Health – We Know Zero

Here we are again

19. March 2026 · Write a comment · Categories: Actuarial, COVID-19, Health, Media & Politics, Professions

I have caught Covid for the third time this week, so naturally my thoughts have turned to how it all began.

There are a few Covid posts starting to turn up online as the 6th anniversary of it all rumbles around. The British Foreign Policy Group have helpfully published a timeline from which I have taken everything that happened before Boris Johnson locked us down for the first time:

So a lot had happened by 23 March. You will all have your favourite bits from the saga above, I think mine is 22 January, when Public Health England announced they had moved the risk level to the general public from very low to low.

I remember teaching a macroeconomics class on 12 March when we knew it was going to be the last session on campus. The penny hadn’t dropped. Students were asking about how they would hand work in. We agreed it would have to be online. Some lecturers were talking about microwaving paper submissions to sterilise them. We had a little giggle about that. I had spoken to Stuart McDonald (now MBE) earlier that day where we had reluctantly agreed to postpone his visit to campus to speak to the Leicester Actuarial Science Society (LASS). Stuart would of course become one of the actuarial stars of the pandemic for his work with the COVID-19 Actuaries Response Group. I had a similar conversation by email with Lord Willetts, who was Chancellor at the University of Leicester at the time and who was going to talk to LASS about his books The Pinch and A University Education. We talked of postponing rather than cancelling. The realisation that everything was changing for the foreseeable future was still not there.

It took a long time for the penny to drop for the Government as well. As this analysis of the establishment of the “Covid Disinformation Ecosystem” says:

January featured fear and disbelief, February proved covid couldn’t simply be ignored, March was when governments realised the hospitalisation rate could overwhelm healthcare.

And a Government that was slow to respond initially was very vulnerable to the groups which sprung up during 2020 and 2021. As the Counter Disinformation Project says:

And the main initial target for the UK section of the ecosystem was Boris Johnson who was meeting privately with newspaper owners and editors. Enough doubt was put into Johnson’s mind that he dithered and delayed when cases began to rise, leading to a private meeting with Heneghan, Gupta and Sweden’s Anders Tegnell in September before he chose to ignore his scientific advisors’ calls for a circuit breaker lockdown. In the run up to the deadliest weeks of the pandemic the papers were calling for Johnson to “Save Christmas’.

However I don’t want to focus on our collective inability to make decisions during crises this time. This time I want to focus on the impact of the pandemic on our mental health.

By coincidence, today the 386 page Module 3 report from the Covid Inquiry on The impact of the Covid-19 pandemic on the healthcare systems of the United Kingdom was published. The longer this Inquiry goes on, the more it appears to resemble a truth and reconciliation commission rather than something likely to improve the handling of future pandemics. It gets past transgressions on the record, but in a way designed to move us on rather than improve our preparedness and organisation. I certainly saw nothing in the summaries that I didn’t already know. Module 3 has made 10 recommendations. The only one which mentions mental health at all is the last one on Psychological and emotional support for healthcare workers.

Looking through the module titles, it would seem that this is unlikely to be rectified until Module 10 – Impact on society – reports, currently scheduled for the first half of 2027. I find this relegation of our collective trauma to the lowest priority astonishing.

Two years ago, the Centre for Mental Health produced a review of the evidence so far on COVID-19 and the Nation’s Mental Health. They noted that:

Data on the prevalence of mental health difficulties is harder to assess. For children and young
people, surveys in England have provided a time series since 2020 that suggests very strongly that
mental ill health is indeed more prevalent now than it was before the start of the pandemic. A steady
rise in the decade prior to 2020 seems to have been followed by a sharp rise, and numbers have
stayed high ever since. We do not have the equivalent data for adults, meaning that a clear picture
has yet to emerge, but there is persuasive evidence that levels of mental ill health have been rising
over the last decade, and the pandemic has contributed to many of the risk factors people face.

Before concluding as follows:

Crucially, the pandemic exposed fault-lines in the nation’s mental health, and the stark inequalities
faced every day by people living with mental illness. The public’s mental health was deteriorating
in the years running up to the pandemic, and mental health services were struggling to deal with
the consequences of many years of underfunding and austerity measures across public services.
People with a mental illness were already dying 15-20 years sooner than the general population, and
facing widespread hardship. The pandemic exacerbated these inequalities, creating new risks to
people’s mental health and reducing access to support.

We now have the opportunity to learn from this experience and build a mentally healthier future.
We can act now to boost the public’s mental health in the aftermath of the pandemic, protecting
those who have experienced the worst effects and offering better support to groups that don’t yet
have access to the right support. And we can incorporate mental health into preparations for future
emergencies, so that responses are psychologically informed from day one.

They also made 10 recommendations, mostly for the NHS and Department for Health and Care, but also covering education, communications and considerations for the upcoming (at the time) review of the Mental Health Act. Less than half of these recommendations have been addressed at all.

Now we are two years on from that report, what has changed?

Well, Roy Lilley has drawn a rather dispiriting picture for us. He draws attention to Wes Streeting’s announcement in the Health Service Journal on 12 March, that the proportion of the NHS budget spent on mental healthcare would be cut for the third year in a row. Lilley lists how the demands on mental health services have mushroomed since before the pandemic:

Around two million people were in touch with mental health services in 2019, today it’s around three million;
Child and Adolescent Services: in 2019 around 500,000 referrals. Now around a million;
And only around 45% of referrals are accepted, meaning the true demand is even higher;
Talking therapies are up by 60%; and
Crisis team referrals and sectioning under the Mental Health Act are also up 60%.

And he summarises the problem like this:

The total economic cost of mental ill-health in England in 2022 was estimated ~£300bn a year when lost productivity, welfare and wider costs are factored in.

The total MH budget is about £16bn. Meaning, the NHS is spending roughly £1 trying to address a £18 national problem.

It feels like we are still waiting for the penny to drop.

Football’s coming home in the worst way

14. January 2026 · Write a comment · Categories: Birmingham, Health, Media & Politics

*The Sun attempts to get a new song going on the terraces. Still not going to be selling newspapers in Liverpool though*

Disclaimer: I support Liverpool FC, so it is entirely possible that the following may be a slightly skewed account of recent football history and its implications.

Last week Manchester United sacked their manager after 14 months. Since Alex Ferguson left in the summer of 2013, United have now had 10 different managers (it was announced this week that Michael Carrick was coming back for a second bash at caretaker manager).

