delirium

When I’m 65. The precarity of delirium. #WDAD2023

I’m not sure that I ‘understand’ delirium, frailty or dementia.

I think few do.

Before the person I ended up caring for 24/7 was officially diagnosed with both frailty and dementia, I had been aware of the magical significance of the number ’65’. Rather like the number 42 being the meaning of life, as attributed to the iconic ‘Hitchhiker’s guide to galaxy’, 65 remains magical for the cut-off between neurology and psychiatry when it comes to dementia services.

I’m old enough to remember when the consultant in Cambridge, whose firm I was once in in 2001 as a house officer, mooted there should be a defence of the term ‘department for medicine of the elderly’. At first it might seem inappropriate you compartmentalised older adults this way, after all 61-70 is very different to 71-80 or 81-90. On the other hand, older people do have specialist needs which come with age.

I came across by relative accident the word ‘precarity’ as applied to frailty from a scientific paper. I think of ‘frailty’ akin to ‘vulnerability’, but the word ‘precarity’ appears bolder than that. It encompasses a meaning of being precarious or uncertainty. In all my time being a family carer, I was struck by the fact that the prevailing wind would change at an instant.

Amanda Grenier’s analysis of precarity made me wonder why older patients with delirium are quite so precarious politically. Grenier cites the dictionary definition:

“Accordingly, ‘precarious, adj.’ is defined as both ‘a right, tenancy’ (that is, something held or enjoyed by the favour of and at the pleasure of another person) and a condition whereby one is ‘vulnerable to the will or decision of others’. The uses of the concept ‘precarious’ range from ‘a line of argument, inference, opinion, etc. [that is] insecurely founded or reasoned, doubtful, dubious’, to something ‘dependent on chance or circumstance; uncertain; liable to fail; exposed to risk, hazardous; insecure, unstable’, to something ‘subject to or fraught with physical danger or insecurity; at risk of falling, collapse, or similar accident; unsound, unsafe, rickety’ (‘precarious, adj.’, nd).”

Governments will argue that they are spending more and more money on care, but it seems that the money being spent is less because the money has to be stretched with such increasing demand. It is impossible to avoid a discussion of how delirium care can be managed successfully with such powerful constraints.

Grenier again,

“The concept of precarity highlights how decisions made about frailty and care are thus political. While the implications of neoliberal priorities and practices are most obvious on marginalized groups who no longer have access to the services they require, an analysis carried out through the lens of precarity also reveals how political priorities and particular responses create ‘care gaps’, and thus how the concept and practices related to frailty operate to reduce and limit access to services and supports. “

If anything, care at home, with an army of unpaid family carers like I once was, or more strategically delivered care, at home will come under increased scrutiny.

It is possible to ignore someone who is delirious, in terms of person-centred care, especially a hospital patient who is sleeping all the time. This is fraught with encouraging risks – such as pressure sores or blood clots (both of which can exacerbate a delirium). Management of a delirious patient to all intents and purposes can be an outpost of veterinary medicine unless you make an effort to involve the patient or carers, or to acknowledge the distress.

You could then find one minute that things were going well. The person you cared for seemed to be sleeping OK, eating and drinking well, moving around OK and reasonably attentive. But then the next morning she could be a totally different person, even accounting for the dementia.

Personal care was now impossible. She didn’t feel like taking her breakfast. And she wanted to sleep a lot even having had a good night’s sleep.

Frailty for me brings with it a sense of complexity in a way I simply don’t understand. It doesn’t surprise me at all that with increased frailty there appears to be a greater prevalence of delirium. Living with frailty is undoubtedly a new normal, but I cannot comprehend how it is possible to live well with delirium.

Delirium seems to mean that the person has difficulty recognising himself or herself, or others, and might talk incoherent rubbish. There is as yet no single bullet to treat this condition, in the same way you might give an antibiotic for pneumonia or anti epileptic for epilepsy.

This is in large part due to the fact that delirium occupies a position of mystery. We know remarkably little about the neural basis of it – what turns it on (other than precipitating and predisposing causes), what keeps it going, and what turns it off. The neural substrates remain to a large extent a mystery, and remain a roadblock to its effective medical treatment.

Delirium seems to ‘recover’ of sorts – but how many people truly recover is a bit of a known unknown. Inroads are being made here.

I don’t deny delirium prevention can be effective through good healthcare, for example attention to mobility, hydration, pain relief, and so on. But what brings it on suddenly in a person living with dementia is scary. We can do our best to understand it for non-hospital settings as well as hospital settings, but there are major holes in our knowledge still. There is yet to be done a conclusive trial as to whether delirium prevention can lead to dementia prevention, although this possibility seems promising given observations such as the fact recurrent delirium episodes might be related to greater cognitive impairment.

The ‘living well with dementia’ narrative was obscured with the fact that it was introduced at a time which coincided with worldwide financial austerity due to a global financial crash. The search for a magic bullet seemed like the perfect excuse, arguably, to strip down the welfare state, such that ‘care’ and ‘dependency’ became dirty words.

Being delirious is, whatever spin, a very precarious state. Without oversight, there is a possibility you could wander off and cause havoc. That’s why laws exist on mental capacity and deprivation of liberty to act as necessary and proportionate measures.

The precarious state in delirium without intervention can become a self-fulfilling doom cycle. In ways we do not really understand, frailty can lead to delirium. this delirium can lead someone to stop eating and so on, lose weight, stay in bed become increasingly frail and reconditioned. And for some the delirium might be linked to some cognitive damage.

I’ve never thought that certain admissions can be completely ‘avoided’. Nor do I think that dementia in the older person is as nice and tidy as dementia in a younger person, for example with a single gene defect.

An inability to spot or detect delirium, in whatever care setting (even at home, in a hospice, in a care home or in a hospital) is something all practitioners should be aware about – like chest pain. We know that delirium somehow adds to the chances of mortality in a way not simply explicable by the medical complications. Greater awareness and attention to care, as well as a research strategy, is needed.

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politics

Gary Lineker is more than a troublesome tweeter. He is a Trojan Horse for the political expression.

Peter Hitchens made one fundamental mistake in his Daily Mail article about Hitler. That mistake was not to argue that Hitler was ‘left wing’. The article served its function, in being a click magnet, and also in trolling individuals of a certain political persuasion.

The fundamental mistake was to define politics in terms of ‘left wing’ and ‘right wing’. Nowadays it is hard to tell the difference between extreme left wing and extreme right wing. But it is also true that politics is not a summation of a million referenda. One of the few people who believed in referenda apart from David Cameron was of course Mussolini.

It is easy to be hyperbolic about the impact of Gary Lineker’s tweeting. Simple solutions would have included a quiet email from Tim Davie or Robbie Gibb to ask him to delete it. But the problem with the tweet is that it is entirely factually correct.

The language used by Braverman, ‘invasion’, is problematic. If Braverman cared about the optics of such a sensitive policy, she has failed.

She has become her own worst enemy, for different reasons to how Boris Johnson became his own worst enemy. There was an important discussion to be had about planning for migrants, for example through the known problems in social housing and local authority services. She has strangled at birth any discussion of this.

This can also be held to be a success. By offering the ultimate ‘dead cat’ of a problem which became opened up through inadequate foreign policy after Brexit, and by ramping up the rhetoric over immigration, Braverman has blown out of the water any sensible debate about this.

This has obliged the Tory Party to resort to a ‘culture war’. But the Gary Lineker tweet neutralises two culture war weapons.

Firstly, freedom of expression. You cannot ‘half believe’ in freedom of expression. This is like being half pregnant.

You may immediately riposte by saying ‘but the law says..’ Too often the law has been used as an argument to shut down any debate.

You may disagree with what he has to say, but his right to say it should be defended. It’s no different to Andrew Neil, Michael Portillo or Lord Sugar ‘having a voice’.

