Why psy-practitioners need to think about the government

In 2001 the Health Professionals Order was passed through the Privy Council. This gave powers to some new institutional forms. One of these is the Health Professionals Council. The HPO2001 vested powers in the HPC and set the wheels in motion to employ people, pay them salaries, allocate budgets, rent offices, and start a process to enlist a huge number of people onto a centralised register. The people employed in the HPC are new to the field, and don't know much about the professions they will regulate. They don't need to. In fact, according to the logic of the HPO2001, its best if they do not. For to know something about the practice, according to the logic of HPO2001, is ipso facto to be prejudiced.

In September 2008, when the Parliament returns from recess, there will be a conversation about an ammendment to the HOP2001 which intends to give more power to the HPC. If this happens, then lots of things will follow, not all of them unpredictable. 

The law sets off from the wrong place. It assumes that professionals are not competent, are self interested and that the public needs to be protected from them. But it also assumes that there is a group of people who are innocent, never incompetent or self interested, and these are the ones who have been given the power. Ironically these are bureaucrats in the employ of the politicians. 

My main concern here is that the kinds of logic behind the current processes will have a destructive effect and expose everyone to the full force of market forces just at the time when globalisation is at its most potent. Commodification races ahead almost unchecked.

Professionals are part of the social fabric that can protect the people from the brutality of market and other forces. It is probably not a good idea to wreck that.

Burning Platforms

In June 2004, I was invited to discuss two texts at the first of a series of annual meetings in the relatively new Said Business School, Oxford. The new Professor of Marketing had been a distinguished Sociologist in the field of Scientific Knowledge, and he had engineered this meeting to bring together the interesting and incisive work from the various fields of sociology of science to see if ideas could translate or transmit to the new business sector (where many sociologists end up working). 

One of the papers was written by prize winning PhD student Stephen Cole who had been honoured by the Society for the Social Studies of Science for his work on finger-print evidence in US courts of law. The other paper was credited to about 8 or so different people, but was in fact written by Marc Berg, a much published author on the way to becoming an independent health consultant in the Netherlands. The practice of including a range of multi-disciplinary stake holders as authors of the paper is a practice that has grown in popularity, alongside the rise in audit culture in some parts of academe. 

Both of the authors were successful in their field but neither had remembered the classic foundations of their chosen disciplines. My essay (on the blog side) put back some of the social staging that makes medicine and law understandable as a human activity. I anchored the action back to its base from a social science point of view and then went on to judge the value of the pieces. Both, I thought, were alarming. Both were highly ambitious. They each wanted to intervene and cause change at the heart of their chosen host field. Cole's pretension was to collapse the value of finger-prints as valid evidence in court. Berg wanted to collapse the practice of medicine in order to make managerial change. The Burning Platforms of my title were his preferred method of practice.

The challenge I faced was that of any scholar: to be true to the principles and knowledge of my discipline, so that the outcome would be an accurate analysis of the papers. If I succeeded then the benefits would accrue all round; witness to my personal worth as a scholar, witness to the knowledge base that I draw from, and an adequate exposure of the strengths, weaknesses and substance of the papers without having to set anyone on fire or collapse a whole tradition.

The meeting itself was set up as a kind of auditing, or auditioning perhaps. Where scholars at different stages in their careers, at different levels in their fields, come together to give a good listening to each other, to rectify wayward practice, argue important points, and learn from developments in adjacent fields. 

Looking back on this with hindsight I see the current regime of audit as extremely out of step with this kind of academic, scholarly, disciplined and learned tradition. One mechanism of auditing a discipline is this very meeting itself. It is one of many ways that academics organise themselves and regulate their practice. It doesn't have to be perfect, and it might not always succeed, but at least it has the virtue of being true to its knowledge, disciplined in its practice, and efficient in the exchange of ideas.

 

Unintended R D Laing

Adam Curtis' trilogy of documentaries came out in March last year. Someone has put short excerpts onto You Tube that relate to the bits about Ronnie Laing's critical American tour (the links are on the blog side).  Curtis argues that Laing's harangue had unintended consequences. In criticising the profession of psychiatry, he paved the way, Curtis says, for a more speedy medicalisation of the mind. 

The argument against the psychiatrists became such a powerful call that it rallied a potent army. Why? Did lots of people suddenly agree that leaving the important business of psychiatry in the hands of a bunch of people following a false science was not a good idea? Laing had said it was a false science propping up a failing society. One of the audience, a young medic named David Rosenhan took up the challenge and invented a radical research project which seems, at least in retrospect, to have catapulted the cause of the anti-psychiatrists into the stratosphere. 

