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The March of Folly


The Alchemist by Ben Jonson is one of my favourite plays and the RSC production I went to see recently did it proud.

Written over 400 years ago, it still has much to say about human folly and our willingness, as a species, to deceive others and ourselves. The plot revolves around a trio of rascals:  Subtle, Face and Dol who use the absence of the Master of the House, Lovewit, during an outbreak of the plague in London to set up a number of outrageous scams to defraud their fellow citizens.

The play is no less harsh on the victims of the fraud as it is on its perpetrators. A series of characters are displayed who through their vanity or plain stupidity are easily lulled into going along with the promises and deceits of the three villains.  In the end their villainy catches up with Subtle, Dol and Face when Lovewit unexpectedly returns to the house but that is of little consolation to the victims.

The play got me thinking about the nature of human stupidity which once Einstein supposedly described as being with the Universe the only things that were genuinely infinite (although he had his doubts about the Universe). For a species distinguished by its cleverness and ingenuity it is striking how frequently our individual and collective history is coloured by episodes of folly.

From a historical perspective there are a number of distinct “types” of stupidity.

The first is what I would call the “free lunch” syndrome, the idea that there is an effortless path to wealth or success. For Sir Epicurus Mammon in the Alchemist it is the belief that the Alchemist can turn the base metal of his kitchenware into gold but how much more stupid is that belief than that which encouraged investment into sub-prime mortgages before the 2008 Financial Crash.

The second type is more subtle and relates to “cognitive dissonance”. First identified as a phenomenon looking at radar operators during the Second World War it relates to our inability to accept new pieces of information which undermine our fixed beliefs.

If cognitive dissonance is an essence a process of the unconscious there are cases of more deliberate stupidity when we chose explicitly to ignore facts or arguments which are inimical to our beliefs, values or interests. In this case we are prepared to deny rational argument or give unthinking support to those who provide an argument which is better aligned to what we want to believe.

There are times too when, privately, we can accept that the facts have changed but, in public, there we lose too much face in accepting that we were wrong and that we must change a course of action. Politicians and Governments find this particularly difficult where admitting a mistake or false belief is seen as a particular sign of weakness.

As a social species collective beliefs and behaviours are crucial in defining acts of stupidity. Peer pressure and group think play an enormous role in what we think and how we behave.  It is much easier to adhere to a majority belief than to be a lone voice opposing the group position.  The fate of the Trojan princess Cassandra sums it up entirely; the horror of being always right but never believed.

While education should be a protection against acts of stupidity, sadly this is not always the case. Indeed from my experience there is nothing worse than seeing a clever person, especially in a position of leadership, trapped in a position of stupidity.  Their intellect and education can give them an armoury of arguments with which they can defend their views to themselves and others.  At the end of the day, however, they are still wrong.

So how can we guard ourselves against being the victims or perpetrators of folly? There are no perfect answers but there are some things which might help.

The first is history and our sense of belonging to it. When things go wrong professionally or personally it is always amazing how easily a sense of hindsight can tell you what you should have done differently in a way which would have been almost impossible to determine at the time.  History is our collective sense of hindsight and history is littered with the signs of folly. Indeed one of my favourite books is the American historian Barbara Tuchman’s  ”The March of Folly” which analyses a series of historical episodes from the Fall of Troy to the Vietnam War to demonstrate how much stupidity has determined the course of events.

This is one of the reasons why a lack of respect for history in modern times so saddens me. Just because we have i-phones does not mean that we have disconnected ourselves from the patterns of events and behaviours which have repeated themselves over the generations.  Recent political events in Europe and the USA only confirm the point.

The second protective factor is inquisitiveness. However much we know we should always be looking for new information and insights, including, challengingly, those which may be at variance with our beliefs.  Sometimes, when we are least expecting it, we can see the “pearl of great price” which the poet R.S. Thomas refers to in his beautiful poem “The Bright Field”  which provides real insight into what is happening and can force us to change our minds.

