Personal Health Budgets and the placebo effect

An idle thought following on from my last post about the evidence base and Personal Health Budgets: what if there’s a placebo effect associated with Personal Health Budgets?

As far as I understand it (as someone who is neither medically trained nor well-versed in the associated literature) there is good evidence that the placebo effect exists: when a patient takes medication or does something they perceive will help their condition to improve, it does (in either their perception or actuality), even if the medication or thing done has no proven effects.

Thus, irrespective of the evidence base of Personal Health Budgets, if people believe having a Personal Health Budget will make them better or contribute to making them better, will the mechanism of a PHB contribute to making them better?

(Note: just to be clear, I find the current evidence base regarding Personal Health Budgets, captured primarily in the PHB Evaluation, persuasive of the benefits of PHBs.)

How many countries are there? On evidence and PHBs

How many countries are there?

This seems like a straightforward question to answer, doesn’t it? Most primary school children could give you an answer, and even if they couldn’t they could quickly look it up in an Atlas.

But perhaps it’s not as simple a question to answer as we think. Scotland and Wales are countries, aren’t they(?), and yet they don’t appear on the list of countries recognised by the United Nations: the UN reckons there are 193 countries, including “the United Kingdom”. My Times World Atlas from 1986 says there were 173 countries. And football’s governing body, FIFA, currently has a list of 209 countries with football rankings.

So, in order to know how many countries there are we need to ask ourselves at least two prior questions: (1) What do we mean by a “country”?; and (2) Who are we asking?

Maybe the question is a bit complicated, so let’s ask ourselves an easier question by going up a level: how many continents on the world are there?

Erm, well. National Geographic reports: “By convention there are seven continents… [but] some geographers list only six [and] in some parts of the world students learn there are just five continents.” Which means the answer again depends on asking other questions, including: (1) What do we mean by a “continent”?; and (2) Who are we asking?

This “facts” business is tricky, isn’t it?

I share this by way of thinking about what we mean by “evidence” in the context of “evidence-based policy” and the recent example of Personal Health Budgets.

A significant announcement by Simon Stevens, the Chief Executive of NHS England, about Personal Health Budgets gave rise to some teeth-gnashing earlier this month.

The gnashing focused on the evidence base that underpins the effectiveness of Personal Health Budgets. Some folks, especially the well-known Ben Goldacre of Bad Science fame, are not convinced by the current status of the PHBs evidence. They think there should be at least a Randomised Control Trial (RCT) to test whether Personal Health Budgets work. Others, including advocates of personalisation in public services more generally, noted both the results of the existing evaluation of the Personal Health Budgets pilot and the value of all types of evidence, especially including the views of patients/users themselves.

Both groups therefore lay claim to “evidence-based policy”, which leads me to two reflections:

  1. It’s hardly an original thought (indeed, there are entire disciplines dedicated to such questions) but we must remember there is value associated with all different types of evidence and research methods. The value derived, and of the associated evidence arrived at, depends on what types of answers you’re hoping to uncover, how questions are framed and what pre-questions and/or assumptions underpin the framing of those questions. Different people have different thresholds for evidence and research methods, quite aside from the fact that one type of evidence or research method that’s a gold standard in one discipline could be next to useless in another.

For me, this is the equivalent of the first pre-question we came to in considering countries and continents: What do we mean by “evidence”?

  1. Let’s not even get into the “policy” bit of “evidence-based policy”. For example, when has policy ever been based on evidence anyway? Does policy making happen in a rational, evidence-led vacuum that is protected from the whims of politicians and public opinion which, heaven forfend, may not be evidence based? Notwithstanding questions of what we mean by evidence, it’s safe to say that not all policy is based on what evidence there is. This is therefore the equivalent of the second pre-question we came to in considering countries and continents: Who are we asking what we mean by “evidence”?

The up-shot of this in the context of the evidence base for Personal Health Budgets is that Ben Goldacre and advocates of personalisation are both right, and they’re both wrong. There cannot be a definitive answer to the question of whether Personal Health Budgets are effective until some other, perhaps unanswerable questions, are considered.

First World War historiography

The First World War is fascinating enough, but the historiography of the First World War – the history of its history – is also fascinating.

Here are two recent historiographical accounts of the First World War I found particularly interesting.

Simon Heffer, writing in the New Statesman:

The historiography of the war began when the war did.

William Philpott, writing in the TLS, on three recent histories of the First World War:

Describing it [WWI] is straightforward, but explaining it is difficult, understanding it, even more so. In the centenary free-for-all there will be rehashing alongside reinterpretation, and expertise or originality may not count for much.

.@neilmcrowther on assisted dying / voluntary euthanasia

At this point in time – and by this I mean in terms of how society currently thinks of and treats disabled people – I have a very firm, personal objection to assisted dying / voluntary euthanasia.

