I’ve just published Chapter 8 of my open access textbook. This new chapter focuses on women’s homelessness.

An English summary of the new chapter can be found here: https://nickfalvo.ca/womens-homelessness/

A French summary of the new chapter is here: https://nickfalvo.ca/litinerance-chez-les-femmes/

All material related to the textbook can be found here: https://nickfalvo.ca/book/

This week, the Express published an article headlined 'taxpayers billed £100 million for NHS translators – could pay for 3,000 nurses'. The story completely missed the point of what the health service does.

The standfirst went on to explain that taxpayers "pick up the bill" for translation and interpretation" to ensure that the NHS can be "accessed in languages other than English”.

Given health and healthcare access inequalities, surely spending money to ensure people get the right care they need is a good thing – not to mention a legal requirement.

The Express article published on 2 April about NHS spending on translators

The Express packaged the story to suggest that it had uncovered a scandal. It included data revealed through Freedom of Information Requests (FOI) to 251 NHS trusts and 42 integrated care boards, which “routinely convert standard hospital and health literature into languages including Romanian, Arabic, Urdu, Bengali and Punjabi”.

The article included comments from a Reform Party spokesman, claiming that translation and interpretation services "were simply not necessary" and that artificial intelligence apps, such as Google Translate, could do the job – or that patients could use family members to translate for them.

The Express article followed the Mail’s report last week on National Trust cafés selling “woke scones” (made with margarine and not butter). It was another example of 'stories’ aimed at stirring up problems, rather than solving them.

The Mail article published on 31 March on 'woke scones'

Helping those in need be heard appears to be a bizarre issue to weaponise in manufactured 'culture wars’.

For starters, the total NHS spend in England for the last financial year was more than £180 billion, with a further £20 billion in local government spending on social care. So £100 million on translation might sound like a big number, but it is a tiny fraction of expenditure and would make little dent in nurse staffing across all NHS organisations.

Citizens or legal residents who don’t speak fluent or even basic English are, just like people with hearing loss, learning disabilities or cognitive impairment, as entitled to NHS care as the rest of the population. And there is already considerable evidence that they are not getting it, with health and healthcare access inequalities between different ethnic communities.

Denying people written information in their own language will only make matters worse.

When people who are sick, scared, vulnerable, distressed or have symptoms to discuss, treatments to understand, or complex psychosocial factors to explain, how can the quality and safety of the care they receive be improved if they can neither express nor understand key information?

There are also legal considerations. To provide valid consent to treatment in common law, patients must have sufficient information about the details, risks, potential harms and benefits of a proposed treatment (which could in some cases involve major surgery, powerful drugs or admission to intensive care). Language barriers must be overcome to make this a reality.

The Mental Capacity Act states that all reasonable efforts must be made to establish decision-specific capacity for treatment or care – which may include overcoming language barriers.

If patients lack capacity, then speaking to those closest to them is a key part of establishing their best interests for further decision-making. Again, this may require translators or clear written information in their first language. We do this for people with hearing loss via written communication or sign language.

Regulatory codes of practice for healthcare professionals are also clear that we must treat people equally, irrespective of characteristics including race, religion or nationality.

Using AI translation apps of variable reliability has its limits in a time-critical or emotionally-charged and challenging situation. And relying on family or friends to translate isn't always possible as not every patient is accompanied. If they are discussing personally sensitive or intimate information, they may be inhibited from doing so. If there are safeguarding concerns regarding abuse or neglect one could suspect the person translating of being coercive when doing so.

The thinly-veiled xenophobia and racism being whipped up by the Express (even against people who pay tax and National Insurance contributions and have precisely the same entitlement to care as native and confident English speakers) is part of a wider set of 'wedge issues’ being pushed by right-wing media outlets and sections of the Conservative and Reform parties.

They share a similar fixation with 'woke’ diversity managers or diversity, equality and inclusion (DEI) policies in the NHS or other public services. Several Government ministers have lined up to call for a 'war on waste’ to remove such posts and policies.

