The gift that keeps you guessing

The government’s NHS funding settlement brings some welcome relief for struggling services, but leaves many tough questions unresolved. Craig Ryan reports. (Published in Healthcare Manager magazine, Summer 2018)

HCM39 Front Cover

The NHS’s 70th birthday present from the government was a bit like one of those gift cards from posh shops that don’t tell you how much they’re worth – when you finally get to the till, it’s always a bit less than you need.

We know quite a lot about what the “long-term funding settlement”, unveiled on 18 June, is not. It’s obviously not, as Theresa May suggested, a “Brexit dividend” – that claim has been so comprehensively rubbished that there’s not need to go over it again here. Neither is it worth £600m a week, as some ministers claimed. That figure is based on the total increase in the NHS budget by 2023 — at 2023 prices, which are meaningless in 2018. In fact, right now it’s worth precisely nothing, as there won’t be a penny of new money until April. And, as another tough winter looms, for many MiP members it’s right now that counts.

Neither is it much of “settlement”, when so much remains to be settled. We don’t know where the money will come from, or if other vital services will be cut back to pay for it. We don’t know if there will be any new money for social care services that are on the brink of collapse. We don’t know much about how the new money will be spent, or how the strings attached by the Treasury will operate. And we don’t know to what extent public health services and staff education, excluded from the announcement, will continue to be starved of funds.

These issues may not be settled until November’s budget or even next year’s scheduled spending review. And with the fate of the government hanging in the balance as I write, who knows if either of those things will happen as planned? The long-term funding settlement may not be very “long-term” either.

In NHS circles, there is near-unanimous agreement on another thing the government’s “settlement” is not – and that is “enough”.

What we do know is that the government has promised to increase NHS England’s budget by £20.5bn by 2023, with corresponding increases of £2bn for NHS services in Scotland and £1.5bn for Wales. For England, this equates to real terms growth of 3.4% per year for the next five years: an undoubted relief after years of painful austerity, but actually the same level of investment made between 1979 and 1997 by those notorious tight-wads Margaret Thatcher and John Major.

“Managers will obviously welcome the easing of underfunding,” says MiP chief executive Jon Restell. “That said, the new money will not stretch to everything the government wants to do, such as investing in integrated health and social care, and moving more care out of hospital. And we’re in the dark on some important budgets such as public health, staff training and capital projects. Plenty of tough choices still remain.”

A month before the funding announcement, the Health Foundation and the widely-respected Institute for Fiscal Studies, with support from the NHS Confederation, published a comprehensive survey of health and care funding. Securing the Future made clear that funding growth of 3.3% was the absolute minimum needed to maintain current standards. 4% growth would allow for some modest improvements, the report said, but to invest properly for future health needs and to deliver the government’s own policies on things like integration and moving services into the community, above 5% will be required. The OBR more or less agrees: its projections reckon annual increases of 4.3% are the minimum needed to meet the government’s objectives.

The government’s plans “will help stem further decline but it’s simply not enough to address the fundamental challenges facing the NHS or fund essential improvements to services that are flagging”, warns Anita Charlesworth, the Health Foundation’s director of research.

The big black hole in the government’s plans remains the funding of social care. Speaker after speaker at last month’s NHS Confederation conference spelt it out: we need a comprehensive funding settlement for both health and social care. The two have been yoked together since birth (our modern social care services are also celebrating their 70th birthday this year – who knew?) and never more tightly than now.

The Health Foundation/IFS report found that social care spending will need to increase by at least 3.9% in real terms for the foreseeable future, just to maintain current (poor) levels of service. Social care underfunding “has a direct impact on the NHS”, warns the report, “including rising numbers of emergency attendances, admissions, and patients facing delayed discharge due to a severe lack of care available in the community”.

“It’s worrying that we still don’t know about funding for social care,” adds Restell. “Social care needs 4% a year in real terms. The public don’t see where social care ends and healthcare starts – but they know more money is needed. The government must make a parallel settlement for social care as a matter of urgency.”

Adding to this uncertainty is the fact that the new money applies only to NHS England’s budget, and not to all spending by the Department of Health and Social Care (DHSC). This is not a technical point – according to the Health Foundation/IFS report, this narrow definition of NHS spending is a “mistake” which has already “lead to damaging cuts to public health programmes, capital investment and the education and training of NHS staff”.

Amazingly, this means the government’s settlement ignores the area where the crisis is most acute: the training and recruitment of skilled NHS staff. At the end of March there were 92,000 vacant posts in NHS providers alone. Health Education England admits that, on current trends, the NHS will manage to recruit barely a third of the clinical staff it needs in the next ten years.

“We also need a long-term workforce strategy to support the funding settlement,” says Restell. “The NHS’s recovery will need managing very carefully, and it’s critical we now invest in our staff – including support staff and managers.”

While it’s always churlish to quibble over the value of a gift, the funding announcement isn’t really a gift at all – simply a response to mounting political pressure. The public have made it clear time and time again that they expect NHS services to be properly funded, and that they are prepared to pay for it if necessary. The new money is a step in the right direction, but in many ways it simply kicks the can down the road. We shouldn’t be too polite to say so.

20 billion quid pro quo

The Treasury and the DHSC has set five “financial tests” for the NHS meet in return for the new money. At the time of writing, it remains unclear how the tests will be assessed and what will happen if they’re not met.

  • Improving productivity and efficiency
    Sources say the Treasury is pushing for a headline target of 1.8% for annual productivity growth in the NHS, more than twice the long-term average of 0.8%
  • Eliminating provider deficits
    Tight financial controls on trusts are unlikely to be loosened much, but new money means fewer trusts will find themselves in financial special measures, leading to a more intense focus on those with the deepest problems.
  • Reducing unwarranted variation in standards
    Greater use will be made of NHS Improvement’s still-embryonic Model Hospital tool, together with the Getting It Right First Time and Right Care programmes.
  • Manage demand effectively
    A vague test, which may involve channelling funding towards collaborative projects and schemes which reduce demand at health economy level.
  • Make better use of capital investment
    Capital investment was excluded from the 18 June settlement, so this test will focus on better targeting of existing schemes, including revisiting the Sustainability and Transformation Plans submitted in 2016 and tighter control of technology funding.