Such an objection extends to thinking it is entirely the right approach to build alliances with other organisations, including faith-based ones, with whom I would ordinarily have no natural affiliation but who also oppose assisted dying / voluntary euthanasia.

The entry of some religious voices into the assisted dying / voluntary euthanasia debate, prompted by current attempts to move assisted dying onto the statute book, has led to much debate.

Generally speaking, I find coverage of policy and politics in the UK dispiriting, mainly because of how ill-informed and binary it is. This is true for pretty much all topics, but especially so when it comes to assisted dying / voluntary euthanasia.

Very rarely are points of view expressed at length from people who actually know their apples with regard to assisted dying / voluntary euthanasia and its policy, legal and moral context/implications given any space.

To this end, I have found Neil’s 3 posts (so far) on this topic truly terrific. They are a welcome, balanced, informed and thoughtful antidote to much else we’re currently subjected to on assisted dying / voluntary euthanasia.

His posts also express almost exactly my own views on the issue, and it is with this disclaimer I commend Neil’s posts to you:

  1. Why there should be no right to assisted dying without the right to assisted living
  2. Killing people with kindness: Why the passing of the Assisted Dying Bill will make disabled people unsafe in our society
  3. Signal failure: Law as social signals, deliberate or otherwise



Focal point for change: necessary, but nowhere near sufficient

Do we need a focal point – such as a figurehead positions, dedicated groups/taskforces or specific pieces of legislation – for change to happen on specific (equality-based) issues in the public sector?

I ask this for 5 reasons:

  1. The Winterbourne View Joint Improvement Programme has lurched from one disappointment to another without having made any obvious difference to the lives of the people it was meant to improve
  2. The Minister for Disabled People is a position that has existed since 1974, but (a) generally remains a stepping stone to “higher” office, (b) has very regular changes of people in it, (c) holds many other departmental responsibilities that have nothing to do with disability (e.g. child support or health and safety), (d) has very little influence across government, especially in Cabinet (it isn’t a Cabinet position)*.
  3. The Office for Disability Issues, established in 2001, has many similar attributes to those of the Minister it serves, the Minister for Disabled People. (See also the Government Equalities Office)
  4. The Autism Act 2009 put legal duties on local councils and the NHS regarding the services and support available for people with autism, but a 2013 review by the National Autistic Society found implementation of the Act’s goals to be very varied
  5. The (UK) Equal Pay Act, which prohibited any less favourable treatment between men and women in terms of pay and conditions of employment, was passed in 1970. In 2012 the UK’s gender pay gap (according to the Office for National Statistics) was 10.5%.

Of course, there are many other examples I could have cited.

It’s a complex question, of course; any question relating to how change happens in the public sector or in society at large always is

Nevertheless I’ll have a go at an answer: a focal point for equality-based issues is indeed necessary, but nowhere near sufficient.

*There has been a strong and regular call for an equivalent “Minister for Older People”, which, based on the precedent of the MfDP, I think would be a step backwards rather than the difference people hope it would be.

Thoreau on progress

People familiar with John Gray’s writing will know Gray thinks human progress is less a fact than a myth.

He means specifically progress in human affairs, rather than in technology or medicine, for example, and it’s a view I suspect Henry David Thoreau would also subscribe to now.

Here is Thoreau writing on what I take to be the myth of progress in Walden:

While civilization has been improving our homes, it has not equally improved the men who are to inhabit them. It has created palaces, but it was not so easy to create noblemen and kings.


Our inventions are wont to be pretty toys, which distract our attention from serious things. They are but improved means to an unimproved end, an end which it was already but too easy to arrive at.

To me it seems Thoreau is picking up on two separate things here: one is the quality of men who have risen to lead, and the second is the quality and type of institutions through which such men govern and to what end. In both points, Thoreau reaches a Gray-like conclusion on the myth of progress.

In Civil Disobedience, his famous ‘political’ essay, Thoreau takes things further: he advocates nonviolent means as the most effective way of creating social change, especially against the law and political institutions.

Though at the heart of Thoreau’s writings is the individual rather than the collective, there is something in what he has to say about ‘the machine’ which is relevant if we are to understand the myth of progress and to proceed anyway:

All machines have their friction; and possibly this does enough to counterbalance the evil. But when the friction comes to have its machine, I say, let us not have such a machine any longer.

On Walden

I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived.

Image from the Thoreau Reader

Image from the Thoreau Reader

In 1854, Henry David Thoreau moved to live in solitude in the woods outside Concord, Massachusetts. Walden is his account not only of the rhythms and patterns of the time he spent there, but a series of reflections on wider themes, particularly the rhythms and patterns of mankind.