Steve Barclay, when Health Secretary in 2023, wrote to integrated care boards in England instructing them to stop recruiting staff as dedicated EDI managers, arguing that the money should be spent on “frontline staff” instead.

The Express has published a number of articles lamenting 'wokery’ in the NHS – including, in January in a story headlined 'NHS spends £40 million on woke non-jobs that could pay for 1,150 nurses'.

Last year, the Spectator ran a FOI-based story showing that, out of an NHS workforce of around 1.5 million people, there were only 800 employees in dedicated EDI roles – yet called for those roles to be abolished.

Again, those employed in such posts account for a small fraction of 1% of the entire NHS workforce or spend. Their presence is de facto required due to the Equality Act and Equality Duty on public organisations and protections in employment law.

NHS organisations do have a very diverse workforce, yet there is clear evidence of ongoing and endemic discrimination towards minorities within it. There is also consistent evidence of discrimination and care inequalities between different ethnic and socio-economic groups the NHS serves.

The idea that a focus on EDI is somehow a bad thing and a distraction from real work, or that organisations should not employ a small number of people to oversee it, is not so much a dog-whistle as a wolf-klaxon. It is a classic distraction from the real issue – the 14 years of Conservative-led mismanagement of health and social care and of wider public health.

This decline has been well-documented by the Institute for Government think tank; as well former King’s Fund chief executive Professor Sir Chris Ham, who set out in expert detail the rise and decline of the service from the late 1990s through to the 2010 election and the current crisis in performance and public satisfaction.

Blaming our NHS crisis on the cost of translation and interpretation services, and diversity and inclusion managers, foments hostility against people from ethnic minorities, white people with poor English skills, and even those with full entitlement to use our public services and who contribute towards their costs.

They aren’t all rich enough to pay for their own personal translator or digitally equipped enough to auto-translate NHS information documents into their own languages.

I don’t see commentators on the right arguing against hospitals in France or Spain finding translations for ill white British expats or embassies around the world employing translators to help British citizens who have found themselves in a spot of bother with the local law. I wonder why.

This article was first published in the March 2024 monthly print edition of Byline Times.

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A major part of the pervasive sense that ‘nothing works in Britain anymore’ is that public services don’t work – meaning not just that they are crumbling under pressure, but that they are systemically dysfunctional and crisis-ridden. 

So whichever party wins the next election will face demands to fix them, while being constrained by tight ‘fiscal rules’. Whether those constraints are regarded as self-imposed or necessary, their consequences are real. 

It’s a lazy cliché to say the solution isn’t just to ‘throw more money’ at public services, which readily morphs into the implication that it isn’t about money at all. That’s absurd.

The cumulative impact of underfunding is undeniable, especially in the austerity years, which saw public spending as a percentage of GDP fall from 46.3% in 2009-2010 to 39.5% in 2019-2020 just before the pandemic. 

Yet those figures don’t tell us everything, as they start from the high caused by the financial crisis, whereas it had been 40% for the previous three years. Now, following another large spike caused by the pandemic, public spending stands at about 45% of GDP. That’s less than Germany (49.7%) and much less than France (58.5%), but similar to the Netherlands (44.6%) and Japan (44%), and more than Norway (38.5%). 

So, while recognising that international comparisons are tricky, because there are many variables, it is legitimate to ask: why do we have a relatively large state but public services which are widely regarded as inadequate?

Typically, politicians of all governments ascribe this to public sector inefficiency. But this both ignores and justifies the way the British state, including local government, has come to rely on outsourcing public services to the private sector. 

Outsourcing has always happened to an extent, as it does in most countries. However, since the 1980s, it has increased precisely as a result of the ideology that the private sector is definitionally more efficient, with market competition the key to making it so.

Crucially, the state has increasingly become a commissioner and regulator of services, rather than a provider – a hollowed-out state rather than a smaller state.

According to an Institute for Government report, there’s no reliable measure of total public services subcontracting, but public sector procurement spending, which includes such subcontracting, now accounts for about a third of total public spending. 

