘People’s Front of Judea’ scenes (Splitters!).

Overall I’m not convinced the mainstream-dissident split is the most significant fracture in contemporary republicanism. Certainly, the strands of thinking represented by some of the more cerebral interviewees – Anthony McIntyre and Tommy McKearney for example – is radically different from those of groups like Republican Sinn Fein (RSF), the 32 County Sovereignty Movement (32CSM) or Soaradh. This is not only in their attitudes towards the use of violence, their analysis of the problems and solutions are also radically different.

It’s possible a more pertinent split is between those republicans whose thinking has evolved and developed in some way - even where this is in very different directions – and those that have maintained rigidly fixed positions like RSF, 32CSM and Soaradh. To my mind the slavish adherence to republican dogma (and self-identification as the only true believers etc) indicates ossified mindsets where re-cycling well-worn rhetoric is rather more important than either progressing the rights of nationalist people in the north or developing any pragmatic strategy that could lay a path towards reunification. They have prioritised gaining republican brownie points over any kind of progress.

Within this the dogged insistence of many radical republicans of framing the issue as one of British ‘occupation’ plays a pivotal role in oversimplifying both the problem (British colonialism) and the solution (British withdrawal). Crucially it avoids radical republicans having to face the awkward reality of around 1m of their neighbours who do not wish to join their idea of a republic and are unwilling to be forced to at gunpoint. This was the root of unionist rejection of home rule in the early 20^th Century (along with the original threat of armed resistance to it) and remains the root of the problem now.

No less importantly, the 'occupation' framing allows radical republicans to avoid the other awkward reality that whilst the Irish Republic may be emotionally in favour of reunification, the reality would be far more problematic and fraught with complexity, risk and cost.

The 1916 proclamation implied there was an artificial division between republicans and unionist sewn by the dastardly Brits for their nefarious colonial ends. If the Troubles teaches us anything, it is how wrong this conceptualisation is. The desire of unionists to remain both British and Irish is both deeply held and sincere (as Richard English has demonstrated – at least to my satisfaction). 

Recognising this reality was one of John Hume’s greatest contributions, as was selling it to Gerry Adams as the basis of progress across a broad nationalist-republican front.  Ms McGlinchey’s book illustrates that some radical republicans steadfastly refuse to accept this, preferring to cling to comfortable simplicities and ancient dogma instead. They are stuck in an intellectual cul-de-sac from which they show no sign of emerging.

Book review: Blanketmen by Richard O'Rawe

See Amazon

Richard O'Rawe deserves huge respect for such an honest account of this pivotal episode in Northern Ireland’s ‘Troubles’.  Most of the key players in the republican movement have been neither open nor honest about events that occurred and their role in them.  Perhaps that is to be expected.  It does make this book stand out from the crowd and means the author stands head and shoulders above his comrades for even trying to shed some light. 

Like the best war memoirs, Blanketmen represents the author trying to process the events he participated in; to make some kind of sense of them, to ‘do right’ by his comrades and achieve an accommodation with his conscience.  I’m not sure that process will ever conclude, but it’s a worthy endeavour.

I disagree entirely with O’Rawe’s politics, but it’s possible to relate on a human level to the situation the prisoners found themselves in, the decisions they and others made and the appalling consequences.  Ironically the excessive blokey banter is no different from that you would find in a group of British squaddies, although the Blanketmen strike me as a more diverse and thoughtful group.

It seems fairly clear O’Rawe’s central contention is correct: the hunger striker’s lives were deliberately sacrificed to further a political objective. This needs some context:   PIRA had considerable form for treating the lives of its volunteers – and the public - with callous disregard.  If the hunger strikers were used as cannon fodder by the army council, that was neither new nor out of character.  The IRA themselves didn’t take prisoners, they executed anyone they caught.

