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Culture and diversity in living well with dementia

This is a very important chapter to me.

Culture and diversity considerations are hugely pervasive in all of English dementia policy: from the point of timely diagnosis and throughout the course of post diagnostic support.

These are the academic journal references I wish to include in my chapter for my book ‘Living better with dementia: champions for enhanced friendly communities”.

Please do let me know of any initiatives, projects, published papers or reports that you should like me to include in this chapter.

What is listed below is only a start. It does include blogposts, which I intend to include too.

This chapter is of course hugely relevant to global dementia policy.




Aminzadeh F, Byszewski A, Molnar FJ, Eisner M. Emotional impact of dementia diagnosis: exploring persons with dementia and caregivers’ perspectives. Aging Ment Health. 2007 May;11(3):281-90.

Botsford J, Clarke CL, Gibb CE. Dementia and relationships: experiences of partners in minority ethnic communities. J Adv Nurs. 2012 Oct;68(10):2207-17. doi: 10.1111/j.1365 2648.2011.05905.x. Epub 2011 Dec 11.

Bowes A, Wilkinson H. ‘We didn’t know it would get that bad': South Asian experiences of dementia and the service response. Health Soc Care Community. 2003 Sep;11(5):387-96.

Burns A, Mittelman M, Cole C, Morris J, Winter J, Page S, Brodaty H. Transcultural influences in dementia care: observations from a psychosocial intervention study. Dement Geriatr Cogn Disord. 2010;30(5):417-23. doi: 10.1159/000314860. Epub 2010 Nov 12.

Chan WC, Ng C, Mok CC, Wong FL, Pang SL, Chiu HF. Lived experience of caregivers of persons with dementia in Hong Kong: a qualitative study. East Asian Arch Psychiatry. 2010 Dec;20(4):163-8.

Connell CM, Gibson GD. Racial, ethnic, and cultural differences in dementia caregiving: review and analysis. Gerontologist. 1997 Jun;37(3):355-64.

Day A, Francisco A. Social and emotional wellbeing in Indigenous Australians: identifying promising interventions. Aust N Z J Public Health. 2013 Aug;37(4):350-5. doi: 10.1111/1753 6405.12083.

Friedman MR, Stall R, Silvestre AJ, Mustanski B, Shoptaw S, Surkan PJ, Rinaldo CR, Plankey MW. Stuck in the middle: longitudinal HIV-related health disparities among men who have sex with men and women. J Acquire Immune Defic Syndr. 2014 Jun 1;66(2):213-20. doi: 10.1097/QAI.0000000000000143.

Johl N, Patterson T, Pearson L. What do we know about the attitudes, experiences and needs of Black and minority ethnic carers of people with dementia in the United Kingdom? A systematic review of empirical research findings. Dementia (London). 2014 May 22. pii: 1471301214534424. [Epub ahead of print]

Khan F, Tadros G. Complexity in cognitive assessment of elderly British minority ethnic groups: Cultural perspective. Dementia (London). 2013 Feb 21;13(4):467-482. [Epub ahead of print]

Kirk LJ Hick R, Laraway A. Assessing dementia in people with learning disabilities: the relationship between two screening measures. J Intellect Disabil. 2006 Dec;10(4):357-64.

La Fontaine J, Ahuja J, Bradbury NM, Phillips S, Oyebode JR. Understanding dementia amongst people in minority ethnic and cultural groups. J Adv Nurs. 2007 Dec;60(6):605-14.

Lim YY, Pietrzak RH, Snyder PJ, Darby D, Maruff P. Preliminary data on the effect of culture on the assessment of Alzheimer’s disease-related verbal memory impairment with the International Shopping List Test. Arch Clin Neuropsychol. 2012 Mar;27(2):136-47. doi: 10.1093/arclin/acr102. Epub 2011 Dec 23.

Llewellyn, P. The needs of people with learning disabilities who develop dementia: A literature review. Dementia 2011 10: 235-247.

Low LF, Anstey KJ, Lackersteen SM, Camit M, Harrison F, Draper B, Brodaty H. Recognition, attitudes and causal beliefs regarding dementia in Italian, Greek and Chinese Australians. Dement Geriatr Cogn Disord. 2010;30(6):499-508. doi: 10.1159/000321667. Epub 2011 Jan 20.

Manthorpe J, Moriarty J. Examining day centre provision for older people in the UK using the Equality Act 2010: findings of a scoping review. Health Soc Care Community. 2014 Jul;22(4):352-60. doi: 10.1111/hsc.12065. Epub 2013 Aug 17.

McCleary L, Persaud M, Hum S, Pimlott NJ, Cohen CA, Koehn S, Leung KK, Dalziel WB, Kozak J, Emerson VF, Silvius JL, Garcia L, Drummond N. Pathways to dementia diagnosis among South Asian Canadians. Dementia (London). 2013 Nov;12(6):769-89. doi: 10.1177/1471301212444806. Epub 2012 Apr 26.

Morhardt D, Pereyra M, Iris M. Seeking a diagnosis for memory problems: the experiences of caregivers and families in 5 limited English proficiency communities. Alzheimer Dis Assoc Disord. 2010 Jul-Sep;24 Suppl:S42-8. doi: 10.1097/WAD.0b013e3181f14ad5.

Nakanishi M, Nakashima T. Features of the Japanese national dementia strategy in comparison with international dementia policies: How should a national dementia policy interact with the public health- and social-care systems? Alzheimers Dement. 2014 Jul;10(4):468-76.e3. doi: 10.1016/j.jalz.2013.06.005. Epub 2013 Aug 15.

Price E. Coming out to care: gay and lesbian carers’ experiences of dementia services. Health Soc Care Community. 2010 Mar;18(2):160-8. doi: 10.1111/j.1365-2524.2009.00884.x. Epub 2009 Aug 25.

Prince M, Acosta D, Chiu H, Scazufca M, Varghese M; 10/66 Dementia Research Group. Dementia diagnosis in developing countries: a cross-cultural validation study. Lancet. 2003 Mar 15;361(9361):909-17.

Regan JL. Ethnic minority, young onset, rare dementia type, depression: A case study of a Muslim male accessing UK dementia health and social care services. Dementia (London). 2014 May 22. pii: 1471301214534423. [Epub ahead of print]

Rovner BW Casten RJ, Harris LF. Cultural diversity and views on Alzheimer disease in older African Americans. Alzheimer Dis Assoc Disord. 2013 Apr-Jun;27(2):133-7. doi: 10.1097/WAD.0b013e3182654794.

Stokes LA, Combes H, Stokes G. Understanding the dementia diagnosis: the impact on the caregiving experience. Dementia (London). 2014 Jan;13(1):59-78. doi: 10.1177/1471301212447157. Epub 2012 Aug 3.

Sun F, Ong R, Burnette D. The influence of ethnicity and culture on dementia caregiving: a review of empirical studies on Chinese Americans. Am J Alzheimers Dis Other Demen. 2012 Feb;27(1):13-22. doi: 10.1177/1533317512438224.

Werner P, Karnieli-Miller O, Eidelman S. Current knowledge and future directions about the disclosure of dementia: a systematic review of the first decade of the 21st century. Alzheimers Dement. 2013 Mar;9(2):e74-88. doi: 10.1016/j.jalz.2012.02.006. Epub 2012 Oct 24.

Wilkinson, H, Kerr, D, Cunningham, C. Equipping staff to support people with an intellectual disability and dementia in care home settings Dementia vol 4(3) 387–400


The GMC will know what is wrong with their fitness to practice procedures for unwell doctors

The GMC are conducting a review into their ‘fitness to practise’ FTP, procedures.

The independent review into deaths of Doctors who have been on their Register, awaiting FTP, is about to be published soon one hopes.

I have decided to write the GMC a last minute contribution to this consultation.

I am on currently on the Medical Register, having been erased from it in 2006/7. It is beyond reasonable doubt that I was severely ill with an alcohol dependence syndrome.

You’ll get fewer people than me wishing the GMC well, still.

I feel that the support for unwell Doctors in the National Health Service, and any hunger for scalps of Doctors will feed into this.

The question is whether the GMC can fit itself into a wider system of learning from mistakes and also supporting Doctors ‘in trouble’.

I have learnt much from my time, not least becoming into recovery from alcoholism, and being physically disabled for the first time.

But I thought it would be incorrect not for me to make some polite views known. As I say, I wish the GMC well. I am also regulated by the Solicitors Regulation Authority, so I will expect the GMC to obey a new Act of Clinical Regulation if it comes into law pursuant to the English Commission’s proposals.


clin reg 1



General Medical Council
3 Hardman Street
M3 3AW

Dear Sir

Re GMC Consultation over fitness to practice procedures

It is with interest I have been following your consultation over fitness to practice (FTP) procedures for the medical profession.

I have thus far tried to keep out of these discussions. I myself was only restored to the medical register earlier this year pursuant to a full Medical Practitioners Tribunal Service (MPTS) panel hearing. I can say with all honesty that being returned to your Medical Register was the happiest moment of my entire life. I consider a massive honour to be there now, and indeed became quite tearful taking about it at the recent BMA Careers Fair held in North London a few weeks ago.

My regulation with the General Medical Council (GMC) has been simultaneously ‘the best of times and the worst of times’. I had resisted of commenting on it, because I can hardly been said to have been detached from the processes. But I have gone through the full regulatory loop.

I also have, since my erasure in 2006, re-trained in law, having even obtained a Masters of Law. I feel that proportionality runs like letters through a stick of rock in all the work the legal profession does. Balancing competing interests is what lawyers do. It is what the GMC has done since 1858, reflected as well in your current tagline.

I have also, as explanation, successfully completed a MBA. I decided to study an area called ‘performance management’. I don’t feel this term is particularly helpful, but the discipline has a lot to offer both the legal and medical profession. I had become regulated by the Solicitors Regulation Authority back in January 2011, following a full due diligence procedure.

At the outset, I should wish to apologise for this short note. But I was moved by your current Chair, Prof Terence Stephenson, who told an audience of us at the Practitioners Health Programme in Swiss Cottage, London, that change is totally possible; however, it tends to be ineffective through loud criticism from the sidelines.

That is why I wish to address your concerns head on.

I feel personally my erasure was completely correct. In response to the Chairman of my MPTS panel who asked me whether my time had ‘gone badly’, I disagreed; I said “it was a complete disaster”.

Nearly a year after direction to erasure, in 2007 June I was blue lighted into the Royal Free Hospital. I had a cardiac arrest and epileptic seizure, with a rampant acute bacterial meningitis. I was then kept on life support for six weeks. I became physically disabled. The NHS, though, saved my life.

I have now been in recovery for seven years at least. I do not in any way condone the events which led to my erasure, but in law I believe that ‘but for’ my alcoholism these events would not have happened.

The direction of travel seems pretty clear. Despite a temporary stalling in the response to the English Law Commission, I feel it is likely the proposals for a root and branch reform of clinical regulation will take place shortly. I full support Niall Dickson in this.

Patient safety is paramount. But the balancing of competing interests is not the reputation of Doctors or the reputation of the regulator, but rather the needs of the patients compared to Doctors trying to do their professional work.

It is often forgotten that many Doctors feel mortified if they make a mistake. But the sheer volume of medical mistakes made daily, for example in medication errors, makes it untenable that every doctor who has ever made a mistake should face a tough public sanction.

Furthermore, cracking down too heavily on Doctors in the medical profession is completely countercurrent to the drive to learn from mistakes in the NHS. There should be a learning culture, and in the drive for quality complaints should be acted upon as gold-dust.

I have every confidence that a well respected medical profession will be possible through a well respected GMC. Ensuring high standards in medical profession is not only achieved through regulation. It will only be possible if seniors in the medical profession show leadership as to the skills they wish to see flourish in the health and care sectors.

There is no doubt for me that the investigations process is too long. There are clear ways in which the GMC departs from the standard English law (e.g. regards costs, telling you how long investigations will take, ambiguities in the civil standard of proof of applied). During that time, the mental health of certain Doctors appearing before the GMC will markedly deteriorate due to stress. Low self esteem is a massive problem in people like me who have faced alcoholism or, in the case of others, other substance misuse problems. When you add to this the trial by media which is out of the GMC’s control, the perfect storm can be utterly disastrous.

