Empowering patients: New Labour's unhealthiest idea?

Everyone slates Blair for Iraq while praising his health reforms. Yet his interventions in the NHS have alienated patients and degraded doctors

After Tony Blair's lip-trembling resignation speech, commentators were inclined to give him credit for his public sector reforms while questioning his judgement over Iraq. But New Labour's widely approved `patient-centred' reforms are a real threat to the quality of healthcare in Britain.

When, a week earlier, Blair visited the offices of the King's Fund, New Labour's favourite health policy think tank, to give a speech commemorating a decade of National Health Service reforms, he received a generally positive response from the assembled ranks of health experts and professionals (1). King's Fund chief executive Niall Dickson set the tone in his congratulations to the prime minister on the eve of his departure for providing `unprecedented levels of funding' and `significant improvements in key areas'. Though there were some reservations about disruptive reorganisations, there was general agreement that New Labour reforms have succeeded in their key objective of making the NHS more responsive to patients. While the soundbites about `patient-centred' healthcare may appear merely banal, they reflect the corrosive cynicism of New Labour that is Tony Blair's true legacy to the NHS.

Speaking to the King's Fund conference immediately before the prime minister, David Pink, chief executive of the Long Term Medical Conditions Alliance, a consortium of more than 100 patient organisations, welcomed the government's commitment to a `patient-centred' NHS. As Pink acknowledged, the very presence on such a distinguished platform of somebody speaking from the perspective of patients was a potent symbol of the transformation of health policy under Blair. He enthusiastically endorsed a number of initiatives that, while purporting to advance patient interests, reveal the destructive consequences of the government's attempts to reform healthcare according to the rhetoric of choice and empowerment.

While many commentators have criticised the Quality and Outcomes Framework (QOF) as a crude target-driven payment-by-results system imposed on general practice, Pink welcomed `a major national programme that has turned the NHS's attention to helping people monitor and maintain their own health'. In practice, QOF operates as a financial lever to shift medical practice away from the diagnosis and treatment of disease towards intrusive and moralising interventions in patients' personal lives, justified by the dogma that this improves health and prevents disease. Far from benefiting those with chronic conditions, this shift is depriving them of continuity of care while doctors' energies are consumed with medicalising the worried well. The provision of an incentive bonus to GPs for recording patients' preferences about where they would like to die - a choice over which neither patient nor doctor is in practice able to exert much influence - aptly symbolises QOF's contribution to patient empowerment (2).

Another New Labour health initiative approved by David Pink is the Expert Patient Programme, a series of formal training sessions through which people learn to manage their own chronic illnesses. (As, according to the Long Term Medical Conditions Alliance, there are some 17million people with such conditions in Britain, at least one in four of the population is deemed eligible for this programme - though only 23,000 have so far participated.) For Pink, `the great significance of this programme is that it is an acknowledgement of the vital role that patients and their families have in improving their own health' - and he welcomed the support of the British Medical Association for the programme.

Though the Expert Patient Programme (EPP) has a commonsensical appeal, it is imbued with bad faith: it offers an illusory empowerment to patients with chronic illness and an illusory relief from the burden of caring for patients with chronic illness to doctors (3). If the EPP was widely taken up, it would affirm an identity as sufferer from chronic illness for a growing proportion of the population while imposing an increasing burden of responsibility for their own care on those with chronic disease. While patronising patients, EPP implicitly degrades doctors, devaluing medical science and professional expertise. Who benefits? Not patients, not doctors, not society; perhaps a few politicians and health policy bureaucrats.

David Pink is also a staunch advocate of `patient and public involvement' in the NHS, another of the favoured slogans of New Labour. Given the `democratic deficit' resulting from the decline in popular participation in political parties, local councils and elections, the government has sought to increase public involvement in many areas of public life, from the arts to schools to hospitals. Such initiatives inevitably have an artificial and bureaucratic character, particularly in the sphere of healthcare, which people - at least in the past - sought to avoid when they were well and to keep to a minimum when they were sick.

