James Purnell: I could have been Iain Duncan Smith

Former cabinet minister reveals that he proposed a universal credit to Gordon Brown.

There's quite a revelation from James Purnell in today's Times (£). He writes that he proposed a version of Iain Duncan Smith's "universal credit" to Gordon Brown and resigned after he was rebuffed.

Purnell writes:

Before I resigned from the cabinet, I proposed a similar plan to Mr Brown. But he was scared that there would be losers, and his refusal to give me any answer made me think that there was no point in staying inside the government to try to influence him.

It's now hard to find a mainstream politican or thinker who isn't in favour of the universal credit, at least in principle, and Purnell deepens the consensus. He describes the IDS plan as a "good reform" and observes (in a point obscured by George Osborne) that "we lose more money in mistakes than in fraud". As Duncan Smith is hailed by the left and the right as the most ambitious reformer since Beveridge, one can hear Purnell mutter: "I could have been a contender."

But he fails to ask the $64,000 question: is welfare reform possible at a time of high unemployment? The truth is that there are no jobs for many of the unemployed, nor will there be in the years to come. The number of long-term unemployed has more than doubled since 2008 to 797,000, while the number of vacancies has fallen to 467,000 – a jobs deficit of 330,000.

Yet, such objections aside, there's now remarkably little to choose between Labour and the Conservatives on welfare. The coalition's much-anticipated assault on universal (or "middle-class") benefits didn't materialise. Child benefit for higher earners was abolished (though the plan looks unenforceable), but the Winter Fuel Allowance, free bus passes and free TV licences were all retained in their present form.

It now seems that, against expectations, the key dividing lines of this parliament will not be over welfare reform.

George Eaton is political editor of the New Statesman.

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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