One of the principal ways in which the GMC departs from the law currently is how there is little emphasis to manage disputes at a local level. Mediation and arbitration is very important under the civil procedure rules of English law, prior to litigation. The GMC approach is adversarial.

I should like enforcement of the current code of conduct, with a view to solving problems rather than publicly sanctioning Doctors as the key priority, to be important. The enforcement of the national minimum wage, for example, has proved problematic, despite it being a very good piece of legislation. Likewise, one can easily argue that requirements for Doctors to express concerns about inadequate resources, or a duty of candour, are already enshrined in the code of conduct, and have been so for many years now.

I mean my short note with complete goodwill. The GMC has an incredibly important function to perform. I am currently under two professional regulators. Since my erasure, I have spent 7 years in recovery, nearly finished five books and graduated in three degrees and one diploma, so rehabilitation is perfectly possible in my view.

As such it’s going to be impossible for the GMC to ‘do outreach’ as regards the health of Doctors. I openly admitted to your MPTS panel that I failed in not putting myself under a GP. I worry about junior Doctors who are worried to seek help over medical issues, because of concerns about their careers. Patient safety is paramount. During time of a lengthy investigation by the GMC, with mental illness not under control, a Doctor due to be appearing in front of you can go from poor health to catastrophic health. They can become in total denial and lack insight.

Whilst I will note why you may not wish to ask about health issues because of various statutory instruments in the English law, one might consider whether it might be proportionate for there to be a ‘middle man’ overseeing sick Doctors. This is essential for separation of powers between the regulator and the regulated. The Practitioners Health Programme and Doctors Benevolent Fund deserve national resourcing. This is not solely an economic case; it is a moral one, I strongly feel.

I trust the GMC will act impressively in response to these demanding issues in due course. Please do not hesitate to contact me should you need to.

Kind regards.

Yours faithfully,

Dr Shibley Rahman


My own medical career may be over, but the GMC must reform their procedures for sick doctors. Lives depend on it.

One of the ways that the General Medical Council will try to pin you down is if you appear blasé in any sense about your own behaviour, or lack insight into its repercussions.

I have a psychiatrist in West London who oversees my recovery. I am a barn door alcoholic now in recovery. One of the wisest things he has ever said to me is that it is impossible to ignore the distress I caused to friends, family and others. I think about this every day of my life in fact. It has left an indelible trace on Google, which I do not wish to forget. That’s why I have never asked for it to be removed.

I get upset that the BBC considers my tragic case of erasure from the Medical Register as ‘entertainment’. Behind this titillating story was someone who was in massive distress, and to some extent continues to be in distress.

I have learnt the General Medical Council (GMC) is only doing its job. Reports, like the latest damning one by Civitas on how the GMC treats sick doctors badly, come and go. And nothing really changes.

But I remember all too well what happened to me. I repeat that I find my behaviour then, as a different person, disgusting and unacceptable. But things came to a head when I was blue-lighted in at the beginning of June 2007 with an asystolic cardiac arrest which I was very lucky to be resuscitated out of. I then spent six weeks in a coma. I was fighting for my life, with drips, a central line, and the full army of Intensive Care machinery. The Consultant at the Royal Free warned people I was not expected to leave the hospital. I was clearly a very sick man.

My late father came to visit every day when I was learning how to walk and talk again at the National Hospital for Neurology and Neurosurgery. That’s where I had spent six happy months, while healthy, learning about general neurology and dementia. It’s where I developed a lifelong interest in neurodegenerative disease, which pervades through my post-doctoral fellowship at the Institute of Neurology thereafter, my mention in the Oxford Textbook of Medicine, and my own book on wellbeing in dementia.

I am happy now that, having learnt how to walk and talk, I was invited to the Alzheimer’s Association International Conference in Copenhagen last month, and I went to the Alzheimer’s Show in Manchester and London this year.  My friends include people living with dementia, and they tell me what’s important in policy now.

I remember though the days of having to hide my name on blogposts or my Twitter account. I remember how I was frightened to show myself in public in the last few years. I remember how my circle of friends completely collapsed, though I am happy with the very small number of very close friends I have now. I still continue to get trolled, like no tomorrow, with words like “Disgusting” and “How do you live with yourself?”

I do also remember how the General Medical Council took years with their investigations. I remember the torrent of newspaper articles explaining how likely it would be I would be struck off. I remember thinking how this was an inglorious end to my ten years training to be a Doctor, a profession which I still feel honoured to have been in once.

But the General Medical Council protracts out their investigations. The GMC never got round to appointing a clinical supervisor (very odd) even though my independent clinical examiners had concluded that I had a severe alcohol problem. So it rumbled on for a few years with my mental health in free fall. Dynamite.

This is extremely risky – dangerous – for the sick doctor. If you lack insight or if you’re in denial you can be finished (as indeed the numbers of people reported to have committed suicide while waiting for their Fitness to Practise sessions show).

I remember how I totally ‘lost it’ in 2005 a year before my final hearing. I had long left a medical job, but I just fell apart while still waiting for my GMC hearing. I went on a massive bender sat alone sobbing into my drink in a pub in Notting Hill very close to Portabello Road, ended up being sectioned, and then was suspended by the GMC.

A year after I was erased, with no job and no family or friends virtually, my life really did take a nosedive. I sat in pubs all day from opening time to closing time. I was done for drunk and disorder offences.

But I woke up after a six week coma, newly disabled, but with a new purpose. I did three books on postgraduate medicine, and I became regulated by the Solicitors Regulation Authority. I have three degrees, my Bachelor of Law, my Master of Law, and my Master of Business Administration, as well as my pre-solicitor training.

I didn’t get very far when I bothered going up to Manchester for my restoration application. The GMC hadn’t bothered to do a basic conflicts session, so the meeting was adjourned after one day. My friend Martin Rathfelder made it to support me. He like Jos Bell and Kate Swaffer are true friends.

It’s a miracle that I didn’t have a relapse being in the City where I had been with my late father, where I was erased, with plenty of bars and restaurants, with plenty of memories. It’s like you’re being set up to fail by the GMC – or else they are incredibly incompetent when it comes to dealing with people with mental health issues.

But I did get as far as asking the panel if I could hold the hearing in public this time. I want to explain to the whole world why and how alcohol destroyed my life, and caused distress to others.

I think the GMC did the right thing in getting rid of me from the medical profession, but I am still bemused why one consultant in West London asked me to sort it out by giving me a phone number of the Priory, did not refer me to Occupational Health, and did not offer me sick leave. I am bemused why various consultants described me as looking dishevelled and alcoholic, and yet allowed me to finish my medical jobs in London, without referring me to Occupational Health. I even ran a number of cardiac arrests successfully, while being allowed to finish that job where the consultants complained some years later, because I had obtained my Advanced Life Support qualification. The practical thing to do would have been to refer me, give me sick leave, assess me, and get me back to work, if conceivably possibly. The alternative was a vindictive complaint, albeit a correct one, years after the event.

By the time I was erased, the GMC had been given five reports from five independent doctors stating clearly that my primary problem was a severe alcoholic dependence disorder, and that I desperately needed help.

I never received this help until the NHS saved my life a year later.

The GMC will wish to ‘win their case’ and I strictly speaking am not allowed to bring any of this up in case it reaks of bitterness.

The GMC opposed my application to explain all this and my recovery in public. The panel rejected the GMC’s case.

In my view, Clare Gerada’s “Practitioner Health Programme” is a necessary lifeline for those are sick Doctors, and who fall under the London jurisdiction.

Prof Gerada is a true inspirational NHS leader.

Needless to say, I’ve never had an alcoholic drink for more than seven years, since my coma. I’m one of those guys who has no off switch after one drink, such that I’ll either end up in A&E or in a police cell.

My case will now be held in Manchester beginning August 20th 2014. If you want to begin to understand how sick doctors cope, or do not cope, please feel to come along.

The case for dementia screening: business case-based or evidence-based?

Dementia screening: what’s the problem?

Whatever your political ideology, you can’t help be aware of the various vested interests at play in society.

Dementia is no different. Evidence-based policy is public policy informed by rigorously established objective evidence.  An important aspect of evidence-based policy is the use of scientifically rigorous studies to identify statistically-signfiicant conclusions, capable of improving policy-relevant outcomes. A business case, on the other hand, captures the reasoning for initiating a task. The logic of the business case is that, whenever resources such as money or effort are scarce, they should be in support of a specific business need, such as delivering a financial surplus or profit.

What is “screening for dementia”?

In the UK, physicians have been pretty clear that screening healthy people for disease or risk factors is justified only if there is strong evidence that the benefits outweigh the harms. Primary care, and the media at large,  can also help to open up a new market by referral to private health providers of screening services.

The “worried well” have traditionally tend to be natural targets, but it has been mooted recently that convincing someone that he or she “needs” to be screened for dementia is made much easier by the fact that she or she may be very frightened about such a diagnosis (Fox et al., 2013). Indeed, earlier this year, some leading medical practitioners warned that, “private health screening companies are using scare tactics to persuade people to part with their cash.”

Screening for dementia in England has been mooted before publicly, and largely has been driven by politicians rather than academics. Screening is defined as the process of identifying apparently healthy people who may be at increased risk of a disease or condition. They can then be offered information, further tests and appropriate treatment to reduce their risk and/or any complications arising from the disease or condition.

A specific problem to do with dementia is that dementia in fact covers a huge number of different causes with different clinical presentations, so it is not possible that there would be a single one ‘test’ for likely dementia in a person who is still living. Alzheimer’s disease, epitomised by early memory loss, is thought to be, by far, the most common type of dementia worldwide.

Are there any benefits of screening for dementia?

An evidence-based analysis of the likely benefits of treatment is important in any medical specialty. Dr Aseem Malhotra queried recently in the BMJ why an asymptomatic and active former US president, George W Bush, receive a stent after a yearly check up. Malhotra cites that, in economic terms, the average purchasing cost of the machine that works the pump is about £40 000 (a specialist cardiac hospital may buy one or two of these), and the individual pumps come at about £800 a patient. .

For the past few decades, scientists have been trying to identify reliable markers of substances found in the fluid surrounding the brain which might act as a marker of the most common type of dementia, Alzheimer’s disease, long before the onset of dementia. Other groups have desperately been trying to scan the brain to see if they can spot subtle changes in the brain much earlier on the onset of symptoms. Even parking aside the costs of these approaches, the results of these aggressive endeavours in biomarkers and neuroimaging have been poor.

There is no ‘cure’ for Alzheimer’s disease currently. “Cholinesterase inhibitors” constitute a class of drug used for Alzheimer’s disease, but the very modest effects of treatments to improve memory such as the cholinesterase inhibitors have in fact been well known for some considerable time (Holden and Kelly, 2002).  At the time of writing this article, these drugs were not shown reliably to slow down the rate of progression in the majority of clinical patients with this disease from any published study.

A mild cognitive impairment (“MCI”) is a clinical diagnosis in which deficits in cognitive function are evident but not of sufficient severity to warrant a diagnosis of dementia (Nelson and O’Connor, 2008). It might be attractive to think that MCI is a preclinical form of dementia of Alzheimer Type, but unfortunately the evidence is not there to back this claim up at present: only approximately 5-10% and most people with MCI will not progress to dementia even after ten years of follow-up (Mitchell and Shiri-Feshki, 2009).

However, it is argued by some that, In terms of service provision, one major issue is that in current systems less than a half of people with dementia have a formal diagnosis made, or contact with specialist services, at any time in their illness (National Audit Office, 2007). Such diagnosis and contact often only occurs late in the illness and in crisis when the opportunities for harm prevention are limited, according to Banerjee and Wittenberg (2009).

Leifer (2003) legitimately asks, “why diagnose a disease in its earliest stages if it cannot be cured?” A compelling reason is provided that patients and their friends or family have the moral right to know their diagnosis. On a practical level, it is reasonable to argue that any potential hazards can be minimised or eliminated (e.g., driving, use of a stove), and education of caregivers regarding the disease and its implications will allow them to adjust and adapt over a longer period of time.