Secondly. it’s Gary Lineker just being ‘nice’ isn’t it? This causes a problem for the Tories. Boris Johnson was not given superstar status because of his immaculate attention to detail. It wasn’t even that he was ‘particularly nice’, as certain people might testify.

In a race between members of the Tory Party and personalities like Carol Vorderman, Marina Purkiss, Jemma Forte or Gary Lineker, the Tory Party cannot expect to win however well articulated their policies.

Gary Lineker has become a ‘lightning conductor’ partly due to massive unpopularity of the Tory Party. Aside from the fact that the Tory Party is an incoherent mess, and their policy solutions become even more desperate to bail themselves out of their self-inflicted ‘forced errors’, their only hope of scraping through is a divided Labour Party.

Those on the left wing are exasperated on the lack of fresh thinking of the monopoly effects of utility companies, or on Brexit, for example. They get exasperated about the lack of support from Labour for Gary Lineker or anyone on strike. Labour despite saying they’re not complacent are behaving as if they are very complacent.

The allegations against members of the Tory front bench on bullying, some already proven, are well known. Gary Lineker provides a further test case as to whether bullies win.

It seems that the BBC leadership and the Tory Party, despite public mutterings from Sunak otherwise, have formed some sort of dubious suicide pact such that they have already decided to go down in flames together.

If that were to happen, Gary Lineker would simply have to find an alternative outlet to present ‘Match Of The Day’.

politics

Being ahead

The famous tweet goes, ‘Anyone who’d be a half decent leader of the Opposition would be twenty points ahead?’ – or something like that.

Things can only get better.

For a few months now, Labour has been way ahead in the opinion polls. Rishi Sunak, as the latest Prime Minister, never really benefitted from a ‘bounce’ in popularity. First impressions of him might be that he’s a bit ‘out of touch’. He comes from a background not unheard of in a Conservative Prime Minister – top public school than Oxbridge than City. He is unlikely to be lying awake at night thinking about his smart meter counting upwards while he heats his (large) house. He is possibly not thinking about the idea of people breaking into his house with a warrant to install a prepaid meter. To all intents and purposes, he is another Prime Minister. His relative popularity in the Red Wall might be more to do with his BAME background, or the financial affairs of his family, than what they really thinking of his policies. Boris Johnson, chief bloviator, has been touring the world – it seems at someone’s expense – and is about to foot a big legal bill defending himself against all sorts of allegations, presumably at the taxpayers’ expense.

This administration confuses me somewhat. When I first heard that Boris Johnson had become leader of the Conservative Party, in my naïvety felt that Jeremy Corbyn would have a very easy time. That was all before he got completely monstered by the media. Fanboys of Keir Starmer on a good day boast how Labour is no longer a ‘protest party’. When empowered by extreme chutzpah and confidence, they say blazingly, ‘There are no longer any Palestinian flags’. It is always hard to work out what is true and what isn’t regarding the Corbyn era. What is definitely true is that there has been an almighty cover up in the media regarding the Forde Report – which some brave journalists have spoken out about. What is also true is that organisations such as Amnesty International have also expressed concern about ‘apartheid’ Israel regardless of awkward words being voiced and apologised for in parliament. What is allegedly true is that members of the Labour Party have been threatened with expulsion, despite being Jewish, for ‘siding’ with the wrong grouping. It is easy to ignore it if you hate Jeremy Corbyn, but socialists generally are unimpressed that they feel that they have been saddled with Keir Starmer under somewhat false pretences.

Whichever way you wish to spin it, Starmer has reneged on all of his promises. The vision of Thatcher, extended and elaborated on by Blair and Cameron, has left us with an awkward legacy of unsafe cladding, huge PFI bills in the NHS and utility companies in England, at odds with the rest of the world, for being privately owned by investors abroad paying tax anywhere other than Britain. The public sector, in as much the legislation has prevented a ‘general strike’, has finally had enough with its lack of remuneration. Not only is the public on their side, but the public sector is populated by the public. Not only has renumeration of workers been poor, but fat cats have become extremely fat, with poor standards in outcomes.

It should be obvious that, given also Kwarteng’s disastrous budget and a string of unforced errors from Johnson, that Starmer would be ahead. But what is so creepy is that he is so unwilling to make a link between economic productivity and the fact we are no longer part of a trade bloc. For all his faults, and we’ve heard them ad nauseam, Jeremy Corbyn proposed in 2019 for the UK to be part of a close trading relationship even despite exiting. Alan Johnson and Sir Stuart Rose were supposedly leading the Remain campaign, but have both disappeared off the face of the planet regarding Brexit. So it’s left to people on the front bench of Labour to ask for a closer relationship with the EU without saying what that is. That is like ripping a wheel off your car, and promising to drive fast with the three remaining wheels. It is not a serious offering. Reeves and Miliband, for all their good points, have been on the subs bench since the early 2010s. Like Starmer, they are not the ‘change’ candidates. They are the stench of no change, epitomised by Reeves promising not to increase your bills – in the same way that Cooper promised not to reverse the outsourcing of the benefits outsourcing.

To say that Labour is a pale imitation of the Tories might be intended as an insult, but it is very much a compliment for those who know that this is the desired strategy. John Rentoul at about 3 am this morning went on the radio with LBC presenter Clive Bull to explain that Starmer is not like Blair, but Starmer still wishes the Labour Party to become closer to the Conservative Party. Rentoul adds that there is no guarantee that things will be ‘better’ under Reeves or Starmer. And there’s the rub. Not only is the offering to the left of Labour that ‘things won’t be worse’ – but there are active differences, such as not nationalising the utility companies, or not supporting the strikers. The calculation is that more Tories will join Labour than Labour lefties leaving Labour. For those who supported and campaigned for Jeremy Corbyn, who judging from his interview with Lewis Goodall is even angrier than ever at injustice, being expected to support Labour is not a ‘given’ any more. Solidarity, a key value within the Labour left, has to all intents and purposes been suspended in a dramatic fashion. Furthermore, Labour lefties who feel very betrayed by prominent people on the Left pleading for people not to vote Labour are ‘expected’ to vote for Starmer now who himself has U-turned on everything so fast he has literally spun himself into the ground like a power drill. They are labelled ‘Tory enablers’.

The next phase of the attack has begun. We are being told that Starmer does not need Scotland to form a majority government. This is close to absolute bollocks in fact, as Scotland, even with the furore over gender recognition and prisoners, is likely to vote nearly 100% SNP. Starmer will require basically all of Labour voters to turn out in England and Wales to get the sort of arithmetic he dreams of, and we know that the ‘swing’ required is now enormous. And factor into that, what does Streeting propose to salvage the NHS? A big recruitment drive, and abolition of non-com status. The tax change raising revenue has been disputed, and the big recruitment drive doesn’t address attrition at every training stage of a doctors’ education. He also wants to oversee a transition from partners to salaried GPs – exactly what multinational corporations want in the integrated care systems as per Health and Social Care Act 2022 – but this will bring the NHS to its knees unless substantially more senior GPs are found from nowhere (or abroad). It all doesn’t add up – and even worse he wants to be sparring in a fight with the BMA, which is a pretty frightful look for Labour which seems to be obsessed with dividing and ruling. Starmer’s self referral for ‘internal bleeding’ is of course the final straw.

It’s clear Labour lacks policies, and lacks vision. They are lumbered with an Islington lawyer who seems to hate Jeremy Corbyn, and, even worse, seems to despise socialism.

Don’t be surprised if Sunak wins.

politics

Can Starmer or Streeting really afford to lose the NHS vote?

Labour for the last few years has been too busy facing inwards. It has become obsessed in fighting deeply unpleasant ideological battles, but the people doing so claim that they had no choice. Labour is at danger of continuing to carry on with this protracted fracture rather than embracing the pragmatic issues of government. Labour does however emphasise the need to make practical pledges. The latest onslaught by Starmer and Streeting, however, could prove to be deeply damaging for their reputation as ‘guardians of the NHS’. It seems to want to turn the NHS into another ‘culture war’. If it does, I think it will fail.

