Before we had feelings

 The most banal question asked by sports reporters on television goes something like this: “Jim, you have just scored the winning goal in the Cup Final/won the Olympic marathon gold medal/come first in the Tour de France, how do you feel?” This is lazy journalism, but it also illustrates a wider trend: a belief that what matters most is the sportsman’s immediate emotional response, rather than any reflection on the tactics they used to secure victory, the mistakes they made, or  the significance of the victory for their team. A similar primacy is given to ‘feelings’ in some news programmes, particularly those in which the newsreaders sit on sofas rather than behind desks. Great events are presented in terms of the emotions of those that have experienced them, rather than an analysis of why these events occurred and what their occurrence means for the future.

This emphasis on ‘feelings’ is something that has occurred in my lifetime, dating from the early 1970s. I remember a time when no-one was asked how they felt, and the resulting confusion some people experienced when they were first asked this question. Trying to explain this increasing dominance of ‘feelings’ over analysis is difficult, but one factor may be change in the nature of work and our relationship to the material world. When I was young, most people’s work was with material goods, doing things like welding, assembling products, digging coal, cooking or laundering clothes. In work of this kind, success or failure, competence or incompetence, was usually evident immediately. Most workplaces were dominated by men, and had the kind of boisterous and critical banter characteristic of much of male society.

But work with things has been increasingly replaced by a more abstract kind of work, in which groups of people collaborate to provide services to other members of the public, or design and market goods which are produced far away. There are many more women in the workplace, and female society seems to be characterised by mutual support and a particular concern (at most times) to avoid hurtful remarks. In workplaces of this kind, success or failure is less easy to observe, and it becomes harder for people to understand how the organisation as a whole functions and generates its outputs. In such circumstances, people are judged by the what they say and how they respond emotionally, rather than by what they achieve.

I remember this transition happening in my own life. After several short-term manual jobs while a student, I eventually became a social worker. Most of my colleagues were women, although men were usually in charge. I realised that I had moved into a very different workplace culture, in which there seemed to me to be acute sensitivity to almost anything anyone said. There were few words of criticism, but that meant that there was little opportunity to learn what mistakes were being made and what could be done better. But more important was the absence of analysis. Social work existed in a world without evidence or even data. We had no statistics on the types of problems experienced by our clients, no results from research about the most appropriate ways of responding to them, and no data about whether our efforts were successful or not. Almost all our interviews with clients were conducted individually and in private, so there was no opportunity to observe how others performed in their work. In the absence of relevant information, analysis would have been pointless because there was nothing to analyse, except the emotional reactions of individual clients. We worked in a world of feelings without meaning.

Coronavirus, utlitarianism and Emmanuel Kant

 The dispute between the UK and the European Union over vaccination against coronavirus is more than just a squabble about contracts: it shows profound differences between countries in how they make policy and the priority they give to the rights of individual citizens. This is shown by the history of the Oxford Astra Zeneca (OAZ) vaccination and the bans on its use in several EU countries. The first of these involved suspending the vaccine for the older age-groups on the grounds that insufficient numbers of the elderly had been included in the Phase 3 clinical trials. Only two months later, the same countries allowed the vaccine to be administered to the elderly but now banned its use for people under the age of 50 years because a very small number of younger people had developed abnormal blood-clots after injection. Denmark has now even banned the OAZ vaccine for people of all ages, even though the risk of blood clots is many times less than that found among women taking contraceptive medication (which of course has not been banned).

There were few such doubts in the UK, which initially placed no limitation on the use of the OAZ vaccine. However, on 7th April 2021, the UK’s Joint Committee on Vaccinations and Immunisation (JCVI) reported that it:
    “has weighed the relative balance of benefits and risks and advise that the benefits of prompt vaccination with the AstraZeneca COVID-19 vaccine far outweigh the risk of adverse events for individuals 30 years of age and over and those who have underlying health conditions which put them at higher risk of severe COVID-19 disease. JCVI currently advises that it is preferable for adults aged <30 years without underlying health conditions that put them at higher risk of severe COVID-19 disease, to be offered an alternative COVID-19 vaccine, if available. People may make an informed choice to receive the AstraZeneca COVID-19 vaccine to receive earlier protection”.

In other words, UK policy was to balance the risks from adverse reactions with the number of lives potentially saved by vaccination, but to ultimately leave the decision to the informed choice of the recipient. This approach shows the influence of two themes in British philosophy, as translated into government policy. The first is classical liberalism, in which individual citizens are regarded as ultimately responsible for their own lives, to make their own ‘informed choice’. The second theme is utilitarianism, which proposes that public policy should be based on the balance for the community as a whole between benefits (the number of lives saved) and losses (the number of people dying because of adverse reactions). It is easy to see why utilitarianism should have appealed to one of the first nations in the world to have a capitalist economy, and British governments have continued to apply the same ruthless principles in determining public policy. In the case of coronavirus, this involved spending vast sums on buying very large stocks of vaccines before their approval by the regulators, indemnifying their producers and funding drug companies to build the factories which produce the vaccines. Priority was given to delivering vaccines to those most at risk of death, and administration of the vaccine on a large scale began immediately after regulatory approval.

Neither classical liberalism nor utilitarianism has commanded much support in continental Europe, where thinkers from Emmanuel Kant onwards emphasised the valuation of each individual human life rather than regarding human lives as a means to an end (or a balance between benefits and losses). Kant lived in the German Kingdom of Prussia at a time when this was ruled by an absolutist king. Kant saw no contradiction between a respect for human rights and the lack of political rights for individual citizens. Instead, he believed that the best state of affairs was one in which the king should rule according to laws which protected the individual rights of the citizens. By this means, Kant could argue that authoritarian government is compatible with the protection of human rights, and thereby deny the principles of both classical liberalism and utilitarianism.  

Most EU governments followed Kantian principles in denying their citizens the right to choose the OAZ vaccine and in proposing that the vaccine be banned because of its possible (albeit very rare) negative impact on the health of individual recipients. In other words, the rights of each such individual were more important than the balance of benefits and losses that would result from the widespread use of the vaccine. Other, less enlightened, factors may also have played a part in their decision-making. These include a desire for revenge against Astra Zeneca because of the company’s failure to meet the agreed rate of deliveries of vaccines to the EU (and revenge against the UK for leaving the EU). Another factor may have been the desire by President Macron of France to undermine trust in a competitor to the much-delayed French Sanofi vaccine.

