"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Monday, 29 August 2016

Abbott should stop acting like a Tory and be more like Blair

On Friday, 26th August, Diane Abbott was interviewed by Shaun Lay on the Radio 4 news programme the World at One. (The podcast can be downloaded here.) The most interesting thing was that she didn't promise any extra money for the NHS. In fact she flatly ruled it out. The interviewer, Shaun Ley, pressed her on this:
“is your only option to say that we actually need to spend more on the NHS as a proportion of GDP, is that fair?” 
to which Abbott replied
“we certainly aspire to maintain what we spend on the NHS in a proportion of GDP”
So Ley pressed her again:
“you say that you do not want any increase in co-payment, you say that you do not want to change the system of funding, then you’ve got to spend more?”
And Abbott refused to promise more funding
“you’ve also got to save money, as I’ve explained to you”.
Abbot refuses to increase spending on the NHS in spite of the fact that the NHS is clearly underfunded. The government says that the NHS “overspends” whereas it's clear the NHS is not funded sufficiently to cover the demand. Labour under Corbyn are now agreeing with the government on the level of NHS funding. This is probably not surprising since John McDonnell agreed with Osborne’s ludicrous Fiscal Responsibility Act. Abbott, who is possible the least informed of any shadow minister ever, trotted out unevidenced tripe. She gave three ways that the NHS reorganised under Corbyn would “save” money.

First, PFI. Abbott said:
“Every year for the coming decade we going to be spending nearly £2bn on PFI and I’ve spoken to CEOs of big London teaching hospitals who are talking about buying out their private finance initiative arrangements because it would be much cheaper at current levels of interest.” 
Ley challenged this:
“to do that will they have to be able to borrow from elsewhere, or will the Treasury have to pay for it?” 
Abbott replied that
“the CEOs I have been speaking to are talking about borrowing money as an institution”.
I won’t defend PFI, it is an expensive mechanism for many reasons, but Abbott is clearly out of her depth on PFI. There are several issues here. Let’s start with her claim that getting rid of PFI would “save” £2bn. The only source for this figure appears to be an article in The Daily Telegraph in July 2015 – a year ago.

The Telegraph says
“The scale of the PFI charges is contained in official figures compiled by the Department of Health and obtained by The Telegraph.” 
Unfortunately the Telegraph do not provide a link to these “official figures” and searches on the Department of Health website does not yield any results. Abbott is quoting figures a year out of date that clearly she has not checked.

Up until April 2016, there were two financial regulators: Monitor for Foundation Trusts and the NHS Trust Development Agency (TDA) for NHS Trusts. In April 2016 these were amalgamated into one regulator called NHS Improvement. Two thirds of trusts are Foundation Trusts. Monitor provides annually consolidated accounts for all Foundation Trusts. The consolidated accounts for 2015/16 says that the capital repayment payments for PFI were £185m and the interest paid was £363m. So the total PFI finance costs for Foundation Trusts was £548m. This is in comparison to the total PDC dividend payments of £544m for Foundation Trusts (PDC is an alternative, government-backed, finance scheme).

The Trust Development Agency did not issue consolidated accounts, but there is no reason to think that NHS Trusts have larger amounts of PFI per trust than Foundation Trusts. NHS Improvement has released the 2015/16 fourth quarter performance report which includes both the aggregated figures for Foundation Trusts and NHS Trusts. This report says that in the 12 months to the end of March 2016 PFI costs (capital repayment and interest) were £898m (compared to £839m for PDC).

Thus we can assume that the finance cost of PFI to the NHS is around £900m a year.

So where does the Telegraph get a figure of £2bn from? The PFI arrangement is usually that a private company builds, and then operates the building on behalf of the NHS. The trust owns the building on effectively a lease mechanism. The “operates” comes in several forms, it could be just the maintenance of the building, but it could include services like cleaning, catering and car parking. These are all services that must be provided, and without the PFI contract, a trust would either have to provide these services themselves, or contract a private provider. (Under a law passed by John Major, there are VAT benefits for a trust to outsource such services to a private contractor.)

The important point is that there will still be a cost, even if a trust provides the services itself. The extra billion that the Telegraph quotes is presumably the service charges. For services the vast majority of the costs will be staff, so it is unlikely that there will be much scope for savings, unless there are staff losses or pay cuts. If there is a saving, it will be in the region of millions over the country rather than billions.

The finance part of PFI involves borrowing money, which can be done cheaply now by the government. However, note that Abbott did not pledge government funding to “buy out” PFI she specifically said that the trusts would have to borrow the money themselves, and this will be at a higher rate than the government would pay.