I remember when I went to a seminar at the Academy of Ideas earlier this year in Church House. As ever, it was brilliant. We spoke our minds and listened respectfully to the views of others. The discussion was supposed to be on the decline on the NHS. Nobody mentioned the crisis in social care or austerity as factors, which surprised me. I pointed this out to the panel, and I remember being aghast when the director of a right-wing think tank told me that austerity had “nothing to do with it”. This is simply not backed up by the evidence. Even this week, a published report, commissioned by the Conservative Party, drew attention to it.

In recent times, the Conservatives have had a formidable reputation for economic competence. This has been enduring a previous Chancellor, Kwasi Kwarteng, causing a crash in the pound through a mini-budget. The Labour Party has always been seen as the “party of the NHS”. In December 2019, under previous management, Labour under Jeremy Corbyn had again warned about further privatisation of the NHS. Is it possible that Labour is finally going to lose its crown as ‘champion of the NHS’?

Heading into a news break this lunchtime, LBC presenter Shelagh Fogarty had to explain to a caller that a ‘zero immigration’ target was unreasonable, and that the country was not falling apart due to cross channel migrants. Brexit has overwhelmingly been found out to be a disaster, and was meant to solve the problem of ‘taking back control. There is unease about Starmer being unwilling to tackle it. Boris Johnson, meanwhile, the former MP who “got Brexit done”, is said to have pocketed more than £1 million in speaking engagements including in India and Portugal following Brexit. In the last week, Wes Streeting has given three interviews with LBC, and they do repeat the same views. Suella Braverman gave by all accounts this morning a pretty disgusting account of the deaths which had occurred on the English Channel this morning. Labour only a few years ago was pimping out its famous immigration mugs. Starmer, who has distanced himself from all policy from 2019 Labour manifesto, including – presumably – the attack on austerity, does not want to appear too ‘woke’ in case he goes ‘broke’ at the next general election in 2024.

The British Medical Association (BMA have apparently criticised Mr Streeting for what it called “disappointing” comments after he used an interview with the Sunday Telegraph to accuse the union of being hostile towards vitally needed NHS reform efforts. Wes Streeting is proud for not being on the side of the doctors but being firmly on the side of the patient, and this position certainly is more convenient also for attracting the ‘anti woke’ or Red Wall vote. Although it is time and time again said that such voters are not racist, there is a rarely a phone-in on LBC without the caller who blames an increased demand on NHS services by ‘immigrants’. Both Streeting and Starmer do not want to appear ‘close to the Unions’, which is a pathetic thing to pander to as neither the RMT or RCN are affiliated to Labour for example.

A symbol of the decline in the NHS has been the “mad scramble” for the GP appointment at 8 am. Most of us have had experience of ringing up punctually at 8 am to make an appointment only to be “number 42 in the queue” if delayed by a few minutes. GPs have been accused of offering fewer face to face appointments. The BMA have repeatedly pointed out that the promised recruitment drive in general practice never materialised, they have a retention problem with the GP workforce, and there has been a vast increase in the number of appointments overall. In July 2020, the then Secretary of State for health and social care, Matt Hancock, now more associated with ‘jungle washing’, had argued that GP apppintments “should be virtual by default“. GPs have a right to argue, therefore, that they have been delivering a system mandated to them, whilst overstretched and doctored. Streeting made no reference to the crisis in general practise in any of the interviews, presumably because he is trying to present himself as the ‘patient advocate’.

In a new policy paper from earlier this year, the Royal College of Physicians repeated the case for long-term workforce planning and sets out a range of short- to medium-term solutions the government must implement now to keep the NHS running. Wes Streeting has repeated many times his aspiration to grow the workforce of the NHS. To avoid the accusation of ‘overpromising and underdelivering’, Streeting made clear in all his recent interviews that the pledge would be paid for from the money accrued rom the ‘non dom status‘. Discussing the “back and forth”, Wes Streeting told presenter Shelagh Fogarty: “We announced the biggest expansion of NHS staff in history — so we would double the number of medical school places, increase nursing and midwifery clinical training places by 10,000, 5000 more health visitors, doubling the number of district nurses.”

But this in itself is a hopeless solution to the NHS workforce crisis in itself. It took a caller to Shelagh Fogarty’s show, “Felicity from Greenwich”, a doctor, to point out that there is a bottleneck for places at every stage of training. With doctors being unable to find jobs, therefore, it is not surprising they are leaving the profession. There is no structured return to work scheme including extended induction or reasonable adjustments (phased return) for disabled doctors for people who have taken unanticipated leave for years off the register; such a scheme is necessary for re-skilling and building up the confidence of such doctors. There is a pensions crisis in the NHS which means that long-established doctors are having to leave the profession rather than to be clobbered by huge tax bills. Wes Streeting acknowledges the campaign on pensions by the BMA. Ask any trainee how they feel about the increase in medical school places, and you’ll soon have your answers.

A report from the right wing think-tank Policy Exchange earlier this year provided details a ‘rescue package’ for general practice.  The report from Policy Exchange recommended specifically:

  • The overhaul of the current core GP contract to redefine incentives, reduce bureaucracy and free-up GPs to help the patients with the most complex needs;
  • A £6 billion ‘rescue package’ to enable improvements to general practice premises, data collection and to enable an orderly transition to new contractual models;
  • The ‘levelling-up’ of general practice with a massive boost in high-quality video consultations in areas where there are not enough doctors;
  • The introduction of ‘NHS Gateway’, a more coherent entry point to primary care and to reduce dependency upon the 8am call to the GP surgery for appointments;

The Daily Mail were so enthused it even ran an article promoting this report to its readers, including a section on how the BMA were unable to support the proposal.

“Family doctors wanted extra funding to cover the rising national insurance costs and inflation.  But the final contract, given to the BMA just hours before being made public, made no mention of the additional cash it had demanded.“

I don’t deny the attraction the Daily Mail must have for Streeting or Starmer, being avid consumers of the Sun and Telegraph. Streeting at no point in his LBC interviews made any mention of why the BMA had been critical of recent proposals, rather leaving the average voter with the impression that the BMA was just a militant union opposed to change. All registered doctors have a regulatory obligation under ‘domain 2’ to commit to improvement of the quality of the service with the General Medical Council, and this inevitably has involved change initiatives.

The Conservatives chose not to implement the Policy Exchange proposal, but were too busy with their own leadership election and the coronation of Liz Truss – who blew a sum vastly larger than this on crashing the UK economy as a sign of ‘taking back control’ (a Brexit dividend) from a ‘Singapore on Thames‘ economy forewarned by her Britannia Unchained movement.

Implementation of technology here might have really helped, however.

I have for nearly a decade commented on how the increasing use of technology is a ‘Trojan horse’ for further marketisation of the NHS. For example, in an article for Open Democracy back in 2015, I commented on a recent speech by Jeremy Hunt, the then Secretary of State for Health. Whatever happened to him?

I wrote,

“This month Jeremy Hunt MP gave what he told us was his “most important speech as health secretary”. The speech – delivered at the Kings Fund, and entitled “”Making healthcare more human-centred not system-centred” – fulfilled its function of generating blockbuster headlines, mostly focused on the ‘7 day NHS’ and consultant pay. But there’s been relatively little comment on his new ‘big idea’ – a patient-centric transformation in a post-bureaucratic age, which he calls “intelligent transparency”.“

Embracing technology within a nationalised service is sensible. Using technology to privatise a service and to demolish the workforce is a different motive, and one which is bound to cause a problem with core Labour voters. It has been a consistent tactic of the right wing opposition and Wes Streeting to frame anyone who won’t embrace technology as being opponents of change. To give just one example, in August 2022, the RMT reported that a funding deal struck by Transport for London and ministers would attack tube workers’ pay and pensions and would lead to further strike action, RMT have warned. The proposals seemed conditional on attacks on workers’ pensions, potential job losses and a push for pay restraint in the future despite the astronomical rise in inflation and an escalating cost of living crisis. Driverless trains are also part of the reforms insisted on by a previous Secretary of State for transport, despite the huge costs involved and safety concerns. Driverless trains are a massive safety concern for disabled passengers, and are not a trivial matter. To frame protection of the workforce as ‘looking after vested interest’ is a political choice which Starmer and Streeting have decided to take. Technology can be used alongside the workforce to improve their working conditions, and not just as a replacement for the workforce to maximise profit margins. Technology besides is not a universal panacea. The report of the AI chat bot which ‘turned racist’ is notorious. Tay was an chatbot that was originally released in March 2016 which caused subsequent controversy when the bot began to post inflammatory and offensive tweets through its Twitter account, causing Microsoft to shut down the service only 16 hours after its launch.