This all had the effect in the EU of undermining public trust in the OAZ vaccine, which has produced a widespread ‘nocebo effect’. This is the opposite of the placebo effect, in which patients claim they have benefited from a pill or treatment which has no clinical content. The nocebo effect occurs when a truly beneficial treatment is regarded with suspicion by its recipients, who then report a range of ailments they ascribe to the treatment. This has certainly been the case with the OAZ vaccine, which has been accused of causing a range of ailments in addition to the small number of blood clots with which it genuinely seem to be associated. Many of these reports can be explained by the post hoc ergo propter hoc fallacy. This Latin phrase translates as ‘after this, therefore because of this’, which in this case means that any ailment which occurs after receiving a vaccination is blamed on the vaccination. Priority for vaccination is usually given to the elderly and those with major health problems - groups prone to experience symptoms in a given period of time whether or not they have been vaccinated.

Suspending vaccination, the nocebo effect and delays in beginning the vaccination programme caused by the desire of the European Commission to prioritise price-bargaining over the quick delivery of vaccine has greatly reduced the rate of administration in EU countries compared with the UK. The result has been deadly. At the time of writing, the UK has 30 deaths/day from coronavirus, compared with 300 deaths/day in France, 380 deaths/day in Italy and about 250 deaths/day in Germany. It appears that there is some point in utilitarianism when applied to public health. After all, what human rights do you have when you are dead?

PS. There is a fascinating example of British policy ruthlessness in the slaughter of 750,000 pets at the start of the Second World War, as a way of reducing the demand for imported food. See British Pet Massacre on Wikipedia.

Coronavirus: the winners

The main winner of the coronavirus pandemic is of course the virus itself, which has multiplied throughout the world at speed, helped by rapid and plentiful international transport. Countries which have avoided large numbers of deaths are those which, like the cities and ports of old, erected effective quarantine barriers to prevent infected people from arriving. This option was available to Britain and Ireland, but was not taken. Instead of keeping out sick people, these (and most other countries) have instructed non-infected people to quarantine themselves in their own homes.

The two main human winners in the pandemic are firms which deliver food and goods to people’s homes and the pharmaceutical industry. The latter, allied with universities and research laboratories, have produced anti-viral vaccines with extraordinary despatch, and have reminded us of how vaccinations have prolonged lives over the last century.

In a medical emergency, governments turn to medical science, and thereby sideline the false prophets of the management consultancy industry. But there have been opportunities for outsourcing firms. In the UK, Deloitte’s and Serco received a Government contract of over ten billion pounds to run a service to test people for the virus and then trace their contacts. After months of confusion and delay, this now tests very large numbers of people, although only 40% of tests are confirmed within 24 hours, while the tracing element has probably had limited impact on the course of the pandemic.

Much more successful has been the vaccination programme in the UK, which has been run by the NHS. This is now vaccinating almost half a million people each weekday, and has built up rapidly from a start in December. From the point of view of the outsourcing companies, vaccination has been a lost opportunity. They could have been paid a further ten billion pounds to run a less effective operation (no doubt supported by a failed computer system provided by Fujitsu), followed by further management consultancy contracts to solve the mess when failure became embarrassing to Government.

There have also been wins in our knowledge of public affairs. Apart from the gains made by medical science, we have learnt that many universities in Britain are venal institutions, run for profit and caring little for their students (except as a source of income). In September 2020, universities encouraged their students to register and fill up the halls of residence, and then locked them in when infection rates rose. Some universities even ordered their academic staff to be on campus to provide the ‘vibrant atmosphere’ promised in every university prospectus. They could have instead encouraged students to work online from home where possible, leaving attendance on campus for the smaller (and hence safer) number who need to study in laboratories or on placement.

Finally, there have been winners in language. Apart from the word ‘pandemic’ and associated public health terminology, we have become familiar with the imported word ‘furlough’. This was used by the British Government for its scheme to pay people laid off work because of the lockdowns from March 2020 onwards. ‘Lockdown’ is itself a new arrival from the same time, as well as the phrase ‘social distancing’. The recommended gap for social distancing in the UK is two metres and not six feet, signifying the triumph of the metric system. The winning dreary cliché of the pandemic is ‘the light at the end of the tunnel’. This is used in almost every press briefing to offer the hope that mass vaccination will eventually end our current nightmare. The real hope should be that when this pandemic is finally past, we learn how to better manage the ones that will succeed it.

Old and vaccinated

 On the 5th of January 2021, my wife and I were vaccinated against COVID-19. We were surprised to be invited because both of us are in Priority Group 4 (people between 70 and 75 years of age), and we therefore assumed that we would have to wait until all the people in England who are in Priority Groups 1 to 3 had received their vaccine. But that was not how it was organised. Instead, supplies of Pfizer vaccine seem to have been distributed to a limited number of locations, which vaccinated as many people as possible in the first four priority groups who were registered with the surrounding medical practices. The vaccine centre for our corner of Worcestershire is in the GP surgery at the nearby village of Ombersley. The process of vaccination was efficient. We waited for about two or three minutes, and then entered one of the treatment rooms in the clinic. We were met by a friendly team of two people who asked us to confirm our identity and whether we had any allergies. We were then given the injection, which was painless. We were told to wait for 15 minutes in the Practice waiting-room. The whole process took 20 minutes, with a new patient vaccinated every five minutes. There were several teams operating in parallel, so that several hundred people were vaccinated in Ombersley each day.

We have not yet had our second vaccination, and are by no means free of any risk of infection, but the odds of us getting COVID-19 are now much reduced. This seems such a obvious gain for minimum fuss that it is bewildering to learn that a substantial minority of people are hostile to vaccination. The most recent survey in the UK found that 76% would take the vaccine if advised by their GP or other health professional, while 8% were ‘very unlikely’ to do so. The rest were ‘unsure’. Those most unsure are those most at risk of contracting the illness, namely people from black and minority ethnic groups. But the ‘very unlikely’ group includes some who are hostile and alienated, believe that COVID-19 is a hoax (even to their last breath) or who do not see why they should suffer the inconvenience of wearing a mask merely to protect other people.  