One English trust, Northumbria Healthcare Foundation Trust, has "bought out" its PFI, however, they didn’t go to the open market to borrow the money. Instead, Northumbria obtained a loan of £114m from Northumberland County Council and the council borrowed this money from the Treasury’s Public Works Loan Board. In effect this is a government loan in a roundabout route. Abbott has ruled out a Labour government financing such “buy outs” of PFI, so Northumbria is not the model she will use. Even so, the loan of £114m would yield a saving of just £3.5m a year to the trust, and if this is scaled up to all PFI schemes, such savings are unlikely to provide savings of “billions”.

Abbott's policy that trusts should make their own arrangements to "buy out" PFI schemes is at odds with many of Corbyn's ardent supporters, who demand that the government should either buy out the schemes or even cancel them altogether. Since Abbott is saying that trusts should borrow to buy out PFI schemes raises the question of whether anything has changed at all since a trust may borrow from a bank, who may be part of a consortium providing PFI services.

Morally, one has to question “buying out” PFI loans. If the PFI companies have been “swindling” the NHS for decades there is no moral case to simply reward them by buying the loan off them. Morally, a radical government would seek redress for such “swindling”. Abbott is not suggesting this, which implies that she really does not regard PFI as being as bad as she is saying in public. What is clear is that there are unlikely to be savings of billions in buying out PFI schemes.

Abbott’s second point was agency staff. She told Ley
“we are spending £3.6bn on agency staff, there is no need for the health service to spending that on agency staff.” 
Here, she is marching in lock step with Jeremy Hunt, and like Hunt she will fail. There are numerous cases around the country where trusts have breached Hunt’s agency cap because trust boards have recognised that care would be unsafe with their staff level without agency staff. Removing agency staff does not solve the workforce problem. The staff shortage problem was caused by the Coalition. Osborne froze NHS pay rises and Lansley abolished the Strategic Health Authorities which were responsible for training. Although Lansley created new organisations to manage the funding of training of staff (Health Education England and Local Education and Training Boards) there was a hiatus in workforce planning. Further, Osborne made this even worse by announcing the abolition of the nurse bursary to pay for nurse training.

Abbott could have used the interview as an opportunity to attack the bursary policy and the woeful workforce policy of the Conservatives, but she didn’t. Instead, she just echoed what Hunt has already said.

The third area that Abbott claimed she would save money was on medicines and in particular Abbott chose to stigmatise diabetics. Abbott told Ley:
“And then there is the question of drugs, some of these proprietary brand drugs there is a mark up of times seventy three, so we think that there is money to be saved. And I think in the long term we do need to look at public health, we do need to look at prevention. Ten percent of NHS drugs bill goes on drugs for diabetes. We think public health issues like diabetes, like obesity, exercise and alcohol could in the long run bring down costs of the NHS as a whole.”
On the question of drug prices, this presumably comes from a report by The Times earlier this year that claimed that there was a “loophole” that allowed branded drugs to make such large mark-ups (accompanied, of course, by cherry picked examples). Abbott mentions “proprietary brand drugs” and presumably she means branded drugs that are dispensed when a chemically identical generic drug can be dispensed instead. (Some drugs are still under patent, so a generic is not available.)

While it is possible to improve the prescribing of generics, the NHS has actually done very well so far. Prof Appleby (then) at the Kings Fund estimated that the proportion of proprietary drugs has fallen by a third since 1976. If this change had not happened then the cost of prescriptions (taking into account that the volume of prescriptions has increased four times) would be twice what they are now. Of course, savings can always be made, but the likelihood is that the easiest savings have already been made, and the next lot of savings will be a lot harder.

I do not think that Abbott has any coherent plan as to make more savings from switching from branded to generics, I think she is making this point because it is part of Corbyn’s campaign against Owen Smith because of his former employment by Pfizer. Note that Abbott does not attack the politically created, but non-evidenced Cancer Drug Fund. She does not supply any new innovative ideas, like NICE. No, she attacks branded drugs because Smith once worked for Pfizer.

After attacking the price of branded drugs, Abbott then goes on the offensive against “diabetics”. She says:
“ten percent of NHS drugs bill goes on drugs for diabetes. We think public health issues like diabetes, like obesity, exercise and alcohol could in the long run bring down costs of the NHS as a whole”. 
While Abbott is right that “diabetes” does cost the NHS a large amount of money she makes the typical second rate politician error of not stating the type of diabetes. There are two: type 1, which is an autoimmune disease and cannot be prevented or cured, and type 2 that has some association with obesity, but is not entirely caused by obesity. Nine tenths of diabetics are type 2, and the NHS is keen on trying, where it is possible, to prevent people developing type 2 diabetes. However, blaming type 2 diabetics for the financial state of the NHS is something that right wing politicians do, now Abbott is joining in.

