More choice in public services

The underlying principle of the main public services which is popular is the principle that the service is supplied free to the user, and paid for by taxpayers. This is true of most healthcare, of most school education, and many social services. No political party with serious aspirations to govern either locally or nationally will challenge this popular base to much public service provision.

This does not mean that users of these services are all happy with what they get, or against improvement. It does not mean that because they are free to the user they have to be monopolies delivered by public officials. The Conservatives, the Coalition and Labour in government have made some moves to allowing charities and private sector companies to provide some of these services. There have also been limited moves to give users some choice.

In education Labour developed an Academy programme which has been taken further by the current government. They have added free schools. Parents and older schoolchildren value having some choice of school. The complaints I get as an MP are where a popular school has too few places, forcing some to go their second or third choice school. I rarely get complaints about the possibility of choice. The issue for the next election is how much further should we go in offering more choice? What other types of school should we permit? How can popular schools expand to provide the desired places?

In the NHS Labour let some contracts to private health suppliers to carry out certain operations and procedures where waiting lists were too long. Patients still received a free service, but at a with profit provider paid for by the NHS. This was broadly popular with patients, and did help reduce waiting lists in the areas targeted. How much  more of this should we do? Should patients have more choice of GP, Consultant and hospital when they need treatment. How much should they be told about success rates and availability when sorting out their diagnosis and  treatment? Was the big idea behind Choose and book a good one?

In social care Councils vary in their approaches, but many do understand the need to tailor care packages to individual needs, and to help people live for longer in their own homes with assistance before having to consider  moving into a home. Is there enough choice and flexibility?

More choice should mean better value for money as well as a service tailored to individual needs and preferences. Having a variety of providers will help deliver value and drive innovation, two things monopolies are usually poor at achieving.

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27 Comments

  1. margaret brandreth-j
    Posted May 31, 2014 at 6:03 am | Permalink

    Council services such as swimming pools and gymns are not free, but the service is good.

    Choice in schools will obviously mean that all will be competing for the places in a couple of schools. Money talks.

    Choose and book is a frustrating bureaucratic exercise. Referrals are stopped . If specialist help was not required the patient would not be referred in the first place. Now a case has to be made……..We are all lawyers for the defence of patients.

  2. Alan Wheatley
    Posted May 31, 2014 at 6:10 am | Permalink

    I agree with choice and the downside of monopolies. But we need to be sure we get right the implementation of what is inherently a good objective.

    Take schools, for instance. Should we treat them rather like a free market? Is the correct response to a shortage of places in popular schools to allow them to expand? What becomes of the unpopular schools?

    If we assume “popular” equates to “good” (or at least better), then clearly the more children educated in good schools the better. But what of the children going to the schools that are not good? Surely they too are entitled to a good education .

    So, perhaps the correct response to a shortage of places at popular schools is to improve education at unpopular schools. Have not surveys shown that parents would prefer to send their children to their local school, providing it is good enough.

  3. Lifelogic
    Posted May 31, 2014 at 6:16 am | Permalink

    The whole idea of confiscating peoples money to provide services to them should clearly be restricted to the very, very few areas where government can actually do a better job. Defence, law and order, roads and not very much else. Where it has to be done it should be done with a voucher system so the users can choose their provider and they get paid only when he/she is happy with the service provided.

    Once they have you money in advance the providers have little or no interest in delivering any real service to you at all (hence are the rationing by delay, age, restrictive terms and inconvenience in the NHS & social housing). They also deliver services that few even want anyway such as motorist parking, bus lane and box junction muggings, holistic and quack medical treatments, victim of crime leaflets and counselling, endless pointless quangos doing little of any use, propaganda organisations like the BBC, misdirected overseas aid, HS2, the pointless Olympic stadia, the Millennium dome, soft loans to the PIGIS, loan to the IMF ….

    It also kills or vastly reduces competition, so social housing puts more efficient providers out of business, wind and PV energy subsidies kill other better energy production methods, free schooling kills more far efficient private schools, free health care kills private health care, university loans & subsidies kill other education services. Subsidies and over taxation of motorist mean people use less efficient trains and cannot afford the car they perhaps need more.