Surveys in the UK have found that older people are more willing than the young to accept vaccination. This may be because the old are less exposed to the Internet, which has become the greatest engine in our society for spreading conspiratorial beliefs. But I think a more important factor is that older people were raised in a time when infectious diseases were a part of everyday life. In my primary school years, I contracted measles, German measles (rubella), mumps and whooping cough. I remember as a child one day looking down at my chest and seeing with dismay the spread of the rash indicating rubella. There was no MMR vaccination then, and so pregnant women were at risk of contracting this illness and giving birth to children who were blind, deaf and with severe learning disability. For the rest of us, however, infectious diseases were commonplace and an expected part of childhood. It was widely believed that it was better to contract these illnesses as a child than in later life.

Quite different were tuberculosis and polio, both of which were widely feared during my childhood. There were still over 50,000 cases of TB notified in England and Wales each year in the 1940s. One of my uncles contracted the disease when serving in the Army in the Second World War. People with TB were often treated in isolation hospitals, many of which were located in the countryside. These were distinctive buildings, designed to enable patients to be separated into single rooms, linked by an open verandah. One of these buildings survives at Sunningdale, near where I live in Worcestershire, although the hospital has been converted into a small housing estate. The incidence of TB began to decline in the 1950s, with the widespread introduction of the BCG vaccine, but also because of better living conditions for the great bulk of the population.  

Polio, unlike TB, was not a disease associated with poverty and seemed to strike adults and especially children at random. A child in my primary school (it was rumoured) had died from the illness. We were all aware of the many children crippled with withered limbs as a result of Polio. What made things worse was that the number of new cases of polio increased in England throughout the 1950s, arriving mainly in summer. This was reversed by the introduction of the Salk vaccine after 1955, named after Jonas Salk, who refused to patent his invention or profit from it, so that it could be distributed to as many people as possible.

COVID-19 resembles TB more than polio, in the sense that its cure will be a result of both scientific development and living circumstances. Also, like TB, COVID-19 will not disappear. It may cease to infect large numbers of people, but it will still be there and may require periodic re-vaccination. TB is still with us, and 4655 people were infected by the disease in England in 2018, with the highest rates among the poor and the homeless. Over 300 people a year die of TB. So we still need the vaccines against polio and TB, as well as the MMR and now the new COVID-19 vaccines to protect us.

The ubiquity of misinformation

Two years ago our parish council was seeking funds to help build a skate park on the village playing field. We learnt that a firm was offering £35,000 to purchase a small corner of the  field to build a transmission mast for mobile telephones. This seemed a good offer, particularly since mobile phone reception was poor for some of the main networks. The Parish Council agreed this was a suitable offer and would help fund our new skate park. The start of each meeting of the Parish Council is always preceded by ‘democratic time’ - half an hour in which any parishioner can raise an issue for the attention of the Council. At the next meeting, one resident stated her opposition to a phone mast because she said she was ‘electrosensitive’ and that the signals from the mast only a mile from her house would produce headaches or even brain damage. Her objections were silenced when a councillor pointed out that the village already had two mobile phone masts in operation (of which she was unaware), and that these seem to have had no adverse effect on her.

The mast has now been built, and is about the same height as the local telephone poles. Mobile phone reception has improved and there have been no fresh reports of ‘electrosensitivity’ in the village. This is a consequence of the fact that this phenomenon probably does not exist. There is of course evidence that people blame microwave radiation for a wide range of symptoms, including even suicide. But several well-conducted scientific experiments have found that, like our local resident, people who complain of ‘electrosensitivity’ are unable to detect when a signal is or is not being transmitted. One study from 2005 is typical and is summarised by the NHS website here: https://www.nhs.uk/news/neurology/mobile-phone-mast-sensitivity-is-it-all-in-the-mind/. This used an experimental group of 44 volunteers who claimed to be ‘electrosensitive’ and a control group of 114 people. The experimental group reported symptoms when they were placed near to a mobile phone mast and told that it was ‘switched on’. When the tests were repeated with the sample not knowing whether the masts were switched on or off, there was no relationship between their symptoms and whether or not mobile phone signals were actually transmitted.

Of course, microwave radiation from mobile phone masts could have long-term effects on people even though their reports of short-term symptoms like headaches are unreliable. Fortunately, there have been several thorough research studies which have attempted to measure the health outcomes of exposure to mobile phone masts. Even better than individual studies are ‘systematic reviews’, which collect every relevant research study, rate their quality according to strict criteria, and come to an overall conclusion based only on the high-quality studies. The World Health Organisation has reported the results of a systematic review of this kind on the health effects of phone masts (https://www.who.int/bulletin/volumes/88/12/09-071852/en/). This looked at 134 studies, of which 117 were rejected as not being relevant or not meeting quality standards. A review of the remaining studies found no evidence of any health effects from mobile phone masts. It also confirmed that people claiming to suffer from ‘electrosensivity’ were unable to identify whether or not they were actually exposed to any such signals.

This is good enough for me, speaking as a retired medical researcher. But it raises the question why many people continue to believe that mobile phone masts damage their health. This is really two questions: why do people attribute the very real problems they may experience in their life (such as headaches or depression) to mobile phone masts, and what social circumstances sustain this belief?

It is common for people to seek explanations for adversity, including problems with their health. In the past, they often identified unseen magical forces such as witchcraft and the desire of local gods (or devils) to inflict punishment. Jews or other stigmatised minorities served as locally-identifiable devils. So in 1670, the Empress Margarita Teresa in Vienna blamed her miscarriages on the magical workings of the local Jews, who were promptly expelled from the City. Technology has provided a sequence of unseen forces, from electricity to television sets, and now mobile phones. Each at various times has been blamed for causing cancer or more minor ailments. Few people now worry about electric sockets or television sets interfering with their brains, but mobile phone masts are comparatively new and still being built, at least in country villages. So they have become the latest focus for anxiety.