All people, including clinicians, are the lifeblood of the NHS, and Labour talking over them is poor mood music.

Here, for example, is Labour taking credit for ‘training doctors’. It is the existing workforce who is expected to train others.

At this very second, the likelihood is that Labour might become the largest party in the 2024 general election, but unlikely to win an overall majority. Streeting says that he and Starmer have been working on a plan for the NHS and social care. Many of us remember how traumatic the last NHS reform was in 2012, a ‘top down reorganisation’ which David Cameron had said would never happen (see for example an open letter some of us sent in 2016). The mood music from Streeting was bad, and has opened up much mistrust amongst hardworking professionals within the NHS. Lifelong Labour voters are telling me now that they might never vote for Labour again, given how bad the coverage was. But there are many patients in the voting public, just as there are many NHS staff who want to vote Labour ideally.

politics

Listen to all the podcasts and sign the petitions all you want, but still prepare yourself for eternal opposition

Podcast audiences don’t win elections. Petitions don’t win elections. Political parties win elections in first part the post in the UK elections.

For the first time in my lifetime, I think the era of mass civil disobedience is coming faster than a Labour government. I wonder if you remember the saying that ‘millions of people are relying on the election of a Labour government’. This was also true for the 2019 general election, dubbed the “Brexit election”. It was pretty easy to identify that Boris Johnson was a repellent liar at the time, even pre pandemic. It was obvious that the arrangements in Northern Ireland were a fudge, and that the trade barriers would be pretty ruinous to the macroeconomy of the UK. Labour had the ‘worst performance for many years’, but it is impossible to untangle from that how monstered Jeremy Corbyn was by the media, from James O’Brien to the Guardian, from Alasdair Campbell to other prominent has beens. On offer were ‘far left’ policies, such as a national care service, national education service, ‘free’ broadband – and what you got was Dido Harding, Matt “Jungle Fever” Hancock and Michelle Mone.

I don’t want even to contemplate what degrees of shit will be voted in next time around. One looming disaster is withdrawal from the European Convention of Human Rights – the perfect ‘get out’ clause to allow flights full of legal asylum seekers to fly to Rwanda, or to do other odious activities with cross-channel dinghies as there are no legal routes to enter the United Kingdom. While the Labour Party appears to have big corporate sponsors now, its Union support is dwindling. Labour cannot offer unequivocal support to the workers, some of whom are affiliated through the trades unions. Labour won’t offer to repeal the mercenary anti-Union legislation heavily signposted for the new year, and seems to wish to do its own form of austerity. Yvette Cooper and Rachel Reeves of course are past masters in their activities with welfare benefits, as most of us from that vintage will remember.

I think Mick Lynch is putting it a bit mildly when he calls ‘Keir Starmer’. At least vanilla ice cream can be soothing or tasty. Starmer’s rhetoric does not give me any confidence that he is the man to get Britain to a state where it is proud of itself. Far before the pandemic crisis or the Ukraine war, it was very obvious that England was in decline. Nowadays the right wing loons are forced to pillar Meghan Markle and her curtsying to detract from the disgusting state of the country. The UK Labour Party doesn’t seem to care that being in England is positively risky to you and your health. Because of a sustained campaign of underfunding, to fork out billions for pointless projects such as Brexit, there is ‘no money left’ for any of the emergency services. If there’s a fire in your flat or house, run and escape for the hills. You’ll be lucky to get a fire engine. If you have a stroke, take a cab to your local hospital as you might be waiting some time for an ambulance. If you have a burglary, kiss goodbye to your property, and buy lots of cheap tat to replace them with off Amazon. The water and gas are nationalised, owned by private equity from abroad. We’re in the process of getting rid of all the EU safeguards, so we can relentlessly pump sewage into the sea. And so it goes on.

The facts are that Labour doesn’t have a hope in hell of getting many seats in Scotland in the 2024 general election, and that some voters still wouldn’t want to touch Starmer’s Labour due to various factors including lack of policy. Depending on tactical voting, and on various outcomes such as whether Sunak can ‘smash the strike’, we’re looking at Labour possibly being the largest party in a hung parliament. If you want Labour to offer something different on austerity, supporting strikers, net zero, HS2, and so on, forget it. Listen to all the podcasts and sign the petitions all you want, but still prepare yourself for eternal opposition. And don’t even rule out an unprecedented re-election of a spanking new Tory government.

practitioner health

Reflections on being a disabled clinician in the NHS

All of things which worry all clinicians – burnout, feeling overstretched, a workforce which is undervalued and under numbered – worry disabled doctors too. Disabled doctors are good people too.

‘Today I feel male. Today I feel disabled.’

All of this is true for me, channeling my inner FIFA president identity.

Infantino had added that he knows what it means to be discriminated [against]’.

I know that feeling too. ‘Institutional racism’ is not just a description that there are many people who are racist in an institution. But it’s a known issue that systemic racism does exist in the NHS. Partha Kar (find him here) has been chipping away at this iceberg gallantly for some time, and the task of tackling this racism is daunting. I find myself excluded all the time from a seat at the ‘top table’ despite me being physically disabled myself, and having trained in equality law through my pre-solicitor training and in performance management through my MBA. NHS leaders can certainly do better, that I agree with from Roger Kline (find him here) (and many other things especially regarding race equality). I am the specialist advisor for an amazing institution called NHS Practitioner Health (find them here), and my job is to advise our clinicians on how best to look after doctors who are disabled. It’s a great privilege, and with my colleague Dr Kelly Lockwood I produced many resources on being a disabled doctor and how to navigate through the system.

I don’t think we value doctors who are disabled highly enough in the NHS. This is such an enormous waste, especially given the workforce crisis that the NHS is in. As I wrote in the BMJ Leader blog, some experiences of disability are good – some are catastrophic. The NHS can be dire in implementing legal requirements such as ‘reasonable adjustments’ allowing disabled individuals to function properly. I wrote about that too for the BMJ Leader blog. Did you for example know that a phased return to work is actually a legal obligation under the Equality Act as it is classified as a ‘reasonable adjustment’?

I was an unpaid family carer for years, and I never thought of myself as a carer. I have a professional medical identity, which has gestated over many years. That is a big part of my life inevitably. But I don’t think of myself as a ‘disabled doctor’ or a ‘BAME doctor’.

There are advantages of not seeing yourself in terms of a label. For example, you don’t ‘other’ yourself – and see yourself as a hapless victim. I don’t think that I have ever ‘benefited’ personally from any equality, diversity and inclusion initiative in the NHS, especially the costly ones such as conferences and marketing. I do have needs which come out of being physically disabled, such as the need for a chair with a back. Virtually all of us who are learning as registered practising clinicians in the NHS are mindful that there is an optimal clinical learning environment. Most of us are very conscious of our teaching requirements in the NHS. I have published many books in medicine (examples here), and I am much enjoying my Masters in medical education at Nottingham University currently as one of their Scholars. As a member of the Association of the Study for Medical Education, I am very proud to promote our collective values of equality, diversity and inclusion.