Book review: The French Exception

psm-winter-2018-coverThe French Exception: Emmanuel Macron – the Extraordinary Rise and Risk (updated edition), by Adam Plowright. Icon Books, 300pp, £8.99. (Published in Public Service Magazine, Autumn 2018)

If you want to be French president, you usually have to be good at waiting. It’s a job for which even political giants, like Mitterrand, de Gaulle and Chirac, spent decades preparing before landing the prize. For others, like Michel Rocard and Alain Juppé, the prize never quite materialised.

But Emmanuel Macron doesn’t do waiting, and the scale and pace of his ambition is exhausting. In this book – a slightly uneasy blend of biography and tour d’horizon of French society – British journalist Adam Plowright portrays Macron as a leader belonging to the more swashbuckling tradition represented by Nicholas Sarkozy and Napoleons I and III: flashy, sharply-dressed, silver-tongued outsiders in a hurry.

The idea of the “providential man” (or woman, in the case of Joan of Arc) who will banish the nation’s woes through sheer force of personality, is deeply embedded in the French psyche, Plowright claims. Quoting the eminent French historian Jean Garrigues, he enthuses about “a form of charisma, an ability to create a sort of collective enthusiasm, which Bonaparte and de Gaulle clearly had”, while also warning about “a Christ-like dimension, a sort of mysticism.”

Macron emerges as surprisingly “cynical” and “manipulative”, even “quasi-monarchical”, for a modern European liberal. There is little internal democracy, Plowright points out, within Macron’s hastily-assembled political party, La Republique En Marche!, which still functions primarily as a personal political vehicle. And he describes how Macron has irked some supporters, and impressed others, with his insistence on the trappings of power – most famously with his bad-tempered rebuke to one young voter who had the temerity to call him ‘Manu’.

For all the novelty of Macron’s youth, his “unconventional” marriage to his former arts teacher, his status as an outsider to the political process, and his sheer freshness in comparison to France’s grey and stale political class (in which some of Mitterrand’s cohorts are still active), what emerges from Plowright’s well-drawn pen portrait is a fairly conventional centrist European politician – though with his emphasis on work and efficiency, one who sounds more a bit more German than French.

But while he offers a few vox-pops from Macron supporters, mostly small business people enthused by the prospect of it being easier to sack people, Plowright never really gets under the skin of today’s France. It remains a mystery how this pro-European, pro-business graduate of France’s elite political school managed to transcend the “sour national mood” in France, and become the unifying national figure who personified the change the nation needed.

One answer, of course is that he didn’t. By peeling away votes from the moderate left and moderate right, and sewing up the centre through his deal with veteran liberal François Bayrou, Macron scraped into the second round of the presidential poll, where, head-to-head against the neo-fascist Marine Le Pen, he was home and dry. His political future depends on holding that coalition together and forging it into something more meaningful and long-lasting.

France didn’t much take to its “normal” president, François Hollande. Yet, with Macron we see something like a palimpsest of his predecessors: the messianic qualities of Napoleon and de Gaulle, some of the cunning of Mitterrand, the centrist pan-European politics of Giscard d’Estaing, the haughtiness and faux-grandeur of Jacques Chirac and the flashy ambition of Nicholas Sarkozy. If he can avoid Hollande’s ponderousness and Pompidou’s chain-smoking, Macron – and France – might just be onto something.

Book review: Doughnut Economics

Doughnut Economics: How to Think Like a 21st Century Economist, by Kate Raworth. Random House Business, 384pp, £9.99. (Published in Public Service Magazine, Spring 2018)


Oxford academic Kate Raworth’s Doughnut Economics, now out in paperback, caused quite a stir when it was first published last year, with Guardian eco-warrior George Monbiot comparing it, somewhat fancifully, to Keynes’s General Theory. That seems like a misreading of the book’s purpose, as revealed by its subtitle: Raworth isn’t offering a a theory or a model, but a well-grounded appeal for us to think differently about economics.

Raworth’s ‘doughnut’ attempts to describe, in a simple picture, a goal for economics; it’s that lack of purpose, Raworth argues, that allowed “the economic nest [to be] hijacked by the cuckoo goal of GDP growth”. The inner ring of Raworth’s doughnut (there’s no jam, today or tomorrow), “the social foundation”, represents the basics we need to lead fulfilling lives – enough food, good education, decent healthcare and housing, political participation and so on – while the outer ring represents the limits of what the planetary ecosystem can bear. The aim of economics is to get us into what Raworth calls the “safe and just space” between them – and to keep us there.

To do this, Raworth argues we’ll need to “design” an economy – she uses the word pointedly – which works in harmony with the natural and social world in which it is embedded. And that work of design has to recognise that much important economic activity takes place outside of the market, in the household, the government and the “commons” – the sphere of sharing, voluntary work and community co-operation.

Along the way, Raworth says we will have to discard “an economic mindset rooted in the textbooks of 1950, which in turn are rooted in theories of 1850”. What if demand curves don’t always slope down? Suppose our complex and ever-changing economy is never at equilibrium. Imagine that what mainstream economists call “external shocks” – environmental degradation, financial crises, social unrest and technological change, for example – are actually inherent to the system. What happens if perpetual economic growth is no longer necessary or even desirable – or, more uncomfortably still, necessary but no longer possible?

Such thinking has been gaining ground for some years, through the work of dissident economists like Steve Keen, Ha Joon Chang and the late Elinor Ostrom – and in response to the global student movement Rethinking Economics. Economics must also join other sciences in embracing “systems thinking”, and “stop searching for the economy’s elusive control levers and start stewarding it as an ever-evolving complex system,” Raworth says. Economists, she suggests, need a metaphorical career change: “discard the engineer’s hard hat and spanner, and pick up some gardening gloves and secateurs instead”.

As well as these sources, Raworth draws heavily on the greatest economic dissident of all, John Maynard Keynes himself. When we finally get to grips with all this, Raworth feels sure Keynes will be “waiting to greet us, ready to get to work on figuring out the economics – and the philosophy and politics too – of the art of living in a distributive, regenerative, growth-agnostic Doughnut Economy”.

How we get there will be up to us – “we are all economists now”, Raworth says. Despite the “very real” possibility of complete breakdown, she believes “there are enough people who still see the alternative, the glass-half-full future, and are intent on brining it about”. With Trump in the White House and so much of new economy in the hands of powerful oligarchs, it can be hard to share Raworth’s optimism. But then again, we may have no choice.