The final quality required to guard against stupidity is humility. It is never easy to admit we are wrong, to back track from long held beliefs and to change our course of action. It is particularly difficult to do so in positions of leadership and, sometimes, one cannot expect to do so without personal cost.  The dictum of J.M. Keynes must be right though “When my information changes, I alter my conclusions. What do you do, sir?”

So all in all, Ben Jonson’s drama of human folly set in London in 1610 is all too relevant in London in 2016. The March of Folly continues but perhaps there are some things we can do to slow it down.

The other kingdom – a farewell to summer



Autumn always comes with a jolt. August turns to September and we’re back to the busy schedule of work and school with the prospect of the long slog to Christmas.  A brief moment of peace over the summer is finished for another year.

This year has been no different. Back from a wonderful holiday in the Austrian Alps it has been straight back to the demands of the STP and all the challenges of running a NHS organisation in the current climate.

Summer holidays have always had a very special place in my consciousness. Much to the annoyance of my family, I can remember the things I have done on the holidays over the years with an intensity it’s hard to bring to other aspects of my life.  They are enjoyed in anticipation and retrospect just as much as they are at the time and it is always important for me to finish the summer with a clear idea of where we will be going next year.

Holidays serve many purposes. At their most basic they serve to provide a period of rest and relaxation, a chance to down tools and recharge the batteries.   That is a very necessary objective and we are all the better and more productive for being able to rest from, time to time, from our work.  If God needed to take a day off after the labours of creation it stands to reason that mere mortals should follow suit.

Holidays can also be the opportunity to indulge in pursuits for which there is insufficient time or occasion to follow at other times. In particular they are the time for reading and my holiday luggage is always weighed down by an enormous pile of books, some of which, at least, I manage to get through.

Holidays provide the chance to learn about new places and immerse oneself in new cultures and new histories. With a lifelong love of history I have always enjoyed stomping around archaeological sites, historic monuments, museums and art galleries, relishing the opportunity to see both the special places I have long heard about but never previously visited and the new discoveries which open a new strand of interest.

As a child many of my summer holidays were spent staying with relatives in Wales.  Without their hospitality we would have probably struggled to go away and I am enormously grateful for those times which in addition to being great fun, cemented my love of Wales, its people and landscape.

In my youthful imagination there was something very special about the views of the mountains of Snowdonia across the Menai Straits from Anglesey, the Edwardian castles of Beaumaris and Caernarfon, the grey stoned chapels which peppered the roadsides, the open skies and the foam speckled sea. It expanded the bounds of my imagination and contrasted so strongly with the mundane everydayness of the city I grew up in.  Being Wales there were many rainy days but if anything they did as much as the sunny ones to engender the sense of otherworldliness associated with those childhood holidays.

This potential of holidays to provide an opportunity to escape not just from the practical details of everyday life but also from its imaginative constraints is something which still remains with me in middle age.  It is the time I feel again that sense of open possibilities, so easy for a child for a child to envisage and so much harder to recapture in later life.  A good summer leaves one refreshed and rejuvenated both physically, psychologically and imaginatively.

However, like all good things in life holidays inevitably come to an end and, in doing so, bring a sense of grief and loss. This year we visited the Wörthersee in Austria where Gustav Mahler took his summer holidays and wrote a number of his symphonies in a small composer’s hut overlooking the lake.  On the walls of the hut there was a quote from Mahler which captured the sense of sadness when the time came to leave his summer idyll and source of inspiration.

“Today I go away from here with a bitter heart. To know one must wait another year is tragic.”

As I left that special place it summed up feelings exactly.


Necessary but not sufficient – the role of regulation in health care quality



In the first six months of this year I experienced CQC inspections as both the Chief Executive of an inspected Trust and as the Chair of an inspection at another Trust. I found it a fascinating experience being on both sides of the process and it prompted me, once both inspections were completed, to want to write about that experience and my views on where regulation sits in ensuring high quality health and care services.

