‘Whole person care’ needs a bit of tinkering and strong leadership

Whole person care

 

 

In a now very famous article, “The genius of a tinkerer: the secret of innovation is combining odds and ends”, Steve Johnson describes how innovation must be allowed to succeed in face of regulatory barriers.

“The premise that innovation prospers when ideas can serendipitously connect and recombine with other ideas may seem logical enough, but the strange fact is that a great deal of the past two centuries of legal and folk wisdom about innovation has pursued the exact opposite argument, building walls between ideas”

“Ironically, those walls have been erected with the explicit aim of encouraging innovation. They go by many names: intellectual property, trade secrets, proprietary technology, top-secret R&D labs. But they share a founding assumption: that in the long run, innovation will increase if you put restrictions on the spread of new ideas, because those restrictions will allow the creators to collect large financial rewards from their inventions. And those rewards will then attract other innovators to follow in their path.”

Bundling of goods can offend competition law, so that’s why legislators in a number of jurisdictions are nervous about ‘integrated care’.

In the past, Microsoft has accused of abusing Windows’ dominant status in the desktop operating system market to give Internet Explorer a major advantage in the browser wars.

Microsoft argued bundling Internet Explorer with Windows was just innovation, and it was no longer meaningful to think of Internet Explorer and Windows as separate things, but European authorities disagreed.

There’s no doubt that ultimately ‘whole person care’ will be some form of “person centred care”, where the healthcare needs (as per medical and psychiatric domains currently) are met.

But it is this idea of treating every person as an individual, with a focus on his or her needs in relation to the rest of the community which is the most challenging aspect of whole person care.

Joining up medical and social care with an ‘unified care record’ has never been attempted nationally, but it makes intuitive sense that care information from one institution should be made available to another.

Far too many investigations are needlessly repeated on successive admissions of the same patient, which is exhausting for the person involved. It would make far more sense to have a bank of results of investigations for persons, say who are frail, who are at risk of repeated admissions to acute hospitals in this country.

And this can’t be brought in with the usual haphazard ‘there is no alternative’ and ‘a pause for consultation’ if things go wrong. The introduction of the Health and Social Care Act (2012) and the CareData makes one nervous that lightning will strike a third time.

Labour has had long enough to think about what could go wrong.

Care professions might feel themselves ill-prepared in person-centred care. A range of training needs, from seasoned physicians to seasoned occupational therapists, will have to get themselves oriented towards the notion of a ‘whole person’. This might involve getting to grips with what a person can do as well as what they can’t do.

The BMA will need to be on board, as well as the Royal Colleges. Doctors, nurses, and all allied health professionals will have to double declutch from the view of people as problem lists, and get themselves into a gear about their patients as individuals who happen to be well or ill at the time.

This needs strong leadership, not people proficient at counting beans such that the combined sum total of a PFI loan interest payments and budget for staff doesn’t send a Trust into deficit.

Nor does it mean hitting a 4 hour target, but missing the point as a Trust does many needless admissions as they haven’t in reality fulfilled their basic admissions assessment fully.

For too long, politicians have been stuck in the groove of ‘efficiency savings’, ‘PFI’, ‘four hour waits’, and become totally disinterested in presenting a person-oriented service which looks after people when they are well as well as when they’re ill.

Once ‘whole person care’ finds its feet, with strong leadership and evident peer-support, we can think about how health is dependent on other parts of society working properly, such as housing and transport.

Technology, if this means that a GP could immediately know what a hospital physician has prescribed in real time in an acute admission, could then be worth every penny.

For the last few years, the discussion has centred around alternative ways of paying for healthcare instead of thinking how best to offer professional care to patients and persons.

The fact that this discussion has been led by non-clinicians is patently obvious to any clinician.

Technology also has the ability to predict, say in thirty years, which of the population is most likely to develop Alzheimer’s disease. Do you really want one of your fellow countrymen to have health insurance premiums at sky high because of having been born with this genetic make-up?

A lot of our problems, like the need for compassion, have been as a result of the 6Cs battling head-on with a 7th C – “cuts”. It’s impossible for our workforce to perform well if they haven’t got the correct tools for the job.

Above all, whole person care needs strong leadership, not just management.  And if we get it right the NHS will be less focused on what it’s exporting, but more focused on stuff of real importance.

Should you give data altruistically, like you donate blood?

blood donation

“Alongside what we have already done with the mandatory work programme and our tougher sanctions regime, this marks the end of the something-for-nothing culture,” Duncan Smith said in a conference speech for the Conservative Party last year.

The “something for nothing” meme, reinforced by the concept that “there is no such thing as society” (which Thatcher supporters vigorously claim now was ‘misunderstood’), remains a potent policy narrative.

The anguish which NHS England has experienced may be due to a fundamental problem with trust, as for example demonstrated elsewhere in reaction to GCHQ or NSA. But it could well be due to the “something for nothing” meme coming back to haunt the Government, which narked off  public health specialists as the “opt out” has become unhelpfully enmeshed with concerns about commercial profiteering from health data.

“The Blood Donor” is a famous episode from the comedy series “Hancock”, the final BBC series featuring British comedian Tony Hancock. First transmitted on 23 June 1961, Anthony Hancock arrives at his local hospital to give blood. “It was either that or join the Young Conservatives”, he tells the nurse, before getting into an argument with her about whether British blood is superior to other types.

The issue of consent has predictably come to the fore, and it is generally felt that the communications strategy of NHS England over caredata went very badly wrong.

In an almost parallel universe, nothing to do with blood donations, it turns out that Labour is looking at bringing in a US-style system of allowing voters to register on election day amid growing fears that millions of people are about to drop off the official register in a “disaster for democracy”.

In a radical move, Labour is considering allowing same-day registration, which is credited with boosting turn-out from around 59% to 71% in some American states, according to the Demos think-tank. But the point is: mass paperwork involving the population at large is possible.

But now the issue has also become “there is no such thing as altruism”.

The Coalition announced in September 2013 that it had sold Plasma Resources UK to Bain Capital, the private equity firm. Plasma Resources UK (PRUK) turns plasma, the fluid in blood that holds white and red cellsin suspension, into life-saving treatments for immune deficiencies, neurological diseases and haemophilia.

The deal was hugely controversial, beyond typical disagreements over privatisation of national assets, because blood transfusions in the UK are voluntary; if donors think that someone is going to make a profit from their donation, they may well not give blood at all.

Richard M. Titmuss was a professor of social administration at the London School of Economics form 1950 until his death in 1973. He had an international reputation as an uncompromising analyst of contemporary social policy and as an expert on the welfare state.

Richard M. Titmuss’s “The Gift Relationship” (recently edited by Ann Oakley and John Ashton) has long been acknowledged as one of the classic texts on social policy.

A seemingly straightforward comparative study of blood donating in the United States and Britain, the book elegantly raises profound economic, political, and philosophical questions. Titmuss contrasts the British system of reliance on voluntary donors to the American one in which the blood supply is largely in the hands of for-profit enterprises and shows how a nonmarket system based on altruism is more effective than one that treats human blood as another commodity.

His concerns focused especially on issues of social justice. The book was influential and, indeed, resulted in legislation in the United States to regulate the private market in blood.

But shouldn’t you simply donate data ‘for the public good’, in the same way you can choose to donate blood?

The start of a new data sharing scheme involving the pseudonymised medical records of those who do not opt out will be postponed to give patients more time to learn about its benefits and safeguards, NHS England has announced.

Part of the semantics of the legal data involves whether a discussion of the giving of data is ultimately separable from the discussion of the purposes for which these data are ultimately applied.

HSCIC, Health Statistics Collaboration with Insurance Companies, reported on its insurance collaboration intentions last August. Section 2.3.1 of its Information Governance Assessment Addendum stated their intentions very clearly, as Roy Lilley earlier pointed out.

“There is no legal requirement to differentiate between the release of data to NHS commissioners and any other potential data recipient. In the eyes of the law, a government department, a university researcher, a pharmaceutical company, or an insurance company is as entitled to request and receive de-identified data for limited access as a clinical commissioning group, as long as the risk that a person will be re- identified from the data is very low or negligible.”

“Furthermore, all such organisations can make good use of the data. Access to such data can stimulate ground-breaking research, generate employment in the nation’s biotechnology industry, and enable insurance companies to accurately calculate actuarial risk so as to offer fair premiums to its customers.”

