Community Care

There is a generally accepted policy that there should be a shift from care in hospitals to care in the community. Not only is this better for the patient, but it is also regarded as being cheaper.

The following table is from the strategy document of my local PCT (covering a population of 450,000). It lists the projected funding for primary (GPs) and community care (district nurses, physios etc) and for acute and tertiary care (hospitals). This was the plan of the PCT and the GP commissioners may not use the same figures, but this table does illustrate an important point.

	Revenue £000
	2009/10	2010/11	2011/12	2012/13	2013/14
Primary and Community	237,192	252,072	271,783	288,752	308,978
Acute and Tertiary	337,849	336,173	310,281	289,801	268,994

Notice how, over four years, funding is transferred from acute care to primary and community care. This is significant because this PCT wholly funds two acute hospitals (35% and 24% of the PCT hospital budget) and partially funds a third, tertiary hospital (30% of the PCT hospital budget, but 22% of that hospital's income) in a neighbouring PCT. The shift in funding is perhaps better illustrated in the following line graph.

There will be a huge shift from acute care (predominately NHS providers) to primary (GPs: independent contractors) and community care. The PCT does not break down their projected rise in the income of the GP practices, but it is instructive to realise that currently 77% of the £237m listed above, is GP funding. GPs (independent contractors) appear to be getting more business at the expense of the NHS hospitals.

The complication is Transforming Community Services. This was the policy of the last government who insisted that from April 2011 PCTs should only commission services and so they had to dispose of any services they provided by this date. In most areas this means Community Health Services has to be moved out of PCT control. There are three options. The service could be merged with a Foundation Trust, it could be turned into a Community Foundation Trust, or it could be turned into a social enterprise. The third option ("right to request") is the preferred option of the current government because it means that yet another part of the NHS is taken out of public ownership. This option has been unpopular, there are just 29 such schemes across England.

The majority of PCT community services have been transferred to hospital Foundation Trusts, and this is the case with the PCT described above: one of the two acute hospital trusts is a Foundation Trust and has taken over the PCT community services.

This makes a lot of sense. Firstly, it is better for the patient: when they have care they have just one provider as opposed to having to transfer between two*. It also makes sense for the hospital trust. The graph above shows that the income of the three hospital trusts funded by the PCT will decrease so that in four years time the one trust that is a Foundation Trust will have around 10% less funding than it is now (around £10m less). Since 60% of the budget of this trusts is salaries this clearly means losing staff. However, since this trust will take over community services, it will have increased income to cover the community services and this income stream itself will increase (by approximately £23m more in four years time than it is now). The extra work in community health services means more staff and hence a hospital trust needing to shed staff can transfer those people to community services. This is called vertical integration and you'll see this term used a lot in the coming months.

It is interesting that Sir David Nicholson referred obliquely to vertical integration when he was interviewed by the BBC a few days ago:

"Most hospitals will be able to survive and thrive in the new world. But undoubtedly there will be those that will find it difficult," he said. "The thing about the hospital service is that it has grown enormously over the last 10 years in particular and we are going into a period where growth in the NHS is what they describe as 'flat real'. Those hospitals whose business model is based on increasing capacity have got to seriously look at the way they operate. That is why some hospitals are looking towards taking over community services."

What Sir David is saying here is hospitals will have less funding in the future and will need to shed staff and this is why they are taking over community services. This explains why some hospital trusts, when replying to the Freedom of Information requests from False Economy have indicated modest job losses. The trusts have been accurate in that they are not losing large number of staff, instead, the staff will be transferred to community health services.

[*However, I mentioned that there were two hospital trusts in the PCT area, so clearly in part of this area patients will get their acute care from the other hospital trust. This is likely to be a source of contention between the two trusts. Ideally, the community services should be split between the trusts, but this was not the offer on the table, particularly because the other trust is not yet a Foundation Trust.]

NHS Privatisation

The privatisation of the provision of NHS services is happening right now. The government is pushing a policy of "Any Willing Provider" and is justifying this as "patient choice". It is not since inevitably your "choice" will be from the provider who have been commissioned to provide the care. As a patient you will not be told automatically what is an NHS provider and what isn't (sometimes the names can be confusing), and if the commissioner only offers private providers you may not even be given the choice of an NHS provider. The choice, as always, is with the commissioners.

The NHS Co-operation [sic] and Competitions Panel have released a report today about the implementation of "Any Willing Provider" (AWP) in England. They make the point that AWP is not a policy of the Health and Social Care Bill going through parliament at the moment, since the previous Labour government legislated to allow AWP and so it is up to the Secretary of State to decide the extent of this policy. The current Secretary of State, Andrew Lansley, wants private providers used everywhere.