CQC comes in from time to time for a bit of criticism. I, however, found the process of inspection on both occasions robust and fair.   Post Francis it was inevitable that the regulator needed to adopt a more intensive process and I am probably, in any case, a supporter of a “boots on the ground” methodology as long as it is used proportionately.  From my perspective there is much to be gained from an inspection team visiting services and meeting front line staff and service users as well as relying on external or internal data.   The CQC process puts a lot of emphasis on the triangulation and corroboration of evidence to reinforce the validity of the judgements which are made.  I welcomed the involvement of peer specialists and of experts by experience and the very significant added value they both brought to the inspection process.  Finally the methodology rightly allows for a focus on good practice as well as the more rule bound aspects of quality.

Inspections are like visits to the dentist.  Nobody enjoys them at the time but they are necessary to the health of the system. There are also clear benefits to the organisation being inspected if the process is embraced in the right way.  At my own Trust the process of preparing for our CQC inspection was very powerful in helping us draw together the strands of our quality work and in ensuring good engagement with front line clinical teams on key issues.  The report, both its validation of what we do well and the recommendations of where we can do better have been helpful in driving our decisions as an organisation of where we go next.  I could see much the same at work in the organisation I was part of inspecting and very much welcomed the open way in which the senior team at that Trust received our findings, both good and bad.

In a system as complex as the NHS there will always be issues with any system of quality regulation. When the reputation and, at times, the future of senior individuals and organisations hangs on what is said by the regulator there will inevitably be tensions about negative judgements and ratings.   CQC focuses on providers and providers may feel hard done by when the fundamental issues behind the judgements made about their performance relate to factors out of the provider’s direct control. This is particularly an issue when there is a blatant mismatch between the levels of demand providers are trying to manage and the level of investment made by commissioners.  In an environment which is increasingly putting more and more emphasis on system performance it is appropriate that the focus of regulation should shift more in that direction.  How to do so is still very much to be worked out.

Another unforgiving aspect of inspection is that judgements have to be made on the basis of what is seen at the time not what might be intended to happen in the future. That can be harsh on organisations where there is a genuine engagement with quality improvement but where there are major structural or cultural issues still to overcome.  Whatever is said in the report a good inspection process will explain the context to judgements and recommendations and give recognition to the efforts of clinical and managerial leaders to tackle underlying issues.

From time to time there has been a debate about whether the strengthened system of inspection has been the right answer to the concerns about quality identified in reports about Mid Staffordshire and Morecambe Bay. I firmly believe that a robust system of inspection is a necessary feature of a good quality care system and that CQC’s regime, while it has room to develop and adapt, is fit for purpose.  However at the same time inspection and regulation cannot be the only mechanism for ensuring and improving the quality of care.

First and foremost quality needs to be owned by the Boards and leaders of organisations.   That ownership should be reflected in the amount of time devoted to quality in Board discussions and the level of inquisitiveness which Executives and Non-Executives have about what is really going on in their organisation.  Wherever an organisation is in its quality journey a good inspection report should bring few surprises to the leadership of an organisation.  If it does that is a judgement in itself.  Boards should be prepared to invest in quality improvement.  They also need to understand the implications for quality of other changes and pressures in their organisation and have an acute sense of where their “red lines” will be in terms of the risks of compromising quality.

However quality also needs to be owned by the system and not just seen as the business of providers. Improving quality is not always a question of additional investment but at a time of rising demand it is likely to have financial implications.  One of the key roles of the regulator must be to provide an independent voice for quality standards with the willingness to “blow the whistle” when financial expediency potentially compromises the quality of care received by patients.

A regulator of quality is an essential component of a high quality system of care and if CQC did not exist it would have to be invented. It needs to do its job well and with integrity and now as much as ever it needs to be uncompromising in championing the voice of quality against other pressures in the system.  However no one should assume that, on its own, CQC can be the guarantor of good quality care.  That is all of our business.