The Centre for the Study of Incentives in Health in London is a cluster of academics  looking at the pros and cons of whether incentives can influence behaviour.

The issue of paying individuals to change their behaviours in health-enhancing ways, for example by encouraging them to quit smoking or take regular exercise, is a highly topical policy issue, in the UK and internationally. Yet personal financial incentives are potentially riddled with legal ethical issues, with concerns regarding their precise effectiveness, and with further concerns that they may have unintended consequences.

Paying people to undertake particular actions may crowd out their intrinsic motivations for wanting to do those actions, as demonstrated by Richard Titmuss’ classic work on blood donations almost forty years ago

Arguably, a final nail in the coffin came from a report by Randeep Ramesh that drug and insurance companies might be able to, from later this year, buy information on patients – including mental health conditions and diseases such as cancer, as well as smoking and drinking habits – once a single English database of medical data has been created.

However, advocates argued that sharing data will make medical advances easier and ultimately save lives because it will allow researchers to investigate drug side effects or the performance of hospital surgical units by tracking the impact on patients.

Possibly, now is an opportune time to revisit Richard Titmuss’ thesis.

One can only speculate what he would have made of the current furore over ‘caredata’. I suspect though he would care.

I loved this comment by Prof Steve Iliffe regarding the timely diagnosis of dementia

I loved this letter by Prof Steve Iliffe.

It captures a lot of the issues I worry about.

I don’t have particularly strong views either way about the diagnosis rates of dementia in England, other than the fact I am mindful that some people wait unacceptably for years before they are formally diagnosed.

This is a concern that some persons with dementia may not wish to have a diagnosis of dementia.

There is some evidence to support this in fact, because of the documented delay in times for people to seek medical help.

There is still unquestionably a stigma for a person receiving a diagnosis of dementia, which is a huge life-changing event for the person involved and those closest to him or her.

GPs are brilliant professionals. My late father was one for about 25 years in fact.

However, some may be mutually colluding with persons who don’t wish to receive a formal diagnosis of dementia, in that either party may prefer to attribute memory problems to ‘normal ageing’.

We do run the risk of pathologising memory problems. Already, receipt of a diagnosis of dementia takes you down a medicalisation pathway as Prof Iliffe states. Pathologising ageing is problematic for very obvious reasons.

I also think this letter touches upon a number of ‘misunderstandings’ of dementia care.

Just because the medications for memory and attention aren’t that successful for many, there’s a huge danger that people are left with the impression that nothing can be done.

Much can be done to improve living well with dementia, including addressing the needs of a person as well as optimising the design of the immediate and built environments.

I must admit that I am biased towards the ‘care’ end of making sure care homes are properly affordable, and something to be proud about. I think that preserving the dignity of a person who happens to be living independently well with dementia, such that he or she exerts control and choice, is a perfectly reasonably one.

I am reproducing Prof Iliffe’s letter below, with kind permission of Prof Iliffe whom I caught briefly at lunchtime today.

The original publication of the letter is here.

___________

Martin Brunet (Rapid response 31st October) adds an important point to the timely and perceptive critique of dementia policy and practice by Le Couteur and colleagues (1). The apparent under-diagnosis of dementia in general practice is presented as a problem needing urgent solution. In my experience few are interested in why diagnoses rates are low. Contrary to the rule of no intervention without a diagnosis, remedies and targets are proposed and pursued energetically.

I suggest eight reasons why there is a diagnostic gap. Changes in thinking, memory and behaviour are not recognised as significant by the individual experiencing them, or by those around them, who may normalise changes as being part of ageing, due to life events or expressions of the personality. Symptomatic individuals may not accept that anything is wrong and resist further investigation. General practitioners may misattribute changes to ageing, well beyond the point of plausibility. General practitioners may protect symptomatic patients from a stigmatising diagnostic label which could place them on an escalator into disability; in doing so they will protect themselves from the consequences of mislabelling. General practitioners who believe that there are few resources to support their patients with dementia may be slow to diagnose. In some patients diagnosis may appear to make no difference to care, or may perversely worsen it by blocking access to rehabilitation or threatening residency in a care home. Memory clinics may have long waiting lists, which lengthen as demand increases. And finally, a formal diagnosis may be made by a specialist but not get recorded in a way that is captured for the Quality & Outcomes Framework reporting.

Different combinations of these (and other) factors may occur in different contexts, making local understanding important. This is not necessarily how the NHS works. The over-emphasis on diagnosis may divert resources away from much-needed community services, in another turn of the Inverse Care Law. Sceptical GPs will be vindicated if low-level support for patients early in the disease course, or palliative care for those at the end of life, fail to meet their needs whilst memory clinics seek extra funding to deal with their backlogs.

(1) LeCouteur DG, Doust J, Creasey H, Brayne C Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis BMJ 2013;347:f5125

 

The Right needs to make up its mind: is society, or the individual, more important?

Individualism

Socialism has never been clearer.

We not consider the State to be a ‘swear word’. We are proud of our values of solidarity, social justice, equality, equity, co-operation, reciprocity, and so it goes on.

The Right, meanwhile, needs to make up its mind: is “societal benefit” more important, or the individual?

The rhetoric under Margaret Thatcher and beyond, including Tony Blair, was individual choice and control could ’empower’ individuals. This was more important than the paternalistic state making decisions on your behalf, and indeed Ed Miliband was keen to read from the same script at the Hugo Young lecture 2014 the other week.

Yet, the phrase “societal good” has been used by an increasingly desperate Right, wishing to justify money making opportunities in caredata, or cost saving measures such as NICE medication approvals or hospital reconfigurations, So where has this individual power gone?

Whilst fiercely disputed now, Thatcher’s idea that ‘there is no such thing as society’ potentially produces a sharp dividing line between the rights of the individual and the value of society.

“There is no such thing as society. There are individual men and women, and there are families. And no government can do anything except through people, and people must look after themselves first. It is our duty to look after ourselves and then to look after our neighbour.

was an individualist in the sense that individuals are ultimately accountable for their actions and must behave like it. But I always refused to accept that there was some kind of conflict between this kind of individualism and social responsibility. I was reinforced in this view by the writings of conservative thinkers in the United States on the growth of an `underclass’ and the development of a dependency culture. If irresponsible behaviour does not involve penalty of some kind, irresponsibility will for a large number of people become the norm. More important still, the attitudes may be passed on to their children, setting them off in the wrong direction.”

(M. Thatcher, Woman’s Own, October 31, 1987)

Whilst the Left has been demonised for promoting a lethargic large State, monolithic and unresponsive, there’s been a growing hostility to large monolithic private sector companies carrying out the State’s functions.

It is alleged that some of these companies are not doing a particularly good job, either.

It has recently been alleged that the French firm, ATOS, judged 158,300 benefit claimants were capable of holding down a job – only for the Department of Work and Pensions to reverse the decision. At the end of last year, private security giants G4S and Serco have been stripped of all responsibilities for electronically tagging criminals in the wake of allegations that the firms overcharged taxpayers

So why should the Right be so keen suddenly on arguments based on ‘societal benefit’?

It possibly is a cultural thing.

The idea that “large is inefficient” was never borne out by the doctrine of ‘economies of scale’, which is used to justify the streamlining of operational processes across jurisdictions for multinational companies.

This was a naked inconsistency with the excitement in corporate circles with “Big Data”, that big is best.

Many medical researchers are rightly excited at the prospect of all this data.  Analysis of NHS patient records first revealed the dangers of thalidomide and helped track the impact of the smoking ban. This new era of socialised big NHS data could be very powerful indeed. Whilst there were clearly issues with informed consent at an individual level, the argument for pooling of data for public health reasons were always compelling.

The fact that this Government is simply not trusted when it comes to corporate capture has strongly undermined its case. Also, if the individual must put itself first, why should he allow his data to be given up? Critically, this knowledge doesn’t just have a social good, or multiple individual health ones. It has economic value too.

It might simply be that the Right is keen on this policy through now is precisely because such data will offer significant financial benefits, and that any to wellbeing are simply pleasant side-effects. The concern that this policy is actually about boosting the UK life sciences industry, not patient care. This is science policy – where science lies  within the technical jurisdiction of the Department for Business, Innovation and Skills – not just health policy.