It is a paradox that beliefs of this kind are sustained in the modern world by means of the very technology that they blame. The Internet, transmitted through wireless routers and mobile phone masts, has become the world’s largest human repository of fantasies and lies. Search for articles on ‘electrosensitivity’, and you will find websites devoted to the concept, often including impressive-looking studies proving their claims. How can a person without expertise in a specialist field distinguish one of these websites from scientifically-valid studies? The answer is that we struggle. What we can do is defer to an expert but be careful in our choices of expert. In particular, we should pay most attention to those who have relevant qualifications and training and who do not have a financial interest in one particular course of action. It is almost certain that a neurologist who has undergone a decade’s training in the science of the brain and its disorders knows more about the causes of headaches than some unknown person running a website on ‘electrosensitivity’. Likewise, more trust should be placed on the opinions of the world’s top climate scientists than an unqualified politician who has been funded by the oil and coal industry (even if he is President of the USA).

The perils of being nice

When I was at school, we were warned against using the word ‘nice’ - a word, we were told, which was milk-and-water, signifying the bland and the inoffensive. Being told to ‘Have a nice day’ was therefore hardly a blessing, which may explain why most English people wish you have a ‘good day’ instead. Nevertheless, niceness is a real and important phenomenon which shapes day-to-day behaviour, particularly in large organisations. The most important part of niceness is an extreme reluctance to say anything which might possibly cause offence to another person, and a corresponding fear of being the subject of complaint by another. Niceness consequently means remaining silent when people do something wrong, refusing to challenge another person’s opinions however wrongheaded they may be, and avoiding any action that might possibly be attributed to you personally.

Niceness is often confused with good manners, but they are different. The core of good manners is consideration and respect for others. This means that you take the opinions of others seriously, disagree where appropriate, but do so in a way that does not humiliate or intimidate. The difference between niceness and manners can be shown in this example. Some time in the 1990s, I was asked to give a presentation at an NHS conference in Birmingham on ageing in society. I was due to speak in the morning session after several other speakers. There were the usual rules in such matters - 15 minutes for each presentation, followed by five minutes for questions. All the speakers kept to these rules until the one before me - a woman who had recently completed a PhD. Her presentation was a description of her research, set out at length, with one tedious detail after another - all spoken in a dull flat voice. Before the talk, she had placed a sheaf of paper copies of her overheads on each seat, and the audience realised after half an hour that she was still less than half way through her intended talk. Despite this, the chairman failed to act until a member of the audience (the local political activist Dave Spilsbury), asked “Mr Chairman - when is this talk going to end? Some of us would like to hear the next speaker”. The chairman, with obvious reluctance, asked the speaker to draw her talk to a close. She droned on with no sign of concluding for another five minutes, until he finally told her to finish. There were of course no questions. It was then my turn. I spoke for ten minutes in as punchy a manner as I could manage. After that, the audience inevitably applauded with great enthusiasm.

As I let the room for lunch, I heard one woman say to another: “That man was so rude”. She meant Dave Spilsbury, not the nice and ineffective chairman, who had failed to exercise the very simple task of keeping a speaker to the allotted time and had therefore shown a lack of respect to the audience and to the next speaker. His behaviour was therefore an example of bad manners combined with niceness.

I had even worse experiences at two other NHS conferences, when the chairmen allowed the speaker before my presentation to drone on for twice their allotted time and then asked me whether I could possibly shorten my talk “because we seem to be running over”. The three ineffective chairmen at these conferences were all senior managers in the NHS, and their niceness may have been a factor in their career success. Niceness was indeed the dominant culture in NHS management and the other public sector organisations in which I have worked, and those who conform to the dominant culture tend to be the most successful.

When I worked in the NHS, one general manager (who later rose to great heights) would look concerned whenever disagreement broke out in a board meeting, and then immediately suggest that the issue should be considered by a subcommittee. This ensured that a nice atmosphere could be preserved at the meeting and that all disagreement (or difficult decisions) could be avoided. One consequence of this tendency is a preference for reacting to events rather than anticipating them. In this way, conflict can be avoided and decisions presented as fait accompli. When I was a member of the same management board, the monthly accounts at the start of the financial year showed a substantial operating deficit. I pointed this out and suggested we start planning how to re-organise services to reduce costs. But this view was dismissed, the deficit accumulated until at the very end of the financial year the general manager announced to staff that the board had reluctantly been ‘forced’ to close a ward.

A second consequence of niceness in organisations is a futile obsession with secrecy. Since criticism is to be avoided at almost all costs, all decisions are inspected for any possible embarrassment they may cause, and a major effort is put into keeping them secret. Keeping things secret is thereby given greater priority than challenging incompetence and dealing with abuse. Staff who abuse patients or clients are therefore quietly re-located instead of being dismissed. The culture of niceness among staff means a lack of respect for those in their care.

See also:The rudeness of strangers

Persecuting the irritating victim

My career as a social worker began in Birmingham Social Services Department, just after the department had been formed in the early 1970s. I was then an ‘unqualified social worker’, and eventually left after only a year to train for my qualification. But that one year gave me a bookshelf of memories of how some of the more bizarre members of society behave, of the distress and suffering caused by misfortune, disability and mental illness, and of how organisations of well-meaning people can add to this suffering.

The most skilled social workers in the Area 8 team of Birmingham Social Services Department had been inherited from the former Children’s Department of the local authority. They were involved in two sorts of work: fostering and adoption; and child protection. The social workers took great care in assessing the suitability of prospective foster parents and adoptive parents, and placing children with the most appropriate family. Adoption in those days usually meant placing newborn babies with married couples who wanted children but were unable to have them. Where did the babies come from? As far as I could work out, a constant supply of babies for adoption were produced by unmarried teenage girls. Even in the early 1970s, there was a general assumption that teenage girls would be unable to support illegitimate children. They were therefore encouraged to spend time in a ‘mother and baby home’, from which they emerged having given birth but without their baby. Television programmes like ‘Long Lost Families’ show the long-term distress suffered by many of these women, now in their sixties.

Older children in the care of the local authority were usually placed with foster parents, in children’s homes, or, if they had committed offences, in residential ‘approved schools’. Many Roman Catholic children went to the nearby Father Hudson’s children’s home in Coleshill, a large orphanage-type building, where they were sexually and physically abused by a team of priests and nuns. The social workers in my team regarded the home as strict, but would have been outraged to learn of the abuse inflicted on the children in its care. The department at that time was in the process of moving residential care for children into smaller homes and making greater use of fostercare. Father Hudson’s home eventually closed in 1988 and the building was destroyed by an arsonist in June 2013.

