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The Open Society


One of the most powerful things I read when I was studying history at University was the philosopher Karl Popper’s “The Open Society and its Enemies.” Written at the end of the Second World War it made the argument, starting with Plato’s Republic, against the closed ideologies of totalitarianism. Popper’s argument is that in trying to order society and insulate it from external change, totalitarian regimes inevitably fall into abuse: suppressing the truth and oppressing their citizens. Manipulation of the historical narrative is one of their principal tools.

I read this work through the lens of the mid 1980s and the latter days of the Soviet hegemony. Popper’s argument appeared a self-evident truth as the communist regimes of Eastern Europe staggered towards their eventual decline. Recent events have made me think, once more, about these arguments as, again, liberal democracy appears to be under threat, a narrow nationalism is on the rise and the principles of the open society challenged and subject to question.

At the heart of the debate is our attitude to the movement of ideas and of people and how we embrace change in our world. Whether, as default position, we are open to change and new developments or whether we wish to look back and lock down the world, in some sense, in a paradigm of a personal, sectional or national past.

All of this appears to be playing out in a large way in current events whether over Brexit, the rise of Donald Trump or the emergence of different shades of nationalist and popularist politics across Europe and elsewhere. The impact of globalisation, the shift of economic and political power from the West, the scale of migration and economic pressure and public austerity all seem to be fuelling a shift against the values of liberal democracy and towards a more inward facing creed of nationalism. History never repeats itself exactly but the parallels with the 1930s are far too close for comfort.

My experience and study of history would teach me to side with Popper. That is that human development and progress has usually been linked to open societies and the free interchange of ideas of people and the creative energy that this unleashes. Nowhere epitomises this more than ancient Athens, the single most brilliant example of human development, in the Western world at least, which in a period of less than 200 years created the building blocks of western intellectual, political and cultural activity and whose legacy can be profoundly felt today.

In saying this it is important not to discount the anxieties which have fuelled the emergence of popularist and nationalist feelings nor is it necessarily wrong to value and want to cherish the past or defend traditional values or activities. The 20th century might have succeeded in condemning the Welsh language and the cultural traditions it embodies to the scrap heap of history. It has taken a significant act of national will to resist that secular trend and to preserve a crucial part of the DNA of the Welsh nation and people. Many people can very legitimately see change as a threat to aspects of life they value, and which have constituted an important part of their own identity.

I think in our own times three factors exacerbate the tension between the new and the old. The first is the ever-accelerating pace of technological and social change and, now, the increasing level of interaction between them. The Internet as mass phenomenon is no older than my children and there is every possibility that the next generation of technological change around robotics and Artificial Intelligence will happen even more quickly. This puts an enormous strain on our powers of adaption.

The second is the shifting balance of generations in our society with the growing numbers of older people and the declining proportion of younger people in society. In 2020 it is estimated there will be, for the first time in history, a greater number of people aged 65 and above than under 5. While there have always been tensions between younger and older generations these are made sharper by the change in the profile of society.

Finally, there is the sense that the hegemony of the west, as we have known it, and the sense of privilege which has gone with that is coming to an end. This creates particular issues and the politics of decline at a time when overall resources are challenged are never easy to manage.

The quality which, for me, is most important, in managing the tensions of these times, is tolerance. In supporting an open society, it is crucial we do so in a way which is respectful of the past and is understanding of those who are left behind by change. While we must always call out hatred and discrimination towards others we must do so in a way which is, in its own turn, measured and free of hatred and intolerance. In an increasingly divided world that is not an easy ask but is an essential if we are to avoid a return to some of the horrors of totalitarianism which Karl Popper was motivated to write about in 1945.



The kindness of strangers





As some of you will know from my posts on Twitter my mother-in-law, who has been developing dementia, went missing on Thursday night. Fortunately, she was alright but, in the hours, until we discovered that on Friday morning, it was a deeply anxious time for my wife and I and for the rest of her family.

One of the compensations was receiving a torrent of messages of concern, advice and best wishes on Twitter after I had posted her picture on Thursday evening. Some of these were from friends and people I knew, some were from total strangers. They were a great source of comfort and reminded me, once again, of how much decency and kindness there is in the world. From the news and some corners of social media it is n’t always possible to get that same message.