This is despite the fact that it is very difficult to establish whether changing managers helps, with most studies citing how many different factors are at play. One masters dissertation concludes that, although it may produce a short term boost, it is generally not enough to save a club from relegation from the Premier League. So why do it?

Surprisingly this leads us into something called Ritual Scapegoating Theory, first cited at least 60 years ago as a possible explanation for managerial succession in baseball. So changing manager may or may not make much difference to performance, but it does make everyone feel better.

And it may be that the catharsis of sacking a Special One every season or so is making Manchester United supporters feel better than the two FA Cups, two League Cups and a Europa League win (that they have managed in the 13 years since Ferguson left) have. In that time Liverpool, with just three managers, have won two Premier League titles and a Champions League, UEFA Super Cup and Club World Cup as well as an FA Cup and two League Cups. Manchester City, with just two managers in that time, have won seven Premier League titles, a Champions League, UEFA Super Cup and Club World Cup as well as two FA Cups and six League Cups.

In the previous 27 years when Manchester United had just one manager, they won 13 League titles, two Champions Leagues, five FA Cups, four League Cups, and the UEFA Europa League, Super Cup and Cup Winners’ Cup, and the FIFA Club World Cup and the Intercontinental Cup. The lesson Manchester United have learned from this apparently is not that they need to minimise manager turnover.

Chelsea are even worse. They have had 13 different managers over the same period. They sacked the current England manager Thomas Tuchel after just 20 months despite him winning them the UEFA Champions League, Super Cup and Club World Cup. They sacked Enzo Maresca after just 18 months despite him winning them the UEFA Conference League and the Club World Cup. That appears to be catharsis on steroids.

Now this doesn’t matter very much when it is just about baseball or football. Despite what Bill Shankly said, life and death and our politics more generally are much more important than football. My fear is that the view that we need to sack someone whenever we don’t get the result we want immediately is leaching out of football into everything else.

Nigel Farage’s favourite phrase appears to be that “Heads must roll”. He has deployed it about the head of children’s services in Rotherham over three children being removed from their foster families in 2012, the whole of the NatWest board when he was refused a Coutts account in 2023, unspecified individuals from Essex Police managing the demonstrations outside an Epping hotel last year, and also last year again feeling that some head rolling was in order in response to the Government’s national inquiry into grooming gangs.

Meanwhile Kemi Badenoch said in 2024 of civil servants “There is about 5 per cent to 10 per cent of them who are very, very bad. You know, ‘should be in prison’ bad”. Last week she called for the Chief Constable of West Midlands Police to go over the decision to ban fans of Maccabi Tel Aviv from the Aston Villa ground for their Champions League match in November (which, hilariously, now appears to have been, at least partly, influenced by how badly Maccabi Tel Aviv supporters behaved at an entirely fictional game against West Ham United). Also in November, she called for the people involved in making the Panorama documentary about the Capitol Riots, to be sacked (another “heads should roll” headline). Also in November, she decided other BBC “heads must roll” over the decision to uphold complaints and reprimand a newsreader for altering her script from “pregnant people” to “pregnant women” on camera in a piece about groups most at risk during UK heatwaves.

It feels like the footballisation of public life. Farage and Badenoch are routinely reported as furious about something or other, in addition to the frequent demands for sackings, nearly always of public servants. They can clearly see there are votes in it, but the effects of this continuous vilification of public services and the people running them go way beyond that.

The immediate effect is often to make someone’s job untenable. So both the NatWest and Coutts CEOs left after the Farage complaint. The BBC’s Director General and BBC News Chief Executive both left soon after the Badenoch complaint. Now these are all comfortably off individuals who will no doubt be fine, but the impact on an organisation of the idea that any of its leaders could be hounded out at any moment, not through any regulatory process or indeed any process at all, but by someone in politics with a big mouth can be seen increasingly in our public institutions.

One example would be in the NHS. The HSJ recently published an article on the distribution of tenure of trust chief executives (it required four screenshots to show you just how long a tail can be!). Notice how it is not until half way up the 3rd screenshot (counting up from the bottom) that you find a CEO who has been in post for 50 months, and four of them are about to leave.

Source: https://www.hsj.co.uk/leadership/trust-ceos-time-in-post/7040645.article?storyCode=7040645

As Roy Lilley says:

Public reporting over the last eighteen months points to exits by:

NHS England CEO, plus
a cluster of senior national directors exiting.
At least 10 ICB chief executives stepping down or being replaced.
Trust CEO turnover approaching a quarter of posts;
implying 50 or more trust-level departures, including permanent and unplanned exits.

Taken together, a guesstimate is between 60 and 80 chief executives and equivalent senior leaders have left their roles across the NHS in the last eighteen months.

As he goes on to say:

High turnover at the top tells the rest of the system that leadership is temporary. Risk is unrewarded and survival matters more than stewardship.

Authority is put at question.

That encourages short-term-ism, compliance and caution. Precisely the opposite of what complex service reform needs.

For those fans of Manchester United’s way of running things who seem to be running things at the moment, that is a hell of a lot of catharsis. Evidence suggests that it is unlikely to achieve much else.

The catharsis never lasts, as at some point the music has to stop, and someone needs to actually be sitting in actual chairs, actually managing the thing. Just ask Chelsea and Manchester United.

Enshittification and Cory Doctorow

04. December 2025 · Write a comment · Categories: AI, Cartoons, Economics, Health, Legal, Media & Politics, Professions, Regulation, Science Fiction

So this is my 42nd blog post of the year and the 8th where I have referenced Cory Doctorow. Thought it was more to be honest, so influential has he been on my thought, particularly as I have delved deeper into what, how and why the AI Rush is proceeding and what it means for the people exiting universities over the next few years.

Yesterday Cory published a reminder of his book reviews this year. He is an amazing book reviewer. There are 24 on the list this year, and I want to read every one of them on the strength of his reviews alone.

I would like to repay the compliment by reviewing his latest book: Enshittification (the other publication this year – Picks and Shovels – is also well worth your time by the way). Can’t believe this wasn’t the word of the year rather than rage bait, as it explains considerably more about the times we are living in.