Services for disabled people in the Area 8 team were mainly provided by occupational therapists and unqualified social workers. They faced the usual problem of front-line staff in public services - insufficient funds to provide the services to which people are supposed to be entitled. The most important of these services were the aids and adaptations for people with physical disabilities. These were rationed by waiting-list, modified for some clients who were regarded as having priority need. In a few cases,  modification could work in the opposite direction. One client I remember was of working age but had suffered an industrial injury which had damaged his back. He was intelligent and assertive, and put forward a series of requests for adaptations that were more comprehensive and expensive than the department was used to paying for. This caused great resentment, particularly for my senior social worker, who began to block his requests and even argued that he was demonstrating an obsessional behaviour that endangered the welfare of his child.

The social work team, for all its faults, did try hard to match their response to their perception of their client’s needs. They were ‘person-centred’ in the grotesque phrase now used in public services. But this was not true of all public agencies. One of the worst was the artificial limb and appliance centre (ALAC), which was at that time part of central government. I was allocated a case of an elderly couple in which the husband needed to use a wheelchair, in which his wife pushed him to the shops. She was finding this increasingly difficult, and so I applied to the ALAC to supply one of their new powered wheelchairs designed to make pushing easier. However, this turned out to be faulty and could only move at running pace. The ALAC were unwilling to modify the wheelchair, or even admit that it was faulty. At the time I left the social services department, they had approached my senior social worker to determine how to get the wife categorised as mentally-incapable of operating the wheelchair.

These two clients were examples of ‘irritating victims’, or people who, wilfully or unwittingly, fail to conform to the expected behaviour of the clients of a government or local government department and thereby become subject to retaliation. I do not know how their story ended, but some irritating victims of government departments can endure years of persecution. One example is Omar Mahmoud Othman, a Palestinian who was granted asylum with his family by the Home Office in 1994 on the grounds of religious persecution. The Home Office may have regarded him as a potential line of communication to extreme jidhadist groups, but this changed after the events of 11 September 2001. Governments in the USA, the UK and elsewhere then fell into a great fear, stripping away the legal protections of citizens and identifying all Muslims as potential terrorists. On the basis of hearsay, the British government decided Omar was a ‘terrorist mastermind’. There was no evidence against him that would survive a criminal prosecution, and so in 2002 the Home Office imprisoned him without trial and began proceedings to have him deported. However, Omar gained the support of various human rights lawyers who exploited the incompetence of the Home Office, and the original deportation was dragged through endless courts before it finally succeeded in 2013.

Throughout this period, no evidence was ever presented in court about Omar’s alleged involvement in terrorism. This is probably because his real offence was to have deeply irritated the Home Office and thereby became the subject of prolonged persecution. Another factor, however, was that Omar looked the part of a terrorist, as envisaged by the media pantomime. He had lost a hand and instead had a rather menacing hook. His wife wore the conventional head to toe black clothes of the ultra-orthodox Muslim woman. Omar is of course usually known now as ‘Abu Qatada’. He has been demonised. Time will tell who the real demons are.

See also The curse of the generic

The impact of research into intellectual disability

Universities in Britain are currently preoccupied with preparing for the next round of assessment for the allocation of government research funding (called the ‘REF’). A particular feature of this round is that universities are required to submit information about the ‘impact’ of their research, which will then be scored and included in the formula for allocating funds. As I noted in a previous posting, the idea that the whole of research can be scored on a simple scale is a prime example of a crackpot idea. However, institutions and governments cling to crackpot ideas, and respond to their inadequacies by making them more complex and hence even more crackpot. So it is with the REF.

Nevertheless, it is still important to consider which research has had the greatest impact, particularly where this concerns the lives of people who are disadvantaged, ill or disabled. If you look at the impact of research in my own field of public policy for people with intellectual disability, you find startling results. The two pieces of research with the greatest impact in the last five years have without doubt been the secret filming by the BBC in 2011 of staff abusing the residents of Winterbourne View, and the 2007 Mencap report Death by Indifference on the death by neglect of six people with an intellectual disability in general hospitals. Both studies received wide publicity and led to government reports, debates in Parliament, and legislation. Yet neither study was carried out by academics, and neither were published in academic journals. No academic study in this field over the last five years has had a remotely comparable impact. Why is this?

One reason is the way in that most policy research in intellectual disability is funded by central government. The Department of Health decided by the time it published the white paper Valuing People in 2001 that the healthcare of people with an intellectual disability was no longer a major policy concern. Little effort was therefore expended on commissioning research into general hospital care for this group of people, and there is still hardly any published academic research on this subject. Department of Health policy also favoured the decanting of people with an intellectual disability into small homes managed by the private sector and a reduction in specialist health services for those with mental health and/or behavioural disorders. However, small homes are usually unable to manage people with severe behavioural problems, and appropriate specialist care is costly. The private sector moved in to fill the gap by providing what were essentially long-term mental hospitals stripped of the level of trained staff that would have been provided if the NHS had managed the institution. The Department of Health did not see this as a problem before the Winterbourne View scandal, and so research was not commissioned.

But even if there had been a desire by the Department to commission this kind of research, it could not have been carried out by academics. Academic research involving human participants needs the approval of an ethical committee and (in the case of healthcare) of the NHS research governance system. Neither of these would have approved of secretly filming staff abusing residents or collecting data from families about how hospital staff caused death by neglect. Health and social services have a streak of self-interest which can be used to obstruct research into the poor quality of the care they can provide. But ethical committees block research for different reasons. Ethical committees apply rules developed in medical research, in which trials of new medications or surgical procedures carry a risk of harm to subjects. Medical trials are required to ensure that subjects give their informed consent to participation, and there are comprehensive guidelines for what counts as ‘informed’ and ‘consent’. This of course has the advantage of transferring liability to the subject. People who have problems giving informed consent therefore present particular difficulties for ethical committees, and it is difficult to gain approval for any research involving children, people with dementia, or people with intellectual disabilities. This is even the case when the research is (like most social research) descriptive and therefore involves no risk of harm from medication or surgery. In fact, the emphasis among ethical committees on the issue of consent makes it almost impossible for an academic to get approval to carry out any descriptive research involving people with an intellectual disability.

