On mental health, we’ve got it so wrong, money alone can’t fix it.

1. When the architects condemn their own building. 

If like me you’ve seen the lives of friends and family ended, ruined or dogged by mental illness and if you too have despaired about the lack of effective help, it can seem obvious that the answer is to just put more money into our current mental health services. It also seems obvious that it’s not a laughing matter. But let’s start with a Woody Allen joke from “Annie Hall”:

“Two elderly women are at a Catskill restaurant. One of them says, ‘Boy, the food at this place is just terrible.’ The other one says, ‘Yeah I know. And such small portions.’”

Thomas Insel used this joke last year to question why the mental health debate has fixated on the quantity of medical services, when actually the quality and the outcomes of the services are so enduringly poor. Until 2015, Insel was Director of the National Institute for Mental Health (NIMH) . In that role he was the US Government’s top psychiatrist and the world’s largest funder of psychiatric research. When he said that modern psychiatry needed to be re-invented, he spoke with authority and shook the establishment. But he was not alone. The most influential architect of  modern mental health services was Robert Spitzer. He literally wrote the book, chairing the task force who wrote the ‘bible of psychiatry’, the third version of the Diagnostic and Statistics Manual (DSM) published in 1980. This has determined the West’s approach to mental health ever since. (Once an American bible, the DSM became the global bible when it colonised the World Health Organisation’s manual for mental health). Yet in 2011, Spitzer despaired that a system designed to treat three to four per cent of the population had “medicalised thirty per cent of the population as mentally ill”. Allen Frances led the updating of Spitzer’s DSM in the 1990s. But he too has now condemned the building he helped design. In 2013, Frances publicly called for the US Congress to urgently investigate “a diagnostic system that is far too loose, a drug industry that is far too unregulated and a mental health system that is badly broken”. He issued a high profile mea culpa for “diagnostic inflation” and the “shrinking realm of the normal”:

“Diagnostic decisions that seemed to make sense were exploited by drug companies in aggressive and misleading marketing campaigns. They sold the idea that the problems of everyday living are really mental disorders, caused by a chemical imbalance and cured with a pill.”

Two groups have benefited financially from this system: medics have had a codified system that grants them exclusive rights and payment for meeting a wide variety of public needs; drug companies have had a global opportunity to match a “pill for every ill”. Rather than blaming the drug companies, Frances laid the blame on himself and his fellow doctors. Ninety per cent of people with mental health problems are treated by general practitioners (GPs). Frances despaired of how within a ten minute consultation under-trained doctors used a checklist of symptoms to diagnose a condition and prescribe a pill to deal with it. In the UK, for example, less than half of GPs have been trained in mental health and yet it is a diagnostic issue in a third of their consultations. But the problems with our current approach to mental health are more profound than poor implementation. When the DSM was updated in 2013, Thomas Insel caused a great stir by rejecting the bible outright. He said “Biology never read that book.” He stressed that very few psychiatric diagnoses are “real medical conditions”. Unfortunately, we just don’t know that much about the brain, an electro-chemical machine with a hundred billion neurons and a thousand trillion possible connections. Undaunted by the lack of science, psychiatry has defined hundreds of conditions. But these conditions are diagnosed simply by a checklist of symptoms. Historically, this used to be true in physical medicine where, for example, dyspnoea or “shortness of breath” was a common diagnosis. Today’s medicine knows it is not a disease but an important symptom of an underlying condition in the heart, lungs, blood or brain. These are the real medical conditions and we increasingly have effective therapies to treat them. In mental health, we are still largely diagnosing “shortage of breath”. Worse still, Insel and other have proven that there is very little reliability, validity or consistency in the mental health diagnoses given by doctors, even for the most common or most serious conditions.

The absence of science is not only a problem for diagnosis. It also holds us back from improving the poor range and the limited effectiveness of the therapies we currently have on offer. When it comes to science and therapies, mental health is forty or fifty years behind oncology. Insel states it starkly:

“Current treatments are not effective enough. While there have been important innovations in the behavioural treatment of borderline personality disorder and family interventions for anorexia nervosa, for many disorders we have little to show after four decades of pharmacologic research except reduced medication side-effects. In spite of exuberant sales of medications and broader use of psychosocial treatments, we are faced with outcomes that are just as unacceptable for serious mental disorders as they would be for cancer. Briefly stated: in many cases patients receiving the best of current care are not recovering. We can blame the mental health care system, the absence of insurance or providers, or stigma, but the inconvenient truth is that our treatments are not good enough”.

2. It’s not the first existential crisis for psychiatry.

If the architects have condemned the building, we ought to be discussing psychiatry in terms of an existential crisis. Unfortunately when it comes to existential crises in psychiatry, as Yoggi Berra would say, “It’s like deja vu all over again.” The only way to understand our current crisis is to look at the history of psychiatry and how we got where we are today.

The first crisis for psychiatry came at the end of the nineteenth century. Since the 1840s, hundreds of thousands of people in western countries had been moved into newly built asylums, based on psychiatry’s promise of a medical regime to make them better. But people didn’t get better. Two-thirds of people never left the asylums and the numbers, and cost, grew inexorably. The only real medical science was Alzheimer’s discovery of dementia. By 1907, the then President of the American Psychiatric Association (APA) publicly pronounced that “Our therapeutics are simply a pile of rubbish”. Psychiatry argued itself out abolition by inventing three new systems of mental healthcare. These systems lasted until the 1960s and 1970s. By then public, and wider medical, opinion had turned against them. The first system treated mental illness as contagious and socially corrupting, reinventing the purpose of asylums as isolating the ill to protect the healthy and often allowing eugenicists to sterilise them protect future generations. For example, between 1907 and 1974, some sixty thousand Americans were compulsorily sterilised, mostly because of perceived mental issues. The second system was the biological movement. From the 1920s to the 1960s, the biological psychiatrists introduced operating theatres and turned the asylums into hospitals, attacking the infections they believed were the cause of mental illness. On an industrial scale, they removed potential sources of infection (teeth, cervixes, spleens, sinuses and colons ), triggered immune system reactions by introducing fevers (with, for example, malaria) and tried to kill poisonous cells in the brain by inducing comas with insulin shock therapy. In the 1950s, they expanded their treatments with the hammering of an icepick into the head to lobotomise the brain. The third system of psychiatry was psychoanalysis. Based on the teachings of Freud and others, the analysts eschewed physical medicine and focused on invisible diseases of the mind. By the 1960s, they dominated US university medical schools and the world’s psychiatric textbooks. Personality traits were illnesses and eccentricities were deviant. For example, most analysts saw homosexuality as a curable disorder, produced by a domineering mother and a weak father. They saw addiction to food, drink and drugs as a reaction to being deprived of breast-feeding. Their Psychosomatic School saw lots of diseases (e.g. schizophrenia, autism and even asthma) as the product of dysfunctional parenting, best addressed by life-long, expensive therapy sessions. The analysts had a profound impact on popular culture and general medical training, although relatively few people were treated by them. By the early 1970s, it was evident to those outside psychiatry, including most other medics, that all three of these systems of psychiatry were pseudo-science, ineffective and abusive.

In 1976, the APA President declared, “Our profession has been brought to the edge of extinction”. Psychiatry was being mocked in the newspapers as a fraudulent pseudo-science. Insurance companies were less willing to pay for treatments. Across Western countries, the asylums were being rapidly emptied and closed. Social workers and psychologists were providing twice as much outpatient support as psychiatrists. After more than a hundred years as a profession and having consumed vast amounts of public spending, psychiatry was humiliated and short of friends. Its diagnoses had been exposed as arbitrary and unreliable. This was destroying its credibility. It didn’t appear to be able to make people better. This was destroying its legitimacy. It couldn’t explain any science behind even the few (accidentally-discovered) drugs which helped people manage their conditions. This was destroying its claim to be medicine. In 1977, Melvin Sabshin, the medical director of the APA, led the fightback, stating that “A vigorous effort to remedicalize psychiatry should be strongly supported”.

3. How we ended-up looking through at society the wrong end of the telescope.

From this nadir in the 1970s, medical psychiatry fought back. And it won. The victory came with the APA’s publication of DSM III in 1980, masterminded by Robert Spitzer. This was a political power play by the psychiatrists. They vanquished the opposition they faced from other professionals, regulators and funders. They also defeated internal resistance from the psychoanalysts, who went from dominance to oblivion in quick order. The World Health Organisation’s International Classification of Diseases (ICD) has been gradually colonised by the DSM, giving it global domination. The Spitzer battle entirely shaped our current approach to mental health, how we define it, discuss it and deal with it. But that system was myopically designed around the self-interest of one group of psychiatrists, not the interests of society at large. If we now want to improve mental health, we have to grasp this point. Our current system was designed from the wrong end of the telescope, focusing on the provision, funding, demarcations and organisation of a particular set of professional services for one in twenty people, regardless of how they became ill. This design ignored the fact that one hundred per cent of people have mental health and that, as with physical health, they are on a spectrum from the super-fit, through the healthy, the unhealthy and the moderately ill to the severely ill. The new psychiatry just focused on this latter group, ignoring the mental health risks, opportunities and challenges faced by the other ninety-six per cent of the population. This had three immediate consequences:

Consequence No 1: We created a binary distinction between normal and ill, and just focused on the ill

Whereas psychoanalysis saw mental health as a continuum, with everyone suffering some form of neuroses, the new psychiatry draw a hard boundary between three to four per cent of people who were defined as medically ill for apparently biological reasons and the great majority who were “normal”. The “normal” were not differentiated. The new psychiatry had nothing to say about, or offer, the “normal” majority. This boundary was explicitly designed to please health insurers who resented paying for professional help for people who were finding life hard and to deny non-medical professionals (e.g. social workers, psychologists and counsellors) the right to treat (and/or the right to third-party funding for) those the psychiatrists defined as medically ill.

Consequence No 2: We became obsessed with diagnostic labels for people’s symptoms

Instead of trying to identify and treat the causes of mental illness (be they social or physical), the new psychiatry focused exclusively on symptoms. DSM III gave the appearance of science, in that it categorised hundreds of allegedly distinct conditions. It focused on the rapid diagnosis of these conditions by verifying the presence of various symptoms. It did not match the condition to a cause or to a treatment. The explicit goal of this system was to achieve more consistent diagnoses. But it had a more profound impact on society as a whole. A medical diagnosis of these conditions became the exclusive access code to health insurance / public health payments for treatment, disability benefits and other public services. People needed, and wanted, these new labels.

Consequence No 3: Only doctors can give out drugs, so we just gave out drugs. 

Having dismissed non-medical professionals (like talking therapists, counsellors, social workers or neuroscientists), the new psychiatrists were keen to maintain their exclusive privileges. Only medical doctors, like them, could dispense drugs. So the new psychiatrists were keen to focus on drugs. The pharmaceutical companies obliged, creating drugs for particular conditions. Relieved of the need to prove cause-and-effect and with a near monopoly on treatment, they grew a huge, global industry with drugs that provided symptom-relief. Other treatments were largely neglected, until psychological therapies like CBT became more popular in the last decade.

4. The five accidents that became an emergency. 

The intended consequences of the 1980 DSM on our approach to mental health were profound. But actually, there have been a series of accidents since then whose unintended consequences have been even more influential.

Accident No. 1: The new psychiatry became a largely GP-based service.

Although the psychiatrists asserted medical supremacy, they did not manage to gain exclusivity amongst doctors. Very few mental health patients get to see a psychiatrist. That’s partly because the DSM III was designed for outpatient care, based on the application of a diagnostic manual and treatment with a branded drug. GPs found that they could deliver that system without recourse to psychiatrists. Given the constraints of their appointment system, they formed rapid conclusions based on a list of patient-described symptoms and, in most cases, felt able to treat the patient directly with a drug, marketed to match one of the DSM conditions. This had profound consequences for how western countries dealt with mental health issues:

  • Whereas the new psychiatry expected three to four per cent of people to fall within the DSM categories, GPs found that the diagnoses covered ten times as many people. For example, in Denmark, four out of ten women and three out of ten men will be medically diagnosed as mentally time during their life. In the US, NIMH found that one in two people will meet the criteria for mental illness at some point in their life. One of the new DSM conditions was ADHD. Originally it was envisaged that, perhaps, one in two hundred might have this condition. In the US, however, one in five boys is now diagnosed with ADHD by the time they leave high school. Two-thirds of them are on permanent medication. A quarter of middle-aged American women currently take anti-depressants.
  • Even a high quality outpatient service has limited traction on the life of a person with mental illness. Whereas inpatient care designs and controls every hour of the patient’s life, an outpatient system directly controls only a few hours of their life, when people attend their outpatient appointments. For mental health specialists, these hours rely on highly-skilled therapy to change people’s thoughts and to help them find self-help skills. A GP-based outpatient service directly controls only a few minutes of people’s life. That isn’t enough time to be therapeutic, even if the doctor had the skills. In this context, the only tool left is medication and the time available is just enough to prescribe and re-prescribe drugs.
  • The medicalisation of mental health assumed that doctors can solve medical problems on their own, in the way that they do for physical illness with biomedical testing, drugs and surgery. That is rarely true in mental health where getting better relies significantly on the patient’s own therapeutic actions and their interaction with their friends, family and colleagues. Outpatient psychiatric care rarely works with the other people in the patient’s life, dealing with the patient one-to-one. Worse still, medical ethics prevent doctors discussing their adult patients, even vulnerable eighteen year olds, with their family and friends.
  • The authority of the DSM system and the fact that almost everybody in western countries has access to a GP have combined to make the GP the mandatory interface for millions of people with mental health concerns. For many of them, a GP diagnosis is the obligatory gateway to the time they need off work, to sickness and disability benefits or access to non-medical support. For others, they are sent to the GP by other professionals (e.g. teachers, HR managers, counsellors) who defer and refer to medical authority on what they perceive to be mental illness. For example, in the last twenty years there has been a thirty-five fold increase in the number of American children classified as disabled by mental disorders.

Accident No. 2: The alternative to inpatient care was often even worse than the old asylums.

Inpatient care was the baby thrown-out with the bathwater when the asylums were closed. A small number of people need indefinite inpatient care, whilst many more need short-bursts of it. There isn’t enough of it. For example, England, like other countries, has only ten per cent of the inpatient places, per head of population, that it had in the 1950s. The US has even less. It wasn’t just the asylums closing. England has halved the number of inpatient places it still had in 1998. Community-based crisis services have not worked well. Only fourteen per cent of English patients who’ve experienced a mental health crisis felt they had appropriate care and there are no English community services rated as good. In the absence of appropriate inpatient care, people who are severely ill are labelled, and dealt with, as non-medical problems, as criminals, as homeless, as addicts, as a public nuisance and as suicides:

  • A lot of people with serious mental illness have ended-up in prison. About a fifth of prisoners are seriously mentally ill. When they are released, they are likely to return to prison. For example, ninety per cent of the seriously mentally ill prisoners in Los Angeles have been in prison before and a third have been imprisoned more than ten times. Forty per cent of all Americans with serious mental illness have been, or are, in prison.
  • A quarter of the people living on the streets in western countries have severe mental illness. English police forces spend twenty per cent of their time dealing with people who are seriously mentally ill, often for their own protection.
  • Huge numbers of people are self-medicating for their mental illness with alcohol, illegal drugs, painkillers and nicotine. Severely mentally ill people are three times more likely to be alcoholic. Nearly half the men who kill themselves in the UK have long-standing drink problems. Significant numbers of people with mental health issues diagnose their problem as chronic fatigue and/or pain, often taking powerful painkillers throughout the day. The opioid crisis has ravaged swathes of middle-aged, middle class America.
  • People in crisis desperate for medical care present themselves in growing numbers in Emergency Rooms in hospitals or volunteer for involuntary commitment to psychiatric care. Ironically, their best hope of medical treatment is for the physical illnesses which are a consequence of their mental illness, like diabetes and cardiovascular disease. But even here, the system is failing, with seriously mentally ill people dying fifteen to twenty years earlier than others due to their worse physical health.
  • More bleak still is the horrifying numbers of suicides where, in the absence of appropriate care, people take their own life. Globally, suicide is one the biggest killers of young people. In America there has a recent upsurge in “baby boomer” suicides.

Accident No. 3: The reactive approach of GPs (and community services) created a mental health service which waited for people to present themselves as mentally ill, often very ill. 