    So the government tax 50% of your earning deliver, little of any real value and kill (with unfair competition) the other providers of services to further restrict what you could do with the 50% they kindly left to you. From this 50% you perhaps get say 10% of real value from the state at best – the rest is wasted in admin, used to do pointless or even negative things or they waste your time with delays, rationing and inconveniencing to restrict supply. They also waste more of you time and money with the absurd complexity and filing requirements of the tax system.

    Worse still the system also provided perverse incentives – spend you money now so you do not have to pay for care in old age or inheritance taxes, become a single parent and get a free house, go to university and then work on a low wage or do not work at all, so you do not have to pay it back, do not insure, save or be prudent as the state will provide. Worse of all they use the money taken of you to “buy” votes through bribes and propaganda in marginal regions.

    Cameron as a Libdem to his heart and soul clearly cannot see this.

  4. Antisthenes
    Posted May 31, 2014 at 6:54 am | Permalink

    There is no doubt that competition works it optimises quality and value of products and services. It is also true that free at the point of delivery makes for abuse and waste. The left of course are in denial on these facts as they are in so many other areas of political, social and economic thinking and that is a considerable barrier to improving public services . Provision and funding of much of that which government provides through the public sector needs radical rethinking because the current methods are not working at all efficiently or in the best interests of their customers the general public. Privatisation is in most cases the answer of both provision and funding. The left of course will say that by doing so the less well off will suffer as they will be priced out of the market. That of course is nonsense as anyone who knows the French healthcare system can confirm. A system of provision and funding that can so easily be applied to vast swathes of public services.

  5. Anonymous
    Posted May 31, 2014 at 7:13 am | Permalink

    The place where we really need more choice is in politics ! The Tories spout on about choice but in the one area in which they can offer us a difference they fail abjectly to deliver.

    Instead we get Blairism.

    Definition:

    A ‘centrist’ political construct which is, in fact, leftist in which capitalism is unleashed and which socialist politicians can make millionaires of themselves with clear conscience.

    Conservative (big C)

    Definition:

    A Blairist party pretending to be Conservative. When things go wrong it blames the EU.

    The EU serves all main parties well, but not the people.

    WHERE IS OUR CHOICE ?

    • Anonymous
      Posted May 31, 2014 at 7:15 am | Permalink

      Politics by the politicians, for the politicians.

  6. Roger Farmer
    Posted May 31, 2014 at 8:57 am | Permalink

    These are some of the subject we should be assessing at arms length and judging by results. The criteria should be, what is beneficial to the people and good for the country. Having established this, get on with it.
    For instance I applaud what Michael Gove is trying to do with education. Expectedly it will have hiccups on the way. A good school attracts pupils, so to a point increase it in size or build another in the area. Let there be more interaction, academic and sport, between the public schools and their neighbours. Lack of vigilance has given us some schools in Birmingham that have been infiltrated by extreme islamic followers. There is no place in UK education for the denigration and separation of women, the breeding of terrorists or for that matter the pushing of any form of religion. Better teach a moral ethic. By pretence that it does not happen and fear of being labelled racist you perpetuate what you might prefer to avoid.
    There is apparently one shinning example of a basket case NHS hospital called Hinchinbrooke being privatised. It is now a joy to work in and a pleasure to be treated in. It has rebalanced the ratio of medical staff to administrators and adopted the best of the workplace ethos from Toyota. Examine, evaluate, and spread throughout the NHS. Don’t leave it all to UKIP to do. By and large, the NHS is considered a sacred cow. It is large, bloated, and grossly inefficient. In many cases it operates in direct opposition to the patients interests, and these are almost the only reasons it exists. The waste is unbelievable. I have seen a pair of stainless steel nail clippers, shop value about £20.00, that have to be disposed of after use on only one patient. Believe me they are good enough for a lifetimes use by any normal person. What has happened to the Autoclave. This one time use policy has not impacted on deaths caused by infections gained in UK hospitals. When you see the size of GP practice centres these days you realise that they must house a large number of GPs. They should be open 24/7 and could easily do so, offering medical aid on a small scale out of hours and throughout the weekend. If Tesco can do it why not GPs.
    I would also consider privatising care for the elderly in their own homes providing the service is properly scrutinised. It is a service for professionals not for staff pulled off the streets.
    As you say monopolies are bad, national and local government monopolies usually far worse.