I lead the special interest group in the neurology of delirium for the American Delirium Society, and indeed lead a group producing a systematic review – including 4 profs – on the rather niche subject of delirium superimposed on dementia. I say ‘niche’, but a very important presentation on the acute internal medical take. As a member of the Royal College of Physicians of London, I am concerned about the application of research to the everyday care of patients. The ‘internet of things’ – and the pandemic – has made remote working feasible and socially acceptable as far as I am concerned.

I feel sorry that there is a lot of marketing to do with disability, a field known as ‘diversity marketing’. It’s a rather corporate thing to do, with a tendency towards a lot of virtue signalling. The PR for conferences or booklets on #ourNHS can’t be cheap. But the reality is that we need to have proper infrastructure support for occupational health in the NHS. Members of the workforce need to be valued and welcomed, as indeed the General Medical Council described and discussed most impressively. Immaculately produced reports on disability such as that produced by the BMA need to be read, understood and acted upon. Collection of data such as WDES is necessary but insufficient.

There’s quite a few of us who are disabled and who are happy to talk about disability. Somebody I admire is Dr Hannah Barham-Brown (find her here). Somebody who is possibly the most inspirational contemporary I’ve ever met is Dr Kelly Lockwood (find her here).

Finally, I was asked recently what I would tell my younger self about disability. I said this.

I’ve got news for you. Disabled doctors are part of the solution, not the problem.

politics

The Tories are finished. This time, the lights will turn out themselves due to power shortages, don’t worry.

“It’s The Sun Wot Won It” is the famous headline which appeared on the front page of The Sun on 11 April 1992. The headline referred to The Sun’s contribution to the rather unexpected Tory victory in the 1992 general election owned by Rupert Murdoch, The Sun had been relentless in its drive to turn voters against the Labour Party leader, Neil Kinnock, and has run successful campaigns pro Blair and anti Corbyn. These days of course, the Tories have contributed to an energy crisis so that forced emergency blackouts may happen of their own accord. The country is in a mess. Liz Truss is possibly the most unsuccessful leader in the Tories’ entire history, a modern day Lord Liverpool.

Something has to be done. As we kept on being reminded by the Labour PLP during the Jeremy Corbyn days, while some of them were actively undermining their leadership as evidenced in the Forde Report, Britain needs a strong democracy. The Tories don’t seem to represent the country, especially those people who need some help to survive. They perpetually refer to people on working tax credits as ‘scroungers’. The toxicity is awful. The Tories are a weird coalition of Red Wall voters and people in the South East, who has been united in the goal of ‘getting Brexit done’. The pity is that they have not much to show for this. And their saviour, Boris Johnson, couldn’t even avoid partying during the pandemic.

I don’t particularly want the Conservative Party to suffer now, now that it is clearly dying. Many do, because of all of the suffering that this political party has inflicted on people, especially the most sick and vulnerable members of society.  The Conservatives have never had any enthusiasm about processing welfare benefits for people who cannot work. Now we know that senior members ‘dream’ of jumbo jets lifting off with people yet to have their asylum applications processed. The NHS is clearly malfunctioning, with a workforce crisis reflecting chronic underfunding and just a complete apathy in making it work. The social reforms have been delayed so much so that Sir Andrew Dilnot CBE will re-appear to give new evidence for the social care Commons committee this week, eleven years after his seminal proposals were first made. The Tory Party is dying a natural death anyway. Liz Truss couldn’t have killed off the Party better had she tried, so much so  Tim Farron MP has been making the joke that she is a ‘secret agent’ who should cover her tracks more carefully.

I despise the Tory Party although I do not despise Tories.

I just want the Conservative Party to have a ‘good death’. Ironically, the Conservatives introduced the construct of ‘necessity’ with their doomed Northern Ireland protocol, where there was no good option when you’re between a rock and a hard place. The Conservatives have entirely got themselves to blame. The Conservative Party  are now pretty damned if they keep Liz Truss at the helm, but also damned if they get rid of her.  They had the option of choosing, albeit out of a pretty awful choice, between two plausible contenders for leader of the Conservative Party. It is possible that Liz Truss MP could yet be further ‘challenged’, so to speak, due to some weird ambiguity of the interpretation of the rules in Sir Graham Brady’s head. Letters could be going into the 1922 committee as we speak. The Conservatives had a choice between someone who warned against the potential economic crises and who had a track record of dealing with the UK economy during a period of unprecedented uncertainty. Or they could choose Liz Truss of ‘Britannia unchained’ fame, whose maverick anarchic economic slash and burn was bound to run into problems. Truss managed to avoid any scrutiny, symbolised by her deft avoidance of Andrew Neil’s glare. She delivered the same attack lines ad absurdum. Nobody ever asked her on where she would get the money for the tax cuts would come from. The sad thing is that the Conservative Party actually voted in Truss – albeit with a decisive but not all that convincing victory. They officially own this result. It’s not as if the tanking of the Pound is that much of a surprise. What is though is a bit unexpected is that she is at -47% in popularity, meaning that single speeches can put mortgages into a tailspin, and individuals in Great Britain can loose their livelihood at an instant. I recently had to wait three hours to a mortgage provider to double check that my mortgage was a fixed rate with a low rate of interest rates, rather than a standard variable rate mortgage. This was as I was waiting for my Royal Mail post to arrive – mid-afternoon – when it would normally turn up punctually in the morning at around 9 am.

I can’t literally think of any one thing which the Conservatives have done to make my life better in any sense. Of course, not everything which has gone wrong with this country is due to the Conservatives. But it’s obvious that the tired mantra such as ‘we want to put more money in your pocket’ are not working any more. More like, the Conservatives want to put more of your money into their friends’ pockets, as exhibited by the ‘Test and trace’ fiasco or the PPE scandal. It’s not just the tanking of the £ which makes one question the economic competence of the Tories. It’s the fact that the economy is fundamentally screwed as well. It has been left to Grace Blakeley and a very small number of people repeatedly to point out that if you privatise monopoly-like behaviour you will end up with a few companies making a lot of money for the few not the many. The tragedy about our utilities is that they are in fact nationalised – but owned and managed by private equity companies abroad. And there is no argument that you weren’t blamed about it. Ed Miliband while he was leader of the Labour Party did indeed complain in some form about croney capitalism, and nobody listened. The Tories were more concerned about getting rid of the Liberal Democrats, and spitting them out such that they could never rise again. David Cameron was forced to embrace his inner UKIP, and the rest is history. A pack of lies came out for the 2016 referendum on both sides, I hasten to add – a decision was made. Nobody talked about it ever again, using tired tropes like, ‘Let’s put it to rest like the 1966 World Cup win’. The problem is, and it is hard to avoid, is that it is estimated that Brexit is costing the economy +4% in GDP deterioration. The pandemic came along, but the impact of Brexit on various industries – such as fishing, farming, the arts, sciences, financial services – has not gone away. As George Osborne said on the Andrew Neil Show, it is possible that there could be a ‘wipeout’ at the next general election in 2024. But he also added that the Tories could turn around their problems, and that Labour has not ‘sealed the deal’. The Red Wall voters are certainly not ‘stupid’, and will be the first to rebel at any whiff that they have bene sold a pup with Brexit. After all, the Tories kept on re-assuring them that they knew they were being lent their votes.