Having grown up with a disabled brother, the kindness of strangers has always been something I have been aware of. Ironically, blindness is a very visible disability and over the years I have witnessed countless acts of kindness towards him. Even in London, with its all rush and bustle, I am always struck by how readily people will give up a seat on the Underground for him.

Such acts of kindness go much wider. Just before I left Rethink Mental Illness I had the privilege of being involved in the events surrounding “Find Mike”. The charity worked with the campaigner and expert by experience, Jonny Benjamin to try find the person who, several years previously, had helped him when he had been on Waterloo Bridge about to attempt suicide. Jonny didn’t know his name but had a recollection he was called Mike. After a week or so the person was found, not called Mike at all, and Jonny and Neil’s story has been rightly celebrated ever since.

One of things that struck me in hearing about what had happened to find the real “Mike” was how many people had come forward. At first, this seemed somewhat disturbing, was there no limit that people would go to for a few moments of celebrity. In reality, it reflected that this was a relatively common situation and that were many “strangers on the bridge” whose intervention made the crucial difference when someone was thinking of taking their own life. On Thursday night the police told me that in cases of missing people, especially older people with dementia, it is usually ordinary people in the street, noticing someone who is distressed, who ensure that missing people are found.

In suicide prevention, the role of ordinary people, whether strangers or wider family and friends, has been recognised. There is an excellent resource which has been developed by the Zero Suicide Alliance and Relias which is designed to help give ordinary people the confidence to support someone who is in distress and maybe thinking of attempting suicide.

Ordinary people of course can also be experts. On Thursday night, as well as messages of concern and best wishes, there was some powerful good advice from those who had been in the same position, both on what was best to do and, just as importantly, how to cope psychologically with the anxiety of the situation.

As we battle to work out, in a time of limited resources, how best we can meet the level of need in society, it is crucial that work out new approaches to make the best use of the role of ordinary people, communities and experts by experience. This needs to be a partnership, not an abrogation of responsibility by the state. There were some positive aspects in the idea of Big Society but it’s juxtaposition with massive cuts in public services negated these and associated the brand with a cynical attempt to cover for the withdrawal of state support.

We’re not always very good, in statutory services, at establishing and nurturing these partnerships. We get too absorbed in our own system and its pressures to look outside and, at times, we can see such initiatives as threatening to our professional identity and worth. Yet as individuals, organisations and systems we desperately need to find effective strategies to harness this dispersed community capital to provide support to individuals in need. Volunteering and the voluntary sector has an enormous role to play in this but the same austerity which has challenged public services has also reduced its resources and capacity.

It is worth remembering that this is not a level playing field. Some individuals and groups will always be more of the subject of acts of kindness and others, whether for reasons of stigma, fear or prejudice, more likely to be shunned. The journey which mental health has gone though in the last 10 years, has, no doubt, impacted positively on the willingness of people to interact and support someone in obvious mental distress.  Other groups still have that more negative experience.

But the biggest challenge is to ourselves. Whether or not you are religious, the story of the Good Samaritan remains one of the most special parts of the Christian tradition. We can all be too busy, too self-important, too frightened  not to stop to help someone in distress but when we do, we do something very special.


The frank acceptance of all experience



Last Saturday I went to see the production of Oscar Wilde’s “An Ideal Husband”, currently playing at the Vaudeville Theatre. An excellent cast, led by father and son, Edmund and Freddie Fox and the timeless Susan Hampshire, did full justice to Wilde’s unique combination of wit and pathos. It was a welcome reminder of how much I have always enjoyed his work.

Wilde remains a very accessible figure for a modern audience and, while, in one way, firmly set in his own era, he also manages to speak very clearly to our own. Next to Shakespeare he is one of those writers whose best lines are instantly recognisable and whose wit has a timeless quality. While less well known than “The Importance of Being Earnest”, “An Ideal Husband”, a story of political corruption and blackmail and the eventual triumph of friendship and love, is an excellent play.

It is all the more poignant, as a piece of theatre, knowing that it was first performed when Wilde was on the edge of his own disgrace and eventual imprisonment. It is hard not to sense the feeling of anxiety in Wilde’s authorial voice. His characters speak of their fear of public humiliation and disgrace and the emotional power and genuine pathos of their words is reinforced by what we now know, with hindsight, of Wilde’s predicament.