Is it not reasonable that an individual should have the right to opt out of having his caredata being absorbed?

“Societal good” has been used by the current Government in a different context too.

The National Institute for Health and Care Excellence (NICE) will consult next month on an update to its methodology for assessing drugs. It had been asked by the Department of Health to make judgments on the “wider societal benefit” of medicines before recommending them for NHS use. But a board meeting this week has decided it would be wrong to make an assessment that effectively would put a monetary value on the contribution to society of the people likely to be taking the drugs.

It is thought that any assessment of “wider societal benefit” would inevitably end up taking age into account, say papers from the meeting. “Wider societal benefit” could therefore be simply an excuse for excluding more costly older patients.

NICE’s chief executive, Sir Andrew Dillon, has said it is valid to take into account the benefit to society of a new drug, but great care had to be taken in the way it was done, so that an 85-year-old was not regarded as less important than a 25-year-old. One group of patients should never be compared with another.

But an older individual must put his access to medications first surely?

A legal challenge brought by the local authority and the Save Lewisham hospital campaign showed conclusively that the secretary of state did not have the power to include Lewisham in a solution to the problems of SLHT.

As Caroline Molloy explains:

“The hospital closure clause gives Trust Special Administrators greater powers including the power to make changes in neighbouring trusts without consultation. It was added to the Care Bill just as the government was being defeated by Lewisham Hospital campaigners, in an attempt to ensure that campaigners could not challenge such closure plans in the future. But the new Bill could be applied anywhere in the country.”

Clinical commissioning groups (CCGs), the groups of state representatives making local health plans about resource allocations, will still need to be consulted in this process, and the consultation has been extended to 40 days. However, disagreements between CCGs may now be overruled by NHS England. So, the most important local decision makers may have no say in key reconfigurations of their hospitals and care services.

An individual within a locality must surely have the right to put his own interests regarding social provision first?

I believe that part of the reason the Right has got into so much trouble with caredata, access to drugs and clause 118 is that it appears in fact to ride roughshod over people’s individual rights, and in all three cases is only considering the potential economic benefit to the budget as a whole. They are not interested in the power of the individual at all.

And the most useful explanation now is actually that with such overwhelming corporate capture engulfing all the main political parties, that there’s no such thing as “Left” and “Right” any more. It might have been once our duty to look after ourselves, but it is clear that conflicts have emerged between individual autonomy and the needs of the corporates.

The “Right” is not actually working for the needs of the individual at all, nor of society.

The most parsimonious reason is that the Right is not as such a Right at at all. It, under the subterfuge of being “centre-left” or “centre right”, is simply acting for the needs of the corporates, explaining clearly why so many are disenfranchised from politics. From this level of performance, the Right has not only failed to safeguard the interests of the Society, it has failed to uphold the rights of the individual. This is an utter disgrace, but entirely to be expected if the Government governs on behalf of the few.

Of course we knew that this would happen under the Conservatives and the Liberal Democrats, but Labour needs to return to democratic socialism urgently.

Sir Stuart Rose’s medicine for the NHS may be too generic

Stuart Rose

 

What lessons can be learnt from reviving Per Una underwear to the 14 Keogh Trusts?

The left wing does business too.

Look at Alan Sugar.

Or maybe not.

Sir Stuart Rose, who was credited with rejuvenating Marks & Spencer during a turbulent six years as chief executive, has been hired to help revive the fortunes of failing hospitals in England.

In “Back in Fashion: How We’re Reviving a British Icon”, Sir Stuart Rose establishes his thinking about turning around the fortunes of Marks and Spencer, in an article in the Harvard Business Review.

In this article, Rose explained that he was a temporary “guardian of this great business and that my job is to leave it in better condition than I found it.”

On his eventual demise, Rose wants people to say, “He could have turned left but, thank God, he turned right.”

This of course is a tongue-in cheek reference to his known sympathies for the ideology of the Conservative Party. But on closer inspection his transformational agenda is not particularly right-wing in the sense that the principles are generally widely held.

In a move dubbed in Whitehall as “M&S meets NHS“, Rose will advise the health secretary Jeremy Hunt on how to build up a new generation of managers to transform failing hospitals. There will be a particular focus on the 14 NHS trusts placed in “special measures” last year.

One of his criticisms is that major decisions were being made by people not experienced enough to make them. But it will be interesting to see how he deals with CEOs of English Trusts, who are not clinically trained, who achieve good four-hour wait targets. And yet the management plans of the patients leaving A&E in those Trusts can be an unmitigated disaster for patient safety. Often, frontline staff in such Trusts are totally disenfranchised, and even discredited by their management.

“For those outside the UK, it is difficult to understand just how powerful the M&S brand is. It is a national institution. Two prime ministers, Margaret Thatcher and John Major, both famously said they bought their underwear at Marks & Spencer, just like nearly a third of the people in the UK.”

And of course the NHS is a powerful brand.

Rose is clearly a marketing guru at heart. The brand is so powerful that even private providers are allowed to use their intellectual property to market their services.

The early events Rose experienced are very revealing.

“Clearly, the battle hinged on our ability to convince reporters, analysts, and investors that I was the one to lead M&S back to prosperity. Having such intense scrutiny of you personally, as a leader, can cause self-doubt.”

One of the issues about Sir David Nicholson’s ability to lead his organisation is the extent to which he appeared ambivalent about the events at Mid Staffs.

Mike Farrar has also had such problems with the media.

Rose has previously spoken about the the “rock star” image and PR skills needed for those at the top of the world of business and politics. One thing that Nicholson and Farrar can’t be called are ‘rockstars’.

Rose warns, “Don’t Even Consider a Plan B”.

And yet it’s this ‘there is no alternative’ narrative which is causing disquiet for people running the NHS.

People are more than aware that some McKinsey ‘efficiency savings’ have in fact led to dangerous staff cuts in certain Trusts, compromising patient safety.

In “The only thing wider than the NHS funding gap is the policy vacuum’ by Colin Leys published in the Guardian today, Leys considers a number of different proposals for the ‘funding gap’.

Leys remarks,

“As a result, there is a policy vacuum, which the private health lobby is eagerly seeking to fill with renewed calls for charging and “top-ups”; in reality, these would do little to close the funding gap, but would mean the end of free and equal care for all. In the meantime, it seems that in official circles it is left to everyone except Hunt to suggest solutions: more “efficiency savings” (Sir David Nicholson); rationalisation, with fewer hospitals offering specialist care (Sir Malcom Grant); more specialist GPs and intermediate care provision (NHS England’s Dr Martin McShane); more self-care (NHS clinical commissioners); more telemedicine (the joint government-industry 3millionlives project).”

“As it became clear that one successful line could not, in reality, fuel a sustainable revival by itself, M&S suddenly discovered the allure of consultants. But for a company that had long prided itself on home-growing talent, the heralding of consultants to bring in “fresh” ideas sent a damaging message throughout the ranks.”

It is well known that the NHS has had trouble in generating home grown talent in management, symbolically heralded by the appearance of Simon Stevens from an US healthcare provider to head up  the NHS.

“One of the most important messages I wanted to send to our staff was that they should trust their own judgment again.”

But this is the very essence of one of the toxic problems of the NHS.

Certain frontline staff, especially juniors, don’t have a say on what is going wrong with patient care, because of some seniors pursuing targets. If Rose is serious, he will need to talk to frontline staff to find out what problems there have been with patient care, and why.

He may find a lot of it does come down to the fact there is an unsafe staffing level, but they’ve had no-one to report their concerns to in a meaningful way.

Another problem comes to analysis of the ‘offering’.

“Then we made changes closer to home. The most symbolic thing we did was to have a massive housecleaning. Because there were so many different subbrands in our shops, we had lots of signage and titles and names on cardboard cluttering up our stores.”

Between NHS hospitals in the round, they need to offer a comprehensive offering, and not miss out any rare diseases. But here the acccusation for cherry-picking for profitability becomes particularly pertinent.

The difference in ethos between the NHS and M&S has parallels with the differences between UK state prisons and US private prisons.

In US private prisons, prisoners are able to pay for a better room – in other words, as US prisons are designed to make money, this creeps into other activities of prisons.