Talking heads

Last year’s Stevenson-Farmer report set out an ambitious agenda for improving mental health and wellbeing in the NHS. Craig Ryan explores the deep culture changes needed to make sure all NHS staff can thrive at work. (Published in Healthcare Manager magazine, Spring 2019)

After another punishing week and a “frantic” 24-hour period on call at the weekend, Paul, a manager for an NHS trust in the South West, found himself unable to get out of bed. He’d been experiencing stress and feelings of anxiety for months, but knew this was different. “I just couldn’t move. My head felt like lead, I couldn’t even contemplate the things I had to do to get into work,” he recalls.

Paul was signed off sick for a few weeks, and was eventually offered early retirement following a capability review. “My line manager was sympathetic, but couldn’t really offer much else. I was in my late fifties, so it felt like the only option,” he says.

Paul was just one of the estimated 300,000 people who lose their jobs every year in the UK because of mental health problems. According to Thriving and Work, last year’s independent review by Lord Dennis Stevenson and Mind chief executive Paul Farmer, the scale of the mental health challenge in Britain’s workplaces “is greater than we thought”. And the NHS is no exception. The 2017 NHS Staff Survey found that 37% of staff regularly feel stressed at work, a figure that has remained constant despite a plethora of national and local initiatives in recent years.

Behind every job lost is often a personal tragedy, but also a considerable financial cost to the NHS. Research for the Stevenson-Farmer report put the cost of mental health problems in the NHS at around £2,100 a year for every member of staff – higher than for any other sector except finance.

And it’s not just so-called ‘frontline’ workers who are affected. In NHS England, designated by the government as an ‘early adopter’ of the report’s recommendations (see below), ‘stress, anxiety and depression’ accounts for 35% of all sickness absence – more than three times as much as ‘colds, coughs and flu’. More than 80% of calls to NHS England’s Employee Assistance Programme concern work-related stress, and almost a third involve a mental health condition.

MiP national officer Jo Spear says she is supporting an increasing number of members suffering from mental health problems, particularly senior managers in provider organisations. “There’s something about that tier of management that seems to make them vulnerable to not just stress at work, but actual diagnosable mental health problems,” she explains. “I think it’s because of the proximity to patients and exposure to risks and governance pressures. With commissioners, we tend to get a lot of bullying and harassment, but fewer diagnosable mental health conditions.”

Spear believes most individual NHS employers simply aren’t “geared up” to deal with mental illness when it affects staff in the workplace. “The policies and procedures are too one-dimensional and they have a very anodyne way of dealing with it. Someone is ill, they go off sick and you need to performance manage them back to work. That just doesn’t fit the bill in the same way it does for physical illnesses.”

Culture change

The Stevenson-Farmer report cites long working hours, regular inspections, lack of interaction with colleagues, lack of control over work, and cuts to budgets and staffing as causes of poor mental health among public sector workers.

Faye McGuinness, head of workplace wellbeing at Mind, who works with NHS England on implementing the Stevenson-Farmer report, says: “The onus should be on employers to support their staff through difficult times, so that they can come into work at their best, and in turn get the best outcomes for their patients… which is why implementing the recommendations of Thriving at Work is so important.”

Senior managers in the ambulance service are already working with UNISON and Mind to tackle the very high incidence of mental illness among ambulance staff, which research found could be explained by the way staff were managed – particularly the handling of organisational change. In 2015, helped by a grant from the Cabinet Office, Mind set up the ‘Blue Light’ programme to provide direct support to emergency service workers with mental health problems, while working with employers to tackle the root causes in the workplace.

Alan Lofthouse, UNISON’s national officer for ambulance staff explains: “These days, your average paramedic is making really big decisions, yet their work life is still quite prescribed, with long shifts, being told where to go, and that constant requirement to do more, keep doing more and keep people out of hospital.”

Add in the high likelihood of being assaulted, the prevalence of bullying, and a poor record on race equality, “and everywhere you looked you had these red flags that something was wrong with the ambulance service,” he says.

“It would be easy for us to criticise management and just say ‘you should be doing something different’,” Lofthouse adds. “But culture-wise, people do what they observe, and historically ambulance services have been managed through grip and command – and through fear a lot of the time… The current managers have developed in that culture, but now we’re asking them to be agents of change and not simply mirror what they did before.”

A healthy workplace?

In England, action at national level has focused on implementing NHS England’s Healthy Workforce framework, which is being updated to incorporate the standards laid down in the report. “We’ve met with… NHS England to discuss the framework and have provided feedback, including the need for them to ensure that they have clear indicators to measure progress against what’s set out in the framework,” says McGuinness.

Despite endorsing the Stevenson-Farmer report as an employer, the government has stopped short of making the new standards compulsory for all NHS organisations – trusts and CCGs will merely be “encouraged” to meet them. “Making implementation mandatory might not be the right approach,” says McGuinness. “We’d hope that the financial argument for putting in place wellbeing initiatives is sufficiently strong that organisations get on board without any coercion.”

McGuinness cites research by Deloitte which found that workplace interventions, such Employee Assistance Programmes, which offer 24-hour confidential support, and NHS First Aider schemes, show a return of between £1.50 and £9 for every pound invested. “Even those with small budgets appreciate there are lots of small, free initiatives that make a difference – such as buddy systems, regular catch up with managers, flexible working hours, and options to work in different places,” she says.

One of the persistent themes in the Stevenson-Farmer report is the need for employers to abandon the traditional ‘performance management’ approach, where mental health problems – if they were discussed at all – were tackled as issues of individual capability.

“You’ve got people working very long hours under extreme financial constraints and they’re expected to behave as if the job is a vocation,” says Spear. “And then when they look like they’re going under, the finger of capability is pointed rather than support.”

Spear is particularly critical of the use of ‘Bradford scores’, where formal procedures are automatically triggered after a number of incidents of sickness (typically three) within a year. “If you have a mental illness, rather than something people can see, like a back injury, the assumption is that you’re just not coping and they start performance managing you, giving you performance standards to meet.

“What they should be doing is giving basic consideration to whether they’re not coping because they have a workload which no normal person could cope with, and that they need to talk to someone other than their line manager,” she adds.

