Peter Drucker, the icon of business management, is widely credited with one of the most important phrases of the field: “If you can’t measure it, you can’t improve it.”
And prima facie that would seem the purpose of Matt Hancock wanting to ‘ramp up’ the number of tests to 100,000 per day minimum.
The NHS has long had a problem with metrics, and this has been encapsulated in Goodhart’s law. Charles Goodhart first advanced the idea in a 1975 article, which has been phrased by Marilyn Strathern as “When a measure becomes a target, it ceases to be a good measure.”
It has been argued for some time that this approach is actually very dangerous, as it is related to an approach that says that what can be measured matters and that what is not measurable does not exist. (1)
In 2017, Dr Peter Bennie, who was at the Scottish council of the British Medical Association, said: ”Multiple targets, an ageing population and the funding gap are creating a vicious circle, stretching the system and the workforce beyond their means. The current culture of using crude measures, often taken in isolation, to judge the complexities of the whole healthcare system, and to apportion blame, must end.” (2)
And target chasing can result in strange behaviours. It must be that Hancock was desperate to fulfil this metric, if a recent interview is anything to go by. Maybe he was trying to avoid blame – and the sack.
The presenter, Nick Ferrari, said: ‘Are you prepared to have a £100 wager, and I will never be happier to write a cheque for £100, when you deliver that 100,000 tests on May the first and the money goes to NHS charities. Are you up for the bet, Mr Hancock?’
Hancock replied saying: “I’ve got enough riding on this already, Nick.” (3)
The current Secretary for State for health and social care has now further been embroiled in accusations of artificially inflating the number of coronavirus tests, in framing the rapid increase in numbers that allowed him to get up to a self-imposed 100,000-a-day target as a “national achievement”. Following meticulous investigation from the HSJ, it later emerged that a third of the 122,347 tests included in the final 24-hour period before the deadline were counted before they had been carried out. They had merely been sent out in the post. (4)
Following a target ignoring other issues is a problem which is a great threat to patient safety in medicine. “Fixation errors” occur when the practitioner concentrates solely upon a single aspect of a case to the detriment of other more relevant aspects. These have especially become recognised in anaesthetic practice, where they can contribute significantly to morbidity and mortality (5).
Take for example one repercussion of focusing on that target of the number of tests. It distracts, for example, from a sensible discussion of where other clusters or outbreaks of infection might take place. There is now the realistic possibility that mental health units will be the next locus of an outbreak in the NHS akin to the crisis in care homes. We don’t know how many infectious doctors or patients there are on mental health wards, which we know have had a problem with supply of personal protective equipment too. Only recently, for example, of the longest-serving staff members, a ward clerk at the Highgate Mental Health Centre, died of coronavirus, as staff nationally have continue to speak out about their safety fears over lack of personal protective equipment (6).
We’ve been here before back in 2008, when the then Labour Government was inundated with complaints of a “culture of fear”, where patient safety came second to presenting a set of statistics suitable for dispatch-box delivery.
In oral evidence, Sir David Nicholson in 2013 said famously, “When I was first appointed to the job, when I came into this particular job, I coined a phrase, which at one level sounds trite but it is really quite an important phrase-“Hitting the target and missing the point.” This is the dangerous place that some organisations got into.” (7)
A later King’s Fund’s review into leadership and engagement for improvement into the NHS, recognised a “command and control style” of management had contributed to poor care, leading for a new ‘push’ for a style of leadership that engages staff and patients (8)
Other industries have had problems with ‘command and control’ cultures. There has clearly been much resistance dragging the NHS away from the nostalgia of the Lancelot Spratt consultant figure-head towards one where a more junior member of the team is actually listened to (9)
The NHS has been desperately trying to move away from ‘command and control’ culture in recent years, not least because international research has mandated that collective leadership is taken seriously, where staff at all levels act to improve care – within and across organisations (10)
If anything, the recent coronavirus crisis has emphasised, furthermore, potential deep seated problems in the culture of the NHS. Particularly worrying has been there has been talk of institutional racism arising from social inequalities.
It has now become imperative for the government to look at the full range of structural inequality impacting BME people in the NHS (11). This means that more attention has to be given into making sure that the NHS culture is truly diverse, rather than relying on a few BAME leaders to make a public show that senior BAME figures can find themselves in leadership positions.
Dr Chaand Nagpaul, Chair of BMA Council, recently stated, “We need to ensure that ethnic minority doctors, alongside all medical staff, can confidently speak up if they feel they have inadequate personal protection. They must not risk their lives due to feeling inhibited from doing so.” (12)
The coronavirus crisis has thankfully, at least, allowed us all to take a step back and think how we would do things differently. Thinking about whether much has changed in NHS culture would be a good start.
(1) Davies, P.G. Measuring performance and missing the point? BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39377.387373.AD (Published 22 November 2007)
(2) Cramb, A. Doctors call for end to target-driven ‘blame culture’ in NHS, 28 December 2017, https://www.telegraph.co.uk/news/2017/12/28/doctors-call-end-target-driven-blame-culture-nhs/.
(3) https://www.dailymail.co.uk/news/article-8265219/Matt-Hancock-makes-100-bet-Nick-Ferrari-UK-meet-100-000-coronavirus-tests-day.html Daily Mail, 28 April 2020.
(4) https://www.theguardian.com/world/2020/may/01/ministers-accused-of-changing-covid-19-test-tally-to-hit-100000-goal, Guardian, 1 May 2020.
(5) Fioratou E, Flin R, Glavin R. No simple fix for fixation errors: cognitive processes and their clinical applications. Anaesthesia. 2010 Jan;65(1):61-9. doi: 10.1111/j.1365-2044.2009.05994.x.
(6) http://camdennewjournal.com/article/two-minute-silence-at-health-trust-after-psychiatric-hospitals-ward-clerk-dies-from-coronavirus, Camden New Journal, 24 April 2020
Covid in care and nursing homes in the UK has become the latest disaster, for example, “the disease may be circulating in more than 50% of nursing homes and mortality is significantly higher than official figures.”
Persons with cognitive impairment, examples of which include delirium and dementia, at the best of times can present a challenge for what we frame as “person-centred care”.
