I don’t have any skin in the game.
I voted Labour all my life – between 1992 and 2019. I’ve never voted Tory.
A small confession. I’ve never met Sir Keir Starmer. I have seen him sitting in the audience as he was supporting the then newly crowned leader of Labour, Ed Miliband.
Ed Miliband is somebody I could happily have as Prime Minister. I remember David Cameron’s Twitter jibe, now infamous:
That was of course he set in motion a chain of events that led to the referendum, causing Britain to exit out of the European Union. It is widely thought that Nigel Farage can be thanked for precipitating this. He of course is not especially happy how Brexit has gone now. And who can blame him, with fishermen losing business, pig culls, huge loss trade, marked shortages in certain sectors of the economy, to name but a few. Luckily for the current Conservative government there are voters who are desperate for Brexit to work, like they are for the Tories to reverse years of Tory austerity under the guise of ‘levelling up’.
I understand Rachel Reeves’ optimism about a possible Labour victory. I also have experienced this illusion of ‘one last heave’ – where one final push will guarantee a Labour government.
But having followed this for years, I don’t think we’re there yet.
There are a number of reasons.
If “Captain Hindsight” can only be offering ‘constructive criticism’ while continuously to carp irritatingly like a back seat driver, “General Sit on the Fence” hardly inspires confidence with his endless streams of boosterism and lies.
A rosette on a Starmer cannot explain the lack of input into policy on Brexit, coronavirus or even the reorganisation of NHS and social care. Starmer and the whole shadow cabinet are lost in action. Nowhere to be seen.
They indeed, like Hilary Benn was so obsessive about, seem to be more focused on winning power than turning heads with policy. The brut force of Michael Foot intellectually, or indeed Enoch Powell, offered something quite unpalatable politically – though in defense of Foot, he never wore a donkey jacket and much of his 1983 offering has now been assimilated into current policy.
I want a Labour government, more than a Johnson one.
I don’t think people are keeping diaries about what they think of their civil liberties, the vaccination programme, or the battle of the dinghies.
But the step before the public vote for a Labour government is them endorsing a new Tory Party under someone like Liz Truss. I thought nobody would ever vote for Boris Johnson, but it turned out the media loved him, and that people had ‘factored in’ all his misfeasance.
Starmer would prefer to keep his mouth shut on environmental issues, or human rights, or policing, or housing.
But this policy of muscular silence is going nowhere. Nobody knows what he or Labour stands for, much that they find this current Government sleazy and a bit dodgy. It could be argued that Starmer has bus loaded in a lot of ‘serious people’ but I can’t name many of them apart from Yvette Cooper or Rachel Reeves who were instrumental in making my life hell for much of the 2010s for feeling guilty for being disabled.
The arithmetic is pointing to a solid SNP victory in Scotland, and it’s very hit or miss who will be the dominant party in England and Wales. Possibly Wales might save Starmer’s bacon, so to speak.
Dame Maureen and Dame Margaret are totally irrelevant to me.
Whilst the poll lead is welcome for Labour, I don’t think it is at all meaningful. John Rentoul, for all his brilliance, is badly wrong – or maybe it’s merely wishful thinking.
Donnez-moi a break.
At a time when Labour has voted in a new General Secretary in David Evans, the news is of sacking staff, threatening compulsory redundancies, losing revenue, and a full frontal attack on members. Evans was hardly voted in with a supermajority. Sadly, the vote was not advisory, even if it was at the level of 59/41, almost exactly the 60-40 split estimated.
To revisit an era, things can only can get better.
It’s on days like this that Dame Margaret Beckett had wished that she’d stayed in her caravan.
Labour has had a disastrous start to its latest conference.
The best that the political commentators could say to Keir Starmer’s handling of the launch of the Labour conference was that ‘it is good for Labour to be seen fighting the Unions’.
I suspect it would be good for Labour to be seen fighting the Sun newspaper, but, at the latest count, the Sun newspaper is out in force too.