New Labour's promotion of `patient and public involvement' has led to the cultivation of the professional patient (together with the professional carer) who purports to express the interests of patients (and carers) in general. Of course, members of the public who are able and willing to assume these roles are inevitably unrepresentative of patients and carers in general - and, unlike local councillors and MPs, are not subject even to the episodic recall of the ballot box and hence are under no obligation or even pressure to reflect the interests of those they purport to represent.

In his enthusiasm for `patient and public involvement' David Pink personifies the defects of these initiatives. While he speaks on behalf of people with chronic illnesses to top politicians and policymakers, he was not elected by people with chronic illnesses and he is in no way answerable or accountable to them. Indeed, as the chief executive of a meta-quango, which strictly represents a number of organisations (also unrepresentative and unaccountable) rather than individuals with chronic illnesses, he is as remote from such individuals as any politician (and vastly more remote than the average GP). In fact, what emerges is that his status at the King's Fund assembly of health policymakers is conferred by government endorsement of his position rather than by any democratic mandate.

It is thus perhaps not surprising to find that, of all the assembled dignitaries, he provides the perfect warm-up man for Tony Blair on his tenth anniversary celebrations.

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British police madness government-driven

Police officers are being driven to make "ludicrous" arrests for trivial incidents to bolster government targets, the new Justice Secretary will be told. The leaders of 130,000 police officers have drawn up a dossier of "lunacy" on Britain's streets. They say that children are being arrested for throwing cream buns and bits of cucumber while adults are getting criminal records for offences that merit nothing more than a ticking-off. The pressure to get results is so bad, they say, that officers are criminalising and alienating their traditional supporters in Middle England and many are so disillusioned that they are considering quitting.

What police describe as a target-driven criminal justice culture will come under attack today as Lord Falconer of Thoroton, QC, who was appointed Secretary of State a week ago, faces a debate at the annual conference of the Police Federation, which represents rank-and-file officers in England and Wales. The conference in Blackpool will consider whether the drive to meet targets is destroying police officers' traditional discretion to deal with minor offences on the streets without fuss or bureaucracy. Officers say that ten years ago a minor incident involving someone without a criminal record would have led to "words of advice". Now, the federation says, performance targets mean that the people involved are becoming criminal statistics.

Jan Berry, the chairman of the federation, said: "We have police officers who are considering leaving the service over this because it is not the job they signed up to do. "These examples we have compiled are ludicrous, but when people are being pushed to show results they will use anything they can to demonstrate they are doing a good job." She added: "Just talking to people and giving them a few words of advice cannot be counted as easily as a ticket. But sometimes it is just as effective as taking someone to court."

A spokesman for the federation added: "We have got into the situation where everyone is so busy chasing targets and securing ticks in boxes we are on the verge of distancing ourselves from Middle England." He said: "The cases we have compiled show incidents where an officer has been under such pressure to deliver that it has resulted in an arrest or caution when even the officer themselves thinks it is ludicrous. Understandably, when the public hears about this they ask: `What the hell is going on?'." The spokesman added: "It is a government agenda that is going down this avenue. Officers are saying they are forced to make arrests or cautions because the Government believes they should be judged by what can be counted."

Chief constables have also complained about the increasing pressures to meet both national and local targets. Last autumn the Home Office issued 30 general targets that police must meet, as well as more specific figures. Earlier this year John Reid, the Home Secretary, who will be speaking at the conference on Wednesday, promised that he would cut some of the targets.

But last month officers in Greater Manchester were warned about issuing fixed-penalty notices to drunks for public order offences so that they would count towards their target of two detected offences a month. Home Office research last year found a nationwide increase in drunks being penalised for causing harassment, alarm or distress. Researchers concluded that the trend may have been driven by government target-setting. Notices issued for offences such as causing harassment, alarm or distress count as a "violent crime" and an "offence brought to justice" for the purposes of Home Office statistics. The alternative, lesser charge of being drunk and disorderly does not count towards police detection targets.