At a practical level, certain individuals who have been living with a chronic, progressive dementia for some time may lose all sense of what time of day it is. At night-time, they may get up repeatedly to check that the front door is locked, and get very anxious about this obsession unless that compulsive check is made. And, because they forget quickly, this can go on many times at night.
Or else, a person may suddenly have a drastic change in behaviour and thinking, and get quite aggressive or agitated, hyperactive, or even quite grandiose and flamboyant in behaviour. Such a flip into ‘hyperactive delirium’ might appear out of nowhere, but could result in a person also wanting to roam around, apparently without an easily understandable purpose.
Both dementia and delirium are significant issues in the era of “Covid19″, infection with the novel coronavirus. Dementia is a “frailty syndrome”, conveying the notion that people with dementia have an increased vulnerability, such that they never quite bounce back to where they were after a challenge such as an infection. The abrupt change which we call delirium can have a number of causes, which we largely view as predisposing or precipitating factors, but it’s relevant to Covid that a respiratory infection can cause hypoxia, electrolyte imbalances and sepsis/encephalopathy which all can produce or exacerbate a delirium.
I should like to focus here on delirium. Helpfully, the HELP team (“Hospital Elder Life Program”) has “created a resource page for all things COVID-19 and delirium, including a Patient Toolkit with all the materials necessary to help older adults maintain cognitive and physical functioning – and prevent delirium“. Delirium can occur out-of-the-blue in any care setting, including the acute hospital, care or nursing home, or at home. It’s tempting to ‘suspend’ personhood in someone experiencing an episode of delirium, as he is ‘not himself’. But this is a slippery slope, to denying personhood, identity of that person, and, at worst, might lead to denial of human rights. Human rights and person-centred care are enshrined in the clinical regulation of professionals, practitioners and institutions, so it would be unfeasible for delirium (and dementia) care to deny human rights or personhood. We know that there has been a number of attempts, presented as ‘social movements’, of activists, said to be ‘living with dementia’, publicised as upholding their rights. This has, of course, got a formidable precedent in the disability movement; dementia under English law is classified as a disability under the Equality Act because of the chronic effects of it. But such rights-based approaches, mainly presented en masse from charities and social enterprises, have tended to focus on a formulation of rights in an almost consumerist way, in a manner where they can be easily marketed through public communication channels such as the social media.
I believe rights are indeed important and indeed crucial – but such an approach has been rather to trivialise the significance of rights. The intentions are formidable, for example in raising awareness of rights and to try to stop and rail against elder abuse, which can lead to loss of fundamental rights such as liberty, privacy or dignity.
But such a simplistic, yet fundamentally important, approach can ignore what rights actually are. Rights have been the subject of considerable scrutiny in jurisprudence theory, as they are of course fundamental to the law. The late Prof Ronald Dworkin was professor of jurisprudence at UCL, and, through his seminal work, we are encouraged to believe that there are two fundamental frameworks; that rights are normally limited, but in exceptional circumstances absolute, or, otherwise, rights are normally absolute, but in exceptional circumstances limited. This led Dworkin to frame his ‘rights as trumps’ viewpoint, and, as an eminent lawyer trained under HLA Hart at Oxford, his thesis is certainly seminal.
But we all live in a civil society, meaning that rights come with responsibilities, and my ‘right’ has an effect on yours. In other words, you could argue that a resident with dementia can’t be allowed to roam around limitlessly, ignoring physical distancing, because of the risk of infecting others with a highly infectious agent. So it might be tempting, particularly if there are staff cutbacks (for example due to staff being ‘off sick’), to use pharmacological rather than non-pharmacological intervention in such a resident experiencing delirium.
In a recent ‘good practice guide’ from the British Geriatrics Society, entitled “Coronavirus: Managing delirium in confirmed and suspected cases”, it is mooted that, “here these interventions are ineffective or more rapid control is required to reduce the risk of harm to the patient and others, it may be necessary to move to pharmacological management earlier than would normally be considered.” And, observing the legal doctrine of proportionality, fundamental to English law where interventions are deemed both necessary and proportionate, this is a very sensible response to prevent other individuals becoming infected, and possibly because of underlying frailty themselves, difficult to treat.
But this is an admission that human rights are not in fact absolute, universal and inalienable, arguably. We have been conditioned to think that we can’t ‘pick and choose’ our human rights, or certainly can’t choose how or why we would choose to apply them, like an à la carte menu – in the same way we can’t choose which individuals to extradite (because readers of certain newspapers believe strongly that human rights are abused in certain circumstances.)
It might also suggest that our application of human rights in delirium care is context-dependent, which seems disturbing at an intuitive level. But this in itself is not a problem. We know from the recent furore elsewhere that guidelines are not meant to be applied in a blanket way, but should, rather, be tailored at a personal, individual level. The recent (excellent) SIGN 157 guidelines, “Risk reduction and management of delirium, a national clinical guideline”, March 2019, says carefully in the quick summary, “There is insufficient evidence to support a recommendation for the use of antipsychotics, dexmedetomidine, acetylcholinesterase inhibitors or benzodiazepines in the treatment of patients with delirium. Expert opinion supports a role for medication in specific situations such as in patients in intractable distress, and where the safety of the patient and others is compromised.” It says rather, “Healthcare professionals should follow established pathways of good care to manage patients with delirium“, referring to a suite of non-pharmacological multi-component interventions.
The problem with guidelines is that, in actual clinical practise, what originally seemed like a good academic idea can be impractical. Infection control is a key aim of treating the delirium in suspected or proven Covid, and we know that the medical regulator prioritises the prioritisation of treatment. We already know the range of arguments against the use of antipsychotics in delirium, which have been extensively studied elsewhere (for example this Cochrane review), but patient safety is the ultimate issue. The case for pharmacological intervention in residential homes for delirium can be easily made, but what happens in home care or domiciliary care where family members can find themselves easily stressed by a relative roaming around but where pharmacological intervention is not possible? Many persons with advanced dementia are living at home, and this indeed has been a goal of national policy, encouraging ‘independent living’ as far as possible.
Furthermore, it can be difficult to distinguish a propensity to roam around, pejoratively called ‘wandering’, resulting from advanced dementia – traditionally and unhelpfully called BPSD – from delirium. So not all people wandering around, with hyperactive delirium, will have Covid. We already know that older people can present altogether atypically, so not all people who are symptomatic or asymptomatic with Covid may have mounted a temperature or an obvious dry cough. So here does the precautionary principle apply, “a strategy for approaching issues of potential harm when extensive scientific knowledge on the matter is lacking. It emphasizes caution, pausing and review before leaping into new innovations that may prove disastrous“? Does erring on the ‘side of caution’ tip the balance from non-pharmacological to pharmacological interventions?
