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.

NHSmail barometer

According to the government, the 'transition' of the NHS from its old, inefficient, un-modernised state, to its new svelt, efficient, modernised state was accomplished on 1 April this year.  At least all of the key tasks of 'lifting and shifting' staff from closing organisations to opening organisations had been done and major change to IT systems had taken place.

I should know, I've read the closure report of the Informatics Transition Programme without falling asleep.

But what's this that a colleague has posted to my email account today?  It appears to be a catalogue of failure for local organisations to properly reconfigure NHSmail to reflect the new organisational structure.

The main points are:

• On 30 June, about 116,000 NHSmail accounts had not been transferred to new organisations (a third of those affected)
• 21,000 generic mailboxes had not been moved
• 76 closed organisations (i.e. those abolished on 31 March) were still creating new NHSmail accounts
• Local administrators had not been assigned to cover pharmacies, opticians and dentists in 7 out of 25 areas

Now there is a limit to the conclusions you can draw from this kind of information, but it does seem that, behind the scenes, it's taking very much longer than anticipated to set up the new, supposedly improved NHS.

The document was provided as background with a request to NHS England to provide assistance and pressure on local organisations to get their act together.  Precious hope there, given that NHS England is still struggling to set itself up, appoint people to key posts and develop its operating arrangements.

It's going to take 3-5 years for this round of changes to shake out and bed in.  And that's only if Andy Burnham doesn't set the whole sorry mess in motion again in 2015.

Plastic politics, plastic politicians

Yesterday I was rather piqued by an article by the BBC journalist Brian Wheeler on NHS privatisation.  The concept of the article was good in that it tried to ask a question too often mired in thoughtless and polarised debate.  Unfortunately it was compromised by only having one view from either side of the argument and very little analysis.

What really stood out though was that both individuals interviewed are part of what is becoming recognisable as a wider political class - a group that is largely white, largely male, largely privately and Oxbridge educated, largely metropolitan and largely unconnected with mainstream England.  Certainly those parts that lie outside the M25.

Part of the disillusionment with current politics is rooted in the sense that 'all politicians are the same' because in so ways they are.  Cameron and Milliband are both forty-something white men with little experience outside of the greater Westminster political  establishment.  Which includes a growing range of think tanks in addition to the party research departments that act as the sole incubators of supposed political talent.

Brian Wheeler's two interviewees are the next generation of this in the making.  Thomas Cawston, BA in history and politics from Exeter, MA in south Asian history from Oxford followed by 'research' (I use the term loosely) at Reform.  Oliver Huitson, more unusually with an OU degree (PPE) and postgrad from Birkbeck (politics and government) followed by some work experience in telesales, communications financial services, topped off with writing for OpenDemocracy and editing a pro-nationalised NHS website funded by the Wainwright Trust. All with a thoroughly metropolitan flavour.

Now I've never been one to dismiss academic study and think tank 'research' as 'fancy book learning' that has no value beside a degree from the University of Life.  But it is noticeable that the colonisation of the political classes by people with such narrow range of backgrounds and experience is having a profound effect on political discourse and debate.

The positions taken in Wheeler's debate is a good example. The pitch on both sides tend to be technocratic, theoretical and idealised.  Unleavened with any sense of real-world messiness and compromise.

Cawston's citing of examples from Europe of more mixed healthcare economies ignores the historical and cultural context of the NHS.  His assertion that competition can drive real improvement in care is not supported by hard evidence.  The example he cites is still in progress and whether it really delivers better care will only become clear some time in the future.

This kind of stuff is fine for scoring points in university political society debates, but this is the real world and real people we're talking about now.  The evidence we have from the compulsory competitive tendering of hospital cleaning services back in the late 80s points in the other direction: quality plummeted and ultimately this lead to MRSA and ridiculous spectacle of Gordon Brown ordering the 'deep clean' of hospitals. 

Two decades on from the purchaser provider split and we are still trying to get the results we want from market-based systems, whilst he overhead costs of maintaining that market in terms of contracting, legal bills and regulation proliferate.

It doesn't help that the person trying to make this argument looks about twelve (he's actually about 27).

Huitson makes a better fist of putting together a convincing argument (although I'll confess it fits with my own view), but it still has that desiccated feel of a final year essay rather than a real life issue affecting real people.  Ultimately, both arguments leave a lingering feeling of inauthenticity.

The net affect is to reinforce the perception that politicians are all dishonest and make politics feel remote and un-engaging to the majority of people.  This is the real reason that people feel no connection with national politics and the people that supposedly represent them in parliament.  If political parties really want to forge a better connections with the population at large, they should start by recruiting from a much wider pool of talent both socially and geographically and try to reintroduce some authenticity into the body politic.