At the launch of the Labour conference in Brighton, the day normally begins with something motivational for the membership. Not this time.
This time, we are told that, for the Labour leadership, the proposals are to raise the threshold of mp nominations, get rid of the “registered supporters”, and a commitment to review rules inc how to restore vote for unions’ political levy payers.
As far as the membership is concerned, Starmer has spent the last two years brown nosing the Johnson government, having given up even on the slightest of ‘constructive criticism’. Nobody can see the point of what is possibly the worst Labour opposition in my lifetime certainly.
Emma Radacanu, having won the US Open, has just said goodbye to her coach. Starmer, on the brink of the worst Labour disaster in history, even with the media this time supporting him to the hilt, is about to make all the offenders Knights of the realm or CBEs in his mission to promote failing upwards.
Starmer had a golden opportunity at the start of conference to make his mark over the energy crisis, inflation hike, driver shortage exacerbated by Brexit, dumping the triple lock, UC cut, NI hike, or public sector pay freeze.
As far as the over-spotted Red Wall voter is concerned, Labour is fronted by a Remainer who hated Jeremy Corbyn so much he was more than happy to be in his Cabinet. This particular Remainer, as it happens, can’t wait to get his teeth into the necks of anyone vaguely socialist in the Labour Party.
Let’s face it – not even an interview between Wes Streeting and Gloria Di Piero on GB News can stop the rot now.
The Conservative, Unionist and UKIP Party don’t especially to seem have any ideological direction to their roadmap, apart from an addiction to authoritarianism and the “market” which has consistently failed in the NHS, gas, education, and, you name it. All it cares about is media management of the latest crisis. Even Liz Truss MP is tipped for the top now.
Labour should be a hot bed of democratic socialism. It is instead a hotbed of undemocratic croneyism. A relatively popular contribution could be Labour’s proposed Fair Pay Agreements would give working people a pay rise and boost our economy. Labour would bring together representatives from workers and employers to agree minimum pay and conditions in their industry. A radical look at workers vs employees, and a revision of workers’ rights in a gig economy, to revise the Employment Rights Act (1998), would be a good contribution.
Instead, whilst the Labour rulebook states that conference should have a formal vote (show of hands) on the NEC report. Dame Margaret Beckett is not one for following rules to hold the vote. There’s no need to rig a vote any more. Just don’t hold it.
Of course, the HGV and tanker driver crisis is nothing to do with Brexit, and all to do with those pesky unions in Swansea at the DVLA, or refusal to do medical checks from lazy GPs. This is a weird dystopian Universe where Starmer has been taken hostage by a weird sect in the Labour Party determined to make Labour look out of touch and irrelevant.
With a new Secretary of State for health and social care, it might look like ‘business as usual’. Different newsreader, but same script?
The script might be more or less the same. But with a possible massive political realignment, the Conservatives and UKIP party, GB News, free market economics and libertarianism, anti-woke culture, all in the ascendancy, the NHS might be about to get ‘cancelled’. And then we have the ‘scorched earth’, provided both by Brexit and the COVID-19 pandemic.
The argument is not at all any more 3 seconds to “save the NHS”, which has been a popular mantra for Labour for decades. But Labour has rarely had such an effective leader, or opposition. Labour is nowhere on all policies, but its opposition to Brexit, COVID-19, and even Matt Hancock’s latest conduct, has been non-existent. There has never been a better time for the Conservative Party to go for it. GB News viewers regularly buy into the “levelling up agenda”, in no way blaming the Conservatives for their policy of austerity. Labour is too busy imploding to intervene. GB News viewers regularly stick up for “home grown” nurses and medics, and make strongly anti-immigration noises, saying that the infrastructure can’t cope with the additional population. Matt Hancock did a ‘brilliant job’, oblivious to the disastrous care home policy or corrupt contracts. Hancock is determined to make a return when the time is right, and it looks as if Boris Johnson will give him his full support. Matt Hancock is one of those people who should be ‘forgiven’ as “we all make mistakes”, according to some. Except – had been a doctor he would have struck off years ago.