Arguably, there is a need for vigilance over this matter.
Look at the WHO definition of “elder abuse”.
“Elder abuse is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person. This type of violence constitutes a violation of human rights and includes physical, sexual, psychological, and emotional abuse; financial and material abuse; abandonment; neglect; and serious loss of dignity and respect.”
Inappropriate use of antipsychotics in “BPDD” in dementia or delirium, especially in the context of vulnerable individuals in society behind ‘closed doors’ with no visitors such as friends or relatives, might be an unintended consequence of behaviour in a pandemic that was intended as proportionate.
But, if all else fails, the whole issue for me has brought into sharp focus the relationship between rights and delirium in the context of person-centred care, and this is to be welcome.
I have always voted Labour.
Whoever is the next leader of the Labour Party, he or she is in for a tough time. I voted for Jeremy Corbyn, and, as time went on, I felt I had made a mistake. Towards the end, I found him grumpy, irritable, and continuously presenting himself as the ‘victim’. I think there will have been a rump of the electorate, for example Wigan, who would have to hold their nose and vote for Labour, but the force was not with Labour. There’s a lot to be angry about, and indeed Corbyn talked of ‘hope’. But people were left with a feeling of impending doom and despair, and it would have been wiser to have some sunny uplands in place of fear.
This situation is a long time in the making. Labour has not turned in itself into an unelectable force overnight. It last won a general election in 2005. I remember when I was briefly a member of the Fabians in the very early 2010s, and Sunder Katwala was leading on various interesting initiatives such as ‘Southern Discomfort’ looking at why voters were leaving Labour in droves in the South. It is now, of course, the very squeezed middle, as Labour has rapidly lost its voting base in Scotland and Wales, ironically after it had championed devolution.
The irony is that it was not so long along that the Conservatives had been staring down the barrel of a gun. They had spent about three years fumbling around with decreasing majorities delivering Brexit. And the inability to deliver Brexit was symptomatic about how they were not delivering on other aspects, such as the NHS, social care or even the economy. It seemed increasingly to me as if Labour was obsessed with one of two extremes, the very poor or the very rich, and had nothing much to say about the bit in between. The offerings were a bit random and numerous, and it looked like smarties for all at too many times, such as a promise for free personal care, or free broadband, or your university fees to be written off. Despite the fact that national debt under the Conservatives has exploded in the last decade of the government of the Tories, Labour is still perceived as being incompetent with the macroeconomy. This is despite people’s personal narratives of lack of security in employment, often just about managing on a gig economy wage. The economic landscape is clearly changing, with many household names going out of business. It was simply insufficient for Jeremy Corbyn to push on an open door, or to preach to the choir always, about burning issues of social and economic injustice, important as they are. Corbyn rapidly is known for what he is against – but there is less clarity on what he wants to do to solve the issues. I see the logic in re-nationalising the utilities, because market failure has delivered increased shareholder profit for foreign investors at the expense of customer value for what is a homogenous good in a near monopoly state. But I do not for the life of me understand how Corbyn was going to integrate health and social care, while clearly he wanted to bring paperclips in the NHS back under state control.
My late father shortly before he died managed to warn me about many things for the future, not least how a bad dancer tends to blame the floor. I think some in Labour have got too obsessed with shooting the messenger rather than thinking about the message, to such an extent that the post mortem of the election has dangerously begun to look like, ‘It’s the electorate stupid’. I do think, however, it was very difficult to market the brand of Corbyn, when he had been vehemently rubbished by members of the Parliamentary Party, but the media cannot be blamed for reporting them accurately. Whatever Corbyn did, it was clearly not enough on anti-semitism, this is a personal tragedy given his lifetime commitment to peace and tolerance. It is also a tragedy that anti-semitism amongst a group of people within Labour somehow took root and got out of control. Whatever Johnson said about piccaninnies and letterboxes, it was clear that certain people thought that Johnson was ‘a good bloke’ you could have a pint with down the local dog and duck.
I’m not so convinced that the next leader of Labour ‘has to be a woman’, ‘has to come from the North’, or has to be ‘pro Brexit’. It is an inescapable observation that many red wallers managed to vote for someone perpetually characterised as an Etonian toff ‘to get Brexit done’. In fact, it might be better for continuity that Labour has in charge an articulate prosecutor who is able to see the merits or dangers of the Brexit case, and communicate them effectively. And it would help if the media were genuinely scared of that person, rather than being able to dredge up dirt from the past, or cast aspersions about competence or ability. It might be better for someone to take over who has followed the ins and outs of Brexit, and still be open to the notion that Brexit might ‘go wrong’ and be sympathetic to the significant minority who never voted for it. If it turns out that Brexit is a pup, and that multinational car plants exit the UK like we exit the EU, some voters might turn on Johnson and the Conservatives. This is of course more likely with ‘no deal’, and ‘no deal’ is more likely if the UK diverges from the EU significantly in their trading goals. The European Union cannot be underestimated either. After months of shadow boxing, they might give the UK a worthless deal – or nothing at all really, because they wish to send out a powerful message that, whilst the trade is welcome, it is better to be in the club than outside of it. Instead of Johnson’s “Project Bullshit”, Project Fear would quickly become a reality, if, say, the UK were unable to piggy back off GPS technology or the EU arrest warrant mechanisms.
But Labour cannot wait for Brexit to go wrong, in however which way you wish to interpret that. For all I know, it might be a magnificent liberation (but I doubt it). Once it’s slayed the dragons of Brexit and Jeremy Corbyn’s bad press and troubled performance at leadership, it needs to address the issues which made voters turn to the Conservatives – that is, those issues stemming from a decade of Conservative policy. Of course it is deeply fraudulent that Johnson is the change candidate, but Labour needs to have the academic flexibility to have a meaningful position on workers’ rights (including independent contractors’ rights), the changing nature of unions (including gender equality), the implementation of human rights in the future, how much of the cuts in legal aid and the reforms in the judicial system it wishes to reverse, how it is going to reconfigure the NHS and social care to get rid of arbitrage and market failure. But it also has to put up with certain voters who will want answers to why there are so many ‘brown’ people in their local village, which may even include proposing the positive case for immigration.
