Mehdi Hasan: Renationalise the railways? Please do.

Will Self triumphs on BBC Question Time.

My fellow New Statesman columnist - and the new professor of contemporary thought at Brunel University - Will Self put in a typically brilliant performance on BBC1's Question Time last night, especially on the subject of rail privatisation.

He interrupted a rambling answer from fellow QT panellist and Conservative cabinet minister Eric Pickes to say:

I merely seek to observe that the [rail] subsidy was £1 billion before [when] they were nationalised, in real terms, and it's now £4 billion.

He continued:

The fundamental mistake - and there were many mistakes about the privatisation of the rail system - but the most fundamental mistake was rail travel, your journey to work, is not a fungible good and that means it cannot be exchanged for anything else. You can't get to Guildford station and think: 'Oh I want go to work in London today. I'll go to Mars on this new rocket train that's been provided by this splendid private company'.

It was a ludicrous idea from the get-go and the particular way that they did it with the track hived off from the rail operators has caused absolute chaos, some dreadful crashes and the current predicament that you find yourselves in.

"So what would you do?" asked Pickles. Self replied, to huge applause from the Surrey audience:

I'd renationalise it.

The 16-year rail privatisation experiment has been an utter disaster. Above-inflation increases in UK train fares - that are now the highest in western Europe - make it more and more unpopular as time goes by. Tory ministers, their cheerleaders in the right-wing press and their Blairite fellow-travellers in the Labour Party often forget - or choose to ignore! - that there is a clear majority in favour of renationalisation of the railways - on the left and the right. The inconvenient truth for ministers is that the likes of Bob Crow - and Will Self! - are more in touch with voters than they are. And the recent row over multi-million-pound, taxpayer-funded Network Rail bonuses - which were eventually and reluctantly waived by Network Rail bosses after public outcry - didn't do the privatisation cause much good. It was another reminder of how messed up the system is.

In fact, as transport expert Christian Wolmar wrote back in October 2008, a month after the start of the financial crisis:

[W]hat New Labour refuses to let on is that the railways are effectively largely publicly-owned anyway. Network Rail, which owns the infrastructure, is a company without shareholders that is dependent on government backed debt (to the tune of £20bn), for its survival. It receives billions in annual grants direct from government and is, to all intents and purposes, a state-run enterprise.

Wolmar also pointed out that with Network Rail already in public hands, it would cost little or nothing to "renationalise them", once the train operators decided to hand back their franchises when their terms expired or once they got into financial difficulties.

This isn't just an ideological or political argument; it's financial. A recent study by the Transport for Quality of Life thinktank found that renationalisation could save the taxpayer £1.2 billion a year "through cheaper borrowing costs, removing shareholders' dividends and reducing fragmentation". £300 million alone, said the study, would be saved if train operating companies were taken into public ownership.

It's a no-brainer: the time has come to renationalise the railways. It would be a popular, effective and money-saving move in our current "age of austerity". Ed Miliband and Maria Eagle - are you listening?

Mehdi Hasan is a contributing writer for the New Statesman and the co-author of Ed: The Milibands and the Making of a Labour Leader. He was the New Statesman's senior editor (politics) from 2009-12.

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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