Reading Walden and other biographical details of Thoreau, I personally found it hard to like him. He feels too critical of fellow men and too impressed by his own actions and way of doing things.

Nevertheless there is a kernel in his thinking I found to be very attractive. This was the sense of focusing only on the things that matter in life to you, and not being distracted from them by “pretty toys”.

Thoreau has found that “the mass of men lead lives of quiet desperation” and that a “stereotyped but unconscious despair is concealed under what are called the games and amusements of mankind”. As a result, he feels that “men come tamely home at night only from the next field or street… their shadows morning and evening reach further than their daily steps.”

Where I found Thoreau most appealing was in his encouragement that the ability to change away from this can come from ourselves. He notes we are all “sculptors and painters, and our material is our own flesh and blood and bones” and that we must therefore:

Learn to reawaken ourselves and keep ourselves awake, not by mechanical aids, but by an infinite expectation of the dawn… I know of no more encouraging fact than the unquestionable ability of man to elevate his life by a conscious endeavour… Every man is tasked to make his life, even in its details, worthy of the contemplation of his most elevated and critical hour.

Though it may not take as radical a solution as being alone in a secluded wood for two years, this essence of Thoreau’s thinking makes Walden a worthwhile, if not challenging, study.

(For readers who may not read it all, the sections on Economy, Where I Lived, Reading and the Conclusion contain Thoreau’s most pertinent arguments relevant to the themes I highlight above.)

Remarkable commissioning decision from the DfE

An evaluation (pdf) on the outsourcing of some parts of children’s services ran to 224 pages – a number which says something about the complexity of public services and how they are arranged.

At the time I tweeted the following associated observations:

Since then, the Department for Education has said it will limit such outsourcing opportunities to not-for-profit providers only. Labour is also making very similar noises with regard to DWP’s Work Programme.

If true, this is remarkable.

As others have pointed out, previous governments have said they would do something similar and that this hasn’t always happened (see here and here). But I don’t think I recall a central government department so clearly saying it will specify what type of organisation will provide a service at this sort of scale.

It offers up all sorts of interesting implications as well.

By “interesting”, I of course mean someone has put a can of worms in a hornet’s nest and each of the worms is about to open their very own Pandora’s Box.

Here are a few quick thoughts:

  • How, exactly, can government effect this? We often hear about procurement rules and regulations that ensure “open and fair” competition for public services, so what magical levers will government now use or create?
  • Even if central government figures it out, how will they support their local government commissioning and procurement colleagues to put nearly 30 years of risk-averse, process-led ‘commissioning’ behind them?
  • What, exactly, is a not-for-profit organisation?
  • How long will it be before for-profit providers (G4S, Serco, A4E etc.) issue legal challenges about unfair competition rules?
  • If such limitations can be imposed in children’s services, why not in health services, social care and employment provision? We knew there was never any overarching strategy to public service reform from the coalition (whatever their Open Public Services White Paper said) but DfE’s move, being so completely at odds with what the NHS and DWP are currently doing through their own reforms, drives a coach and horses through the space any strategy might have existed.

It’s very exciting for people like me who have gone on about how existing commissioning levers can be used to level the playing field for smaller, particularly voluntary sector organisations. Admittedly, people like me tend to need to get out more, but we’re in for some fun and games if DfE and/or Labour really try to do what they say they will.


I’ve been a bit grumpy on Twitter lately [surely not? – ed.]. A focus of that grumpiness has been innovation or, as I seem to be casting it, “innovation”.

May I submit Exhibit A:

and Exhibit b:

It’s not innovation per se that’s the problem here: it’s more someone hitting upon something “innovative” that is actually no such thing – repetition masquerading as innovation, if you will.

A while ago, @georgejulian, @fergusbisset and me came up for a shorthand that enabled us to indicate when we thought this was happening. It is simply #slippers, and its provenance can be traced to the time Ali G met J.K. Galbraith:

7 reasons why I was late for meetings with @paul_clarke

Apropos of this.

  1. I was involuntarily detained for several hours whilst a man explained to me it was him who had invented the #uksnow hashtag
  2. Whilst writing a film treatment of the GDS story (working title: “One Website to Rule Them All”), I spent too long deliberating if Francis Maude or Mike Bracken should be the Gandalf-type character
  3. The sight of Tim Kelsey in animated discussion with Achilles and a tortoise stopped me in my tracks
  4. I was playing Flappy Bird
  5. I couldn’t figure out if the position of the apostrophe in “The Taxpayers’ Alliance” means they represent me or not, so I spent much longer on the phone than I anticipated talking about it to the founder of Pret A Manger and Itsu
  6. I’ve spent all morning trying to think of an aphorism
  7. I was walking through central London when I saw some bloke on a Brompton giving me weird looks. He said he thought I was a bit of a character and asked if he could take my photo. Weirdo.



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