I don’t think the solution is to throw the baby out with the bathwater, and I can see that John McDonnell is genuinely upset. But I for one will be glad to see the back of Len McCluskey, and a rather toady croney part of Labour which is acting like a lead weight. I think the antagonism to Tony Blair’s tenure of office is completely unreasonable, uncharitable and unpleasant. For the critics of Labour, it really was Christmas come early, as the verdict appeared like a vindication of the attraction of Boris Johnson. But it really wasn’t. Corbyn for too many people looked like the wrong person at the wrong time, and prolonging the agony over Brexit did not really help. But now that the Labour Party has a chance to watch Brexit unfold from the sidelines, and to watch whether the Unicorns appear, it has a chance to build on whatever it wants to from the Corbyn era but to move on swiftly. I think the whole drive to ideological purity is absolutely pointless if you then subsequently go on to fail to win a general election. I wonder whether I should have listened to Nick Cohen years ago.
It wasn’t just Jeremy Corbyn who lost the election – it was the whole of Labour.
The election was not just a ‘Brexit’ election – it was a referendum following a hate campaign about Jeremy Corbyn. No longer relevant was Priti Patel and her lobbying, Boris Johnson calling people ‘piccaninnies’ or similar, it was a referendum on the historic allegations about Jeremy Corbyn. There were blatant double standards in holding people to account. If Laura Kuenssberg had live tweeted that Corbyn killed puppies with his bare hands, nobody would have held Kuenssberg to account (like they didn’t over her dreadful postal vote remark).
Of course it can be criticised that Labour’s offer was too grandiose and lacked priorities. But it did have as a priority personal care, whereas Johnson just lied about the fact there were any plans for social care. The policy of free broadband was heavily criticised, but the fact that Johnson simply made up figures about nurses and teachers seemed immaterial. For the ‘Red Wall’ to be unaware that Johnson was making a cosmetic minuscule sop to the decade of austerity beggars belief, but we’re to understand that Corbyn was hated so much on the doorstep, it didn’t matter what Labour had to offer.
But make no mistake. Any leader of the Labour Party who is sympathetic to the Palestinians will be a target of abuse and attack from significant people. It’s no accident that the Chief Rabbi’s attack on Corbyn appeared from nowhere during the election campaign. Gone out of the window was any Christian notion of forgiveness.
So now it is fair game for any criticism of Jeremy Corbyn and Labour. The smears have begun already for Rebecca Long Bailey – how she has dropped the hyphen in her name. Certain journalists have gone into overdrive with their ‘told you sos’. Some people are loudly and proudly saying, “I am (for example John Rentoul) – and I’m a Blairite.”
The destruction of support for Labour might be that voters genuinely thought that Johnson was “the change candidate”. Jeremy Corbyn would then be portrayed as incompetent with the finances, even though national debt under the Conservatives has rocked up due to faltering growth and faltering tax receipts into the Trillions. Corbyn would then be portrayed as a threat to national security, even though it was Johnson partying with the Russian aristocracy after the election (and suppressing any reports to do with the Russians).
This is all very alarming. With NHS performance really struggling despite heroic efforts from the staff, none for the blame was taken by the Conservatives. The Liberal Democrats seemed totally uninterested in attacking the performance of the Conservatives, sand their hate campaign against Corbyn was so vitriolic it was hardly surprising they destroyed any chances of a Liberal Democrat renaissance.
The smears against Corbyn were relentless.
My late father used to say ‘A bad dancer blames the floor’. The aim though was definitely to kill the messenger – and once the messenger had been killed to kill the message. The plan was to say ‘Nationalising railways was always going to be unpopular’ – but tell me ridiculous state handouts to privatised industries to keep them afloat and unbelievable prices (whether gas or train) were never hugely popular WERE THEY?
Under the Tories and their chums in the media, fake information became an art form.
Truth and analysis went out of the window. Brexit should have been easy to criticise. Nobody reasonable can think there will be a free trade agreement made by the end of 2020, unless there is such regulatory alignment with the EU this makes a FTA with the US impossible. It makes sense for the EU to punish the UK as much as it can without affecting its own GDP, and culturally there is absolutely no love lost. Whether or not Ireland can welcome a border down the Irish Sea is interesting, whether that will bring an united Ireland closer. Whether or not the SNP will allow themselves to be stonewalled from Westminster will get interesting – or Scottish voters realise they might have been better off with a strong Labour voice rather than having 50 SNP MPs being ignored.
While the threat of a Scottish referendum is still on the table, Labour looks weak. But how far should Labour go to winning back the ‘Red Wall’? I am simply disgusted how the term ‘politics of identity’ has become an euphemism for nakedly racist, xenophobic vile opinions, which are acceptable and normalised now. To win back the Red Wall, should Labour promise to bring back the death penalty?
If Brexit goes wrong, the Tories should take ownership of it. If the economy declines despite millions of pounds of quantitative easing to ‘make Brexit happen’, the Tories should take ownership of it. The membership of Labour, which of course is dynamic and changing all the time, will elect the new leader of Labour. They may not wish to turn a blind eye to the cuts in legal aid, the welfare benefit cuts, or food banks. They may not think Tony Blair is the answer.
For what it’s worth, I don’t think Corbynism, however so defined, was the answer either. For example, the response on the NHS was solely about funding and privatisation (important issues, I have no doubt). But there was no civil debate about integration of health and social care, which even Andy Burnham had tried to formulate in 2015 in ‘whole person care’. There seemed to be a lot of what Labour was opposed to, as opposed to what Labour was going to legislate to make the system better.
Jeremy Corbyn was the man who was ubiquitously unpopular – but it was Johnson who hid in a fridge and avoided facing up to scrutiny with Andrew Neil.
Maybe we should just accept a changing England. Monkey chants in football grounds are a price worth paying to get Brexit done?
And, whilst I don’t think it’s necessary to pander to a large vile section of the electorate simply to get elected, I think we have to concede it will be nearly 15 years since there has been a Labour government, especially when the Conservative government has been so bad. Let’s face it – with the level of vitriol against Jeremy Corbyn, it would have taken a miracle for him to be elected. But I don’t feel the experience has been a waste of time.