The early Thatcher years saw many ancillary services, such as hospital cleaning and council waste collection, outsourced. This intensified under the Major and New Labour Governments, not just in scale but in depth and complexity, so that outsourcing came to include core state functions such as running prisons and hospitals. Some local councils, such as Barnet and Northamptonshire, adopted a model of near-total outsourcing. Even policy-making, the very epicentre of state administration, has become increasingly reliant on consultancy firms.

Some argue this doesn’t matter to the public if the outcome is high quality services. As the New Labour slogan had it, “what matters is what works”. But far too often it doesn’t work. 

There have been a litany of scandals and failures in outsourcing – from Army recruitment to the probation service – in every public service sector. Even if not ending in abject collapse, the quality of provision is often poor in the most essential of ways. A recent study in the Lancet, for instance, showed that the outsourcing of NHS services was associated with increases in treatable mortality rates. 

Indeed, scratch the surface of just about any public service failure of recent years and outsourcing features as a key cause. The National Audit Office endlessly produces reports documenting the waste involved, which may be ‘only’ a few million pounds here, or a billion there, but it cumulatively adds up to a constant drain on effective service delivery. On top of that, billions end up in the coffers of the super-wealthy, regardless of service failures.

These multiple shortcomings aren’t coincidental or inexplicable.

The fundamental reason for them is that outsourcing is predicated on the free-market theories that profit is a payment for risk and that competition between contractors ensures high standards. In practice, neither is the case.

Risk is never really transferred to the contractor when it relates to core public services, which the Government will always, ultimately, have to deliver. A high-profile example was the need to use troops to provide security at the 2012 London Olympics because the contractor, G4S, failed to provide enough staff. In less high-profile cases, the risk is borne by users, who have to cope when services aren’t delivered to a decent standard.

Equally, the market isn’t really a competitive one. It is an oligopoly whereby a handful of firms, despite their repeated service failures, continue to be awarded new contracts. That’s partly because of the byzantine nature of the bidding processes, which effectively excludes all but the big outsourcing specialists.

It’s also because of cronyism and the quasi-corruption of a weakly-policed ‘revolving door’ between the politicians and civil servants who commission services and the firms that bid for contracts. This not only means that service delivery is more likely to be inadequate, it also reduces political accountability for such inadequacy. It makes blame-shifting easier, while making it harder to know what is being done with public money because contracts are typically shrouded in commercial confidentiality.

Many of these deficiencies were exposed by the spectacular collapse of outsourcing giant Carillion in 2018. Some thought this would be a turning point and, to a limited extent, it was. Since then, the Government has been more cautious about outsourcing, and there has even been a degree of insourcing, with the reversal of the disastrous outsourcing of the probation service being a major example. 

But the Carillion debacle also revealed just how reliant the British state has become on the remaining few large firms, some of which are even more deeply embedded than it was in service delivery. What may have started as a convenience has become a dependence.

Certainly, for all that the shine may have come off it, outsourcing continues across a whole swathe of public services.

The Conservatives had a chance to address some of these issues when the party passed last year’s Procurement Act. This, for once, was accurately billed as an opportunity to use post-Brexit freedoms because the UK has left the EU public procurement framework. However, the Government refused to make private contractors liable to Freedom of Information requests or to create an independent body to evaluate the value for money of contracts awarded. It also ignored demands for a public interest test to be applied to public service outsourcing. 

So there is now both an opportunity and a challenge for the expected incoming Labour government. 

Locally, when Labour took control of Barnet in 2022, it comprehensively reversed the “failed experiment” of its ‘EasyCouncil’ model. Nationally, in her conference speech the same year, Deputy Leader Angela Rayner promised “the biggest wave of insourcing for a generation” if Labour comes to power, and there have been suggestions of reforms to the procurement system. Sticking to this in government may be another matter. 