Moral panic 

There has been much interest in working out why there has been a sense of ‘moral panic’ about certain public health messages. Dementia has often been presented as an ‘epidemic’ in the media, and Campos and colleagues (2006) believe that part of the answer may lie with overlapping (and often conflicting) set of economic interests among various public health constituencies. They cite that many of the leading obesity researchers who have created the official standards for what constitutes ‘overweight’ and ‘obese’ have also received sizable funding from the pharmaceutical and weight-loss industries.

People with financial interests seek out ways of affecting the social or political climate in which their business-oriented activities can thrive, to create new wealth. Tullock’s (1967) paper in the Western Economic Journal (now Economic Inquiry) is the foundational event in the theory of “rent seeking”. Whether  intended or not, the recent “Prime Minister Dementia Challenge” has created a perfect environment for such activities to take place.

Unfortunately, it is completely legal for the companies to offer these screening services, but their promotion of these services contrasts with the stance of the NHS which introduces screening programmes only after a robust review of the evidence against internationally recognised criteria by the UK National Screening Committee (McCartney, 2009). The UK National Screening Committee (“UKNHSC”) is responsible for making recommendations for screening across all clinical areas, including cancer. The last review completed in June 2010 decided that the UKNHSC did not recommend systematic national screening for Alzheimer’s disease in the UK.

This was yet further confirmed only a few months ago in the finding from a systematic review that screening the population for dementia offers no clinical benefits, while potential harms such as the risk of depression, anxiety, stigma or loss of independence remain unexamined in any study the researchers could find  (Hawkes, 2013). The study was presented this week at the Alzheimer’s Association International Conference in Boston.

All in it together?

There is now a ridiculous situation where even medics might be ‘divided’ over this issue. While the academic community is pretty consistent in their criticism, there is currently a policy in place for GPs to be paid for meeting targets in tests related to the dementia diagnosis known as “QOF” (currently under review.)

The ‘political drive’ in the UK most famously came under fierce criticism in the BMJ as follows:

Expanding the diagnosis of dementia mostly increases profit for corporations and industries involved with developing screening and early-diagnosis tests, and pharmaceutical and complementary medicines marketed to maintain cognition in old age.

.. The desire of politicians, dementia organisations, and academics and clinicians in the field to raise the profile of dementia is understandable, but we risk being conscripted into an unwanted “war against dementia.

(Le Couter et al., 2013)

The academic community, nonetheless, have possibly played a part in feeding this commercial “market”; they are themselves dependent on financial grants to survive.  The ‘Googlescope’, i.e. word searches through Google Scholar within the health-related literature, shows up a remarkably well-ordered increase in the proportion of papers mentioning ‘risk’ over 5-year periods from the 1950s to the present day (Heyman et al. 2009).


In any objective ‘Fact Check’, one cannot perhaps help avoid the conclusion that the case for dementia screening has been business case-led or evidence-based. It is a sad observation that the dementia policy is more to do with the economic, social and political power of vested interests rather than in the hands of experts who know about this field. Hopefully, with time, this mess will resolve itself.


Selected readings

Banerjee S, Wittenberg R. (2009) Clinical and cost effectiveness of services for early diagnosis and intervention in dementia. Int J Geriatr Psychiatry. 2009 Jul;24(7):748-54.

Campos P, Saguy A, Ernsberger P, Oliver E, Gaesser G. (2006) The epidemiology of overweight and obesity: public health crisis or moral panic?Int J Epidemiol, 35(1), pp. 55-60.

Fox C, Lafortune L, Boustani M, Dening T, Rait G, Brayne C. Screening for dementia – is it a no brainer? Int J Clin Pract. 2013 Aug 16. doi: 10.1111/ijcp.12239.

Hawkes N. Systematic review finds no benefits to population screening for dementia.BMJ. 2013 Jul 19;347:f4638. doi: 10.1136/bmj.f4638.

Heyman, B. Alaszewski, A, Shaw, M, Titterton, M. (2009) Risk, safety and clinical practice: health care through the lens of risk. Oxford: Oxford University Press.

Holden, M., and Kelly, C. (2002)) Use of the cholinesterase inhibitors in dementia, Advances in Psychiatric Treatment, 8, pp. 89-96.

Le Couteur DG, Doust J, Creasey H, Brayne C. Political drive to screen for pre-dementia: not evidence based and ignores the harms of diagnosis. BMJ. 2013 Sep 9;347:f5125. doi: 10.1136/bmj.f5125.

Leifer BP. Early diagnosis of Alzheimer’s disease: clinical and economic benefits. J Am Geriatr Soc. 2003 May;51(5 Suppl Dementia):S281-8.

McCartney M. (2012) What companies don’t tell you about screening. BMJ. 2012 Mar 28;344:e2311. doi: 10.1136/bmj.e2311.

Mitchell, A.J., and Shiri-Feshki, M. (2009) Rate of progression of mild cognitive impairment to dementia -meta-analysis of 41 robust inception cohort studies. Acta Psychiatr Scand, 119(4), pp. 252-65.

National Audit Office. 2007. Improving Services and Support for People with Dementia. TSO: London.

Nelson, A.P., and O’Connor, M.G. (2008) Mild cognitive impairment: a neuropsychological perspective, CNS Spectr, 13(1), pp. 56-64.

Tullock, G. (1967) The welfare costs of tariffs, monopolies, and theft. Western Economic Journal, 5(June), 224–232.


 CV here

Reconfigure in haste, repent at leisure

Monitor has just announced that it intends to conduct an investigation into the challenges faced by small district general hospitals (DGHs) in their efforts to provide high quality and sustainable care. The regulator is asking for views from patients, providers, commissioners, healthcare professionals and other interested parties.

Even in the ‘neoliberal landscape’, there is a coherent economic argument that smaller DGHs can be more flexible, nimble and resilient in coping with the economic challenges of the NHS, as elegantly described in this recent Health Services Journal article.

District general and smaller hospitals are still populated by Doctors there with approximately at least ten years of medical training under the belt. So the idea that they are offering a second-rate service for the common medical emergencies is a fraudulent one.

Sure, it is possible to frame an argument that you can deliver a ‘mega hospital’ a bit like a “mega dairy“, but the argument that ‘big is more efficient’  is genuinely barking up the wrong tree.

For example, you will always need Doctors, nursing and allied health professional teams to deal with the ‘bread-and-butter’ of the acute medical take. This might include chest pain, acute shortness of breath (including acute severe asthma), acute exacerbation of an inflammatory bowel disease, an acute pneumonia, an acute headache, and so on.

Patients, understandably, wish to get to a local hospital without any fuss, and to be set on course for the correct treatment. They can of course be referred onto specialist centres if need be (for example an acute headache might be a bleed in the brain which requires neursurgical evacuation.)

The irony is that even people who understand markets appreciate that the market is ‘segmented’. It is impossible to address the needs of your ‘customers’, unless you understand what groups of customers desire.

The essential management steps of virtually acute medical emergencies are the same whether or not you happen to be in a district hospital or a large teaching hospital. This is because there is an acceptable standard of treatment of what clinicians would do for patient safety reasons.

For example, if you’re having an acute severe asthma attack, you are almost certainly going to have your treatment as described here on p.62 onwards of the British Thoracic Guidelines on asthma.

Monitor curiously mentions that ‘it does not wish to pre-empt the outcome’. This is extraordinary messaging. If it really really was confident about not pre-empting the outcome, why did Monitor feel to mention it at all?

We all remember David Cameron’s “no more top down reorganisations” pledge at the Royal College of Nursing Congress. The other classic is from August 2007, where Cameron promised a “bare knuckle fight” with the then Prime Minister Gordon Brown, when he launched a campaign to safeguard district hospitals.

There are reasons why one cannot be reassured about what is happening.

Whilst Lewisham won its landmark fight at the Court of Appeal against the Secretary of State for Health this week, it has just been announced that two accident and emergency (A&E) units in London are to be downgraded.

Furthermore, it is reported that fast-track hospital closures through extension of the powers of the Trust Special Administrator, have been tagged onto the Care Bill through an amendment which has received widespread opposition.

And the previous mood music hasn’t been great. For example, in their pamphlet, “Dealing with financially unstable providers”, the King’s Fund stated that:

For a competitive market to work, it is argued that there must be consequences for inefficient providers and those who do not attract patients. Again, this requires a mechanism by which providers that lose business are allowed to fail and exit the market.

The Monitor consultation therefore feels, instead, somewhat like an undertaker doing a ward round on the intensive care unit populated by critically ill patients.

Fundamentally, the problem here is one of equitable access to healthcare in the NHS.

Suppose I offered you a choice between a carton of milk in your local corner shop which you can easily walk to, or from a supermarket five miles away. You can only get to the supermarket by getting in the car. It’s the same carton of milk. Which shop do you prefer?

The issues about ‘access to medicine’ are complex. They are also hugely relevant to what sort of society we want.

It would be a grave error to ignore the views of professionals such as Dr Jonathon Tomlinson, who for example here in the London Review of Books describes a typical surgery of his.



CV here



Making the initial training contract application to the graduate recruitment officer

Different  recruiters  will  have  their  own  ways  of  assessing  these  forms.  Some  look  at  the  holistic  nature  of  the  form,  more  than  others.  Some  require  cover  letters,  but  others  do  not,  and  such  firms  put  a  lot  on  emphasis  on  their  cover  letters.  This  document  is  not  supposed  to  provide  the  substrate  of  a  ‘perfect  answer’  for  the  “marking  matrix”  used  by  these  firms,  but  is  supposed  to  provide  clues  as  to  the  rationale  for  asking  the  question  in  the  first  place.

Competencies  are  knowledge  and  skills  statements  and  not  task  statements.  For  example:  conducting  the  meetings  is  a  task.  In  order  to  do  so,  one  needs  required  competency.  Therefore,  in  this  case  the  required  competency  is  the  combination  of  skills  to  make  an  agenda,  to  promote  a  healthy  group  process,  to  resolve  conflicts,  to  manage  time  etc.  