Laing's gambit was a classic manouevre to open up a space for his own radical and interesting ideas. But his style of attack on his fellow professionals seems at least in part to have produced the conditions for a non-human intervention to take its place. How? The logic is over simple. If the men in white coats weren't to be trusted, we should turn to their non-human replacements. Why? Because it is men per se that is the problem? How does this actually happen in practice?

It can be ridiculously difficult to get a good idea into circulation (think Galileo, Copernicus, and Zero), so why is it easy to get a crackpot idea into circulation? What are the mechanisms that thrust RD Laing onto centre stage as a major player in this drama? 

Curtis's argument is an interesting one if approached in a sensible way. Because it is true that we are now in an era where criticism of professionals has become a serious argument for wheeling in non-human rationality as a replacement. But what are the conditions that have brought this strange situation into being? Why should people latch onto the argument against one idea and completely forget the other. After all, no-one was arguing for a marketing drive for medication. Certainly not R D Laing.

Taking Liberties

Last year Chris Atkins released a film and a book called Taking Liberties (Revolver, 2007). In it he documents the wave of changes in the law that Tony Blair's government have made. Not only were more laws passed than at any other time in history ever, but the particularity of the laws have obliterated the Magna Carta.

The supposition has tuned away from a presumption off innocence until proven guilty. 

When a Prime Minister's strategy of reform ends up tearing up the Magna Carta, it is a very different thing from having him harangue a crowd from a podium, and designate a particular group as The Ones who must be removed. But the lack of evil intent simply removes the consistency in the system. What we have instead is an unpredictable law of unintended consequeces - a great degree of risk and uncertainty.

In Chris Atkins film he re-presents the moment when Walter Wolfgang was slung out of Jack Straw's talk at the Brighon Labour Conference (2005). Wolgang, a very slightly built man in his 80s, had been unable to stop himself shouting Nonsense when Straw was talking of the war. Watching this footage is chilling. Not only is it horrible to watch big beefy bouncers manhandling a little old man, but it is also very upsetting to see most other people stunned into inaction. One brave bloke who attempted Wolfgang's rescue was himself seized, dragged off into a room where the camera couldn't follow and was physically abused. Atkins' film then cuts to a smiling shot of a bemused Blair who says: "I wasn't there".

Desire, life, death, and drive

Socrates, Cicero, and Montaigne have all said that to philosophize is to learn how to die.

This line is from a review in the Times Literary Supplement (21 May, 2008) by Daniel Pick of a new book by Mark Edmundson
THE DEATH OF SIGMUND FREUD
Fascism, psychoanalysis and the rise of fundamentalism
282pp. Bloomsbury. £18.99.
978 0 74758607 4

My thanks to Penny Geogiou for bringing this to my attention moments after I received an email from from a sociologist who had told me the rather pitiful tale of one of his colleagues. They are suffering an excess of audit in their department and being asked to spend lots of time on form filling that has no value for the work that they do, in fact it is detrimental. The colleague was very vocal in her refusal to indulge in such nonsense. Her outburst was sufficient to call a senior administrator in to defend his labyrinthine predilections. Perhaps it is the shift in power relations that led the academic to immediately capitulate. She found herself praising the virtues of the red tape equally loudly, much to the surprise of her colleagues. The administrator withdrew, satisfied.

I wondered what happened to this woman. It is not unusual to find someone beating themselves up after such an unpleasant encounter. When a bully succeeds in pressing home his power, the bullied has three options to deal with the residue that results. Self punishment. Passing the indignity onto someone else. Sublimation, or turning it into something more creative. 

Figuring out how to live with the excesses of our drives is one of life's more important questions. Antiquity and classical literature is full of it, and Freud and Lacan champion it. But in modern British life, it appears to have fallen out of fashion. 

English Professors against QAA

Thomas Docherty, professor of English at Warwick University published a new book this year: The English Question or Academic Freedoms (Sussex Academic Press, 2008). The Guardian's Chris Arnot wrote a column that pit Docherty against some QAA advocates. 

Here's a quote from Docherty: "The QAA, for those of us who have suffered under its tawdry posturing, is a cancer that gnaws at the core of knowledge, value and freedom in education; its carcinogenic growth is now perhaps the greatest pervasive danger to the function of a university as a surviving institution," he writes. "It has presided over the valorisation and celebration of mediocrity, paradoxically at the very moment when it is allegedly assuring the public of the quality of education and universities ..."

and here's part of the riposte: "Hefce has defended its creation. "We strongly refute Professor Docherty's comments," says its director of learning and teaching, Dr Liz Beaty, "and have complete confidence in the way the QAA is carrying out its role." [my emphasis - JL] She points out that, in response to concerns about the administrative burden, the agency adopted a "light-touch" approach after 2001."

