Occupy the Bank

The surprising new radicalism on Threadneedle Street.

At last we are getting some hard-hitting ideas about how to reign in and reform free-booting finance capitalism. From those camped outside St Paul's? A new left wing think-tank? Perhaps a leading financier gone-rogue in the manner of Soros or Buffett?

No, nothing so predictable. The new ideas are flowing from that well known citadel of radicalism in Threadneedle Street. It's not just the Bank of England's now familiar, yet still striking, use of aggressive and unorthodox monetary policy that best captures this new disposition. Nor is it the fact that Mervyn King led the way in calling for far-reaching structural reform of the banking system, making it more difficult for the government to recoil from the proposals in the recent Vickers report. In fact, the new radicalism isn't really about the Bank Governor -- rather it's coming from other senior figures working for him.

This week Andrew Haldane who leads on Financial Stability -- a name you may not have heard before, but certainly one you should watch out for -- made a powerful proposal about containing the pay of the overlords of finance. His argument is that both short-term investors and bank executives have extracted huge rents from the finance sector, at the expense of other groups like tax-payers and long-term investors. His suggestion is that rather than link bankers' pay to share value (return on equity) it should be tied instead to the return made on assets (for example, bank loans). A technocratic tweak? Well, it's one that bites. Haldane points out that if this approach had been followed in the US over recent decades then CEOs of top banks would have had to scrape by with salaries a mere 68 times the typical household income rather than their current ones which are 500 times that of the ordinary family.

And this comes hot on the heels of Mr Haldane's historically rooted and empirically robust critique of City short-termism -- "mounting myopia" as he terms it -- as well as his hard-headed assessment of the still unfolding consequences of the personal debt tsunami and its implications for the real economy and households.

None of this is to suggest that Mervyn King himself is becoming a force for radicalism. The Governor's widely reported opposition to the Bank getting involved in direct lending to businesses, reiterated yesterday at the Treasury Select Committee, reflects a deep rooted institutional conservatism on this front. His recent remarks about how until the recent eurozone crisis things were "on track" with the UK economy look a bit detached, and have already attracted the ire of some commentators. And that's leaving to one side his hawkish views on fiscal stimulus and controversial role at the time the coalition was formed.

But this doesn't change the fact that the Bank is becoming one of the most interesting homes for fresh and original thinking about the nature of serious economic and financial reform that we desperately need. That's not a sentence you could have written before.

So what's changed? Part of it is doubtless the Bank flexing its intellectual muscle in advance of it reclaiming regulatory powers that it no doubt feels it should never have lost to the FSA in the first place. Another explanation is that the genuine and laudable desire among its leading lights to get ahead of the systemic risks facing economic stability in Britain (and contemporary capitalism more generally). Which in part, at least, will be spurred by the widely shared belief that the Bank fell badly behind events in the recent past: both in failing to see the crisis coming, and then in reacting too slowly in its early days. On top of this, it may also be that Mervyn King, the career academic, may have become comfortable playing the role of "department head", allowing his leading lights at the Bank to think aloud.

Whatever the reason, it's a welcome development. Let's hope the free-thinking in Threadneedle St continues -- and that both the Chancellor and his Labour counterpart are listening. They need to be.

Gavin Kelly is chief executive of the Resolution Foundation 

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Want to know how you really behave as a doctor? Watch yourself on video

There is nothing quite like watching oneself at work to spur development – and videos can help us understand patients, too.

One of the most useful tools I have as a GP trainer is my video camera. Periodically, and always with patients’ permission, I place it in the corner of my registrar’s room. We then look through their consultations together during a tutorial.

There is nothing quite like watching oneself at work to spur development. One of my trainees – a lovely guy called Nick – was appalled to find that he wheeled his chair closer and closer to the patient as he narrowed down the diagnosis with a series of questions. It was entirely unconscious, but somewhat intimidating, and he never repeated it once he’d seen the recording. Whether it’s spending half the consultation staring at the computer screen, or slipping into baffling technospeak, or parroting “OK” after every comment a patient makes, we all have unhelpful mannerisms of which we are blithely unaware.

Videos are a great way of understanding how patients communicate, too. Another registrar, Anthony, had spent several years as a rheumatologist before switching to general practice, so when consulted by Yvette he felt on familiar ground. She began by saying she thought she had carpal tunnel syndrome. Anthony confirmed the diagnosis with some clinical tests, then went on to establish the impact it was having on Yvette’s life. Her sleep was disturbed every night, and she was no longer able to pick up and carry her young children. Her desperation for a swift cure came across loud and clear.

The consultation then ran into difficulty. There are three things that can help CTS: wrist splints, steroid injections and surgery to release the nerve. Splints are usually the preferred first option because they carry no risk of complications, and are inexpensive to the NHS. We watched as Anthony tried to explain this. Yvette kept raising objections, and even though Anthony did his best to address her concerns, it was clear she remained unconvinced.

The problem for Anthony, as for many doctors, is that much medical training still reflects an era when patients relied heavily on professionals for health information. Today, most will have consulted with Dr Google before presenting to their GP. Sometimes this will have stoked unfounded fears – pretty much any symptom just might be an indication of cancer – and our task then is to put things in proper context. But frequently, as with Yvette, patients have not only worked out what is wrong, they also have firm ideas what to do about it.

We played the video through again, and I highlighted the numerous subtle cues that Yvette had offered. Like many patients, she was reticent about stating outright what she wanted, but the information was there in what she did and didn’t say, and in how she responded to Anthony’s suggestions. By the time we’d finished analysing their exchanges, Anthony could see that Yvette had already decided against splints as being too cumbersome and taking too long to work. For her, a steroid injection was the quickest and surest way to obtain relief.

Competing considerations must be weighed in any “shared” decision between a doctor and patient. Autonomy – the ability for a patient to determine their own care – is of prime importance, but it isn’t unrestricted. The balance between doing good and doing harm, of which doctors sometimes have a far clearer appreciation, has to be factored in. Then there are questions of equity and fairness: within a finite NHS budget, doctors have a duty to prioritise the most cost-effective treatments. For the NHS and for Yvette, going straight for surgery wouldn’t have been right – nor did she want it – but a steroid injection is both low-cost and low-risk, and Anthony could see he’d missed the chance to maximise her autonomy.

The lessons he learned from the video had a powerful impact on him, and from that day on he became much more adept at achieving truly shared decisions with his patients.

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide