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Leader: Imperfect it may be, but AV is the start of an essential journey

It may not be a proportional system but AV would represent a significant improvement on first-past-t

Were one founding a new democracy, it is unthinkable that first-past-the-post (FPTP) would be adopted as the electoral system. It penalises small parties, wastes votes and encourages politicians to concentrate their policies on swing voters in marginal seats. FPTP might have been tolerable in 1955, when Labour and the Conservatives won 96 per cent of the vote and 99 per cent of the seats. But it is unfit for a three-party era in which political loyalties are more fluid. In the last election, Labour and the Tories won just 65 per cent of the vote but ended up with 87 per cent of the MPs. It was with good reason that post-apartheid South Africa, the former eastern bloc countries and the young democracies of Latin America all chose to adopt proportional models of voting, rather than FPTP.

On 5 May, for the first time ever, the British people will have a chance to reject FPTP and replace it with the Alternative Vote (AV). AV is not the system that we would have chosen. In some circumstances, it can lead to even more disproportional outcomes than FPTP. As the Jenkins commission on electoral reform noted, had the 1997 election been held under AV, Labour's majority would have swelled from 179 to 245. A genuinely proportional system, of the kind we support, remains the more desirable option.

But AV would represent a significant improvement on FPTP. It would lead to fewer wasted votes, greatly reduce the need for tactical voting and ensure that most MPs are elected with at least 50 per cent of the vote in their constituency. By requiring candidates to win second-preference votes, it would also encourage the parties to engage with all voters. The adoption of AV would enable the creation of a more pluralistic political culture, in which parties emphasise their similarities, rather than merely their differences.

The relentlessly negative approach of the No to AV campaign has only highlighted the paucity of the arguments for FPTP. In their desperation to preserve the status quo, the opponents of reform have claimed that AV would benefit the British National Party, that it would be "too expensive" and that it would prove to be too "confusing" for the electorate. In reality, no system is better at keeping extremists out; AV would not require expensive voting machines; and a system that is already widely used by businesses, charities and trade unions would not prove too complex for the electorate.

AV is not a panacea and, taken alone, it will not repair Britain's broken democracy. Reform of the voting system must be combined with the creation of a fully elected second chamber and the introduction of a written constitution. An increase in the number of directly elected mayors, as Andrew Adonis writes on page 74, is another measure that could address the democratic deficit. But it would be careless to miss an opportunity to reject the voting system that has done so much to discredit the UK's political system.

Those such as the former Social Democratic Party leader David Owen who have argued for a No vote in the hope of securing a more proportional system in the future are playing a dangerous game. As the Chancellor, George Osborne, has said, a No vote on 5 May would close the question of electoral reform "for the foreseeable future".

Not only would FPTP be preserved but it would be strengthened by a victory for the No campaign. A Yes vote, by contrast, would increase the possibility of a subsequent transition to proportional representation (PR). The claim that there is no appetite among the public for reform will have been exposed as a myth.

If the next election results in a hung parliament, the Liberal Democrats will no doubt demand a referendum on PR as the condition of any coalition. But that is a battle for another day. For now, the priority is to deliver a death blow to the unfair, undemocratic and unrepresentative FPTP system. It is for this reason that we encourage progressives of all parties to vote Yes to AV on 5 May.

This article first appeared in the 25 April 2011 issue of the New Statesman, Easter special

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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