General suggestions

  •  Be  clear  in  your  own  mind  why  you  want  to  join  the  firm  and  why  you  wish  to  become  a  commercial  lawyer.  What  is  it  that  really  interests  you  about  the  work  we  do?  Match  what  you’ve  got  to  what  they’re  looking  for.  Most  employers  nowadays  select  against  criteria.  The  more  precisely  you  match  them,  the  harder  it  is  for  them  to  avoid  interviewing  you!  A  detailed  list  of  what  they’re  looking  for  often  comes  with  the  application  form  but,  if  not,  go  systematically  through  their  website  or  recruitment  literature;  you  may  find  it  especially  useful  to  look  at  their  graduate   recruitment  pages,  especially  “what  we’re  looking  for”  and  any  statements  of  competences  or  shared  values  of  the  firm.  Knowing  precisely  what  they  want  will  help  you  match  up  your  own  qualities  when  you  complete  the  form.
  • You’re  applying  to  a  commercial  law  firm  so  you  will  be  expected  to  know  about  the  world  of  business  and  the  issues  that  affect  the  firm  and  its  clients.  It’s  probably  worth  your  while  if  you  identify  one  or  two  key  business  or  legal  news   stories  that  interest  you  and  follow  them  for  at  least  a  few  weeks  before  the   interviews,  so  you  can  talk  quite  broadly  about  the  main  issues.
  • Take  your  time.  Look  at  various  websites,  brochures,  careers  fairs,  presentations,  and  other  online  resources  like .  Time  spent  preparing  is  time  well  spent.  It’ll  make  those  “why  do  you  want  to  work  for  us?”  questions  so  much  easier.  With  longer  forms  you  may  need  to  break  it  into  chunks,  filling  the  form  in  over  two  or  three  sessions.
  • Make  it  easy  for  the  graduate recruitment officer.      Give  your  answers  a  clear  structure.  Directly  match  the  skills  they  want  to  your  own,  using  headings  if  necessary.  Think  about  what  sets  you  apart  from  other  applicants.  This  is  your  chance  to  sell  yourself,  so  use  a  range  of  examples  from  both  inside  and  out  of  university  to  highlight  your  skills  and  achievements.
  • Where’s  the  evidence?  Many  applications  lack  the  individuality  injected  by  small  bits  of  specific  detail  which  make  them  come  alive.  Give  relevant  interesting  examples  -­  go  into  detail.  Make  every  effort  to  include  practical  examples  of  when  and  where  you’ve  demonstrated  the  skills  they  want.
  • Don’t  be  modest.  Application  forms  (and  interviews)  are  all  about  letting  people  know  what  we’re  good  at.      
  • Treat  it  like  an  exam  i.e. answer  the  question!  Recognise  a  multi-part  question  and  tackle  all  its  parts  separately,  using  sub-­??headings  or  breaking  it  up  into  paragraphs.  Treat  each  bit  separately –  don’t  smudge  it  into  a  single  answer.
  • Don’t  be  afraid  of  your  failures.  Application  forms  can  read  like  an  unstinting  list  of  successes.  It’s  sometimes  worth  going  on  to  analyse  the  lessons  learned  –  why  did  things  go  wrong,  how  might  you  do  them  differently  next  time?
  • Vary  it!    Get  together  a  list  of  examples  you  might  use.  You  can  call  on  all  sorts  of  things  -­ holidays,  summer  jobs,  flatshares,  voluntary  work,  committees.  Then  go  through  the  form,  considering  which  example  is  strongest  for  each  of  the  answers.  Think  about  the  job  you’re  applying  for,  and  try  to  use  the  most  relevant  examples.
  • Don’t  overdo  the  academic.    Employers  seek  rounded  individuals,  adept  in  a  number  of  situations,  not  people  whose  main  experience  of  teamwork,  achievement,  challenge  and  communication  comes  through  their  course.
  • Attention to detail is a key skill for a lawyer and this starts with your application, so check thoroughly for grammar and spelling errors. his is the number one training contract application mistake to avoid on every recruiter’s list. There are good reasons for this. It is something that can be easily avoided. Quickly pasting your work into a word processor for a grammar and spelling check should get most of the job done. Printing a hard copy and proof reading it, with a pen in hand, will do the rest. Do this when you are completely cold to what you have written, the next morning for example. Making these types of mistakes shows a lack of attention to detail, which is not taken lightly by prospective employers. Given the type of service that Law firms provide to their clients, attention to detail is especially important. Errors in drafted legal documents expose cracks in a firm’s amour of professionalism. You can imagine that a client will then start to question the firm’s competence in other less visible but more important areas. Drafting errors also provide ammunition for the opposite side and their lawyers. In the manoeuvreing that happen during negotiations it is much harder to hold your ground and assert your side of the argument if your work is being questioned for lack of quality.
  • Copy and pasting. There are no shortcuts to a well-written and constructed application. Next to spelling and grammar errors, cutting and pasting from other sources is not only a waste of time with applications, but also easy enough to detect. Copying and pasting is often betrayed by inappropriate or incorrect information. Addressing the application to the wrong person or company happens all too often.


?  Give an example of ..”

Competencybased  questions  often  involve  you  demonstrating  these  key  attributes  so  really  think  about  the  answers  you  give  and  explain  your  examples  in  full.  Examples  should  have  a  clear  structure  to  highlight  your  skills  and  achievements  but  remember  to  answer  the  question  succinctly.  If  you  need  help  with  structure,  you  may  want  to  think  about  the  STAR  technique:

  • Situation
  • Task
  • Actions
  • Results

A  good  way  of  dealing  with  this  type  of  question  is  by  using  the  CAR  approach.  CAR  stands  for  Context,  Action,  Result.  It  helps  you  to  structure  your  answer  as  a  convincing  way.  The  CONTEXT  forms  an  introduction,  describing  the  scenario  you  faced,  date  and  place.  The  ACTION  forms  the  main  body  and  should  be  the  longest  part.  The  RESULT  is  the  conclusion,  and,  like  the  introduction,  should  be  quite  short.

Other  aspects  might  include:

  • Try  to  give  quantifiable  results  if  possible.
  • If  the  result  was  negative,  then  say  what  you  learned  from  the  experience,  and  what  you  would  do  differently  next  time.    Sometimes  interviewers  will  ask  you  about  a  situation  where  you  were  unsuccessful.  This  is  an  excellent  opportunity  to  demonstrate  how  well  you  learn  lessons  from  failure,  but  also  to  demonstrate  qualities  such  as  resilience  (to  bounce  back  and  try  again);  determination;  strength  of   character  (when  the  going  gets  tough,  the  tough  get  going!);  flexibility; initiative;  and   lateral  thinking.  There  is  a  saying  that  “The  most  successful  people  have  failed  the  most   as  the  best  way  to  learn  is  via  your  mistakes.
  • Don’t  go  into  too  much  background  detail  –  keep  to  the  point!  Often  there  isn’t   enough  room  to  use  the  CAR  approach,  but  it’s  still  worth  keeping  in  mind  when  you   prepare  your  draft  answer.   Think  of  the  most  relevant  examples,  rather  than  the  most  impressive”.
  • Use  action  verbs  to  improve  your  content.


?  Background

“[X]  has  minimum  academic  requirements,  so  before  completing  our  application  form  please  give   careful  consideration  to  the  following  questions:

Do  you  have  3  A  levels  at  grades  A,  B,  B  or  equivalent?  (N.B.  Taken  in  one  sitting  and  NOT  including  General  Studies.

Have  you  gained  or  are  you  realistically  expecting  to  gain  a  minimum  2.1  honours  degree  or  equivalent?

Have  you  previously  made  an  unsuccessful  application  to  []?”


?  Languages

Multiple  languages  can  be  added  by  selecting  the  language,  and  fluency  levels.

?  Education

Percentage  grades  are  now  required  for  undergraduate  and  postgraduate  subject  results.  You  are  required  to  ensure  that  your  institution  details  and  results  are  correct.  You  must  include  at  least  one  secondary  and  one  undergraduate  record  (including  all  results).  You  are  also  obliged  to  provide  a  complete  breakdown  of  all  your  grades  by  subject,  obtained    during  secondary  school  and  university.  Please  list  your  all  of  your  GCSEs  and  A’?  Levels  or  international  equivalent.

?   How did you hear about us?”

Various  options  are  given.  See  also  the  section  on  “Firm  choice”  below.  

?  Referees

You  are  normally  required  to  enter  details  of  two  employers  at  least,  sometimes  one  academic  and  one  vocational.

? Other details

Excluding motor offences not resulting in a custodial sentence or disqualification from driving, have you ever had a criminal  conviction (including  any spent conviction which, by virtue of the Rehabilitation of Offenders (Exceptions) Order 1975, should  be disclosed)?

You  will  need  to  disclose  any  criminal  convictions  anyway  if  you  wish  to  gain  student  enrolment  with  the  Solicitors  Regulation  Authority  to  do  the  Legal  Practice  Course.

Do you have any disability for which you require  any assistance for during the selection process?

As  well  as  being  a  practical  point  such  that  “reasonable  adjustments”  can  be  made  for  any  assessments  you  do,  including  for  online  assessments,  the  law  firm  will  be  interested  in  issues  of  accessibility  for  the  place  in  which  you  have  your  interview/other  assessments,  or  any  necessary  adjustments  (e.g.  special  lighting,  ergonomic  chair)  consistent  with  the  Equality  Act  [2010].

?  Work experience

Please  set out details of your work experience. (Normally 4 + “others”)

Many  large  solicitors’  firms  run  formal  work  experience  schemes,  generally  known  as  vacation  placements.    As  well  as  shadowing  solicitors  and  completing  small,  discrete  tasks  there  may  well  be  presentations  about  the  firm  and  its  work  and  a  number  of  social  events.    Unsurprisingly,  vacation  placements  are  extremely  popular  –  it  can  be  harder  to  get  onto  one  than  to  get  a  training  contract.  Most  vacation  placements  will  have  fixed  closing  dates.  As  well  as  spending  time  with  a  solicitors’  firm,  other  good  forms  of  legal  experience  include  volunteering  at  a  Citizens  Advice  Bureau  or  law  centre.

? Detailed questions

? Activities, interests, positions of responsibility

Please  give brief details of your key non-academic extra-curricular hobbies, activities, leisure interests, highlighting any positions of responsibility whether at school, university or otherwise.

Describe  your biggest achievement and/or most demanding position of responsibility you have held to date; why did this achievement stand out for you, and what did you learn  from this?

This  question  is  trying  to  assess  how  you  manage  your  time.  What  have  you  been  or  are  you  doing  whilst  studying  at  university  or  Law  School?  If  you  are  involved  with  any  sporting  or  charity  work  tell  them  all  about  it  -­ be  specific.  Talk  about  what  you  have  done,  what  contribution  that  has  made  and  what  you  gained  from  your  involvement.  These  activities  provide  opportunities  to  develop  skills  that  will  be  useful  at  work  and  your  response  should  show  that  you  understand  this.  A  simple  list  of  things  that  look  good  is  less  important  than  offering  evidence  of  what  you’ve  gained  from  them.  If  possible,  show  how  your  interests  have  developed  your  skills,  for  example  in  teamwork,  business  awareness,  or  communication.    Try  to  show  results  in  terms  of  objectives  set  and  achieving  improvements.  These  sections  are  often  quite  tight,  so  some  say  it’s  permissible  to  provide  an  answer  in  note  form.

? Prizes

Please  provide details of any academic prizes, distinctions, skills, scholarships and any other noteworthy achievements. In the case of skills please specify level of proficiency.

Sometimes  the  question  will  specify  which  “level”  of  your  education  these  refer  to,  e.g.  school,  college  or  university.

? Firm specification

Please  explain  why you think you are well suited  to [], and have chosen  to apply to [] for a training  contract or vacation scheme placement? why you think you would  make a successful trainee?

[X] is a leading  UK law firm. How do you think we are distinct from other law firms?

All [X] trainee  solicitors are based in our [Y] office. Please give your reasons for choosing  to live in or around and train at the [Y] office.

Again  this  question  is  trying  to  determine  your  commitment  to  a  career  and  specifically  your  commitment  to  their  particular  law  firm.  Recruiters  look  for  motivation,  commitment  and  enthusiasm.  So,  why  have  you  chosen  them?  Is  it  because  you  have  spoken  to  trainees  and  like  the  sound  of  the  firm’?s  working  environment?  Have  you  researched  their  work  and  found  a  specific  case  /  area  interesting?  Do  you  have  relevant  industrial  experience?  Do  you  have  a  language  or  are  from  a  country  that  they  have  clients  /  offices  in?  Is  there  something  particular  about  their  training  that  appeals  to  you?  Show  that  you  have  done  your  research  about  the  firm  and  that  you  are  genuinely  interested  in  them.

Apparently most  law  students  do  extensive  research  in  fact  into  their  choice  of  firm.   It’s  also  worth  noting  that @AllAboutCareers  and @AllAboutLaw  are  very  helpful in this regard, as well as “The Training Contract Handbook”.

? Career motivation

 What qualities do you think you possess  to be a successful lawyer in location [X] with [Y]? Which areas of law interest you and why?

Please  explain  what attracts you to a career as a solicitor at an international business  law firm, with reference to other careers  that you might have considered and why you chose  not to pursue them.

This question tries to determine your commitment to a career in law: the thinking and research you have done about the profession and what you want from a career as a lawyer. Can you demonstrate enough commitment and interest in law to persuade the firm to invest money and time in you for the Graduate Diploma in Law, Legal Practice Course and/or training contract? This may seem an obvious question but do you really know why you want to be a solicitor or barrister – think hard about it, this may be asked at interview.

If you can produce a convincing answer to this question you’re one step ahead. Think about what first sparked your interest in law, or what you like most about it. Maybe being a solicitor was your childhood dream, or maybe it runs in the family. Whatever the case, you need to show that you are passionate about the law. With all the academic requirements and vocational training, becoming a solicitor is a long-term project. To be offered a law training contract you need to show that you have the passion and the drive to see it through to the end.

Be specific in your reasons for choosing a legal career. Have you had any relevant work experience that has helped you to see first hand what a lawyer actually does? Have you had any personal experience of the work of a lawyer – perhaps through family or friends? Even if you have done pro bono in a law centre or a CAB, has this experience been useful in you understanding generic skills such as teamwork, communication or meeting deadlines? Has your law course or degree furthered your interest and commitment to law? Have you developed a substantial interest in access-to-justice? Have you had any relevant experience that has developed skills that would be easily transferable to a career as a lawyer?