Boris Johnson is no angel either.
This situation might be a lot more complicated than making it Jon Lansman’s fault.
The blame for this does not lie with Dame Margaret Hodge.
I’m not a Corbynista, nor a Blairite. I am though in my mid 1940s, and I have voted for the Labour Party all of my life. I had no sudden urge for voting for Boris Johnson, so not surprisingly my immediate reaction to seeing the ‘exit poll’ for the first time was a sense of impending doom. Not one for hyperbole, but a feeling of cataclysmic disaster, one of the worst days of my life.
We’re left struggling for simple narratives. This election was a referendum on Brexit – or telling the truth – or Jeremy Corbyn – or the NHS.
Paul Mason didn’t hold back:
“Brexit will happen, Scotland will become independent within a generation, the political centre in parliament has evaporated. And Corbynism has failed. It failed because, for around a year now, it has been less than the sum of its parts.‘
The Tories took Blyth Valley which has been Labour since it was created in 1950,in the first shock result of the general election. Ian Levy got 17,440 votes, beating the Labour candidate by more than 700 votes. There was also a win for the Tories in Durham North West, where Labour’s Laura Pidcock lost to Richard Holden.
Laura Pidcock – she was the future once – had only recently on Facebook written the following,
“They don’t feel what we feel
Ignore the polls.
Ignore the negativity.
Ignore the lies and the hate.
It’s a waste of your precious energy.”
There have of course been many equally bad days, and plenty more to come. The sense of disbelief at the exit poll from me must have come from a sense of ‘one last heave’ that I had felt after the 2017 election. There were too many ‘twists and turns’ for me to remember as to how we came to be in this horrible mess, ranging from the soap opera with Dominic Cummings to false reports of people being punched. It was difficult to tell fact from fake news, but somewhere in there was some actual news. Jeremy Corbyn was quite unpopular on the doorstep, or the plans for government were too diverse and unrealistic. Or that the early postal votes were in fact ‘grim’, and people were sick of Brexit.
But the basic question is – if Labour was offering so many good things, why were they so unpopular consistently? It’s possible that Labour defectors were much more worried about Jeremy Corbyn than about Brexit policy. It’s possible that certain Labour voters are now more concerned about Scottish independence. The basic plan for Boris Johnson to lead a greater number to getting Brexit through parliament is, I suppose, one with which ‘Workington man’ or a London black cab driver could collude with. There are so many possibilities for what we wrong. It could be that Momentum strategists wanting to keep things simple, by being seen to address lots of wrongs, such as WASPI, universal credit, lack of broadband, etc., simply by making pledges. But it might be still that the perception of macroeconomic competence is not strong enough for Labour. Possibly people care less about national debt going through under the Tories than they do about Boris Johnson’s track record in telling the truth.
This appeared to be an election at risk of double standards. I feel the pain of the Chief Rabbi, and yet islamophobia was brushed under the carpet. The Conservatives didn’t want to talk about the details of the Withdrawal Agreement, but they couldn’t be criticised by Labour for this as Labour didn’t wish to discuss the details of Brexit either. The cult of Jeremy Corbyn was criticised, and yet the cult of Boris Johnson was not important. Labour seemed pre-occupied with their social media campaigning, but Boris Johnson found time to put out a ‘Love actually’ type video.
The Tories may appear not like ideal dinner party guests, but Labour still looked like a party at war with itself – with Lisa Nandy, Jess Phillips and Wes Streeting in one corner, and Jeremy Corbyn, Richard Burgon and John McDonnell in another. Out of everything, I still have no idea what Labour’s plans were for certain things. I don’t know how it intended to progress with the integration of health and social care. All I heard about was privatisation including PFI. But the Tories did not get into heavyweight arguments of their own, focusing on the numbers of new nurses, or the numbers of new hospitals. I didn’t know, if austerity is such a problem (which it is), how did Labour intend to reverse the cuts in legal aid. If Labour is too obsessed with presenting London élite, how come there was so much exposure of Laura Pidcock and Rebecca Long-Bailey? Maybe the ‘cut through’ had to be more than Ash Sarkar wearing a Marx t-shirt on Newsnight?
It could be that the election of a strong and stable Boris Johnson government is indeed a good thing, in that the European Union is forced to deal with an output decided with some certainty from a UK parliament. I don’t know whether ultimately Britain will benefit or not from Brexit, but it could be that the UK parliament does benefit from getting Brexit ‘out of the way’. Brexit will not finally ‘end’ though – if there is no solution to free trade agreements or freedom of movement which makes sense to all. But likewise we don’t know exactly what Labour intended to negotiate in six months, and whether there was any point in presenting this in front of the UK electorate.
Lancing the boil of Brexit, making the case of independence, is odd given the call for a United Ireland or Independent Scotland. It could be that Boris Johnson’s latest lie is talk about ‘One Nation’, when the majority of MPs in Scotland are SNP – but there could be a genuine repulsion of Labour by voters in certain ‘heartlands’. Voting Conservative might lead to better living standards through reduced immigration, and that might be a price worth paying. Or it could be that the Conservatives have tapped into a sense of national identity and pride, which Labour had no hope of identifying. At worst, both Conservatives and Labour could be accused of ‘divide and rule’, by presenting certain sections of society as ‘the victim’. Or it could be that Ash Sarkar and Grace Blakeney were simply talking to themselves very loudly.
With Brexit getting done, and improvements being made to public services, despite a recent track record, might make the next five years attractive, but that is to airbrush out problems with probation, NHS and social care capacity, food banks and poverty. But maybe its condrascending and patronising to say that the ‘working class vote’ can be enticed by talking about poverty, other injustices, and NHS seemingly a lot of the time. Previously, the attack on Labour was lacking ‘aspiration’ – so here the accusation is that Labour by sitting on the fence had no aspiration to get something positive out of Brexit; rather Labour wanted to block Brexit at all costs. When you consider that Swinson wanted to block Corbyn in forming a government of national unity, and that Corbyn might have to block in future a demand for another Scottish referendum, maybe the bottom line was that the advocates of Brexit simply were less disunited. Either way, the end result is that we may have an unfettered Conservative government for another 5-10 years at least, and this could make life very difficult for many in reality.