  7. Bert Young
    Posted May 31, 2014 at 9:56 am | Permalink

    The rates I pay bare no resemblance to the , so called , services I receive . My house refuse is collected every other week , my child attends an independent school , the road through my village is in a shocking condition and has received no real maintenance during the 31 years I have lived here and at times it takes 10 minutes to access the main road due to traffic congestion , the drainage system means it floods most years , the nearest bus stop is almost a mile away and so on and so on ( I pay £2,800 in rates ) . There should be proportionate reductions according to the advantages/disadvantages each household receives – as you say ” a service tailored to individual needs “. I believe a bottom up appraisal of the rating system is long overdue .

  8. Max Dunbar
    Posted May 31, 2014 at 10:50 am | Permalink

    Many charities are already simply government front-organisations with the vast majority of their funds coming from the taxpayer. The political power that many of these ‘charities’ wield is also considerable. It would be worth investigating the Charities Commission and its alleged links to Common Purpose.

  9. oldtimer
    Posted May 31, 2014 at 11:10 am | Permalink

    OT: Professor Ross McIntrick has posted a very good talk on the weaknesses of the climate and economic models that are used to determine public policy. He points out that the social cost of carbon as calculated by Integrated Assessment Models (IAMs) is based on General Circulation Models (GCMs) which do not match the observed evidence. I found him very convincing in his analysis and conclusion.

    His presentation posted here:

    There is a pdf version here:
    http://www.friendsofscience.org/assets/documents/McKitrick2014_ThePause.pdf

  10. Denis Cooper
    Posted May 31, 2014 at 11:57 am | Permalink

    The coalition government has failed to meet its target for reducing net immigration.

    That alone means that whatever plans it had about the future provision of public services will be inadequate for the demands of an increased population.

    In some cases, such as healthcare, the inadequacy of the planned provision will become apparent sooner than in other cases, such as education.

  11. acorn
    Posted May 31, 2014 at 12:16 pm | Permalink

    We get state health care for a shade under £2000 each per year. We spend about £350 a year each on private medicine. The US pays over twice that total per capita, with over half of that private spending. So we get a pretty good deal when you consider 0ne cataract surgery cost £2,200 in a local private hospital.

    What or which goods and services are universally required across the population? If such goods and services have high fixed or sunk costs, does it make sense to have a monopoly supplier? Should the Government be the Purchaser AND the Provider of such goods and services? At which points in a supply chain, can you introduce competition?

    All fairly easy questions until political ideologies get involved. Then it’s ping pong; Punch and Judy; nationalisers to the left; privatisers to the right. http://www.ons.gov.uk/ons/dcp171766_361313.pdf .

    • Colin
      Posted June 1, 2014 at 8:59 am | Permalink

      I suppose it’s pointless trying to explain that there are in fact more than two countries in the world, and the NHS is not the envy of most of them…

  12. rick hamilton
    Posted May 31, 2014 at 12:59 pm | Permalink

    Of course people should choose whichever doctor, consultant or hospital they wish to go to based upon reputation and published data including ratings by patients and relatives. Why not? Taking responsibility for the management of your own and your family’s health is a basic obligation of all adults.

    The fundamental problem is the ‘free at the point of delivery’ obsession. As in most countries with a national health system that works well, if you pay a small amount for each visit, with a cap for chronic or expensive treatments, there will be more recognition of what health care costs and less demand for trivial or vanity procedures. There will also be an element of competition among hospitals, etc to provide the best care and outcomes they can possibly achieve.

    Nobody really values something that appears to be free, even though we all know that it is nothing of the sort.

  13. Richard Roney
    Posted May 31, 2014 at 1:32 pm | Permalink

    Choice is important and it seems odd that even today choice in the NHS is limited. Why for example if one goes to a private GP are you not allowed to get the drugs he prescribes paid for by the taxpayer? Why won’t an NHS GP accept the result of an ultrasound paid for privately? Why does he insist on another ultrasound on the NHS before he’ll organise an MRI scan that the expert who looked at the original ultrasound has already recommended be effected? You would think that the NHS would be happy to have people reduce its costs by paying for some things themselves but apparently not. No system in the private sector would last for long that was so ignorant of costs and structured to please its employees rather than its customers.