The easiest way of not addressing the pensions issue in the NHS, the workforce crisis, the crisis in mental health or social care, the backlog in clinical care across the board in the NHS, would be literally to rip up the NHS and start again. Sajid David has still been a paid JP Morgan advisor, and it is well known that JP Morgan have long wanted to get into private healthcare. For the people who dislike the NHS, this is their chance to get rid of it. The anti-wokists, contrary to their usual feelings about the ‘cancel culture’, would happily get rid of the NHS, thinking of it as an inefficient relic of yoke culture, which believes too much in equity, equality and fairness. They feel their views criticising the NHS should not be cancelled. Free speech, and ‘polite debate’, is welcome, so long as you don’t disagree. There would be no imperative to provide a comprehensive NHS, nor indeed mental health care, if it is not profitable, even if the demand is there. Social care, for all the initiatives about ‘social care future’, would simply be whatever the multinational corporates propose – and persons with learning difficulties or dementia might not be high priorities. If you believe racism doesn’t exist, racial discrimination won’t happen. If you are out of the EU, then the EU working time directive doesn’t apply. See what I did there?
We live in interesting times. With Labour having killed itself, and with the help of sabotage from the ‘left wing media’, there is the real material prospect of George Galloway depriving Labour of a win in Batley and Spen. The spin will be that the Conservatives ‘won’ Batley and Spen, reflecting how the public don’t really care about infidelity and corruption, in the same way that they don’t actually care about expensive wallpaper. With more dead cats than can be accommodated in a cattery, the privatisation of the NHS has never looked so good. It won’t be a big IPO – no need to tell Sid. Learning from the utilities, the new NHS England CEO will take care to fragment the NHS into further pieces before transferring the units to the private sector. And with the new NHS reforms, and no immediate blueprint for the social care sector, absolutely anything can happen. And it probably will.
“If Sir Keir Starmer QC wishes to resign, I will support him.”
Groan. I started the pandemic, it feels like many years ago, being a loyal Labour supporter. I had voted Labour all of my life. But this policy of ‘constructive opposition’ was the pits. All of the mistakes Johnson had made were whitewashed, but in fairness the vaccine rollout from the NHS was a massive success.
Starmer and I have an interesting history together. I once saw him sitting in the audience of an election hustings for Ed Miliband in a primary school which Ed Miliband attended in Haverstock Hill. I remember thinking that Starmer would be the future one day. I remember reading about him in the Times. I suppose in those days there was a strong movement for Labour members to be in the metropolitan graduate class – the wokey class, rather than the working class.
It’s a ridiculous stereotype of course that the working class wear cloth caps, drink beer and eat fish and chips. And yet that is precisely the stereotype Starmer bought into with his photo ops when visiting ‘the North’. The argument from Labour goes that the Conservatives have parked ‘tanks’ on Labour’s lawn. But this framing for me exposes part of the problem. It is not Labour’s lawn. Daniel Finklestein is half right – and has told a half truth. The Tories are good at ‘reinventing themselves’. But unpacking this a little bit, the Tories have been very good at convincing voters, somehow, that they are the “party of change” – and will come to the rescue after years of austerity. This is the austerity that they caused.
It could be that Andy Burnham is also right. His landslide victory is a demonstration that localism can work. Not only can woke. I think there is a connection there with voters who want investment in people and services, and that this energy is both powerful and positive. It might be that extrapolation that Labour is finished as a national party. But Johnson can do localism too – look at the Mayor of Teeside, or the good showing in London. The travesty is that there are many in the Labour Party who want to exit now because they are sick of being victimised, in everything from micro aggressions to finding themselves as defendants in a lawsuit from members of a WhasApp group. My frustration is that this extreme version of navel-gazing meant that decent conversations about a national broadband offering, a national social care service, or a national education service got jettisoned. And from that point in Labour deserved all it got, as far as I was concerned.