The right strategy would have anticipated the predictable risks to mental health which people face in life, proactively helping them to manage those risks and responding rapidly when illness occurs:

  • We know that people have a higher risk of mental ill-health around certain stages of life and key events. This includes: adolescence; having a baby; bereavement; relationship breakdown; becoming chronically ill or disabled; having financial problems; retirement; loneliness; being physically abused; unemployment. These were just the sort of “everyday living problems” the new psychiatrists and the health insurers wanted to exclude from mental health services. They were also the causes of mental illness which were deemed irrelevant in the DSM’s pseudo-biological approach to mental health. By the time these events caused people to see the GP, the symptoms of mental illness had often set in and it was these symptoms which were treated.
  • The lack of a proactive public health strategy around the risky events in life has been profoundly harmful. We can see this most starkly with children and young people. Half of all mental health problems have manifest themselves before the age of fourteen and three-quarters of adults with mental illness had their first symptoms before the the age of twenty-four. Yet, in the UK for example, children only benefit from six per cent of mental health spending. Young people struggle to get referred by GPs to specialist help and those who do get referred wait an average of ten months to start treatment. Similarly, we know that up to one in five women are at risk of perinatal mental health problems, yet only fifteen per cent of communities in the UK have even an “adequate service” for these risks and forty per cent have none. Only fifteen per cent of people in the UK who would benefit from psychological therapy receive it . Of course, many people never make it to even the GP, a major reason why three-quarters of British people who the DSM defines as having depression or anxiety receive no treatment at all.

Accident No. 4: Everyone bought the “chemical imbalance” theory and ten per cent of people ended-up on anti-depressants. 

The drug companies retro-fitted a theory to their serendipitous discoveries that certain drugs had some beneficial effects on some people. They claimed that depression, and other common illnesses, result from a chemical imbalance in the brain and that their drugs correct this balance, e.g. increasing serotonin to tackle depression. The drug companies used this theory to build a massive global business. GPs adopted it because it fitted their apothecary-style practice, narrowing a psycho-social illness into a bio-chemical condition that can be corrected with tablets. For understandable reasons, the anti-stigma movement of mental health campaigners welcomed the theory and promoted the mass use of these anti-depressants. This is perhaps the biggest of the accidents:

  • Today about one in ten people are currently take anti-depressants in the US, UK, Canada, Sweden and Australia. In most western countries, the proportion taking antidepressants has doubled or more since 2000. Some countries, including France, South Korea and the Netherlands, take much less and have resisted these rates of growth. Japan has only adopted anti-depressants since 2000, having previously resisted the concept of depression of an illness, seeing it as a personality type instead.
  • Unfortunately, there is no scientific proof of the chemical imbalance theory, in spite of a massive and expensive effort to prove that it is true. That shouldn’t prevent doctors prescribing these drugs so long as they are effective and safe. Unfortunately, the evidence for this is weak.
  • Doctors tell people that anti-depressants have a positive effect on half of the people who take them. That is true, but misleading. Even drug companies only claim that their drugs have a positive impact on one in eight people who take them. A further three in eight people benefit from a placebo effect. Indeed, even the one in eight who appear to benefit from anti-depressants may just be experiencing a ‘super-placebo’ effect from the side-effects they suffer from the anti-depressants. Placebos which induce these side-effects have been show to have the same efficacy as actual anti-depressants.
  • The degree of improvement enjoyed by the half of people who benefit from anti-depressants is limited. To be fair, drug companies only claim a “moderate” reduction in depressive symptoms. Independent research shows the impact to be even less than that. For example, for adolescents the “effect size” for people who do benefit is 0.25, whereas a moderate effect would be 0.5. Drug companies are also clear that the beneficial effects of the drugs take two to six months to kick-in. Without medication, a third of people with depression are better after three months and two-thirds are better after six months. For the people who do benefit, these drugs are probably best compared to a band-aid, increasing the natural healing process a little.
  • There is a small minority who appear to be greatly harmed by taking anti-depressants, with a doubling of the suicide rate for peole with depression and the triggering of psychosis in significant numbers of people. But the biggest harm of the anti-depressant accident is that their domination of psychiatric care has crowded out better and more varied solutions to common disorders and left millions unable to get well again.

Accident No. 5: Episodic and one-off illnesses were systematically turned into permanent and chronic disabilities. 

This had been one of the biggest criticisms of the asylums, where people whose illness ought to have been temporary or infrequent were indefinitely removed from society and pharmaceutically incapacitated. Unintentionally, Care in the Community has created similar problems, with people becoming permanently ill, dependent on drugs and economically excluded:

  • The first problem lies in the system of disability benefits. In the UK, for example, half of all claimants of these benefits have a mental disorder. Two-thirds of them claim for depression and anxiety. The UK number has doubled in the last twenty years, driven largely by people with depression. The numbers have grown even more sharply in the US. Thirty years ago, only one in fifty US disability payments were for mental disorders, now it is a third of them. These mental disorders, which ought to be temporary or infrequent have been treated as a permanent and continuous disability. For example, the UK numbers receiving disability benefits for mental disorders for more than five years have doubled in the last decade. Intended to be kind, the benefits often have the perverse consequence of keeping people out of work, when we know that work is one the most therapeutic activities. GPs have no incentive to either assertively reach out to people in these circumstances or to provide therapeutic support to get back into work.
  • The second problem is the way that GPs prescribe drugs. For example, in spite of the evidence that drugs only have a short-term impact for depression, many people are taking them for extended periods. Two-thirds of Americans on anti-depressants have been taking them for more than two years and one in seven has been taking them for a decade or more. It is undisputed that these drugs have debilitating side-effects, like fatigue, obesity and mania, which reduce people’s ability to participate in society. There is also evidence that long-term use induces chronic depression, which simply doesn’t go away. Most perniciously, it seems that rather than treating a chemical imbalance, these drugs create an imbalance where there wasn’t one to start with. This imbalance makes it hard to come-off the drugs, as there are serious withdrawal symptoms and, for half of people, psychological problems arise, as the brain continues to fight the drug’s effects even after it is withdrawn. Both of these problems can make people feel resigned to taking the drugs indefinitely. For many people taking one drug is the first step to taking many drugs. Unguided by real science, doctors try a drug and as most of them don’t work for most people, they try another one and as many suffer serious side-effects, they prescribe a compensating drug, like a mood-stabiliser for the mania induced in some by anti-depressants. For some conditions, the medical protocol is to prescribe drugs for life. That’s true, for example, with antipsychotics, even though the best research shows that forty per cent who discontinue these drugs recover their health, compared to seventeen per cent who continue to take them. But coming off anti-psychotics is hard, as dopamine levels can surge as the brain continues to compensate for the now withdrawn drug and this surge can cause immediate relapse into psychosis.

This combination of indefinite out-of-work benefits and drugs can leave many people feeling they are living in a ‘virtual asylum’, rather than recovering from their illness, managing their condition and living a full life.

5. Seven steps to turn around the telescope and focus on society’s mental health.

For the last four decades we have looked at mental health through the doctors’, and the wrong, end of the telescope, reducing our field of vision to the detail of the medical services available to those who are already mentally ill. We need to seize back the telescope and turn our view to society as a whole and explore a wide range of strategies, going well beyond medicine, to maximise everyone’s mental health.

Step No 1: We should focus on mental health, rather than just illness. 

Everybody has mental health, in that they have a brain, they have emotions and they have cognitive skills. Instead of worrying about whether five, ten, twenty or thirty per cent of people have mental health issues, we need to sell the message that one hundred per cent of people need to improve, protect and repair their mental health. At any one time, we can all be ranked on a mental health spectrum as super-fit, healthy, unhealthy, moderately ill or severely ill. There is a normal distribution across this spectrum and people can move up and down the scale over time. We should have a public health strategy that mirrors our approach to physical health. That would mean a big focus on the unhealthy, trying to ensure that they consciously work towards good health and avoid sliding into ill-health. It would mean a big push to tackle early signs of illness and to prevent moderate conditions becoming severe.

Step No. 2: We should link mental health to success in life, rather than failure.

Most of the world’s most successful people (be they in business, sport, entertainment, the professions or the military) spend  a lot of time self-consciously improving, protecting and repairing their mental health. In sport, for example, it is commonplace to say that the success, or failure, of top tennis players, footballers and golfers is all in the mind. The British Cycling Team which has dominated world cycling for the last decade attributes much of its success to its psychological coaches. At the more mundane level, we know that good (or improved) mental health is vital to our progress in education, employment and family life.

Step No. 3: We should educate people about the key components of mental health.

Most people actually have a lot of knowledge of physical health. They know the importance of cardio-vascular exercise, the genetic risk of certain cancers, the risks of being over-weight, the harms of alcohol and tobacco, what to do if they get the flu, etc. However, few people know much about mental health. But if we want to empower people to understand and look after their mental health, we shouldn’t just wait to educate them when they, or their loved ones, are so ill that they are being treated by a doctor. People need to understand and think about their genetic inheritance, in terms of genetic risks (e.g. schizophrenia) and their inherited character traits (e.g. being introverted, conscientious, open to new experiences, etc). They need to understand the powerful evolutionary instincts which can take over our brain (e.g. the rejection of new-born babies or the overwhelming desire to fit in). It is important to understand how the way that we live influences our mental health, for good and bad. Our habits can adapt our character traits. We can get stuck in the past or fearful of the future, making it hard to deal with the present. We can get into virtuous or vicious circles with our mental health, where problems lead to problems or success leads to success.

Step No. 4: We should re-define mental illness as either “Emotional Health” or “Neurological Health”.

Modern psychiatry has led us to define mental illness as one thing. We haven’t done that in physical medicine for a few hundred years. Even within particular parts of the body, physical medicine is specialised. For example, we don’t lump together ophthalmology and ENT (ear, nose, throat) specialisms because they are both focus on the head. Given our limited scientific understanding of the brain and of the biological causes of illness, I think that, currently, it’s best to define mental illness in terms of its effects. Firstly, we can divide those effects into two broad categories of illness: emotional distress and cognitive problems. If either of these effects endure, they need attention. Both can range from mildly disruptive to fatal. Emotional distress occurs when we struggle to regulate our emotions and it includes stress, anxiety, depression, trauma, compulsive disorders and a range of behavioural problems. Given the lack of neuroscience insight, our main tools to tackle “Emotional Health” are self-awareness, talking-therapies, social support, self-help techniques and lifestyle changes. Cognitive problems are related to learning, memory, perception and problem-solving. They relate to dementia, autism, learning disabilities and most types of schizophrenia. “Neurological Health” for historical reasons already deals with some of these areas and should be expanded as a discipline to cover all cognitive problems. For neurological problems, the main therapeutic hopes lie in imitating the life science breakthroughs in oncology.Unfortunately, science has not yet produced significant treatments for cognitive problems. Therefore, the current focus is ensuring that people have sufficient personal care, in addition to what they can get from their friends and families.

Step No. 5: We should distinguish between “dysfunction” and “malfunction” in Emotional Health. 

With a dysfunction, our mind works but is poorly maintained and prevents us dealing with the world appropriately. Emotional dysfunctions can be rooted in a mix of evolutionary instincts, our genes, our character, our experiences and our habits. The dysfunction impedes how we want to live our lives. Negative emotions undermine our quality of life: fear, stress, sadness, low self-esteem, anger and dark thoughts. Everybody is dysfunctional to some extent, sometimes in very minor ways, other times in very significant ways. The effects of a dysfunction are likely to be that we are mentally unhealthy or mildly ill, although some people find ways to manage a dysfunction and live a mentally healthy life. The point about a dysfunction is that we can do a lot on our own, or with lay help, to reduce or remove the dysfunctionality and, critically, to prevent a malfunction. We should stop over-medicalising dysfunctionality and empower people to help themselves and others, as well as accessing non-medical professionals. However, with a malfunction, our mind stops working, as the illness is overwhelming, we can’t function and we can’t fix ourselves without very skilled help. A malfunction can quickly become a vicious circle in which people go from bad to extremely bad and where there can be fatal consequences. We see this in the levels of death from suicide, addiction, eating disorders, self-neglect and violence to others. With malfunctions, immediate and intensive expert support is vital. Half measures and delays are the enemy.

Step No. 6: We should connect good mental health with good physical health. 

When it comes to physical health, public health campaigns tend to focus on what everyone can do to maximise their good health, including diet, exercise, abstention from drugs, sleep and relaxation. The good news is that these are also essential features of protecting and improving our mental and emotional strength. These are not just prophylactic effects. We know, for example, that exercise compares favourably with both drugs and talking therapies in treating mild to moderate depression. We also know that the most pressing issues in physical health, like obesity and addiction, are rooted in mental and emotional health.The physical solution to obesity is easy – eat less, especially less bad things. The only barriers to this solution, for most people, are mental and emotional. If a new approach to mental health did no more than inspire people to follow existing lifestyle advice for physical health, it would make a big improvement in society’s mental health. And that in turn could transform the lifestyle-driven problems in physical health.

Step No. 7: We must recognise that the way our society chooses to live has a big impact on mental health, for good and bad, and can be changed. 

The medical model has over-emphasised the individual and the biological. Our mental and emotional strength is heavily influenced by our social interactions. And therefore, we are all responsible for our impacts on other people’s mental health. The good news is that being altruistic and caring for others is one of the best things we can do to improve our own mental and emotional strength. Mental illness and poor health are often based on underlying feelings that one has lost autonomy and/or community-connectedness, experienced as helplessness, hopelessness, passivity, boredom, fear, isolation and dehumanisation. These are social problems which have medical consequences. The best solutions are, often, therefore social rather than medical. In terms of physical health, many of the biggest achievements in have come from non-medical solutions. We live longer and better in large part due to clean air, safe water, better vehicle and workplace safety, less tobacco smoking, more and better food, fluoridated water. We could need a similar public health approach for the social causes of mental health issues. For example:

  • We know that loneliness causes both physical pain and mental distress. It’s an evolutionary reaction, warning us of the dangers of social isolation. We know that it’s at the root of many young and old people presenting with depression and other mental illness. It also causes physical harm, as much damage as smoking fifteen cigarettes a day. It’s both extensive (e.g. one in five Americans is chronically lonely) and growing rapidly (having trebled on some measures in the last two or three decades).
  • Whilst doctors are busy putting children in the US, UK and Germany on lifelong medication for ADHD, we know ADHD-labelled children are indistinguishable at school from other children when they have chosen their learning activities and are interested in them. Children with this label do worst in environments which they find boring, repetitive and overly-controlled.
  • However, ADHD-labelled children are not alone in being disengaged from school. For example, only forty per cent of American high school students feel engaged by school, down from eighty per cent at elementary school. Significant numbers of them are prescribed anti-depressants and others are mentally unhealthy.
  • Similarly, only thirty per cent of American workers feel engaged by their jobs, twenty per cent hate their work and fifty per cent are disengaged. At least a third of sickness absence from work is due to mental and emotional issues. The biggest causes of work-related stress are the relationship with one’s boss and colleagues, performance management, work/family conflicts and unclear or unsatisfying roles.
  • A quarter of UK university students say that they have mental health problems, including a third of female students. They see their academic work as the biggest cause of their mental problems, followed by concern about their future career and relationship issues.
  • It is clear that social media have introduced new risks to mental health. For example, it has made bullying easier and potentially more intense. It has increased the pressures of social comparison. Some teenagers find it hard to switch it off and get the rest and recuperation they need.
  • Money problems cause mental health problems and poor mental health is more likely to led to money problems. Debt is a major underlying cause of mental illness, and vice versa. We know, for example, that ninety-four per cent of British women with mental health problems say their spending increases when they are unwell, mostly as “comfort spending”.
  • Regular access to green and tranquil spaces, especially naturalistic areas, is very beneficial to mental health. However, many people lack easy access to these areas and the growth and densification of many cities is failing to improve this.
  • Career paths have become less predictable and pay progression harder to achieve. A lot of people feel economically insecure and feel they lack personal agency to improve their future. Many of the economically elite deal with these issues by finding and working with mentors, who help them chart the best course, solve problems and improve their personal effectiveness. But the most economically insecure who could gain most from such mentoring the most tend to be excluded from it and suffer the consequences.

Whether it’s schools, colleges, workplaces, online communities, neighbourhoods or banks, the design of these institutions and how we use them are entirely within our control. Whilst many people thrive in these social institutions and enjoy positive mental health, there is at least a large minority who do not. Making things work better for them would transform society’s mental health.

8. An eight point policy plan for the future. 

Once we have taken these seven steps and turned the telescope around to look at society’s mental health as a whole, we can focus on the policies to fix our current broken system. I have suggested eight policies that I think would make a big difference across western countries.

The first four policy proposals are to urgently deal with the broken system for adults who are mentally ill and should be in place by 2020:

Policy No 1: General practitioners (GPs) should no longer be able to prescribe drugs for mental illness. 

This is essential to turn our backs on the excessive and ineffective medicalisation of moderate mental health issues. It also the disruptive action which will force countries, against a deadline of the closure of this service in 2020, to urgently put in place a new approach to mental health. Of course, all doctors including GPs will be free and encouraged to identify mental health issues, including serious illness. But we do not expect a GP who suspects cancer to start immediately administering chemotherapy. Instead, they refer the patient for rapid specialist diagnosis and treatment. That’s what we need to build for mental health. Whilst there is no urgency to most of the mental health drugs, as their effects, such as they are, take months, rather than days, GPs should still be able to prescribe an urgent anti-psychotic, but only very short-term.

Policy No. 2: Inpatient places should be, at least, trebled to offer more safe refuges for people whose care cannot, for periods of time, be secured in the community.

A trebling would provide a bed for one in a thousand people in the UK or one in two thousand in the US. That’s not a return to the 1950s, but a humane steam-valve for people in acute crisis. However, they should not be hospitals or hospital-style facilities, which are an unnecessary hang-over from the biological days of the asylums. Instead, we need small-scale, compassionate and peaceful refuges, close to people’s homes. In addition to these in-patient facilities, we need to accept that a significant number of people will need residential care for long periods of time. This has happened for older people with dementia, who now dominate residential care homes. As a minimum we need to offer long-term residential support for the seriously mentally-ill who are currently ending up in prisons or living on the street. But we can also think more imaginatively. For example, the Shared Lives scheme in the UK places adults with learning disabilities into family homes, who are paid like foster parents would be for young children. Similar schemes could work for other adults.

Policy No. 3: Adults should be able to directly access CBT (and other accredited psychological therapies) whenever they want, face-to-face or online/mobile, without delay, the need for approval or worry about the cost. 

There are too many barriers and delays to people helping themselves to proven therapies as soon as they need them. Where people’s emotional health is dysfunctional, they should be able to directly and immediately access accredited therapies and therapists, without delay or intermediaries. Indeed, that is what people do now when they have the triple luck to know that such therapies exist, to have the money to pay for them and to find a highly skilled therapist. Too many people lack this triple luck. With a good therapist, the diagnosis is part of the therapy and they will quickly identify where an individual is suffering a malfunction which requires more intensive or medical support. Government and health insurers should invest in training a lot more therapists and creating a stronger system of accreditation and ratings by patients. Most critically, they should ensure that everybody can access the therapy, irrespective of income. In countries like the UK that means making it free-as-you-go on the NHS. In others like the US, it means that insurers do the same. In some cases, it maybe means-tested, in the same way that other health services would be. Or employers and universities may choose to fund their own services. In the scheme of things, these therapies are inexpensive and short-term. We should encourage people to use them freely and worry about the net cost if it becomes a big problem. I suspect it won’t and will instead reduce other current costs considerably.

Much of the investment in this area should be in online and mobile services. There is clear evidence that written therapy, by text and online, and telephone/video therapy both work as well as face-to-face therapy. They reduce the barriers to access and the stigma of medical appointments. They also reduce travel and time constraints for both patient and therapist, as well as creating a more natural conversation for many people. However, the investment should go further and create automated services, as well as professional help. This should include online courses to train people in CBT skills to improve their own help, like This Way Up which has had outstanding results in Australia. It should also accelerate the new AI-based bots which provide therapeutic conversations and intervene with therapeutic suggestions when their passive monitoring detects unhealthy behaviour on smartphones and other devices. Similarly, people should be offered automated initial diagnosis, given that AI can use the same checklists as GPs, but also has facial and audio recognition that can detect and diagnose mental illness better than most doctors. For example, we have voice-recognition software  which can predict psychosis in the next thirty months with one hundred per cent accuracy.

Policy No. 4: Adults whose lives are dominated by poor mental health should be offered a new, all inclusive health service through a specialised Accountable Care Organisation (ACO).

There should be a new type of care-provider for people with long-term conditions. This includes both people with severe mental illness and those whose moderate conditions have become chronic disabilities. Their support is currently fragmented across GPs, community mental health services, addiction services, justice services, public housing, employment services and welfare agencies. Instead, they should be offered the chance to opt-into a dedicated ACO, which provides all of their health needs, both physical and mental, from GP services through rehabilitation to crisis support. A variety of ACOs should be set-up and patients would be offered a choice, of whether to switch to an ACO and which one. Some might be specialised by disorder, e.g. for eating disorders or for chronic depression/anxiety. They should all bring together a mix of professional skills, both medical and non-medical (e.g. debt management, personal trainers, etc). The ACOs should rationalise the current fragmented and hierarchical professional mess (doctors, nurses, social workers, psychologists, occupational therapists, etc) and define new types of professional based on patient need and efficiency, not old intra-professional battles. They would have full accountability for the person’s health and picking-up the pieces when other agencies like the police, a court or a homeless charity are dealing with their patients. Some people would opt to stay with the specialist ACO indefinitely because their of condition, but for most people the goal would be to return to mainstream provision. The various current funding streams would all be merged to create a single, capitation fee paid to the ACO to meet all the need of a cohort of individuals. They would also be rewarded for getting people better and improving their participation in the community, including working. These rewards would be funded out of anticipated savings to Governments and health insurers. However, this model is more about improving quality and ending the fatalism of the current system, than it is about trying to save money. Top priorities would be reverse the trend for people with depression and anxiety becoming permanently ill and unemployed and to introduce global best practice therapies. For example, Finland’s Open Dialogue therapy has meant that after five years of treatment eighty per cent of people who had psychosis are living without symptoms, the same percentage are in employment and only a third still take drugs. This contrasts with the UK where after five years, eighty per cent still have psychotic symptoms, very few work and nearly everybody is still on drugs.

The next four policy proposals are to improve the future mental health of our population:

Policy No. 5: There should be a high-profile education and social action programme for Emotional Health that actively engages the majority of the adult population. 

There is a big remedial job to do on adult education, to ensure that people understand at least as much about mental health as they do about physical health. There is also a pressing need to empower people to improve their own emotional health and to actively support other people to do the same. Each country should tackle this in an ambitious and sustained programme, that has the high profile given to other campaigns like smoking, AIDs, cancer and obesity. The key to this campaign is creating a digital platform in each country (a website and/or an app) and encouraging every adult to go there to learn about emotional health and what they can do about it. It should be sold in two ways, “Be A Great Mate” (learning about emotional health issues and how to support people you know) and “Check On Your Emotions” (assessing, and re-assessing, yourself on an emotional health scale and working out what you can do to improve things, and then whether they are getting better or worse). People should be encouraged to take an accredited test for both of these things to show what they’ve learnt, and to keep it updated. The digital platform should give them to chance to drill-down and find-out more about particular health issues and solutions, once they are engaged or when they revisit. The platform could curate and offer links to useful resources and support, including clicking through to therapy or joining a support group. People could be offered a more intensive education about high risk events, e.g. pregnancy or divorce, as well as being inspired by people, famous and not, who are mentally superfit and/or who’ve recovered from big setbacks. These are not pie-in-the-sky aspirations. For example, in the UK the Alzheimer Society is already training four million people to be Dementia Friends. And around the world, hundreds of millions of people are using self-help health sites, taking quizzes or using wearables to monitor their health and fitness. The problem for mental health is not demand, but supply.

There should also be high profile social action opportunities. Every country should have days like Australia’s “RU OK?” day, which captivates the country every September. They should inspire people to train and volunteer to offer emotional health support to others. This could, for example, replicate the success of Crisis Text Line in the US, or create a wider supply of education and employment mentors, or recruit and train support group leaders. It is essential to nurture and fund more peer-to-peer online platforms, which are accredited by health regulatory bodies as meeting minimum ethical and safety standards, but which recruit as many volunteers as people who need help.

To have a successful, sustained campaign over many years, there should be a common language and a standard core approach to emotional health that is widely shared across society. The more this is standardised, the more it will be socially reinforced and the more it will change norms and behaviours. There are currently lots of different approaches to emotional health and little standardisation. It is a Tower of Babel. There are no doubt a range of good options, but one approach should be chosen. Personally, I would choose Steve Peters’ “Mind Management”, set out in his book “The Chimp Paradox”. Peters has combined the latest neuroscience with a lifetime’s experience of clinical psychiatry to create a comprehensive, but simple and brilliantly communicated approach. It’s been lapped-up by elite sports and business people, with some distinguished celebrities crediting their Olympic Gold medals to Peters.

Policy No. 6: There should be a new national “Best Minds Service” for young people, which replaces all existing services, which educates all young people about emotional health and allows those who are ill to self-refer to immediate and better help.

Investment in the mental health of young people is probably the most important of all the investments that can be made. Adolescence is a high-risk period, but also a highly malleable period when the brain is being shaped and character is being adapted. There is a need for a new service focused on the needs of 12-22 year olds. The new Best Minds Service has two key priorities. Firstly, to shift the debate and attention from illness to health, from a small minority to everybody. Secondly, to bring a fresh approach to the services for young people who are dysfunctional or who malfunction.

In shifting the focus to health, rather than illness, the Best Minds Service needs to put in place a youth version of the adult education and social programme set out in Policy No. 5 above. That would include a digital platform with a tailored version of “Be A Great Mate” and “Check On Your Emotions”. It would also include further age-related modules like “Healthy Social Media Use”, and “Starting University”. Young people would be accredited for successfully completing these programmes. All young people would be obliged by their school, college or university to produce their accreditation and to update it at least every two years. This would be a legal requirement on the institution, as part of its statutory duty of care.This would mirror the way that, for physical health, people are expected to produce vaccination certificates or certificates for safety training. Over and above this basic standard, all educational institutions would be offered the chance by the Service to be accredited as a “Best Minds” institution. To achieve this, they would be required to monitor, improve and report on the collective emotional health of their students, increasing the numbers who are super-fit and healthy, reducing the unhealthy numbers and having timely responses for those at risk or becoming ill. The challenging accreditation would be for the successful outcome, with the institutions free to find the best way to achieve it. That might include mental training programmes, lessons on emotional health, peer support, pastoral care and parental involvement. There should be social pressure for all institutions to gain the accreditation and report on their annual progress.

In terms of starting again with services for young people who become ill, the starting points are the same as for adults. That means no GP prescriptions, sufficient inpatient places for young people in crisis and unfettered digital access to psychological therapies like CBT. The Best Minds Service should be the national provider of all services, although it may choose buy some of them from both national and local third-parties, working through contract and under the Best Minds brand. All young people should be guaranteed these four services, with Governments or health insurers making sure that there are no financial barriers to universal access:

  • A new primary care service, based on the successful Headspace model in Australia. These centres, backed by online and telephone help, are staffed by a mix of professionals, including doctors, and are designed with young people to be attractive and welcoming places. Young people, and their families, can turn up when they want to get help with depression, anxiety, stress, addiction, sexuality issues, relationship problems and bullying. Whilst young people and their families should access the centres directly, the Best Minds Centre is where a concerned GP would send a young person. These Best Minds Centres (and their online and phone equivalents) should not just focus on people with problems, but also advise young people on general fitness (like a gym would do for physical health) and handling everyday challenges (e.g. exams, relationship breakdowns). The philosophy of Best Minds would be, by default, to include family and friends in their relationship with the young person, rather than exclude them for medical ethical reasons.
  • A national online Peer-to-Peer service, where young people can anonymously both give and receive support from other young people on emotional health issues. This should be well-funded and regulated so that a well-moderated service can be recommended safely to young people. The platform would automatically monitor young people’s use and discussions to offer them confidential prompts for self-help and for professional help, which should be accessible by clicking through from the site.
  • Immediate access to therapies, without the need for referral, allowing the therapist to judge the self-diagnosed problem and guide the next steps. As with adults, this should include unfettered access to CBT (and similar) therapy and teach-yourself-CBT skills. It should also allow for immediate self/parent-referred access to specialist and rigorously accredited therapy for eating disorders, psychosis and personality disorders.
  • Self-referral to immediate inpatient care when young people are experiencing a malfunction and they, or their family, feel that a community service is inadequate during the crisis. Inpatient care should be small-scale, local and non-hospital-like.

Best Minds should also meet the needs of parents and teachers, who often feel unable to deal with young people’s emotional health issues and who are frightened-off by the current over-medicalisation. This could be done by offering an online platform, with an accredited learning experience to “Be A Great Parent”, backed-up by an online peer-to-peer parent site and online resources to deal with reducing their children’s unhealthiness, dealing with high-risk events and supporting young people through illness. The focus for teachers should be about actively promoting good mental health for all children, training teachers in positive programmes to measure and improve each child’s emotional health during their school and college life.

Policy No. 7 : There should be a new statutory duty on certain services and employers to actively promote good mental health. 

Most western countries have legislated to place a statutory duty on certain services and employers to actively avoid discrimination against certain groups. The scope of this duty varies across countries, but typically it guards against discrimination by disability, race and gender. As a minimum, it should be clarified that, for these purposes, disability includes mental illness, both moderate and severe. However, a more transformational version of this policy would place a duty on certain services and employers to actively promote good mental health. This duty could be placed selectively, e.g. it might be placed on services with involve a higher-risk to the emotional health of consumers (like financial services) or on larger employers, who have the resources to be proactive.  It could also be placed on key government services, like urban planners to ensure that they are obliged to mitigate risks to emotional health, like the lack of green, naturalistic space or safe places to walk or cycle.

Policy No 8 : There should be a bold new international, publicly-funded research and development “Mind Programme” to discover new therapies. 

A new “Mind Programme” needs to emulate how cancer research, at its best, has organised itself in the last twenty years or so. We may not know much about the mind today, but we can be optimistic about what we are about to learn. As Thomas Insel says, “What the EKG did for cardiology, the bacterial culture did for infectious disease, and molecular biology did for oncology, neuroscience should provide for the study of mental disorders”. We do now have better tools to understand the brain, like high resolution imaging, connectomics, high-throughput sequencing for DNA/RNA and whole genome epigenetic analysis. The programme needs to be publicly-funded (and/or Not-for-Profit funded) as the drug company incentives (and current investment plans) are not aligned to what’s needed. It should be genuinely international, to deeply share resources and collaborate on R&D activities. Whilst neuroscience will be key, we should guard against jumping from “brainless psychiatry” to “mindless psychiatry”. So, the “Mind” programme should be as multi-disciplinary as possible, bringing together neuroscientists, psychological therapists, evolutionary psychologists, educationalists, urban planners, data scientists, sports coaches, social workers, etc. The programme should be entirely open-minded about whether the right therapies are drugs, counselling, lifestyle changes, social support or self-help techniques. All solutions should be trialled to clinical standards.

9. Conclusion. 

In conclusion, I agree that more money will have to be spent on mental health. But I have tried to show that money on its own will not be enough. We have to recognise what’s gone wrong in our approach to mental health in the last forty years and how, sadly, we can’t just trust the current professionals to sort it out. Instead, we need to shift our focus to society as a whole and radically raise our ambitions about what can be done. I am not an expert in mental health and I have probably not got the analysis or the solutions entirely right. However, I hope my attempt at both will at least stimulate others to produce something better. I am keen to ally with anyone who cares enough to imagine and bring about a new approach.


What do we need trade unions for?

A lot of workers are losing out. And an even bigger number face huge threats coming down the line. Workers need more help. Help to get better wages, help to gain new skills, help to create new careers, help with childcare, help to work longer and help to cope with dramatic changes from new technology and global competition. Where are they going to find that extra help? Not many of them are seeking it from trade unions. In the UK, only one in seven private sector employees are in a trade union and that’s higher than most other Western countries. Maybe the State has made trade unions, or much of what they currently do, redundant. In most Western countries, workers don’t need to join a trade union to win employment rights now guaranteed by the State (e.g. holidays, parental leave, health and safety protection, non-discrimination, etc) and the State has taken the financial heat off employers in providing old age pensions, top-ups to low wages and free healthcare. Indeed, France has the lowest union membership in the OECD  but the highest employment protection. Employment issues (e.g. the minimum wage, migration, childcare, etc) are front and central in the political agenda in Western countries, but it is no longer the trade unions driving this agenda. Has the baton for helping workers been permanently passed from unions to Governments? Are Governments doing the right things for the future and are there limits to what the State can do? If so, is there a need for a new era of organised labour and what should that look like? The answers depend on what extra help we think workers need.