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British education failure

After 10 years of `education, education, education', Britain's teachers are drowning in paperwork, targets and banality - and the very idea of a liberal education is under threat

For over a decade, New Labour has been awash with soundbites. The party was `tough on crime, tough on the causes of crime'; there would be `an end to boom and bust'; we'd have `strong Britain, strong leadership'. And then there was the soundbite that stuck better than any, Tony Blair's 1996 pledge that the three priorities of his government would be: `Education, education, education.'

Nowhere has Blair's Orwellian approach to society been writ larger than in his translation of that bare word `education' into Newspeak. For what he has achieved during his decade-long reign has been a narrowing of the very concept of education: the abstract ambitions of pupils have been worn down, and the love and passion some teachers felt for their job have been undermined. We are left with a conveyer-belt process of tests, targets, objectives, goals, tickboxes and paperwork. The idea of the liberal education is under threat at the end of Blair's Britain, as horizons are narrowed and the classroom reduced to a bulletin space for government initiatives. Schools have become a place where the new conformism is taught and enforced.

`Go to your local school', Blair urged after his victory in the 2005 General Election. `You can see the progress in the buildings, in the computers and in the results.' To mark 10 years of education, education, education, I did just that. It's a dreary morning, in an idyllic setting. The neat school building (which I will not name, in order to protect the identity of its staff) rests on a slope, overcast by a vast country church and next to a plantation with great green trees, some of which have been cleared to make way for a playground. The children play there, building small dens and hanging off the various items of play equipment. Smatterings of pink blossom coat the grass. The church bell rings in 9am, and the children, already a little untidy in their bright, blue school uniforms, rush inside. In one classroom, the kids sit on a mat and poke at a hamster called King Alfred; they chatter above the din of an aerated fish tank.

The children's poster paint artwork is pasted on to the walls; the room is a jumble of primary-coloured equipment, books, guides and measures. The children are miniature pots of enthusiasm, fidgeting and clapping their hands and shuffling about on their bottoms until called to attention. Filing into assembly minutes later, they get on with singing hymns and learning a new story about Jesus. `Team points' are given when a child answers a question about the moral of the story correctly.

In this school, as in so many others, the various demands of Blair's Britain have been imposed, by school inspectors, county advisers and the constant tide of new guidelines, new programmes, new initiatives, new glossy booklets - which often contradict last year's glossy booklets - and new schemes for the betterment of the children within the school walls. The teachers inside tell me they feel under siege: unable to teach with freedom, many distrust themselves and their abilities. They are the fag end of Blair's education revolution. Let us consider, then, what `education, education, education' has wrought in Britain's schools.

Under Blair, the public eye has pried into the private world on an unprecedented level. Turning Thatcher's `there's no such thing as society' into `there's no such thing as a private life', schools have become one of the principal instruments for manipulating a new generation into new thought patterns. This week it was announced that schools must foster positive race relations or face closure. Fruit is provided at breaktime in order to improve children's diet because, of course, parents cannot be trusted to feed their kids well. And, under the new Social and Emotional Aspects of Learning scheme (SEAL), teachers are now responsible for shaping the emotional and social lives of the children in their care.

Increasingly, children are taught the correct ways in which to express their feelings. In some schools they participate in group massage sessions, in which they must knead each other's shoulders and send their own positive `toxins' into the air to help the emotional wellbeing of those recalcitrant youngsters who don't want to be group-massaged, or whose parents have denied permission.

This approach permeates a whole new approach to teaching, in which children (especially in the early years) must actually not be taught at all. In fact, in policy circles, teachers are teachers no more: they are `practitioners'. In indoor PE, children are not to be taught how to do a roly-poly anymore; rather they are supposed to `experiment travelling in and through'. (At the school I visited, one teacher, a worried look flickering across her face, told me: `I'm not sure I was ever supposed to teach them how to do a roly-poly..')

To try to teach a child, via the tried and tested `talk and chalk' method that has successfully educated children for generations, is now considered to be wrong. It is too elitist and judgemental apparently.