“The stores looked dated. We weren’t in the same league as trendier retailers like Zara, Next, and Topshop. It was the beginning of a major store-by-store refurbishment program, which cost us more than £500 million by the end of 2006, with an additional £800 million earmarked after that.”

Many people are indeed impressed by the brand-new spanky new hospitals funded by PFI, but find horrific the idea of hospitals looking like hotels a bit nauseating if there’s insufficient money to staff them properly.

But Rose is known to be very keen on showing visibly the hallmarks of his ‘turnout’.

Presumably Rose will want there to be external markers of turning around the Keogh Trusts.

But that’s admittedly another problem, and why Rose’s medicine is ‘too generic’. It is all too easy for clinical staff to be forced to cover up bad care because of not wishing to get into trouble with their regulators and a lack of duty of candour (not necessarily working independently.)

The danger is that the Keogh hospitals end up ‘looking nice’ but are still as dangerous/safe as previously.

“Having cut so many staff from a business as culturally embedded as ours, I had to spend probably 90% of my time over the next six months convincing people who were already pretty disillusioned that we were making progress.”

It’s well known that Rose cut thousands of staff to stem the fall in drop in profits.

The problem with the NHS, more so than with M&S possibly, is that it might be easier to find alternative employment for staff in the NHS about to be made redundant.

And the idea of the need to make staff redundant is still a problematic one for the NHS.

This is because, despite the urge for ‘efficiency savings’, the demand in the NHS has been traditionally described in rather hyperbolic terms such as “exponential”. In other words, the messaging problem for those who want to cut staff numbers in the NHS is that the demand on the NHS is huge.

And if the Government wishes to feed the demand, such as a ‘seven days a week service’, the demand is by definition going to get greater, unless you literally vary unilaterally employment contract terms for Consultants and their junior staff.

It is said, furthermore, that Rose is known for taking a personal interest in his customers’ thoughts on his products – he once arranged a meeting with Jeremy Paxman following the BBC presenter’s criticism of M&S men’s underwear.”

But the actual experience of many who have complained about the NHS is that complaints get sat on.

Rose was knighted in 2007 for services to the retail industry and corporate social responsibility, had worked his retail magic.

But corporate social responsibility in the NHS will not be achieved by green light bulbs or clever marketing.

There needs to be a genuine ‘investment in staff’. Trades unions for nurses and other clinical staff cannot be any longer totally ignored in policy decisions regarding the NHS.

The Health and Social Care Act (2012) was itself a monumental failure of the mantra, “no decision about me without me.” So were the decisions about the Lewisham decided in the second and third highest courts of the land.

“We’d also finally regained our stride in advertising and marketing. We led from the food side of the business, because it had suffered less than the clothing side and for that reason was seen as our stronger asset.”

For the NHS, Rose will have to concede that a bone marrow transplant for a rare blood disorder is as important as a hernia operation for the patient involved. But this is where a left-wing twang, regarding equity, might be significant after all.

How will Rose know when his Trusts have got better?

A cosmetic refurbishment, realigment of the product offerings, or better marketing are not the solutions.

They are too generic for retail, and not appropriate for this sector.

As someone else might say, he is hitting the target but missing the point?

TTIP presents as a crucial test for Labour’s future direction on the NHS

The EU-US (TTIP) trade deal could be worth £67 billion to the EU, and could bring 2 million new jobs to the EU. Here in the UK, it is expected to add between £4 billion and £10 billion a year to our economy. That could mean new jobs for British workers, and stronger, sustainable growth for the British economy. The car industry keeps on bringing up as the poster body for TTIP, but everyone knows there are clear differences.

In Peter Mandelson’s “The Third Man”, Mandelson talks about how his aim was to seek a post-Blair era in leaving a legacy of New Labour. However, he also describes the personal tensions between Blair and Brown. Mandelson felt that there was an inevitability about Labour losing the election in May 2010, but how the mantra “it’s the global economy stupid” might work for Gordon Brown. It didn’t.

The next General Election is due to occur on May 7th 2015. It will be first which Ed Miliband fights. It could also possibly be his last. Miliband is still not ubiquitously popular within his party. If he loses the election, he almost certainly will be ditched by the Party. It would be inconceivable for Ed Miliband to wish to bang on about ‘One Nation’ should the electorate deliver a defeat for his party.

If Ed Miliband loses, there will be a leadership election. Clearly activists, even those who are ambivalent about Ed’s leadership will not wish for anything other than a Labour victory. The chances of a leadership fight, given how time consuming the last one was for Labour, are virtually non-existent. It seems we are ‘nearly there’ with the Labour Policy Review and the Sir John Oldham Commission on ‘whole person care’. It’s unlikely to be as bad as 1983, but who knows. Under Michael Foot, in the 1983 general election Labour had their worst post-war election result.

Not waving but drowning

It is intriguing how much both will have Andy Burnham’s personal stamp on it. Ed Miliband doesn’t wish to commit to the members of his Cabinet, if he were to be elected as Prime Minister. Likewise, there’s a growing feeling that some of the leading candidates, were he to fall on his sword, don’t particularly need his backing. Whether or not Labour can commit to Andy’s hopes would then become irrelevant, unless Andy Burnham becomes a central figure in health after the election. If somebody like Chuka Umunna takes over,  what Burnham says now might not matter to an extent.

What Burnham says now can act as a ‘weather vane’ as to the opinions of grasssroots membership of Labour. There has been a growing feeling in this parliament that Labour has acted as a frontman for the corporate establishment. As criticism of monolithic unresponsive outsourcing private providers continues, Ed Miliband may wish to capture on certain elements of left populism, as indeed he did at the Hugo Young Lecture. Miliband has offered to repeal the Health and Social Care Act (2012), and has overall made pro-NHS noises.

There’s no doubt that the Tories are scared of Burnham as a potential returning Secretary of State for Health. When David Cameron first addressed Parliament on the Francis Report, he told MPs that he didn’t wish to seek scapegoats. Despite numerous parts of a ‘smear campaign’ from Jeremy Hunt, with one even culminating in a legal threat from Burnham, Burnham has appeared surprisingly resilient. The only explanation of this is that he still carries with him considerable clout within the Labour Party.

The most notable comments by Andy Burnham in George Eaton’s New Statesman interview were on the proposed EU-US free trade agreeement and its implications for the NHS. Many Labour activists and MPs are concerned at how the deal, officially known as the Transatlantic Trade and Investment Partnership (TTIP), could give permanent legal backing to the competition-based regime introduced by the coalition.

A key part of the TTIP is ‘harmonisation‘ between EU and US regulation, especially for regulation in the process of being formulated. In Britain, the coalition government’s Health and Social Care Act has been prepared in the same vein – to ‘harmonise’ the UK with the US health system. This would open the floodgates for private healthcare providers  well known in the US already. Simon Stevens as the incoming head of the NHS will wish not to appear unduly sympathetic, despite his own background with a US healthcare corporation.

When Eaton spoke to Burnham, he revealed that he will soon travel to Brussels to lobby the EU Commission to exempt the NHS (and healthcare in general) from the agreeement. He said:

I’ve not said it before yet, but it means me arguing strongly in these discussions about the EU-US trade treaty. It means being absolutely explicit that we carry over the designation for health in the Treaty of Rome, we need to say that health can be pulled out.

In my view, the market is not the answer to 21st century healthcare. The demands of 21st century care require integration, markets deliver fragmentation. That’s one intellectual reason why markets are wrong. The second reason is, if you look around the world, market-based systems cost more not less than the NHS. It’s us and New Zealand who both have quite similar planned systems, which sounds a bit old fashioned, but it’s that ability of saying at national level, this goes there, that goes there, we can pay the staff this, we can set these treatment standards, NICE will pay for this but not for this; that brings an inherent efficiency to providing healthcare to an entire population, that N in NHS is its most precious thing. That’s the thing that enables you to control the costs at a national level. And that’s what must be protected at all costs. That’s why I’m really clear that markets are the wrong answer and we’ve got to pull the system out of, to use David Nicholson’s words, ‘morass of competition’.

I’m going to go to Brussels soon and I’m seeking meetings with the commission to say that we want, in the EU-US trade treaty, designation for healthcare so that we can exempt it from contract law, from competition law.

Burnham’s opposition to HS2 was also highly significant.