I have been a fan of Doctorow for a couple of years now. I had had Walkaway sat on my shelves for a few years before I read it and was immediately enthralled by his tale of a post scarcity future which had still somehow descended into an inter-generational power struggle hellscape. I moved on to the Little Brother books, now being reenacted by Trump with his ICE force in one major US city after another. Followed those up with The Lost Cause, where the teenagers try desperately to bridge the gap across the generations with MAGA people, with tragic results along the way but a grim determination at the end “the surest way to lose is to stop running”. From there I migrated to the Marty Hench thrillers, his non-fiction The Internet Con (which details the argument for interoperability, ie the ability of any platform to interact with another) and his short fiction (I loved Radicalised, not just for the grimly prophetic Radicalised novella in the collection, but also the gleeful insanity of Unauthorised Bread). I highly recommend them all.

I came to Enshittification after reading his Pluralistic blog most days for the last year and a half, so was initially disappointed to find very little new as I started working my way through it. However what the first two parts – The Natural History and The Pathology – are is a patient explanation of the concept of enshittification and how it operates assuming no previous engagement with the term, all in one place.

Enshittifcation, as defined by Cory Doctorow, proceeds as follows:

First, platforms are good to their users.
Then they abuse their users to make things better for their business customers.
Next, they abuse those business customers to claw back all the value for themselves.
Finally, they have become a giant pile of shit.

So far, so familiar. But then I got to Part Three, explaining The Epidemiology of enshittification, and the book took off for me. The erosion of antitrust (what we would call competition) law since Carter. “Antitrust’s Vietnam” (how Robert Bork described the 12 years IBM fought and outspent the US Department of Justice year after year defending their monopolisation case) until Reagan became President. How this led to an opening to develop the operating system for IBM when it entered the personal computer market. How this led to Microsoft, etc. Then how the death of competition also killed Big Tech regulation ( regulating a competitive market which acts against collusion is much easier than regulating one with a small number of big players which absolutely will collude with each other).

And then we get to my favourite chapter of the book “Reverse-Centaurs and Chickenisation”. Any regular reader of this blog will already be familiar with what a reverse centaur is, although Cory has developed a snappy definition in the process of writing this book:

A reverse-centaur is a machine that uses a human to accomplish more than the machine could manage on its own.

And if that isn’t chilling enough for you, the description of the practices of poultry packers and how they control the lives of the nominally self-employed chicken farmers of the US, and how these have now been exported to companies like Amazon and Arise and Uber, should certainly be. The prankster who collected up the bottled piss of the Amazon drivers who weren’t allowed a loo break and resold it on Amazon‘s own platform as “a bitter lemon drink” called Release Energy, which Amazon then recategorised as a beverage without asking for any documentation to prove it was fit to drink and then, when it was so successful it topped their sales chart, rang the prankster up to discuss using Amazon for shipping and fulfillment – this was a rare moment of hilarity in a generally sordid tale of utter exploitation. My favourite bit is when he gets on to the production of his own digital rights management (DRM) free audio versions of his own books.

The central point of the DRM issue is, as Cory puts it, “how perverse DMCA 1201 is”:

If I, as the author, narrator, and investor in an audiobook, allow Amazon to sell you that book and later want to provide you with a tool so you can take your book to a rival platform, I will be committing a felony punishable by a five-year prison sentence and a $500,000 fine.

To put this in perspective: If you were to simply locate this book on a pirate torrent site and download it without paying for it, your penalty under copyright law is substantially less punitive than the penalty I would face for helping you remove the audiobook I made from Amazon’s walled garden. What’s more, if you were to visit a truck stop and shoplift my audiobook on CD from a spinner rack, you would face a significantly lighter penalty for stealing a physical item than I would for providing you with the means to take a copyrighted work that I created and financed out of the Amazon ecosystem. Finally, if you were to hijack the truck that delivers that CD to the truck stop and steal an entire fifty-three-foot trailer full of audiobooks, you would likely face a shorter prison sentence than I would for helping you break the DRM on a title I own.

DMCA1201 is the big break on interoperability. It is the reason, if you have a HP printer, you have to pay $10,000 a gallon for ink or risk committing a criminal offence by “circumventing an access control” (which is the software HP have installed on their printers to stop you using anyone else’s printer cartridges). And the reason for the increasing insistence on computer chips in everything from toasters (see “Unauthorised Bread” for where this could lead) to wheelchairs – so that using them in ways the manufacturer and its shareholders disapprove of becomes illegal.

The one last bastion against enshittification by Big Tech was the tech workers themselves. Then the US tech sector laid off 260,000 workers in 2023 and a further 100,000 in the first half of 2024.

In case you are feeling a little depressed (and hopefully very angry too) at this stage, Part 4 is called The Cure. This details the four forces that can discipline Big Tech and how they can all be revived, namely:

Competition
Regulation
Interoperability
Tech worker power

As Cory concludes the book:

Martin Luther King Jr once said, “It may be true that the law cannot make a man love me, but it can stop him lynching me, and I think that’s pretty important, also.”

And it may be true that the law can’t force corporate sociopaths to conceive of you as a human being entitled to dignity and fair treatment, and not just an ambulatory wallet, a supply of gut bacteria for the immortal colony organism that is a limited liability corporation.

But it can make that exec fear you enough to treat you fairly and afford you dignity, even if he doesn’t think you deserve it.

And I think that’s pretty important.

I was reading Enshittification on the train journey back from Hereford after visiting the Hay Winter Weekend, where I had listened to, amongst others, the oh-I’m-totally-not-working-for-Meta-any-more-but-somehow-haven’t-got-a-single-critical-word-to-say-about-them former Deputy Prime Minister Nick Clegg. While I was on the train, a man across the aisle had taken the decision to conduct a conversation with first Google and then Apple on speaker phone. A particular highlight was him just shouting “no, no, no!” at Google‘s bot trying to give him options. He had already been to the Vodaphone shop that morning and was on his way to an appointment which he couldn’t get at the Apple Store on New Street in Birmingham. He spotted the title of my book and, when I told him what enshittification meant, and how it might make some sense out of the predicament he found himself in, took a photo of the cover.

My feeling is that enshittification goes beyond Big Tech. It is the defining industrial battle of our times. We shouldn’t primarily worry about whether it is coming from the private or the public sector, as enshittification can happen in both places: from hollowing out justice to “paying more for medicines… at the exact moment we can’t afford to pay enough doctors to prescribe them” in the public sector, where we already reside within the Government’s walled garden, to all of the outrages mentioned above and more in the private sector.