In part we revere Wilde for his wit, in part as man who became a victim of prejudice and hypocrisy on account of his sexuality. Personally, I admire Wilde for both of these things but, more than anything, I admire him for his love of beauty, his humanity, and his non-judgemental acceptance of his own fate.

Born in Dublin in 1854, the son of a successful Anglo-Irish family, his father Sir William Wilde was an ophthalmic surgeon. After first attending Trinity College Dublin, Wilde came to study in Oxford in the 1870s and later established himself as part of the English aesthetic and intellectual scene. A man who could literally live of his wit, famously telling the American immigration authorities on a trip to America in the early 1880s “I have nothing to declare except my genius, there is no doubt he would have thrived in our own age as a darling of chat shows and television game shows.

Despite this, during the 1880, Wilde struggled to establish himself as a serious intellectual figure. He was versatile in a number of artistic forms, but it was, as a playwright, in the 1890s that he really made his name and it is through these plays which he is largely remembered today.

Wilde was much idolised by society but he also made enemies, none worse than the Marquess of Queensberry, the father of Wilde’s lover Lord Alfred Douglas. With relentless hatred and prejudice, fuelled, in part, by his pathological relationship with his own son, he pursued Wilde to his eventual conviction for “gross indecency”. In a fall from grace of epic proportions, Wilde turned overnight from the society darling to a common convict sentenced to two years hard labour.

Though Wilde’s charm and wit remain a source of delight it is in the Wilde of the years of disgrace that I find the most to admire, captured in his two final works, “The Ballad of Reading Goal” and “De Profundis”, both works of great beauty but written in a very different key from what went before.

In the “Ballad of Reading Gaol” Wilde gives a profound and moving account of the horror and pointlessness of prison, made all the more poignant because its base is not self-pity but, rather, a deep sense of empathy for his fellow prisoners.

In De Profundis, the subject of the very first of my blogs, Wilde makes a reckoning of what has happened to him. In doing so, he recognises not only the horror of what has happened to him, but also, this own role, in those events. “I turned the good things of my life to evil”. Most beautifully it acknowledges his gratitude to those, such as the man who greeted him with respect when he was standing outside the Court of Bankruptcy in his prison garb, who were prepared to show kindness to him in his darkest hour.

One of my favourite pieces of music is Tchaikovsky’s Pathetique Symphony. It contains a gripping shift of mood between the third and last movements which resounds with an enormous sense of sadness. It is a piece of the same era and days after its first performance Tchaikovsky, himself a troubled man, was dead. There is a striking resemblance to the mood of Wilde’s last works.

There is a line in De Profundis where Wilde talks of the humility as the “frank acceptance of all experience. It is a deeply moving definition which I have often thought about. Wilde was a man who experienced the heights and depths of the human condition and was in the end, capable of looking both in the eye. It is that for which I most love him.

And the greatest of these is empathy – a series of reflections on the NHS at 70


It is one of the most amazing things about being human that we can find ways of communicating, verbally and non-verbally, about how we feel. At its best, our sense of emotional connectedness is our great strength as, as a species. Its absence lies at the heart of many acts of neglect and cruelty.

Nowhere is that quality more important than in the relationship between caring professionals and those they care for. An empathy which can see, listen too and feel another person’s distress and provide support, reassurance or just a sense of being there. In mental health, but also in physical health, it is the quality, more than anything else, distinguishes outstanding care. It can not be prescribed or, necessarily, planned for but its absence is felt profoundly.

Empathy is a quality which we learn at our mother’s breast. Supported by early parental love and support we learn to make the good attachments which are so fundamental to our sense of wellbeing. So many later problems of mental distress and emotional development can be dated back to early difficulties in making attachments.
Yet empathy is often a quality we neglect in the planning and management of healthcare at the expense of more tangible things such as technical knowledge or the narrow counting of activity and outputs. Yet, to use the words of the poet R.S. Thomas it is “the pearl of great price, the one field that had treasure in it.”