One thing many workers need is access to more job and career opportunities. And that means weakening the grip of some existing trade unions. The Left likes to portray trade unions in terms of a struggle between labour and capital, or labour and the State. But a lot of trade union activity is about creating and protecting a set of privileges for one group of workers at the expense of others. This matters because the labour market is increasingly sharply divided between a smaller number of professionalised and licensed jobs, which are well-rewarded but have high barriers to entry, and a bigger number of lower-skilled jobs, which are easy to access but less well-rewarded. A good example is the divide between nursing and social care. In the UK, the nursing union campaigned to make nursing a graduate-only profession. This means that people wanting to be a nurse have to undertake five years of post-compulsory education, including a degree in nursing. Unions and Government have combined to centrally plan the numbers to be college-educated and recruited to nursing, making sure that numbers don’t undermine the scarcity value of nurses. The graduate-only and restricted-numbers policies have been a disaster. The UK has a desperate shortage of nurses and even after exceptional levels of overseas recruitment it cannot fill its nursing vacancies. There is a much larger nursing workforce called social carers. In reality nursing is a broad continuum between some highly specialised medical tasks which require doctor-level education and very basic personal care which requires no training at all, with all shades of tasks in between. But nursing unions, and the regulation they have sponsored, overly restrict the nursing tasks which social carers can undertake. Unless social carers can take years out of the labour market to become a graduate nurse, they are limited to low-paid, low skill and dead-end jobs. Nursing could be re-regulated to allow modular accreditation of social carers to undertake specific medical tasks, with the ability to work towards full nurse status through in-work training and assessment. By taking on higher value tasks, social carers could earn higher wages, develop a rewarding career and be upwardly socially mobile. (In turn, the tasks and status of doctors should be opened up to nurses in a similar modular approach to in-work progression.) Even this one example matters – as within the next decade social carers will become one in ten of the UK workforce. But the problem is much more widespread. It is particularly entrenched in three areas: the regulated professions (e.g. law, accountancy, banking, medicine, architecture, etc), the public services (e.g. education, police, social work, health, etc) and where licences-to-trade are required (e.g. taxi drivers, financial advisers, street traders, driving instructors, etc). The privileges accorded to each of these jobs have their origin in the medieval patronage of the State affording workers and traders exemption from competition. In the twenty-first century, one in three American jobs is state-licensed and it is one-in-four in Europe. More generally, the demarcations and exclusive roles of many professions and licensed-occupations are the same now as when they were created 200 years. In most cases, it is organised labour which preserves these privileges for the current job-holders. The organising form varies from traditional trade unions through professional institutes to licence-holder associations. But they are all unions, and they are anti-competitive unions. In many cases, consumers are denied the benefits of open competition and technological innovation. But it is also the wider labour market which suffers. Workers are locked out of the chance to move up the food chain, or to move across and combine roles, or to move into a new job in middle age, or to innovate with new types of job. Most of these privileged workers are increasingly worried about being replaced by software and artificial intelligence. But new technology can be used by lower-paid and lower-skilled workers to augment their own skills and knowledge and allow them to take on higher-paid and higher-skilled jobs. Meanwhile the privileged workers are doing their best to slow down these threats, e.g. the remarkably slow adoption of technology in education. In order to open up the best job opportunities for the many rather than the few, western countries should create a powerful Employment Opportunity Regulator. The regulator should be empowered to identify and remove any unnecessary restrictions on open competition between workers, in the same way that the best regulators open up competition between companies. The regulator would cover all areas of the labour market, accelerate new technology, remove unnecessary restrictions and, where restrictions are necessary, force modular accreditation which allows workers at any age to be approved for specific tasks, or to move up to the next level or to combine any roles together in new types of hybrid jobs. There will be losers, as privileges are removed. But there will lots of winners. And just as importantly, there will be more dynamism in the labour market, fuelling productivity growth and better social mobility. The goal would be an Opportunity Society, where anyone at any age can have a fair crack of making the most of their talents.

But workers also need more economic security. How can we square the circle of increasing the dynamism of the labour market with improving economic security for workers? The answer lies in the State creating the right system of “flexicurity” which supports workers throughout their life, as they change jobs and careers. At one level, balancing flexibility and security is a matter for an individual employer and its employees, both collectively and individually. It is at this level that traditional trade unions are an important part of rebalancing the power of employers and employees. But it is not enough. This is particularly true given the scale of technological change that we face and the urgency of improving productivity. The State needs a national system of flexicurity which ensures that employers are free to manage their business and respond to the market, whilst workers are able to have a successful working life, find new jobs when they want them, develop new skills and cope with periods of unemployment, under-employment or low income. Workers are voters and most voters are workers. Public confidence in the national system of flexicurity is the key to the politics of economic change. Millions of workers feel threatened by new technology, migration and international trade. This is manifesting itself in populist politics, nationalism and anti-business sentiment. Politicians appear to be offering one of these three types of solution to the public’s search for more security:

  • a promise to resist change and to turn back the clock;
  • a plan for the State to take back control from the market economy;
  • an offer of more support for workers affected in exchange for letting the market rip. 

I am broadly in favour of the last option. And therefore the State should offer workers a flexicurity system with these features:

  • keeping it (fairly) easy to fire workers, so that it also easy to hire them; 
  • encouraging flexible jobs (e.g. part-time, self-employed, zero hours, etc) to increase participation in the labour market; 
  • generous State top-ups to the earned income of low-wage workers;
  • State-funded healthcare so that workers can take more risks without worrying about losing employer-funded healthcare;
  • generous, time-limited out-of-work State benefits, easing the transition for workers as employers improve productivity;
  • rights to employment flexibility, for parents and people with disabilities; 
  • State-funded lifelong education, with income-contingent repayment from workers through loans or specific taxes; 
  • good transport links and a sufficient supply of affordable housing to allow geographical mobility, both regionally and nationally. 

Most Western Governments have a lot to do to fully deliver this framework, e.g. France needs to liberalise employment, the US needs to boost self-employment, the UK needs to sort out housing and everyone needs to sort out lifelong learning. If Governments can deliver on this policy framework for flexicurity, as well as open-up new opportunities for all in the labour market, then we need modern trade unions to take on two big roles.

Firstly, we need to see a big step forward in industrial democracy. Every employer of a certain size should be legally obliged to appoint an independent, third party “Staff Association” to organise and represent employees. (If the minimum size was 50 employees, 50% of the UK workforce would be covered. If it was 10 employees, the coverage would be two-thirds). The key word is “appoint”. In my model, the employer and employees would have to agree on which independent Staff Association they chose for their company and it would then be appointed by the employer. They would choose after a beauty parade of potential providers and a secret ballot of employees. Many of these providers would be existing trade unions or professional associations, but private companies and NGOs would be free to compete for these roles. The Staff Association would be funded through a mix of payroll deductions and employer contribution, at or above a statutory minimum fee.  Like traditional trade unions it would operate through staff representatives, supported by the professional staff and services of the Association. If there is no agreement between staff and employer on which Association to choose, then an independent statutory office would select and mandate a provider. The dual-key appointment (and future re-selection) of the Staff Association is at the heart of this model. Both sides need to work together to help the business adapt to change, thrive in the market and share the risks and rewards fairly between the owners and the employees. They need a Staff Association which builds co-operation, pushes for better management and helps engages and motivate the workforce. The Staff Association would have at least one seat on the Main Board and be represented in the Remuneration Committee. All employers (above the minimum size) should also be legally obliged to formally consult their staff, at least once every five years, about employee ownership. Employers would be required to set out the options for greater employee ownership, explain the company’s approach and listen to staff opinion. The options could include stock options, profit sharing, voting rights and full or partial mutualisation. There would be no compulsion on companies to increase employee ownership, only to consult upon it.

Secondly, we need to see a big step-forward in the mutual support workers offer each other. Governments should help nurture a set of “Career Guilds”.  Guilds would offer workers a community, over and above their current job. They would address the issue that workers don’t stick to one employer or career for life and therefore people’s long-term success increasingly depends on their personal networks and their ability to update, reinvent and market themselves. Whereas many well-off people are already have formal or informal career guilds, the majority of workers don’t. In this model, Guilds would compete for their Members, but their aim would be lifelong retention of their Members, offering them the support they need to thrive as they navigate their career through a variety of jobs, employers and customers. The Guilds would be owned by their Members and, whilst they would offer a wide range of professional services, their focus would be on organising mutual support between Members. They might be industry-focused (e.g. construction or childcare), or they might be geographically-focused (e.g. a big city) or they might be solving a common issue (e.g. women in engineering). There would be no compulsion for anyone to join a Guild, but Governments would incentivise membership, e.g. refunding membership fees through a tax rebate to workers, seed-funding a dozen Guilds for the first three years of their life, moving some of the vocational education funding from public colleges to the Guilds, etc. Over and above promoting an esprit de corps and an intensive social network between Members, the Guilds would provide a variety of services:

  • Employment agency – Guilds could eliminate the need for their members to work through separate employment agencies. In the UK, 1.2m workers are on a temporary contract via an employment agency, which is taking a significant percentage of the total wage paid by the employer. Employment agencies in the UK are a business, with 96,000 staff, more than the total number of trade union representatives. The Guild could act an employment agency, pushing for the best wage deal for its Members and mutualising any profits back to the Members. (Most other countries have a much higher proportion of temporary workers than the UK, e.g one in four in the Netherlands vs one in twenty in the UK. So their prize is bigger still)
  • Sharing economy within the Guild – Guilds could digitally match-up their Members to pool their resources. For example, parents with part-time jobs could provide regular, free and reciprocal childcare for each other on the days they themselves are not working. Or self-employed Members could share vehicles, tools, premises and office services to improve utilisation. Flexible workers might pay a commission to each other for helping them find work. Some Members might start small businesses to meet the needs of other Members, e.g. offering P.A. services or security. Guilds might offer peer-to-peer funding, as a saving and credit union, as well as a source of capital investment.
  • Digital marketplaces – Guilds could offer their Members digital marketplaces, their own version of Uber or Task Rabbit, but where all the profits are mutualised back to Guild Members. For example, there is a great opportunity for home carers in adult social care. In the UK, local authorities pay an average of £15 per hour for this service, with the carer typically earning a minimum wage of £7.20. Many workers and clients are equally alienated by the way they are allocated to each other by remote agencies. An Uber style marketplace could allow carers to directly choose and rate self-employed carers, allowing those carers to earn much more of the full £15 and possibly more where they are highly appreciated by their clients. Guilds could bring this type of disruptive empowerment to other areas of blue-collar alienation, like contract cleaning and security.
  • Skills and accreditation – Guilds could transform vocational training. They could turn their community of Members into a hive of mentoring, apprenticeship, work experience and collaboration. They could commission high-quality digital education for their Members, with world-class content, learning records and peer-to-peer forums. They could commission and brand their own accreditation of key skills, whether they have been self-taught, learnt on the job or gained through an educational programme.
  • Financial services – Too many financial products (e.g. pensions, vehicle and equipment leases, unit trusts, insurance) offer poor value for money. Guilds could use their muscle to provide low-cost or specialised options. But Guilds should be able to go further than this. For example, they should be able to offer personal pensions which Members take with them as they change jobs and into which each of their employers makes its contribution during a period of employment. Guilds should be able to offer their Members opt-outs from State  social insurance, e.g. for unemployment insurance. Many flexible workers (e.g. self-employed) will need high quality administrative services (e.g. book-keeping, payroll, etc) and Guilds could offer a trusted service to their Members.
  • Mobility – Guilds could help their Members to move around geographically. This might be through encouraging Members to offer accommodation to each other (e.g. a spare bedroom for someone working away during the week) or it might be having dedicated student-residence style accommodation for people who are working away or just settling in a new area. However, it might  often be about Members offering friendship and support to other Members moving into, or considering moving into, their area.

I think any new support for workers has to have the four strands I have set out above:

  • the State acting to open-up job and career opportunities by re-regulating professions and licensed occupations; 
  • the State putting in place the right system of “flexicurity” to be on the side of the disrupters and the disrupted; 
  • a legal obligation on employers to appoint a third-party organisation to organise and represent its employees; 
  • a new movement of mutual-aid organisations which help workers support each other throughout their working life. 

If we act on all the strands together, we could build the new progressive institutions we need to unlock economic growth, improve equality of opportunity and to rebuild social cohesion.

This piece was published by Radix on 25 September 2016 in its report on the future of trade unionism. This is well worth reading if you’re interested in this subject. http://radix.org.uk/wp-content/uploads/2016/09/Radix-Trade-Unionism-Report-2016-1.pdf

A policy agenda for the White Working Class

The Brexit referendum has poleaxed our national politics and caused millions of us to think deeply and emotionally about our divided society. My wife and I have been reflecting on what’s happened to the nation in our own lifetimes. When we were little, between us, we had two grandfathers working on the Liverpool docks and two in Sunderland, one at the shipyard and one at the pit. Their jobs disappeared in the 1970s and they were forced into early retirement. None of them were romantic or nostalgic about the tough lives they’d led. But when docks, shipyards or pits close, whole communities collapse. Many of those communities still look shattered 40 years later. Our fathers, like many other intelligent but poor boys, failed their 11-plus. Fortunately, both won a good apprenticeship, one an electrician, the other a gas engineer. Those skills gave them mobility. Unfortunately, my father’s took him to work in one of the many brand new factories in Skelmersdale New Town. In the early 1980s, in its very first decade, Skelmersdale totally collapsed. It still looks shattered 30 years later. When my wife and I met as Oxford students in the mid-1980s, it seemed the most natural thing join picket lines in the miners’ strike, standing up for threatened industrial communities. It didn’t work. By the early 1990s, we were living in the Nottinghamshire coalfield as the final pits were closed, devastating our local communities. Many of them too still look shattered 25 years later. Now we live in a, literally, completely different world, in the most prosperous part of the south of England. Not many people here know what life is like in those shattered communities of the North and Midlands. And vice versa. When we return to the North, many of our family and friends have little idea just how good life in the UK can be, for some.

I think we all need to urgently get comfortable talking about the rights of the White Working Class to have a better future. I make no apology for adding and stressing the word “White”. It hasn’t been racist to stand up for better opportunities for ethnic minorities. And it isn’t racist to stand-up for a big slice within the ethnic majority which finds itself an economic and social minority. If this group is not recognised for the problems it has, we can’t be surprised if some of its members assert themselves in unpleasant and racist terms. The political class has to name this race and class problem for what it is and deal with people on their own terms. It is not about white superiority. In many ways, the White Working Class is getting an inferior deal. Their wealth, health and opportunities are unacceptably poor. Social mobility isn’t working well for individuals. Nor are the attempts to ignite the dynamism of many shattered communities. Let’s take the example of poor white working class boys, who now achieve the worst exam results at schools. Much lower than, for example, poor Bangladeshi or African boys. The worst problem is for poor white boys in poor areas. Their results are 60% worse than for poor white boys living in better-off areas. This is indicative of the risk of  concentration effects in a depressed community with low aspirations, tolerating poor public services and losing its best talent to more dynamic areas. Many shattered communities abandoned the Tories back in the early 1980s, leaving Labour to become a complacent monopoly, until the SNP, UKIP and (pre-Coalition) Liberal Democrats appealed to disappointed Labour voters. Now instead of the Blairite and pseudo-Blairite hunt for swing middle class voters, the moral imperative of our political times is to appeal to the the white working class vote with positive, liberal and Unionist policies which they can rightly believe will make their future better. That’s about inspiring aspiration, creating opportunity and fairly sharing the rewards. As a minimum, that must now include White Working Class rights to: world-class healthcare, home ownership, controlled immigration, great education, a better labour-market and a powerful political voice. Let’s take those in turn.


The NHS is the best peacetime expression of our national solidarity.  Free healthcare for everybody whenever they need it, no questions asked. For 93% of us, we are genuinely all in it together. But for the less well-off, that solidarity matters even more. If the NHS isn’t good enough, they can’t opt for private medicine. In the Brexit debate about who we are in the world and how secure we feel, the NHS was a rallying point for those wanting to protect British institutions from external threats and those worrying that the future will be worse than the past. Many people were motivated by the Brexit hopes that £350m per week could be diverted to the NHS, that pressure on services would be relieved by reducing immigration and that we could have fewer foreign staff in the NHS.

People are right to worry about the future of the NHS, especially when the general public finances are still weak and now face fresh challenges. It will need a lot more money in the future. But even if we didn’t still have a large deficit, the public has shown little electoral appetite for higher taxes or increased public spending. So how can we help working class people feel more secure about, and more in control of, the future of the NHS? One answer would be to remove the NHS from general taxation. We could rename National Insurance “NHS Insurance” and hypothecate it to the NHS. It’s raises about enough to pay for the NHS. We could increase it to close the current gap, balanced by a cut in income and business taxes to neutralise the effect. NI, with its mix of employer and employee contributions, is a good basis for a health insurance system. It is a progressive tax and we could be make it more so in the future. NHS tax and spending decisions would be removed from the Treasury’s control of tax and public spending. Instead they would be decided on the basis of national need and the public’s willingness to fund healthcare through this dedicated tax. It would also mean that the public could choose a political party which was broadly committed to low taxes and low spending in other areas, without worrying about the consequences for the NHS.