    • Iain Gill
      Posted June 1, 2014 at 1:35 am | Permalink

      It is a complete nonsense that a private dentist who does no NHS work whatsoever is able to write an NHS prescription but a private doctor (who often does both private and NHS work) cannot write an NHS prescription and instead has to issue a private prescription.
      It is also a complete nonsense that lots of medicines cost significantly less when paying normal market price via a private prescription than the NHS prescription price. Why bother with the admin costs of putting it through the NHS system?
      It’s a nonsense the way local fashions exist in the NHS. Some parts of the country take blood for blood tests there and then in the GP surgery. Other parts of the country send patients to central locations where specialised blood taking operations run, often in a main General Hospital. The later means folk have to take another half day off work, and means ill people are meeting up more and spreading germs amongst each other and bringing those germs into the hospital unnecessarily. In none of this does the patient have any buying power to determine how they want to be served.
      It’s a joke that lots of NHS consultants issue appointments for their entire days out patients for 9.30 in the morning, knowing that many will not be seen until the end of the day and will spend the whole day in the waiting room.
      In all of this the NHS is obviously running an inefficient service to anyone caring to take a casual glance.

    • Colin
      Posted June 1, 2014 at 9:01 am | Permalink

      You would think that the NHS would be happy to have people reduce its costs by paying for some things themselves but apparently not.

      It’s not about cost, it’s about power…

  14. Narrow shoulders
    Posted May 31, 2014 at 1:35 pm | Permalink

    Far better for the users to actually pay for the service. The rate can be determined accordimg to ability to pay. Lower taxation will free up funds for payment and those paying will value the service more and demand better.

    Academies under the Conservatives have generally become less good at educating. Those that converted under Labour had funding thrown at them which in education does deliver results. Tbose converting now get similar funding than they had before but must procure services and assistance without the economies of scale the local authority was able to provide (insurance is now provided by the DfE). Public funding is being trousered and ‘experts’ have proliferated.

    Free schools are not created where there is pressure on placss so just take more funding from the pot. Most unsatisfactory.

  15. waramess
    Posted May 31, 2014 at 3:25 pm | Permalink

    More choice? Certainly. More providers. Most definitely. Free at the point of use? Well, that is what any insurance policy provides and health is an insurance provided benefit, isn’t it?

    If I crash my car the insurer provides me with a new one free at the point of use and, if my house burns down then the insurer provides me with a new one, free at the point of use.

    There is no good reason why the government should feel the need to provide insurance; it may, quite rightly, wish to supervise the quality of insurance protection being provided by the private market and it might certainly wish to ensure those at the less well off end of society are provided with a safety net but, provide the insurance?

    Why should they? Equally importantly is why should we trust them to also provide the hospital care? A very real conflict of interest in the absence of a robustly competitive environment.

    There is a worrying attitude displayed by all parties in Parliament that the government either does it best or the private sector cannot be trusted to do, whatever it happens to be.

    Real choice will never be available in a government run institution. You will get whatever they decide to dish up and a few soothing noises. Nothing else.

  16. Mark B
    Posted May 31, 2014 at 3:55 pm | Permalink

    John Redwood MP said;

    “The underlying principle of the main public services which is popular is the principle that the service is supplied free to the user, and paid for by taxpayers. “

    The NHS, Schools, Welfare and other public services which are funded by the taxpayer are undoubtedly popular to the ‘end user’, especially if that end user has never contributed to the funding of said services.

    Time for a rethink. Its time that the people who ‘actually’ fund these services had a bit more of a say on the amounts that they wish to contribute.

    Also, politicians and political parties keep making promises with what is, other peoples money. This must STOP !!!

    Only properly costed policies should be allowed on the electoral manifesto. No more pie-in-the-sky ideas of; “If elected we will do this and that for you.” Tell me where you intend to get the money first.

  17. Cliff. Wokingham.
    Posted May 31, 2014 at 5:38 pm | Permalink

    I am a retired psychiatric nurse and have worked in both the NHS and private hospitals.

    In my opinion, the biggest and perhaps, most important discussion which will need to take place about the future of the NHS, is to decide exactly what we want the NHS to do.

    When the NHS was set up just after the war, it was to provide basic healthcare, free at the point of use, for the whole population. Now it seems to me, that it has morphed into a giant, out of control money pit.