I spent a fascinating evening, last week, with one of our clinical teams which works with children in local primary schools. The team is largely drawn from trainee child psychotherapists, who have come from a wide range of professional backgrounds, clearly motivated by a desire to help children experiencing distress and other emotional and developmental difficulties. They were talking about some of the cases they were dealing with and, in particular, the feelings of both children, families and therapists in dealing with endings. I was humbled by the commitment of the group and by their recognition of the need to make an empathetic connection with the children they were trying to help. When they succeeded in doing so it was for them indeed “the pearl of great price” but it often required great patience and thoughtfulness to reach that point.

It has long been a tenet of the Tavistock clinic, where I work, that you can not see the needs and emotions of those being cared for from those of the individuals who are attempting to provide care. Caring, while being surrounded by distress, is an emotionally demanding task. However willingly people come into working in healthcare the fact needs to be recognised alongside the conflicting emotions relating to a sense of the recognition that it is not always possible to provide more than “good enough” care.

When we look at the use of resources in the health and care services it is essential that we factor in sufficient time and support to allow the impact of caring responsibilities to be processed and the capacity for empathy to be restored. There are a variety of approaches for how this time can be organised: Schwartz Rounds and Balint groups are some of the best known. However, what ever approach is taken, there must be mainstream ownership and proper recognition of this activity in the allocation of resources. This is so crucial at a time, when rightly, there is a focus on issues of productivity and the proportion of time which is spent on the delivery of care.
The voice of service users and carers is also crucial. It provides the narrative for understanding what it means to live with the distress of illness and disability and should set our benchmark of what constitutes good and bad care. In essence, it helps set a common language of empathy.

I have long believed that stories, as much as quantitative facts and data, is an essential ingredient of education for health and care practitioners. They always form for me the most important part of Board meetings, setting the tone and context for other discussions. When things go wrong it is the story of what happened and the emotional impact it has had on all concerned which makes the biggest difference in defining what needs to change.

As we approach the 70th birthday of the NHS let us remember more than anything else the sense of empathy which motivates our collective desires to set up and maintain a health service for all. A sense of empathy which can feel out for the suffering of others, knowing that, at some time, we too will needs its support and care.

Death in Leamington




On Thursday I attended the funeral of an old family friend who had died recently in Leamington at the age of 98. As she had no close family of her own, the task fell to me of organising the funeral. It was the first time in my life I have been so closely involved in the practical arrangements surrounding a death and it made me reflect on that hidden, but most inevitable of, human experiences.

The funeral itself passed off well and I am full of admiration for the undertakers and the vicar whose combination of sympathy, dignity and attention to detail was exemplary. There can be no more difficult work than supporting strangers at a time of bereavement. It is immensely important.

Our friend had died peacefully after a long life. She had gone to university before it was at all common for women to do so, she had been a capable and devoted teacher in a secondary school in the North West. She was a woman of intelligence, of strong values and strong views. On retirement, she had moved back to our roots in Warwickshire where, amongst other acts of kindness, she had supported my great uncle, her former teacher, at the end of his life.

In the last couple of years her health had declined, and she had had to leave her own home and move into a nursing home. Like an increasing number of people surviving to a great age, she had lived out a tail to her life marked by physical frailty, some psychological distress and a growing withdrawal from the world. There was some sense of relief in her eventual passing from this life.

Reflecting on the funeral, I was struck by how awkward we are with death these days. To start with we have drifted away from a common narrative of what death means and what might be expected to happen after death. There is no right or wrong to this, and maybe behind the front of collective religion, it was more the case in the past than we suspect. However, it means that we have allowed ourselves less space to talk about death and less of a common language in which to express that conversation.

The events of death also used to be something which happened in the heart of communities and which we have now moved to the margins in hospitals or crematoria where they are not visible. Unless we are clinicians, few of us are familiar with the physical patterns and processes of death. When somebody dies we are, unless they are celebrities, less aware of the fact, less drawn into the ritual of marking their parting, which in the past, would have impinged on the whole of the community. Our more rootless existence and the more drawn out nature of life, mean more people are dying in loneliness and isolation.

It has also been interesting to observe the process of drawing someone’s earthly affairs to a conclusion. In a way I am very grateful that it is so straightforward, and, in any case, our friend’s affairs were in very good order. Nonetheless it has been striking to see how simple it is to make the transition.

I was struck, in preparing for the funeral, in looking at a poem by John Betjeman of the same name as this blog. It describes the quiet and lonely death of an elderly women in Leamington and the matter of fact reaction of her nurse, bringing her afternoon tea, and realising that her patient has passed away. It could have been written for our friend.