One of the features of the ripostes is that they call on a tawdry notion of evidence to refute Docherty's argument - look closely and you find that the way they comport themselves is the question, not the reason or logic of their act.  This is part of an attack on the real value of academic work, and the beginning of a slide into fakery (ie pretending to do something by going through the motions).   Arnot frames a clash of paradigms here.

http://education.guardian.co.uk/higher/news/story/0,,2240583,00.html


The book's title resonates with the important work of Conrad Russell: Academic Freedom (Routledge, 1993). http://www.atm.damtp.cam.ac.uk/people/mem/papers/LHCE/uk-higher-education.html

If EBM is the answer, what was the question

If EBM is the answer, what was the question? Who asked it? When?

Although Archie Cochrane is implicated in this process, he didn't spearhead the current rise of RCT in the NHS, and amongst those that did, few mention the man. It was as if it emerged out of nowhere, attached to no-one.

For some bizarre reason, EBM has not become a new science. Instead it has become entangled in politics and is best understood as a rhetorical phrase.  

The phrase has power to hypnotize people. In the particular arrangement of the NHS, the Government and the University sector, it has become a key phrase which is shaping people's livelihoods, money, and jobs. 

Whatever Evidence Based Medicine might have been, it has become the rallying cry in a strange kind of paradigm war. Intended or otherwise, under the banner of EBM a backward step is being taken.

The war is odd tho. Instead of finding pioneering scientists championing new ideas and new ways of doing things, we find bureaucratic systems, and an apparent army of nameless automatons. 

Evidence Based Medicine

Archie Cochrane died in 1988 but in 1972 he published a little book in which he championed the EBM cause in the name of the Randomised Controlled Trial. He said that the first couple of chapters were an easy write, but the rest of the book was a depressing grind. He had said all he wanted to say in the first few pages, but was obliged by the sponsor to pad out the pages to make it into a book. The book sets off saying how little of what doctors do is based on evidence. 

But what kind of evidence is needed in medicine, and who is to be the judge? 

Archie Cochrane points out in his book that if you take a map of the world and place a black dot everywhere you find an RCT you will notice that all the countries concerned are those of a protestant persuasion. Communists and catholics are bereft of the thing. At least that was true in 1972.

This is a very interesting observation. Archie Cochrane, however, joked that it simply showed the natural superiority of the protestant. 

The automated booking system in the nhs

In February this year I visited my GP. One outcome of the visit was that I wrote a letter to Alan Johnson (linked to this blog, and in the side bar). You will see that the process was about an appointment with a specialist team in a local hospital. As the weeks progressed the need  for the appointment receded, so I tried to cancel it. Here's a very short version my three attempts to do that:

1. The automated telephone answering machine: "we are sorry but we are experiencing an unusually high volume of calls and all our staff are speaking to other callers, if you have access to the internet ..."

2. The automated computer response: "We are sorry, but the web browser you are using is not compatible with the online Choose and Book service. We apologise unconditionally for any inconvenience caused by this problem and can assure that we are working to make sure that future versions of the Choose and Book online service work in as many types of browser as possible. You can still book over the phone by calling 0845 60 88 8 88 (Textphone: 0845 8 50 22 50). Booking lines are open from 7am - 10pm. A translation service is available if you cannot speak English. Please have your appointment request letter to hand when you call."

3. The real person, reading from a script, ie the automated person: "Can you give me your special code word ... thankyou, ... and your password ... thankyou. 
Now can I have your full name ...  thankyou
and your date of birth?

My date of birth? For goodness sake, all I want to do is cancel an appointment in the diary!

I'm sorry madam, I cannot do that unless you give me your date of birth. It is a security measure for the computer.

-----------------


"Since coming to power in 1997 New Labour has spent upwards of £70billion on management consultants and new IT systems." p98, Taking Liberties Atkins, Bee & Button 2007. 

Schizophrenia

Schizophrenia - on radio 4 this week, there was a report on the move amongst a group of psychiatrists to drop the word schizophrenia from the next DSM. They hope this will solve the problem of stigma associated with the word. The BBC interviewer suggested that the way to change stigma was to be more open about the condition, to spread information and enlightenment. The psychiatrist responded by saying only 7% of people in a survey wanted to be known a schizophrenic. 

The interviewer attempted to lead the doctor into a different frame, and to use reason to think through the possible consequences that follow on from action. The psychiatrist responded with marketing-type data, which implies that the patient is a customer and leads to something very like re-branding a product. 