The PFI local health hubs set out in last week’s budget take us back to perhaps the ultimate enshittificatory contracts the Government ever entered into, certainly before the pandemic. The Government got locked into 40 year contracts, took all the risk, and all the profit was privatised. The turbo-charging of the original PFI came out of the Blair-Brown government’s mania for keeping capital spending off the balance sheet in defence of Gordon Brown’s “Golden Rule” which has now been replaced by Rachel Reeves’ equally enshittifying fiscal rules. All the profits (or, increasingly, rents, as Doctorow discusses in the chapter on Varoufakis’ concept of Technofeudalism) from turning the offer to shit always seem to end up in the private sector. The battle is against enshittification from both private and, by proxy, via public monopolies.

Enshittification is, ultimately, a positive and empowering book which I strongly recommend you buy, avoiding Amazon if you can. We can have a better internet than this. We can strike a better deal with Big Tech over how we run our lives. But the surest way to lose is to stop running.

And next time a dead-eyed Amazon driver turns up at your door, be nice, they are probably having a worse day than you are.

Again and again and again

27. November 2025 · Write a comment · Categories: Economics, Health, Media & Politics

On 20 November, the UK Covid-19 Inquiry published its second report and recommendations following its investigation into ‘Core decision-making and political governance’. The following day these were the headlines:

This contrasts with the Inquiry’s first report and recommendations following its investigation into the UK’s ‘Resilience and preparedness (Module 1)’ on Thursday 18 July 2024. Then the following day’s headlines looked like this:

Whereas the first report had recommended a radical simplification of the civil emergency preparedness and resilience systems, including:

A new approach to risk assessment;
A new UK-wide approach to the development of strategy, which learns lessons from the past;
Better systems of data collection and sharing in advance of future pandemics;
Holding a UK-wide pandemic response exercise at least every three years and publishing the outcome; and
The creation of a single, independent statutory body responsible for whole system preparedness and response.

The second report on the other hand merely reran the pandemic, pointing out where we went wrong on:

The emergence of Covid-19;
The first UK-wide lockdown;
Exiting the first lockdown;
The second wave; and
The vaccination rollout and Delta and Omicron variants.

And crucially who to blame for it. Its recommendations were far less specific and actionable in my view than those from the first report. And yet it got all the headlines, with glowering images of Baroness Hallett and pictures of Boris Johnson with head bowed.

The first report dealt with what we could do better next time and was virtually ignored (only The Daily Mirror and The Independent carried “They failed us all” headlines about the Covid Inquiry first report). The second dealt with who to blame and it dominated the headlines. I think this neatly encapsulates what is wrong with us as a country and why we never seem to be able to learn from our own past mistakes or the examples of other countries.

This is not about defending Boris Johnson or any of his ministers. It is about realising that they are much less important than our own ability to sort out our problems and study any evidence we can to help us do that.

The NHS suffers from the same problem, as Roy Lilley has described here, too many inquiries and most of their recommendations ignored. Again and again and again. We choose to focus on the minor and irrelevant at the expenses of the major and important. Again and again and again. As Lilley says:

Until we make it OK for people to say… I made a mistake… we will forever be trapped in a Kafka world of inquiries coming to the same conclusions…

…If inquiries worked, we’d have the safest healthcare system in the world.

Instead, we have a system addicted to investigating itself and forgetting the answers.

It is part of a pattern repeated yesterday, focusing on the micro when our problems are macro. Rachel Reeves increased taxes by £26 billion in yesterday’s budget, which was much less than the £40 billion in her first budget, and yet still led to the BBC reporting “Reeves chooses to tax big and spend big” and the FT leading with “Rachel Reeves’ Budget raises UK tax take to all-time high“, and with this graph:

This is hilariously at odds with the message of what it was reporting last week:

The latter was obviously an attempt to head off a wealth tax, which appears to have been largely successful. Our averageness when it comes to tax, though, is supported by this graph using OECD data from Tax Policy Associates:

Our position in the middle of the pack will be little affected by what happened yesterday. And that and all the chatter about the OBR leaking it all an hour in advance rather drowned out the fact that there was relatively little additional spending (around £12 billion overall, a quarter of which was on the welcome removal of the two-child limit). The main point was to increase our “fiscal headroom” to £22 billion, ie the amount the Government can spend before they breach their own fiscal rules.

It looks like we are going to do what we are going to do, with fiscal headroom management masquerading as economic policy, and otherwise just sit around waiting for the next disaster. Which we will then have a big inquiry about to tell us that we weren’t remotely prepared for it. Which we will then ignore…and so it continues. Again and again and again.

Boxes

24. October 2025 · Write a comment · Categories: Actuarial, Birmingham, COVID-19, Health, Legal, Media & Politics, Regulation, Risk

*The warehouse at the end of* *Raiders of the Lost Ark*

In the year when I was born, Malvina Reynolds recorded a song called Little Boxes when she was a year younger than I am now. If you haven’t heard it before, you can listen to it here. You might want to listen to it while you read the rest of this.

I remember the first time I felt panic during the pandemic. It was a couple of months in, we had been working very hard: to put our teaching processes online, consulting widely about appropriate remote assessments and getting agreement from the Institute and Faculty of Actuaries (IFoA) for our suggested approach at Leicester, checking in with our students, some of who had become very isolated as a result of lockdowns, and a million other things. I was just sitting at my kitchen table and suddenly I felt tears welling up and I was unable to speak without my voice breaking down. It happened at intervals after that, usually during a quiet moment when I, consciously or unconsciously, had a moment to reflect on the enormity of what was going on. I could never point to anything specific that triggered it, but I do know that it has been a permanent change about me, and that my emotions have been very much closer to the surface ever since. I felt something similar again this morning.

What is going on? Well I haven’t been able to answer that satisfactorily until now, but recently I read an article by David Runciman in the LRB from nine years ago when Donald Trump got elected POTUS the first time. I am not sure that everything in the article has withstood the test of time, but in it Runciman makes the case for Trump being the result of the people wanting “Trump to shake up a system that they also expected to shield them from the recklessness of a man like Trump.”. And this part looks prophetic:

[Trump is]…the bluntest of instruments, indiscriminately shaking the foundations with nothing to offer by way of support. Under these conditions, the likeliest response is for the grown-ups in the room to hunker down, waiting for the storm to pass. While they do, politics atrophies and necessary change is put off by the overriding imperative of avoiding systemic collapse. The understandable desire to keep the tanks off the streets and the cashpoints open gets in the way of tackling the long-term threats we face. Fake disruption followed by institutional paralysis, and all the while the real dangers continue to mount. Ultimately, that is how democracy ends.