A tenth of diabetics are type 1, and there is little that can be done about reducing the cost of their treatment. Even if Abbott is claiming that she can save money on treating type 2 diabetics, she is being misleading. There is a growing obesity problem, and obesity may lead to type 2 diabetes. However, the age demographics of current type 2 diabetes is that it is a condition of the elderly. It is being old that is the cause of their condition. There are ways to make the treatment of type 2 diabetes in older people safer and more effective (and consequently, save money) but Abbott did not mention these ways and I am sure she does not know about them.

Everything about the interview screamed: a clueless politician briefed by an ignorant researcher. Spouting nonsense loses the confidence of the public, and worse, it threatens Labour's rightful claim to be the party of the NHS.

Abbott says that she will keep to the Tory NHS funding levels. This is appalling; the most effective way of destroying the NHS is to keep to the damaging flat funding policy of the Tories. Abbott needs to acknowledge that in 1997 Blair promised to raise the funding of the NHS every year in real terms. And on this Blair won a landslide. Then in 2000 Blair pledged to raise NHS funding as a proportion of GDP to European levels. And on this Blair maintained an enormous Commons majority in the 2001 election.

These figures are clear: Abbot should stop acting like a Tory, and should be more like Blair.

Tuesday, 28 June 2016

Second Brexit Referendum: a Positive Resolution

It is clear that the the next Prime Minister after Cameron will have a tough time deciding whether to recommend to Parliament that the UK should make an Article 50 notification (of the Lisbon Treaty) to the European Council. The current timetable is that the Conservatives intend a quick election campaign, appointing their leader (and hence the Prime Minister) by the beginning of September.

If the UK goes into recession  then there will be political pressure not to invoke the A50 notification which will be seen as an action that could make matters worse. (Technically the country cannot go into recessions because the definition is that there has to be two quarters of negative growth, and September is less than two quarters away, so I should say "if it looks like the country is heading into recession".)

In the few optimistic moments I have had over the weekend I have come up with this scenario.

The UK Parliament will have to approve the A50 notification, and Parliament is about to go into summer recess and does not meet again until September, then pauses for the party conferences, and real business starts in October. So the A50 notification cannot be done before October. At which point there will be:

  • a new Prime Minister (which could be pro-Remain May or Osborne); 
  • a summer of the civil service planning for how long, and how many resources, it would take to disentangle EU laws from UK law (most likely: a long time and a lot of people that they do not have); 
  • a summer of MPs talking to businesses and communities and finding out the real effect of Brexit (a lot of scare stories will be gathered); and 
  • the party conferences allowing MPs to get the opinion of party members. 

After all of this, a good many of the "the people have spoken" MPs will think "maybe if we can get a better deal then the people will think again".

Since it was clear that immigration was the top line issue during the referendum, the "better deal" will have to be about immigration from the EU. We know that it is a red line for the EU: access to the single market, inside or outside the EU has to have an agreement on free movement of people. That won't change.

In my opinion, immigration is good, but you have to have the infrastructure for the increase in population. So the "better deal" I suggest is that the EU will have to agree to pay for the building of this infrastructure: schools, health centres, hospitals, as well as social housing, in areas with a large influx of EU migrants. This policy would cover the entire EU, not just the UK, so it could get the approval of all countries. Such a policy would mean that EU migrants will no longer be seen as a drain on public services, but will be seen as the reason for the improvement of public services. A positive policy, and a second referendum will approve it, in my opinion.

Sunday, 8 November 2015

Unbiased Journalism

It doesn't happen. It cannot. Journalism always contains some bias. I have written for a living since 1996 (books, journal columns, features, and more recently, training courses and presentations) and I can confidently say that, from my experience, journalism is never unbiased.

We know that the national newspapers have their own overt biases. When we pick up a newspaper we know their political leanings (they all tell us who to vote for at the General Election, so of course they all have a political bias). We also know, in general, how a newspaper will react to a news story and we make allowances when we read the article and subconsciously strip out the opinion and bias to extract the news. (However, to be frank, the Daily Express support for Junior Doctors surprised me).

Journalism always has a bias. Journalists on the Nationals usually excuse themselves by giving a quote from someone who is known to have an opinion contrary to the main opinion they are reporting. I find that lazy and inadequate. A formulaic quote from a Press Officer at a government department, or a public body, can never be regarded as a balanced response. For a start, a Press Officer is, by definition, detached from the issue, they are not responsible, nor are they necessarily knowledgeable of the subject. A Press Officer is simply another journalist, poacher-turned-gamekeeper: a journalist giving a quote to another journalist. Worse, a Press Officer is merely parroting the statements from the person who the article's journalist should have interviewed, so why haven't they?