Now it seems, from a totally unaccountable rumour, that Ed Miliband is to veto a policy by Burnham to hand over control of billions of pounds of NHS funding to local councils. Burnham, outlined proposals last year that would have committed a future Labour government to transfer around £60 billion of NHS money to local authorities to create an integrated health and social-care budget. It appears now that proposals have been rejected by both Miliband and Balls. Both men believe that the policy is misguided and would allow the Tories to accuse Labour of imposing another top-down reorganisation in England. Labour will still attempt to integrate health and social-care budgets to provide “whole person care”, but funding is likely to remain within the NHS.

But it is of course possible that Burnham wants increasingly to not pin his personal fortunes to Ed Miliband, but to what he believes in. And Ed Miliband may not necessarily taking Labour in the direction of a NHS relatively free from a ‘free’ quasi-market.

There are particular concerns about the potential implications of a mechanism called Investor-State Dispute Settlement (ISDS), if it is included in the trade agreement. ISDS allows investors to challenge governments in an international tribunal if the government’s actions threaten their investments. There is concern that this could bypass national courts and limit the ability of democratic governments to enact their own policies. This on top of the EU procurement law fixes the domestic government in a rather tight spot, threatening our national legal and political sovereignty potentially.

There are also particular concerns that the ISDS could apply to the NHS. The Health and Social Care Act (2012), widely held to be a ‘vanity project’ from Andrew Lansley but actually legislated by a neoliberal coalition including the Conservative Party and Liberal (Democrat) Party allows American health care companies to compete for and win NHS contracts. There is a risk that if ISDS was applied to the NHS, repealing the Health and Social Care Act could be deemed to be in breach of the free-trade agreement. This would be a catastrophic legacy for Labour to pick up in May 2015, regardless of whether Burnham is in situ. Of course, many hope dearly he will be Labour’s Secretary of State for Health.

Negotiations are still going on, and Labour will continue to pressure the Government to ensure that the agreement does not place undue limits on future administrations. While Labour are in favour of a transatlantic trade agreement, once a draft agreement is reached, a review will be needed as a matter of some urgency.

For flood victims, the State is not a dirty word. So why should it be for patients of the NHS?

Flood

Ironically, just as Ed Miliband gave his Hugo Young 2014 lecture on “an unresponsive State”, many people in the SW England saw their sandbags being delivered to a different location.

The floods have revealed what many of us have suspected all along.

The response to the floods has revealed a painful fault line in our narrative of ‘The State’.

There’s no COBRA meeting when fourteen Trusts run into difficulties with patient safety, because of the common thread that they don’t have a safe minimum level of safe staffing.

The acute general medical take for many health professionals is a ‘firefighting experience’, with the aspiration of lean management to mean there’s actually insufficient capacity in the system to cope with increased demand.

It is now being reported that some British insurers are unwilling to take on the risks of certain flood areas, feeling that the market is somehow rigged towards only benefitting “cherrypickers”.

It makes us wonder who the postman will be, now that Royal Mail is privatised benefitting hardworking hedgies.

And yet this is precisely the criticism that anti-privatisation campaigners on the NHS have been saying since initial discussions of the Health and Social Care Bill (2011) commenced.

The market is unable to guarantee complete coverage for all scenarios. In the case of private insurance and health, rarer ‘unprofitable’ diseases will just become out of scope. Like Owen Paterson’s ‘badgers’, the location of the goalposts will be redefined so that some NHS interventions are no longer ‘necessary’.

David Cameron’s response curiously has not been to resuscitate his flagship turkey.

You would have thought, if you believed any of Steve Hilton’s hype, that people would fight them in the dinghies as a “Big Society” response.

Or somehow the market could be “nudged” into action, where the market could be realigned with financial incentives to make us want to give a shit about our fellow man or woman now underwater.

Instead, David Cameron has been trying to fatten up the impoverished State.

If you think that the current debate about the actual fall in NHS spending is going nowhere, that’s clearly small change compared to what may or may not been happening to Lord Smith’s Environmental Agency.

For flood victims, the State is not a dirty word (save for those victims who feel profoundly let down by the lack of response by the State). So why should it be for NHS patients?

It’s well known that the current Government considered implementing an insurance-based system but eventually went against it. The implementation of personal budgets has been progressing over the few years, with rather little discussion.

And yet, personal budgets could become a major plank of Labour’s “whole person care”. Somewhat reminiscent of ‘expert commentators’ who were slow on the uptake when it came to uptake on competition in section 75, they appear equally sleepy on the significance of unified budgets for health and social care.

From one perspective, they ’empower’ persons, and give them ‘choice’. But from another perspective, they actually disempower persons when the State runs out of money, and you have to top up your budgets from some other means.

It’s this two tier nature which causes the most alarm. Already, there’s been much finger pointing about ‘personal responsibility’ of people building homes knowingly on flood plains. The shift of potential blame as well as shift in personal responsibility is a deliberate change of emphasis in policy, and one which Labour must have an open discussion about if it wishes to retain any vestiges of trust.

The whole basis of trust of the public has for some time taken a knocking, with implementation of the private finance initiatives (PFI) and discussion of caredata.

While budget sheets are in the hock of paying off loan repayments, rather than paying for much needed staff to take the level of staffing beyond ‘skeleton’ or ‘extra lean’, the talk about a ‘more responsive State’ is all fluff.

While the NHS complaints system remains unfit for purpose, it’s all fluff.

It may be the fluff which keeps Alan Milburn and Tony Blair happy, but, despite the three general election victories, it has been a policy issue which Labour must revisit.

Proper levels of funding of the NHS and social care have long been popular and populist policies for Labour, and so has effective State planning.

It remains thus all the more strange that the only State that the Labour Party in fact cares about is the Square Mile.

What mandate does Miliband seek for his version of the State, and will he deliver?

 

MB

 

“Every time I’ve introduced a reform, I wish I’d gone further.”

Tony Blair felt that political opposition to any reform was inevitable. But not even he could have predicted the opposition that faced the Health and Social Care Bill (2011), and the subsequent £2-3 bn top down reorganisation.

The striking thing was that Ed Miliband’s “Hugo Young” speech yesterday did not, in fact, leave you with the impression that his Government “believes in public services”.

Blair felt that his first term in government did not adequately deal with public services. Blair set out his agenda on winning a second term.

“It is a mandate for reform, and an instruction to deliver.”

With the landslide victory of Tony Blair in 2001, Blair believed that Labour “was at his best, when he was at his boldest”. On the other hand, Gordon Brown believed that Labour “was at its best when it is united, best when it is Labour.”

In January 2000, Blair responded to a flu crisis by producing a massive splurge on the NHS. Labour now is obsessed about sticking to the austerity programme, to prove its fiscal credibility. So spending to kickstart yet further reforms of the NHS may not be an immediate option.

The extent to which a Miliband government would be able to deliver a costly set of reforms depends on what his relationship with his Chancellor of the Exchequer is like at the time. At the moment, it can’t be certain that this person will be Ed Balls, who generally positioned himself in the impossible position that the recession would never end.

If Miliband is genuinely concerned about ‘accountability’ for the financially autonomous independent NHS Foundation Trusts, he will have to address how local accountability is in fact lost, in terms of ability to pay for staff and services, if budget sheets are biased by unconscionable interest repayments for PFI.

If Miliband is genuinely concerned about ‘accountability’ for clinical performance, the NHS complaints system and higher regulation must be made fit for purpose. There are concerns about both aspects, and much can be done procedurally to make improvements here.

Ed Miliband wants to be the man to ‘clean up politics’.

It might be procedurally easy to promise and deliver low taxes, if the economy is growing. However, it is an altogether different matter to take to the public that lower taxes might lead to more unaccountable outsourced functions, say in probation or health, where taxes end up subsidising shareholder dividends.

So one of the reforms left to Ed Miliband is public ownership.

It has been argued that bringing NHS services back such that delivered by the State would be prohibitively costly, but not if a Government wishes to maintain excellence in NHS-supplied services and therefore aspires for the NHS to win contracts on an equal playing field basis. At the moment, pitches are won on the slickness of the presentation rather than corporate  ongoing performance management.

Miliband may wish the NHS is not political. But it is.

For example, if he wishes primary care to be run by outsourcing companies on behalf of the NHS, there is nothing to stop him legislating for this.