All Quiet Now on the Western Front


Over the last week I have cycled some 500 miles along the line of the Western Front in the First World War. It’s been a trip I have wanted to make for some time and has been a powerful way in which to experience the landscape in which this terrible conflict was played out.  In my panniers I carried, as well as maps and guidebooks, a volume of the First World War poetry as an emotional and psychological guide to what I was seeing.

Cycling is a perfect way to appreciate any landscape.  You travel slowly enough to be able to observe the terrain around you and you do so with all five senses.  You are acutely aware of gradient and intuitively stop at the top of any major climb to admire the views in front and behind you.  You also travel fast enough to be able to see the changes in landscape and the subtle differences between areas and regions.  You can travel far enough in a week to make sense of an area as large as that in which the First World War was fought.

I started in Belgium to the north of Ieper. Belgium was the little country whose fate was central to this becoming a World War.  It was the official reason for Britain joining the conflict and the fate of Belgian civilians featured strongly in the recruiting propaganda of Lloyd George and other British politicians. For most of the war only a small part of the country remained in Allied hands but it was interesting to visit Belgian cemeteries and see memorials to the sacrifice made by Belgian soldiers to the war effort.

Cemeteries dominated the route. I stopped at lots and I have no idea how many I passed. There is a particular character to First World War cemeteries.  They are scattered across the landscape because they reflect where men were buried at the time of battle.  In many cases they stand alone at the roadside or across a field but in other cases, for instance the cemetery which I visited in Arras where the poet Edward Thomas is buried, they are surrounded by more modern buildings.

There is a powerful uniformity of design to the cemeteries: gravestones in serried ranks as if they are on parade. They are all immaculately maintained and there is an order and purpose in these places in such stark contrast to the circumstances in which many of those buried there ended their lives.

Some soldiers have names and ranks and others are anonymous, euphemistically in English “soldiers of the Great War known to God”, in French much more brutally “inconnu”.  Yet despite this there is an irony that the occupants of these graves are better remembered than many others who have died before or since.

The cemeteries and memorials I passed also reminded me of the range of different backgrounds, nationalities and religions of those who took part. I stopped to see the beautiful memorial to soldiers from the Indian sub-continent at Neuve Chapelle (and next to it a cemetery for Portuguese soldiers), the Irish Peace Tower at Messines (commemorating the place where Catholic and Protestant Irishmen first fought alongside each other in 1917), a memorial to Australians at Peronne, another to South African troops engaged in action at Delville Wood during the early weeks of the Battle of the Somme, a monument to the Basques and, as might be expected, memorials to Welsh troops at Langemark near Ypres and to the 38th Welsh Division at Mametz Wood on the Somme.

One of the most striking cemeteries I visited however was further south on the Chemin des Dames in the French section of the front. At Cerny en Laonnais French and German cemeteries are placed directly alongside each other.  I had a sense of young men, motivated to fight each other by many of the same values of patriotism now lying at peace next to each other.

La Chemin des Dames, a long ridge north of the Aisne Valley fought fiercely over during the whole period of the War, was one of a number of places which brought home to me the importance of high ground in this conflict. My route also took me over Vimy Ridge taken the Canadians in 1917.  It was staggering, as I struggled to get up them on my bike, to think of soldiers attacking these positions under heavy fire.

One of the most moving things I saw was right at the beginning of my trip. In Poperinge near Ieper (and just behind the British lines) it is possible to visit the cells in which British soldiers, convicted for desertion (some suffering from shell shock), were held the night before their execution and the yard in which they were shot.  Of all the brutal images in a brutal war nothing stands out as far.

The final image of my trip is that which I have used as the header for this blog. We are used to the poppy being the symbol of the conflicts of the 20th century but it was especially moving to cycle through the battlefields and see the poppies growing amidst the cornfields, such a poignant reminder of the lives of young men sacrificed a hundred years ago.

The guns are silent and all is now quiet on the Western Front. I thought that one thing which would have united young men from all the nationalities who lost their lives on these fields was that the horrors which they experienced would represent a war to end wars.  Sadly a hundred years I am not sure that we have learnt this lesson.