The work of solicitors is more varied than you might think. There are a number of different settings in which solicitors work, for example commercial, private or in-house practice. You should be aware of the differences between the various settings, but if you’re not, do some research. Find out about the kind of role you might find yourself in if you were to go for commercial practice, for example. Is this what you hoped for when you embarked upon your law studies? If not, look into the other options. Being aware of your preferences is vital when choosing a firm with whom you want to carry out your training. Not only will it make what you learn more worthwhile, but you will find it easier to choose a firm. The firm will also find it easier to choose you.

For most training contract applicants, the choice boils down to the simple question: “Do I work in London, or do I work for a local regional firm? This is something of a personal choice, with implications that will affect your quality of life and your career. The largest firms are based in London and the legal market which circles the capital’s financial services industry is one of the most lucrative in the world. This translates into higher average pay packets for London solicitors. Aside from the careers benefits to choosing London, trainees can enjoy all the social and cultural activities that the cosmopolitan city has to offer. However, the cost of living is higher in London and you will have to content with the traffic and rush hour crushes on the tube. Working hours are often longer at London firms and you may find a more attractive work-life balance at firms outside of the capital. The choice, as always, is yours.

? Commercial awareness

Identify a current  commercial article that you read  or a recent  event  from the business  world which has attracted your attention recently.  Why do you consider  it to be significant? Who are the key stakeholders in this situation and what are the implications for those concerned?

Business  acumen and commercial awareness are important elements to becoming a successful solicitor. Please outline, in your opinion, why you think this would  be important and tell us about a time  when  you’ve demonstrated your abilities in this area. What was the occasion and what impact did possessing this awareness have over the final outcome?

Choose  a sector group of the firm and summarise the biggest challenges and opportunities they will face in the future.

Commercial  awareness  is  something  that  firms  almost  without  exception  mention  as  a  desirable  quality.  Commercial  awareness  is  generally  defined  as  a  candidate’?s  general  knowledge  of  business.  It  can  be  summed  up  as  an  interest  in  business  and  an  understanding  of  the  wider  environment  in  which  an  organisation  operates:  its  customers  and  competitors.  For  corporates,  this  is  about  establishing  “competitive  advantage”,  and  it’s  often  interesting  to  work  out  how  companies  enter  new  markets  (especially  the  BRIC  emerging  economies),  and  what  barriers  there  might  be  for  companies  competing  effectively  in  critical  markets.

Commercial  awareness  generally  means  an  understanding  of  a  client’?s  business  and  the  industry  or  sector  in  which  it  operates.  It  is  a  key  competency  for  applicants.  It  involves  not  only  keeping  up  to  date  with  commercial  issues  and  it  is  also  about  being  able  to  demonstrate  commercial  awareness  through  any  business/work  experience  and,  specifically,  the  applicant’s  understanding  of  the  type  of  firm  to  which  they  are  applying.  Clients  seek  business  solutions,  presented  in  a  way  that  makes  sense.  An  understanding  that  a  law  firm  operates  in  a  competitive  industry  is  also  considered  as  being  commercially  aware.

As  a  result  you  may  be  expected  to  demonstrate  an  understanding  as  to  how  the  firm  or  chambers  markets  itself  to  its  clients.  To  know  who  the  firm’s  main  competitors  are.  To  explain  how  you  would  attract  a  potential  client  by  explaining   the  unique  selling  points  of  the  firm  (USPs).  For  example,  if  you’re  applying  to  a  foreign  firm,  it’s  not  inconceivable  you  could  be  asked  who  the  major  players  are  in  that  particular  market  (e.g.  the  US  market).  In  addition  to  this  you  will  be  expected  to  know  about  the  practice  areas  in  which  the  firm  or  chambers   operate  and  to  be  aware  of  key  changes  in  legislation  and  the  economic  market  which  may  affect   the  way  in  which  they  operate.

Have  you  done  a  LL.M.  in  international  commercial  law  where  you  might  have  gained  important  experience  in  drafting  or  case  analysis  in  this  particular  field  of  law?  Have  you  even  done  a  M.B.A.  where  you  have  studied  business  management  in  great  detail?  You  could  also  think  about  participating  in  any  student  societies  where  you  are  doing  the  GDL  or  LPC  –  these  are  very  active  the  vast  majority  of  “learning  providers”.

Mention  any  business/commercial  experience  you  have  had,  including  non-­legal  work  and/or   roles  which  involve  dealing  with  clients  or  members  of  the  public.  Have  you  ever  been  a   Director  of  a  private  limited  company  yourself?  This  can  highlight  your  awareness  of  customer   needs  and  expectations.  Were  you  ever  given  the  task  of  improving  a  current  service  or  product?  Did  you  add  value  to  it?  If  so,  how  did  you  go  about  it,  what  factors  did  you  have  to  take  into  consideration?  Are  you  able  to  identify  the  long  term  and  short  term  goals  of  an  organisation  or   a  project?

Thinking  in  terms  of  a  SWOT  (the  strengths,  weaknesses,  opportunities  and  threats)   analysis  of  the  firm  or  legal  sector  can  be  helpful.

Did  you  have  a  key  role  in  any  society  committees  at  school  or  university?  Were  you  given  a  financial  role?  Any  of  these  can  be  good  indicators  that  you  have  had  to  think  about  different  perspectives  in  the  market  place.

Have  you  ever  raised  money  for  a  charity,  secured  sponsorship  for  an  event?  What  process  did  you  go  through   to  secure  the  funds?    Read  the  business  press  regularly.  Try  to  know  something  about  current  leading  stories/issues,  and  how  they  might  have  an  impact  on  the  firm’s  clients.  Look  out  for  stories  that  will  affect  the  firm  to  which  you  are  applying,  or  its  clients,  directly  or  indirectly.

Look  at  the  BBC  news  and  business  website.  Read  also  publications  like  the  Financial  Times,  the  Economist,  and  The  Lawyer.  There  are  business  related  programmes  on  BBC  Radio  which  are  also  available  to  listen  again  on-­??line  and  as  podcasts  such  as:

The  Bottom  Line  (with  @EvanHD)    “Insight  into  business  from  the  people  at  the  top.  Evan  Davis  meets  influential  business  leaders  for  a  round  table  conversation  about  the  issues  that  matter  to  their  companies  and  their  customers.”


? Proactivity

 Describe  an occasion when  you spotted an opportunity to make an improvement in ‘going the extra mile’, and took action without being asked  to do so. What steps did you take? What was the outcome? Explain why you think this attribute is relevant for a solicitor.

This  question  is  testing  your  problem  solving  ability.  Detail  what  the  issue  was,  why  it  was  difficult  and  then  what  you  did  to  resolve  it.  If  you  are  talking  about  a  group  activity,  do  not  put   ‘?we‘?  -­  they  are  interested  in  what  you  did.  As  with  all  your  answers  use  this  question  to   differentiate  yourself  i.e.  make  it  personal  and  substantiate  what  you  say  with  specific  examples.

Aspects  of  a  good  answer  might  be  as  follows.

  • Use  initiative  to  act  on  opportunities.  Become  a  leader  before  other  people  view  you  as  one.  Healthy  organisations  often  reward  those  who  take  the  lead,  not  just  those  with  formal  management  roles.
  • Take  responsibility  for  own  objectives:  set  priorities.  Display  a  “?can  do“?  attitude  even  in  demanding  situations.  Try  to  solve  problems,  rather  than  to  pass  them  on  to  other  people.
  • ?Go  the  extra  mile?  when  asked  to  do  tasks.  Go  beyond  your  job  description.  Do  work  that  gets  you  noticed.  Show  enthusiasm:  this  will  be  noticed  and  you  will  eventually  be  rewarded.
  • Take  ownership  of  problems:  anticipate  potential  problems,  take  pre-­emptive  action  and   act  quickly  to  resolve  problems.  Develop  innovative  practices.  Value  innovative  thinking.
  • Learn  new  skills  that  will  enhance  capability.


? Flexibility  

Describe  a time that you have had to change your approach to a project or task halfway through. What changes did you have to make? Why did you need to make these changes? What was the outcome?

This  means  that  you  are  able  to  modify  your  approach  to  achieve  a  goal,  and  you  are  open  to  change  and  new  information;  you  can  rapidly  adapt  to  new  information,  changing  conditions,  or  unexpected  obstacles.  Legal  recuiters  are  often  looking  for  the  following  aspects.


1.  Values  need  for  flexibility:  

  • Accepts  that  other  people’s  points  of  view  are  reasonable  or  valid.
  • Acknowledges  that  people  are  entitled  to  their  opinions,  and  accepts  that  they  are   different.
  • Steps  into  colleagues’  tasks  when  needed  or  required.

2.  Demonstrates  flexibility:  

  • Works  creatively  within  standard  procedures  to  fit  a  specific  situation.
  • Understands  policies  and  can  work  within  them  to  meet  office,  work  group,  team  or   individual  goals.

3.  Adapts  approach:  

  • Changes  one’s  approach  as  required  to  achieve  intended  outcomes.
  • Prioritises  actions  effectively  in  order  to  respond  to  numerous,  diverse  challenges  and   demands.

4.  Adapts  strategy:  

  • Changes  the  overall  service  plan  and  implements  new  practices  when  original  approach   and  assumptions  are  no  longer  valid.
  • Able  to  shift  strategic  focus  and  activities  quickly  in  response  to  changing  organisational  priorities.

? Teamwork

Teamwork  is  considered  crucial  to  functioning  well  as  a  trainee/junior  in  a  corporate  law  firm.  

Please  give an example of a situation where  you were required to work in a team to accomplish an important objective and describe your role in achieving  this objective.

A  law  student  who  is  good  at  teamwork  might:

  • Believe  that  working  together  with  others  or  in  teams  gives  higher  synergies  to  self  and   the  teams,  and  therefore  is  positive  and  enthusiastic  about  teamwork  and  team  building.
  • Contributes  significantly  when  working  as  a  member  of  a  team  or  when  working  as  a  team  leader  to  build  a  strong  team;  respects  all  the  members  of  the  team  and  cooperates  with  every  team  member  and  the  team  leader.
  • Provides  help  and  support  to  those  team  members  who  are  in  need  of  help  and  support,  and  shares  relevant  knowledge  and  information  with  all  the  team  members  including  the   team  leader.
  • Maintains  the  required  level  of  communication  in  terms  of  quality,  quantity  and   timeliness  with  the  team  members  and  the  team  leader.
  • When  working  as  a  team  leader,  facilitates  developing  team  goals  with  team  members’  participation.
  • Motivates  the  team  members  while  working  as  a  leader  of  the  team  or  even  when  working  as  a  member  of  the  team,  building  up  high  team  morale;  creates  a  sense  or  feeling  of  cohesiveness  among  the  fellow  members.
  • Is  good  at  resolving  the  conflicts  that  might  arise  due  to  diverse  personalities  of  various   team  members.
  • When  the  members  seem  to  err  from  the  shared  mission,  goals  and  priorities,  brings  them   back  on  the  desired  focus.
  • Seeks  for  each  and  every  member’?s  active  and  enthusiastic  participation  all  the  time  and  accordingly  motivates  the  members  who  seem  to  be  getting  disinterested  or  tuned  out  from  time  to  time.
  • Makes  every  member  feel  that  each  one’?s  work  or  contribution  is  equally  important.
  • Shares  credit  for  success  of  team  with  all  the  others  in  the  team.
  • Celebrates  the  team’?s  success  together  with  all  the  others  in  the  team.
  • Makes  sure  that  the  various  teams  do  not  become  islands  in  themselves  and  form   unnecessary  boundaries  around  them.

? Defining qualities of the candidate

 What can you tell us about yourself that sets you apart from other applicants, and which are convincing reasons why we should  recruit you?

In  a  sense,  your  answer  to  this  question  is  to  some  extent  governed  by  your  personal  qualities  not  covered  elsewhere  in  the  form.  Here  are  some  further  competences  which  might  be  relevant  here.


A  trainee  will  be  expected  to  upholds  the  principles  of  the  current  SRA  Code  of  ConductSome   aspects  might  include:

  •  Holds  to  a  laudable  value  structure  all  the  time  and  in  all  the  situations.
  • Practices  integrity  while  dealing  with  everyone  and  therefore  is  regarded  as  trustworthy   person.
  • Does  not  turn  and  twist  the  information  to  gain  something  or  to  score  a  point  in  an   underhand  manner.
  • Uses  confidential  information  confidentially.  Does  not  divulge  the  confidential  information   even  under  any pressure.
  • Does  not  indulge  in  any  kind  of  corruption  or  corrupt  practices.
  • Motivates  others  to  practice  integrity  by  being  an  example  to  others.