Paul agrees that sickness absence procedures often make things worse, by hiding the real problems and piling more pressure on already over-worked staff. “They make it all about you, not about the job, or looking at what made you ill in the first place. And that just makes you feel less capable and less supported – sort of hopeless. I can’t see how that’s supposed to help anyone, to be honest.”

Lofthouse expresses sympathy with line managers who, in the ambulance service, are often under pressure to reduce sickness absence and meet response time targets. “Our message is that if that if the treat staff well and look after them, that will have an impact on those things – but do they really understand that and does the organisation at board level say that as a clear message?” he says.

This need for leaders to take responsibility is behind one of the Stevenson-Farmer report’s most striking recommendations: that NHS chief executives should have the mental wellbeing of staff enshrined in their performance objectives.

“It’s important that… NHS chief executives lead by example, and consider how they can be held accountable for the wellbeing of their staff,” says McGuinness. “Having performance objectives relating to employee mental health is one way they can do this… Showing staff that employee mental health is a key priority, and one that they are willing to be measured against, is a step towards creating a positive culture where staff feel able to talk about their mental health problems.”

This would certainly be an unprecedented step, with big potential to drive meaningful change. But how

it will be implemented across the NHS remains to be seen. “We don’t yet have any other examples of this being done before,” admits McGuinness.

Culture of silence

Claire, a service lead for a community health trust in the South East, recently returned to work after several months off with a mental health condition. She says the biggest problem in the NHS is that people simply feel unable to talk about problems at work that might lead to mental health conditions.

“Everyone pretends they’re at this level of ‘just about coping’,” she says. “No one talks about being not able to cope until it’s too late. There’s a sort of tipping point. The support you get when you’ve been diagnosed with [a mental health condition] should be there long before things get to that point.”

The Stevenson-Farmer report takes particular aim at this ‘culture of silence’, where employees kept quiet about mental illness for fear of being stigmatised, demoted or even losing their jobs. Instead, says McGuinness, employers need “to create a culture where staff feel able to talk openly about stress and mental health, and know that if they do, they’ll be be met with support and understanding rather than stigma and discrimination.”

Claire cites supportive colleagues, a sympathetic line manager and a recently-established staff support network as factors which enabled her to resume her career, more or less where she left off.

“I was lucky,” she explains. “I work in mental health, so I had a good understanding of my own condition and could navigate the system. Having a supportive manager is really important – someone who’s prepared to put her neck out and challenge [the employer] if needs be. But most people don’t have that.”

She warns the persistent stigma over mental illness still prevents most people from getting help. “The staff network helped me a lot, but it’s mostly the same people – therapists and a few managers – talking to each other. Most people don’t come because they think everyone will know they’ve got problems, and they don’t want their manager finding out.

“We want people to know that it’s okay to talk about this, whether they’ve already got an illness or not. When that happens, we might be getting somewhere.”

Stevenson-Farmer: key recommendations for the NHS

  • Chief executives of NHS organisations to have performance objectives relating to employee mental health
  • Regulatory bodies (e.g. CQC) to include the employer’s approach to staff mental health in their assessments
  • Routine monitoring of employee mental health
  • Enhanced mental health training for staff at all grades, especially for line managers
  • Employers to identify staff and higher risk of stress or trauma and develop a national framework of support
  • Tailored in-house mental health support for larger organisations, with signposting to clinical support
  • Measures to encourage open conversations about mental health and the support available to staff

All in the mind

Last year’s Stevenson-Farmer report set out an ambitious agenda for improving mental health and wellbeing in the civil service. Craig Ryan explores the deep culture changes needed to make sure all civil servants can thrive at work. (Published in Public Service Magazine, Spring 2018)

In January 1974, at the height of the three-day week crisis, the head of the civil service, Sir William Armstrong, suffered a stress-induced mental breakdown. According to several accounts, Armstrong was found naked on the floor of the Downing Street waiting room, chain smoking and raving about the end of the world. The following morning he convened a meeting of his Permanent Secretary colleagues and harangued them about preparing for Armageddon. Armstrong was admitted to hospital, but was back at work within a few weeks. Three months later, he left the civil service and became chairman of Midland Bank.

Armstrong’s breakdown was hushed up and the lessons ignored. Although colleagues later said the warning signs had been there for years, Armstrong received no support and never talked about his problems. The impact of severe stress and overworking on his ability to advise the Prime Minister at a crucial juncture in Britain’s history was never considered. And the effect on Armstrong’s own health – he died just a few years later – was perhaps greater than he knew.

On the surface, the contrast with today’s civil service couldn’t be greater. Government Chief People Officer Rupert McNeil has spoken openly about his problems with anxiety and encouraged colleagues to do the same. Departments have health and wellbeing champions, and have rolled out a plethora of mental health initiatives in recent years, including mental health first aider training, expanded employee assistance programmes and networks where staff get together to talk about workplace problems and the impact on their mental wellbeing.

When Lord Dennis Stevenson and MIND chief executive Paul Farmer published their independent review of workplace mental health, Thriving at Work, in October last year, the government not only accepted all the recommendations as an employer, but designated the civil service as an ‘early adopter’ of the mental health standards laid down in the report (see box). It was, and was intended to be, a clear signal that the civil service is now taking mental health seriously.

But it still has a lot to get serious about. The Stevenson-Farmer report says the scale of the mental health challenge in Britain’s workplaces is “greater than we thought”, and the civil service is no exception. According to MIND’s Workplace Wellbeing Index, public sector workers experience poorer mental health than those in the private sector, with one in six describing their mental health as “poor” and 53% saying they regularly feel anxious at work. Research by Deloitte’s puts the cost of mental health problems to the government at around £1,500 per civil servant every year – again, higher than the average for private sector employees.

Duncan is a senior manager with a large civil service agency who has suffered from stress-induced anxiety and depression for several years. Two years ago, he was signed off sick after visiting his GP. “I realised quite suddenly that I couldn’t cope, but the problems had been building up for a long time,” he says. “My workload was ridiculous – but so was everyone else’s. There’s this enormous pressure to be busy and to be just about coping, so I just tried deal with it. But I wasn’t sleeping properly, I was drinking a lot and things were starting to fall apart at home.”

Although Duncan’s manager was “not unsympathetic”, Duncan didn’t feel confident discussing his mental health. “I felt I couldn’t cross that threshold, admit I had a real problem. You don’t want to open up that whole can of worms – with capability reviews and assessments by [occupational health]. I was worried about my PMR, my reputation, I was worried about being made redundant – everything really.”