Tunnel visions

Some years ago I got a taxi up to Leeds-Bradford airport and I fell into conversation with the driver, a friendly, chatty chap.  He also happened to be a Muslim and he couldn't understand why people would want to drink alcohol when it made them behave so badly and feel so ill the day after.

I tried to explain that it's possible to drink alcohol for pleasure rather than just to get drunk - that the actual drink itself could taste pleasant and you could drink enough to reach a state of relaxation without actually getting utterly legless.  He seemed doubtful. I didn't blame him.

I expect that if you don't drink yourself but spend most Friday and Saturday nights ferrying people around Leeds in varying states of inebriation, you might have a similar reaction.  If you have to put up with drunken people being rude and abusive on a regular basis or witness the kind of pointless violence that often goes together with night time drinking in towns and cities, you might take a dim view of alcohol and the kind of culture and society that embraces this kind of behaviour as normal.

My taxi driver seemed bewildered by this kind of behaviour, but you can see that other people from that community might react differently.  With irritation or disgust for example, or condemnation, or they might develop a sense of superiority from what they see as a debased indigenous culture.

Racial and cultural stereotyping has a long and inglorious history, but is still pervasive, even in supposedly enlightened circles.

I was slightly irked by an article some time ago in New Statesman by Alice O'Keefe, relating the experience of being undercharged for a duvet in John Lewis and the travails of a relatively financial constrained 'middle class' person when faced with the moral dilemma of whether to be honest and take it back or not.

The upshot of the article is that 'middle class' morality wins out and she dutifully goes back to the checkout, but the article finishes with the line 'Us middle class types are mugs, right?'

No is the obvious response, you just have standards you were brought up with that mean if you don't go back, you'll feel like you've let yourself down and that your parents would be very disapproving.  But the problem I have is the assumption that these kind of standards are the preserve of the middle classes.  That a working class person, say, wouldn't be such a 'mug' and would just take it as a piece of luck.

Obviously, you can't extrapolate from individual cases, but pretty much everyone I can think of in my immediate family (largely blue collar or very lower middle class) would have done exactly the same, and I can't imagine we are complete outliers.  In fact, it would never have occured to my parents that there was a moral dilemma here at all - you would just go back, no question.

Ultimately, we are all highly influenced by our experiences and surroundings and this feeds into our view of the world.  But we need to be alert to the distortions that this inevitably gives rise to. To take some examples:

I regularly see coarse, drunken white people behaving badly - ergo my culture is morally superior to theirs

My only experience of working class people is watching Shameless and Eastenders - ergo all working class behave like that

I'm surrounded by people from ethnic minorities who treat me with contempt, ergo immigration is a bad thing

I work with lots of professional / hard working people from overseas, ergo immigration is a good thing with great benefits to society

All of these are pieces of a jigsaw, none completely right and none completely wrong.  What we forget at our peril is that these kinds of views (including our own), and the experiences that give rise to them are the products of constrained experience - either geographically or socially or both.  The challenge to them is to introduce a broader perspective from wider experience, so some kind of context can be achieved.

Breaching the redoubt

The Labour Party and the Unite union are in the middle of a damaging spat over the selection of candidates in the Falkirk by-election.  It's the sort of thing that plays right into the hands of the Tories and could, if not contained, cost Labour the next election.

The accusation is that Unite used tied to stack the candidate list with its 'placemen', and Dan Hodges was on the Today Programme this morning making the point that it's known Unite policy to do this.  In his opinion, Unite are out of control.

Assuming the accusations of rigging are true, I'm not for a minute condoning Unite's approach which has all the hallmarks of nefarious union behaviour from the 1970s and before: dirty tricks, rigged elections, manipulation of strike votes and the rest.  These are the behaviours of the bad old days that brought the world, and Maggie crashing down on union heads.

But setting aside the methods, there is an underlying problem here that is failing to be addressed and its one that runs to the heart of the current disillusionment with politics and politicians: the lack of diversity in the political establishment and, in particular, the lack of routes for people outside of the mainstream of Oxbridge and think tanks or local government, to get into national politics. 

Now this problem is pervasive and not restricted to any particular political party, although I suspect it applies rather less to those on the fringes such as the Greens and UKIP, and maybe that is another reason for their relative success.

But this is also related to the issue of unpaid internships acting as a mechanism for a wealthy, connected elite to ensure their children have a fast track route into lucrative and powerful careers.  It's all part of a landscape where the odds are stacked hugely in favour of a privileged few.

You can see that in this context of gross unfairness and disenfranchisement, it doesn't take much for someone with less than a cast-iron sense of morality and honesty to justify a few dirty tricks to push forward their agenda; the ends of breaching the bourgeoisie political  redoubt justify the means.