Outsourcing can be tempting as it sometimes creates superficial savings in departmental budgets, even if it displaces costs elsewhere. Moreover, there are already reports of outsourcing firms lobbying the party.

There will always be a place for outsourcing some public services to private contractors. But, some recent reversals notwithstanding, the scale and depth of its use over the past four decades has created the worst of all worlds: the inefficiency and lack of market accountability which the right associate with the public sector, and the greed and lack of public accountability which the left associate with the private sector. 

That won’t be easy to unpick, but doing so would go some way to resolving the paradox of having an ostensibly relatively large state and yet public services which do not work.

Chris Grey is Emeritus Professor of Business and Management Studies at Royal Holloway, University of London. He writes the Brexit & Beyond blog and is the author of Brexit Unfolded

Black and ethnic minority Metropolitan Police employees are four times more likely to quit due to bullying and harassment than their white colleagues, according to internal data obtained by Byline Times.

The figures, from March 2023, also show employees of colour are five times more likely to resign due to discrimination compared to white colleagues, and that females were three times more likely to resign due to bullying, harassment and discrimination than men.

One-fifth of all female leavers cited bullying and harassment as the reason for quitting, compared to 9% of men.

The findings come after Byline Times reported last month that Amina Ahmed, a senior female Asian Met employee, quit her job citing an “environment [of] discrimination, bullying and harassment”, one week after the National Black Police Association (NBPA) called for a boycott of the Met by people from ethnic minority backgrounds.

NBPA president, Andy George, said that the data on resignations "comes as no shock to our members" as their “lived experiences of working in the Met is one of hostility from colleagues and a lack of support from managers".

George believes that Met Commissioner Sir Mark Rowley "has tried to engage in a PR exercise" to highlight reforms being made, but "this data shows that things are not as they appear".

“The Met has also taken no action to reduce the disproportionality in the misconduct system despite Baroness Casey highlighting that black officers were 81% more likely to be disciplined," he added.

“The Met must take a step back, confront the reality of racism in the force, and bring about meaningful and impactful changes rather than engaging in a PR campaign which dismisses the experiences of black, Asian and minority ethnic officers and staff”.

Miss Ahmed told Byline Times that black, ethnic minority and female Met employees were leaving “in their droves” due to the “toxic” environment.

The Met responded by saying it was undertaking “extensive work” to “address valid concerns about disproportionality and to provide officers and staff from all backgrounds with the confidence that they will be supported to succeed and progress in their careers”.

The Met’s so-called ‘exit data’, generated during interviews with those leaving in the year ending March 2023 – the same month that Baroness Casey’s report found the force was "systematically misogynist and racist" – revealed that 13% of all leavers had reported having “experienced or witnessed bullying or harassment” in the previous 12 months. The figure rose to 27% across their career in the Met.

It suggests disproportionately high levels of staff who are leaving the Met come from black or ethnic minority backgrounds (26% compared to the 19% of the workforce who are from those communities), or are female (42% compared to the 37% of workforce who are women).

Forty per cent of black and ethnic minority leavers said they had experienced or witnessed bullying or harassment in the past 12 months, rising to 46% across their time on the force. That compares to 11% of white staff.

Almost half (49%) of female leavers said they had experienced or witnessed bullying or harassment during their employment, compared to 19% of men, with 32% having experienced it in the past year, compared to 11% of men.

The Met’s publicly available HR workforce data, published in November 2023, shows that there are no chief superintendents or commanders who are female and from an ethnic minority background. Only 7% of all chief superintendents and commanders are from ethnic minority backgrounds, despite these individuals making up 46% of London’s population.

Despite an uplift in the overall number of police officers, sergeants and inspectors between December 2022 to November 2023, the percentage drawn from ethnic minority backgrounds has remained stagnant, with the biggest uplift in sergeants being those who are white.

The percentage of detective inspectors from ethnic minority backgrounds fell by 7% (from 67 to 62) between December 2022 and November 2023. Only 6% of superintendents are from ethnic minority backgrounds, numbering six compared to 104 who are white.