Some journalists have suggested that any subconscious bias in their copy is removed by editing. I find this hard to believe, particularly if an article is written by a "specialist journalist". As their title suggests, specialist journalists are unique at the publication. Other journalists editing the piece will not have adequate knowledge of the subject to be able to determine if there is "bias" in the article. At most publications, the editing that occurs is more about the publication's style guide, grammar, spelling and legal liabilities, than about the subject of the article.

Most of my career has been writing for technical journals. I have never used the term "reporter" to describe what I do, and I rarely use "journalist". The reason is because I wrote columns and features and refused to report on the carefully created press releases, or press conferences, from the vendors of the products I wrote about. More recently, I have worked for those vendors and have written such press releases (or "white papers" as the vendor insists on calling them) and feel justified that I ignored them when I wrote for the journals. I always called myself a "writer" because I knew that everything I wrote was my - well researched - opinions, and I was employed because the journals' editors trusted my opinions.

These journals always had a rather unhealthy relationship with the dominant vendor because although they were subscription publications, and had some income from their readers, a significant proportion of their advertising came from the dominant vendor. Thus, the articles were about the products of the provider of the journal's main income. That is a difficult situation to manage and can lead to a form of hagiography, or worse, simple churnalism where press releases are regurgitated. This is not how I worked.

I always made sure that whenever I wrote an article I always went back to first principles: try the product myself and write about what I experienced, and not what the vendor said I should experience. Further, if I was critical - which I usually was - I would say why there was a problem with the product, but more importantly, how the reader could work around the issue. The vendor was generally happy because I was helping them to improve their product and provide ways to keep their customers using their product. I could not do this by merely reporting what the vendor said because the vendor rarely wanted to publicise flaws in their product.

Sometimes (but not often) I would be contacted by people who worked for the vendor and they would indicate issues they were concerned about. Whistleblowing is an overused phrase, but I guess it's possible to say that such people were "whistleblowing" on the product. A journalist on a national newspaper would have reported such issues as "concerns from an unnamed source". I never did this, because I could see that there was nothing to be gained by reporting second hand concerns. If an issue was reported to me, I would replicate the issue, sometimes spending a large amount of time writing code to illustrate the issue and its cause. I would then publish my findings and how to replicate the issue. I would never jeopodise a source by quoting them as "an unnamed source" and I would never write an article based solely on the opinion of someone unwilling to be named: I would always do the research myself first,

My opinion is that all written words are biased to some extent, and that it is impossible to remove all bias. Worse, any attempt to "remove" bias by so-called balancing opinions with bland statements from Press Officers is amateur and lazy. It is far more important that a journalist clearly states their biases so the reader can take them into account when reading the article, than to attempt to remove (in their opinion) any traces of bias from the report.


You may have detected the use of the past tense when I talk about writing for journals. The reason is that a few years back I wrote a critical piece about the most significant product of the dominant vendor. As always, I provided the results of my research and the tools for readers to replicate my findings. After the article was published, I was contacted by a senior manager at the company who asked me to retract my findings, and gave me an incentive, he offered contract work to help them improve the product. It turned out that the manager was not authorised to make the offer of work (and so it was a hollow promise), and anyway, I later learned that a manager several levels up in the company had declared that I was not welcome at any of the company's sites and my name was removed from the list of writers would got preview copies of their products. In effect, my career writing for journals was shut down.

Ironically, after that I worked for a publishing company where I wrote conference presentations and "white papers", for the vendor who had "banished" me. My name never appeared on these items, so the manager who had declared me persona non grata was none the wiser, and was likely to have given one of my presentations.

Saturday, 25 July 2015


It is worth listening to Peter Hennessy's Reflections interview with Nigel Lawson, the Listen Again link is here. What is immediately apparent is how arrogant Lawson is. Here is a man who's policies caused the so-called Lawson Boom that pushed up inflation and hence interest rates (to 15%! a level that seems incredulous now) and which lead to a catastrophic bust, and yet he never had a single regret and blamed everything on everyone else because in his mind he could do no wrong. In the interview Lawson said:
the idea that you go from state ownership to private ownership that had had never been tried anywhere in the world and we were the pioneers in this country and it was subsequently followed all over the world, first in the western world and subsequently in the countries that had escaped from the Soviet Union - the Soviet empire rather - and they went in for privatisation and indeed it was not only this country that gave the policy to the rest of the world but gave the word privatisation which is used in every language under the sun 
Well, thank you Nigel, we now know that not only have you screwed up this country, but the entire world! Such arrogance.