In the school I visited, the early years teacher seemed to have lost confidence in her own ability to teach, following a negative Ofsted inspection. Her paperwork had been found wanting, and then she had been found actually teaching children as she saw fit.which is the greatest crime under today's inspection regime.

Teachers, like every other public sector worker under New Labour, now drown in paperwork. There is an incessant flood of forms that need filling. They are given `PPA' time, cutting out half a day's teaching, in order to help them cope with the forms and documents. In 2006, the Education and Inspections Act revolutionised the inspections system: it brought in a system where schools have to be prepared for an inspection at any moment (only two days' notice is given) and where schools are assessed on their own internal assessment systems.

It is now all about the paperwork. Like a Soviet Five-Year Plan, if it's down on paper, it happened - if it's not, it didn't. So this school was hauled up for a `culture of bullying' - not because it had a bullying problem (it didn't), but because it did not have a government-advised system of `playground angels' and `buddy benches' to deal with any potential bullying that might arise or have already arisen without the teachers noticing.

The sheer detail in which a child's education is now charted is breathtaking. As Helene Guldberg has shown elsewhere on spiked, under New Labour infants now have `69 early learning goals' (see A tick-box attitude to toddlers, by Helene Guldberg). In this school's classrooms, as in most others, there are now 44 goals in the teaching of literacy. One teacher tells me that striving to achieve such goals often detracts from fundamental lessons that teach children how actually to read. These days while they read, young children have to explain whether a particular character is `good' or `bad', and why they are good or bad. `Instead of concentrating on what really matters, they'll be given a target, something specific, that's disembodied from enjoying reading. It doesn't lead anywhere', the teacher told me. What New Labour seems to have done is to break down reading into a set of meaningless facets, effectively `quantifying the unquantifiable', as the teacher put it.

An Ofsted report cited recently in the Daily Telegraph outlines the new teaching culture that Ofsted wishes to inculcate in our schools: `Too often, the teacher does most of the talking. It is frequently restricted to explanations and predominantly closed questions which ask for recall of previous learning.' Teaching in such a way (explaining a principle, demanding `right' or `wrong' answers to questions) is now looked upon as heresy. Instead `Ofsted prescribes "lively debate", "buzz groups", exercises in "empathy", "scope for pupils to make choices", working in groups, and "drama techniques" such as "hot seating", in which teacher and pupils exchange roles.'

As Ofsted says: `A key characteristic of the best lessons is the opportunity they provide for pupils to talk and collaborate.' This is not just a silly PC idea that we can laugh off; it fundamentally undermines the idea that teachers have something important to impart to children in favour of allowing children themselves to set the agenda by talking and playing and thinking out loud in class. It is little wonder that some teachers feel devalued.

If a teacher asks for advice on how they are supposed to do all this new stuff - how they are meant to reach their targets through drama and buzz groups - they are not likely to find any officially endorsed answer. The paperwork and the new ideas are foisted on schools from on high, and the schools are expected simply to get on with it all by the time of their next inspection.

This imposition of new rules and methods distances children from their own education. Learning programmes for individual kids are now planned out without the adviser who does the planning ever having met the children in question. `I get certificates for going to all these seminars', a teacher explains to me. `I've got them all for my portfolio. But what do they mean? We go, and when we have listened to all the new ideas, we ask for specific methods. And the advisers turn to us, and they say, "You can just do it. You're the professionals - you know how." And yes I did know. Or I thought I knew.'

Children are supposed to be au fait with all the terms their practitioners now use. So instead of `letters' and `sounds' they are encouraged to talk about `graphemes' and `phonemes'. `Tricks' that help young children to learn how to read are definitely out. Today explaining about the magic or silent `e' - which many spiked readers will understand from their own childhood education - is held to be detrimental because `you're giving them a trick to use instead of getting them to understand how various graphemes can make phonemes', the teacher explains. Imagine how baffling it must be for a young child instantly to learn about graphemes and phonemes rather than about magic letters that do certain strange things to words? `Children understand "magic" things. It's part of their world. It's much more understandable to them to see a magic thing coming along and changing a sound rather than a phoneme holding hands and pushing a grapheme out of the way', the teacher says. But no `magic' is allowed in classrooms these days.