Some  aspects  might  include:

  •  Can  envision  the  advancement  and  growth  opportunities.
  • Possesses  abilities  for  high  degree  of  conceptualization,  strategising  and  analysis.
  • Demonstrates  high  achievement  orientation.  Therefore,  emphasises  commitment, accountability,  action  orientation  and  results.
  • Adept  at  interpersonal  relationships  and  puts  emotional  intelligence  in  action.
  • Excellent  communicator.
  • Uses  his  excellent  influencing  skills  for  bringing  out  the  desired  consensus,  decisions  and   actions.
  •  Very  good  at  decision  making  processes  and  once  decisions  are  reached,  displays  firmness  and  decisiveness  in  implementation.
  • Displays  required  flexibility  and  adaptability  in  different  situations  and  times.
  • Is  great  team  builder  and  team  player.  Provides  necessary  support  and  cooperativeness.
  • Possesses  high  commercial  awareness  and  business  acumen.
  • Develops  many  next  line  leaders.

? Communication skills

 All solicitors at [X] work with a wide range  of people so need to be able  to persuade, influence and display effective communication skills. Describe  a situation when  you have had to communicate effectively.

You  should  think  of  various  forms  of  effective  communications,  e.g.  oral  presentations,  written  papers,  written  papers,  drafting,  interviewing  or  advising  (on  the  LPC),  practical  legal  research  (on  the  LPC),  blogging,  participating  in  podcasts,  and  how  you  have  adapted  your  method  of  communication  according  to  the  target  audience.  Your  answer  is  bound  to  be  more  compelling  if  you  can  give  concrete  examples.  Some  related  specific  competences  are  given  as  below.


One  scenario  where  persuading  skills  can  be  important  is  the  job  interview,  but  the  following  tips   are  valuable  in  many  other  settings.

  • Focus  on  the  needs  of  the  other  party.  Take  time  to  listen  to  them  carefully  and  find  out  about  their  interests  and  expectations.  This  shows  that  you  are  really  interested  in  them  and  they  are  then  more  likely  to  trust  and  respect  you.  It  will  also  make  it  easier  for  you  to  outline  the  benefits  of  your  proposal  in  terms  they  understand.
  • Argue  your  case  with  logic.  Do  careful  research  on  your  ideas  and  those  of  your   competitors  (if  there  are  any)  and  make  sure  that  any  claims  you  make  can  be  verified.
  • Use  positive  rather  than  negative  language:  instead  of  saying  “?You’?re  wrong  about  this”?,   say  “?That’?s  true  but  ….”?,  “?That’?s  an  excellent  idea,  but  if  we  look  more  deeply  …..”?  or  “?I   agree  with  what  you  say  but  have  you  considered  ….”?.  


Some  aspects  might  include:

  • Believes  that  listening  strengthens  the  quality  of  communication,  interpersonal  relations,   human  relations,  emotional  intelligence,  conflict  management  and  team  management.
  • Every  interaction  requires  one  to  respond  and  since  the  quality  of  response  depends  on   the  quality  of  listening,  tries  to  improve  quality  of  his  listening  constantly.
  • Thus,  listens  to  understand  the  other  person  and  not  just  to  react,  reply,  control  or  manipulate  the  other  person.  By  understanding  the  other  person  properly,  can  respond  or  act  in  the  best  possible  manner.
  • Generally  respects  other  people  and  demonstrates  openness  and  trust  through  his  body   language  and  spoken  words.
  • Then,  paves  way  to  influencing  the  people  in  right  directions  by  diagnosing  the  issues  and   concerns  of  others  in  a  better  way  for  effective  problem  solving.
  • Promotes  a  more  participative  style  of  managing  by  involving  people.

? Conflict and pressure

The success  of [X] is built on the self-motivation and applied  effort of all its employees, as demonstrated by their ability to work through setbacks coping effectively with conflict and pressure.  Describe  a situation when  you have had to deal  with conflict and pressure. Which other people involved?  What did you learn about yourself?

Some  aspects  might  include  the  observations  that  the  law  student:

  • Recognises  the  fact  that  conflicts  are  quite  natural  in  any  organization  and  yet  these  need  appropriate  redressing  to  move  on  with  apt  solutions,  thereforeis  willing  to  take  up  the  responsibility  of  managing  and  resolving  the  conflict.
  • Can  think  through  clearly  in  a  conflicting  situation.
  • Keeps  his  eyes  constantly  on  the  desired  goals  and  therefore,  does  not  drift  away  from  them  despite  conflicting  arguments  and  points  of  views.
  • Listens  well  and  patiently  all  the  conflicting  arguments  and  presentations.
  •  Controls  the  people  and  their  communication  patterns  in  the  discussions  that  takes  place   when  resolving  a  conflict.
  • Facilitates  the  innovative  and  creative  thinking  of  the  people  caught  up  in  the  conflict.
  • Does  not  take  sides  of  any  particular  set  of  people  or  their  thinking.  Rather,  tries  to   facilitate  working  out  genuinely  appropriate  and  optimal  solutions.
  • Contributes  his  own  inputs,  ideas,  creativity  and  analysis  to  supplement  the  missing  or  erroneous  information  and  thus  uncover  the  real  issues  and  reasons  that  led  to  the  conflict.  Then  proceeds  to  help  find  the  answers.
  • Gains  agreements  without  leaving  behind  any  bitter  taste  or  disrupting  the  human   relationships.
  • Is  proactive  and  as  far  as  possible  anticipates  the  conflicting  situations  and  dissolves  them   well  before  they  turn  into  conflicts.

? Commitment to excellence

Describe  an occasion when  you have demonstrated commitment to a task or project  that resulted in you exceeding expectations either for yourself  or others. What steps did you take? What was the outcome?

You  will  be  able  to  achieve  the  excellence  in  any  skill  or  competency  only  if  you  rehearse  or  practice  the  learned  skill  a  large  number  of  times.  Knowledge  alone  is  no  guarantee  for  achieving  great  levels  in  skills  or  competencies.  For  example,  only  if  you  start  swimming,  you  will  become  a  swimmer;  mere  knowledge  of  swimming  or  great  theories  of  swimming  will  not  automatically  make  you  even  an  ordinary  swimmer.  Knowledge  surely  helps  and  is  a  must  but  without  doing,  it  is  of  no  use  to  you.  Implementation  of  knowledge  is  the  name  of  the  game.  Wisdom  is  in  knowing  what  to  do  and  how  to  do  but  the  virtue  is  doing  it.

It’s  said  that  you  should  become  both  consciously  and  unconsciously  competent  in  your  strive  for  excellence.  Consciously  competent  means  gaining  the  knowledge  about  the  skill  to  be  mastered  and  begin  practicing  the  knowledge  gained  (example:  gaining  knowledge  on  how  to  swim  using  proper  styles  of  swimming  and  start  swimming  using  the  right  styles  of  swimming).  On  the  other  hand,  unconsciously  competent  means  keep  practicing  the  knowledge  gained  till  you  gain   mastery  in  the  skill  (example:  you  have  now  become  an  expert  swimmer  since  you  have  been   swimming  using  the  proper  styles  of  swimming  over  number  of  hours  and  you  can  now  give  yourself  9  on  10  or  even  10  on  10).  For  greater  success  in  life,  you  should  try  to  reach  the  unconsciously  competent  level  in  the  skills  required  by  you  for  your  professional,  personal,  family  and  social  activities/tasks/projects.

? Personal challenge

Describe  a significant challenge that you have faced  outside of your academic studies ideally from the last 2 years. How did you initially analyse the challenge? What approach did you take to solving it? What did you learn from this challenge?

  • Successful  answers  to  these  sorts  of  questions  need  to  be  as  concrete  as  possible.  Supply  specific  detail  on  the  situation,  the  actions  taken  and  the  results  achieved.  Figures  can  be  particularly  useful  in  this  context.
  •  Your  example  need  not  be  very “significant”.  Go  for  something  you  genuinely  believe  to  be  a  real   achievement  rather  than  give  them  something  you  think  they  want  to  hear  -­ it’ll  be  more  convincing.  The  important  thing  is  to  set  it  in  context.  Explain  why  it  was  significant  to  you  -­ if  you’re  unsporty,  uncoordinated  and  broke  your  leg  six  months  previously,  learning  to  stay  upright  while  sliding  a  few  hundred  metres  downhill  may  well  have  been  a  major  achievement.    
  • A  useful  device  is  the  Trojan  horse  technique,  which  allows  you  to  smuggle  in  other   examples  as  in  “  I  considered  selecting  one  of  several  achievements,  including  x  and  y.  However  I   have  chosen  z  because…....”    

Aspects  of  a  convincing  answer  might  include  the  following.

1.  Recognises  Lack  of  Success:

Acknowledges  areas  where  expectations  are  not  met,  and  provides  reasons  which  may  or  may  not   involve  self.

2.  Remains  Positive:

Re-­energises  after  loss  or  failure  or  after  encountering  a  significant  hurdle  to  readdress  the  situation  and  to  overcome  it;  approaches  new  situations  with  continuing  positive  outlook,  despite  previous  disappointments.

3.  Takes  Responsibility:

Acknowledges  personal  responsibility  for  outcomes,  even  when  not  all  elements  of  a  situation  are   within  direct  control  but  could  have  been  personally  managed.

4.  Learns  from  Mistakes  and  Successes:

Analyses  situations  on  an  ongoing  basis  to  improve  own  performance;  designs  a  personal  action   plan  to  address  own  issues  constructively  and  decisively.

5.  Shares  Learning  with  Team:

Deals  openly  with  failure  by  bringing  team  together  to  define  specific  problems  and  present  solutions;  may  involve  team  in  diagnosis  and  in  developing  solutions  to  effectively  transfer  knowledge  into  the  organisation.

? Mitigating circumstances

Are there any important mitigating circumstances why you feel the exam  results you have listed do not fully reflect your abilities?

There  may  be  good  reasons  why  you  ‘underperformed’,  due  to  recent  bereavement,  or  illness  and   disease,  and  these  should  be  set  out  with  reference  to  documentary  evidence  where  possible.

Additional information

If applicable, please  state any additional information which you think is relevant and supportive to your application or which you think has not been covered adequately in this form.

This is a good opportunity to do precisely that!




I did at least predict the winner of the Eurovision Song Contest 2013

This was the final results scorecard for last night’s Eurovision Song Contest:

  1. Denmark: Emmelie de Forest, Only Teardrops – 281 points
  2. Azerbaijan: Farid Mammadov, Hold Me – 234 points
  3. Ukraine: Zlata Ognevich, Gravity – 214 points
  4. Norway: Margaret Berger, I Feed You My Love – 191 points
  5. Russia: Dina Garipova, What If – 174 points
  6. Greece: Koza Mostra feat. Agathon Iakovidis, Alcohol Is Free – 152 points
  7. Italy: Marco Mengoni, L’Essenziale – 126 points
  8. Malta: Gianluca, Tomorrow – 120 points
  9. Netherlands: Anouk, Birds – 114 points
  10. Hungary: ByeAlex, Kedvesem – 84 points
  11. Moldova: Aliona Moon, O mie – 71 points
  12. Belgium: Roberto Bellarosa, Love Kills – 71 points
  13. Romania: Cezar, It’s My Life – 65 points
  14. Sweden: Robin Stjernberg, You – 62 points
  15. Georgia: Nodi Tatishvili and Sophie Gelovani, Waterfall – 50 points
  16. Belarus: Alyona Lanskaya, Solayoh – 48 points
  17. Iceland: Eythor Ingi, Eg a lif – 47 points
  18. Armenia: Dorians, Lonely Planet – 41 points
  19. UK: Bonnie Tyler, Believe In Me – 23 points
  20. Estonia: Birgit, Et uus saaks alguse – 19 points
  21. Germany: Cascada, Glorious – 18 points
  22. Lithuania: Andrius Pojavis, Something – 17 points
  23. France: Amandine Bourgeois, L’enfer et moi – 14 points
  24. Finland: Krista Siegfrids, Marry Me – 13 points
  25. Spain: ESDM, Contigo hasta el final – 8 points
  26. Ireland: Ryan Dolan, Only Love Survives – 5 points

And here’s how I voted, only on the basis of listening to 10 seconds of each:

1 Denmark 12
2 Iceland 10
3 Germany 8
4 Azerbaijan 7
5 Finland 6
6 Russia 5
7 Latvia 4
8 Malta 3
9 Austria 2
10 Belarus 1

11 Switzerland
12 Ireland
13 Georgia
14 United Kingdom
15 Norway
16 Sweden
17 Italy
18 Moldova
19 Spain
20 Lithuania
21 Albania
22 France
23 San Marino
24 Croatia
25 Israel
26 The Netherlands

Outsourcing, NHS, and the “modern anomie”



Jon Cruddas recently gave a progress report on how the evolution of ‘One Nation’ policy was going, In an article by Patrick Wintour published yesterday, Cruddas describes a ‘modern anomie’, a breakdown between an individual and his or her community, and alludes to the challenge of institutions mediating globalisation. Cruddas also describes something which I have heard elsewhere, from Lord Stewart Wood, of a more ‘even’ creation of wealth, whatever this means about the even ‘distribution’ of wealth. One of the lasting legacies of the first global financial crisis is how some people have done extremely well, possibly due to their resilience in economic terms. For example, it has not been unusual for large corporate law firms to maintain a high standard of revenues, while high street law has come close to total implosion in some parts of the country. In a way, this reflects a shift from pooling resources in the State to a neoliberal free market model.