And it suddenly hit me that this was something I had indeed taken for granted my whole life until the pandemic came along. The only thing that had ever looked like toppling society itself was the prospect of a nuclear war. Otherwise it seemed that our political system was hard to change and impossible to kill.

And then the pandemic came along and we saw government national and local digging mass graves and then filling them in again and setting aside vast arenas for people to die in before quietly closing them again. Rationing of food and other essentials was left to the supermarkets to administer, as were the massive snaking socially-distanced queues around their car parks. Seemingly arbitrary sets of rules suddenly started appearing at intervals about how and when we were allowed to leave the house and what we were allowed to do when out, and also how many people we could have in our houses and where they were allowed to come from. Most businesses were shut and their employees put on the government’s payroll. We learned which of us were key workers and spent a lot of time worrying about how we could protect the NHS, who we clapped every Thursday. It was hard to maintain the illusion that society still provided solid ground under our feet, particularly if we didn’t have jobs which could be moved online. Whoever you were you had to look down at some point, and I think now that I was having my Wile E. Coyote moment.

The trouble is, once you have looked down, it is hard to put that back in a box. At least I thought so, although there seems to have been a lot of putting things in boxes going on over the last few years. The UK Covid-19 Inquiry has made itself available online via a YouTube channel, but you might have thought that a Today at the Inquiry slot on terrestrial TV would have been more appropriate, not just covering it when famous people are attending. What we do know is that Patrick Vallance, Chief Scientific Advisor throughout the pandemic, has said that another pandemic is “absolutely inevitable” and that “we are not ready yet” for such an eventuality. Instead we have been busily shutting that particular box.

The biggest box of course is climate change. We have created a really big box for that called the IPCC. As the climate conferences migrate to ever more unapologetic petro-states, protestors are criminalised and imprisoned and emissions continue to rise, the box for this is doing a lot of work.

And then there are all the NHS boxes. As Roy Lilley notes:

If inquiries worked, we’d have the safest healthcare system in the world. Instead, we have a system addicted to investigating itself and forgetting the answers.

But perhaps the days of the box are numbered. The box Keir Starmer constructed to contain the anger about grooming gangs which the previous 7 year long box had been unable to completely envelop also now appears to be on the edge of collapse. And the Prime Minister himself was the one expressing outrage when a perfectly normal British box, versions of which had been giving authority to policing decisions since at least the Local Government (Review of Decisions) Act 2015 (although the original push to develop such systems stemmed from the Hillsborough and Heysel disasters in 1989 and 1985 respectively) suddenly didn’t make the decision he was obviously expecting. That box now appears to be heading for recycling if Reform UK come to power, which is, of course, rather difficult to do in Birmingham at the moment.

But what is the alternative to the boxes? At the moment it does not look like it involves confronting our problems any more directly. As Runciman reflected on the second Trump inauguration:

Poor Obama had to sit there on Monday and witness the mistaking of absolutism for principle and spectacle for politics. I don’t think Trump mistakes them – he doesn’t care enough to mind what passes for what. But the people in the audience who got up and applauded throughout his speech – as Biden and Harris and the Clintons and the Bushes remained glumly in their seats – have mistaken them. They think they will reap the rewards of what follows. But they will also pay the price.

David Allen Green’s recent post on BlueSky appears to summarise our position relative to that of the United States very well:

War Games

27. August 2025 · Write a comment · Categories: Climate Change, COVID-19, EIOPA, Health, Media & Politics, Risk

I watched The War Game this week, as it had suddenly turned up on iPlayer and I had not seen it before. It was the infamous film from 1966 on the horrors of a nuclear war in the UK that was not televised until 1985. It has been much lauded as both necessarily horrifying and important over the years, but what struck me watching it was how much it looked back to the period of rationing (which had only ended in the UK 12 years earlier) and general war-time organisation from the Second World War. It would be a very different film if made now, probably drawing on our recent experiences of the pandemic (when of course we did dig huge pits for mass burials of the dead and set up vast Nightingale hospitals as potential field hospitals, before the vaccines emerged earlier than expected).

But what about the threat of nuclear war which still preoccupied us so much in the 1980s but which seems to have become much less of a focus more recently? With the New START treaty, which limits the number of strategic nuclear warheads that the United States and Russia can deploy, and the deployment of land and submarine-based missiles and bombers to deliver them, due to expire on 5 February 5, negotiations between Russia and the United States finally appear to be in progress. However China has today confirmed that it does not want to participate in these.

In Mark Lynas’ recent book Six Minutes to Winter, he points to the Barret, Baum and Hostetler paper from 2013 which estimated the probability of inadvertent nuclear war in any year to be around 1%. This is twice the probability of insolvency we think acceptable for our insurance companies under Solvency II and would mean, if accurate, that the probability of avoiding nuclear war by 2100 was 0.99 raised to the power of 75 (the number of years until 2100), or 47%, ie less than a fifty-fifty chance.

That doesn’t seem like good enough odds to me. As Lynas says:

We cannot continue to run the daily risk of nuclear war, because sooner or later one will happen. We expend enormous quantities of effort on climate change, a threat that can endanger human civilisation in decades, but ignore one that can already destroy the world in minutes. Either by accident or by intent, the day of Armageddon will surely dawn. It’s either us or them: our civilisation or the nukes. We cannot both survive indefinitely.

The Treaty on the Prohibition of Nuclear Weapons (TPNW) was adopted at the UN in 2017 and came into force in 2021. In Article 1 of the Treaty, each state party to it undertakes never to develop, test, produce, possess, transfer, use or threaten to use nuclear weapons under any circumstances. 94 countries have signed the TPNW to date, with 73 full parties to it.

The House of Commons library entry on TPNW poses a challenge:

It is the first multilateral, legally binding, instrument for nuclear disarmament to have been negotiated in 20 years. However, the nuclear weapon states have not signed and ratified the new treaty, and as such, are not legally bound by its provisions. The lack of engagement by the nuclear weapon states subsequently raises the question of what this treaty can realistically achieve.