“Get Brexit done” is, of course, as utterly meaningless as “Brexit means Brexit” or “Strong and stable”.
As Johnson knows from his undergraduate rudimentary study of Ancient Greek, language in Thucydides and the Peloponnesian War poses a problem. The Athenians, for example, assume a fundamental distinction between erga, “real things,” and logoi, “words,” with the erga constituting reality and logoi a kind of secondary phenomenon.
Occasionally, the mask ‘slips’. The façade of a vivacious charismatic lover of the joie de vivre is suddenly disposed of to reveal a highly unpleasant narcissistic arrogant person who clearly over rates himself. He’s played the system, having been to Eton and Oxford. But that in itself does make him wise or intelligent.
Johnson’s reaction to the news of a boy sleeping on the floor of a hospital was not even faux outrage. It was to stuff a reporter’s smartphone into his pocket. And yet this is a nice parallel to his general approach to evidence. Take for example, the lie exposed about the barriers between Northern Ireland and the rest of the UK, exposed by DExU, the Treasury, an interview with Sophy Ridge, and the leader of the DUP, for a start. Or the lie about the 60 or so hospitals which turned out to be a handful of allocated ‘seed’ funds. This approach to evidence is sympathetic to his contempt of the law, in the alleged abuse of power getting special favours for his technology partner, or riding roughshod of the law such that the Supreme Court had to interview on behalf of decent patriots including HM The Queen.
Johnson does not understand the NHS or social care. Nor does his Secretary of State, Matt Hancock. Johnson’s immediate oven-ready soundbite in reaction to the latest incarnation of the 1992 war over Jennifer’s Ear was to talk about the ‘record investment’ in the NHS. But we know from all the ‘independent’-ish think tanks that this claim is false. We know there’s no green paper on social care. We know there’ve been savage cuts in social care. We know that integrated care under Jeremy Hunt stalled, whereas Andy Burnham’s ‘whole person care’ was oven-ready back in 2015.
Hancock instead sees staff as a costly nuisance in running the service. He is prepared to do something about NHS pensions such that he can’t be blamed for the disgusting performance over the winter crisis to come. He sees data as black gold, so much so he is willing to get into an unconscionable relationship with multinational corporations such as Amazon and Google, to make data breaches from local hospitals to make your eyes water.
The strangest thing about the record of the Conservatives in 2010-5 is that Johnson has managed to deflect criticism of this period onto his LibDem counterparts. He has managed to do this because Jo Swinson is either deeply fraudulent or idiotic in saying that she did not understand the impacts of the austerity policy on disabled citizens, some of whom lost their benefits and later died prematurely. One of the achievements of Jeremy Corbyn and John McDonnell, not McDonald, is that austerity has been exposed as a huge con. A con similar in ridiculousness as Labour causing the global economic crash of 2008. The crash, caused by financial products in the US, allowed a ‘scorched earth’ reaction of austerity. The next scorched earth event to happen is of course Brexit.
Jo Swinson has utter hatred for Jeremy Corbyn, and this has detracted away from the genuine offerings of the Labour Party over the NHS, social justice and tackling inequality. This is not something which ‘tribal’ Labour members will be able to forgive in a hurry. Sure, Swinson’s remarks like the Chief Rabbi or Laura Kuenssberg’s fake report of an altercation on Twitter, get more space than Windrush or islamophobia, but not everyone is deceived.
Jo Swinson has not facilitated any meaningful debate on the economy, climate change, or the NHS.
There will be some people who don’t vote Tory. These include Scots who wish to remain in the EU. Some people will vote for Labour, despite Jeremy Corbyn. This is because it is impossible for the Tories to defend their record. There might be some die-hard Brexiteers who want to ‘get Brexit done’, and, if so, even Dennis Skinner will lose his seat.
But Johnson is a pest, and doesn’t deserve to get a majority. If he does, he will find the country unmanageable.
Labour for me has many faults. It has people who are MPs whom I dislike. It has policies which I think are over-the-top.
I have voted Labour all my life. I am now 45.
To be honest, Jeremy Corbyn’s personal style annoys me sometimes; he can appear stubborn and aggressive. There is, no doubt, some frustration on his part, for how the media chooses to interact with him.
I just wish Brexit would go away. With the outcome of Brexit to run into the millions or billions, I think the democratic vote has been exercised enough. I don’t think it was the ‘will of the people’ to impose savage devastating cuts in living allowance on disabled people. I don’t think it was the ‘will of the people’ to introduce NHS reforms in 2013, or to slash legal aid. Or maybe it was the will of some people.
I am not particularly interested in the views of somewhat narcissistic supporters of Jeremy Corbyn pretending to be Nobel Prize winners in economics.
Social care is on its knees. The national debt is now running into the Trillions. David Cameron has set in play a chain of events where we are closer to leaving the European Union, and breaking up the domestic Union.
Taking back control puts international supply chains at risk, international political influence at risk, and lives of people living on essential medications at risk.
I think Boris Johnson loves himself too much, and is not quite as intelligent as he thinks. His Withdrawal Agreement Bill is truly a dogs’ dinner.
We should be prepared to forgive and forget. We all make mistakes – even Tony Blair. But the Liberal Democrats have in their time made some ‘whoppers’ over NHS reforms, legal aid reforms, and austerity in general.
I dislike the outcome of the Referendum of 2016, but this a Tory treaty which has been drafted up by the Tory party for Brexit-leaving voters. It seems far more desirable to try drafting another exit strategy with a fresh pair of hands, and to see whether the UK can approve it. Maybe they can. Maybe they won’t.
The issue is that the Labour Party can work with the SNP and Greens if it wishes to, to see if the EU exit can work. But I think unilaterally pulling the plug on it straight away would be dangerous politically.
I think the consequences of a Tory Brexit, and a further Tory government, are simply not worth thinking about. With my many reservations of the present Shadow Cabinet, I think it is far too risky to do anything other than to vote Labour.
It’s a bad start for the leading finalists in the Conservative leadership election to say that their party will be annihilated unless Brexit is ‘delivered’. Let’s face it – the implementation of Brexit by the Conservative Party, with no involvement of devolved governments or the official opposition, has been a disaster after three years. You only need to look at Jeremy Hunt and Boris Johnson to see that the Conservative Party will soon be totally unelectable for a generation.