People are also right to worry about the dependence of the NHS on overseas doctors and nurses. It is a visible that sign that the supply of medical staff in the UK is broken. We have the highest proportion of foreign-born doctors in Europe. 35% of our doctors are from overseas, versus 11% in Germany and 5% in Italy. 22% of our nurses are foreign-born, compared to 6% in France and Spain. But it’s a bigger problem than importing our staff. We just don’t have enough medical staff, whatever their nationality. In terms of doctors per head, we rank 24th out of 27 in Europe. Our totally inadequate services for people with mental health issues and chronic illnesses are held back by a shortage of staff with the right skills. On top of that we have persistent unfilled vacancies for medical staff. Not having enough staff and appearing to be scraping-by with foreign recruits are corroding public trust that national politicians are looking after “their” NHS. We need to do something dramatic. That could be, for example,  a doubling of the numbers of doctors in training. Or a massive programme of training mature adults to be nurses and therapists, as an alternative to the university based systems which lock so many British adults out of the chance to get a great job. These investments could be funded through the NHS Insurance tax.

Leaving the EU will give fresh impetus to making sure that non-UK citizens pay, and are seen to pay, their fair share when they use healthcare services in the UK. The current systems for checking entitlement and charging for services are not robust enough. But it’s not just about cash. We need to recognise that the NHS is our agreed way to ration scarce medical resources. It is an act of social solidarity to trust the NHS to make the best use of its fixed resources. We accept the price we pay in waiting lists, queues, rushed services and eligibility limits. It’s not enough that a short-term migrant has paid a few months taxes or that a medical tourist has paid handsomely for an operation, if the effect is to consume fixed resources which are then unavailable to British people. That undermines the long-term social solidarity which binds us together in an NHS. The solution is to increase capacity (more doctors, more hospitals, etc) , transparently funded by the additional income we receive from shorter-term immigrants and visitors. This could allow us to grow our economy, by earning large overseas revenues from medical tourism and, with digital medicine, from overseas patients.

We also need to acknowledge that White Working Class people have worse health than other groups. People live shorter lives and those lives are more likely to be blighted by chronic illnesses, some of which have become synonymous with poverty. Solving this problem is partly about inspiring people to lead healthier lives and that will take time. Right now there is an urgency to transform the support available to people whose lives are already being limited by their chronic conditions. There are millions of working-age people who are not working because of their long-term illnesses and disabilities. Whether it reading the statistics or just taking a walk around the neighbourhoods, it is staggering how blighted by chronic illness and disability some White Working Class communities have become. The neglect of this group should shame Governments of all colours over the last four decades. Disabled people can be empowered to lead full-lives and, in many cases, to improve their condition. Far too often they are not. We have a set of services which are fragmented and incoherent, operated with too much paternalism and bureaucracy. The spend on this group is massive, across DWP benefits and services, GPs, out-patient clinics, social services and housing. But in too many cases (like mental health, muscular-skeletal diseases and neurological services) people have no access to the high-quality therapeutic support they need and deserve.  We need now to pull the fragmented benefits and service provision together and put disabled people in charge of their lives and the support they receive. We should urgently trial, and then roll-out,  the different ways that we can do this. That includes : Personal Budgets (which give people the chance to make their own decisions on how the money is spent and makes providers compete for their custom) and Accountable Care Organisations (which meet all the support needs of a person in one integrated package). We need to expand the Peer-to-Peer online support available to people with different conditions, alongside a massive investment in R&D in assistive technologies. And we need to put on hold the punitive systems of sanctions, which add insult to injury for disabled people who cannot find the support they need to make the most of their lives.


Actually, the 52% vote for Leave understates British concerns about immigration. Even more people are really worried about immigration. Whilst there are differences of view within the Leave vote about future immigration policy, Leavers are united in believing it should be a British-determined policy. In the cold light of day, it is obvious that European freedom of movement feels like an existential threat for people who feel economically insecure and democratically ignored. It is disempowering to be told that 455m Europeans are entitled to come to a country of 65m as they wish and to have equal rights to jobs, housing and public services from day one. Particularly, if politicians have previously promised that the actual numbers coming here would be much lower than they have been in practice. No matter how many economists explain that it is good for the economy, that doesn’t answer the question of “Why can’t we decide on who comes to our country?”. It’s not inherently racist or illiberal to want to do that. Canada and Australia are great, tolerant countries with strict immigration controls, which engender public support for very high levels of immigration.

So a key response to Brexit must be to give people a lot more democratic control over immigration. However, it is clear that different parts of the country either want or need different levels of immigration. Getting to an immigration policy that’s acceptable to the whole of the UK looks very challenging. London’s role as the world’s most successful city is inseparable from the fact that four out of ten Londoners are foreign-born. And London is in favour of high immigration. In the last decade, Scotland has managed to reverse its long-term population decline by attracting immigrants. But there are areas with virtually no immigration. And they are often the most opposed to the UK being open to immigrants.

One answer would be to let the devolved nations and English city regions make their own decisions about immigration policy. Visas could be tied to particular locations within the UK. In fact, that is mostly the case already for non-EU immigration. For non-EU immigrants, their right to study or work in the UK is tied to a place at a specific college or university or to a job with a sponsoring employer. If they leave the course or the job, their visa ends and they have to leave the UK. Their visa for Edinburgh University or a job in Edinburgh is in effect a Scottish visa. It’s entirely feasible for the Scottish Government or the Mayor of London to decide on immigration policy for students, workers and entrepreneurs. If Lincolnshire doesn’t want many immigrant workers, but is keen to have more university students, then it could decide that democratically in Lincolnshire. Our national systems to fund health and education mean that money will follow the numbers of residents and taxes are currently being localised to respond to local economic growth or decline (e.g. business rates, Scottish income tax). Areas could compete through policy. So, for example, Liverpool City Region might tackle its shortage of 25-34 year olds through attractive work visas for graduates. Visa-holders would, of course, be free to travel around the UK, but they would need to live and work/study in the region which awarded the visa. A balance could be struck between nationally uniform policy (e.g. for elite sports people) and local flexibility. The system would be administered nationally and in practice be little different to that which is operated for most non-EU immigrants.


Housing was a big issue behind the Leave vote. This had a different character is different areas. But it included: the declining prospects of home ownership for many; housing costs rising whilst incomes are stagnant; the proportion of young people obliged to live with their parents; high housing costs pricing people out of moving to areas of greater opportunity; unprecedented numbers of foreign workers in the construction industry; bleak social housing estates. And we can’t deny that immigration has had a negative impact for some people. Up to half of the extra demand for housing has come from immigration and the supply of housing has been chronically unresponsive to our rapidly growing population. That wasn’t the fault of immigrants. It was the fault of long-term failures in housing policy. But that doesn’t mean people are wrong to be angry about their housing options. It is also true that the availability of skilled and mobile East European workers removed the need for the UK construction industry to train, employ and better reward British workers. We need to help more British people to get the skills they want to thrive in the construction industry. We also need to recognise the regional problem. Construction levels are likely to remain highest in the most successful areas. We need to help people in more depressed areas to benefit economically from that construction.

Building and selling homes is easy. It’s the politics of building new ones, where people want to live, that is hard. We’ve tried the line of least resistance for the last few decades. There have been few revolts about development, and there have been too few new homes. Existing Conservative policies on housing have been held back by two principles, which are highly admirable but which, in the current situation, are dysfunctional. The first has been to decentralise decisions on housing supply to the most local level. This is clearly not delivering enough houses. Nor is it likely to. If we look back over the last century, there were two periods when we built serious numbers of housing. One was the 1930s when there were no planning controls and the other was the 1950s and 1960s when Government (local and central) was directly and massively involved in major construction projects. In the 1950s and 1960s, housing was driven forward by strategic authorities, not local district councils. It was mostly the big County Councils (including London which even led major developments well beyond London). They were locally accountable, but not paralysed by parochial resistance. In getting back to serious numbers of new houses, I don’t think there is anyway we can revert to no planning controls. So the only other proven option is for Government-led construction. And that brings us to the second of the current principles defeating progress – that we should leave housebuilding to the market. But that won’t work. Even if Government (local or central) granted lots of planning permissions, private sector developers wouldn’t build them in the quantity or at the pace we need. In our current system, private sector developers aim to keep house prices stable or growing, which means slowing down their construction to keep supply scarce. The opposite of what we need. Yes, we need, over time,  to fundamentally change the incentives for house builders to make the market work better. But in parallel and right now, we need to get houses built in large order quickly, to make up for decades of under-supply. And the urgency is not just about housing demand. It’s also about having a weapon to fight a forthcoming recession. Whether or not Brexit triggers a recession, we are due (on the balance of probabilities) a recession in the next few years. A major housebuilding programme is a perfect response. The construction of 100,000 homes in a year adds 1% to GDP and employs 240,000 people. If we committed to building an additional 200,000 homes per year for 5 years, that would lock-in an extra 2% of GDP per year and nearly half a million jobs throughout the period.

There is nothing, but political will, to stop us building a couple of million extra homes in a hurry. The demand is there, suitable land is plentiful and we could reshape our economy by doing it. There are choices about the policy for an immediate massive programme. But it could include these elements:

  • Government can finance the major housing developments directly to ensure that a couple of million market homes are completed rapidly and it can take on the risks of any delay in selling or a reduction in prices due to rapid increases in supply. There are lots of technical options that make this easy to do. Government can also cash-flow the new infrastructure ( transport, hospitals, etc) ahead of the houses. We should remember that the Treasury got all its money back from the New Towns it financed.
  • Big new permissions could be granted by more strategic authorities. In England, this could be through existing national powers (of the kind that created the London Dockland Development Corporation or the Milton Keynes New Town) or the new City Region Mayors. These powers include the right to grant permissions, to compulsorily purchase land and do the building. The other national governments in NI, Scotland and Wales have similar powers to act strategically.
  • Social homes could be sold on the open market when tenants decide to move on and the money raised (about £90,000 per property after the debts are paid-off ) is more than enough to subsidise the building of a brand new, better social home for each one sold. This alone would be big enough to build 200,000 extra homes every year for 20 years. There would be no fewer social homes, only better ones.
  • We could move to greater off-site construction. A big planned programme would allow us to set-up major employment sites in deprived parts of the country, to manufacture most of the homes which are then put-up in high-demand areas. Outside the EU, we would no longer have the current limitations on such state intervention to stimulate a new industry.
  • A massive apprenticeship programme could be created for people of all ages, but especially the young. Without EU restrictions on labour, we could build a new generation of British builders.

Of course, for every one delighted with their new more affordable home and for every new skilled builder, there will be people unhappy that new homes are being built in their area. In my experience, this is a time-limited reaction and people do get used to the change. In the short-term, though, the parochial politics is fiercely hard to deal with. There will also be a negative reaction from the highly-profitable big builders and those who want to profit from over-priced land.There is a need for really strong political leadership, nationally and in the strategic authorities, to manage this reaction. (Perhaps, we need to help this with more of the profit from land sales going as private compensation to those most affected). At some point, though, houses need to be built. Currently, we are only deferring the political fight, at the expense of today’s disillusioned young people, and their families, up and down the country.


Life chances for the White Working Class are not good enough. We don’t yet have all the answers. But we do have some of them. There needs to be an aggressive, urgent programme of bringing those solutions to the White Working Class. And a parallel track of experimenting and searching the world to find fresh solutions.

As Michael Gove once said, a place at a good school should be seen as a Civil Right. An inalienable and universal right. We need a national, urgent response to any denial of such Civil Rights, in the same way that JFK intervened in the 1960s to impose Civil Rights on reluctant States. After 25 years of serious school reform, we can’t keep waiting for some areas to get their act together. In 25 years, inadequate schools will have let down five generations of 11-16 year olds. Whilst primary schools have improved across the country, progress in secondary schools is unacceptably poor in too many areas. But we know what to do. London has shown the whole world how to reform schools serving poor communities. The success of many London schools in the most challenging circumstances is simply stunning. The risks of going to a school where most pupils are disadvantaged have been eliminated. Half of pupils on free school meals in London now get five good GCSEs, compared to one in five in 2002 and one in ten in 1987. But in Knowsley it is still only one in five. In Greater Manchester, it is less than one in three and in Liverpool one in four. There are great successes in the North. Newcastle, like London, has 85% of schools rated good or outstanding. But in Knowsley, for example, there are no secondary schools which are good or outstanding, in spite of massive public spending on its schools. The Government urgently needs to mandate a London-style, no-holds barred transformation in each under-performing White Working Class area across the country. It should be flexible on the means, be it the arms-length trust that worked in Hackney, the local authority leadership that inspired Tower Hamlets or the Ark-style academy chains which offer parents a trusted brand. It’s time for pragmatism, not dogma. The time for patience, however, has passed.

But education up to 16  is not just about schools. Affluent families complement schools with a wide range of educational opportunities. That’s one of the reasons working class families are at a disadvantage. There is an urgent need for Government to offer more than schooling. Digital platforms provide the chance to inspire and engage young people outside school. Why don’t we have an Open School to mirror the Open University’s success? Sesame Street had more impact on poor kids’ life chances than expensive nursery education. So, why don’t we invest in exciting digital content. The National Citizen Service is a great way to bring young people together at 16. But we need a bolder, bigger extra-curricular programme that starts at the age of 7 – a sort of Duke of Edinburgh Award on steroids.

The education offer to working class youngsters after the age of 16 is simply not good enough. It is morally wrong to allow colleges and universities to recruit students to courses which offer poor value in terms of improved life chances. It is heart-breaking to see working-class students embark on 2 to 5 years of full-time education when the routes they are taking have a high probability of failure. They are often sacrificing several years of wages, taking on large personal debts and missing-out on better career routes to pursue courses that are clearly a bad bet. It is morally right to turn this around. For example, student loans could be conditional on a ‘credit rating’ for each course, excluding those courses with high dropouts, low entry standards, poor degrees and insufficient earnings premium. That might exclude 20% or more of current courses. Beyond universities, we see only one in three FE colleges are good or outstanding and only half of apprenticeships get a positive rating. We should accelerate the policy switch from full-time FE courses to on-the-job training by putting more of the funds and choices into the hands of students and employers. We need to transform online training, perhaps with a massive Open College to build on what the OU has done in HE. We also need to upgrade and expand apprenticeships. Apprenticeships should not be seen as a consolation prize for non-academic young people. All of the top jobs (in law, medicine, accountancy, etc) are based on a formal apprenticeship, of supervised on-the-job training. As well as improving access for working class youngsters to these esteemed jobs, we need to replicate the esteem of these traineeships in other apprenticeships. We have that already with some technical employers, like Rolls Royce in the aerospace industry. And we mustn’t constrain working class youngsters to the vocational education on their doorstep. In the same way that they are fully supported to travel to university anywhere in the UK, they should be supported to move anywhere they choose for a high quality apprenticeship or FE programme.

Creating better life chances is not just about improving educational opportunities. We need a powerful new Employment Regulator, whose job is to liberalise the employment market and to break down the barriers that limit the careers of working class adults. The Employment Regulator should be tasked with ensuring that everybody in the Labour Market has the ability to earn the most they possibly can and it should actively remove any unnecessary barriers to their ability to do that. This would mirror what competition regulators do to ensure that any business has the right to compete in markets where vested interests or out-of-date rules get in the way. Let’s use the example of Adult Social Care. It currently employs 1.6m people. This is predicted to grow to 2.6m by 2025. It is a huge employer of the White Working Class. Too often, the jobs are badly paid, the work is alienated by a mix of bureaucracy and exploitation, and the occupations are seen to be a dead-end with zero progression. Sadly, nobody is on-the-case to make it work better for this vast number of hard-working people. A muscular Employment Regulator would look at, for example, the fact that 700,000 home care assistants earn just £7.20 out the £15 which is paid (by local authorities and private clients) for an hour of their time. The Regulator might step-in to replace the current alienated employment system with online, on-demand systems where clients directly choose and then rate their carers, ensuring that much more of the fees go to the staff, rather than being lost to them in both agencies and public sector providers. But the Regulator should also be empowered to remove unnecessary restrictions on what people can do. In the case of social care staff, many of the care tasks which they could (after additional training) perform are off-limits to them and reserved for nurses. Nurses have to be graduates with a comprehensive medical training. This creates an artificial gulf between who is allowed to provide services and who isn’t. The Regulator could de-regulate and open-up the supply of care services, giving working class staff the incentive to upgrade their skills and the ability to earn much more by providing services currently restricted to a scarce group of professionals. The Regulator should also be tasked to steer the best course through technological disruption. Let’s look at the 700,000 drivers, many of whom are White Working Class. In the foreseeable future, many vehicles (cars, lorries, buses, vans, etc) will no longer need a driver. Right now, technology (like GPS or on-demand marketplaces) mean that traditional restrictions on who can work as a driver are out-of-date. It is one of many areas where we need a Regulator who can ensure that disruption happens to benefit consumers, but who is also charged with creating the best opportunities for the disrupted employees. On the side of disruption and the disrupted. And using disruption of the status quo as a force for good for the working class.