    Do we want the NHS to provide fertility treatment for example? What about cosmetic surgery which are purely elective and for reasons of vanity? Should the NHS fund gender reassignment procedures? Should it fund obesity treatments, such as gastric bands or bypasses? Should it fund treatments of sports related injuries or should those participating in such sports take out some insurance? What about smoking/drug/alcohol related diseases? Should sufferers be charged for treatment or should the relevant industries pay an extra levy for the harm they do?
    I am not advocating nor am I dismissing any of these thoughts or questions, I am merely proposing a sensible, measured and hopefully, non party political discussion takes place.

    I think we could have further discussions on many other public services along the same vein…….What do we expect our indoctrination, opps sorry, education system to provide? Do we want it to educate in the real academic sense or do we want it to just churn out operational units for businesses? Do we need to be more choosy about the type of further education we offer? Should we encourage youngsters to go to university or to take jobs which offer a clear career structure? Is it morally right to have university tuition fees at all? Was it morally and ethically right for those who benefited from a free university education to vote to charge fees? If graduates are earning high salaries, surely they pay high levels of tax so, would the cost of their education effectively be paid for?

    What do we actually want the state, at local, national and international level to do for us? Do we need so much state?

    These are, in my opinion, the kind of questions we need politicians to answer and to discuss.

    • outsider
      Posted May 31, 2014 at 10:56 pm | Permalink

      Dear Cliff Wokingham, You make some good points. In principle, the National Health Service is the expression of an insurance policy to treat us when we are ill or have symptoms that may betoken illness. The insurance policy must take us as we are but is not there to provide some of the lifestyle choices that you mention. These can be life-changing procedures but seem best financed by charities. Many people who have benefited would be only too happy to fund such charities and the National Lottery could help too. NHS as an organisation can of course provide the services.
      Likewise, the NHS should not spread its insurance funds on public health (eg smoking cessation) other than for children. Prevention is much better than cure but there are other ways to fund and organise this. The NHS should stick to tests and cures.

  18. Iain Gill
    Posted May 31, 2014 at 7:11 pm | Permalink

    For healthcare I think the politicians should stop trying to constantly reinvent the wheel. Instead copy the health system from some other country where it’s more successful. I would recommend the health system in New Zealand or Belgium. In neither of these countries do the poor go without medical care, in both the patients exercise real buying power, in both of these countries care is significantly better than here.
    If not prepared to do that I would turn the NHS into a state backed medical insurance company, into which everyone pays according to ability through taxes, and patients get pay outs according to need to take to any provider they choose. Get the state out of owning and operating providers of care. Probably some subsidy needed to keep provision going in rural areas, but that’s no different to now.
    The current “take it or leave it” and “GP as the gatekeeper” model just does not work, especially for those with poor GP’s.
    “Choose and Book” was never going to work as designed, even if implemented well. For one GP’s are not qualified to comment on which provider to use in areas like eye care, for two choice only at the beginning of the treatment cycle is not enough. People need to be able to walk out of a dirty/late/rude waiting room and go somewhere else and take their money with them at any point in the treatment cycle.
    For schools give the parents control of their education budget, let them take it anywhere they want. Shut down local education authorities. Get the state out of owning and running schools, instead the state should concentrate on making sure everyone has enough budget to afford a decent school.
    Buying power with the individual end consumers is the only thing which overall can force providers to optimise their provision.

  19. forthurst
    Posted May 31, 2014 at 9:39 pm | Permalink

    “More choice should mean better value for money as well as a service tailored to individual needs and preferences. Having a variety of providers will help deliver value and drive innovation, two things monopolies are usually poor at achieving.”

    JR, having had experience in the private sector knows that what crucially determines the success of a business is that it has a product for which there is a genuine demand and senior management and workforce who are properly skilled and motivated to deliver that product to customers. When a business falls down through incompetance or no longer offering what the market now desires, there will be others to step in to take its place; this is broadly satisfactory in the supply of goods and some services; however, when it comes to health and education, switching suppliers is not an option; children only grow up once, seriously ill people may need the correct diagnosis and treatment initially if they are to survive.

