Cameron's "rehabilitation revolution" will struggle at a time of cuts

The PM's "tough and intelligent" approach is welcome. But it is hard to see it working when so many local services are being cut back.

David Cameron has today announced that he is to "put rocket boosters" under the coalition's payment by results approach to reducing reoffending. The biggest problem in penal policy is how we can reduce reoffending: the public have little time for politicians who are 'soft on crime' but they see little sense in prisons simply warehousing offenders if they come out just as or more likely to offend as when they went in. There was a danger that the departure of Ken Clarke in the reshuffle would have spelt the end of the government's focus on this critical area of systemic policy failure.

So there is much to welcome in the Prime Minister's "tough and intelligent approach". In particular, his pledge to address the fact that short stay offenders get little by way of rehabilitation and no probation support when they leave prison has created a 'revolving door' and a cycle of reoffending.

But there was little that was actually new in Cameron's speech. There are currently four prisons pilots at Doncaster, Leeds, High Down and Peterborough. The Peterborough pilot was set up by Labour. Other areas are running community-based payment by results pilots.  The coalition had already said that it wanted to see payment by results spread throughout the country by 2015.

There are two challenges that ministers must face up to if they are to make a real difference. First, rehabilitation costs in both the short to medium term. Rehabilitation requires investment in wrap around services, drug and alcohol programmes, and mental health services to provide people with the support to make a change in their lives. Yet the Ministry of Justice is facing massive cuts to its budget over the course of the current spending period. It is hard to see how a rehabilitation revolution can take off when so many local services are being cut back.

Second, we need to think about how to institutionalise a more effective and joined up approach to reducing reoffending in the long term. This is where there is a role for the new Police and Crime Commissioners. The "and crime" part of the title is important. It is plausible that at least part of the prison budget and some local prisons could be devolved to PCCs. They would then have an incentive to reduce reoffending because they would keep the savings from any fall in the local prison population. There are arguments about how much of a cash saving such 'justice reinvestment' mechanisms can yield, but the evidence from the United States where penal policy is locally administered is promising.

So the rehabilitation revolution appears to have survived the Clarke/Grayling transition. But it remains to be seen how powerful Cameron's rocket boosters actually are and whether this will produce the kind of step change we need in the offender management system.

Rick Muir is associate director at IPPR

David Cameron is escorted around the C wing of Wormwood Scrubs Prison earlier today. Photograph: Getty Images.

Rick Muir is associate director for public service reform at IPPR.

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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