On Monday, David Cameron made it abundantly clear that this meant privatising NHS services:

"We will create a new presumption – backed up by new rights for public service users and a new system of independent adjudication – that public services should be open to a range of providers competing to offer a better service."

Note that there is no mention of "patient choice", patients cannot choose to have a public provider, instead David Cameron will allow private providers to choose what services are available for the patient, through this new "presumption" that they will be able to take over NHS services. (Don't forget Cameron's meeting in December 2009 with the far right Nurses For Reform who said "the state should not own or have any of its agents manage hospitals". A statement that seems prescient: Cameron is implementing this policy right now.)

Lansley says he wants AWP to become "the reality in the vast majority of NHS-funded services by no later than 2013/14", so this policy is being rolled out at breakneck speed. Of course, Labour started all of this "patient choice" nonsense (nonsense because the patients rarely ever chose) under a policy called the Extended Choice Network (ECN) and Free Choice Network (FCN). However, Burnham put breaks on the policy by making NHS hospitals the preferred provider (freezing out the private sector), but once he got his feet under the table at the Department of Health, Lansley started up the Blairite privatisation process, and wants it accelerated, to create what the Letwin calls a "health market".

The CCP say:

"All regions (with perhaps only a few exceptions) now have a process underway for transitioning from national- to PCT-based contracts with independent sector providers of routine elective care. However, some PCTs and SHAs appear to have started the contracting process quite late, and in most cases PCTs and SHAs are looking to finalise new contracts with independent sector providers in the next few weeks."

This indicates that in the next few weeks GPs will be able to refer patients to a wider range of private providers. However, it turns out that some PCTs are dragging their feet on this:

"A significant number of PCTs (approximately 70) have been identified to us as engaging in conduct that raises issues of consistency with the Principles and Rules as well as, in some cases, the Choice of Provider Directions."

And further, there are problems creating the contracts with the private providers:

"It seems likely that few of the new PCT-based contracts with independent sector providers will be finalised before ECN/FCN arrangements come to an end on 31 March 2011. If this is the case, the scope for patient choice will be substantially reduced from 1 April 2011 given that independent sector providers account for around 175 of the approximately 475 acute care sites from which routine elective care is available to NHS patients.

"While this reduction in patient choice may only be temporary while new contracts are finalised, the damage to independent sector providers from this interruption may have a longer term effect on their ability and willingness to provide services to the NHS."

The stark reality of AWP is that if a private provider treats you that means less money for the corresponding NHS provider, and if this happens too often, with too many patients, the NHS provider will no longer be financially viable and close close. If that provider is your local NHS hospital, then it will mean that the service in the hospital that does not break even will close, but it could have a wider implication because NHS hospitals use the surplus generated from one service to subsidise services that generate deficits.

For example, at my local NHS hospital all services make a surplus except for two: paediatrics and A&E. The hospital provides those two services knowing that they will generate a deficit because the hospital knows that the community needs these services. If patients choose to have their hip or cataract operation at a private hospital, that will mean the surplus from performing that operation will not be available to subsidise the other services at the NHS hospital. Instead, that surplus will be a profit, and paid as a dividend to the shareholders of the private hospital. Literally, if you have you hip operation paid by the NHS at a private hospital, there will not be the money to treat sick kids.

The CCP are blatant about this:

"The underlying rationale of providing patients with the ability to choose between providers of routine elective care is that the need to attract patients (in order to earn revenue given the Payment by Results system of tariffs) ensures providers have an ongoing incentive to offer the highest quality care. Providers that are successful in attracting patients will be able to earn revenues that, in the case of NHS Foundation Trusts for example, can be reinvested in other services. Providers that do not attract sufficient patients face the prospect of being unable to meet their financial obligations."

Make no mistake about this. The last sentence means that if a service does not "attract sufficient patients" it will close. The AWP policy has nothing to do with improving NHS care, it is all about closing NHS hospitals.

The CCP give a graph showing how, over the last few years, the privatisation has progressed:

As you can see, the process is relentless, although the current figure of about £22m per month (about £260m a year) is quite tiny compared to the overall spend by the NHS on elective treatments. (However, I am not sure that these are the complete figures. In the OFT says that in 2008 the total value of the market for private healthcare in the UK was estimated at just over £5.5 billion, and 23% was from NHS-funded patients - £1.265m. There is a £1bn difference between these two figures.)