Boris Johnson exudes incompetence, arrogance, faux intelligence and self-entitlement. Jeremy Hunt fraudulently pretends that his negotiation with junior doctors was a success despite being deeply traumatic unnecessarily for all parties involved.
Brexit will do nothing to help with knife crime, or the parlous state of social care. ‘Taking back control’ means reinforcing your borders. So it’s no surprise that Ireland wants to reinforce its border to stop non-EU goods leaking from the UK into the EU single market. Brexit will do nothing to make universal credit run more smoothly.
Whatever your views on the economic future of the UK after Brexit, it’s beyond any reasonable doubt that the reputational damage for the UK in terms of an influential world force for good, apart from Trump’s America, has been enormous.
If the UK exits the European Union with a successful negotiated settlement, it is pretty likely that the Pound will plummet further. This of course is an opportunity for short-sellers. But the benefit for the City is likely to be shortlived, if the EU denies passporting rights for transactions in London.
I don’t understand some voters who might want to ‘get on with it’. I liken this to someone arsoning your flat. Instead of putting out the fire, you are asking the arsonist to pour more petrol on the flames. I don’t understand why some voters have gone all silent on immigration. Maybe they know that Brexit might actually catapult an increase in brown or black faces in their local vicinity. I don’t understand why some voters are still passionate about past glories of England, when their local car plant is being shut down to be relocated to somewhere more sensible for dealing with the international supply chain,.
Being socialist meant to me being social. This does not mean turning our backs on, socially, politically, or economically with our EU neighbours. The pretence that Brexit can build a socialist nirvana in one country has never been tested for. It is naïve at best, and profoundly economically illiterate at worst, to think that multinational corporates can be completely obliterated from a post-Brexit UK.
It’s too late to honour the referendum result, unless the same parliament, with a different Prime Minister, can ‘seal the deal’ with the negotiated outcomes. This is unlikely if Labour continue to reject the deal, which they should do as it does not fulfil their original stipulated requirements of being at least as good as membership. The EU after their summer recess have no intention of re-opening the negotiation. The whole country apart from the Conservatives and Rory Stewart know that the positions of Jeremy Hunt and Boris Johnson are a pack of lies.
The only way forward is for Labour to decide on whether it wants to renegotiate a settlement (to which the EU would have to agree) or whether it simply wishes to end this stressful madness by revoking Article 50.
David Cameron’s ‘holding operation’ of an EU referendum has stunningly backfired. If Labour is unable to get a majority in the general election, to work with the Greens, SNP or Liberal Democrats, and to form a coalition of sorts will have to adopt a pro-EU position. These facts need to be stated clearly ahead of any general election it wishes to participate in, unless it is Labour’s intention to scoop up votes to form a coalition with the Brexit Party.
If Labour were to take a pro-EU stance, if the EU can’t renegotiate the settlement, it’s my genuine belief that the Conservatives will be out of power for a generation.
And, if so, good riddance to them.
The fireworks, after Sadiq Khan’s recent display, have certainly been impressive, with the likes of Roger Helmer foaming and frothing at the mouth. I am happy with what the current leadership of Labour has achieved. I have no intention of ‘smearing’ members of Labour. I would dearly love to see a Labour government. But it is an inescapable fact that there is, in fact, no version of Brexit that will satisfy both ardent supporters of Brexit and citizens of the UK who want to remain members of the European Union. If a further referendum is held, the possibility is that whichever side wins won’t win by that much of a margin. If ‘leave’ win, the words ‘be careful what you wish for’ will come back to haunt many. Many of the people who want a People’s Vote want ‘Remain’ to win, and simply wish to hold a referendum to maintain the importance of ‘democracy’. But democracy would possibly mean the UK could bring back capital punishment. Brexit as a solution to all the problems caused by neoliberal capitalism including austerity is a false, fraudulent prospectus. Attacks on ‘Blairites’ are in my view utterly irrelevant now to getting Labour into a position to form the next Government; this does not mean I am a ‘Blairite’, and such a lazy attack would be yet another dead cat.
There are some people who are determined to make this all about Jeremy Corbyn. I voted for Jeremy Corbyn twice, as I wanted stability in the Labour Party. I think though the obsession with him has become insufferable, including people who spend all the time flooding my Twitter timeline with plans for “Twitterstorms”. The perception is that Jeremy Corbyn has become more obsessed with getting into Number 10, rather than sorting out other desperate problems within his party, including Brexit. There’s an argument that ‘conference had decided’ that there would be a “people’s vote”, and failing that there would be a general election. However, events have been evolving fast. The Labour position is deeply unconvincing, and, whilst Jeremy Corbyn’s position ‘has not changed’, the notion that it will be able to negotiate successfully a solution to Brexit, the unicorn approach, is deeply unconvincing. This is nothing to do with my views of Barry Gardiner. The nature of the debate has become extremely toxic, with callers to local radio here in London referring to ‘illegal immigrants’ who can be shown not to be telling the truth with bone marrow aspirates diagnosing to the year their biological age, or “strapping Sadiq Khan” to a Catherine wheel (like yesterday).
The leader of the Conservative Party has had her position consolidated as a result of the failed ambush by the ERG. The only event which is likely to happen is that preparations are being made for the Theresa May negotiated agreement with the European Union to be rejected by parliament. In which case, a central plank of Government’s policy will fall, and it could be then that Labour is saving itself for a ‘no confidence’ vote in the Government, having previously precipitated a no confidence vote in the Prime Minister personally. Brexit has already proven to be a ‘financial opportunity’ for those sympathetic to the views or personnel of this Government, including problematic private companies taking on substantial financial transactions in commercial transactions extracting money from the State to fund their shareholder dividends. This is classic privatisation. The worst is yet to come, of course, with ‘patriotic’ Conservatives short-selling the currency, so betting on its demise, to make millions.
This is of course a far cry for why certain might have voted to ‘leave’ the European Union. It is speculation why exactly they believed a position which was impossible to negotiate bilaterally, given the sheer torrent of lies told by Nigel Farage, David Davis, Dominic Raab, Boris Johnson, and their ilk. But the potent ‘taking back control’ did tap into a rump of voters who felt as if the economy had not been working for them, by immigrants under-cutting their wages, and themselves adding to pressures on state-run services, inter alia. Many such voters, many of whom were also Labour voters, do not agree with the nationalism of some members of local clubs. The narrative had emerged that the UK can make a success on its own.