However, on the basis of ‘reforming public services’, it may be a step too far for the ordinary Labour voter.

The argument, that if the time it takes to see your GP is improved, it doesn’t matter who provides your GP services would be the predictable counterargument. It’s this sort of argument which will differentiate Miliband from New Labour – or not.

The paradox is, even if you discount that the greatest legacy of Baroness Thatcher is said to have been New Labour by the lady herself, the centre of gravity has swung away from fragmented, privatised services to a more left-of-centre dialogue.

A gift which has been handed to Miliband on a plate is the failure of the privatised utilities. From that, it has been low hanging fruit to redefine the Markets.

In response to Jeremy Paxman’s question whether Ed Miliband wants a “slimmed down state”, Liz Kendall MP, Shadow Minister for Care Services, offered that Miliband wants a “reformed state”.

Of course, offering unified personal budgets in the form of ‘whole person care’ would be a perfect vehicle for a reformed state. But Labour knows – and ultimately we will know – that it might also be a cover for a ‘slimmed down state’.

Ultimately it’s never been proven that the public actively endorsed the selling off of State assets, like Royal Mail, where there had been some public investment; nor did they ever sign off foreign ownership of previously State infrastructure.

But whilst Labour is in the hock of the City and the hedge funds, rather than the Unions, the reformed State might simply be the Square Mile after all.

What mandate does Miliband seek for his version of the State, and will he deliver?

 

 

 

 

 

Ed Miliband: the Hugo Young lecture 2014

Labour Conference Focuses On Leader's Speech

 

It is a huge pleasure to be here with you tonight.

And to be giving the Hugo Young Lecture.

Hugo Young was a figure of great decency and integrity.

He wrote beautifully and insightfully and gave journalism a good name.

As Alan Rusbridger wrote after his death, “Hugo never forgot why he was there: not to make friends or amiably to chew the political cud, but to report and to explain.”

Of the many things that made Hugo Young famous, was the phrase “one of us”.

It was the title he gave to his renowned biography of Margaret Thatcher.

As Hugo began the book:

“Is he one of us? The question became one of the emblematic themes of the Thatcher years.”

“Posed by Mrs Thatcher it defined the test which politicians and other public officials vying for her favour were required to pass.”

Now, I cite this not because I think we should take it as a model for government.

Nor for appointing civil servants.

But in the use of the phrase, Hugo Young was making an important point.

The very fact that Lady Thatcher was able to ask that question meant that she was absolutely clear what she stood for.

Prime Ministers are elected on a manifesto and make policy on that basis.

But in my view whether they achieve lasting change depends not just on specific policies but whether they can define the purpose and mission of their government.

With thousands of decisions taken in government every day, unless there is that sense of purpose, ministers and the people who support them will simply go their own way.

And the whole will be far less than the sum of the parts.

This is particularly true when it comes to the incredibly complex task of running the state and public services.

Over twenty Whitehall departments, more than a hundred local authorities, thousands of hospitals and schools.

Millions of choices are made each year in these organizations.

Even the most hands-on Prime Minister cannot determine those choices—-nor should they want to.

But a Prime Minister and a government can establish a culture for the way public services ought to work.

And the reality is that it doesn’t need civil servants to be ‘one of us’ to respond.

All of my experience is that public servants want a sense of the culture of public service the government wishes to see.

Because this sense of purpose acts as a guide for them.

My aim tonight is to say what that mission would be if I was Prime Minister.

My case is that the time demands a new culture in our public services.

Not old-style, top-down central control, with users as passive recipients of services.

Nor a market-based individualism which says we can simply transplant the principles of the private sector lock, stock and barrel into the public sector.

The time in which we live and the challenges we face demand that we should always be seeking instead to put more power in the hands of patients, parents and all the users of services.

Unaccountable concentrations of power wherever we find them don’t serve the public interest and need to be held to account.

But this is about much more than the individual acting simply as a consumer.

It is about voice as well as choice.

Individuals working together with each other and with those professionals who serve them.

This commitment to people powered public services will be at the heart of the next Labour government and tonight I want to set out why it matters, and what it means in practice.

This vision for public services is rooted in one of the key principles that drive my politics.

The principle of equality.

In his poem, The Prairie Grass Dividing, Walt Whitman talks about what makes for a successful democracy and says it is about a country where people can “look carelessly in the faces of Presidents and Governors, as to say, Who are you?”

Of course, politicians today quite often have that experience.

But not quite in the spirit Walt Whitman meant.

He is expressing the belief that each person however powerful or powerless, matters as much as one another.

An ethical view about the equal worth of every citizen.

This is the foundation of my commitment to equality too.

Whoever you are, wherever you come from, you are of equal worth.

It is the standard I seek to hold myself to as a person.

It means seeking to walk in the shoes of others, not looking over their shoulder to someone more powerful.

And that defines my politics too.

Because from that flows a belief in equal opportunity.

How else can we fulfil our commitment to the equal worth of every citizen?

And from it also flows a belief that large inequalities of income and wealth scar our society and prevent the common life I believe in for our country.

As Benjamin Disraeli wrote in Sybil in 1845 the danger is of “two nations, between whom there is no intercourse and sympathy; who are as ignorant of each other’s habits, thoughts and feelings as if they were dwellers in different zones or inhabitants of different planets”.

Those words were true then and feel as true today.

For decades, inequality was off the political agenda.

But nationally and internationally, this is changing.

Many people across every walk of life in Britain – politics, charity and business – now openly say they believe that inequality is deeply damaging.

Internationally too, political and civic leaders are talking about inequality in a way that they haven’t for generations.

At the end of last month, President Obama put it right at the heart of his agenda for government.

A few months before that the Democratic candidate for Mayor of New York, Bill de Blasio, was elected with precisely the same message.

We now have a Pope who says the same.

And that’s because people the world over are beginning to recognise some fundamental facts again.

That it offends people’s basic sense of fairness when the gaps between those at the top and everyone else just keep getting bigger regardless of contribution.

That it holds our economies back when the wages of the majority are squeezed and it weakens our societies when the gaps between the rungs on the ladder of opportunity get wider and wider.

And that our nations are less likely to succeed when they lack that vital sense of common life, as they always must when the very richest live in one world and everyone else a very different one.

I believe that these insights are at the heart of a new wave of progressive politics.

And will be for years to come.

Indeed, not just left of centre politics.

Intelligent Conservatives from David Skelton outside Westminster to Jesse Norman inside recognise the importance of inequality as well.

I believe that the public want to know we get it; we understand the depths of the cost of living crisis they face.

And we can’t go on with countries where the gap between those at the top and everyone else just gets bigger and bigger.

Tackling inequality is the new centre ground of politics.

In the last few years, I have been setting out what that means for Britain.

Of course it is about a progressive tax and benefits system.

But the lesson of the New Labour years is that you can’t tackle inequality without changing our economy, from promoting a living wage, transforming vocational education, to reforming executive pay, to helping create good jobs with decent wages.

I believe that inequality matters in our politics too.

We need to hear the voices of people from all walks of life not just the rich and powerful.

Building a real movement is the best hope of keeping the political conversation grounded in the reality of people’s lives, which so often doesn’t happen at Westminster.

Rooting the Labour Party in every community and every workplace in the country are what my party reforms are about.

Having explained what my beliefs mean for the economy and for politics, today I want to explain what they mean for the state and, in particular, for the way public services work.

For the left and for Labour, public services have always played an essential role in the fight against inequality and poverty.

An essay written in the late 1940s by T. H. Marshall called “Citizenship and Social Class” explained the idea of how public services could act against inequality.

Just as in the 18th and 19th century, civil and political rights had guaranteed a degree of equality, so too social rights would in the 20th.

A free national health service.

Decent state education.

Legal aid.

Pillars of the welfare state and a bulwark against inequality.

For much of the 20th century, politics became a battle about who was best placed to protect and expand this legacy.

For Labour the lesson of all this was a simple one: win power and use the levers of the state to fight against injustice.

That belief endures today.

And understandably so.

But we should never think it does enough on its own to achieve equality.

Because this traditional description of the task of Labour leaves out something fundamental.

I care about inequality of income and opportunity.

But I care about something else as well.

Inequalities of power.

Everyone – not just those at the top – should have the chance to shape their own lives.