Reported on You and Yours, Radio 4 (21 Nov 2007)

Unintended, yet not unanticipated

This snippet is from Roger Litten's presentation at the College of Psychoanalysts-UK International Conference PSYCHOANALYSIS AND STATE REGULATION, 31 March-1 April 2006



... not only does regulation not achieve what it claims to set out to achieve
but also entails consequences and effects that just happen to be the very opposite of what it claims

In other words we set out from a rationale for regulation, elaborated on the basis of a discourse of public protection, only to stumble into a system of audit and accountability that at certain points can be seen to provide no protection at all to the very people it claims to serve.

Follow the link in the title of this entry, and you will find the full text of this talk.

Evidence or reason?

Alistair Darling said of the missing discs of child benefit info "there was no evidence it had been used for fraudulent activity." In the old days, he might have said 'there is no reason to believe that ..." What is it with this word Evidence? It appears to have taken the place of truth and knocked the judge out of the picture. How can this have happened?

Quality audit - ideology responsible for the missing disc?

Those missing discs. It seems that the discs have to travel in order to fulfil requirements from a national quality audit process. In other words, it is already part of a process that has been removed from the reality of the data and the discs. The layer of bureaucracy created by the audit process creates a false world of pure signification, where grown men and women behave as if the mere following of pre-written rules is enough to judge whether something is going well or not. The removal of something real from the process can easily lead to problems. In the old days, when unions were active, there used to be something called 'work to rule', where the union members did everything according to the rule book. This strategy soon brought everything to its knees, and forced people (managers) to acknowledge that there was something beyond the formal rules. This old strategy of resistance has become the new norm of practice - and it is having a similar effect.

from:
http://news.bbc.co.uk/1/hi/uk_politics/7104115.stm

Small print and nasty surprises

You & Yours, Radio 4, 21.11.07 (podcast available from BBC website)

1.  a labyrinth of rules and practices have sprung up around train tickets. This has created a set of conditions where a traveller cannot reasonably be expected to know it all, and takes the small print on trust. Even the automatic ticket barrier at the station in this particular case was not sophisticated enough to know all the rules and let the man through and onto the train. This left it to the ticket collector on the train to be the One who had confront the traveller who happened to have broken a bit of small print rule. This confrontation of strangers had to be done in front of more strangers on a crowded train and of course, this leads to anxiety, embarrassment, and bad stuff for all the ordinary people involved.   

In this case the small print even contained a link to the legal system which empowered the ticket collector to put the man off the train and threaten him with more law. As it happened, in this particular case the traveller was a lawyer.  It was an 'innocent' (and trivial) mistake that led to his not having the return portion of the ticket about his person that day. All that fuss. All that fluster. All for what? What good can it possibly do?

Junior staff blamed for not following the rules

Looking for a scape goat.

BBC Radio 4 news today said that a govt spokesman denied that the recent merging of 2 govt departments and the huge loss of jobs (10,000) had nothing to do with the breach of security where 25m people's private inforation went missing. They blamed it on a junior member of staff who didn't follow the rules. An enquiry will follow.

Centralised data base - breach of confidentiality

Huge data bases and the large number of people who routinely need access to them to do their jobs, led to the possibility that a minion was able to download data onto 25 million people, and possibly even to sell it. This was the way the news was framed when two discs went missing in the post (information about child benefit claimants).  

Prof Ross Anderson, Cambridge University said: the govt consistently brush aside our reports which argue that large scale centralised data bases are vulnerable to unintended consequences. 

Prof Ross Anderson was also behind the campaign last year against the centralised storage of NHS records and constructed a form letter for people to send to the DoH and to their GPs. "what can patients do to ensure confidentiality of NHS records?"
http://www.cl.cam.ac.uk/~rja14/

UK's families put on fraud alert
http://news.bbc.co.uk/1/hi/uk_politics/7103566.stm

Audit water

The water industry was privatised and at the same time it was 'made more business like'. This was achieved by large scale computerisation and centralisation of data. In effect this stripped data away from the people who understood how it was made and what it related to, and most important, how it related to the effluent and the other natural things that make up the water industry. The experienced workforce was effectively replaced by large computerised data base that fed into the newly created call centres. There was a mass stripping away of knowledge from the people working with stuff, and a movement of data to computers, and to people who knew more or less how to operate them. In effect the link between information and the people who are responsible for keeping it real was broken.   In the news we don't find an analysis of the detail of reality, instead we find sensational accounts which presume to know the shortcomings of people involved.

Mark Milner, industrial editor
The Guardian
Thursday November 15 2007

Water industry regulator Ofwat yesterday announced plans to fine Southern Water £20.3m for misreporting and poor service. The fine is the biggest imposed by the watchdog under powers which came into effect in 2005. The previous record was a £12.5m fine slapped on Thames Water this year.