    On education, enormous sums are spent on new schools and new concepts; schools are calibrated according to ‘success’ in passing exams. However, no recognition is given to the fact that some children have higher inductive capacities than others and that parents of bright children would like them to be given an education commensurate with their ability in selective schools (as private schools are). The failure to acknowledge the Bell curve also means that exams have been dumbed down so that the fiction of a more equal ability range is maintained; in the process, the examination system has also been infiltrated by those who in history want to substitute our brilliant Island story for events which may have taken place abroad, to replace our unparalled literary heritage, particularly WS, with the second rate. They have done this firstly to promote their own group interest and second to deprive children of the knowledge of who they are. In summary, in supplying a service like education, the refusal to offer children the education their parents desire, or the failure to administer the system at all levels to prevent incompetants and subversive entryists from infiltrating the system means there is no real attempt to optimise the quality of what is provided ‘free’.

    The NHS fails far too many patients; there are some truly appalling cases regularly featured in the Mail. Today different doctors failed to diagnose a life threatening illness thirty times and the patient died in great distress. The quality of clinical staff is crucial; the best way to ensure this is to train all our own doctors to our own exacting standards and to offer them terms of service which means most will choose to remain here after qualification. This is something which the DoH deliberately fails to ensure. In addition, the GMC may be licensing to practice some whose qualifications in terms of clinical expertise or dedication to their Hippocratic Oath is not up to first world standards and failing to immediately root out such people when they fail patients.

    The NHS is overburdened with staff who are not clinically trained; what do all these people do apart from drawing resources away from the those who treat patients? Why are they allowed to make decisions over when and who will treat patients when they entirely lack medical training? What action is taken to ensure that administrators have the managerial ability to fulfill their roles?

    Other countries can offer publicly supplied services like education and healthcare which are broadly satisfactory; why can’t we?

  20. outsider
    Posted May 31, 2014 at 11:06 pm | Permalink

    Dear Mr Redwood, I agree entirely with your sentiments but one must always remember that choice is anathema to publicly funded service. This is because choice requires spare capacity and to the Whitehall mind, spare capacity means waste. So whenever there is pressure to economize on public spending (ie in the downswing of every economic cycle) choice is likely to go. It helps if the spare capacity is provided by the private sector, as with Labour’s waiting time opt-out but this is often not possible.

  21. David
    Posted June 2, 2014 at 7:55 am | Permalink

    I agree with having more choice. How about a reform of the electoral system so new parties can arise. In private industry successful companies can fail e.g. Woolworths.
    In countries with PR parties can go from Government to non existence. However in the UK no new party apart from the SDP has got an MP in the last 100 years – and that was a split from Labour.

  22. Lindsay McDougall
    Posted June 3, 2014 at 11:39 am | Permalink

    The old publicly funded NHS monopoly is still there, though. Many people, especially the wealthier older people, are willing to contribute more to health services. That’s health services in the PLURAL. What we are not willing to do is contribute more money so that Andy Burnham or Jeremy Hunt can take all the decisions on how it is spent.

    If nothing else, the State monopoly should be willing to bring back the haggle, but it is too inflexible.

    Take the case of my hopefully about to happen (at long last) hip replacement operation. At first, I hoped to live with the arthritic hip condition. Then the condition worsened and I was due to have an operation on 6th February. That was cancelled the day before it was due, without so much as a by-your-leave because the medical profession, in its infinite wisdom, decided that there was an unacceptable risk to my slightly malfunctioning kidneys from the operation. Unacceptable to whom? There was no consultation with ‘the patient’ (try thinking CUSTOMER once in a while), no bothering to quantify the risk and communicate the numbers, no bothering to find out if my income would be adversely affected. The NHS hasn’t heard of semi-retirement.

    The choices with a hip operation are the NHS, who offer an 18 week wait (much more in my case), or to go private for about £10,000. In my case, the only reason to fork out money was to be able to earn money abroad. However, the projects are subject to competitive tender and there is only a one in 5 chance of success on any one bid. Ergo, I would be willing to contribute £2,000 more to hasten the operation. However – catch 22 – the NHS has no mechanism for this and it would be regarded as corrupt ‘queue jumping’. You can’t win.

    I believe that in the long run people will see that their are better ways of helping the poor than messing up an entire market. There’s no way that this will happen by 2015. By 2020 I have hopes that public opinion will change.

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  • About John Redwood

    John Redwood has been the Member of Parliament for Wokingham since 1987. First attending Kent College, Canterbury, he graduated from Magdalen College, and has a DPhil from All Souls, Oxford. A businessman by background, he has been a director of NM Rothschild merchant bank and chairman of a quoted industrial PLC.
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