This leads to a bizarre paradox: research is deemed ‘unethical’ even where it aims to expose the grossly unethical treatment of vulnerable people (and hence protect them from further abuse). We therefore know remarkably little about the real world of residential care as experienced by this group of people or the real extent of the neglect and abuse they may suffer. This leads to a further paradox. Academics carry out little research in this important field of public policy: we rely for what we know on journalists and investigators in charities.

See also:
http://stuartcumella.blogspot.co.uk/2010/08/research-without-fear.html
http://stuartcumella.blogspot.co.uk/2009/10/great-crackpot-ideas-of-past.html

First days at work

We all remember our first day at work - the uncertainty, curiosity and fear. But some first days are a lot worse than others. In 1986 my contract with the Medical Research Council was due to come to an end, and I accepted an invitation to apply for a new post of Director of Planning and Information at what was then the Mental Health Unit of Central Birmingham Health Authority. Since I was the only candidate for the post, the job was mine. The Unit had been under the temporary management of a psychiatrist (Dr Patsy Goodyear) until the first of the new NHS general managers could take post. My appointment was intended to promote the very innovative ideas for mental health services developed by Dr Goodyear, and her colleague Dr Michael Radford. We were later joined by a superb psychogeriatrician Dr Hilary Nissenbaum.

On my first day, I arrived at the John Connolly Hospital. This was a rather battered building, dating from the 1960s,, which had originally developed a reputation as a rather non-conformist therapeutic community. By 1986, it had become a more standard inpatient unit, admitting patients from designated city wards in Birmingham, divided into ‘adult’ and ‘elderly’. Nevertheless, the Hospital was in a pleasant open space, patients could come and go easily, and patients and nurses would kick a ball around in front of the hospital at lunchtimes.

After arriving at reception, I was met by an efficient personnel officer and shown to my ‘office’. This was actually a partly-enclosed space in a corridor next to the toilets. There was a very old desk and chair, and a broken telephone. I gathered that my arrival was not welcomed by all the senior staff in the Unit. There was no induction training, or any indication of what I should do, so I wandered round making appointments to see whoever I could. Later that day, a cheery bricklayer arrived and began to wall me in to create a room. In the next few days, better office equipment arrived, I met the Unit General Manager, and began to be useful.

Over the four years I was in the post, the Unit planned and opened a phenomenal range of innovative services: inter-disciplinary mental health resource centres, the first team in the UK to treat people with acute and severe mental disorders in their own home, an intermediate treatment unit in an old people’s home, and community psychiatric nursing teams that recruited from all languages in the City, while we also planned (with Professor Ian Brockington) a new specialist academic psychiatric inpatient unit at the Queen Elizabeth site. We were therefore in process of developing something quite different from the model of psychiatric services which had been government policy from the mid 1970s. I also helped develop a low-cost computer system which generated rather better data than the expensive Patient Administration System (PAS) promoted by the computer companies and their satraps in different parts of NHS management.

Unfortunately, the satraps won. Central Birmingham Health Authority was merged with its equivalent in South Birmingham, and the combined mental health unit fell under the control of managers and senior nurses who had learnt their trade in big old-fashioned psychiatric hospitals. They were suspicious of academic clinical units, and naturally committed themselves to PAS. The new inpatient psychiatric unit opened in 1991, but became over-crowded. It was demolished 15 years later to make room for a new general hospital, and its replacement is a typically-plush product of a PFI deal. But as you pass it on the railway line, you can see the tiny exercise spaces and the high fences round the inpatient wards. This is to some degree the consequence of the very reforms we promoted. As more and more patients with acute mental illness were treated at home, only the most dangerous and disturbed were still admitted to inpatient care. Psychiatric hospitals became progressively more restrictive.   

Our dynamic staff team was also demolished. People retired or moved to new posts. The general management team fell into disarray, and the general manager developed an interest in setting up his own private nursing home. One day, without warning, his office had been cleared and he was never seen at the hospital again. I left in 1990, and, to my great surprise, became an academic. However, I still look back on my four years in the NHS as the time in my working life when I was most useful.

Meet the new boss - same as the old boss

Politics is theatre, and those who strut and declaim on the stage do not usually write their own script. The more sober of politicians’ autobiographies acknowledge this. Looking back on their career, their authors describe their achievements in limited terms - getting a new law passed against the odds, changing public perceptions of a problem, or perhaps averting a crisis. Read the political memoirs of the former Labour MP Chris Mullin, and you find ambition for office tempered by a realisation that a minister has little or no influence on policy, and spends his time reading out (usually badly-written) speeches prepared for him by civil servants. The actual job of politicians is in reality a salesmen - to sell policy to Parliament and the public. What better person to do this than a natural actor (Tony Blair) or a public relations professional (David Cameron).

There are of course politicians who can claim, with some justification, to have changed the direction of the country. Margaret Thatcher blundered into the Falklands War, and pushed for the Poll Tax, while Tony Blair became unpopular in Britain but popular in Washington by promoting war as an alternative to diplomacy. However, many of the policies associated with a senior politician predate their time in office and bind their successors. All British governments for the past 20 years have promoted the interests of  the financial sector over those of manufacturing industry, have sought to undermine employment rights (calling this ‘flexibility of labour’), and have facilitated the plundering of the public purse by management consultants, IT firms and the PFI/privatisation complex.

Chris Mullin’s memoirs are also a guide here. They show that each government ministry (or part of a ministry) is at the hub of a set of stakeholders. These usually comprise key business and financial interests rather than the wider public. The ties between ministries and stakeholders are held together by exchanges of senior staff and the availability of well-remunerated positions for senior civil servants and politicians when they leave office. This works to create great continuity in public policy, which may only occasionally bend to public protest. Note that this is not a conspiracy theory - the policies of different ministries or parts of ministries may conflict, resulting in a policy stalemate. The Iraq War enquiry reveals major divisions between and within military, intelligence and diplomatic services. The one group not included in these debates was the British public, despite a million-strong march on the eve of war.