I meet as many people frustrated by the unresponsive state as the untamed market: the housing case not dealt with, the special educational needs situation unresolved, the problems on the estate unaddressed.

And the causes of the frustrations are often the same in the private and public sector: unaccountable power with the individual left powerless to act against it.

So just as it is One Nation Labour’s cause to tackle unaccountable power in the private sector, so too in the public sector.

Of course, there is a vibrant and important tradition on the left which takes these inequalities seriously.

More than ever we need to rediscover this tradition.

Michael Young is most famously known as the author of the 1945 Labour manifesto which some saw at the blueprint for a centralized state.

But in 1949 he wrote the book Small Man, Big World which argued that the “large institutions of modern society tend to ignore the interests of ordinary people, who suffer collectively as a result.”

In the 1960s, the New Left and their colleagues also argued for a different kind of state.

The American Saul Alinsky wrote: “self-respect arises only out of people who play an active role in solving their own crises and are not helpless, passive, puppet-like recipients of private or public services.”

And at the same time, feminists were pointing out that women were often especially poorly served by the existing structures of the welfare state.

In my thinking, I have been much influenced by a book written by Richard Sennett, called Respect: The Formation of Character in an Age of Inequality.

He grew up on a Chicago housing estate, and he talks about the interaction between the “professionals” of the welfare state and those who lived there.

And he talked in a memorable phrase about the “compassion that wounds” – well-intentioned, properly motivated, but nevertheless disempowering.

Since then, people like Hilary Cottam have been actively creating new ways of providing public services, moving beyond the old model of delivery.

So the issue of power in public services has always been important.

And it is, in fact, even more urgent today.

For a whole set of reasons.

Because the challenges facing public services are just too complex to deliver in an old-fashioned, top down way without the active engagement of the patient, the pupil or the parent: from mental health, to autism, to care for the elderly, to giving kids the best start in the early years.

Because we live in an age where people’s deference to experts is dramatically waning and their expectations are growing ever higher about having their say.

And because the knowledge and insight that users can bring to a service is even more important when there is less money around to cope with all the demands and challenges.

Clearly the next Labour government will face massive fiscal challenges.

Including having to cut spending.

That is why it is all the more necessary to get every pound of value out of services.

And show we can do more with less.

Including by doing things in a new way.

At the same time, while the challenges are greater for public services than ever before, and make the issue of power all the more urgent, there are greater reasons for optimism too.

Contrary to a 1980s view of self-interested individualism, people by instinct want to help each other.

And that means if we care about giving power away, there will be someone to give it to.

Similarly, technology makes things possible, in ways that simply wouldn’t have been possible in the past.

Big Data, sometimes provided by the public themselves, provides entirely new ways of tackling everything from crime to improving the environment.

And today, the internet means that whether you are a parent, a patient, or a carer you don’t need to be left on your own but can link up with others.

Able to form communities of interest even when people are thousands of miles away.

So the challenge of power is both pressing but also more capable of being solved.

Some people, including the present government, conclude from this challenge that the answer is simple.

Addressing inequalities of power just means crudely importing principles of the private sector into the public sector.

Choice, contestability and competition have a role.

Labour showed in government how the private sector could help to provide extra capacity and speed up hip replacements and cataract surgery for the NHS.

And where existing services have consistently under-performed then alternative providers, including private, third sector or mutuals, are important as a way to turn things around.

But to conclude that market principles are a panacea is simply wrong.

The logic of market fundamentalism is that just like we have a choice over which shop we go to or which cafe, so too we should apply the same to public services.

But it is fairly obvious that this logic is flawed.

Making a decision about which cafe to go to, is something which can be made each time you choose to go out.

It is a completely different story with my son’s school.

If I wasn’t happy with the teaching he was receiving, I shouldn’t have to take him out of the school, disrupting the family, moving him away from his friends.

Even having to set up a school myself.

There should be a mechanism to improve the school.

And this is not the only issue.

Even if we did think market principles were the answer, the resource constraints on government will always limit their effectiveness.

When this government sets up Free Schools in places where there are already surplus places supposedly to create more choice, it does so by taking money away from other kids in real need of a school place.

And we have a looming school places crisis as a result.

Even more problematically, the promised choice often isn’t real.

Replacing one large public sector bureaucracy with a large private sector bureaucracy doesn’t necessarily make the system less frustrating.

Once a government contract for the Work Programme is signed or a train franchise is confirmed, people themselves have no choice over which provider to use because the choice has already been made by the government.

And it turns out that the Serco/G4S state can be as flawed as the centralized state.

Finally, while the creative destruction of the private sector is what powers an economy forward overall, there are other principles that drive public service success.

Like co-operation and care.

If you want to know what can go wrong, just take the government’s decision to import the principles of the privatisation of the utilities in the 1980s into the NHS.

It has meant that hospitals that want to co-operate with each other and integrate are prevented from doing so by an army of competition lawyers who say that’s “collusion”.

The Chief Executive of the NHS himself is saying it is now bogged down in a morass of competition law.

Unable to integrate services which is crucial to improving care and controlling costs.

So while David Cameron promised a Big Society, to unleash the forces of the voluntary sector, he has delivered something rather different.

In some cases, the monolithic private sector replacing a monolithic public sector.

In others, a crude application of market principles which simply hasn’t worked.

And in others still, leaving the unsupported voluntary sector to pick up the pieces where the state has abdicated its responsibility.

It’s no wonder he never uses the phrase Big Society any more.

So what are the principles that should guide us in tackling inequalities of power and improving public services?

What kind of culture would a Labour government seek to encourage?

I want to suggest four principles that will guide what we do.

And these are principles that I hope will be welcomed by millions of public servants who work tirelessly, day in day out, often for low wages, to serve the public.

They often feel that we have a culture that stops them doing their best.

Because the system doesn’t allow them to put those they serve at the heart of what they do.

First, we should change the assumption about who owns access to information because information is power.

And if we care about unequal power, we should care about unequal access to information.

From schools to the NHS to local government, there is an extraordinary amount of information about users of public services.

But the working assumption is still that people only get access to it when the professionals say it is OK or when people make a legal request.

Our assumption should be the opposite.

That information on individuals should be owned by and accessible to the individual, not hoarded by the state.

That people get access to the information unless there is a very good reason for them not to.

As the government has already acknowledged, that must include the right to access your own health records, swiftly and effectively.

But we should go beyond that.

Take education.

Schools collect huge amounts of information on our kids.

The old assumption is that it gets shared with us once or twice a year at a parents’ evening.

But this is a very old fashioned assumption.

As good schools are already showing, there should be continuing access, all year around.

Many good teachers know that its better if parents shouldn’t have to wait for a parents’ evening to understand how their son or daughter is doing, where things are going well and what more they could do.

And new technology makes the sharing of this information much easier.

As at Shireland Collegiate Academy in the West Midlands which provides teachers, pupils and parents real-time information on pupil attainment.

Indeed the Learning Gateway they pioneered is now used by over 100 schools.

And just as with the best private sector companies, we can “track our order”, so too in the public sector we should be able to “track our case”.

Whether it is an application for a parking permit or when you have been a victim of a crime.

Boston, in the United States, pioneered that kind of service a few years ago.

And the Labour council in Birmingham has already created an app for a mobile phone that can do it as well.

We are still in the foothills of what we can achieve for users in the transformation of public services through new technology.

If it can be done by one local council, it should be possible in every government department.

And that’s what we would task the government’s digital service to do.

Guaranteeing for the first time that people get the information they need.

But information is not enough if we are going to tackle the inequalities of power that people face.

My second principle is that no user of public services should be left as an isolated individual, but should be able to link up with others.

The old assumption is that success in public services comes from the professional delivering directly to the single user.

What I have called the “letterbox model”.

Indeed the very term “public service delivery” conjures up this idea of waiting for a service to be delivered by somebody else.

In fact, there is now a wealth of evidence that the quality of people’s social networks with other patients, parents and service users can make a all the difference to the success of the service.

A recent study in the United States found that women suffering with serious illness, with small social networks had a significantly higher risk of mortality than those with large networks.

Support networks made it easier to keep to recommended treatment schedules and, just as important, kept the morale of patients higher.

This is not surprising.

Nothing makes people feel more vulnerable than having to stand on their own.