It is, however, important to remember that this mess should be owned by the Conservatives. This means that the failure of Brexit must be owned by the Conservatives. It is all very well for Theresa May to ask for no arguments and reconciliation, but she was the one who took her toys home two years ago and produced a deeply divisive partisan strategy for conducting the negotiations on behalf of the country with the European Union. The European Union cannot be blamed for their agreed settlement. If parliament votes it down, it should not be allowed to allow ‘no deal’ to be shoo-horned through, especially since the country is totally unprepared for it. The only people who are prepared are the ones about to receive privatised contracts from friends in the Government, or people ‘betting’ in the City. They have no interest in the destruction of the UK, including what happens to the NHS and social care. This is a betrayal of a phenomenal scale, and the Labour Party should keep a safe distance so it is not implicated in causing this disaster. The ‘shock’ of a no deal is of course will be exactly the sort of climate where the ERG or those in the ‘hard left’ can see themselves flourishing. It might even be a tempting climate for ‘Lexit’ to take root, but I don’t believe Lexit provides a solution either economically or socially, definitely not politically, to Brexit.
The only solution for me is for Labour to campaign on a platform in any general election to go back to the European Union, and to argue not only for a seat at the table of an influential trading bloc, but to ‘remain and reform’. I understand how tempting it might be for the UK to ‘go it alone’ and get contracts with Russia or China, but it is in reality hard to say that this would be easily possible. Having been a devotee of Tony Benn, and read all his diaries more than once, I am sympathetic to the Bennite view. But that’s where it ends. I think we can no longer within Labour waste any more time thinking Twitter arguments. There is an economic crisis to avert, but there’s more to Labour than a new radical model of economics even. Brexit will be more of a threat to welfare and social care, and the NHS, than even austerity has been, and there will certainly be no finality to the repercussions for Brexit for many years to come. It’s time for the ‘membership’ of Labour Party to stop thinking about Twitter campaigns, stop speaking to themselves, and put the country first.
I had first become interested in the language surrounding dementia in 2014, when I presented a poster on the G8 pitch, at the Alzheimer’s Europe conference in Glasgow.
At that point, I realised that sticks and stones could break my bones, but words could hurt me.
I have long since not attended any national or international conferences, not simply because I found the same topics being discussed in perpetuity, but because I felt the conferences were for an in-house cliques who were far more into massaging their own egos and putting themselves up in flash hotels than the reality of dementia.
But I later returned to the issue of language, in relation to stigma, in my second book on dementia ‘Living better with dementia’ published in 2015 by Jessica Kingsley Publishers. As my own mother lives with me, and as her dementia advances, I’ve genuinely found my own book to be a source of information and support. For example, only last night I was reading up on my own thoughts of the ‘sweet tooth’ in dementia and the neuroscientific evidence for why it occurs. Latterly, I’ve toyed with the idea of writing a cookbook for unpaid carers, living with limited resources including scarce money and time, of people living with dementia. I would love to work with someone who’s interested in this specialist field, such as a nutritionist or dietician, to help me.
I became physically disabled in 2007 after more than a month unconscious on the intensive care unit of a local hospital, where I was invasively monitored for acute meningitis. Although I subsequently read Goffman on stigma about a decade later, I had the misfortune to experience stigma first-hand. The sense of ‘otherness’ is something you experience if you’re in a wheelchair, and a London cab refuses to stop despite the cab having its yellow light on. Of course, I had direct experiences of ‘otherness’ as other medical professionals disowned and excluded me when I needed help the most – both in my alcoholism and in recovery. I am currently doing professional dilemma questions, and the knowledge that senior clinical people I worked with turned a blind eye, or did not know what to do and did not admit it, to my illness still frightens me.
As a result of this, I have a low threshold to calling out ‘otherness’, that is where you define people as different to you, and, more than than that, try to discredit them. This might include supporters of Brexit or not, Jewish or Muslim citizens or not, or even living with a long term condition. I don’t think the key to destigmatising stigma is by segregating people. At worst, this might include the ghettoization of people with dementia or mild cognitive impairment such that they all safely live in the same ‘dementia village’, to all intents and purposes ‘out of sight’ and ‘out of mind’. Care homes used to be criticised, by some, for potentially warehousing individuals if the prescription of chemical or physical restraints was frequently abused, similarly. This is not real integration and inclusion, in other awards appreciating the diversity of individuals, but actually lumping all people together with the same label.
For example, in ‘dementia friendly communities’, we don’t acknowledge individuals have different qualia of cognitive impairments, in memory, language or whatever, at various degrees of severity. We don’t discuss how the social determinants of health impact on the health and wellbeing of people, such as poverty or the shutting of day centres. We just clump all people together as ‘dementia’. This is not a million miles off of creating vast groups comprising unique individuals, such as ‘learning disabilities’ or ‘the elderly’.
Whilst the counter-argument is that identification of these groups of people means that their needs can be serviced, often the opposite is true. Recently, a paper has been published on identifying the most ‘frail’ people so that we can be aware that they are the most intense in resource allocation. But think about this carefully. This can mean that we use the information to discriminate actively against the most vulnerable – ‘equity’ and ‘justice’ are not necessarily compatible ethically.
Above all, I am scared how language is used to legitimise discrimination, ‘otherness’ and to embolden other people’s vulnerabilities and weaknesses.
I did a brief scan of some ‘offending’ words, and I compiled them into a table.
I have been much derided for talking about “assets” and “strengths” as well as “deficits”. For example, one person commenting on a piece I wrote in the Guardian remarked similar to, “We don’t need to worry about this patient lying on the operating theatre table with advanced pancreatic cancer. She has great teeth.”
But I strongly believe that it is not difficult to slip into the patronising ‘does he take sugar mentality?’ I don’t wish to turn the medico-legal concept of ‘paternalism’ into a “dirty word”, but, as for our experiences with individuals with special needs, it is a slippery slope to outright dehumanisation and depersonalisation.
I never really understood what it was like to lose your sight until I went blind in one eye last year – but this was surgically operated upon with success. Likewise, I think many of us think we won’t be the ones who get diagnosed with cancer or dementia. But the law of averages means that some of us will be.
And we should think about how “we” would feel if “other people” talked about “us” like that.