What is striking, however, is that while the parliamentary Labour Party has not sealed the deal, there is much to be said for left wing politics in general. The ‘Enough is enough’ campaign has struck a chord with many who do not see why unconscionable profits are being made by some in companies with a public service rôle. Nurses can be easily stereotyped as tub-thumping Corbynistas, but the truth is very far from that. Nurses see cutbacks on their wards directly impacting on the quality of care. They literally don’t have time or other resources to care, as Andy Burnham had indeed warned about when he was the shadow Secretary of State for health I n2014.  Nurses do to want to strike and their professional code imposes very strict sanctions if they pose any risk to patient care. Nurses like many in the public sector feel that they need to organise through their Unions. More’s the point, they feel that their concerns are falling on deaf ears with the Tories. The problem with Labour is also if they appear to be tone deaf to the concerns of the public sector. Symbolically the Labour Psrty leadership doesn’t want to be seen as ‘crossing picket lines’, but the discussion is far more nuanced than that. Nurses who have asked to address the cost of living crisis by putting on an extra wooly jumper are more than aware that millions are being siphoned off away from frontline patient care into paying off loan repayments from the private finance initiative agreements from the Tories and New Labour days. The neoliberal framing has clearly failed, and Labour won’t get power if it does not become popular. The general public is actually quite astute, and in these days of social media very well informed.

There’s a general consensus that Starmer is not at where Blair was at. Sure, there are similarities, such as the culture of sleaze engulfing the Tory Party much as in the dying days of the Major government. But Blair had a policy offering which made sense, as well as being a charismatic leader. Starmer seems to be going for a ‘safe option’, not daring to mention the Forde Report or other seismic internal problems. He seems ready to embrace a market economy and let go of the more extreme absurdities previously proposed. He might appeal to ex-Tory voters, but he has to weigh this up against potentially losing left-wing voters who are still curiously loyal to Jeremy Corbyn. A week is a long time in politics, so it’s possible that the national mood might lift. The general public are notoriously amnesic when it suits them. When it comes to 2022, it is possible that Liverpool delivers a Eurovision bounce; and 2023, it is possible that the Coronation makes the country patriotic again. Starmer can prove then that Labour is intensely patriotic, and already the pro-Merseyside lovefest has started. The fault lines might still remain, like Starmer being perceived as ‘North London’ or a ‘remainer’. Starmer is certainly the antidote to the very worst of the Tory administration so far – Cameron, May, Johnson, and Truss – and his ‘boringness’ may be just what the country needs during these turbulent times. Scotland may end up voting SNP, and uncertain voters who want to vote Labour but who for whatever reason can’t may vote Liberal Democrat. All of this makes it more likely that the arithmetic will favour a Lab-Lib hung parliament.

A Lab-Lib hung parliament in 2024 would be very interesting for the Brexit question. Assuming that the problems with the Northern Ireland protocol and the cross channel crossings are negotiated, Brexit does leave the country with an economic difficulty regarding productivity and growth. The UK may be OK when it comes to its geo-political soft power and influence, because of its historic legacy. But the UK cannot force members of the European Union to trade with us especially if we bonfire all of their laws and we diverge from their commonly agreed standards. The LibDems have already decided to sit on the fence regarding Brexit, and so have Labour. It is however becoming increasingly difficult to understand how the UK can sustain this degree of ‘hard Brexit’, and with a deterioration in the performance of the UK economy it may be quite unavoidable to re-join the single market. It is unclear how all the people newly enobled following their ‘success’ in Brexit supported such a ‘hard Brexit’, but we are where we are. Starmer did not oppose it. Starmer does not oppose it. Starmer will not oppose it.

Liz Truss has undoubtedly suffered from a number of  setbacks, but the unusual aspect to these setbacks is that they are largely predictable. They are all unnecessary unforced errors, which have cost the reputation of the country and the Party dear.  The problem here is that with such multi-organ failure the Conservatives might aim for a good death rather than the crises becoming more frequent and more severe in intensity.  The economic model of the Tory Party is undoubtedly a busted flush, with it increasingly being seen as a Ponzi scheme run for the benefit of its corporate donors. It always has been socially divisive, but in a world of zero sum gain it is hard not to acknowledge that they have set out to pick winners. The problem is that Truss openly, having been backed allegedly in her leadership campaign by hedge funders and other equally savoury financiers, does not ‘believe’ in re-distribution and believes in trickle down economics. It is impossible to reconcile this with the need for huge amounts of borrowing with little or zero productivity. Whatever the motives of the New York Times or Bloomberg, it is not in the UK’s interest for the economy to be viewed as a ‘basketcase’ by the markets. As Thatcher said, ‘you can’t buck the markets’. The Tories might not especially benefit from a ‘period of opposition’, but they have definitely lost their way. The reason I feel that people are genuinely willing to look at other parties now is that they are not scared off by Jeremy Corbyn (and this is a controversial issue anyway), and the Labour Party cannot conceivably be any worse than the Tories. One of the biggest mistakes for Truss surely was not to unite her own party. There have been limited offerings to Sunak supporters, especially notably in the Cabinet. Truss’ really catastrophic mistake is that she appears to have no intention to unite the country. Her anti-growth coalition is laughable if only for the sheer volume of it.

I have said all along that I live in North London. I think Labour has lost its way in not having an appealing offer to its traditional voters. Whilst my initial dislike of Brexit has subsided, I think Brexit can be made to work only if we are open about what its successes and failings have been, and there needs to be an honest discussion with the voters who had so much faith in it. If public services were good, the economy was fantastic and the UK had a brilliant reputation abroad (apart from Johnson’s tub thumping about Ukraine), the room for manoeuvre with the Tories and Truss in particular would be greater.  Tory/UKIP supporters have long been able to use the existence of Jeremy Corbyn, their myth over economic competence,  and Brexit to maul the opposition, but these are losing their potency. Brexit has been a drug delivered by the Tories, such that some of the general public have become addicted. They  have become tolerant to the lies, and needed an increasing dose of unicorns to get their fix. It is hard to see how Starmer or Truss can ‘make Brexit work’, but having spent billions on making it work so far with no immediate advantage, all the political parties need to come clean with the general public about its future. Truss is certainly a lightning conductor for all that is not right with this country, but I don’t think she is solely to blame. Thatcher always boasted that the foundations she laid were fundamentally wrong.

It is clear that the foundations that Thatcher laid were actually fundamentally wrong.

politics

Is this a ‘Labour moment’, or is it in fact a false dawn?

This was meant to be, as Martin McCutcheon, would say – a “perfect moment”. Keir Starmer had a bounce in his step. He had a new found confidence, and was thrashing out all the hits like ‘workers’ – no mention of socialism though, There was no heckling. No dissent. Everything was fine, apart from the ‘superficially black’ slip up. This is Labour’s election to lose. OK, Starmer may not be into ‘bungee jumping’, but he’s a ‘safe pair of hands’.

It actually costs me money to vote, unless I walk this time to the polling station in Primrose Hill. It will not affect the outcome as the vast majority of Camden is a ‘safe seat’. On a matter of principle, I can’t blame anyone if I get an unappealing government which I didn’t vote for. The reality is that, since 2010, I have put up with a government which I didn’t vote for. I have only voted Labour since 1992, including the last election in 2019.

I am not a member of the Labour Party any more. There were three years in a row when I did go to the party conferences more than a decade ago in Manchester and Liverpool. I actually went to London Olympia today to attend the exhibition on non-alcoholic beverages and hospitality. I ended up chatting with a Scouser, and swopping notes on Huyton being the constituency of the late Harold Wilson.

Harold Wilson came up in conversation with a cab driver of a London black cab today. The cabbie, whom I assume to be a Tory Brexiteer as they tend to be, despised TFL, London Mayors, low traffic zones, and loved Brexit. Like all the other cabbies I have ever spoken to, he supported Brexit but thinks that the implementation of Brexit has been a total disaster. He is also not at all happy about the state of the NHS, giving as examples long ambulance waits and the ‘8 am’ ritual for making an appointment with a GP. He is also intensely disgusted at the running go the economy, explaining that he will not benefit from the tax cuts for highest earners, but that the fall in the value of the £ will probably affect the cost of borrowing on his mortgage.

Inevitably, I ask people if they intend to vote Tory. They don’t like Starmer, saying he’s a Remainer, and not ‘one of them’. There are some doubts about the meme that Starmer’s father was a toolmaker. There is some talk of his father actually owning a tool factory allegedly. He didn’t know about the ‘green’ policy to launch a GB Green Energy firm. In my experience, London cabbies are not a particularly useful microcosm in which to test the political temperature.