A lost friend

Andrew, ever dashing, ever bold

Will never see your friends grow old.

Your mind as sharp as all the best

Now lies, eternally, at rest.

And we will never understand

Why it was the almighty’s hand

Took you with so much more to give

Left us alone on earth to grieve.


As the summer’s heat begins to fade

All nature’s work is soon decayed.

And though our mortal frames will ail

Your memory ought not ever pale

Your smile, your wit is what we knew you by

The mystery why you had to die.



Now let us praise famous men


My father turned 90 yesterday. Even in an age where many more people are living so much longer it remains a very significant milestone.  It felt a good time to reflect on what I most admire in him.

My father came from a very different world to the one I and my children have grown up in. Born on 2nd July 1926 in Clydach Vale in the Rhondda Valley, it was the middle of the bitter Miners’ Strike.  My grandfather who had caused some sort of trouble during the strike lost his job and was unemployed until the early 1940s.  As a result, like many in that community in the 1930s, my father grew up in significant material poverty.  His father found solace for his disappointment in life in the pub.

Despite this my father is immensely fond of his upbringing. The Rhondda was a strong community, with an enormous sense of shared identity, based on working class solidarity, Welsh culture and Nonconformist religion.   Despite individual material poverty there was a network of social support and communal facilities (including libraries and healthcare funded by the Miners’ Federation).  The mountain just above where my father lived provided a wonderful playground.

My father was able enough to get to Grammar School and would have easily been bright enough to go to University. Those opportunities were not open to a working class boy at that time and it remains one of his regrets that he did not have that opportunity but one of his joys that his sons and now grandchildren have had it.

After the War, and a tour of National Service in Palestine, he did get the opportunity to go to teacher training college and spent his working life as a primary school teacher, and later head teacher, moving to Birmingham where he met my mother and where he still lives. As I discovered as a child Birmingham is, or at least was, full of Welsh teachers.

I have learnt lots of things from my father over the years but here there are the things I most admire about him and which I hope I have picked up some shadow of.

The first is his sense of community and of the equality of individuals within that community. Everybody in a community matters.  Nobody is too important not to bother with other members of their community.  Nobody is not important enough to be bothered with.

The second is a strong commitment to help those who are disadvantaged in society. My father’s motivation to become a teacher was an encounter with a fellow soldier when he was on National Service who was unable to read.  Much of his teaching career was spent in quite deprived schools in Birmingham and in working with children who often had little motivation and encouragement to learn.

However the biggest impact on my father’s life (and indeed on my own) was the disability of my elder brother. My parents had a very difficult time when my brother was young and they were discovering the extent of his difficulties and his support (and that of my mother) for Peter has been a constant source of inspiration to me. Through my brother my father became involved in the world of disabled sport and after his retirement my father spent many years running a disabled sports club.

My father is a man of great integrity, of strong values and beliefs who is prepared when necessary to stand up for what he thinks is right. I do not always agree with him on everything but it has hard not to respect his opinions.  He has always been an enemy of petty authority, most notably in a clash early in his teaching career with a martinet of a head teacher.  It did not look, at the time, as if it would be a great step forward in career but it did make an impression on another young teacher at the school – my mother!

I have also admired my father’s sense of interest and enquiry. While not an intellectual or with the benefits of university education as I have had he remains fiercely interested in what is happening in the world outside. It is one of the reasons why he remains sharp and with all his faculties at the age of 90.

Finally he has been a very generous father, with his time and money. He always supported the opportunities I wanted to take as a child, even if they were not those which matched his own interests.  He did so when I am sure he and my mother had to make sacrifices to do so.  He has also supported my children and my brother’s children and it was lovely to see yesterday, at his birthday lunch, the deep love his grandchildren have for him.

So I have been very lucky to have such a good and inspiring father. I am very conscious of the difference such an influence can play in one’s life and the fact that many, for whatever reason, are not so lucky.  So in the words of the writer of the book of Ecclesiasticus :

“Let us now praise famous men, and our fathers that begat us. The Lord hath wrought great glory by them through his great power from the beginning.”