Death should be higher in our public consciousness. Facilitating a good death should be a more prominent purpose of health and care services, recognising the psychological, practical as well as the medical aspects of this. We should be more bothered about this, at times, than we are about our obsession to lengthen life beyond its natural limits. The circumstances of death of so many people should be a further reminder of the bitter consequences of loneliness and social isolation. Above all else we should make sure, as individuals, we are prepared to look ahead and consider ourselves what constitutes a good death.

It is in the nature of the human condition that it is hard to understand or reconcile ourselves to ultimate ending of our days. It is not helpful though, to ignore the issue.


Breaking news


Don’t get me wrong news and current affairs are central to the health of democratic life and taking account of what is going on in the wider world is a crucial duty of any citizen of a healthy society. As John Donne famously said, “No man is an island, entire of itself” and as political and social animals we should be open to an interested in what is happening around us.

However, that said, it seems to me we have a problem about the role of news and media in our society, one which has become more challenging with the emergence of the 24 hours news cycle and the rise of social media. These issues are exacerbated by other factors such as the speed and relentlessness of change. In addition, the growth of isolation means that for increasingly large numbers the media, whether television, radio or the internet, has become a dominant form of social contact.

There are four issues, none of them new, which warrant consideration.

The first is the focus of the media on bad news. While the idea that calamity and misfortune are fascinating is not surprising, the quantity of breaking bad news, in particular, when expressed as a competition for attention between news channels adds to a sense of societal anxiety. This is, perhaps, particularly so for those for whom there are few compensatory events from real life.

The second is the tendency to narrate events through a series of polarised stereotypes. I know from my campaigning work in mental health how difficult these are to shift whether the stereotype of the “mad axeman” or that of “real men don’t get depression”. When views and attitudes are grounded in media stereotypes, rather than real life experience, they tend to be less positive. The success of Time to Change and other initiatives to improve attitudes towards mental health has been based on reconnecting people with the lived experience of mental health problems amongst their friends, family and colleagues.

The third disturbing feature is the narrow focus of the media both in terms of geography and issues. Important though President Trump is and distressing though some of his tweets are, I sense, at times, that they can attract a disproportionate level of attention when there are issues, in many parts of the world, which will struggle to secure the coverage they deserve. In this country our media continues to be London centric. This has always been obvious to someone of Welsh origin, but it also explains the level of shock represented by the Brexit vote which brought to surface many longstanding issues of concern and disillusionment which had been registering in many part of the country over a long period of time.

Finally, there is the phenomenon of fake news. Again, this is not new but, in an era, where there are so many sources of formal and informal news the scale of what is possible has grown. There are two manifestations of fake news. First the actual propagation of false information. Second the ritual denial of information on the basis of the source without a further thought about its veracity.

Looking at society, our presentation and consumption of media is fuelling both our sense of collective anxiety and the polarisation of society. The problem is exacerbated by the decline of traditional media which has to shock and shout ever more loudly to attract our attention and our collective ambivalence about the impact of social media and other online communication. They also speak loudly about the decline of some intellectual traditions in our society.

Are there remedies? I will make a couple of points about how our own actions can help.

The first is to extol the virtues of slow news. For several years we have taken “The Week”, a very good publication in many ways, but best of all for presenting the news through the lens of 7 days rather than that of the breaking headline. It is striking how often, even over a week, the focus of a story will change. History encourages us to always look at the longer term rather than just the froth of current affairs. The less rapidly we leap to conclusions the better.

The second is to be bold enough to listen to the views of those we don’t agree with our and to take the time to engage with opinions which are different from our own and about places and issues which are not the usual focus of one’s interests. Our own stereotypes can just be as destructive as those of others. The willingness to change one’s mind and modify one’s views is an underrated quality and one, which, these days requires some bravery. Above all we must be willing to avoid simple binary paradigms, real life is never as simple.

The third is to privilege the stories of real life over the media stereotypes. The complexity and genuineness of lived experience can always make it possible to think again, and, in particular, evoke in us the sense of human empathy which connects us to our fellow humans.