The global financial crash did not see a widespread rejection of capitalism, although the Occupy movement did gather some momentum (especially locally here in St. Paul’s Cathedral). It produced glimpses of nostalgia for ‘the spirit of ’45”, but was used effectively by Conservative and libertarian political proponents are causing greater efficiencies. Indeed, Marks and Spencer laid off employees, in its bid to decrease the decrease in its profits, and this corporate restructuring was not unusual. A conservative and a libertarian have several things in common, the most important is the need for people to take care of themselves for the most part. Libertarians want to abolish as much government as they practically can. It is thought that the majority of libertarians are “minarchists” who favour stripping government of most of its accumulated power to meddle, leaving only the police and courts for law enforcement and a sharply reduced military for national defence. A minority are possibly card-carrying anarchists who believe that “limited government” is a delusion, and the free market can provide better law, order, and security than any goverment monopoly.


Essentially a libertarian would fund public services by privatising them. In this ‘brave new world’, insurance companies could use the free market to spread most of the risks we now “socialise” through government, and make a profit doing so. That of course would be the ideal for many in reducing the spend on the NHS, to produce a rock-bottom service with minimal cost for the masses. And to give them credit, the Health and Social Care Act was the biggest Act of parliament, that nobody voted for, to outsource the operations of the NHS to the private sector, which falls under the rubric of privatisation.  Outsourcing is an arrangement in which one company provides services for another company that could also be or usually have been provided in-house. Outsourcing is a trend that is becoming more common in information technology and other industries for services that have usually been regarded as intrinsic to managing a business, or indeed the public sector.


Many expected the election of the present government to herald a more determined approach to outsourcing public services to the private sector. Initially came the idea of the “big society”, with its emphasis on creating and using more social enterprises to deliver public services, but the backers for this new era of venture philanthropism were not particularly forthcoming. The PR of it, through Steve Hilton and colleagues, was disastrous, and even Lord Wei, one of its chief architects, left. No one in the UK likes the idea of domestic jobs moving overseas. But in recent years, the U.K. has accepted the outsourcing of tens of thousands of jobs, and many prominent corporate executives, politicians, and academics have argued that we have no choice, that with globalisation it is critical to tap the lower costs and unique skills of labor abroad to remain competitive. They argue that Government should stay out of the way and let markets determine where companies hire their employees. But is this debate ever held in public? No, there was always a problem with reconciling the need for cuts with an ideological thirst for cutting the State. Unfortunately, cutting the State was cognitively dissonant with cutting the ‘safety net’ of welfare, which is why the rhetoric on scroungers had to be ‘upped’ in recent years by the UK media (please see original source in ‘Left Foot Forward’). And so it came to be, the Compassionate era of Conservatism came to pass.


Here in the UK, in 2010, the government indicated that it wanted to see new entrants into the outsourcing market, and the prime minister visited Bangalore, the heart of India’s IT and outsourcing industry, for high profile meetings with chief executives of companies such as TCS, Infosys, HCL and Wipro. Nobody ever bothers to ask the public what they think about outsourcing, but if Gillian Duffy’s interaction with Gordon Brown is anything to go by, or Nigel Farage’s baptism in the local elections has proved, the public is still resistant to a concept of ‘British jobs for foreign workers’. However, it is still possible that the general public are somewhat indifferent to screw-ups of outsourcing from corporates, in the same way they learn to cope with excessive salaries of CEOs in the FTSE100. The media have trained us to believe that unemployment rights do not matter, and this indeed has been a successful policy pursued by the Conservatives and Liberal Democrats. People do not appear to blame the Government for making outsourcing decisions, for example despite the fact that the ATOS delivery of welfare benefits claims processing has been regarded by many as poor, the previous Labour government does not seem to be blamed much for the current fiasco, and the current fiasco has not become a major electoral issue yet.


And the list of screw-ups is substantial. G4S – the firm behind the Olympic security fiasco – has  nowbeen selected to support the Police Service of Northern Ireland at the G8 Summit next month. Despite the company’s botched handling of the Olympics Games contract last summer, G4S has been chosen to supply 450 security staff for the event at Lough Erne, County Fermanagh The leaders of the world’s eight wealthiest countries are expected in Fermanagh on June 17 and 18. Meanwhile, medical assessments of benefit applicants at Atos Healthcare were designed to incorrectly assess claimants as being fit for work, according to an allegation of one of the company’s former senior doctors has claimed. Greg Wood, a GP who worked at the company as a senior adviser on mental health issues, said claimants were not assessed in an “even-handed way”, that evidence for claims was never put forward by the company for doctors to use, and that medical staff were told to change reports if they were too favourable to claimants. Elsewhere, Scotland’s hospitals were banned from contracting out cleaning and catering services to private firms as part of a new drive towards cutting the spread of deadly superbugs in the NHS. There were 6,430 cases of C. difficile infections in Scotland in one year recently, of which 597 proved fatal. The problem was highlighted by an outbreak of the infection earlier this year at the Vale of Leven hospital in Dunbartonshire which affected 55 people. The infection was identified as either the cause of, or a contributory factor in, the death of 18 patients.


Whatever our perception of the public perception, the impact on transparency and strong democracy merit consideration. As we outsource any public service, we appear to risk removing it from the checks and balances of good governance that we expect to have in place. Expensive corporate lawyers can easily outmanoeuvre under-resourced government departments, who often appear to be unaware of the consequences, and this of course is the nightmare scenario of the implementation of the section 75 NHS regulations. Even talking domestically, Where contracts privilege commercial sensitivities over public rights, they can be used to exclude the provision of open data or to exempt the outsourcer from freedom of information requests. Talking globally, “competing in the global race” has become the buzzword for allowing UK companies to outsource to countries that do not have laws (or do not enforce laws) for environmental protection, worker safety, and/or child labour. However, all of this is to be expected from a society that we are told wants ‘less for more’, but then again we never have this debate. Are the major political parties afraid to talk to us about outsourcing? Yes, and it could be related to that other ‘elephant in the room’, about whether people would be willing to pay their taxes for a well-run National Health Service, where you would not be worried about your local A&E closing in the name of QUIPP (see this blogpost by Dr Éoin Clarke). Either way, Jon Cruddas is right, I feel; the ‘modern anomie’ is the schism between the individual and the community, and maybe what Margaret Thatcher in fact meant was ‘There is no such thing as community’. If this means that Tony Blair feels that ‘it doesn’t matter who supplies your NHS services’, and we then get invasion of the corporates into the NHS, you can see where thinking like this ultimately ends up.

A response to Tony Blair's "advice" this morning




This is a response to “Labour must search for answers and not merely aspire to be a repository for people’s anger”, by Tony Blair, published in the New Statesman on 11 April 2013.


Fundamentally, Blair is right in that Labour cannot merely be a conduit for ‘the protest vote’, but the issues raised by heir to Thatcher are much more than that to me. Blair argues that, “the paradox of the financial crisis is that, despite being widely held to have been caused by under-regulated markets, it has not brought a decisive shift to the left.” I am not so sure about that. Whilst I have always felt the taxonomy of ‘left’ versus ‘right’ largely unhelpful in British politics, I think most people in the country today share views about bankers and the financial services ‘holding the country to ransom’ (like the Union Barons used to be accused of), the failures of privatisation, the failures in financial regulation (PPIs), for example, which might have been seen as ‘on the left’. Tony Blair had a good chance of coming to power in 1997, and ‘the pig with a Labour rosette might have won at the 1997 General Election’ is not an insubstantial one. To ignore that there has been no shift in public opinion is to deny that the political and social landscape has changed to some degree. Whilst ‘South Shields man’ is still living with the remants of the ‘socially divisive’ Thatcherite government, what Michael Meacher MP politely called yesterday “a scorched earth approach”, voters are indeed challenging flagship Thatcherite policies even now.


Some Labour councillors and MPs did indeed embrace the ‘right to buy’ policy, but likewise many MPs of diverse political aetiology warn about the currentcrisis in social housing. Blair is right to argue, “But what might happen is that the left believes such a shift has occurred and behaves accordingly”, in the sense that Ed Miliband does not wish to disenfranchise those voters who did happen to embrace New Labour pursuant to a long stretch of the Conservative sentence, but we have a very strong danger now of disenfranchise the core voters of Labour. They are rightly concerned about workers’ and employees’ rights, a minimum wage (a Blair achievement), and a living wage (possibly a 2015 manifesto pledge by Ed Miliband.)  Nobody wants to re-fight the battle of ‘left’ and ‘right’ of those terms, but merely ‘building on’ the purported achievements of Margaret Thatcher has to be handled with care.


Blair further remarks: “The Conser­vative Party is back clothing itself in the mantle of fiscal responsibility, buttressed by moves against “benefit scroungers”, immigrants squeezing out British workers and – of course – Labour profligacy.” Of course, Blair does not address the growth of the welfare dependency culture under Margaret Thatcher, but this is essential. Blair has also airbrushed the core of the actual welfare debate, about ensuring that disabled citizens have a ‘fair deal’ about their benefits, but to his credit addresses the issue of pensions in his fourth question. However, Blair falls into the trap also of not joining up thinking in various arms of policy, in other words how immigrants have in fact contributed to the economy of the UK, or contributed essential skills to public services such as the National Health Service. This is indeed a disproportionate approach to immigration that was permeating through the language of Labour ministers in immigration towards the end of their period of government. Blair fundamentally wishes to fight this war – indeed battle – on his terms and Thatcher’s terms. This is not on – this debate is fundamentally about the divisive and destructive nature of policy, of pitting the unemployed against the employed, the disabled against the non-disabled, the immigrant versus the non-immigrant, and so on. Part of the reason that Thatcher’s entire hagiography cannot be a bed of roses is that there exists physical evidence today of this ‘divide-and-rule’ approach to leadership.


Blair, rather provocatively at this stage, refers to the ‘getting the house in order’, which is accepting the highly toxic meme of ‘A Conservative government always has to come in to repair the mess of a Labour government spending public money it doesn’t have.’ However, the economy is in a worse state than bequeathed by Labour in 2010, and therein lies the problem that the house that the Tories ‘is getting in order’ is in fact getting worse. Acknowledgement of this simple economic fact by Blair at this juncture would be helpful. Blair’s most potent comment in the whole passage is: “The ease with which it can settle back into its old territory of defending the status quo, allying itself, even anchoring itself, to the interests that will passionately and often justly oppose what the government is doing, is so apparently rewarding, that the exercise of political will lies not in going there, but in resisting the temptation to go there.” Like all good undergraduates, even at Oxford, this depends on what exactly Blair means by the “status quo” – the “status quo” is in Thatcherism, and the “greatest achievement” of Conservatism, “New Labour”, so a return to listening to the views of Union members, ahead of say the handful of wealth creators in the City, is in fact a radical shift back to where we were. In other words, a U-turn after a U-turn gets you back to the same spot.