Confronted with a vast and complex world of services that they can’t make sense of or options they don’t understand.

A friend of mine was telling me just the other day, what it felt like when his son was diagnosed with autism.

And he was battling the local council for proper support.

He and his wife didn’t know what they were meant to do.

They didn’t know what information to trust, or who to believe.

They felt they were standing alone in the world.

What really would have made the difference was being able to talk to other parents in the same position.

That way they could have made sense of the services that were available.

And asked for different teaching methods.

Eventually after years of struggle they managed to do this, but no thanks to the state.

Just as the presumption should be that the user owns and has access to their information, so the presumption should be that service users have the right to be put in touch with others.

Of course, there are already some amazing organisations in Britain that help people do exactly that.

Voluntary groups, for the ill, and the old, for those with kids in local schools, for those battling to look after relatives.

But too often at the moment, rather than helping people come together, the official services feel they’ve been told by people at the centre that their job is not to help put people in touch.

There is often no requirement on them to do so.

It is not part of their training.

Not a central part of what they are expected to do.

We need to change that.

There are already some examples that do precisely this.

In Newcastle, GPs don’t just prescribe drugs to patients, as a norm, they also put patients with chronic or complex conditions directly in touch with others who have the same concerns.

Whether it is diabetes, cancer or Parkinson’s.

The options flash up on the doctor’s computer screen, in exactly the same way the other treatment options do, and they are passed on to the patient.

So no-one has to deal with a long-term condition by themselves.

With the political will, and a small change to the existing information made available to GPs, we could make that possible in every GP’s surgery across our country.

And that is what a Labour government would do.

It is the right thing to do, keeping people healthier and less likely to end up in hospital.

It also means that people have greater power to hold to account a state that is not being responsive.

Some people will fear this.

I think we should embrace it.

Empowering people against the state where necessary.

And we should make it happen in every service that we can.

But if we are truly to make our public services open to the voices of those they are meant to serve, we need to throw the decision making structures open to people too.

We need to tackle inequalities of power at source.

So my third principle is that every user of a public service has something to contribute and the presumption should be that decisions should be made by users and public servants together, and not public servants on their own.

Of course, this is what so many great public services already do.

Personal budgets have allowed many disabled people to shape the services that matter for them, working hand-in-hand with public service professionals.

On a community level, the co-operative council model in Lambeth also shows us the way.

Its services are shaped and controlled directly by the people who they serve, not just by the council staff.

Despite reductions in budgets, services in Lambeth have been improved by this model.

From parks to youth services.

And we should apply this principle more widely.

Take the most difficult decisions that have to be taken in public services, like the restructuring of services in the NHS.

David Cameron used to go round in Opposition saying he would have a moratorium on all hospital changes, that closures would never happen.

He has monumentally broken that promise, including at hospitals he stood outside with a sign opposing change.

Recently the government attempted to close services at Lewisham and downgrade the A and E.

But they failed because they ignored the voice of patients.

Now, instead of learning the lessons, they want to change the law so they can change services across an entire region, bypassing patient consultation.

I am not going to make promises I can’t keep particularly on this issue.

No service can stand still.

But if we truly believe in pushing power down to people, we have to accept that we can’t at the same time defend a system where decisions this important are taken in a high-handed, Whitehall knows best way.

Indeed, the problem with the current approach is that it creates a dynamic of decisions taken behind closed doors, lacking legitimacy, with little public debate about the real reasons a change is being proposed.

Clinicians, managers and patients across the NHS know the system we have isn’t working.

We need to find far better ways of hearing the patient voice.

So a Labour government will ensure that patients are involved right at the outset: understanding why change might be needed, what the options are and making sure everyone round the table knows what patients care about.

No change could be proposed by a Clinical Commissioning Group without patient representatives being involved in drawing up the plan.

Then when change is proposed, it should be an independent body, such as the Health and Wellbeing Board, that is charged with consulting with the local community.

Not, as happens now, the Hospital Trust or Commissioning Group that is seeking the change.

And we will seek to stop and will, if necessary, reverse the attempts by government, to legislate for the Secretary of State to have the power to change services across whole regions without proper consultation.

This is just one example of how we can involve people in the key decisions that affect their lives.

Not saying change will never happen.

But saying no change will happen without people having their say.

We need to do the same in schools.

Having promised to share power, this government has actually centralised power in Whitehall.

Attempting to run thousands of schools from there.

That doesn’t work.

And as a result some schools have been left to fail.

Just last week we saw the Al-Madinah School in Derby close, because its failings were spotted far too late.

Clearly, we need greater local accountability for our schools.

And in the coming months, David Blunkett will be making recommendations to us about how to do this.

As part of that plan, we must also empower parents.

Parents should not have to wait for some other body to intervene if they have serious concerns about how their school is doing, whether it is a free school, academy or local authority school.

But at the moment they do.

In all schools, there should be a “parent call-in”, where a significant number of parents can come together and call for immediate action on standards.

This power exists in parts of the United States.

And I have tasked David Blunkett with saying how that can happen here too.

The fourth principle is that it is right to devolve power down not just to the user but to the local level.

Because the centralized state cannot diagnose and solve every local problem from Whitehall.

And if we are to succeed in devolving powers to users, it is much harder to do that from central government.

It is right that we elect a national government to set key benchmarks for what people can expect in our public services.

That’s part of tackling inequality.

Like how long we have to wait for an operation in the NHS.

What standards of service the police should provide.

And to ensure that the teachers in our classrooms possess a proper qualification.

But how specific services are delivered within these standards and guarantees cannot simply be dictated from Whitehall.

For the last year, as part of Labour’s Policy Review led by Jon Cruddas, our local innovation taskforce comprising outstanding council leaders from Manchester, Hackney and Stevenage has been looking at how we can deliver more with less.

And Andrew Adonis has been leading work on city regions, and their potential to drive our future prosperity if we devolve budgets and power down.

The conclusions of both these important pieces of work will be published in the coming months.

And as we prepare for a Labour government the on-going Zero-Based Review across all of public spending, being led by Ed Balls and Chris Leslie has these ideas at its core.

This work is clear that by hoarding power and decision-making at the centre, we end up with duplication and waste in public services.

As well as failing to serve people, particularly those with the most complex problems.

That is why the next Labour manifesto will commit to a radical reshaping of services so that local communities can come together and make the decisions that matter to them.

Driving innovation by rethinking services on the basis of the places they serve not the silos people work in.

Social care, crime and justice, and how we engage with the small number of families that receive literally hundreds of interventions from public services.

And so too in the coming months, across the major public services, we will be showing how we can improve genuine local accountability.

In addition to the Blunkett Review in education, the Institute of Public Policy Research’s Condition of Britain project is doing important work here.

John Oldham will also be reporting on how we can fulfil the vision of “whole person” care, better co-ordinating mental health, physical health and social care by devolving power down.

And following the Stevens Review on policing, Yvette Cooper will be coming forward with recommendations on how we can bring decisions on neighbourhood policing closer to local people.

In all of these public services, we are determined to drive power down.

This devolution of power is the right thing to do for the users of public service and is the right way to show that we can do more with less.

When I set out on the journey of becoming Leader of the Opposition nearly three and half years ago, I knew the most important thing was to do the hard thinking about the condition of Britain and what needed to change.

As Hugo Young knew, ideas and hard intellectual thinking are the most under-rated commodities in British politics.

To be a successful Opposition, you need to be able to tell the country what’s wrong and how it can be changed.

And to be a successful government, you need a defining mission.

Hugo Young and I didn’t agree with Lady Thatcher on most things.

But I suspect he would have agreed with her on this: “Politics is more when you have convictions than a matter of multiple manoeuvrings to get you through the problems of the day.”

Over the last few months, whether it is on energy or banking or on 50p tax, Labour has prompted debate and indeed criticism.

I relish that debate and believe strongly that the criticism just comes with the territory.

It is what happens when you make the political running.

I know that we are putting the right issues at the heart of our programme.

And we are standing where the British people stand.

They want a government that will stand up for them against unaccountable power, wherever it is.

They want more control over their own lives.

I am determined that is what the next Labour government will do.

That is the culture of the government I want to lead when it comes to public services.

Tackling inequality in income, opportunity and power.

That will be Labour’s mission in 2015.