Monday, 13 July 2015

NHS Funding Inquiry

Lord Patel, a Crossbench peer and Obstetrician, on the 9th of July moved a debate in the House of Lords over the "sustainability" of the NHS. In effect, this was the House of Lords debating whether taxpayer funding of the NHS was a good idea. Predictably, the debate was mostly filled with anecdotes from people who appear not to realise that their one anecdote is just one treatment out of the 18 million that are performed every year and is thus not representative. Also predictable was that the Tory peers who spoke acknowledged the need for taxpayer funding but expressed their favour of having an inquiry to bring in insurance or user charges.

At no point during the General Election was there any suggestion that any political party would change how the NHS was funded, the "sustainability" of NHS funding was not, and still isn't in doubt. The service is funded by general taxation and if it needs more money, more money is found from taxation. At the budget the Chancellor promised an extra £8bn - not enough, but it shows that taxpayers can afford to pay more if there is the political will. So why the debate?

I suspect it is more to do with the Junior Minister who represented the Government in the debate than with Lord Patel. The minister, Lord David Prior, is a former Tory MP and deputy Chair of the party, and was the previous chair of the Care Quality Commission. Prior is a loose cannon, who is well known for wanting to extend private provision in the NHS:
"We need more competition to drive up standards of care; more entrants into the market from private-sector companies, the voluntary sector and other care providers"
This makes him useful to the Government because he can be expected to initiate the sort of debates that no one has voted for, and where better than in the House of Lords, which no one has voted for? Lord Patel is a Crossbencher and so is not restrained by party political strictures. This meant that he was able to ask a question that party politicians cannot ask - can we fund the NHS in ways other than taxation? The right-wing Prior saw Lord Patel's debate as an opportunity.

The NHS principles that have (mostly) stood firm since 1946 are summed up in clauses 4 of Command Paper 6761:

That is, the NHS is available to everyone, whether or not they can afford to pay user charges, or whether they are insurable. This says quite clearly, that the NHS cannot be funded by co-pay or health insurance. The question about whether the NHS could be funded through user charges or insurance is answered here: No it shouldn't.

The Conservatives, as can be expected, were far more in favour of moving away from tax funding. For example, Lord Cormack, while acknowledging that the NHS would need more money, would not even countenance a tax rise:
"All forms of funding must be looked at. We have to have a plurality of funding if we are to have a sustainable NHS. Whether the extra funding comes from compulsory insurances or certain charges matters not, but it has to come—we have to have a quality service that does not lurch from crisis to crisis, from one application of sticking plaster to the next. It is crucial that we attain that."
Matters not!? As a true Tory, he says that the funding should not come from taxing the rich, but instead from taxing the sick.

More disappointing were the contributions from Labour peers. Lord Warner is well known for being in favour of the private sector and even suggested in his speech that "failing" providers should be privatised. On the issue of NHS funding he said:
"Our tax-funded, largely free at the point of clinical need NHS is rapidly approaching an existential moment. The voices of dissent and outrage will no doubt be deafening but a wise Government should begin now the process of helping the public engage in a discourse about future funding of the NHS."
This is hardly an endorsement of the tax-funded system, indeed, he appears to suggest that the government should "help" the public to think of other ways to pay for healthcare. Another Labour peer, Lord Desai, even made the bizarre suggestion that people should be issued with an "Oyster card" which is deducted whenever a patient uses healthcare, and patients should receive a "bill" at the end of the year:
"Another suggestion that I have made before in your Lordships’ House is that, although we do not want anyone to feel that they are being charged for using the health service, we ought to make clear to people the cost of providing it. People think that because it is free, it is costless—but it is not. We often worry about people missing GP appointments, so I propose a sort of health Oyster card for every citizen. Every time they used the National Health Service, they would have to swipe their Oyster card and a certain number of points would be deducted. The Oyster cards could be recharged. At the end of the year, people would get a bill showing how many points had been used and on which health service facilities. If people missed a GP appointment, 15 points would be deducted rather than two—things like that. Perhaps something like that could be done to make it clear to people that a free National Health Service is not a costless one. If we can somehow get people involved as patients and potential patients so that they modify their behaviour in demanding healthcare, it may solve some of the problems of the National Health Service."
This is another version of  Jeremy Hunt's daft suggestion to put the price on prescription medicines, a policy expertly dismissed by Roy Lilley recently. The problem with the NHS is not unnecessary demands, it is the sheer magnitude of people who need healthcare. An "NHS Oyster card" will not reduce the number of elderly people with acute co-morbidities. And if "consumer demand" is a problem, the solution is to turn patients back into patients rather than healthcare consumers, and remove the market.