“Working in the civil service is demanding,” says Faye McGuinness, head of workplace wellbeing at MIND, who works with the civil service leadership on implementing the findings of the report. She cites long working hours, regular inspections, lack of interaction with colleagues, and cuts to budgets and staffing as factors that can put pressure on the mental health of all public sector workers.

“The onus should be on employers to support their staff through the difficult times, so they can come to work at their best, and in turn get the best outcomes for the people they represent – which is why implementing the recommendations [of the report] is so important,” says McGuinness.

Work across Whitehall is being lead by Jonathan Jones, the Ministry of Justice Permanent Secretary who is also the civil service health and wellbeing champion, with support from the Civil Service Employment Policy (CSEP) unit in the Cabinet Office and wellbeing champions in each department.

Jones tells PSM that he has “identified strategic priorities to change the culture towards health and wellbeing in the civil service… These include emphasising visible leadership, enabling honest and open conversations about mental health and encouraging an all-round healthy lifestyle.”

Work is already underway in 18 departments to benchmark existing programmes against the standards set in Thriving at Work . The report identified areas of existing good practice and those where collective improvement was needed, Jones explains, “including how we communicate our offer on mental health to employees, how we continue to build line manager skill and confidence, and how we consistently support people with mental health conditions within the recruitment process.”

The newly rebranded Ministry of Housing, Communities and Local Government (MHCLG) is widely recognised in Whitehall for being ahead of the curve on supporting workforce mental health. “When I joined the department in 2016, what really struck me was the openness within the [health and wellbeing] network, but also more broadly to talking about mental health issues,” says Jillian Kay, the ministry’s health and wellbeing champion.

“There were events going on where people were sharing their own lived experiences quite comfortably and openly, and similarly people sharing their own experiences online,” she recalls. “So I sensed that in terms of breaking the stigma it’s certainly a place where lots of people felt safe to share their stories, which felt like a really positive thing.”

In 2015, The department introduced mental health first aid training and a mental health ambassador listening and support service. MHCLG now has 150 trained mental health first aiders and has a thriving health and wellbeing staff network, and last year was it chosen to design and deliver the mental health awareness workshop at Civil Service Live.

Kay emphasises that the engagement of senior managers is crucial to shifting the workplace culture towards improving mental health. “I was a bit surprised to see members of the SCS on the mental health first aid training when I joined, but actually we’ve now trained 12 SCS members,” she says. “More than 40 first aiders have gone on to become mental health ambassadors, and they provide a listening and advice service to people who need it, including line managers who want to support their staff.” The ministry also runs specialised wellbeing workshops for senior leaders, including one recently facilitated by FDA national officer Jane Cockram.

Staff resilience and good mental health is very much a live issue for Kay as a manager. In her ‘day job’, she leads for the department on Grenfell recovery and resilience. “Some of our teams have been working with Kensington and Chelsea Council on support for all those affected by the fire. So I’ve get a set of staff who’ve had to be quite resilient over the last year,” she says.

“It really brings home the point that we’re trying to get across in the civil service that we all have good and bad mental health at different times depending on what we’re experiencing. An important part of this is making sure that mental health isn’t a kind of niche agenda, it’s something that’s relevant to everyone – and it became really relevant to all of us over the last year.”

At the same time, the civil service needs to identify and meet the needs of staff who are at a higher risk of developing mental health problems because of the nature of their work, which may include “mainstream” civil servants like Jillian Kay’s MHCLG staff, as well as more obvious candidates like people working for the security services or the National Crime Agency.

“Departments are being supported centrally to identify teams where there may be a higher risk of stress and trauma, [and] to in turn identify tools and best practice to help all departments address these issues,” explains Jonathan Jones. “Because the support may vary according to the types of work, it’s right that departments lead this work as they’re closer to the detail.”

One of the persistent themes in the Stevenson-Farmer report is the need for employers to move away from the traditional ‘performance management’ approach, where mental health problems – if they were discussed at all – were tackled as issues of individual capability. This lead to a ‘culture of silence’, where employees kept quiet about mental health problems for fear of demotion, reprimand – or worse.

Instead, says McGuinness, employers need “to create a culture where staff feel able to talk openly about stress and mental health, and know that if they do, they’ll be be met with support and understanding rather than stigma and discrimination.”

This also means managers taking some responsibility for the mental wellbeing of their staff, something that is reflected in one of the Stevenson-Farmer’s most striking recommendations: that civil service leaders should have the mental wellbeing of their staff enshrined in their performance objectives.

“It’s important that Permanent Secretaries and Chief Executives lead by example, and consider how they can be held accountable for the wellbeing of their staff,” says McGuinness. “Having performance objectives relating to employee mental health is one way they can do this… Showing staff that employee mental health is a key priority, and one that they are willing to be measured against, is a step towards creating a positive culture where… staff feel able to talk about their mental health problems.”

This would certainly be a unprecedented step, with big potential to drive meaningful change. “It’s difficult for us to talk about how this would be implemented as this is based on how they manage this internally. We don’t yet have any other examples of this being done before,” adds McGuinness.

Since returning to work, Duncan says he has benefited from some adjustments to his workload and from taking part in a staff wellbeing network. “Colleagues have been much more supportive than I expected and [management] have been willing to make some changes, which have definitely helped me,” he says. But he still fears his career has suffered, and doesn’t feel confident about pursuing promotion opportunities in the near future. “I still feel there’s this bit of a stigma hanging over me,” he adds.

Duncan still doubts many of his colleagues would be willing to discuss mental health problems openly with senior managers. “Maybe more managers are willing to have that kind of [supportive] conversation now, but I don’t think it’s enough to change the way people feel,” he says.

Whitehall has come a long way since Sir Robert Armstrong was reduced to rolling around on the Downing Street floor, and mental health problems are being discussed in a way that would have been unthinkable a generation ago. MIND’s Faye McGuinness, who has monthly meetings with civil service leaders to monitor progress, says: “We know there is a long way to go, and that change doesn’t happen overnight. But it’s positive that Government, and in turn, civil service employers, have accepted all the recommendations from the review and see the value in implementing them.”

For Duncan, the big challenge is ending the culture of silence around mental health, and that takes time: “In the end, it’s not about what support programmes there are, but whether people have trust and confidence to use them. I don’t think we’re quite there yet,” he says.