Finally, as someone who took a deliberate view, a couple of years ago, that starting my day with Radio 3 was better for my sense of wellbeing, I think there are times when we should force ourselves to take a break from the news and enjoy the more timeless things of life.

Investing in the Future


It’s the end of March so the streets are full of roadworks and Finance Directors, across the public sector, are scratching their heads about how to manage end of year underspends. The constraints of annuality remain one of the striking examples of how the rules of public sector finance can provide obstacles to taking the most prudent decisions about spending and investment. While always frustrating, those constraints have a particularly negative impact at a time of austerity.

In any endeavour there is always a balance between long and short-term interests but at, the current time, when not only is money tight in the short term but there also major challenges about the long-term sustainability of public services it is particularly difficult. Whether in the NHS, local Government, criminal justice system or any other public service the logic is that we should be doing everything we can to invest in prevention and early intervention with the aim of reducing long term demand pressures. In reality, the system is forced, when resources are tight, to focus disproportionately on the management of short term financial pressures and concentrate spending on the most expensive parts of the system where demand cannot, in the short term, be, easily avoided.

These issues are not new and, to be fair, the system is nothing like as limited as it was when I started my career in the public service when, even budgets for Government Departments, were set on an annual basis in the Autumn Statement. The Comprehensive Spending Review and the introduction of 3 years spending settlements have been positive developments as have been aspects of the new financial regimes for bodies such as Foundation Trusts.

However, three aspects of the overall regime for public sector finance still stand in the way of the best overall use of public resources and the most effective (and efficient) deployment of public services.

The first, which I have already alluded to, is the restrictions in carrying money forward from one financial year to another. This causes artificial pressures on how resources are used, in particular in cases where the purpose of resources has been clearly decided in advance, for instance as part of an agreed project plan. Great flexibility here would promote better use of resources by removing the pressure to rush important decisions about the design of initiatives or sub-optimal decisions to spend in haste so the money is not lost. It would allow precious management attention to be focused on the task in hand rather than being wasted on the management of financial rules.

The second issue is more fundamental and is the perennial challenge of programmes focused on investing to save. Across public services there is good evidence for how investment in one sector or organisations can liberate savings in another sector. The structures of public sector finance, however, stand in the way of realising benefits for the system as a whole. It appears we are working on solutions. Placed based budgets and integrated care systems are examples of trying to facilitate the joined-up commissioning of services.

The third challenge relates to funding longer term interventions. Often such interventions relate to upstream and preventative initiatives, many of which can demonstrate an excellent return on investment, I heard, this week, about anti-bullying initiatives which can demonstrate lifetime savings of £146 for every £1 spent on the programmes. There is a case for trying to separate such programmes from the mainstream of public spending. There would, for instance, be a case for totally separating public health from other spending to ensure that investment in the future health of the nation continued, whatever the vagaries of the economic cycle and short term pressures on other health and local government services. If that was not possible, there could be an argument for funding public health and other long-term initiatives on a capitalised basis (as we do for buildings, IT and other public assets) which would allow upfront investment against an evidenced stream of longer term benefits.

The same argument would apply to the costs of transformation where an element of upfront investment or double running costs are an inevitable part of any plan to reshape services and moving from one service model to another. Such transformation investment was, eventually, permitted with the closure of the long stay hospitals, in that case set against the anticipated capital receipts from the sale of prime real estate.

There are many reasons why the Treasury and others are reluctant to embrace the risks of more innovative models of financing. In a complex and dispersed financial system one can appreciate the nervousness of losing financial control. On the eve of nearly going broke in the 1970s the administration of New York had capitalised a quarter of its overall expenditure as a means of living beyond its means.

However, by their nature, public finances are long term. National debt and the security of future tax receipts should allow the State to take a level of risk in making investments which smaller institutions are unable to do so. It was only in the early 2000s that we paid off the last of the debts accumulated in the two World Wars.

My argument is not to let go of overall control of public finances but to consider, in an open way, a range of innovative solutions, which facilitate well-constructed and evidenced base investment in initiatives which can help deliver a sustainable future shape to public services. Such initiatives need to have clear burdens of proof and clear lines of accountability for the delivery. However, the biggest lesson of austerity for me is the need to think about the long term. In the short-term services may be under pressure. In the long term, if we don’t do something different they won’t be there at all.