An example of this continuity is the reform of the NHS proposed by our coalition government. This is presented as a radical innovation, but bears all the marks of every other management reform (or ‘redisorganisation’) of the NHS since the 1980s. As usual, it is hyped as devolving power while actually centralising control. The recipients of the supposed devolved power in this case (as in 1997) are consortiums of general practitioners, but the central NHS commissioning board will have extensive and expanded powers to make sure the GP’s do what they are told. The consortiums will certainly not have much power over what they commission. Like all the NHS reforms since the early 1990s, this one confirms the steady drift to the marketisation of healthcare services. Consortiums will be required to choose the lowest price tendered, and providers will be able to compete on price. Needless, to say, even this limited power can not be contemplated without diverting funds to the giant management consultancy combines, who will move in to manage the commissioning consortiums, supposedly on behalf of the GPs. The previous two heads of commissioning in the NHS have gone to work for more than a pittance with KPMG. I would not of course suggest that the current one had this in mind when the NHS awarded a large contract to KPMG for commissioning in London.

Finally, this re-organisation, like all its predecessors in the last 20 years, has been rushed, with many details not worked out, no feasibility trials, and no effective project management. Why is this? I think there is a Darwinian explanation. After so many re-organisations, the NHS has become a bizarre ecological niche, to which NHS managers have evolved in response. Only those most able to respond rapidly and with enthusiasm to the latest shift of policy (in whatever direction it takes), espy the best time to jump ship, and rapidly create a new mini-empire for themselves can hope to survive. They naturally shape their environment to suit these survival skills, which means ever more redisorganisations. Each one of course is applauded by the well-rewarded management consultants, the usual squad of compliant social policy academics, and the politicians who read out the speeches written for them.

Read also: http://stuartcumella.blogspot.com/2009/12/pic-complex.html

The curse of the generic

I became an (unqualified) social worker in the early 1970s, just after the creation of social services departments in England. These merged three former organisations, each of which comprised professionals skilled and experienced in work with distinct groups of people: children’s departments employed children’s officers who dealt with child protection and adoption and fostering; welfare departments employed welfare officers who maintained long-term contact with disabled people; and mental health sections of local health departments had their mental welfare officers who supported people with a mental illness living outside hospital.

The decision to merge these departments followed the ‘Seebohm Report’, which correctly noted that some families were involved with two or three of these agencies, and incorrectly proposed that it would be more efficient to have a single generic ‘family’ service. The resulting merged social services departments were large and had management hierarchies rather than being led by a senior professional. The commitment to ‘generic’ social work, in which each member of staff dealt with the full range of clients, became departmental orthodoxy. Both these trends led to a rapid exit of the most skilled and senior staff. They were replaced during my first year as a social worker by people like me: well-meaning, untrained and incompetent.

The results across the country were a radical decline in the quality of child protection, and support for disabled and mentally-ill people. The first indicator of this was the avoidable death of the child Maria Caldwell. The subsequent official enquiry identified that a major cause of institutional failure was the confusion among social workers about whether their primary responsibility was to the child or to the ‘family’ (ie her parents). This was the first of many such enquiries, which led to a succession of management ‘solutions’, from inter-agency committees, registers of children at risk, centrally-imposed targets, inspections, child databases, and repeated re-organisations. No-one in power paid much attention to enhancing the professional skills of social workers involved with children, enabling them to develop specialist skills, or setting up the kind of small specialised and professionally-run departments that had been a success in the past. When specialism did arrive, it was implemented as part of a bizarre governmental reform which merged local authority child protection services with local education departments.

Why this resistance to specialism? I think it is a product of the managerial control that arises with the creation of large public organisations. In small organisations, staff are known as individuals, and there is an awareness of their different strengths. Staff can be assigned to different work informally, and their supervisors can generally assess their performance by observation and informal meetings. Large organisations see staff as a block of people to be matched with some quantitative indicator of workload. It is easier to move people around if they are supposed to have generic responsibilities rather than diverse specialist skills.

The drive to generic work and consequent de-professionalisation arises in many large public organisations. This can occur even in organisations in which specialist professional skills are regarded by almost everyone as being essential. The National Health Service has attempted to grade all its diverse professions on a single ‘knowledge and skills framework’ - a spectacular example of the kind of ‘blue skies’ (crackpot) thinking that occurs in very large organisations. At the same time, the government has attempted to reduce the time spent in specialist medical training. There are similar trends in universities. These value their most highly skilled staff, at least as long as they attract large research grants, but post-doctoral researchers and academic staff who specialise in teaching are sometimes treated as classes of helots, interchangeable and disposable.

The curse of the generic partly explains an apparent paradox: as public organisations get larger and employ more managers, the less competent they are in delivering effective public services. There are other explanations for this paradox: the conversion of previously-autonomous professionals into highly-regulated functionaries produces the alienation familiar in industrial process work. Also, long management hierarchies move decision-making further from the organisations’ customers, who usually encounter junior members of staff with limited authority to adapt procedures to meet individual needs.

We therefore need revolutionary change - towards small-scale public services, with a re-assertion of professional specialism and autonomy. We need to down-size schools with thousands of pupils, so-called ‘local’ authorities which cover wide areas of the country and multiple and formerly self-governing towns, and large welfare departments which fail to protect children at risk or adequately support the disabled. Of course, some public agencies will always need to be large: big cities need governments, and the large numbers of students in higher education will probably require large universities. However, authority can be devolved within cities to community councils (as in Scotland and Wales), while universities can operate more on the Oxbridge model, with academic staff working in semi-autonomous colleges. After all, Oxford and Cambridge Universities have hardly been failures despite lacking the benefits of centralised management.

Where is the love?

As you get older, you spend more of your time in hospital - not just for your own ailments, but for those of your parents. This accelerates with increasing age. There are visits with your parents to a widening range of specialists followed by ever-longer hospital admissions, and then terminal care. You remember the grim meeting with medical staff leading to consent for ‘Do not resuscitate’, followed by the wait as the defences of a weakening body finally give way. These memories stay with me, but I also remember sitting by bedsides watching life in a hospital ward. What I usually observed was active neglect. Nurses would talk to each other in their ward station while incontinence bags overflowed. Every 10 or 15 minutes a nurse would walk round the ward looking briefly at each at patient but not talking to them. No-one in the hospital saw it as their responsibility to comfort the sick and the dying.