It then goes on to state the position of the UK Government:

The British Government did not participate in the UN talks and will not sign and ratify the new treaty. It believes that the best way to achieve the goal of global nuclear disarmament is through gradual multilateral disarmament, negotiated using a step-by-step approach and within existing international frameworks, specifically the Nuclear Non-Proliferation Treaty. The Government has also made clear that it will not accept any argument that this treaty constitutes a development of customary international law binding on the UK or other non-parties.

There are 9 nuclear states in the world: China, France, India, North Korea, Pakistan, Russia, Israel, the UK and the United States. Israel recently conducted a 12 day war with Iran to stop it becoming the 10th. Many argue that Russia would never have invaded Ukraine had it kept its nuclear weapons (although it seems unlikely that they would have ever been able to use them as a deterrent for a number of reasons). So the claims of these nuclear states that they are essential to their security are real.

But is the risk that continued maintenance of a nuclear arsenal poses worth it for this additional security? For the security only operates at the deterrence level. Once the first bomb lands we are no more secure than anyone else.

Which makes it all the more concerning when Donald Trump starts saying things like this (in response to a veiled threat by the Russian Foreign Minister about their nuclear arsenal):

“I have ordered two Nuclear Submarines to be positioned in the appropriate regions, just in case these foolish and inflammatory statements are more than just that. Words are very important, and can often lead to unintended consequences, I hope this will not be one of those instances.”

But with a probability of avoiding “unintended consequences” less than fifty-fifty by 2100? That really doesn’t feel like good enough odds to me.

The End of the Professions?

24. July 2025 · Write a comment · Categories: Education, Health, Professions

On Wednesday last week the report from the Leng Review into the safety and effectiveness of physician associates (PAs) and anaesthesia associates (AAs) was published. Although it concluded that:

Research on the safety and effectiveness of PAs and AAs was limited, generally of low quality and either inconclusive or demonstrated a mixed picture.

This apparently did not prevent Professor Leng from feeling able to go right ahead and make 18 recommendations. Neither did it prevent NHS England announcing the same day that it would be expecting all PAs and AAs in the NHS to immediately:

Take on the new names for their roles of physician assistant and physician assistant in anaesthesia respectively;
No longer triage patients or see “undifferentiated” patients.

The rationale for the first of these was the fear that PAs and AAs were being confused with doctors. That this has been addressed by immediately making PAs and AAs much more confusable with each other is just one of the many hilarious things about this report. They also appear to have forgotten to let the General Medical Council (GMC) know, as their website still looks like this:

Then there is the meticulously recorded bile directed at PAs and AAs and their capabilities throughout what is described all over the website as an “independent” report. There were several charts of the opinions of PAs and AAs about their ability to carry out their duties compared to those of doctors. Here is one of them:

The fact I feel able to describe this as mostly bile is the template job descriptions at Appendix 5 of the Leng report. The one for PAs in secondary care includes the following principal duties and responsibilities:

carry out assessments of patient health by interviewing patients and performing
physical examination including obtaining and updating medical histories (looks like B and E);
order and perform agreed diagnostic tests including laboratory studies and
interpret test results (looks like J);
perform basic therapeutic procedures by administering all injections and
immunisations, suturing and managing wounds and infections (looks like M);
help to develop other members of the multidisciplinary team by providing
information and educational opportunities as appropriate (looks like L).

So even the Leng Review appears to have concluded that many of the doctors’ opinions polled here are ridiculous.

Of course I am lumping all doctors together here because the Leng Review does for the most part. There is one sentence where it is admitted that senior doctors, including GPs, tended to be more positive than resident doctors, but this is not really quantified.

The Leng Review will not be the last of its kind. It has taken up the concerns of a threatened profession and worked with them to connive in the othering of another sub-profession (set up, as admitted in the Leng Review report itself, by the Department of Health under, in the case of PAs, a competency framework in conjunction with the Royal Colleges of Physicians and General Practitioners) rather than tackle the actual threats the profession faces. As Roy Lilley wrote:

The BMA can stand in the way, or stand at the front, shaping how technology and new roles like PAs can improve care, close gaps, and make healthcare safer and smarter.

History teaches us that you can’t halt progress by breaking the machinery or driving new careers into a cul-de-sac.

So why are the doctors, particularly resident doctors (formerly known as junior doctors), so offended by the use of PAs and AAs in the NHS? Is it really about safety and effectiveness? Or is it that the British Medical Association (BMA) has finally lost the trust of its more junior members after years of inadequate representation and now is throwing its weight around with the campaign against PAs and AAs and now the resident doctor strike in a desperate attempt to convince them that the reason they are paid less than PAs and can’t get a job after graduation is not the fault of the BMA, but that of the Government, PAs and AAs?

As the Leng Review admits:

Since the early 2000s, and in response to increasing workforce pressures, there has been a growing recognition of the PA role across the globe as a flexible way to address doctor shortages and improve access to healthcare. Today, PAs or their equivalents are employed in over 50 countries, although the role is often adapted locally to meet specific healthcare system needs.

Is it perhaps this very flexibility which is the threat here, when NHS England are already reviewing postgraduate medical training due in large part to resident doctors’ “concerns and frustrations with their training experience”?

The doctors are not the only threatened profession. According to The Observer this week:

The big four accounting firms – Deloitte, EY, PricewaterhouseCoopers and KPMG – posted 44% fewer jobs for graduates this year compared with 2023.

These are the big beasts for finance and actuarial graduates and tend to set the market for everyone else, so these are big changes. Ian Pay of the ICAEW’s quote from the article is even more alarming:

Historically, accountancy firms have typically had a pyramid structure – wide base, heavy graduate recruitment. Firms are now starting to talk about a ‘diamond model’ with a wide middle tier of management because, ultimately, AI is not sophisticated enough yet to make those judgment calls.

A diamond model? That surely only makes sense for those at partner level currently interested in the purchase of diamonds? Sure enough, the article continues:

Cuts to graduate cohorts since 2023 have ranged from 6% at PwC to 29% at KPMG. According to James O’Dowd, founder of talent adviser Patrick Morgan, these are accompanied by senior employees being paid more and more job offshoring. Up to a third of some firms’ administrative tasks are carried out in countries with lower labour costs such as India and the Philippines.