 It is clear that AWPis here with us now, regardless of what happens to the Health and Social Care Bill. The question is how much the process will be accelerated, and what effect this will have on NHS hospitals.

The Conservatives are using the concept of "patient choice" to push through a policy that will inevitably lead to the privatisation of the NHS, bit-by-bit. So why not turn this policy n its head? If the intention is to close NHS service because too many patients choose private providers, we can close private providers by persuading patients to choose the NHS providers. If, in the future you need care paid for by the NHS, ask your GP to tell you which providers are NHS providers and do not allow your doctor to offer you the choice of a private provider.

Efficiency and quality care

I posted this as a comment over at Liberal Conspiracy, but I thought I may as well put it here too.

Incidentally, does anyone know where the "£20 billion efficiency savings" comes from? I mean, it couldn’t just be made up, could it?

No. It comes from a report compiled by McKinsey. In this they list areas of the NHS where they think that money can be saved. (Selling off land appears to bring in a lot of money in their report – I wonder if they have any property developer clients? – but it is hardly an "efficiency saving" since it can only occur once.) McKinsey says that the NHS can save £15-£20bn over four years with their "efficiency" recommendations. The current government have decided that the NHS has to save £20bn, therefore, in the following, I have to use the maximum estimates from McKinsey.

McKinsey says that £9.2bn can be saved by efficiencies in providers (hospitals, community health services and GPs, p8). This can be achieved by £3bn from increasing productivity of acute providers and £1.9bn from productivity gains of non-acute providers (p10/13). Rather helpfully they say that acute providers have to spend 14% less than in 2008/09 and non-acute providers (GPs, community services) have to spend 12% less. These are big cuts efficiencies.

Since everyone is hysterical about nursing at the moment, let's have a look at what McKinsey says about that area of care. They recommend that acute providers can save £1.1bn on nursing out of a budget of £8.1bn, 14% (p14). Their rationale is that there is variation of productivity across the country and so if those providers at below the median increase their productivity by 80% of their variation from the median, then that will lead to the £1.1bn saving. Unfortunately, McKinsey does not say where the variation comes from. Could it be because there is a variation in the age of hospitals, so that clinicians are trying to provide 21st century care in 19th century buildings?

Increasing productivity means that the same number of nurses do more work for the same pay; or the same amount of work using fewer nurses. The RCN estimates that NHS providers intend to cut 17,932 nurses, so clearly providers are opting for the second case: fewer nurses. Whichever way you look at it (more work per nurse, or fewer nurses) the McKinsey recommendations will lead to the patient seeing less care from nurses.

Roy Lilley at nhsmanagers.net points out that from the McKinsey breakdown of the work that nurses do the 14% cut that is needed is equivalent to the time spent by nurses in "Psychosocial care of patients". This is exactly the sort of care that the Ombudsman was so critical about: she was complaining that there was not enough of this type of care. Yet the providers with the lower levels of productivity could dispense with this vital area of care so as to raise their productivity to the median.

What about community care? Well here McKinsey says that if district nurses saw more patients then there could be a saving by cutting staff by 15%. The report does not skirt around the issue, they specifically say that there should be 15% fewer frontline staff.

McKinsey give the following graph:

This, we are told, shows the variation of the productivity of district nurses. McKinsey does not say whether the survey compared like-with-like. So the nurses who see 11 or 12 patients each day, are they providing exactly the same treatments and travel the same distance to each patient as the nurses who see 1 or 2 patients a day? Could the variable be due to some nurses working in urban areas (less time travelling between patients) and some nurses working in rural areas (with much longer travel times)? Could it be that some nurses are performing complex, time consuming treatments and others provide more simple treatments? We do not know because McKinsey does not reference their research. If there are 15% fewer nurses, with each seeing more patients each day, then inevitably each nurse will have less time with each patient. I wonder what the Ombudsman will say about that?

The "£20bn efficiency savings" is not optional. It has to be done because the budget will be cut by £20bn - oh, sorry, to satisfy the pedants: there will be more work, equivalent to £20bn worth, but the NHS will not get the money to pay for it, they will have to find the money by having fewer nurses visiting more patients every day, and hospital nurses not having the time to talk to patients on the ward.

The McKinsey report is recommending that the NHS delivers worst care.

UPDATE:
And now McKinsey are providing commissioning support for "dozens of consortia" according to Pulse.