If Labour has taken for granted, it could be that the Conservatives have taken the voters for fools. But, if so, I feel it is equally the case that the Labour leadership has taken some of its membership for fools. It screwed up on Brexit. That is public knowledge. If you wish to engage in single issue politics, it is crucial not to misjudge that single issue. And again history repeated itself. Starmer took a single issue. Sleaze, encompassing wallpaper in John Lewis, and Johnson’s morality. Except, this doesn’t work. Why? Most people dislike hypocrites. And we know that Tony Blair, pre-existing widespread use of the mobile phone, himself was embroiled in cash for peerages and Formula 1, and so on.
So Alastair Campbell is partly right too. Johnson is a perpetual liar, and somehow gets away with it. People know this. Millions of people have factored Peter Stefanovic’s video into their understanding of the situation. Supporters of Labour when it was led by Jeremy Corbyn were not all anti-Semitic. The problem was many innocent people, by supporting Corbyn, suddenly became anti-Semitic as a matter of guilt by association.
Starmer of course did another issue on top of the single issues of Brexit and sleaze at different times. He has consistently made hating Jeremy Corbyn his flagship policy since he became Leader, quite ironically given that Starmer was a major architect of Labour’s failure in December 2019. Even Adonis knows that Starmer has no political capital in the bank and wants to sell sell. Some Blairites know their reputation is soiled by having Starmer as the pin-up boy of their legacy. For all of Blair’s faults, his Government had major successes in human rights, minimum wage and freedom of information. And Blair’s fiascos in government that even he is very much haunted by them, one assumes. But Blair had a policy on the NHS. It was a legacy of Thatcher’s, and it could be that many voters think they might as well give the Tories a ‘go’ as Labour has at least contributed as much to this mess as the Tories. And to dismiss community investment as ‘pork barrel politics’ is not the point. Years of underinvestment has been coupled with false promises from Labour about levelling up.
So I might be yet another ‘woke social media warrior’. But I am deeply concerned about the direction of Labour. It could be that there is as much problem with the messenger as the message, but then again I don’t know anyone who forms their views after reading ‘Labour List’. Corbyn may not get away in blaming all his misfortune on media misrepresentation. Nicola Sturgeon and Boris Johnson had both been the targets of intense smear campaigns – and they survived.
Either way, Starmer needs to go. The needs of the Labour Psrty are more substantial than the needs of a single mega-Establishment mouthpiece. Starmer has no vision apart from exterminating Jeremy Corbyn. Starmer’s problems are focal to Starmer, however. Steve Rotheram did well. Mark Drakeford did well. I completely reject the notion that there’s no obvious challenger to Starmer’s leadership. I think Clive Lewis would be a great future Labour leader.
I think Starmer is offensive to my values as a former Labour voter. It’s too late definitely for a Starm offensive in any case.
Brexit is not the direct reason why the Nightingale Hospitals can’t be staffed adequately in the current pandemic. But it is a boil which David Cameron wanted to lance once and for all.
I apologise that, before writing this, I haven’t “cancelled” the use of labels such as ‘Brexiteers’ and ‘retainers’. We are a deeply divided nation, and even more so due to the 2016 referendum. The UK could become even more divided, literally, if Scotland becomes independent, and Northern Ireland splits to unite with Southern Ireland. Even if Labour abstains on the deal today, it would still be partly responsible for the whole package. This is because when the referendum result was announced Jeremy Corbyn launched a three-line whip to trigger Article 50. Labour has had no part to play in the negotiations with the European Union, so it has played the silent bystander since 2016 about exiting the European Union. It chose to leave the single market, and it chose to set up a hard Brexit. So it shouldn’t be surprised now that that was what was negotiated. With all the best will in the world, you would expect Alastair Campbell and Lord Andrew Adonis to reject the resultant trade deal. You’d expect Ben Bradshaw MP to reject it. To all intents and purposes, the proposed trade deal might be quite fair in that both parties have made massive concessions, but it is not what anyone wanted ideally.