More interesting is how much the decision to drag out the strike was made by the army council, and how much was Gerry Adams’ decision alone.  After all, the army council had opposed the hunger strike, and would have contained members deeply hostile to the expansion of political activity, in line with republican orthodoxy.  It is also likely (as the author surmises) that Adams had recognised the limitations of the armed struggle years before and had a long-term project to redirect the republican movement towards politics.  In that context, the hunger strike and the opportunity afforded by Bobby Sands’ election was too good to waste.  It’s at least possible that Adams way playing his own game, manipulating both the army council and the strikers to further his own political agenda.

So were the hunger strikers misled?  Was their struggle for special category status used as a trojan horse for a shift from the Armalite to the ballot box? Perhaps, but the prison campaign was itself a form of proxy war – the armed struggle by other means – so there’s a kind of logic in the longer-term outcome.

Ultimately I have to agree with Professor English in his introduction: that this book’s real value is in the wider insight it provides into the republican movement, the individuals involved, their characters, motivations and relationships, as much as illuminating the events themselves.  For someone who grew up regarding the Provos as the enemy, it’s made them rather more real and a little more comprehensible.

I still think republican ideology is fundamentally wrong-headed and Provo methods execrable.  But you can’t fault the dedication, tenacity and bravery of the Blanketmen and hunger strikers themselves. Whether they knew it or not, their sacrifice helped to move things in the right direction.  It’s a sad inditement of the time, the place and the politics that these men’s effort and talents couldn’t have been better employed.

Richard O’Rawe has done a great service by shining the light of honesty on a very dark chapter.

Transparent Tim's faded glory

So Tim Kelsey will be treading a similar path to Richard Granger in the aftermath of NPfIT, by flitting to a private sector job in Australia (Granger left for KPMG, whilst Kelsey will go to Telstra Health).

Understandably, the announcements in the digital health media have all sought to accentuate the positive, lauding Kelsey for his vision and giving him further platform to pontificate about a digital revolution for the NHS.

So firstly, a quick recap of Tim’s progress is required. Prior to being given a custom-made shoe-in job at NHS England courtesy of his friends in Number 10, Kelsey was a successful journalist working both as a freelance and then for the Independent on Sunday and Sunday Times.  He’s also a published author having penned a travel book on Turkey.

The big break with journalism came with the setting up of Dr Foster with Roger Taylor (no, not that one) and Roger Killen.  Dr Foster sought to capitalise on a line of thinking in the NHS that saw consumerism and choice as a means of getting the NHS to up its game. 

Some of the people pushing this agenda, notably Bob Gann at Help for Health Trust, saw it through the prism of patient information: i.e. provide patients and the public with more and better information about services and it will help them make better informed choices and take more responsibility for their own healthcare. Gann developed this idea firstly with the Health Information Service (HIS) telephone helpline and then with NHS Direct and its early web offering, NHS Direct Online.

Dr Foster took a slightly different tack, focusing on performance and quality data that could be used to underpin patient’s choice of services, and it was this model that gained the upper hand in the Blairite reform years of the late 1990s.  Dr Foster had a lot of success in compiling and publishing hospital performance data – data that the Department of Health had historically shied away from publicising because it raised difficult questions about quality and consistency in the service that had the potential to embarrass ministers.

Ultimately, Gann and Kelsey would join forces on NHS Choices, the national website of patient information and data that was intended as the keystone of a consumer-driven revolution in healthcare. At the time it might well have seemed like a match made in heaven.

Although it’s clear that significant numbers of people have used NHS Choices, it’s far from clear what impact the website has really had on the public: these things are notoriously difficult to demonstrate, so the default is to fall back on positive anecdotes.  What is clear though, is that NHS Choices cost quite lot of money, having signed a 3 year deal with Capita with a value of more than 60M (for comparison, the early NHS Direct website cost less than 5M for an equivalent timespan).

To cheerleaders like Kelsey, NHS Choices was going to herald a revolution in the relationship between patients and the public, in the same way that the Internet itself was going to for all sorts of activities and businesses, and he was far from alone in that view.  At the same time, there was an opposing camp, embracing moral panic with a similar level of gusto.  These were the people (frequently GPs) issuing po-faced warnings about ‘cyberchondria’ and bemoaning the armies of the worried well turning up in surgeries armed with fists full of printouts from dodgy websites.