I have tried to illustrate some of the policy ways that our national politics could respond to the needs of the White Working Class. There are many others and there will be better solutions than mine. What matters right now is not the specific proposals, but the process of listening, engaging and creating a shared political agenda for the White Working Class. One which provides hope and opportunities for a better future.

Squaring the Circle – Letting different parts of the UK have the immigration they want

There are two really pressing issues of national cohesion in the aftermath of the Brexit vote. Firstly, we have to create our own immigration policy, with emotions running very strong on both sides of this debate. Secondly, there is huge tension between different parts of the UK about who is going to be telling the others what they have to do. These two issues come together on immigration, with,for example, London and the East Coast of England having contempt for each other’s views. Being in the EU meant that the UK tended to walk away from these internal conflicts. We knew that we had no control over EU immigration and left it up to EU immigrants to choose where they settled. But now that we are taking control back from the EU we have to face up to the tensions. Is it possible to square the circle and let different parts of the UK have the immigration they want? And could this be a key part of a wider strategy for a Brexit UK, using our new control to create a flexible UK, defusing the anger of both Remain and Leave areas and creating a Re-United Kingdom?

I have an idea that I think is worth considering. We could have regional immigration visas. Rather than just having a blanket national policy, we could devolve decisions on much of immigration to the nations and city-regions of the UK. This may sound bonkers to many people. But the great majority of our current visas for non-European immigrants are already tied to a specific location. If you want a study visa, you have to be accepted on a government-approved course at a specific accredited university or college. If you drop-out of that specific university, your visa is invalid and you have to leave the UK. The same is true of most work visas. Most individuals from outside Europe who want to work in the UK need a government-licensed UK employer to sponsor their visa for a particular job. If an individual stops working for that employer, the visa is invalid and they have to leave the UK. By definition, these visas are tied to a location. Your visa for Edinburgh University or for a job in Edinburgh is tied to you living in Scotland. It is already a Scottish-specific visa. And we should remember that this is true in other Western countries – visas for work and study in North America or Australia are, in practice, similarly tied to specific locations.

As we have a robust system for location-specific visas already, it is entirely feasible to devolve control for much of immigration policy to sub-UK levels of government. Visas would still be issued and operated by the Home Office. We could tighten the locational aspects of the existing system further to secure public confidence. For example, individuals could be required to be registered for, and paying, Council Tax (as their primary home) in the nation or region to which their visa is attached. Or those on an Entrepreneur Visa could be required to be to be registered for, and paying a certain level of, Business Rates in the location for which their visa was granted. We would need to tighten-up the system of immigration enforcement to ensure that people don’t breach their visas, but we need to do that anyway, especially once we’ve left the EU.

In theory, control of visa policy could be devolved to any level of government. But I think some are more appropriate than others. There is an overwhelming argument to give this power to the Devolved Nations of Scotland, Wales and Northern Ireland. Next in line would London, which has both a legitimate and accountable government in the Mayor of London and clearly a unique position as a world city, where almost four out of ten people were born abroad. There is a strong case for the new Metro Mayors (e.g. in Greater Manchester, Merseyside and the West Midlands) to have the same powers. There may be a case for some of the large Counties like Kent or important cities like Bristol or Newcastle. The only real limitation is that there has to be a legitimate and accountable government for the location, which people can kick-out if they don’t like its immigration policy.

We could exempt a range of visa categories from devolution. But only if we want to. It could be a narrow or broad list of national entitlements for a visa. A narrow list might include existing distinct categories in our current non-EU immigration system, such as elite sports people, intra-company transfers in multi-national companies and the (limited) ability to join family already in the UK. In terms of a broader list, I assume it’s the settled will of the country to allow all Irish Citizens the right to live and work in the UK. We might want to extend that to others like Canadians or Australians. We might want to exempt all student visas from devolution and simply declare that the UK is open for business on education. The education system for non-EU students is already pretty tough in its requirements (on the levels of approved courses, standards of English, proven ability to fund life in the UK, paying a charge for the NHS, registering with the Police, etc). Or we might want to stick to a very narrow list of national entitlements for a visa and devolve most decisions to a sub-UK level.

If much of immigration was devolved, what would happen? Well, politicians would need to win local public confidence in their local immigration policy. They would need to find the Goldilocks level (not too much, not to little) to drive their economy whilst maintaining public support. This would allow London and Scotland, for example, to do what they wanted, with the political risks and rewards localised. London may, for example, want to expand visa opportunities for low-skilled workers, if that makes political and economic sense for the people of London. An area like Merseyside could devise an attractive immigration policy to solve the problems of its declining working age population, the disappearing 25-34 year olds and the lack of business start-ups. Other areas might decide to have very little immigration. In practice, that is likely to be areas which have little immigration right now. They might change their mind if they see other areas thriving, with their locally-determined higher levels of immigration. Or they might not. But that would be their democratic right. It would also be the limit of their democratic right. They couldn’t decide to stop London or Scotland or Wales or Manchester or wherever else doing what they wanted to do.

Clearly local areas would need to make economic and financial calculations about immigration levels. Increasingly, the fiscal system will fund any expansion, or punish any contraction of the population, especially of the economically active population. Scotland is now exposed to growth or decline in income tax. English local authorities will be raising all their finance locally and local taxes (Council Tax and Business Rates) respond to immigration levels and activity. A devolved immigration system, with public support for the planned levels, might improve public support for greater house-building in their own area. And the national per capita funding systems for health and education will increasingly direct funding to areas of growing population, and away from those areas with relative decline. If politicians can show that housing and funding for key public services are increasing (or declining), they will be able to lead a robust immigration debate in their area.

This idea has much to recommend it. Our non-EU visa system is already, essentially, location-specific, as it is in other Western countries outside the EU. Different parts of the country want different levels and types of immigration. This idea builds upon the theme of “The People Taking Control” and creates a much more democratically accountable system for immigration. And the beauty of the non-EU world is that if we don’t like how it works in practice, we can just change it. Whenever, and however, we choose.

The Brexit Referendum: A Game of Many Halves


Half-In or Half-Out?

We don’t have a choice about being In or Out of the EU. We have a choice about being Half-In or Half-Out. They may sound the same but they’re not. Right now, we’re already Half-Out. That means we are in the EU, but we have opted-out of, for example, the Euro, Schengen, the European Central Bank, the bail-out plans and the Commission’s refugee plans. We have enthusiastically opted-into the free trade in goods, the expansion of liberal democracy and the cheap travel and phone calls. We have mixed views as a nation about the free movement of people, energy policy and the accession of some of the new or future countries. But, love it or loathe it, we know what EU deal we already have. We can’t be made to give-up what we have, like our opt-out of the Euro or our budget rebate. If we remain Half-Out, then we know what we’re entitled to block, modify or opt-out of in the future. If we vote for Brexit, then we could be Fully-Out. But that won’t happen, because we’ll end-up arguing our way back into parts of the EU and thus become Half-In. But if we decide to be Half-In, we lose all our current certainty about which half we can have and which half we can forget. We lose our veto over the EU’s decisions. And we lose our automatic rights to anything all. We will have to hope that we’re given somethings we want and that the price the EU charges us for those things isn’t too painful. One of the faults of the EU is that it is protectionist and against outsiders. If we stay, we can try to change that. If we leave, I fear that we will experience the same frustrations as others who try to trade with the EU. We do need to be at least Half-In. Like it or loathe it, the rest of Europe has decided to govern itself through the EU. So that’s where they will decide upon the direction of Europe, the operation of its markets and how it relates to the outside world, which would include us, if we leave. That Europe would be 20 miles away and the source of half of our trade and foreign investment. Our most successful industries (aerospace, automotive, pharmaceuticals and financial services) are woven into the European ecosystem. I make a rule of always discounting all economic forecasts, as economists have no more certainty about a highly uncertain future than anyone else. But it’s clear that the disruption of leaving the EU would have a big short-term hit on the UK economy. Beyond that no-one knows. But it’s not just about trade and investment, vital though that is. It’s about all the big strategic issues. It is clear that the US has pivoted towards the Asia Pacific region and now expects a rich and highly developed Europe to increasingly sort itself out, and its backyard. They have a point. Much of Europe has been a free-rider on US defence spending and diplomatic power for decades. Europeans are going to have to step-up, spend-up and face-up to the regional big issues on their doorstep, including Russia, Turkey and the Mediterranean countries of the Middle East and North Africa. These issues won’t fit neatly into NATO and the EU will be key forum for our main allies. Anyone who thinks we can ignore the EU as a geo-political forum hasn’t looked at the  parlous state of the UN recently. There simply isn’t an alternative for our wider region. And, anyway, at times we may want to side against the US and with our European neighbours, as we should have done over Iraq in 2003, for example. I am certainly not arguing that we are too weak to be Fully-Out of the EU. The comparisons with Norway, Switzerland or Iceland are a category error. By population, the UK is 8 times bigger than Switzerland, 13 times bigger than Norway and 200 times bigger than Iceland. The UK’s economy is much bigger than India and twice the size of Russia. A UK outside the EU is probably more analogous to Canada’s relationship with the US. A good place to be, but not good enough for the UK, by a long way. We will not want to be Fully-Out, because there is so much we will need to influence. My point is that the world is regionalising, both economically and politically. To most countries and companies in the world, we sit in a region they call “EMEA” (Europe, Middle East and Africa). The other two global regions are “ASPAC” (Asia Pacific) and “The Americas” (North, Central and South). Both business people and diplomats have to work within these very real, and deepening, divisions of the commercial and political world. The EU will dominate, for good or bad, what’s happening in much of EMEA and we will have to influence that. The seats for that influence sit within the EU. Nowhere else. So, I have concluded, as fully paid-up Eurosceptic, that we can’t be Fully-Out. If we had to be a Fully-In member of the current EU (with the Euro, etc) then I would almost certainly vote to leave. And if our membership of the EU required us to join a United States of Europe, with a federal government for Europe, I would definitely vote to leave. But the best way to stop that happening is to stay in the EU, where we have a total veto on a United States model. I do think that idea is dead and buried anyway. But just in case it rises from the dead at some point or in some form, we have the legal right, in our current Half-Out state, to veto it. If we leave the EU and creep our way back into a Half-In state, then we will have no such power to prevent the rest of Europe committing an error that make the Euro look like a minor hiccup. If we leave, it’s hard to imagine ever getting a Half-In position anywhere near as good as our current Half-Out one. So let’s hang onto it. And if the worse to come to the worse, we retain the power to leave the EU in the future if we want. If we leave now, we have no right of return.

Half-Full or Half-Empty

But hanging onto our Half-Out EU membership doesn’t mean just accepting the EU we have now. The point of remaining in the EU is to make it better, not just for us, but for our trading partners and our military allies, whose strength and stability is our strength and stability. In fact if the EU was already perfectly placed for the future, it might be easier to decide to leave it, knowing all would be well. Agreeing whether the EU glass is Half-Full or Half-empty, and in what ways, is the critical next moment for Europe as a whole. It’s definitely not empty. The EU has, for example, created the incentives and framework for Eastern Europe to move from being poor, totalitarian communist states to the liberal democracies and increasingly prosperous economies they are today. It similarly supported Spain, Portugal and Greece on their journey from dictatorship in the 1970s to today’s democracies. The Balkans are being incentivised out of their genocidal destruction to a much better future. By any measure, the EU has created a remarkably strong single market in many sectors. However, the EU glass is definitely not Full either. And it’s certainly not Over-Flowing in bad ways, as some of its existential critics allege. Freedom of movement is not out of control. 97% of Europeans live in the country in which they were born. Countries have overwhelming sovereignty over their own affairs. You only have to contrast the UK’s flexible labour market with the French labour market to see this. No-one is forcing us to have Denmark’s tax levels or Italy’s business-stifling regulation. No-one is stopping us emulating Germany’s skill system or fixing our own housing problems. Nor is European regulation out-of-control compared to the rest of world. In fact it is quite the opposite. But even to its supporters, the EU can look Half-Empty, often for different reasons to those with competing visions. To the federalists, there is the Half-Emptiness of economic policy-making, where currency union has not been matched by fiscal union and the structural imbalances which make the Euro such bad news for some countries have not been addressed. The federalists can see that whilst the EU now represents Europe in foreign policy forums (eg the G7), it does so as a very junior partner alongside the sovereign leaders of the member states. I don’t think the federalist glass is Half-Empty, so much as broken and leaking. The last few years have shown the Federalists that their dream is over – there was no appetite for fiscal transfers to Greece; there was no acceptance of a co-ordinated plan for allocating refugees across Europe. Public sentiment in many countries turned strongly against further European integration. And it’s obvious that perpetually half-pregnant solutions like the Euro will need to be rethought. To the free-marketeers, their sense of Half-Emptiness focuses on the incompleteness of the single market, the EU’s protectionist attitude to trade with non-European countries and its favouring of regulation at the expense of economic dynamism. Like others who have run global businesses, I know that, compared to most of the world, the EU is very definitely Half-Full, rather than Half-Empty as a free market. But it could be so much better. There is an urgent need to complete a single market for services, which really doesn’t exist. We’ll know we have this when, for example, Google responds to our retail searches with the best offers and adverts from right across the EU. There is a pressing need for a fresh attitude to trade deals outside the EU. On the one hand, the EU’s approach is stifling other countries, e.g. on food trade with Africa. On the other, the EU is held back by the lack of trade deals with the world’s two biggest economies, the US and China. Unless the EU embraces and demands more creative destruction in the economy, it seems unlikely that the EU will catch-up with the US on new technology. Without intense EU collaboration, it is hard to see Europe’s universities catching up with the US or our defence industry surviving in the face of US competition. Those who believe that Europe is not capable of working together to create world-beating industries only need to look at the amazing, inter-governmental success of Airbus. With the federalist dream now dead and the increasingly pro-market reforms in countries like Italy, this is a good moment to ask not whether the EU glass of the last 20 years is Full or Empty, but how many glasses do we want in the future (i.e. what do we want to do together, or not) and how big should they be (i.e. how far do we want to pool sovereignty for our own good). A good example is free movement of people. We need to debate how big this should be. Perhaps, countries could have the power to cap free movement at the European average level of 3% and after that apply their discretion. I am big fan of free movement, but I don’t think its sustainable to say that well over 400m Europeans have the right to live in the UK if they want. Nor is it right to deny people control over such a key issue about their country. The time is right for this debate, and a much wider reset of what the EU is about. And it’s no longer just the UK asking to have the debate. If we vote to stay a member of the EU, we have a powerful position to shape the next Half of the EU’s life to suit our vision for the future and the best way to get there. If we leave, we’ll most likely just be a nervous spectator, ignored and resented by all. And without us as a member and without our current veto, the EU’s ability to get it wrong or skew things in a way that is bad for the UK is a real and present danger to our future. And we get all this influence by simply staying Half-Out.

Half-Hopeful, Half-Fearful

The third Half of the game is how we move-on from the referendum. Because the country is clearly split down the middle, with the vote itself on a knife-edge. Nearly Half of the country will be disappointed by the end of this week. It’s important to see how people are dividing. It seems likely that the biggest difference will be age. People under 43 seems to be in favour of staying, with that feeling strongest amongst the youngest. People over 43 seems to be in favour of leaving, with that feeling strongest amongst the oldest. It is, co-incidentally or otherwise, 43 years since the UK joined the EU. But the vote is also likely to be divide by social class, with the poorer groups wanting to leave and the richer ones wanting to stay. And the geographical divides are likely to be quite stark, with London and Scotland overwhelming wanting to stay in the EU. This isn’t just about the Optimists versus the Pessimists. I am definitely an Optimist. On any objective measure there has never been a better place to live than the UK in 2016. There are, of course, some equally good places enjoying record success in 2016. I want the UK to be even better in the future, more equal, more inventive and more caring. But I feel very positive about the UK’s future. And one of the problems in this Referendum is that the Optimists are divided. Some have a strong preference to be Half-Out of the EU (like me) and some want to only be Half-In in the EU (like some of the people I admire hugely who have joined the Leave side). Both believe that the UK is a great place and that it can be better still. But with the Optimists divided into two camps, each needs to attract a large number of pessimists to achieve more than 50% of the vote for their favoured EU solution.  The Remain side has targeted the risk-averse and vocally stressed the risks to win their vote. The Leave side has targeted those who blame others (immigrants, Brussels, etc) for things they don’t like about the UK today and who don’t trust the opinion of the elites. By definition, the risk-averse tend to be those who have most to lose or who are most positive about the current path the country is following. By contrast, those who distrust the elite, want someone to blame or prefer the past, are more likely to be the have-nots, the older population and those in depressed local economies.  The combined and (mostly) unintended effect of the campaign has been to create a degree of doom, gloom and division which is out of proportion to the problems the UK faces, either now or in the future. Whichever way the vote goes, there will be a need for a really strong One Nation political leadership. We will need it to heal the divisions of the referendum. If we decide to leave the EU, we will need it to hold Scotland within the UK. If we’re leaving the EU, it will take something extraordinary to prevent millions of settled, successful EU immigrants from panicking and throwing our economy and public services into complete chaos.  But the referendum has also shown that we need a One Nation politics to bind together the optimists, the risk averse and the dissatisfied into a new coalition that protects what’s great about the UK, as well as confidently opening up to the world and to economic disruption to create an even better future. This need cuts across traditional party politics, as many Labour politicians have been shocked to see during the campaign. I think that many people are deeply uncomfortable with a binary vote of being In or Out. Nearly everyone wants a different type of EU and to be selective over which parts of the EU they want to keep or lose. I think our best shot at achieving this sort of third way is being a strong One Nation country which votes to remain Half-Out of the EU and from that powerful position plays a leading role in reshaping the EU into a powerful alliance of liberal, prosperous and independent nations who shape their individual destinies together.