Do what we need not just what we can



So it won’t be long before we have driverless cars and lorries and fast food outlets are already looking to use robots to serve their food. I am sure there are benefits in both but the story of the relentless drive to replace people with machines cannot but stir some level of anxiety about the future.

The use of technology is one of mankind’s defining achievements.  Whether it was the discovery of fire, the first use of stone tools, the development of agriculture, the invention of the steam engine or the internal combustion engine or the arrival of the internet and the i-phone, humans have had a brilliant capacity to harness technology to triumph over their environment and promote their species.  However have we now got to the point where the process of technological development has got out of control?

There is nothing new in such fears. We are familiar with the term “luddite” with its origins in the early 19th century agitators who tried to stop the adoption of new technology in the cotton industry.  The French word “saboteur” has similar origins referring to the fact that the French agitators threw their clogs “sabots” in the machinery to put it out of action.

Much of the time those who have been anxious about the advent of new technology have been proven wrong. New technology has been disruptive but in the end has increased prosperity.  Old jobs have been replaced by new jobs and the world has moved on.

We have even survived 71 years in the shadow of nuclear weapons, the technology which gave humankind the potential to self-destruct. However, as the details of history become clearer, we have discovered that we came closer on occasions than we may have thought to doing so. As Barrack Obama’s speech in Hiroshima on Friday, highlights, despite a quarter of century since the end of the Cold War, the nuclear threat is far from finished.

I am not a natural Luddite although at times the passing of the “old ways” can be upsetting. I do have concerns, however, that we have lost some of the ability to harness technological innovation to address the most pressing problems faced by humankind. There are two issues.  First we have allowed scientific problems, in some senses, to be prioritised over moral ones.  Second, and in part as a result of the first phenomenon, we have abrogated too much of the control of technological development to private interests.

This has left us with a mixed legacy from the golden years of technological development. For instance we harnessed technology to massively drive up living standards but have been unable, or unwilling, to address the issue of inequality or even to eliminate levels of absolute poverty in certain parts of the world.  Technology has not succeeded in making the world a safer or more secure place, indeed at times, has done the opposite.

There is a dimension to this healthcare. Medical research has achieved phenomenal things in the century or more in combatting disease and in extending the span of human life.  For a person born in 1900 the modal age of death would have been 1, for someone born in 2010 it is estimated to be 90.

However its progress has left significant issues in its wake which we have failed to resolve and to address with the same focus as we have brought to biological medical research.

The development of medicine has n’t succeeded in reducing health inequalities and there is an increasing concern that priorities for research, in particular in pharmaceuticals, will be driven by the needs of the global elites able to pay for new treatments.

A model of medicine focused on extending life has also left a moral question about the balance between additional years and wider issues of wellbeing. I have just finished reading Atul Gawande’s excellent book “Being Mortal” which makes a very powerful case for rethinking paradigms about what matters as we grow older and frailer and what the role of medicine is in facilitating this.

So my plea is not to stop the development of technology in healthcare but rather to reframe the debate in which helps drive its priorities. Happiness, quality of life and wellbeing for the greatest number should be more central in our thinking.  That would inevitably shift more focus to research in mental health, at present hopelessly underrepresented in research priorities in proportion to the size of the burden of misery and costs to individuals and society it is linked to.

In an age where there are increasing concerns about the costs of universal healthcare systems more effort should be invested into interventions which reduce rather than increase the cost of healthcare delivery, either because they can offer the genuine prospect of cure or because they can significantly reduce the costs of delivery of existing treatments. More research should go into self-care and self-management where technological enablers have some genuine potential to improve outcomes.  Public health and research which focus more on the determinants of health and illness should also feature higher

All of this will require some significant changes in the setting of research priorities, systems of funding and the processes set by NICE for the adoption of technological advances and new treatments.

Technological advancement has been mankind’s defining achievement. Let it not become our master rather than servant and let’s harness it to solve those problems which are most pressing for our society.