With the benefit of hindsight, both positions seem slightly comical: the cyber-utopians believing the web would fix everything, and the cyber-dystopian prophesying doom.

So things move on and the dotcom boom and bust roll by.  The internet does eventually fulfil some of its early promise, but over a much longer time span than most believed, but then the revolution rolls on into web2, social media and smart-phones, the logical extensions of the internet.

It’s not surprising that those dreams left unfulfilled by the first wave of Internet development would be transferred to the second wave, and that’s exactly what happened.  Sometime in the 2000s, Tim Kelsey drifted from being an evangelist for the web and NHS Choices, to being an evangelist for apps and social media as the foundations of a patient’s revolution – something that might address the fundamental information and power asymmetry at work in the NHS.

It’s probably churlish to dismiss Kelsey as some kind of bandwagon hobo, always jumping aboard the latest gimmick-train.  I’m sure his views are sincerely held and have developed as a response to a changing world and the emergence of new ideas and technologies.  However, it’s possible to see a mind lacking in scepticism and rather dazzled by novelty.  Every new gadget or gizmo promises to deliver the revolution for patients that he craves. Whereas in reality, we’re only taking small steps, and frequently the benefits of each step are equivocal.

After a brief (blink and you missed it) term at McKinsey and shoed-in as a government ‘transparency czar’, Kelsey has his perfect job created for him in the role of Director of Patient Experience at the newly created NHS Commissioning Board (soon to be renamed NHS England). 

The role must have seemed like a dream come true: at last the power and authority of a senior role in a newly created uber-quango from which to affect the kind of change he had dreamed of. But here is where the wheels begin to come loose and wobble disconcertingly.  Affecting change in an organisation like NHS England is intensely difficult, even with a high level of authority. Add to that the paralysis caused by the immature and unformed nature of the organisation and it becomes next to impossible to affect change on the scale that Kelsey envisaged.

As a reluctant and inexperienced bureaucrat, Kelsey was always going to be at a disadvantage.  Initial promises of a paper-free NHS by 2015, stores of accredited apps, an investment fund for new IT projects have all been dragged under by the interminable bureaucracy and cost-cutting required by austerity.  It must have been intensely frustrating for him to have been handed what appeared to be the keys to the drinks cabinet, and to have found instead, a labyrinth designed by Kafka with the bottled hidden in every nook and cranny.

The signs have been there for a while: bold announcements and statements of purpose have given way to exhortations.  The Personalised Healthcare by 2020 document was a paper tiger; an unleaded pencil.  Its purpose appeared to be largely decorative: to pay lip-service to Kelsey’s agenda and give NHS England a (very thin) veneer of modernity, whilst committing to diddly squat.

It consisted of relatively modest aspirations with no real sense of how these might be achieved.  As a product of a bureaucratic-political organisation like NHS England, its decorative, ceremonial nature demonstrated just how little power and leverage Kelsey really had.  It might as well have been a roll of wallpaper.
 
After such a frustrating experience, it’s hardly surprising that Kelsey would retreat to the private sector where it may be easier to achieve things quickly, albeit on a smaller scale.  It will be interesting to see whether the long-wished for revolution for patients ever will materialise, and whether this will be driven by data, apps and individual choices, or by bigger slower, more tectonic technological forces as work under the bonnet of the NHS.
What is certain is that Kelsey’s time at NHS England has been far from a resounding success, however much it’s wrapped up in nice words.  In this case at least, it takes more than some big ideas and well-connected friends to start a revolution in the NHS.

To have and have not: the geography of power

The hilariously imbecilic comments by Lord Howell on appropriate locations for shale gas 'fracking' have helped to reinforce the stereotype of out-of-touch Tories as home counties types with an ignorant and clichéd view of places beyond the southeast. You do suspect that what he really meant was fracking is OK, so long as it happens a long way from where I (and lots of other important people like me) live and work.