It is time to end traditional trade unions and replace them with New Unions

Workers today badly need strong unions. But they don’t need the traditional trade unions of the 20th Century which are as obsolete as the traditional industries and socialist aspirations in which they were born. Labour is currently losing the battle against capital. In the 1950s and 1960s, Western labour and capital worked together pretty well. The returns to labour (wages, conditions, entitlements) rose steadily, whilst the returns on capital were actively reinvested into businesses and grew productivity. It went wrong in the 1970s. Labour got too greedy, it fought against change and the wheels came off. Increasing globalisation left uncompetitive businesses exposed. Capital fought back hard in the Reagan and Thatcher era, and won. Although the next generation of political leaders (Clinton, Blair, etc) used the state to ease the pain, labour has not recovered parity with capital since the battles of the 1980s. But workers need more than just politics to sort this out. Workers need unions who focus on helping their members as individuals to each earn the most money they can in the world we now have – a world of flexible jobs, global competition and technological disruption. They need their unions to be creative players in the economy, not commentators, politicians or protestors.  We need a set of New Unions. New Unions who have just one mission: to help each individual Member earn the most money they can, right now and into the future.  They should compete with each other for Members based on who delivers the best earnings. They should do all and anything they can to win this battle. They should offer a lifelong community, based on careers not particular jobs or employers, be multi-disciplinary so they don’t resist change and focus on total earnings, not an individual wage. If I was starting one of these New Unions, I would call it “EarnMore”. I am going to set out 8 things which an EarnMore could do to win its first 1m members and boost their net incomes.

But first let’s look at the starting point for New Unions. Or, rather, the end point of traditional trade unions.  83% of workers in OECD countries have chosen not to join a union. In the US, the proportion of workers in a trade union has fallen from 31% in 1980 to just 10% today. In the same period, it fell from 50% to 25% in the UK, from 49% to 17% in Australia, from 35% to 18% in Germany and from 19% to just 8% in France. Only the Scandinavian countries (with up to 68% in unions) and Belgium (at 55%) have a majority of their workers in a union. The UK, for example, illustrates the death of the union. Membership rates are just 14% in the private sector, 13% for low paid workers, 15% for temporary employees and 16% for smaller firms. 4 out of 10 members are over 50. Membership levels are only strong in the public services and utilities. In hotels and catering, for example, membership rates are just 4%. One reason for their decline is that much of their job has been done for them by governments. Employment legislation in western countries protects all workers (whether union members or not) against discrimination, dismissal, unsafe working, abusive wages and excessive hours. This problem is shown in France, where trade union membership has always been low and now is far and away the lowest in the OECD. But French workers enjoy the greatest employment protection in the OECD. For example, temporary workers have 10 times more protection in France than in the UK and 3 to 4  times more than Germany, Sweden and Japan But it’s not only employment protection legislation that has rendered traditional unions redundant. There has been a big growth in occupational licensing and regulation by Western governments. Typically, in European countries, a hundred or more jobs are now regulated. Across Europe, between 10-24% of the workforce has a regulated job. In the US, 30% of jobs are now licensed by the government, compared to just 4% in 1950. This licensing in the US and Europe adds a significant wage premium of up to 20%. In most countries, there are more licensed staff than there are trade union members. Trade unions have historically played a big role in campaigning for these employment rights and regulation, and opposing de-regulation and flexible employment. But they have in fact legislated themselves out of a job. The political landscape on employment issues is now a crowded space and traditional trade unions won’t be missed. Anyone who doubts this should look at the current high profile political debates in Western countries – how far to increase the minimum wage, how to liberalise European labour markets, how to reduce the gender pay gap or whether to allow more competition for licensed taxi drivers. Trade unions are no longer the main actors in these debates.

So if we abandon the traditional mission of achieving socialism through political action, what can unions actually do to help their members earn more, now and in the future? One place to look for insight is 15th Century Italy, in Florence. Modern capitalism started in Florence.  It invented investment banking, merchants, the industrial city, patents, trademarks and the trade union. The Florentine union, or “guild” as it was known in the 15th Century, was much more powerful than a modern trade union. The guilds incorporated the city’s businesses and nominated the city’s government. They trained workers, organised trade, protected intellectual property, provided welfare to members’ families and support services (like watchmen) to members’ businesses. Becoming a member of a guild was the route to a skill (through the apprenticeship route to master or even grandmaster level) and to a commercial income (through the protection a licence offered against competition). It was also the route to social and political status. There were 3 levels of guild – Arti Maggiori (the 7 major guilds like lawyers, bankers and doctors); Arti Mediane (the 5 middle guilds like butchers, masons and smiths); Arti Minori (the 9 minor guilds of inn keepers, carpenters, bakers and wine sellers).  But the majority of the population (the Minute Populo) were not even allowed to form or join a guild. This included skilled workers like weavers and boatmen who all remained waged staff. To cut a long story short, the Arti Maggiore became all powerful. Other guilds gradually disappeared as they got in the way of the new capitalist merchants. In the end all of Florence’s guilds were abolished in 1770. The legacy, though, is profound. Today’s Arti Maggiore have many of the characteristics of a Florentine guild. Law, medicine, banking and accountancy: all have tightly regulated professions; they group together to train their apprentices; form partnerships to maximise individual incomes; exclude competition through regulation; enjoy high returns on their scarcity and barriers to entry. The most affluent in our societies are doing really well out of employment unions. Many middling occupations (the equivalent of the Arti Mediane and Minori) have retained the protected trade mix of self-employment and state regulation, e.g. bar owners, taxi drivers or electricians. And the great majority (the Minute Popolo) have remained dependent employees with limited occupational regulation or economic power. We undoubtedly need to tackle the self-interest of today’s Arti Maggiori where they conflict with consumers’ best interests, as they often do. But we also need to help the Mediane, the Minori and, most importantly of all, the Minuto to emulate the economic power of today’s Maggiori. That’s the role of the New Unions.

Here are 8 ideas for New Unions to provoke debate:

  1. Totally replace employment agencies – In the EU, 1 in 7 workers (14%) are on temporary contracts. In some countries (e.g. Poland, Spain, Netherlands) this increases to 1 in 4 workers, or more. The proportion is much lower in countries where it is easier to hire and fire permanent staff (e.g. just 6% in the UK and Australia). Unionisation of temporary workers can be very low. In the UK, for example, only 15% are in a union (vs 25% of the total workforce). Employment agencies are often the best hope for temporary staff, as they are heavily incentivised to match jobs and people. Using the UK as an example, employment agencies place about 700,000 people a year in temporary jobs and about 1.2m people are on a temporary contract secured by an agency.  It’s big business, with revenues of £33 billion last year. There are 11,000 agencies employing almost 96,000 staff. That means there as many as staff in agencies as there are union representatives in the UK. The New Unions should take on these roles. The margins of 20-30% provide a good source of attractive dividends for their members. But more importantly, if the purpose of the New Unions is to maximise staff (rather than shareholder) returns, they can create economic power for their members. This might mean that permanent employees opt to become temporary ones.  We can already see this happening in the UK in healthcare and education (with nurses and teachers choosing agency work as higher paid than regular contracts). A halfway house may be that employers hire staff but they are obliged in the deal to use the particular New Union’s terms, conditions and contract not have their own.
  2. Create a sharing economy within the New Union – A New Union should aggressively drive sharing between Members to help them earn more. A simple example might be childcare. For many parents, the cost of paid childcare is prohibitive, limiting how much work parents can afford to take on. Or if they do pay for childcare, greatly reducing their net income from working. But let’s think differently. Think of a parent working 3 days per week and spending 2 days at home with a young child. That parent could provide free childcare to another parent on 1 or both of those days that they are at home with their own child, in exchange for free childcare for their own child when they are at work. This could transform net income for working parents. Babysitting circles have worked on the same principle for a long time. Similarly, within the New Union, people could exchange or buy the downtime of other members’ tools, vehicles, workshops, offices,etc. Members could sell car sharing to each other for commuting and provide cover for each other to reduce losses due to illness or emergency leave. They might earn a paid commission from other Members for finding them extra work.
  3. Own and expand the “Gig Economy” for Members – The New Unions should compete to offer the best digital solutions to help their Members earn more money. That means, for example, having their own version of Task Rabbit or Uber. It requires New Unions to use the same means as private companies (digital marketplaces, consumer rating of workers, simple apps, etc) but having a different end (the enrichment of Members rather than shareholders). As well as the technology itself, there is lot to learn from the tech economy. This includes providing attractive, flexible workspace in a club-like environment. It means holding frequent networking events, providing mentors and crowdsourcing funding. But owning the Gig Economy means looking beyond tech. For example, many lessons come from looking at immigrant communities in Western countries. For example, Pakistani employment communities have developed in many British cities, often dominating the taxi and restaurant industries with intra-community capital, networking, purchasing and employment. A wide variety of communities exist to connect people with opportunities, including Alumni groups, Soroptomists, Chambers of Commerce, Freemasons, Rotary Clubs, etc. This is the spirit of mutualism, solidarity and serendipity that New Unions need to copy.
  4. Become a welfare provider, over and above whatever the state offers – A New Union should offer a social insurance for its members. The need for this varies by country. For example, in the US, the pressing need is for maternity leave benefits. Only 13% of women have the right to paid maternity leave. A quarter of new mothers are back at work within 2 weeks of the birth. In other countries, like Britain, where most employment benefits are means-tested, the New Union could offer premium benefits over and above the State funding or legal rights. But the New Unions can be more inventive. For example, they could provide student-style halls of residence to help their members move to high employment areas. Teney could go further and offer a wide range of financial products. Too many work-related financial products (pensions, insurance, savings schemes, unit trusts) offer poor value to their users. A New Union could create high-trust, low-cost products, e.g. a pension fund with a 0.2%, not 2%, annual fee. The funding of this extra welfare could work in 4 ways: employees paying a monthly deduction into a Union insurance scheme; the New Union using it’s bargaining power with employers to get a greater contribution from them for Union members; having an opt-out from State schemes, where instead of paying social insurance to the State individuals and employers pay into a New Union scheme instead; using the Union’s income surplus (e.g. from commission for temporary staff) to fund member benefits.
  5. Replace government regulation of staff with New Union accreditation – The state regulation of jobs has got out of hand. Instead of looking for market solutions, too often governments respond to consumer concern about issues by regulating jobs. This can mean issuing state licences, requiring certain qualifications or experience. Not only does this impede market innovation, over time it allows the regulated staff to assert their interests before those of consumers or competitors. Research shows that licensing regimes which were in place 40 years ago or more give workers a 30% wage premium. Those established in the last 20 years offer a premium of just 4%. The extent of job regulation is remarkable. In the US, for example, 21 states require tourist guides to be licensed. In Nevada that means 733 days of training and a $1500 fee. In Tennessee, a “shampooer” in a hairdressing salon requires 700 days training, 2 examinations and a licence fee. A different approach would be for the State to withdraw from many areas of regulating individual workers. Instead, where Governments feel that some regulation is necessary, they could license New Unions to run their own schemes. For example, my New Union “EarnMore” might train, accredit and discipline its own home care assistants – just like many professional associations would do. Employers would hire the home care assistants because it trusted “EarnMore” accreditation. If EarnMore doesn’t do it well enough, employers would choose to recruit members of other New Unions. Consumers could come to respect and request the EarnMore workers. This would build brand value for workers. Workers would join the New Union that offered the the best way to be licensed and helped them earn the most money. This would be a market-based solution.
  6. Recruit and support the self-employed – The traditional union has neglected the self-employed as their mindset has been about imposing things on employers. However, many self-employed people are not affluent and some are very poor. They need the support of an employment union as much as anyone else. In the EU, 1 in 6 workers (17%) are already self-employed. This is much higher in Greece (37%) and Italy (25%). With the exception of the UK (17%), self-employment is lower in the English-speaking world (e.g. US 7%, Canada 9%, Australia 10%). But the trend towards more self-employment looks certain. Many employees are also self-employed part-time. With a philosophy of “EarnMore”, New Unions need to be help more people become self-employed, at least part of their time, to maximise their earnings. A New Union can offer a full set of administrative support e.g. bookkeeping, payroll, insurance, office services. They could offer peer-to-peer support within the Union, including mentoring, collaboration, procurement and financing. And they can offer all the other benefits of a New Union (internal sharing, the Gig Economy, temporary work, welfare, etc) to the self-employed.
  7. Turn employees into shareholders – An important way for New Union members to earn more is to have equity in the companies for which they work so that they profit from the profits made. New Unions should have an aggressive agenda to increase employee ownership. This might be full ownership, like the UK’s success stories in John Lewis (with 87,000 staff) or professional service firms like Mott MacDonald or Arup (with a combined 26,000) or the health and social care firms like Sunderland Home Care Associates and Central Surrey Health. Or it might be partial ownership, where staff buy or earn equity, like senior executives do, or how start-up firms incentivise their staff in the early years.
  8. Provide world class learning and development – A key route to earning more is gaining skills and having them accredited. Too many vocational colleges are poor and too many employers fail to offer high quality development. For staff who move between employers or even countries and for self-employed, they need the ongoing support they can’t get from any current job. The New Unions should have learning and development as a central mission. This means organising apprenticeships and other initial training. But it also means lifelong learning. New Unions could use digital learning to create their own Academies. These would not only train Members but also create online professional communities where people collaborate, mentor, counsel and share best practice, top tips and connections.The New Unions should accredit all development, with both proprietary branding (e.g. being an EarnMore Master or Grandmaster) and transferable credits with other New Unions’ accreditation schemes. The New Unions should have active plans and communities to better their members’ interests – e.g. support groups for women in their 30s who are juggling family responsibilities with career progression. The New Unions should also reach out to those who are not in work, taking over welfare-to-work and other employment programmes. They could fill the vacuum in the market for high quality careers information and guidance. How could all this be paid for? Firstly, done digitally and using peer-to-peer approaches, the costs could be managed down. Secondly, the New Unions could take over from traditional vocational colleges (FE in the UK, TAFE in Australia or Community Colleges in the US) and take on their state funding. The New Unions could also take over a lot of other state funding going into apprenticeships, welfare to work and other programmes. A proportion of the funding would come from subscription fees and some of it would come from additional purchases from individual members and employers.

So what’s to stop these New Unions happening? The traditional unions need to step aside or reinvent themselves. Governments need to roll back the legislative approach to employment and create the space for the market solutions of New Unions to take over. Governments also need to give New Unions access to funding, e.g. for training and to allow members to opt-out of some state welfare schemes and put their money into the New Union. They also need to give New Unions a legal status to play its role in the wider regulatory systems. And New Unions need regulation too, e.g. they shouldn’t be allowed to have more than 30% of employees in any geography or industry. But most of all what is needed is for dynamic Social Entrepreneurs to come forwards, start-up the New Unions and attract paying members. Entrepreneurs, not bureaucratic socialists, are what ordinary workers need, helping them to get stuck into the modern economy, become winners and shape the world they live in. The New Unions would combine social solidarity with capitalist dynamism. Labour can have parity with capital again. Ordinary people can earn more.

Do we still need prisons?

