I disagree with Nick

The Lib Dem leader has to come clean about his U-turn on spending cuts.

When did Nick Clegg change his mind on spending cuts? It's a simple question but after much flip-flopping we are none the wiser.

On last week's BBC documentary Five Days that Changed Britain, the Deputy Prime Minister told Nick Robinson that events "between March and the actual general election" triggered his Damascene conversion to Conservative economic thinking: he, too, thinks deep and immediate spending cuts are necessary.

So did he change his mind before or after telling the electorate in March that "merrily slashing now is an act of economic masochism" and that "of course" he would not compromise on this in any coalition negotiations?

Did he change his mind before or after telling Jeremy Paxman in April: "Do I think that these big, big cuts are merited or justified at a time when the economy is struggling to get to its feet? Clearly not."

Or did he change his mind less than a week before polling day when he said to Reuters on 1 May: "My eight-year-old ought to be able to work this out -- you shouldn't start slamming on the brakes when the economy is barely growing. If you do that you create more joblessness, you create heavier costs on the state, the deficit goes up even further and the pain with dealing with it is even greater. So it is completely irrational."

Since the election, the Deputy Prime Minster has been less than forthcoming about what he thought and when he thought it.

On 12 May he concluded the coalition agreement with the Tories -- his new partners in fiscal retrenchment -- and promised a "significantly accelerated" deficit reduction plan, referring to "immediate cuts". On 6 June, in an interview in the Observer, he acknowledged that his view had "shifted", citing as reasons the events in Greece and a conversation with the governor of the Bank of England around the time the full coalition agreement was being finalised.

So far as Clegg's Greek defence is concerned, the governor told the Treasury select committee in February that "I do not think you can compare the UK with Greece". In fact, Clegg himself had claimed in March that "the guaranteed way" of producing Greek-style unrest would be "macho", deep, immediate spending cuts.

As for their big conversation, Mervyn King told me last week at a hearing of the newly constituted Treasury select committee that he had given Clegg no new information on the debt situation during their chat. Indeed, the day after our hearing last week, it was revealed that Clegg had changed his mind before the election -- an election in which he sought votes on the basis set out in his manifesto:

If spending is cut too soon, it would undermine the much-needed recovery and cost jobs. Our working assumption is that the economy will be in a stable enough condition to bear cuts from the beginning of 2011-12.

So, having disposed of the reasons cited by the Deputy Prime Minister for his change of position, we are left with a far more serious question: why did Clegg not tell the electorate that he would follow Conservative economic policy before 6.8 million people cast their votes for him on 6 May?

Did Clegg not think the British people deserved to know what they would be voting for? According to last weekend's Sunday Times, Clegg had not even informed his Treasury team -- Vince Cable included -- of the line he would take once the polls shut. A full and frank explanation is needed, otherwise the electorate, never mind his MPs, will be entitled to ask: How can we trust anything you say?

Chuka Umunna is the Labour MP for Streatham and a member of the Commons Treasury select committee.

Chuka Umunna is the shadow business secretary and the Labour MP for Streatham.

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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