Stevenson-Farmer: key recommendations for the civil service

  • Permanent secretaries and agency chief executives to have performance objectives relating to employee mental health
  • Commitments to mental health standards to be written into Single Departmental Plans
  • Routine monitoring of employee mental health
  • Enhanced mental health training for staff at all grades, especially for line managers
  • Employers to identify staff and higher risk of stress or trauma and develop a national framework of support
  • Tailored in-house mental health support with signposting to clinical support
  • Encourage open conversations about mental health and the support available to staff

Read the Stevenson-Farmer report, Thriving at Work, at:

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Should I vote for Jeremy Corbyn?

I’m a social democrat. My political hero was Denis Healey. So why am I even thinking about voting for Jeremy Corbyn?

New Statesman Cover 21-27 August 2015

A version of this post was published in the New Statesman on 17 August 2015.

In politics, I like to think of myself as principled but realistic. I’m a social democrat, not a Marxist. My political heroes were mostly practical, moderate socialists – intellectual heavyweights for sure, but people who didn’t mind getting dirtying their hands in getting something done: Denis Healey, Tony Crosland, Shirley Williams, François Mitterrand. People who understood the grubiness of the material world and were prepared to work with it. People who had no illusions about how working people think, or about where extremism can lead.

When I was at university, 25 years ago, I was mocked (in a comradely way) for being the most right-wing member of the Labour club (although, as I remember, I was the only one prepared to join the Anti-Poll Tax Federation, a proscribed organisation in the Labour party at the time). When I left, the committee gave me a copy of The Ragged-Trousered Philanthropists, inscribed with warnings not move further to the right or become any more “careerist” (no worries on that score).

Inevitably, more than one or two of the wellwishers in that book went on to be leading lights in Tony Blair’s New Labour project. The party moved round me. What I thought of as mainstream social democracy went from being on the right of the party, to the centre and then to the left. Even “Red Ed” Miliband couldn’t put together a coherent social democratic programme – although that had as much to do with lack of confidence as lack of conviction. By about 2000, it was a mark of the hard left to be in possession of, to use Denis Healey’s preferred definition of democratic socialism, “an obstinate will to erode by inches the conditions that produce avoidable suffering”.

The definition is, I think, Kolakowski’s. But Healey went on to expand on his own feeling for what socialism should be:

Socialism emphasises the community rather than the individual, consensus rather than confrontation, public welfare rather than private gain; it puts the quality of life before the quantity of goods. But its priorities are not absolute; it does not deny that the values which it normally puts second will sometimes need to come first, or that it’s opponents may also give some importance to socialist values. 1

Spot on. But that’s Denis Healey, one-time monetarist chancellor and bête-noire of the Labour left in the 1980s. Spout that kind of stuff within earshot of today’s shadow cabinet today and you will see them visibly flinch.

Every fibre of my being says I shouldn’t vote for Jeremy Corbyn, but the reasons just keep melting away like snow on a hotplate. I think austerity is nuts; Corbyn is the only anti-austerity candidate. I think the NHS has had enough marketisation and privatisation; he’s the only one to rule out any more of it. I’ve always supported renationalising the railways; Corbyn is only candidate to say he agrees (I suspect Burnham and Cooper agree too, but are afraid to say so – hardly a compelling reason to support them). I’m against the cuts in tax credits which, after years of both parties telling people they would be looked after if they got a job, are cruel and unnecessary. Corbyn is the only candidate who voted against them in the Commons.

These are not extreme or “hard left” policies. They’re solid, social democratic positions. And I’m willing to bet plenty that they’re all shared by a majority, or at least a very large minority, of the British people.

And then, just when I thought I’d found my personal red line, Corbyn ruled out supporting Brexit in the EU referendum.

But, scream Corbyn’s enemies, he can’t possibly win the election! True, all conventional wisdom and experience says it’s very unlikely. (I actually remember 1983). But that argument only holds water if you think any of the other three can win. I don’t.

Liz Kendall is in many ways an admirable candidate, but I’ve already written about how her England-only strategy simply cannot work. Andy Burnham and Yvette Cooper have so far offered little that’s new or interesting. And don’t even get me started on the delicious irony of a shadow cabinet which has led Labour to two disastrous defeats in a row lecturing the rest of the movement about winning elections.

What passes for Corbyn’s electoral strategy involves winning over non-voters and supporters of the Greens and the SNP. We don’t know if that can work; no one’s really tried it before. Election gurus tell us that non-voters are very hard to mobilise and many people think Scotland has “gone” already. So it looks optimistic, to say the least. But, after an election in which Labour lost 40 seats to the SNP and the Tory vote hardly changed, to say all we need to do is move closer to the Tories is just witless.

The best argument against Corbyn is simply that he isn’t a serious candidate. He doesn’t really want to be leader, still less prime minister. It’s hard to imagine him going up against Cameron at PMQs. He’s too old (71 at the time of the next election). The rest of the shadow cabinet won’t work with him. There are some unpleasant people associated with his campaign talking about purging the party. Corbyn himself has taken foolish positions with respect to the IRA and Hamas in the past, which will be ruthlessly deployed against him in the future.

Much more importantly, Corbyn’s policies, attractive as many are to people on the left, don’t add up to a coherent programme for a socialist government. I’m disappointed with Corbyn on policy; I hoped he’d be more imaginative and serious once it became clear he had a chance of winning. Corbyn’s campaign still prefers to chant slogans about the failures of free-market capitalism rather than do the hard thinking about how to transform it into something better for working people. There’s no attempt to develop a serious political strategy that can unite more of the anti-Tory majority around a progressive platform. And I’m still baffled by Jeremy’s reluctance to back electoral reform. (Corbyn is now promising to make his website a forum for serious policy debate. Marina Mazzacuto and Will Hutton’s thinking about an “enabling” or “entrepreneurial” state – refracted into a political programme by Peter Hain – might be a good place to start.)

But if Corbyn’s campaign looks like a protest movement, that’s because it is. It increasingly resembles a typically-English, cobbled-together version of the movement against austerity and neo-liberalism we’ve seen in Scotland, Greece, Spain and other parts of Europe. Young people, in particular, are flocking to Corbyn and his campaign seems to be igniting interest and passion in politics in the same way as the Scottish indepedence referendum did last year. If Corbyn can forge that movement – which stretches from moderate social democrats like me to the far fringes of the Occupy movement — into a political fighting force, that might better for the left than trying to scrape together a Labour majority from soft Tories and refugee Lib Dems.