Twitter is not the place either to test the political temperature. Labour ‘supporters’ seem divided into those who want to give Starmer full support, and his team, and those who feel Jeremy Corbyn was the target of a hate campaign as evidenced in the Forde report. I think what they have in common is a dislike of the current Government, thinking that Truss and Kwarteng have little to offer them. Some people in Labour still blame Corbyn as a vote loser, and yet Corbyn supporters are still adamant that he was popular and that his policies were popular. On the antisemitism and islamophobia issues, there are deep divides. Labour supporters also seem to have different views on ‘flag shagging’, the importance of being ‘woke’, and, of course, the big one – immigration. Wokism seems to cluster with views on lockdown and coronavirus vaccination, which is also an interesting one.

I am always amazed how Brexit will not be openly discussed ever apart from some thought leaders. It seems to me that if Truss and Starmer wish to improve the ‘productivity’ of the United Kingdom (with Starmer feeling that it might be attainable through means other than tax cuts and other figments of the ‘Britannia unchained’ delusion), they will need to embrace at least superficially the significance of the ‘single market’. This requires a very different relationship with the European Union. Anoth

politics

The clock is ticking. Does Labour know what it’s up against?

There is an important and distinct political choice on offer in 2024. In Liz Truss’ favour, for whatever reason, she comes in as Prime Minister with rather low expectations of the Tories in general. Any achievement from Liz Truss can therefore end up looking incredible. But Liz Truss gave a strong performance in #pmqs today. The messages of ‘on the side of people who work hard’ and ‘in favour of aspiration’ are well road-tested. Whilst the Tories have established themselves in terms of economic competence, despite much alleged pandemic-related corruption, they have not established themselves as having much regard to social standards such as pumping sewage into the sea. Liz Truss has up to 50% of her own Party not in full support in that they voted ‘for the other candidate’, but Rishi Sunak has urged the Tory MPs to ‘unite as one big family’. On that, the problems in the Conservative Party are nothing compared to the mayhem in Labour, where some of the membership still remain loyal to Jeremy Corbyn personally and his socialist policies. But things are not clearly quite right yet. Today, the British pound has fallen to its lowest level against the US dollar since 1985, when Margaret Thatcher was running the country Spooking the markets is not something the Tories want to be known for. The markets may go for consistency and steely views.

Assuming that Sir Keir Starmer is still the Labour leader in 2024, it is likely that the next general election will be interesting. Starmer’s supporters believe very much that he is the man for them, so much so thay strongly believe him to be the next Prime Minister, but those non-believers cite reasons for their difficulty in supporting Labour. Labour is substantially ahead for the first time in ages in polls, but even Margaret Thatcher claims that she never looked at the polls. There is only one poll that counts. The last real poll was in 2019, and ‘influencers’ came out to tell people not to vote for Jeremy Corbyn. Corbyn was in the unusual position of being ‘unelectable’, and yet it was an achievement according to both Liz Truss and Boris Johnson that “Corbyn was crushed”. Voters apparently voted to ‘get Brexit done’, but Labour does not wish to discuss Brexit at all, denying a voice for millions of people who continue to be criticised as ‘remoaners’. This relentless personalisation and vilification of the attack, to which many are thick-skinned anyway, means there is no discussion of the breaches of the Northern Ireland protocol, where the Northern Irish border in effect, the decimation of industries, the queues at Dover, the effect on trade, and the security checks about to be implemented for the UK as a third country.

When Joe Lycett came to criticise so vocally on the inaugural episode of ‘The Laura Kuenssberg Show’, basically the flagship political discussion programme of the BBC on Sunday mornings, it came as a shock to some who were not expecting somebody there ‘taking the piss’ in broad daylight. It was completely cognitively dissonant, in that this was unexpected and confusing. But equally for many it was very funny. Emily Maitlis has her critics, so much so she was even accused of being a ‘plant’ for the Labour Party in the BBC, but she has an arguable point over false equivalence. For an organisation which prides itself on its public funding and ‘impartiality’, it was clearly going to be a problem for Kuenssberg to have a comedian as a member of a panel, odd in number, and so small in number. Satire itself has a long tradition in the BBC, for example ‘That was the week that was’, but the inclusion of satire in itself is not a culpable sin (take for example BBC Question Time which is regularly accused of substantial right-wing bias).

As Liam Halligan said today on GB News, ‘Can they afford to do an energy rescue package or can they afford not to?” Halligan is a highly respected economist and journalist, and he succinctly set out the potential danger of businesses going to the wall. It apparently is uncertain how the markets will take to as much as £100 billion (or more) of help, and Halligan set out the uncertainty of knowing how much it would cost due to the lack of knowledge about the international price. One is rather reminded of how David Cameron used to tour the TV studios religiously to tell people how Gordon Brown had ‘maxed out the credit card’, after a global financial crash over securitised mortgages attributed by Cameron to Gordon Brown. Some economists would argue now that this was used an excuse for the failed policy of austerity which did substantial economic and social damage. Proponents of the free markets claimed that that was no where near austerity. If there is any. whiff that the general public has been dumped with an extra cost for ten years, whilst something could have been to tax unconscionable profits from the energy providers, Keir Starmer could prove to be very popular indeed. The #enoughisenough movement is already very strong due to remarkable work by Mick Lynch and Eddie Dempsey. They have been protecting workers’ rights in a way many wish Keir Starmer and Labour had. But the idea that the Conservatives are a party which only looks after the interests of large corporates, especially after the way some smaller businesses were treated during the pandemic, could turn out to be extremely toxic like the Poll Tax. If the general public is to pay for it for ten years, the mood music might change.

If Brexit in 2016 was the solution, what was the problem? The dinghies have become symbolic of trafficking and immigration. The problem here is that immigration is still sky-high, immigration is needed to fill employment gaps in some critical sectors, and Brexit led to the abolition of the Treaty of Dublin which had safeguarded cooperation with France. We have pumped billions into this, with very little accountability from the media including the BBC or the opposition parties. It is conceded that growth and productivity are issues decades old unresolved successfully from the UK government, but an act of economic self harm through Brexit is hard to justify. Not trading in products which meet the specification of your target audience abroad could lead to the imposition of tariff barriers, further causing problems. It is possible that due to signing up to the European Convention of Human Rights flights cannot leave for Rwanda or extremist (normally illegal) action cannot be taken against dinghies. It seems that Raab’s Tory Bill of Rights is a bit of a mess. Now that the chief cheerleader for it, Dominic Raab, has been asked to leave, the legislation is considered to be a mess. But Suella Braverman has an immediate problem on her hands, in an area where Priti Patel is generally thought to have failed by supporters of Nigel Farage – the English Channel crossings. It could be the departure from the European human rights convention could be put on hold until a mandate is achieved in 2024. Truss may double down with her identity politics, ‘anti-woke’, hits to make the political transformation of the Tories complete. The productivity challenge had been thought to have been solved on paper by Liz Truss and colleagues through changing the work culture of Brits, and a low-tax economy. Being free marketeer and also being sympathetic to the ERG, where some members are coincidentally now planted in the Northern Ireland office, Liz Truss seems resistant to go back to joining the single market, the big market on her doorstep. Surely that would be rather important for productivity? Liz Truss at the weekend stated clearly that she did not see redistribution as a priority, but later said that levelling-up is a priority. In theory, she might be levelling up through pre-distribution, which possibly became peak in popularity about a decade ago, but that would be a rather left wing thing to do.