The terms of the EU trade deal in large part are not a surprise, given the way that the Conservative Party negotiated it. This is why it has ‘passed’ the inspection of the Star Chamber, some operation within the ERG. There is no sovereignty about fish quotas, there is an abolition of freedom of movement, and so on. What is more mysterious is why the British government are so trenchant about our departure in ERASMUS, but it has hard to tell what the vision of UK in the world is from the Tories. We do however know that Boris Johnson has held repulsive, racist and xenophobic views, which might quite play well with members of both Labour and Conservatives in ‘Red Wall’ Britain.
The vote today is irrelevant in far as rubber stamping this deal is concerned. The Tories have the numbers there, despite the position of the SNP and the Liberal Democrats. Also irrelevant to the general public is the view of the current professor of EU law at Cambridge about how the new legislation is good for a supremely powerful Executive and international public lawyers. How the Conservatives got into a position of abolishing free movement of persons and abolition of frictionless trade through the erection of non-tariff trade barriers is easy to understand for the need of the Conservative Party leadership to control a micro-culture heading back to the leadership of Enoch Powell. The rot has persisted under Hague, Cameron, and Major. And now Johnson. The hard Brexit is an ideological position which could mean EHIC is replaced by some private subscription to private health insurers, but that is entirely the choice of certain individuals who want to see private insurance flourish.
Labour is not supporting the terms of the deal as such, but says that is opposing a “no-deal”. The trouble is, however, that everytime something goes wrong with the deal, the Conservatives can legitimately say that Labour voted for it. Labour could of course abstain. What is ridiculous is that a lawyer can agree to a document without having read it. This is like a surgeon agreeing to do an operation without reading any of the medical notes of a patient.
The European Union is sick of the excessive time they’ve spent on it, but they are not pursuing arrangements out of love or goodwill. They are agreeing to the deal to protect the single market in future. And they’ve been utterly united throughout. The main political parties have got away with taking a wrecking ball to the geo-political relationship between the UK and the European Union, and our international reputation is one of a basketcase. The deal is still subject to the UK’s co-operation with the European Court of Human Rights, which is in the sights of certain members of the Government (like the death penalty.)
The positions taken by Alastair Campbell and Lord Andrew Adonis are totally understandable, in that the actual deal is nothing like the requirements for passing the ‘tests’ Labour had set. But they are also not flavour of the month of some ardent Brexiters. And Frances O’Grady leading the TUC has opined that the proposed deal is barely better than ‘no deal’, as regards issues as fundamental as workers’ rights. So there is a strong case to oppose the proposed deal, but it is better than ‘no deal’. But voting for the deal makes the perception of the Scottish independence case amongst the Scottish nationalists. It trolls the ‘remainers’ in the Labour Party, who are not easily going to forgive and forget in the name of unity. The damaging effects of Brexit will be felt for decades, and there are no obvious advantages to the UK’s exit from the European Union.
But whatever Labour does now it will never be perceived as having got behind Brexit. It will have successfully alienated some of the ‘remainers’ in the Labour Party if it votes for the proposed deal, but it will also have garnered the support of others who feel that this is the time to move on. The time to move on is possible if Labour has a vision about what it wants from its place in the world, but it needs to spell out what it wishes to surrender in the name of improved sovereignty. The problem is that in the real world sovereignty is a bogus notion, because international market entry depends on nurturing relationships between party and understanding the law of conflicts as well as contract.
The leadership of Labour does however have to be called into question over this. The approach taken by Keir Starmer elsewhere of ‘divide and rule’ is unlikely to work over the thorny European question, and could precipitate the splitting of the Labour Party at the very worst. The Labour Party is quite unlikely to split over this, although it could split over Jeremy Corbyn. And if Labour sits on the fence then perhaps it can be seen to work better with the Liberal Democrats who remain utterly opposed ideologically to the current deal. But it is completely unclear what Labour wants to achieve in a renewed negotiation in the European Union, and whether it really wants to fight for it in the pursuit of voters more interested in ‘flag and country’. However, the argument that the European Union is not the source but rather the potential solution has never been put vociferously by Labour recently. At the moment, it looks as if it is being opportunistic in waiting for the deal to unfold, rather than being in any way pro-European.