Blair then has a rather sudden, but important, shift in gear. He writes, “The guiding principle should be that we are the seekers after answers, not the repository for people’s anger.” This is to some extent true from the law, as we know from the views from LJ Laws who has described the challenges of making dispassionate legal decisions even if the issues are of enormous significance in social justice. Blair, consistent with an approach from a senior lawyer remarks, “In the first case, we have to be dispassionate even when the issues arouse great passion.” But then he follows, “In the second case, we are simple fellow-travellers in sympathy; we are not leaders. And in these times, above all, people want leadership.” Bingo. This is what. Whatever Ed Miliband’s ultimate ideology, which appears to be an inclusive form of social democracy encouraging corporate as well as personal citizenship, people ultimately want a very clear roadmap of where he is heading. The infamous articulation of policy under Cruddas will help here, but, as Ed Miliband finds his feet, Miliband will be judged on how he responds to challenges, like Thatcher had to respond to the Falklands’ dispute or the Miners’ Strike.


Blair fundamentally is right to set out the challenges. In as much as the financial crisis has not created the need for change per se, to say that it has not created a need for a financial response is ludicrous. The ultimate failure in Keynesian policy from Blair and Brown is that the UK did not invest adequately in a period of growth, put tritely by the Conservatives as “not mending the roof while the sun was shining”. Mending the roof, to accept this awful image, is best done when the sun is shining. Therefore, Labour producing a policy now is to some extent not the best time to do it. Blair had a great opportunity to formulate a culture in the UK which reflected Labour’s roots in protecting the rights and welfare of workers, but it decided not to do so. Tarred with the ‘unions holding the country to ransom’ tag, it decided to Brown-nose the City quite literally, leading to an exacerbation of the inequality commenced under Thatcher. Blair skirts round the issue of globalisation and technology in a rather trite manner, one assumes for brevity, but the wider debate necessarily includes the effects of globalisation and technology on actual communities in the UK, and the effect of multi-national corporates on life in the UK. Even Thatcher might have balked at the power of the corporates in 2013 in the same way she was critical of the power of the Unions throughout all of her time in government.


Whilst “Labour should be very robust in knocking down the notion that it “created” the crisis”, there is no doubt that Labour has a ‘debate to be had’ about how the Conservatives did not oppose the legislation of the City at the time by New Labour (and even advanced further under-regulation), why George Osborne wished to meet the comprehensive spending review demands of the last Labour government, and how the Conservatives would not have reacted any differently in injecting £1 TN into bank recapitalisation at the time of the crisis. The idea of spending money at the time of a recession has been compared to supporters of FA Hayek as ‘hair of the dog after a big binge’, but unfortunately is directly relevant to Blair’s first question: “What is driving the rise in housing benefit spending, and if it is the absence of housing, how do we build more?” Kickstarting the economy and solving the housing crisis would indeed be a populist measure, but the arguments against such a policy remain thoroughly unconvincing. The second question, “How do we improve the skillset of those who are unemployed when the shortage of skills is the clearest barrier to employment?”, is helpful to some extent, but Blair again shows that he is stuck in a mysterious time-warp; two of the biggest challenges in employment, aside from the onslaught in unfair dismissal, are the excessive salaries of CEOs (necessitating a debate about redistribution, given Labour’s phobia of the ‘tax and spend’ criticism), and how to help the underemployed. The third question is, course, hugely potent: “How do we take the health and education reforms of the last Labour government to a new level, given the huge improvement in results they brought about?” Fair enough, but the immediate problem now is how to slow down this latest advance in the privatisation of the NHS through the Health and Social Care Act (2012), and for Labour to tackle real issues about whether it really wishes to pit hospital versus hospital, school versus school, CCG against CCG, etc. (and to allow certain entities, such as NHS Foundation Trusts, “fail” in what is supposed to be a “comprehensive service”).  The other questions which Blair raises are excellent, and indeed I am extremely happy to see that Blair calls for a prioritisation of certain planks of policy, such as how to produce an industrial strategy or a ‘strategy for growth’, and how to deal with a crisis in social justice? There is no doubt that the funding of access-to-justice on the high street, for example in immigration, housing or welfare benefits, has hit a crisis, but Blair is right if he is arguing that operational tactics are not good enough. Sadiq Khan obviously cannot ‘underachieve and overpromise’ about reversing legal aid cuts, but Labour in due course will have to set out an architecture of what it wishes to do about this issue.


Ed Miliband knows that this is a marathon, not a sprint. He has the problem of shooting at a goal, which some days looks like an open goal, other days where the size of the goal appears to have changed, and, on other days, where he looks as if he runs a real risk of scoring an ‘own goal’. It is of course very good to have advice from somebody so senior as Tony Blair, who will be a Lord in the upper chamber in due course, and Miliband does not know yet if he will ‘squeak through’ in the hung parliament, win with a massive landslide, or lose. Labour will clearly not wish to say anything dangerous at the risk of losing, through perhaps offending Basildon Man, and, whilst it is very likely that South Shields Man will remain loyal, nothing can be taken for granted for Ed Miliband unfortunately. Like Baroness Thatcher’s death, Tony Blair’s advice at this stage was likely to rouse huge emotions, and, whilst the dangers of ignoring the advice might not be as costly as Thatcher’s funeral, it would be unwise to ignore his views which, many will argue, has some support within Labour. However, it is clearly the case that some of the faultlines in the Thatcher society and economy have not been healed by the New Labour approach, and Ed Miliband, many hope, will ultimately forge his own successful destiny.


What will a Miliband-Thatcher brand achieve?



Characterising the leadership of Margaret Thatcher is difficult. The problem is that, despite the perceived ‘successes’ of her tenure of government, her administration is generally accepted to have been very socially divisive. For many, she is the complete opposite of ‘inspirational’, and yet listening to current Conservative MPs talk there is a genuine nostalgia and affection for her period of government.


What can Ed Miliband possibly hope to emulate from the leadership style of Margaret Thatcher? Thatcher’s early leadership can definitely be characterised as a ‘crisis’ one, in that full bin liners were not being collected from the streets, there were power blackouts, Britain was going to the IMF to seek a loan, for example. However, the crisis now is one which does not have such visible effects. Miliband can hope to point to falling living standards, or increasing prices due to privatised industries making a profit through collusive pricing, but this is an altogether more subtle argument. A key difference is that people can only blame the business models of the privatised industries, not government directly. Whether this will also be the case as an increasing proportion of NHS gets done by private providers is yet to be seen.


It is perhaps more likely that Thatcher’s leadership, in the early stages at least, migth be described as “charismatic”, involving both charisma and vision. Conger and Karungo famously described five behavioural attributes of charismatic leadership. They are: vision and articulation, sensitivity to the environment, sensitivity to member needs, personal risk taking, and performing unconventional behaviour. In a weird way, Thatcher in her period of government can claim to have provided examples of many of these, but it is the period of social destruction at the time of closure of coal mines which will cause doubt on sensitivity to the environment. While ‘Basildon man’ and ‘Ford mondeo’ man might have been looked after, apparently, ‘Easington man’ was clearly not. A ‘One Nation’ philosophy promoting one economy and one society might not be a trite construct for this, after all. The problem is that ‘Basildon man’ has himself moved on; the ‘right to buy’ is the flagship Tory policy epitomising independence, aspiration and choice for the modern Tory, as resumed by Robert Halfon, but there is ultimately a problem if Basildon man is not able to maintain mortgage payments, or there is a general dearth of social housing.


In a way, looking at the failures of Thatcher’s leadership style is a bit academic now, but still highly relevant in reminding Miliband that his ‘political class’ cannot be aloof from the voters. It is a testament to the huge ‘brand loyalty’ of the Thatcher brand that there are so many eulogies, and one enduring hagimony from the BBC, to Thatcher. Jay Conger provides a way of understanding how charismatic leadership is to be maintained, and the “Poll Tax” is symptomatic of Thatcher’s failure of these aspects. Conger identifies continual assessment of the environment, and an ability to build trust and commitment not through coercion. Miliband likewise needs to be mindful of his immediate environment too: his stance on Workfare disappointed many members of Labour, causing even 41 of his own MPs to rebel against the recent vote, and upset many disabled citizens who are members of Labour. What happens when charismatic leadership goes wrong can be identified clearly in the latter years of the Thatcher administration. These include relatively unchallenged leadership, a tendency to gather “yes men”, and a tendency to narcissism and losing touch with reality. I still remember now (and I am nearly 39), the classic, “We have become a grandmother” and that awful Mansion House spectacle when Mrs Thatcher proclaimed that ‘the batting had been tough of late’ whilst maintaining a quasi-regal ambience.


I personally disagree with the notion that elections are won from the ‘centre ground’, particularly because I conceptually do not find the classification of ‘left’ and ‘right’ helpful (especially if you, like me, wish to embrace “One Nation Labour” with genuine goodwill). To use the market analogy, I think it’s like making an offering which looks and functions like an iPod, but which has some of the features missing; you might as well buy the real thing. A more sensible strategy for a competitor to the incumbent is to offer something really disruptive; in other words, something which offers some of the good qualities of the current market leaders, but which adds useful value. Ironically, enough time has passed since the airbrushing of socialism from the mainstream UK political system occurred with the advent of New Labour for Ed Miliband to give this another go. You can argue until the cows come home, and many mere mortals who are management theorists have given it a go, about whether charismatic leadership needs both charisma and vision. Despite Denis Healey’s famous doubts about whether Ed Miliband has charisma, it seems that Fraser Nelson has latterly judged Ed Miliband to be quite personable. Certainly, Ed Miliband to come close to becoming a charismatic leader himself needs to have an extremely clear vision. He may have to “think the unthinkable”, and make an unrealistic promises such as a NHS which is ‘comprehensive, and free-at-the-point-of-use’ (still miraculously, though, in the current NHS constitution). However, to borrow George Osborne’s phrase, “there is a debate to be had”, about whether the deregulation of markets under the Conservatives and New Labour did lead to a climate which encouraged the global financial crash to spread to the London markets. There is also a debate to be had about the ‘market failures’ of privatised industries. Sure, nobody is wishing ‘Thomas Cook’ to become a state-owned travel agent, or you to wait a month to have a phone line fitted by the State. But this is to present outdated, prejudiced, ‘Aunt Sally’ arguments. There is a debate to be had instead about whether we wish certain national services, like utilities or railways, to be fragmented, at relatively high prices, and where there is clearly a substantial benefit to shareholders and corporate directors but little benefit to consumers. Nobody wants to see the Unions ‘holding the country to ransom’, but it is a triumphant failure of Tony Blair and New Labour that this demonising malicious memes have been allowed to remain alive almost forty years on. Nearly all people, instead, firmly believe in the idea of democratic representation, and this has now become vital in abuse of the workforce by certain employers. We hear stories all-the-time of powerful corporates using ‘zero hour contracts’, and it is this Government which has seen the dilution of employment rights of workers and employees (reduced eligibility for unfair dismissal claims, and a lower quantum of award.) And, finally, there is a debate to be had about what exactly underlies the ‘maximum number of people in employment’ claim; is it for example an increased number of part-time, flexible workers who are under-employed, or is it an artefact of migrant workers from Eastern Europe who are doing temporary jobs in the UK?


Ed Miliband has often many times remarked about his thoughts have been ‘shaped’ by Margaret Thatcher, despite the fact he is very clear he disagreed with many of the views of Thatcher. We need, however, a frank discussion of where Britain goes from here. Frankly, a pig with a rosette could have won certain Labour seats in Scotland, but those days are over. Labour’s membership started to go into decline from around 2002/3, long predating the fall in membership after the Iraqi war. The ‘paying of respects’ to the late Baroness Thatcher has allowed some Tory ideology to go unchallenged, such as the importance of the Unions in society, or the failure of privatised industries. However, what Ed Miliband can hope to emulate is a precise articulation of a vision. Miliband has to prove that he is the right person for the right times (2014/5), like Blair, Thatcher and Cameron/Clegg might have been. If Labour is to be given the honour of a mandate in 2015, it needs to have an extremely clear idea of what it hopes to achieve, and for whom.

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