In addition to resolving the energy crisis in the short term, and the productivity puzzle, Liz Truss has made it clear she intends to address the NHS. Therese Coffey, who appears to have been extensively ‘shamed’ on Twitter including by those accused of being ‘liberal lefties’, allegedly, has set out an ABCD plan, ambulance waits, backlog, care and doctors and dentists. Ambulance waits cannot be resolved unless ambulances can enter A&E, and that is not possible unless patients can leave hospital which is made much harder by a decade of swingeing social care cuts. Social care’s raison d’être is not simply for the benefit of the NHS, but is intended to enable and protect individuals of all ages. Coffey will be in discussion with Amanda Pritchard, boss of the NHS England, today to talk about how to improve the backlogs for procedures which might include instructing the private sector, mitigating years of lack of workforce planning in both the NHS and social care. GPs have been attacked for only working 3 days a week, but a previous SoS had himself suggested alternative means of GP consultations at the time of the pandemic. There is a discussion to be had how to get patients to their doctors most easily, as there is a substantial GP workforce retention problem. Getting a GP appointment at 8 am should not be a ‘star prize’ like winning energy bills paid for from ‘This Morning’, in some poverty porn extravaganza.

Polly Toynbee may feel that Starmer’s Labour has nothing to fear from Liz Truss, having ‘no vision, no charisma, no real plan’. Truss has laid out a plan on energy, growth (and low taxes) and the NHS, which one may disagree with, but it is a vision. It may be ideological; it might not be. It may not be the vision I would want, for example in employment rights or breaking up failed privatised monopolies in the country’s infrastructure, but it is a vision. Starmer has not produced a vision or plan either (or if he has produced a vision, he might not have time to share it yet), and he has 2 years to produce one. Even Wes Streeting on Iain Dale’s discussion programme this week conceded that Labour could not win through opposition alone. It is perfectly possible that Sir Keir Starmer does have a coherent plan for government, does have a workable vision for running the country, and is the perfect candidate to be a national statesman with an innate passion for justice and fairness. As John Prescott argued, when you want to be a passenger on the plane, you don’t care if the pilot is not particularly charismatic. Labour is clearly still split as the recent NEC elections demonstrated, opening up old wounds. Labour still has a serious problem living with itself, and it is as if the days of Kinnock, Benn and Healey are not behind Labour yet. It is as if Nye Bevan’s call to not run after pure socialism, articulated in ‘In place of fear’ has gone unheeded. Here it is quoted by Foot:

The clock is ticking, and the next week or so will be a good clue as to whether the public want to buy into a change through Keir Starmer’s Labour. The politics and economics are complex, but they involve choices. We don’t know what the public make of these solutions to the choices yet. We will one day. Can Liz Truss ‘deliver’? Growth is potentially compromised by externalities such as the Ukraine conflict, and whisper it gently Brexit. The NHS ambulance waits themselves depend on funding social care and increasing capacity of A&E departments. And the energy crisis is anyone’s guess. Two years is a long time in politics.

politics

After a decade of Cameron, May and Johnson, has ‘Britannia Unchained’ got what it takes?

Keir Starmer, 60 today, will need a larger majority than Tony Blair to sweep to victory in the next general election. Currently, the approach of the Tory leadership is unpopular, and even the current finalists of ‘Britain’s not got any talent’ are not cutting the mustard with all of the Conservative membership. The traditional adage is that parties don’t win elections, but parties lose elections. Like all things Boris Johnson, that might be one final trend to be bucked.

Boris Johnson is still popular amongst his cult and the Tory Party, like the Labour Party, is a coalition. The future looks pitch black, not because the lights have gone out yet with or without rationing of energy supplies, but Liz Truss is a known unknown. Keir Starmer, although maintaining influence on the NEC and some degree of stability on and off the picket line, has U-turned on all his pledges, so the pitch on “telling the truth” lands uncomfortably with some, despite Johnson defending himself on the reputation of being an inveterate lawyer. Starmer is still unpopular with some within Labour (mainly socialists), but popular with others who genuinely feel he has a good chance of winning the next election.The ‘Enough is enough’ movement is gaining momentum with celebrity appearances such as Bernie Sanders. Liz Truss and Rishi Sunak still are chucking out the bangers like aged rockstars. Truss boasts confidently, ‘I am a woman’, while Sunak says ‘We will get rid of the European definition of asylum’ – at least one of those must be true?

For all the bluster of putting country ahead of party, you have to worry about an opposition unable to win with the NHS struggling and the economy falling apart. Just as it is unclear that Labour was solely responsible for a global economic crash in 2008/9, it is equally unclear that the Ukraine war is responsible for the high inflation in the UK. The arguments for why this is not the case perhaps have been exhausted elsewhere. Certainly inflation is movable feast, with the US dollar being strong against the sterling pound and Euro. As we know food prices started going up due our supply chain problems were not due to Brexit, so they say. All alcoholics in recovery to have the courage to face the things they can, so both Labour and the Conservatives acknowledge their lack of influence on externalities presumably. But one internal dispute within the Conservative Party became very public within the whole country, and is as yet unresolved due to issues such as the Northern Ireland protocol or regulatory alignment. A culture war may be beginning to make an appearance causing a fracture within Labour too. One only has to look at Owen Jones and Eddie Dempster, and their groups, to know that there is a meeting of minds over neglecting the concerns over the ‘working class’. But the argument is clearly nuanced – so for example not all of the working class are White, and not all racists live in the North (apparently they mainly live in the South East, where coincidentally much of the Conservatives membership lives.)

It feels as if Labour has somewhat been thrown off track from its founding ideas. Mick Lynch is clearly concerned that founding values are not audible in statements made by Labour’s leadership. I think this is true. It doesn’t seem to say much on employment rights. It doesn’t say much on why it has accepted the economic model of Thatcherism in the privatisation of elements of the State, even though the unconscionable profits of directors are clearly at odds with the 1975 privatisation think tank within the Conservative Party which said that privatisation was partly charged with redistribution of profits to workers fairly. Starmer possibly wants to have his ‘red meat’ clause 4 moment. The Beecroft report from 10 years ago is still fresh in the mind of the Free Market group members, Kwasi Kwarteng, Liz Truss, Priti Patel and Chris Skidmore. This ‘liberisation of the workforce’ is together with tax cuts designed to promote productivity in a Singapore-on-Thames is an appealing idea, except without any state intervention it is possible that many SMEs will go to the wall – and then there will be not much growth, and much unnemployment. The pitch on low taxes is clearly Wild West politics, and it would be more ‘grown up’ to think about maximising markets, not just pork markets, to improve productivity. But this might necessitate discussion of the topic which cannot be mentioned – that of course is Brexit. The Tories have had various crises to contend with apart from Brexit such as the coronavirus pandemic. So it’s quite possible that we never saw ‘peak Johnson’ as he was negotiating one crisis and the next.

We know what happened to what was called a ‘far left’ approach. Somebody told me that he considered Labour to be ‘far left’ because of their Green policies, wanting to increase spending in the NHS and social care, abolition of tuition fees, and so on. Each to their own. But it could be that the ‘radical right’ goes unchallenged – and certainly not subject to quite the same degree of toxification from the media. Energy issues, such as the lack of market, wind farms, insulation – have all been known issues when Ed Miliband pitched for a Labour government in 2015, but it was considered more important to get Brexit done in 2016. That Brexit is yet to achieve its full potential is illustrated in the damp squib of the Festival of Brexit.

Nobody can define what ‘Britannia unchained’ will end up looking like. It’s an experiment in economic liberalism to continue the legacy of Margaret Thatcher which is effectively an obsession – which only a Truss/Kwarteng government can deal with as a compulsion. With ambulances delayed, social care on its knees, people not able to pay their utility bills, it could be that Cameron’s volunteers in the ‘Big Society’ are stretched to their limit. But apart from food banks and warm houses, what more is there to be done? The failure of Tory policies is glaring, and there are few else to blame. For Liz Truss to succeed, she is going to have to tear apart her own record, including legal aid cuts (criminal barristers are on strike), not having gas storage (gas import is costing us dear), and not having environmental safeguards (it is difficult not to go for a swim in certain beaches without contracting a life-threatening illness.)

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