So what happens when AI is sophisticated enough to make those judgement calls, calls which are often sophisticated forms of pattern spotting and which, quite frankly, AI systems are already much better than humans at in many cases already? Will the diamond model collapse still further into a “T-model” perhaps, with the very senior survivors being paid even more? Don’t expect labour costs in India and the Philippines to remain lower for very long as demand increases from their own economies as well as ours.

And the most important question? What then? Who will the senior employees who seem to be doing so well out of this at the moment be in 20-30 years’ time? Where will they have come from? What experience will they have and how will they have gained it when all the opportunities to do so have been given to the system in the corner which never gets tired, only makes mistakes when it is poorly programmed or fed poor data, and never takes study leave at the financial year end?

So Medicine, Finance and now Law. Richard Susskind has been writing about the impact of AI on Law, and with his son Daniel, on other professions too for some time now. The review of his latest book, How To Think About AI, has the reviewer wondering “Where has Reassuring Richard gone?”. In his latest book, Susskind says:

“Pay heed, professionals – the competition that kills you won’t look like you.”

So probably a threatened profession there too then.

In the 1830s and 1840s, according to Christopher Clark’s excellent Revolutionary Spring, the new methods of production led to “the emergence of a non-specialised, mobile labour force whose ‘structural vulnerability’ made it more likely that they would experience the most wretched poverty at certain points in their lives.” The industrialised economies changed beyond recognition and the guilds representing workers, with skills the need for which were being automated away, retreated to become largely ceremonial.

Then the divisions were those of class. This time they appear to be those of generation. Early career professionals are seeing their pay, conditions and status under threat as their more senior colleagues protect their own positions at their expense.

It remains to be seen what will happen to our threatened professions, but it seems unlikely that they will survive in their current forms any more than the jobs of their members will.

Humpty Dumpty and the Terrorism Act

07. July 2025 · Write a comment · Categories: Birmingham, Cartoons, Health, Legal, Media & Politics

*Illustration of Humpty Dumpty from Through the Looking Glass, by John Tenniel, 1871.*

“When I use a word,’ Humpty Dumpty said in rather a scornful tone, ‘it means just what I choose it to mean — neither more nor less.’

’The question is,’ said Alice, ‘whether you can make words mean so many different things.’

’The question is,’ said Humpty Dumpty, ‘which is to be master — that’s all.”

This is the country we are now living in. Because 4 members of a group sprayed red paint on some aircraft and caused some damaged using crowbars at an Oxfordshire base, as part of a series of protests designed to end international support for Israel’s war in Gaza for which they have all been arrested and charged, the whole organisation has been “proscribed” following a vote of 385 votes to 26 in the House of Commons and the order subsequently signed by the Home Secretary, Yvette Cooper, putting it on a par with organisations like ISIS (a full list of the 81 organisations proscribed under the Terrorism Act 2000 and the 14 Northern Ireland organisations proscribed under previous legislation can be found here).

Proscription makes it a criminal offence to:

belong, or profess to belong, to a proscribed organisation in the UK or overseas (section 11 of the act)
invite support for a proscribed organisation (the support invited need not be material support, such as the provision of money or other property, and can also include moral support or approval) (section 12(1))
express an opinion or belief that is supportive of a proscribed organisation, reckless as to whether a person to whom the expression is directed will be encouraged to support a proscribed organisation (section 12(1A)) – this one was added by the Counter Terrorism and Border Security Act 2019.
arrange, manage or assist in arranging or managing a meeting in the knowledge that the meeting is to support or further the activities of a proscribed organisation, or is to be addressed by a person who belongs or professes to belong to a proscribed organisation (section 12(2)); or to address a meeting if the purpose of the address is to encourage support for, or further the activities of, a proscribed organisation (section 12(3))
wear clothing or carry or display articles in public in such a way or in such circumstances as to arouse reasonable suspicion that the individual is a member or supporter of a proscribed organisation (section 13)
publish an image of an item of clothing or other article, such as a flag or logo, in the same circumstances (section 13(1A)) this one was also added by the Counter Terrorism and Border Security Act 2019.

References are to sections of the Terrorism Act 2000.

In order to be proscribed, the Terrorism Act states that an organisation must have:

committed or participated in acts of terrorism;
prepared for terrorism;
promoted or encouraged terrorism (including the unlawful glorification of terrorism); or
be otherwise concerned in terrorism.

And terrorism is defined as:

the use or threat of action which: involves serious violence against a person; involves serious damage to property; endangers a person’s life (other than that of the person committing the act); creates a serious risk to the health or safety of the public or section of the public or is designed seriously to interfere with or seriously to disrupt an electronic system.

The use or threat of such action must be designed to influence the government or an international governmental organisation or to intimidate the public or a section of the public, and must be undertaken for the purpose of advancing a political, religious, racial or ideological cause.

As a consequence, 29 people were arrested under terrorism legislation for protesting about the proscription, including an 83 year old retired priest, arrested after appearing to be in possession of a placard. I assume it was the one shown here.

The organisation’s website now displays the following message:

Co-founder of Palestine Action Huda Ammori is seeking to bring a legal challenge against the Home Office with a hearing for permission to bring a judicial review set to take place during the week of 21 July. Meanwhile a new group has suddenly appeared, armed with a fresh supply of red paint and targetting Time Logistics (which they say supplied one of Israel’s biggest weapons companies) lorries near Birmingham.

And the name of the new group? Yvette Cooper.

Financial consequences

03. July 2025 · Write a comment · Categories: Economics, Health, Media & Politics

According to Pat McFadden, a Government minister, there will be “financial consequences” to the decision to modify the planned cuts to disability and health-related benefits in order to win the vote on the welfare bill. There certainly will be for people receiving these benefits.

The changes to the bill in order to get it voted through will still:

reduce the health element of the Universal Credit for new claims from £97 to £50 per week from April 2026 and restrict payment to claimants over the age of 22, although now the benefit will continue to increase at least in line with inflation;
possibly re-introduce some of the restrictions to eligibility for personal independence payments following a review.