Prior, summed up the debate by saying that he was personally in favour of a taxpayer funded system:
"However, I have listened to the debate and the strength of feeling about whether we should take a longer-term view that goes way beyond this Parliament. The sustainability of the health service is an issue that extends out 20 years, probably, but it is one that every developed country faces. I would like to meet the noble Lord, Lord Patel, and maybe two or three others, to discuss this in more detail to see whether we can frame some kind of independent inquiry—I do not think that it needs to be a royal commission. We are not short of people who could look at this issue for us; there are health foundations, such as the Nuffield Trust and the King’s Fund. The issue is: what will the long-term demand for healthcare be in this country in 10 or 20 years’ time? Will we have the economic growth to fund it? 
At heart, our ability to have a world-class health system will depend on our ability to create the wealth in this country to fund it. I am personally convinced, having looked at many other funding systems around the world, that a tax-funded system is the right one. However, if demand for healthcare outstrips growth in the economy for a prolonged period, of course that premise has to be questioned."

The statement at the end is a curious one, suggesting that he is not wholly convinced because he would support other funding mechanisms if the state of the economy demanded it. (An odd statement to make because it implies that if the country goes into recession, and people lose their jobs and have to spend less, he would be in favour of taxing the sick through health insurance and user charges.)

However, Prior goes way above his station by declaring an inquiry on an issue as fundamental as how the NHS should be funded. If Jeremy Hunt, George Osborne or David Cameron had suggested such an inquiry I would express my opposition, but at least those politicians hold significant positions in the government and have the power to order such inquiries.

But why is a junior minister, the "Under Secretary of State for NHS Productivity", announcing an inquiry in an area that is outside of his remit? I suggest the reaction of the Press is the reason: this inquiry has not been reported in the mainstream media. If the Health Secretary, the Chancellor, or the Prime Minister had announced such an inquiry it would have been on the 10 o'clock News, the front pages of the national newspapers and there would have been a whole Newsnight devoted to what the inquiry will be looking at. Because a little known minister announces such an inquiry, the media are not interested, and so something as fundamental as the funding of the NHS will go ahead without any public scrutiny.

There is one final point to be made. Prior says:
"We are not short of people who could look at this issue for us; there are health foundations, such as the Nuffield Trust and the King’s Fund."
Indeed. The Kings Fund has already carried out such an inquiry, it was called the Barker Review. Barker says:
"We looked hard at the question of introducing new charges into the NHS. However, most options for charges seem likely to raise administrative problems and the risk of adverse impacts, which make them unattractive."
Barker rejects any idea of user charges, did any of the Lords in Lord Patel's debate mention this? Further, Barker suggests that the gap in health funding should be met by more taxes, not fewer:
"We make two suggestions to close this gap, although clearly there are others. The first is a review of wealth taxation, including inheritance tax, which is too frequently avoided. The second is a package of increases in National Insurance, affecting those over 40 (who will be considerable beneficiaries from the new settlement) and the higher paid."
It is interesting that the Chancellor has removed the ability to raise taxes through inheritance tax by raising the tax threshold in the Budget, and he has cut some National Insurance contributions. In other words the very things that Barker says should happen, Osborne does the opposite. On can conclude Osborne is likely react similarly to Barker's opinion on user charges.

The government already has a detailed report into NHS and social care funding, one which recommends raising taxes. Rather than acting on this report, Prior (taking an action which few people would regard him as authorised to do) orders another inquiry, this time using people he has chosen and presumably people who will produce the desired result.

Sunday, 7 June 2015

Prisoner debt

If I were ever to become a Special Advisor to the Conservative Party not only would I lose all credibility and respect of all of my friends and family, but I would also lose any credibility and respect I have for myself. So take this as a declaration that the following is not what I think should happen, but, considering that we have one of the most right wing governments ever elected to this country, this is what may happen.

Comfort Allowance

In March 1943 my grandfather, grandmother and father (then 10) were interned in the Civilian Internment camp at Lunghua in Shanghai. (Yes, the same camp as JG Ballard, and no, Empire of the Sun is not autobiographical; the camp was not like that and Ballard has even written saying that the book was a novel and the event did not happen.)

In August 1945 the camp was liberated and in September 1945 my grandmother and father (who was seriously ill) were repatriated (first via plane to Hong Kong, and then a three month journey via a military hospital ship back to Liverpool). My grandfather stayed on in Shanghai and returned to the job he had before the war. I have the letters that my grandfather wrote back to England (he returned back to the UK in July 1946, it was not his intention to return, but that is another story...).

The letters are mostly about his failing health, and about money: he expresses great regret that he could not provide more money for my grandmother. Bear in mind that my father needed many operations and this was before the NHS, so my grandmother would have to pay the medical bills.