In this, he's probably not all that different to some of the protesters in Sussex taking direct action against Quadrilla's exploratory drillings. As ever, the protesters are made up from a hotchpotch of groups and individuals including bigger organisations like Friends of the Earth.

I'm perfectly happy with the idea of people protesting on the basis of a moral objection to fracking per se, probably because I agree with them. The worst thing that could happen environmentally is for us to find a cheap and plentiful source of oil and gas, allowing us to continue on our merry way to climate change hell in a gas guzzling handcart.

The problem is that many of the protesters are not coming from any kind of moral position on this, even though they may mobilise environmental concerns to aid their cause. Many of them, like Lord Howell, don't care whether fracking takes place or not, so long as it doesn't take place near them. They may even applaud the provision of cheaper fuel.

That is the essence of nimbyism - it's not just 'not in my back yard', it includes notions of 'I don't care if it's in your back yard'. At root it's an inherently anti-communitarian and anti-collectivist impulse.

Earlier in the week Geoffrey Wheatcroft tried to make a positive argument for nimbyism in the Guardian: that everyone fighting hard to protect their own local environment is the only real defence against the encroachment of modern ugliness and despoiling which is the flip side of economic growth.

It's a superficially attractive argument particularly to those on the right because it incorporates the idea that local activity based on self interest (enlightened or otherwise) has primacy. It conveniently ignores the realities of power politics: that the negative aspects of economic development tend to be heaped (sometimes literally) on the poorest because they are least able to fight their corner, lacking the social and financial means to do so.

As an argument espoused by a national media journalist living in the prosperous enclave of Bath, this appears to me to be a self-serving and rather complacent line to take. So, there is a recognisable geography of power. The most powerful tend to live in nicer (i.e. more aesthetically pleasing) areas.

This closely aligns to the geographies of wealth and social class, but has a distinctly north / south flavour because the concentration of important social connections (i.e. connections to those in national politics and the media) is primarily concentrated in the greater south-east.

The result of the wealthy and well connected being geographically concentrated in more aesthetically attractive areas makes it easier for them to make a case against economic development, when such proposals emerge. They are fighting from the high ground, whereas the poor have no such tactical advantage.

The logical conclusion of this arrangement of power, geography and aesthetics is that even those small pockets of greenery in poorer areas to be sacrificed for development, whilst the wealthy are able to prevent even those economic developments that might benefit the country as a whole.

From those that have much, nothing will be asked. From those that have little, everything will be taken.

I think I’ve just found the Conservatives’ strapline for the next election.

Man make fire

The other day I bought a lighter.  Not just any lighter, but a Turboflame lighter (Turbo2).  It's like a cross between a miniature blow torch and a light sabre.  It is fantastic.  I can't begin to say what a great thing it is.

I've never smoked, but it's always useful to have a lighter around for barbeques, candles and such.  We usually have cheap disposable ones, although I do have zippo tucked away somewhere.

As with so many things, it's not so much about what it does, but how it does it, and its aesthetics as an object.  A nicely painted cast alumumum body with a satisfyingly robust flip-top lid is a good start.  The shape is vaguely remeniscent of a very small light sabre.  But click the little button and you get two (yes two!) little jets of blue flame and a most satisfying hiss. The last time I saw anything that impressive it was the afterburners of a pair of RB199s on the back of Tornado jet fighter taking off.

As with so many objects of desire, it has a nice size and weight, fitting neatly into the palm of a hand and heavy enought to feel substantial.  At 9 pounds sterling, it's not too expensive either - a Zippo will set you back twice as much at least, and whereas most other lighters will get blown out by any amount of breeze, with the Turboflame this is next to impossible.

I don't know whether my enthusiasm for the Turboflame indicates some kind of incipient mid-life crisis, or a developing addiction to
'boys toys'.

I prefer to think it's just the emergence of some primative instict - that finding satisfaction in the ability to make fire or build shelter is a connection to our ancesters.  Just one step on the road to connecting with our inner Ray Mears.