But there is not going to be an imminent “second vote”, and at the moment there is no contemplation of the re-running of the arguments. It would be hard to tell that, if the economy implodes, whether that’s due to Brexit or the worsening coronavirus pandemic. But the increased cost of living and the increased unemployment may not be a price worth paying. One thing is for sure that, whilst David Cameron’s wish that we all shut up over Brexit may not be heeded, the Conservatives maintain their competitive advantage in completing Brexit whatever the consequences.
Like ships in the night, I have seen many millions of opinions shoot past about visiting loves ones in care homes. My loved one is with me at home, but she has advanced dementia. Not everyone who’s a resident in a care home has a dementia. I get that. But I would like to put down on paper a personal opinion about this. This was provoked by an excellent comment made by Vic Rayner in the Commons Health Select Committee this morning.
Vic Rayner emphasised the importance of relationships in social care. I couldn’t agree more. It happens to be a pivotal part of the ground-breaking work that Prof Julienne Meyer led on. Relationships are a crucial part of preventing burnout in staff, and they are also in understanding the resident as a person. It’s impossible to understand a person without understanding his or her social context, people who do or don’t matter to them, and the people who light up a life.
I worry that – and there are many people like me – that mum will soon forget who I am if I leave for too long. I have her nextdoor to me basically. But imagine if I had to be without her for a week. I’d be heartbroken. I often ask her if she remembers who I am, and sometime she hesitates. When she can finally remember, I feel as if I have won the lottery. It’s that one confession that keeps me having a tangible link with my mother. She can remember me. She can possibly remember giving birth to me. She can perhaps taking me up to school or university.
In about 1881, a famous French neurologist published on a theory of the formation of long term memories. Paraphrasing what he said in French, Ribot wrote ‘the old perishes after the new’. Speak to anyone with moderate or advanced dementia of the Alzheimer type, the person will find it much easier to remember what he or she was doing six years ago, compared to six minutes ago. I find that making a connection with me keeps her in the present. I think divorcing mum from me would be very upsetting for her – and very upsetting for me.
But it is also important, I think, to be open about a certain taboo. That family carers are essential care partners. When for example mum has to go into hospital for an acute emergency admission, I get a massive sense of loss as all the care transfers from home to professionals in a hospital. There are, furthermore, certain instances when my account of what has been happening is important, not being hyperbolic about my own contribution. A way of ascertaining whether mum has had an acute change in personality and behaviour, through delirium, is by asking me. Delirium is a medical emergency. Secondly, I know mum’s past medically, and can overcome any cultural including language difficulties. Thirdly, I can act as a reassurrance to mum while she goes through the distress of being a patient with an acute medical emergency. Finally, if care is not appropriate, such that someone does not treat her with dignity or totally misunderstands a situation, I can contribute to help. Unfortunately, it happens to be the case that in health and social care environments people can feel threatened by unwelcome additions to the care team. I’ve experienced this myself when one member of a care team actively makes an official complaint against another. But, when it works well, we can all act together, united, to help the health and wellbeing of people we love.
I understand how this conversation has become one of process and procedure, infection control and even dispute resolution. I could theorise for hours, even days, on the jurisprudence of the human rights involved. But I feel it’s fundamentally a lot more than that – the inhumanity of the separation from people we love. As was put a long time ago, care homes are not fortresses or prisons – they should be somebody’s home. Turning them into prisons is not a proportionate response. It saddens me deeply that so many people have clearly lost their way, but I am heartened by some exceptional leaders such as Kate Lee, Dr Jane Townson, Prof Adam Gordon and Vic Rayner on this.
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.