But that does not appear to be what McFadden was talking about, as he went on to list a number of taxes the Government would not raise. Instead the financial consequences comment sounded more like the empty threat of the playground bully when his victim has unexpectedly given him a bloody nose and he is trying not to lose face. Because nearly all of the newspaper coverage of this event appears to have been focused on this reputational aspect rather than on the fiscal significance of the changes:

In my last post, I referred to Harvey Whitehouse’s excellent Inheritance – the Evolutionary Origins of the Modern World, which included this definition of gossip:

When we lived in small communities, in which everybody knew everybody else, news consisted mainly of socially strategic information about who was hoarding wealth, who was telling lies, who was sleeping with whom, who was stealing, who was free-riding, and so on. In most of these newsworthy stories, there would be transgressors and victims, and news purveyors and consumers would be very sensitive to the reputational consequences of this information. The common term for this is gossip.

So by focusing on the reputational consequences of a welfare bill in the House of Commons, these newspapers are preferring to present a story which affects the livelihoods of up to a million people as if it were gossip. This approach is justified by the media as something the public are interested in and therefore something we will buy. Our bias towards stories about reputational consequences, even of people we do not know or are ever likely to meet, is therefore used against us and the world gets a little less understandable with every gossipy take of a more complex story. This has other implications (or perhaps what McFadden would call “consequences”): the rest of the day’s news seemed to revolve around whether someone had been mean to the Chancellor of the Exchequer and made her cry.

And the actual financial consequences? Well, the BBC made much about the impact of the Chancellor’s tears on the bond and currency markets. Morningstar went further and claimed that investors had saved the Chancellor’s job by forcing the Prime Minister to support her very publicly after failing to do so initially. The unspoken assumption is that the markets control the economy and all we can do is have gossipy conversations in our impotence about whether Rachel, Ed, Wes, Liz or Angela are up or down this week.

This is self-fulfilling: we can be as powerless as we decide to be. Or we can realise that the way we run our country and society is up to us. The £5 billion all of this is supposedly all about could be raised in any number of ways: slowing down the quantitative tightening programme the Bank of England is set on, a policy of selling bonds before maturity not adopted by the European Central Bank or the Federal Reserve in the United States, or any of a number of suggestions made by Richard Murphy which would have been focused on the top 10% of earners. Instead we went after the disabled first. Noone forced us to. We did it to ourselves.

Perhaps we should all be a little tearful about that.

The Redistribution of Space

10. April 2025 · Write a comment · Categories: Birmingham, Climate Change, Health, Media & Politics

My 60th birthday celebrations, a couple of years ago now, centred around train journeys to the South of France and then onto Madrid. The highlight was (pictured above) spending a large part of my birthday, in mid October, on a huge deserted beach at Narbonne and being able to comfortably swim in the sea. So much space.

And the trains also seemed so much more spacious. I travel a lot on trains in the UK, with sometimes comedically little space. And I am not just talking about space in terms of leg room in European trains, but also whenever you want to walk over to the restaurant carriage on the upper floor of a double decker train to improve the views, with a bar and an array of kidney shaped tables dotted around the carriage to eat hot meals at, before ambling back to your seat. Mental space is much greater too, with fewer announcements and partitions between passengers to reduce the amount of conversation bouncing around the carriage. I had several 5-6 hour journeys over the two weeks I was away, and they were without exception very relaxing experiences.

So enough travelogue. What point am I making? It is the importance of space.

I think of other things where my view of it has been affected by the space attached to it. Take swimming, for example. I spent three of my formative years (aged 3 to 6) in Singapore where my father was stationed with the RAF. We swam outdoors at the Singapore Swimming Club every afternoon and lived in flats right next to a beach. Swimming was all about space – on my back staring up at the limitless sky, or mask and snorkels on and face down to explore the depths of the pools.

Back in the UK, it has never been anything like the same experience. I have swum in pools in village schools in Yorkshire, council pools in Cheltenham and Witney, the pools built for the Youth Games in Sheffield, a private school’s tiny pool in Oxford where I did my bronze survival badge. Endless school outings with compulsory swim caps and cold water. I have swum in lakes and spent probably more time in the Cherwell than was strictly healthy, sometimes deliberately, sometimes because the canoes we were given at school were designed to be manoeuvrable rather than stable. I have swum in decaying metal structures in spa towns and pools fed by spring water with no heating in the Peak District. I only discovered body boarding relatively late and the joys of doing it for much longer in colder seas with a wetsuit even later (last year). I also spent a fascinating morning with the Wild Woman of the Wye, Angela Jones, learning how to swim safely in the river in our current polluted times. And it certainly feels like the decline in swimming quality in recent years extends indoors as well as outdoors. The Wyndley or Beeches Leisure Centres near my part of Sutton Coldfield just don’t hold much appeal for me. Sure there are bodies of water there, but nothing to lift your spirit while using them and the constraints, in terms of the narrow time slots and even narrower lanes you are confined to, are the very opposite of my earliest experiences of water. I am lucky enough to be able to afford the local David Lloyd Centre, with much less pressure on their pools, in particular their excellent outdoor pool in Birmingham, which is miraculously underused. On a day with bright sun, with the birds singing and a light breeze rustling the trees just enough to drown out the industrial hum from next door and push back the smell of solvents, I can sometime almost imagine I am back in the Singapore Swimming Club.

But generally when you attempt to venture outside you find the constraints are even greater than those at Wyndley swimming pool. According to the Right to Roam campaign group we only have access to 3% of rivers in England. Meanwhile the Outdoor Swimming Society are campaigning for swimming access to reservoirs.

On land we have slightly more access, but half of the land area of England is owned by around 1% of the population. As Guy Shrubsole points out:

The aristocracy and landed gentry still own around 30% of England, whilst the country’s homeowners own just 5% of the land. The public sector owns around 8% of England; the country’s 24 non-Royal Dukes own a million acres of Britain.

I can only redistribute some space in my direction, on a train, in a pool of water, by paying more than most can afford for those experiences, and allowing me to behave like a non-Royal Duke for a short time.

This has huge implications for carbon sequestration of course, with, for example, 60% of deep peat owned by just 124 landowners. These landowners are not looking after it very well either, with upland peat being degraded as a result of moorland burning for grouse moors, and lowland peat in the Fens and elsewhere being damaged through drainage for intensive agriculture. As a result, England’s peat soils are now a net source of carbon emissions rather than a sink, leaking around 11 million tonnes of CO₂ annually. The Government has committed to protecting 30% of land in the UK for nature by 2030, but is itself hugely constrained by the concentrated ownership of land.

So our land is like our swimming pools: tightly constrained by the narrow time slots and narrower lanes most of us are allowed access to. We are being stifled by the property rights of a tiny minority.

We Know Zero