Voting for Corbyn means gambling with the life of the party we love for an uncertain, amorphous return. In normal circumstances I’d never go near it. But these aren’t normal times; across Europe, the future of the democratic left itself is at stake. It might just be worth rolling the dice.

  1. Denis Healey, The Time of my Life, London 1989, p 578-9.
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The free-market eats itself

Pfizer’s putative takeover of British pharma giant Astra Zeneca exposes yet another intellectual paradox of free market economics. Left to their own devices, firms will always try to takeover other firms or force them out of business. But every takeover (or bankruptcy) by definition reduces competition and choice, which is supposed to be the whole point of the free market in the first place.

It’s always seemed to me that the three top dogmas of free market economics — rational behaviour, perfectly functioning markets and government non-intervention — contradict each other. If companies and firms always act rationally in their own self interest, they will always try to subvert the free market, unless the law stops them (and sometimes not even then). But in a free market, the government is supposed to stand aside. How can this work? Imagine a football match in which all 22 players are determined to commit as many fouls as they can get away with. Then send the referee to the stands.

Free market fundamentalists are always trying to kid us that firms are falling over themselves to "compete" for our custom. They aren't. Occasionally some business people will claim that they “welcome” competition. They don't, or if they do, their shareholders or owners certainly don’t. They don't want competition. They want, if possible, a monopoly, or as close to one as they can get. Is there any example, anywhere in the world, of a joint stock private company willingly giving up its stranglehold over a market? I tried really hard, but I couldn't think of one.

So how can “free” markets ever work perfectly, or even near perfectly, if every firm in the market has an existential urge to make sure they don't? It’s an idea that, as soon as it’s set in motion, destroys itself from the inside out.

As usual, free marketeers have little to say when the weird contradictions in their beliefs come to the surface. Some do admit that enforcing the rules of the free market might be a legitimate role for strong government, but they always seem to cry foul whenever a real government proposes to act — for example by blocking a takeover like Astra Zeneca which, whatever other damage it will do, will definitely reduce choice and competition.

In theory, a real free market government should not allow any takeovers at all, except where the target firm is seriously at risk of failure. But then it wouldn’t be a free market any more, would it?

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Machiavelli and the Half-Blood Prince

I’ve just caught up with Alan Yentob’s BBC documentary on Machiavelli and The Prince, broadcast (I think) around Christmas. Old Nick is going through something of a rehabilitation at the moment (Jonathan Powell has recently published a sympathetic “updating”, for example) at the hands of our plutocratic elite, who are increasingly confident and willing to openly flaunt their Machiavellianism. Boris Johnson’s remarks last year about greed being good and rich and poor deserving their lot was another example of this tendency.

Taken on its own, The Prince is a horrible book, but one perfectly in tune again with the age. One of Yentob’s contributors made the point that we’re living through times remarkably similar to those Niccolò Machiavelli lived through at the beginning of the Renaissance: intense but futile competition for power, instability, a collapse of old certainties, widespread fear about security, and a bunch of unscrupulous rulers of dubious competence.

It’s an age of turbulence and Machiavelli’s harsh message strikes a chord with many. Not least those in power, to whom it offers a virtual carte blanche to behave as they see fit if they can get away with it.  “The common people,” Machiavelli wrote, “are only interested in appearances and results.” But what are these “results” and why should a Machiavellian ruler care?

Machiavelli’s fans — always most plentiful among the rich and powerful — contend that he is “only telling it the way it is”. Like it or lump it, people really do only care about themselves, and experience shows it is better to be feared as a leader than loved (obviously no one told that to Nelson Mandela). But for me it’s never been really clear what all this Machaivellianism is for. Often boiled down to “the ends justify the means”, Machiavelli’s thinking in The Prince seems to lack any concept of the common good. What are the ends exactly? Sometimes he talks (in striking echo to today’s leaders in the US and UK) about the “security of the state”, but this often means little more than the leaders own personal interests.

Machiavelli’s is an impoverished view of human nature. Even if it’s true to some extent of all of us, it’s not all that we are. Yes, we all want power and control over our own destiny, not everyone wants the same destiny, or sees the means of pursuing it as irrelevant to the value of acquiring it. He assumes everyone wants to live in a perpetual state of competition. This may suit the story of hyper global capitalism, but I don’t think it’s how most people want to live their lives.

The Prince is a book born of despair, written by a desperate man just released from prison trying to ingratiate himself with the new Mr Big in Florence, Lorenzo di Piero de’ Medici. It leaves no room for love or kindness, or for the idea that the people might want to collaborate (or any other “idea” for that matter). Machiavelli knew a lot about one aspect of human nature and one aspect of power, but he either knew nothing about the other half, or chose not to express it in The Prince. Probably, every politician needs a bit of Machiavelli. But Machiavelli’s Prince, and Powell’s “new Machiavelli”, would be half a politician and, worse still, a bloodless half of a human being.

(Incidentally, Machiavelli emphatically did not take his own advice. Shortly after writing The Prince, he retired to his vineyard outside Florence and lived a quiet life writing books and plays. You can still buy his wine – I imagine it leaves a bitter taste.)

Andrew Rawnsley wrote on Nelson Mandela: ‘His ego was pressed into the service of an idea, not self’. Machiavelli has nothing to say about ideas and, for him, self-interest is the only thing that a prince should concern himself with. But there is low scheming and there is scheming in pursuit of an idea, what Rawnsley called Mandela’s ‘classy cunning’. Ultimately, what’s wrong with the Machiavelli of The Prince is not that he thinks the means don’t matter (although they do a bit, because bad means can tarnish good ends), but that he doesn’t think the ends matter much either.

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A new Bambi or a new Speedy at the Matignon?

Manuel Valls, France’s new prime minister, is often compared to Tony Blair. He even describes himself, without apparent irony, as “Blairiste”. Surprisingly, this hasn’t done him much harm. In recent months, Valls has emerged from relative obscurity to become by far the most popular member of France’s embattled Socialist government.