Teachers' scepticism about new teaching methods is not appreciated. As in so many other professions today, bureaucrats have been trained up to counteract doubts among those at the frontline of teaching the nation's youth. Legions of school advisers, in every county of the land, come up with a succession of great new examples from other schools that have better Ofsted outcomes, schools that have put all the New Labour theories into practice and achieved great results: the advisers hold these schools up as models in order to force other schools to change and accept the new way of doing things.

A big buzzphrase today is `outdoor learning'. The teacher tells me that at one seminar she attended, `An early years adviser was raving about how wonderful a certain class of children had been, because they had a lesson outdoors in which they were picking up sticks and making graphemes out of them. I couldn't help thinking it would be far better for them if they had done that on paper, with a pencil. It's almost like going back to cave-man times..'

Of course, there is nothing wrong with learning outdoors, investigating and getting to know more about wildlife and the natural environment. But words and language and grammar are surely better taught indoors, in a classroom - unless that, too, is too old-fashioned an outlook for the constantly churning education system.

Attendance is paramount in New Labour's new education system. You can find the attendance stats for any school in the land, simply by typing the name of the school into a portal on the BBC's education website. Under the Blairites' target-obsessed learning system, parents are constantly warned not to take their kids on holiday during school time or to allow them to have many (if any) day absences, because the child might fall behind and prevent the class from reaching its targets.

The obsession with attendance can lead to a culture of snooping. At the school I visited, one of the pupils had a condition called `slap cheek'. It is infectious to other children, but it is not very debilitating for the child who has it and it is easily cured. The child's mother took her daughter out of school while she had the affliction, and on one of the days off school mum took her daughter to the supermarket; there was no one else to look after her at home and the shopping needed to be done. In this sleepy rural town, the child was spotted by a Community Support Officer, who reported the mother to the school. The school was instructed to keep a special eye on the child in future.

Behaviour has to be managed within schools, of course. And as you might expect, new approaches have also been brought in for this area of school life. Today teachers are advised never to be negative towards children; they should not tell a child off, but rather encourage him or her, through incentives, to behave well. In some schools, there is a new behavioural system called `golden time': this is a period of time at the end of the week where all the good children are allowed to do fun tasks but those who have been naughty are excluded. So instead of reprimanding bad behaviour when it happens, and explaining why it is a problem, schools are encouraged to reward all children except those who have done something bad.

In certain schools, `golden time' actually plays into the hands of children who misbehave. After all, the only thing that happens to them is that they miss out on golden time. In schools with big behaviour problems, it is apparently now cool to miss golden time. In this rural school, Year Six children (10- and 11-year-olds) were rewarded with a golden time of `hammer beads', which a teacher described as a `glorified colouring-in exercise, fine for Year Two children but not Year Six'. Any self-respecting 11-year-old, especially of the naughty variety, would not be overly concerned about missing out on such an exercise.....

After a decade of `education, education, education', it is surely time for the government and its myriad minions to get out of the classroom. Government should fund education and direct it, but it should not interfere with absolutely every aspect of school life, teacher-pupil relations, playtime, and children's eating habits, behaviour, weight and so on. Teachers must be allowed to refer to themselves as `teachers' again, not practitioners - and they must be allowed to `chalk and talk' if they want to. In short, they should have the freedom to teach in ways they see fit, and to invigorate the young minds in their trust with enthusiasm and ideas that are not rigidly defined by government targets and health, social, emotional and wellbeing messages.

To paraphrase another New Labour motto, which they borrowed from pop group D:Ream and danced to, excruciatingly, in 1997: `Things in teaching can only get better.' And they will, once we teach ourselves to trust our teachers once more and allow schools to go back to being centres of knowledge and learning rather than outlets for government posturing and social engineering.

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