Southern, which was bought for £1.3bn last month by a consortium of infrastructure investors, said it accepted the punishment. "Southern Water fully acknowledges Ofwat's requirement to fine the company for its misreporting of customer service performance and failure to make all guaranteed standards payments," the company said in a statement.

Regina Finn, Ofwat chief executive, said: "Southern Water deliberately misreported its customer service performance to Ofwat and systematically manipulated information to conceal the company's true performance over an extended period."

As a result customers missed out on payments they were entitled to for service failures and were overcharged.

Southern Water, which serves some 2.3 million water and 4 million waste water customers, itself discovered the irregularities as it was introducing a new billing system. It reported its own findings to both Ofwat and the Serious Fraud Office.

Yesterday Ofwat acknowledged Southern Water's action and its cooperation with the investigation. However, Finn noted: "The magnitude of this fine reflects the magnitude of the offence - deliberately misleading the regulator, failure of the Southern Water board of directors to pick up the deception, the resulting poor service to customers and damage to the regulatory regime in general."

The fine will be paid by Southern Water's shareholders and cannot be passed on to customers.

Ofwat said it only had powers to impose a fine for two specific one-year periods even though the problems went back to before 2000 and Southern had received money it should not have done in the 1999 and 2004 price reviews.

It could have imposed fines of up to 10% of turnover, which would have amounted to more than £100m, but opted for a sanction of 3.5% of turnover for the deliberate misreporting and 0.1% for providing sub-standard services to customers by failing to meet guaranteed levels of service.

Southern Water said it had reduced bills this year and would do so again next year to repay the money to customers. A spokeswoman said the overcharging amounted to an average of £1.50 a year over seven years.

Les Dawson, Southern Water's chief executive, said: "I understand Ofwat's intention to fine us for what has happened in the past. Today, I would like to reassure customers that those historically entitled to guaranteed standards payments have now been paid and that we are well on course to meeting a service improvement plan agreed with the regulator."

http://www.guardian.co.uk/business/2007/nov/15/southernwater?gusrc=rss&feed=networkfront

The scale of the fine imposed by Ofwat, which is subject to a consultation process over the next five weeks, met with general approval.

David Bland, chairman of the Consumer Council for Water Southern and Thames, said: "We believe that the level of the fine is appropriate to the circumstances. We are also pleased to note that Southern Water's shareholders will bear the entire cost of the fine, which should not fall on the customers who were badly served under the previous management.

"Because customers suffered from Southern Water's shortcomings we believe that the £20.3m fine should be used for the benefit of customers as opposed to being paid to the Treasury.

"Southern Water has accepted the fine and the Consumer Council for Water will work with them to put in place their service improvement plan as agreed with Ofwat."

Tim Wolfenden, head of home services at uSwitch.com, the independent price comparison and switching service, said: "The priority here is to ensure that consumers are fully recompensed, and Ofwat does seem to have this well in hand. The regulator has made it clear that shareholders rather than customers will be footing this bill. However, it could go one step further and prescribe what should be done with the fine - the icing on the cake would be to see this £20.3m fine invested directly into improving our worn out water systems. This would serve everybody's interests best."

Privatisation + Audit = what?

SOUTHERN WATER
OFWAT has fined Southern Water £20.3 million - their biggest ever fine - for misreporting information and providing a poor service to customers. The Serious Fraud Office dropped its fraud investigation earlier this year because of lack of evidence. This is the big news of today.

Rather than assuming that the managers were all frauds, it might be more productive to wonder how this farce has come to pass.

Non-human surveillance?

"what are you looking at?"
We have more cameras per head than any other country in the world
1 for every 14 people, that’s 1/5 th of all cameras in the world
more than 80% are such poor quality that they can’t really be useful to the humans charged with policing our society in one way or another.

This fact cropped up in the last 10 minutes of the Today programme (Radio 4, 1 November 2007) and included a fun interview with Ross Clark, author of a new book - The Road to Southend Pier: One Man's Struggle Against the Surveillance Society. He has also written a book entitled: How to Label a Goat: The Silly Rules and Regulations That Are Strangling Britain

One interesting idea that emerged in the item was a kind of creative resistance : you can write to the council and ask for your image: you have a right under the Data protection act. This might be an amusing way to draw attention to the nonsense of the camera, and to get people to think about what is going on. However, it is just as likely to end up fuelling a bigger effort to improve the surveillance by making the cameras more effective.

What unintended consequences are there of this kind and level of surveillance?