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Power to the Proles: why Orwell got it wrong


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Friday, 23 September 2011

Power to the Proles: why Orwell got it wrong

In George Orwell’s novel Nineteen Eighty-Four, Big Brother and the members of the ruling elite, the Inner Party, monitor the population by telescreen, a surveillance device in every home, public space and place of work.

The logical problem with this concept is that Big Brother could not possibly watch everyone all of the time, even if he had an army of monitors.

Orwell died 25 years before the first personal computer and 40 years before the web revolution. The first commercially successful computer appeared in 1951, a year after his death.

Written in 1948, the year the NHS was created, Nineteen Eighty-Four accurately predicted a world dominated by information technology. But it got one thing critically wrong. IT is not a tool for state control but for the empowerment of the Proles.

Sixty years on, everyone owns their own telescreen and Big Brother and the Inner Party are quaking in their boots.

You can rate the service you receive from your local hospital or general practice on NHS Choices. Other websites allow you to go further. The iWantGreatCare website encourages patients to rate their doctors and dentists, praising the good ones and naming and shaming the bad.

Sites like this create a dangerous illusion of democratic legitimacy but actually achieve little more than a paralysing atmosphere of scrutiny and blame. 

The idea is that everyone has a say and that the collective weight of opinion makes us all better informed, better able to exercise “choice” as we trundle down the health aisle of Tesco and Asda.

But everyone doesn’t have a say. Five people express their indignation and another five express vacuous gratitude for a “great service” or a “brilliant doctor”.  Even if there is a clear verdict it will have been delivered by a jury representing a tiny proportion of the population. In a practice with 10,000 patients, 10 voices equate to just 0.1%. And in matters of health, every negative opinion, every bad experience will outweigh a bland expression of satisfaction by a factor of thousands to one.  

If Harold Shipman’s patients had been given the opportunity to tweet their views, he would have had a five-star rating. The “not sures” were too dead to vote.

The experience of patients is important, but experience is a slippery commodity, which has very little to do with health outcomes and everything to do with rude staff, bad hospital food and an exaggerated sense of entitlement inflated by the media.

If we ever reach the point where everyone expresses a view, what do we do with all the “information”? Direct representation only works at a small scale. The Greeks, who invented democracy, could only make it work for 5000 people before it got out of hand, but then they didn’t have Facebook. 

Now that there is no limit to our ability to build a bigger amphitheatre we like to think we are better informed and have more choice; in practice we are more baffled than ever.


stuartabbott@nhs.net says:
Sep 23, 2011 11:34 AM
If you had actually read 1984 rather than the myth that has grown up you would know that only party members are actually monitored at all. The proles are actually fairly free and unmonitored if poor.

So the problem of only watching the party members all the time is greatly reduced. 1984 is actually about a government watching its civil servants at all times, not the populace.
julian@cohear.com says:
Sep 23, 2011 11:41 AM
What a nice post. I sometimes think that the most powerful driving-force in the history of the 20th century was the switch from individual to the state and then back again to the individual. Democracy is of course very flawed – as Winston Churchill once said “the best argument against democracy is a five minute conversation with the average voter,” yet he also warned that “democracy is the worst form of government except for all the others that have been tried.” He and Orwell knew little of empowerment, a concept that became in vogue much later. However, the concept of empowerment itself is a state invented one. If empowerment is to really work it has to come from the individual. The trouble is that in a conventional 20th century system “empowerment” is essentially a hierarchical concept, a word used by a superior when awarding power to an inferior or subordinate – or the state empowering the individual. The power can always be taken back any time the empowerer feels uncomfortable.

Maybe the individual will now be ready to take charge of governing themselves? This may be wishful thinking on my part but we just might now be approaching a new epoch: the age of personalised medicine – made possible by a combination of new technology and improvement science/ systems thinking which will enable us to make sense and ameliorate our own bafflement. In such an epoch empowerment would be something that cannot be taken back any time the empowerer chooses for this has always actually been as nonsensical as a queen ant trying to disempower a worker ant. As Peter Scholtes once highlighted “it is the height of arrogance for any person to think they can motivate another person, it is actually only possible to demotivate them.” Indeed in the 1990s many organisations initiated empowerment programmes, but almost all of them failed because the very concept of empowerment is actually inherently flawed – as Chris Argyris at that time pointed out ..“despite all the talk and all the change programmes, empowerment is still mostly an illusion.”

jpatterson says:
Sep 23, 2011 12:45 PM
Stuart, guilty as charged. Last time I read it was some time in the 1970s.
dave.hutchinson@sth.nhs.uk says:
Sep 23, 2011 01:00 PM
He may not have been spot on with the methodologies but given the ubiquitousness of the CCTV and the amount of spyware on just about every PC on the planet his notion of everyone being watched was pretty accurate and getting more so by the day.

Oh to be a prole and free.
phodgkin2 says:
Sep 25, 2011 12:43 PM
Interesting post. As you say the critical difference to the world of 1984 is that voice has been democratised - anyone can blog, tweet or share their views on FaceBook. It is also now really easy (ie cheap) to find 'people like me' who suffer from advanced renal carcinoma, want to stop their local hospital from closing - or for that matter to join Al-Qada. And to organise together to achieve these ends.
In themselves these tools are neutral - Twitter was instrumental in coordinating both the riots and their clean up. What democratised voice does do is to transfer a modicum of power from big hierarchical organisations to networks of loosely coordinated citizens. Such 'sous-veillance' from the bottom up citzenry is an an uncomfortable reversal of the surveillance we're so used to imposing on patients but can be uncomfortable for professionals and managers. But it is still there and still changing the world - as in the Arab Spring and Mumsnet members tightening the rack on News International.
The issue therefore is not whether this tsunami of voice carried by social media platforms is 'good' or 'bad' but how to create tools that make it productive not destructive.
Having set up and run www.patientopinion.org.uk for the last 7 years we now know that this is at least in principle possible.

This ket thing to recognise is that this is about voice not data. When someone says on Patient Opinion 'Everytime I visited my mum in St XXX I found her meal tray placed just out of reach. She lost 1.5 stone in 10 days' they are a. telling us valuable stuff and b. want a reply. What is needed is to ensure these comments reach busy staff in ways that make it easy (and if possible enjoyable) to reply, to feel good about the interaction and where ever appropriate make a service improvement (often not difficult to do - just put the tray in reach). We then log these improvements and display them on the site.
These conversations will never be representative - what they are is a way of collectivising patient insight and when appropriate changing these into better services. The stunning thing is that people want to help - for example at Patient Opinion we have to remove a racist or obscene word from fewer than 1 in 3,500 stories and around 50% of postings are people saying Thank You.
 All this at very low cost and in ways that already scale to cover the whole of the NHS across the UK. Which is quite close to what I think Julian is suggesting. Perhaps the future is alrady here?