There’s no shortage of people worrying about the world running out of things. Oil, water, food, antibiotics, polar ice – they all have people worried. But no-one seems to be worrying about the shortage of something that’s essential to social justice. We are running out of punishments. As societies become more civilised, they find punishing other humans less and less attractive. This is a new problem. For most of their history, humans have been disturbingly inventive in devising punishments for rule-breakers. People have been burned, hung-drawn-and-quartered, flogged, enslaved, exiled, relieved of their fingers, branded, transported, stoned, had their heads shaved, been tarred-and-feathered and put in the stocks – to name just a few. Most punishments have been physical ones – death, mutilation or beating. In Western Europe, we often forget that most people in the world (over 60%) live in countries which still use the death penalty. But most of them don’t use it very often. Perhaps surprisingly, fewer countries still use corporal punishment – only 33 countries, a mix of Islamic countries or former British colonies which kept the British tradition of flogging. As countries have abandoned, or at least reduced their use of, physical punishment, they have tended to fall back on imprisonment as the only remaining “serious” punishment. In many Western countries, unless a convicted offender is sent to prison they are seen by much of the public (and the media) as having “got off with it”. A UK poll showed that 80% of the public and 90% of the police thought non-custodial sentences were “soft punishment”. Whilst many of the public said prison didn’t work, two-thirds of them thought that was because sentences were too short and prison life too lenient. The punitive alternatives to prison are not obvious. Serious financial penalties are hard to impose on poor people, so they aren’t. And most people in prison are poor people. US data shows that, before going to prison, prisoners had only 50% of the median income of their ethnic and age group, e.g. young hispanics in prison had only half the income of other young hispanics. Many fines are not repaid. The UK Government, for example, has written off hundreds of millions of pounds of fines in recent years. The penalty for not paying a fine, of course, is to go to prison. But imprisonment has its opponents too. We know what most offenders need to avoid re-offending:  a home, a job, a loving relationship, self-esteem and a positive peer group. We also know that the biggest threat to all these is being sent to prison. Indeed, that is the explicit point of prison – to remove what people most value in the world. It feels as though the West is at a turning point in its use of prison. The US is considering big cuts to mandatory sentences. Europe is struggling to afford it’s prison population. The UK and others are recognising that prison isn’t the right solution for many prisoners such as the seriously mentally ill.  But if we stop imprisoning people, what punishments will we have left for serious crime or where offenders don’t respond to other punishments or interventions? Yes, justice is about rehabilitation and restoration. Prison does seem a bad route to these goals for too many offenders. But justice is also about retribution, deterrence and incapacitation. Only prison currently seems to deliver for the public on those goals. (Anyone who doubts this should look at the Netherlands where liberal sentencing has led to empty jails but politicians who are unwilling to be seen closing prisons. Instead, the Dutch are housing Belgian and Norwegian prisoners to fill their prisons.) So, if it’s all we’ve got left, will prison be the last of the brutal punishments to survive and how could it evolve?

It’s tempting to think that imprisonment has been used as a punishment, like capital and corporal punishment, for thousands of years. But that’s not true. It’s a fairly modern invention and has changed in nature hugely since it was introduced. Before the 17th century, a prison was used simply to hold people pending a trial or a punishment. It was not a punishment in itself. In fact, modern prisons were a cuckoo that took over a different nest. The first modern prison is usually seen to the London Bridewell.  But this was initially a house of corrections for the poor, vagrant and homeless, aiming to take them off the streets and instil a work ethic into them. This side of it was widely replicated as “Workhouses”. But the idea got taken over by prisons. It was the public reaction in England against death sentences in the late 18th century that led to the growth of prison, hard labour and transportation as common sentences. At its peak in 1800, there were 220 offences that could earn a death sentence in an English court, most of them trivial. Juries would sometimes refuse to find someone guilty of minor theft or poaching to avoid the sentence. Even if issued, death sentences were mostly commuted – only 7,000 out of 35,000 English death sentences between 1770 and 1830 were carried out. As the use of prison grew, there was growing Western social science and philosophy about the best sort of regimes to optimise punishment and rehabilitation. For much of the 19th century, this often meant separation of all prisoners (effectively solitary confinement), silence and continuous hard labour. It was taken for granted that prisoners would be beaten whilst in prison. In the US, for example, late 19th century prisons tortured prisoners with a water coffin, iron cages on their heads and frequent use of the lash and paddle. Flogging in prisons has disappeared only fairly recently, e.g 1962 in the UK and 1972 in the US. Most Western prison regimes are now pretty similar. What varies enormously is the proportion of the population who are imprisoned. The US has increased its state and federal prison population from 320,000 in 1980 to 1,560,000 at the end of 2014 – a 380% growth. If we add in, the 700,000 in local jails and detention centres, there are 2.3m Americans in prison. Per head of population, the US imprisons 10 times more people than Germany or Denmark. The UK and Australia have pretty big prison populations, with an imprisonment rate roughly double that of the Scandinavian countries. The UK has doubled its prison population in the last 20 years. But the US has 20% of the world’s prison population, versus 5% of the world population. 7% of babies born today in the US will go to prison. There is a 70% chance that a black man born in 1975 who dropped out of school will spend time in prison and 1 in 3 black men will spend time in prison. The US “experiment” offers us the chance to see whether prison works in terms of deterrence and rehabilitation. A major study of US prisoners released in 2005 followed their progress for 5 years to 2010. Unfortunately, the results are appalling. 3 out 4 prisoners were arrested within 5 years of their release – many within the first year of release. And 16% of the released prisoners comprised a full half of all arrests in the US in the next 5 years. The data on “frequent fliers” in prison is depressing. In New York City, for example, the 800 most frequently jailed individuals between 2008-13 had 18,713 incarcerations. That’s 22 each. One person was jailed 66 times. 9 out of 10 offences were misdemeanours. Looking at the frequent fliers, 84% used crack/cocaine, 37% used heroin, 52% were homeless and 37% needed anti-psychotic drugs in prison. This picture is repeated in other Western countries.

In terms of rehabilitation, prison looks like a bad solution. But there are a lot of other potential benefits from depriving offenders of their liberty. It prevents them committing crimes whilst locked up. It can deny them access to harmful drugs. It can disrupt their social network. It can offer them a supervised opportunity to reflect on their offences, change their behaviour and plan for a better future. And it can satisfy society’s demand for retribution. So whilst there are many other policy issues about prison (e.g. better early prevention of criminal behaviour; decriminalisation of drugs; etc), we need some new ways to use imprisonment that can be sold to, and involve, the public as credible and well-understood punishments. This could include:

  1. House Arrest – The question is partly ‘how we can simulate its benefits without sending people to prison?’. But it’s also ‘how we can satisfy the public’s desire for retribution and incapacitation?’. The answer requires us to be tougher on removing the civil liberties of convicted offenders who are not sent to prison. For example, in prison, an offender loses all privacy and is under observation at all times, including, for example, when mixing with others, when in bed or even when using the toilet. If non-prison sentences could be this draconian in removing liberties, then a better alternative to prison could still be created, that still satisfies public desire for retribution and supervision. The alternative should be just that – a better option for those who would otherwise be sent to prison, rather than a way of toughening-up existing non-custodial sentences. So, civil libertarians please note, whilst my alternative is draconian, it is much better than prison. There are already sentences that limit people’s liberty in the community – home detention in New Zealand and Italy, house arrest in the US, electronic tagging in the UK, curfew orders and drug testing in the US. But they lack a strong brand and the ingredients of the sentence are often random and unpredictable – undermining their purpose in satisfying the public’s demand for justice. In Canada, for example, the Government has eliminated ‘house arrest’ for many crimes in the last few years and insisted on prison.  Let’s consider a new formal sentence called “House Arrest”. Sentences would include a fixed package of the community sentences currently available to the courts in many countries, including curfews, electronic tags, bans on meeting certain people, drug and sobriety testing, unpaid work, etc. However, it could be extended to include other restrictions and intrusions to simulate prison. This might include having all rooms in the offender’s home monitored for images and sounds on webcams, censorship of communication or bans on using phones or computers. Again, simulating prison, the offender could be allowed a certain amount of time when they were not “banged up” in the home and where, under supervision, they are out allowed to exercise or work, whether paid or unpaid.  An example of such a sentence for a 12 month sentence of House Arrest for an unemployed single man might include a requirement to:  be in his designated home for 21 hours per day, wear a GPS electronic tag, pass weekly blood tests for illegal drugs, avoid meeting or communicating with a list of specified people, have a webcam monitoring each room and achieve functional literacy. By contrast, a woman with young children might be sentenced to 24 months of House Arrest to include, for example: a requirement to be in the designated home for 16 hours per day, continue to do her job for 6 hours per day, as well as take children to and from school, etc. She might be required to wear not just a GPS tag, but also a sobriety tag and be required not to associate with certain people or visit a list of named places. Her ability to leave the house for 8 hours per day could be subject to her continuing to be employed, her children attending school and her successful completion of a drug addiction programme. Whilst in the house, she might also have to do unpaid work (e.g. online or telephone work) for a certain number of hours per week. It’s important that House Arrest sentences are predictable and comes as a entire package. Sentencing guidelines should set out a clear tariff of what total package comes for which offence and when house arrest should be used rather than a custodial sentence.
  2. Deferred sentences – The threat of going to prison is a big one. Clearly, it’s not a strong enough deterrent for everybody or no-one would commit crime. However, there is a way to use it’s deterrence when it would be most effective. That is when someone has been convicted of a crime and sentenced to prison. At that moment, the hope of avoiding prison (e.g. not being caught, or winning in court, or a getting a non-custodial sentence) has disappeared. At this moment, a conditional sentence could be hugely powerful. A court could say “In 12 months from today, you will go to prison for 2 years unless you meet certain criteria”. These criteria could include, for example:  having been employed continuously for a certain time, having clean drug tests, becoming functionally literate, paying maintenance for a child, sticking to a curfew order and successfully completing an accredited programme to reduce aggressive behaviour. Being convicted of another crime during the conditional period would automatically initiate the custodial sentence. However, a deferred sentence is different to a suspended sentence. With the latter, if someone does something bad they go to prison. With a deferred sentence, someone goes to prison unless they do good. A range of US states (e.g. NY, Texas, Washington) use “deferred sentencing” where in exchange for a guilty plea they adjourn sentencing for a period. If during that period an offender meets the court’s requirements the case will be dismissed with no sentence and, in some States, no criminal record. If the court’s requirements are not met, the offender will be sentenced.  This approach could work well with many offenders. However, my deferred sentence (rather than sentencing) is tougher and necessary to carry public confidence in many cases.
  3. Adult fostering – Many people in prison are vulnerable adults, who failed to cope outside and whose vulnerability is often made worse in a prison environment. This includes people with learning difficulties, mental health problems and poor life skills. It also includes people without family support (e.g. 1 in 4 prisoners have been in public care as children). However, many of these prisoners are a real social nuisance and /or at risk of harming themselves. Partly for punishment and partly for want of anywhere else to send them, they end up in prison to be housed and supervised. An alternative approach in such cases would be adult fostering schemes, where they live with and are closely supervised by a family, in a similar way to children being fostered under state supervision up to the age of 18. For example, the UK has an NGO called Shared Lives, offering 12,000 vulnerable adults a foster home. This concept could be extended to take people on sentence, with many of the conditions outlined in the Home Arrest option (e.g. curfews and staying off drugs)  but housing them with a supportive, well-trained and well-paid family. This would still be cheaper than prison. One option is for the foster parents to have full parental / guardian rights (irrespective of the age of the offender) and control the offender’s money and key life decisions during the sentence. They should also have the right to recommend that an un-cooperative offender goes to prison.
  4. Flexi-prison – Sending people to prison full-time deprives many of them of their jobs, their marriages or relationships, their homes, their family / social structure and their income. On the one hand that is what makes it a punishment. On the other hand, the things which are lost are the things which prevent reoffending. A balance could be struck if prison was part-time for some people. This could allow people to both lose what is important to them and their future, for part of the time, and to keep it too, for the other part. A part-time sentence might, for example, require that over a 12 month period the offender serves 100 days (24 hours long) in prison, equivalent to most weekends plus annual leave from a job. Or it might stipulate that every weekend and 1 named night each week are spent in prison. Or that people need to find a job that works at weekends and attend prison during the week. Some people, if they can plan it and give enough notice, may be able to arrange things so they can manage a 60 day stint in one go, without losing their home or job.
  5. Japanese Hogo-shi – One of the biggest problems about prison is that it takes, mostly, socially excluded people and excludes them even further from society. Hardly anybody from mainstream society visits or engages with prisoners. There is a lot to learn from the Japanese system of probation (Hogo-shi). Unlike Western countries, 98% of the State’s 49,000 probation officers are volunteers. They have the status of part-time but unpaid civil servants. They supervise and give support to 40,000 offenders on parole and probation. They mostly use their own homes to meet the offenders. They commit to working with the offender’s family, help them find jobs and make social connections. Post-prison Hogo-shi halves re-offending rates. I think this would be a great idea for non-custodial sentences in other countries. But we could take this idea a step further. Whenever a person is sentenced to prison, part of the sentence could be that they accept the supervision and support of a volunteer probation officer. The prisoner could be required to meet the volunteer prison officer at least once a week and they could enjoy visiting and communication rights similar to a lawyer. The volunteer probation officer could be a formal part of any decision-making about the prisoner (e.g. education, therapy, moving prison, internal sanctions, parole, exit plans, etc). Critically, part of the sentence would be to fully co-operate with the volunteer probation officer for a defined period after leaving prison (e.g. 12 months) and for the volunteer to play an active role in helping the prisoner get a job, a home, stay clean, sort out any benefits and keep out-of-trouble. Like other probation officers, they would have the right to take offenders back to court if they are breaching their sentences. This would have the added benefit of opening-up prisons to the community and reconnecting the excluded with many privileged and compassionate individuals. If every prisoner had one volunteer probation officer, we would have some 60,000 new people involved in our criminal justice system.
  6. New Psychiatric Prisons – We can’t get away from the problem that too many seriously mentally ill people end up in prison because there’s nothing better for them. Mental health services are generally dreadful in most Western countries. But there is a particular problem about prisons. In the US, 40% of people with serious mental illnesses have been in jail at sometime. 20% of the US prison population at any one time has serious mental illness. Of this group, 90% have been in prison before and 31% have been in prison 10 times, or more. Like other Western countries, the US radically reduced the institutionalisation of the mentally ill by closing hospitals. It reduced the number of psychiatric beds by half-a-million (90% reduction between 1955 and 2005, despite a rising population). Since then, the mentally ill prison population has increased by some 400,000. In the UK, there were 150,000 people living in 120 “Lunatic Asylums” in 1955. Today there are just 18,000 in-patient psychiatric beds in the NHS. That number is just half of what it was 20 years ago, and falling. Meanwhile in the UK the prison population has quadrupled since 1955 and doubled even in the last 20 years. It’s contentious and speculative to say that most of those people in Western countries who would have been in mental institutions were just re-institutionalised into prisons. But clearly many were. And too many. The bigger job is to fix mental health services in the community. But a part of that is create a large number of appropriate and dedicated custodial facilities for seriously ill people who have to be imprisoned, but who are highly vulnerable, often terrified and in need of treatment. Such institutions need to find appropriate ways to punish as well as to treat and to care, but putting such ill people in a general prison environment is a disgrace.
  7. Hard Labour – Prison and labour were for a long time seen to be a combined package when people were sent to prison. But the West’s use of labour for prisoners has declined. During the 19th century, prison labour was mostly designed to be pointless. This included: turning a crank handle thousands of time in silence every day, moving cannonballs from one spot to another or powering a treadmill with one’s feet. In both cases, the labour achieved nothing. Convict labour gangs were widely used in the Southern USA, but too often looked like a new form of slavery to remain acceptable. In the 20th Century, some prisons have had useful voluntary labour, e.g. sewing mailbags or creating licence plates. There are some really inspiring work programmes, e.g. the Timpson’s scheme in the UK to train prisoners to be cobblers with the promise of a job when released. But forced labour for prisoners has disappeared from Western jails. Unpaid work in the community as an alternative to prison has struggled to convince the public that it’s a serious punishment. Unpaid, hard, mandatory and purposeful work needs to be built back into prison sentences and to remain a commitment when offenders are released under licence. Civil libertarians hate forced labour. But it would mean that prisoners were unlocked from their cells, usefully occupied and, where it makes sense, taken out into the community to do the work. Work is good for mental and physical fitness. And a good preparation for life outside prison. But where will the work come from? One solution would be to place a statutory duty on local government to create sufficient forced labour schemes and to use online voting locally to allow local people to choose what work they most want from their prisoners. This can be white collar as well as blue collar work. And if local businesses benefit from the work done, good luck to them, so long as the public backed the option.

If prison is the only remaining serious punishment, we do need to re-imagine how we use it. Hopefully, my options will stimulate people to think of better ones. Alternatively, those more imaginative than me might come up with a totally new punishment that strikes the right balance between public retribution and the dignity of the offender. In Dante’s inferno, the nine circles of Hell include unique punishment for each sort of sin: e.g. pushing boulders (for hoarders); being immersed in human excrement (for flatterers); wearing a cloak of lead (for hypocrites); being permanently lodged headfirst in a block of ice (for betrayers of family); or, being chased and bitten by reptiles (thieves). But in our real world, the options may be more limited.