In one of the letters is a passage that says:
"Our firm promised to pay for comfort allowance but whether they will pay for our wives + families remains to be seen."
This needs a bit of explanation.

The camp provided little food to the internees. Part of the reason was that there was little food in Shanghai during the war. The camp had a small farm with chickens, and my grandfather had to pay for eggs and milk (I have records of how much he paid, and even in the camp there was rampant inflation). My father was a young boy so it was important that he had milk and eggs. (By "eggs" I mean not only the gooey stuff inside that could be boiled, poached or fried, but also the shell. Egg shell was ground up and children had to eat this as a source of calcium.)

In addition, the internees could receive Red Cross Parcels. These were not charity, the name comes from the fact that the Red Cross delivered the parcels and ensured that they were checked and did not contain forbidden items. Before they were interned, people gave some money to a trusted friend who would not be interned, and this friend would purchase allowed items and package up for the Red Cross to deliver. My grandfather worked with a Rumanian Jew, Bernard, who had escaped Nazi East Europe. In some of his letters Bernard gave his nationality as "Rumanian" in others he described himself as "stateless", but since he was not from an Allied country, he was not interned by the Japanese. My grandfather gave Bernard money to provide Red Cross parcels, but since no one knew how long internment would last, and the money soon ran out.

Internees could borrow "comfort allowance". Since this money would be used to pay for essentials, the word "comfort" was certainly a euphemism. The money came through the Swiss Consulate who handled British affairs in occupied Shanghai. The British government reimbursed the Swiss government for this money. At the end of the war, the civilian internees were expected to reimburse the UK government for this debt.

That's right, people were interned for two and a half years in appalling conditions, with inadequate food, and the UK government treated it as if they were staying in a holiday camp, running up a bill that had to be paid.

The comment in my grandfather's letter referred to an offer from the company he worked for to pay for the cost of his internment "comfort allowance", although he was unsure as to whether they would also pay for my grandmother and father. I have no other references to these payments, so as far as I know my grandfather paid for the food my grandmother and father had while interned. Since my father was seriously ill during the last 6 months of internment, there were also his hospital bills and medical for that time. (On two occasions my father was allowed out of the camp to go to a hospital in Shanghai for x-rays.)

Ludicrous and Unbelievable Election Pledges

The Cameron government were elected with an unexpected majority. It surprised Conservatives as much as it surprised everyone else. They did not expect to get a majority, and so, in the last few weeks of the election campaign, to give them some chance of forming a minority government, or be the biggest party in a coalition, the Tories went on a rampage of throwing money around in a series of election pledges they did not intend to honour. The problem is that they did get a majority and they do have to deliver the election pledges.

Such pledges include: cuts in inheritance tax, rise in the tax threshold, an extra £8bn for the NHS and (the expensive pledge of) seven day working, right to buy of Housing Association houses underwritten by the public purse and increases in the state pension. Big expensive pledges. All of these come at the same time as a ludicrous law that says that income tax, VAT and National Insurance will not be raised during the Parliament, and an unbelievable pledge that the government will generate a surplus in 2018-19. These expensive pledges have to be paid for and the government have said they will do this with cuts including £12bn to welfare.

Cutting their way to a surplus will be very difficult, so I reckon the government will find ways of raising revenue, and this means they will look towards user charges.

"Prisoner Debt"

The Ministry of Justice estimates that the cost per prisoner is £34k per year (2013-14 pdf). Compare this to higher education students who leave university with (on average) a £44k debt. Assuming that the student debt was generated over a 3 year period, this means an average debt of £14,600 per year per student. Basically - using these contrived figures - prisoners are twice as expensive as students.

The cost of higher education has been "solved", or at least the Conservative government thinks so since they do not intend any significant reforms in the student loan system, except, perhaps, the sale of the Student Loan Company as a asset to pay for their reckless election pledges.

The government has squeezed the provision of prisons, with many prisons privatised, and services like probation moved to privately provided "payment by results". However, these reforms have been more ideological than a sure way to make sustainable savings. It could be argued that there is little scope to make prison provision cheaper, so the only way to reduce the government's contribution will be to find another source of income.

This is why I said above that I think the government will look to user charges. Prisoners cost the state £34k a year, the government could regard this as an "obligation" of the prisoner, just as they regard the cost of higher education tuition to be an "obligation" of the student. Every year the prisoner remains in prison, their "debt" will go up. If the prisoner shows good behaviour and receives a cut in their sentence, their "prisoner debt" will be curtailed. Right wingers like financial incentives and this will fit into their ideology: the prospect of curtailing their "prisoner debt" will make prisoners reform! Of course, giving a prisoner a bill when they are released could be counter productive since most prisoners will not want to be released, so steps will have to be taken to avoid this.