How could this happen? One possible reason is staff burnout. Many people find talking to ill people emotionally taxing. This can wear down the kindest of people, who escape pressure by reducing the emotional content of their interaction with patients or clients, and convert their work to a set of technical procedures. But this raises the question of why organisations do not take steps to avoid burnout or why they continue to tolerate it among their staff. I think the main reason this happens is because the emotional content of professional and personal support work is seen as problematic: the direction of training this group of staff has therefore instead emphasised the acquisition of technical skills. Ethics is still taught as a subject in professional training, but has been reduced to a set of guidelines to follow in obtaining consent for research or for the application of medical, nursing or other procedures.

This loss of the emotional content of health and social care is part of a wider trend towards the excision of passion and feeling from organisational life. It is assumed that no-one works because they have skill and personal commitment, and a passion to apply it to their work. One consequence is the belief-in-practice (written into numerous guidelines and codes of practice and quality assurance manuals) that no-one can be trusted and no-one can perform well unless regulated and inspected or, if they are senior managers, given generous financial bonuses to do their work. This belief becomes self-fulfilling: staff become de-motivated and truculent under the weight of inspection, while senior managers become oriented solely to their bonuses and neglect wider responsibilities.

Of course it is often argued that such mechanisms of control are necessary to manage large organisations and complex centralised states. But this fails to ask whether we need such large organisations or whether our society should be so centralised. It is possible that this trend to centralisation has come about not because it is better at producing goods and services, but because it has generated a new and dehumanised ethos of organisational rationalism. This incorporates the distrust of human emotion and commitment, and hence the negative view of human nature. It proposes instead that humans are properly motivated only by a combination of financial rewards and penalties. This looks rational in the sense that economists speak of rational behaviour, but at its core are the darker emotions of greed, fear, and love of power.

Compliments not complements

I live in a rural area amply provided with therapists. The listings page in our village magazine advertises two counsellors, an acupuncturist, and a firm selling ‘health and nutrition products’. Also listed within a few miles are providers of osteopathy, cranial osteopathy, shiatsu massage, reflexology, neurostructural integration technique, and magnetic therapy. Complementary and alternative therapists do not yet outnumber our electricians, plumbers and plasterers, but they are a large enough army to challenge our doctors, nurses and professions allied to medicine.

This is a small local example of a national pattern. Complementary and alternative therapies are now a very big business indeed, with ‘health food’ shops on every high street, television programmes promoting ‘nutrition therapy’, and with more complementary and alternative therapists than medical practitioners in the UK. Businesses need customers prepared to part with their money, and this particular business succeeds in getting them to do so on a large scale, even though access to medical care in this country is free. Complementary and alternative therapy can therefore be compared with bottled water, except that bottled water is exactly the same product as the stuff that comes out the taps. Complementary and alternative therapy, by contrast, is offering something different. What could that be?

‘Alternative medicine’ sounds like a pretty clear concept: it means attempting to attain better health without using the services of a trained medical practitioner and being enthusiastic about receiving treatments which have not been shown by research to be therapeutic and safe. There are no end of alternatives too, a bit like a therapy supermarket. And there are plenty of people who report that they feel better as a result.

Of course, many illnesses get better whether treated or neglected, while the very experience of meeting a therapist and being given any sort of treatment can itself make people feel better. This is the ‘placebo effect’, and it works for conventional medicine as well as for complementary and alternative therapies. This is why medical research has developed elaborate research techniques using randomised controlled trials to detect whether a specified treatment results in an improvement beyond the placebo effect. Unfortunately, medical research techniques are difficult for many people to understand, and fall before the power of the personal anecdote which guides so much human behaviour.

Alternative medicine is always going to use therapies which have not been rigorously tested because, once shown to be effective, they cease to be alternative. Soaking the bark of willow trees to produce an infusion did succeed in reducing pain, and the key ingredient was eventually refined and sold as aspirin. There is also reliable evidence that some forms of counselling reduce the symptoms of depression, distress, and various other mental disorders. They too have now become mainstream treatments in mental health and primary care services.

The concept of ‘complementary therapy’ is a bit less clear than alternative medicine. In what way does it complement conventional medical treatments? Taking alternative therapies in addition to the treatments prescribed by their doctor is probably quite common. But ‘complementary’ could also mean therapies for people who do not have an illness, or have an illness for which there is no known effective treatment. The second group can easily be exploited. Complementary and alternative therapists can offer short-term hope to the suffering, and even if what they prescribe does not in the end produce relief, then it can still generate a tidy profit in the meantime.

My proposal, however, addresses the large group of unhappy and distressed people who do not have an illness recognised by a medical practitioner, but who still wish for some kind of relief. Most people, when they are unhappy, seeks the company of friends and family for comfort and praise, but this avenue is not open to all and some alternative is required. This is the key task of complementary therapy in such cases - to produce good placebos. We should therefore assess complementary therapy not by whether it makes an improvement over placebo effect, but by the quality of the placebo it provides. This will vary from person to person. Most people respond enthusiastically to the invitation to talk about themselves at length, and, speaking personally, the experience of being rubbed in warm sweet-smelling oils by an attractive young woman would certainly brighten my day.

Are there any opportunities for developing new complementary therapies that will deliver an even better placebo? The therapy supermarket is already well-stocked, but I believe there is one gap in the market: complimentary therapy with an ‘i’. This essentially consists of praising the client fulsomely. To be a really good placebo, this should take account of the kind of compliments that work best for each particular client. People who are miserable because they believe they have not made a success of their lives are told that they are highly-talented and that their achievements will be recognised. People who are unhappy because they are rude, offensive and unpopular will be assured that they have a quiet sensitive side that is under-appreciated by others.

There are objections to complimentary therapy. Critics complain that it amounts to little more than sustained flattery. But flattery is therapeutic. Why else do so many rich and powerful people surround themselves by flatterers? A second objection is that there are some people with a more masochistic streak who respond not to compliments but to enemas and other forms of humiliation and pain. Fortunately, there is a counterpart of complimentary therapy designed to meet their special needs. This is ‘insulting therapy’. I do not have the right sort of personality to engage in this, although come to think of it, there are one or two people in powerful positions that I would really enjoy insulting - particularly if they paid me money to do so.

Stuart Cumella