Like Blair, he comes from the right of of a left-wing party. Like Blair, it’s crime that brought Valls to political prominence. Blair made his name with his “tough on crime, tough on the causes of crime” slogan as shadow home secretary in the early 1990s. As interior minister since 2012, Valls has revelled in his role as France’s premier flic (‘top cop’), and ruffled the feathers of his socialist comrades with his generally hawkish approach to crime and immigration. And like Blair, Valls likes preaching the virtues of free market capitalism to a party that remains very suspicious of its vices.

Valls was even endorsed by the free marketeers house rag, The Economist, (also an early fan of Blair’s) — when he ran for president in 2012. This didn’t impress Parti Socialist activists much: he got just 6% of the vote in the party’s primary

To me, a more useful comparison would be with Hollande’s predecessor as president, Nicholas Sarkozy. Valls’s energetic, media-savvy image, evokes Sarkozy’s time as interior minister under Jacques Chirac, when he earned the nickname “Speedy”. Valls has enthusiastically adopted Sarkozy’s ultra-aggressive style. Hollande, announcing his appointment on Monday night, was playing this up when he said Valls’s administration would be ‘a government for combat’.

Both as mayor of the depressed Paris suburb of Evry (Essonne) and as interior minister, Valls has endorsed — and even stepped up — Sarkozy’s policies on immigration and crime.

Valls took a lot of flak over his support for cops in their heavy-handed deportation of a 15-year-old Kosovan schoolgirl from France last year. Tough new immigration rules and quotas, introduced by Valls, build more in Sarkozy’s legacy than Socialist Party principle. His remarks on Roma people — “these people have ways of life extremely different to ours”, and claims that it was impossible for most Roma to integrate into France, echo similarly controversial remarks by the former president.

(Interestingly, like Sarkozy, Valls is of foreign origin himself. Sarkozy was famously the son of Hungarian immigrants, while Valls is a Catalan, born in Barcelona, who did not become a French citizen until he was 20.)

Valls’s appointment sets the seal on Hollande’s “tournant social-démocrate”, his supposed shift towards pro-market and austerity-based solutions to France’s economic woes. While Valls’s is hard to pin down on economics (he’s certainly more “left”, as we Brits would understand it, than Tony Blair, although not necessarily more so than Sarkozy) there’s no doubt Valls is a more credible frontman for Hollande’s “responsibility pact” — his pledge to cut France’s deficit in line with EU demands — than the outgoing Jean-Marc Ayrault.

Valls is an enthusiast for austerity. He has supported the idea — floated by Sarkozy himself — of enshrining the need for a balanced budget (France hasn’t had one since 1974) in the French constitution. Valls’s enthusiasm for “TVA sociale” — shifting some of France’s social insurance charges onto VAT — is another a policy which finds more favour in Sarkozy’s party than his own.

He has also been critical of France’s 35-hour working week, introduced by Lionel Jospin’s Socialist government in 1998, which remains a talismanic policy for many French Socialists. The policy was also a frequent target of Sarkozy’s ire, although he never got round to doing much more than moaning about it. In true Blairite style, Valls talks about “flexisecurité” — a vague and meaningless blend of protection against unemployment and making it easier to sack people.

The appointment is not without risks for Hollande. Valls is loathed by many on the centre and left of the PS and has little real power base in the party. The Greens have threatened to leave the government over his appointment. And everyone knows, like Sarkozy, Valls is murderously ambitious.

Sarkozy’s noisy campaigning for the presidency was a constant pain in the backside for Chirac after the president passed over his interior minister and appointed the donnish Dominique de Villepin as prime minister in 2005.

In sending Valls to the Matignon, Hollande has perhaps been shrewder, and tied Valls’s political fortunes to his own. Yes, the president has a big problem in 2017 if his ambitious prime minister is successful. But he has an even bigger one if he isn’t.

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Is France being let down?

Is France going into a deflationary spiral? Some economists — a minority, admittedly, but a growing one — fear it might be. If so, the consequences for France, for the eurozone and ultimately for the UK, would be serious indeed.

In 2013, inflation in France averaged just 0.9%. For January 2014, the estimate is lower still, just 0.7%. As the respected French columnist Christine Kerdellant said recently, ‘If this isn’t deflation, then it’s certainly disinflation.’

Things are heading the same way across Europe. In January, UK inflation dipped below the Bank of England’s 2% target for the first time in years, despite the supposedly “strong” economic recovery, which would normally be expected to add to inflationary pressure.

Few people, I think realise, how serious deflation is. Falling prices sound nice, but they’re never good news for long. Just ask Japan, which took two decades to recover from the deflation of the early 1990s. Even a small bit of deflation can be catastrophic, especially in a modern economy where reaction times are faster, panic spreads quicker, sacking people is as easy as pie, and everyone’s up to their eyeballs in debt.

Once prices start to fall, people stop buying. Why shell out for that new computer or holiday when it will be cheaper next week or next month? People stop investing. Why buy that expensive piece of kit when it might well be cheaper next year, and when the price you get for whatever you’re making or doing is falling. People stop borrowing. Why take out a loan, when the real value of the debt will get bigger not smaller?

Inflation erodes the value of debt, helping over time to make it more manageable. With deflation, this process goes into reverse, inflating the burden of mortgages and loans.

Companies, seeing the price of their products fall, may try to recoup their losses by cutting wages or laying off staff, triggering another vicious downward swing in the spiral. Confidence drains away, uncertainty takes grip. Pretty soon, everything starts to fold.

If deflation takes hold in France — or any other eurozone economy — the only way to avoid this vortex will be for the European Central Bank to effectively start printing euros (and perhaps, as Ben Bernanke suggested for the US, dropping them over Paris and Marseille from a helicopter). France desperately needs looser monetary policy to counteract the tightening of fiscal policy imposed on François Hollande by the international markets and Eurozone rules.

But with a single currency and open borders, there’s no way to flood France with euros without also flooding Germany. It’s one big bath and there’s only one tap. Germany wants the tap turned off. And with the ECB, what Germany wants, Germany usually gets.

Deflation in an economy as big as France’s could put at least as much pressure on the euro as Grexit or any of the other crises which have threatened to blow the single currency apart in the last five years.

Germany’s antipathy to even mild inflation is often attributed to the hyperinflation of the 1920s. But it’s worth remembering that it was Heinrich Brüning’s disastrous policy of deflation in the early 1930s that led directly to Hitler’s rise to power.