There is a model in student loans that can be used. When students leave higher education they are not presented with a bill and told to pay it immediately. Students do pay off their loans, but not in a lump sum. They pay off their loans gradually via automatic deductions from their pay packet. The infrastructure is there. It works, so why not use it as a mechanism for ex-cons to pay off their "prisoner debt"?

Government Charging Prisoners

Of course, there will be objections to charging prisoners for their spell in prison, but as I have already shown above, the British government already have a precedent for doing this: they charged people who had committed no crime and were imprisoned by a foreign government! If they can charge citizens they know to be innocent, what moral objection will they have to charging people who have been convicted of committing a crime?

You may balk at the idea of charging prisoners for their board and lodging while incarcerated, but bear in mind that many people are already being charged for services that the state should provide and it is likely that other user charges will appear in the next few years ("hotel charges" for staying in an NHS hospital is a likely charge). We have a right wing government, committed to reducing the state, so don't be surprised of the extremity of the schemes they will create to pay for the reckless pledges they made to get elected.

Friday, 27 February 2015

DevoManc: Huge Centralisation of NHS Commissioning

One Health and Wellbeing Board to Rule Them All

The proposals, that are known as DevoManc, are huge, they promise lots and yet there are very little detail about how they will work. Labour should be very cautious about them.

The normal way to make huge changes to how we are governed is for a political party to put the proposals in their manifesto and ask the public to vote on it. Osborne has not done this, so it is legitimate to say it is not democratic and probably not constitutional. At the very least, since it will involve a lot of legislation, there should be a white paper on the DevoManc proposals so that there is a consultation process involving experts. This has not happened, which means that we have a huge change that has not been properly consulted upon. Worse, the negotiations about this policy has involved months of secret negotiations between the (mostly Labour) leaders of the ten Greater Manchester councils and the (Conservative) Chancellor. How can this be a proper way to decide the future of a region, policy by secret meetings?

To any Labour politician who is thinking about DevoManc, I suggest you get yourself a barge pole and keep it far away from this policy.

The DevoManc Memorandum of Understanding (pdf) says under the agreement NHS commissioning will be devolved to the Joint Commissioning Board (GM JCB) this will include:
  • Acute care (including specialised services);
  • Primary care (including management of GP contracts);
  • Community services;
  • Mental health services;
These services are either commissioned currently by the twelve Clinical Commissioning Groups, or will be soon, under NHS England's new plans for co-commissioning. (The only exception is "specialised services" which only makes up 10% of the NHS budget.)

The other services that the GM JCB will commission are:
  • Social care;
  • Public Health;
  • Health Education
  • Research and Development
The first two are currently commissioned by the ten local authorities and, along with the commissioning carried out by the NHS CCGs, are overseen by the local authorities' Health and Wellbeing Boards (HWB). (The last two services in the list will involve further consultations because neither CCGs nor Local Authorities are responsible for them, however, taking the responsibility for training and research out of national bodies is very worrying.)

Think about this. This is not devolution this is centralisation! The only part of the NHS budget that is being devolved is the specialised services which is about 10% of all NHS money spent. That means that 90% of NHS money in the twelve CCGs and the ten local authorities that make up the Greater Manchester Combined Authority will be centralised, not localised.

Also, note that CCGs are membership groups. Were the GPs, who are members of the CCGs, consulted about this, and did they approve it? (For the curious, the answer is no, the discussions were secret, remember.) Primary Care Trusts were criticised for being big and remote, the GM JCB will be the granddaddy of big and remote.

Greater Manchester have already created the GM Health and Wellbeing Board. This is "one board to rule them all!" The very existence of this board means that it will override the subservient boards of the ten councils, localism of NHS and social care in the region will undoubtedly be controlled by Manchester City Hall.

This is in no way like the careful plans that Andy Burnham created. Burnham said that under Labour existing NHS structures would be retained (in particular, CCGs and HWBs). He did this specifically because the very last thing the NHS needs right now is yet another re-organisation. Burnham's plans would be for local HWB to have more control over local CCGs, in particular, to ensure that the "NHS Preferred provider" policy is followed. Burnham is not suggesting a radical re-organisation.

DevoManc is a huge, disruptive change and it cannot go ahead without a lot of legislation (not least, changing the behemoth that is the Health and Social Care Act 2012). It cannot be done before the election. Labour's approach should be to calm this down, point out how reckless it is to make policy by secret agreements and promise after the election to have a proper commission on devolution, and before any legislation is changed, have a white paper with proper public consultation.