Tories attack Labour on a policy that the government is implementing

I was not happy with Labour's 2010 election manifesto on health, because it was so similar to the Conservative manifesto. The following caught my eye this evening (from the Guardian):

Simon Burns, the NHS minister, said: "The £20bn efficiency challenge was set out by the last Labour government in 2009. Unlike Labour, who planned to cut the NHS budget, the coalition government will ensure that every penny saved will be invested back into patient services. So while it is for local trusts to determine their specific workforce needs, we have been clear that money saved must be put back into improving care for patients."

The fact is, Labour said nothing about what they intended to do about funding. The hapless (and useless) Andy Burnham tied himself in knots about this when challenged, but there was no written policy.

The Labour manifesto, and the Labour manifesto for Public Services, say nothing about funding. The nearest we can get to a policy is in the March 2010 budget which said:

6.13 In the 2009 Pre-Budget Report the Government made a clear commitment to protect key frontline public service priorities in 2011-12 and 2012-13 and announced that:
• NHS frontline spending – the 95 per cent of near-cash funding that supports
patient care – will rise in line with inflation;

Note: no real terms cuts, but no real time rises either. If you read my last blog you will recognise that this is flat funding for two years (but no clue about what the funding would be like afterwards) and is exactly the same as the current Conservative government policy!

It just goes to show how useless Labour is at the moment, that the government are successfully attacking Labour on a policy that they are implementing while saying how generous they are!

NHS Cuts

The Conservative party went into the 2010 election with the slogan "I'll cut the deficit, not the NHS". Labour knew that it was not possible to do the former without doing the latter, and because they didn't give a straight answer about how they would change NHS funding, they lost their traditional NHS electoral advantage. The Conservatives had a clear message: "year-on-year, real terms increases", and although they (have almost) delivered on this, it is not what the public expected.

The House of Commons Library Standard Note SN/SG/724 gives tables of NHS spending from when the service was created. In this document Table 2 gives the expenditure on the NHS in England in 2009/10 prices (ie adjusted for inflation, these are "real terms" prices) from 1974/75 to 2014/15, the last five years are the planned expenditure by the current government.The following graph shows the data plotted.

The actual data is plotted in blue. I have also fitted two trends to this data (the red dashed line). Although there is some variation, it is clear that from 1974 to 1998 there is a year-on-year increase (in real terms, around £1bn each year). Then we had the 1997 election with a pledge from the Labour party to increase NHS spending up to the European average in terms of percentage of GDP. This is can be seen on the graph, the gradient of the line increases significantly between 1998 and 2010. The graph indicates that in real terms there has been an increase of approximately £4.8bn every year.

After 2010 the projected spending is flat. The actual figures show a small increase, but this increase is so small that it could easily be turned into a real terms cut if inflation increases.

Technically the government has met the pledge of a "year-on-year real terms increase". Since the amount of money going into the NHS will not decrease this means that NHS funding has not been "cut". However, this is not what the public interprets when they think about a cut in funding. To the public a cut is when the NHS is receiving less money than it needs.

This graph shows three approaches to the NHS funding.

The first is the Thatcher/Major approach that is roughly a £1bn real terms increase every year. We know from experience that this lead to long waiting times, poorly maintained hospitals and demoralised staff. The NHS was clearly not being funded appropriately, it was not receiving the funding it needed, even though there were a real terms increases.

The second is the Blair/Brown approach that is roughly a £4.8bn real terms increase every year. We know from experience that this lead to short waiting lists, new hospitals and well paid and well trained staff.

The third is the Cameron approach, which is a tiny real terms increase every year, (and if inflation rises, a real terms cut). We know that the Thatcher/Major approach produced bad outcomes, so the only conclusion we can make is that the Cameron approach will be devastating. The public sees that the yearly NHS funding increases has been cut. This is the cut that the public experiences.

The Blair/Brown years were good for the NHS, but we know that after the 2008 financial crisis this level of year-on-year increases in funding could not continue. Since the Thatcher/Major approach on NHS funding increases was clearly inadequate the public expected increases between the Thatcher/Major approach and Blair/Brown approach. The following graph shows the projected funding of the NHS in 2009/10 prices with the Thatcher/Major (red dashed line) and Blair/Brown (green dashed line) approaches.

The difference between the green dashed line (Blair/Brown) and the blue line is the cut that the public will bear. The graph shows that if Cameron had taken the Thatcher/Major approach he would give more money to the NHS, and we know from experience that the NHS would suffer. (To those people who will inevitably claim that the NHS was over-funded during the Blair/Brown years, tell me why you think that the Thatcher/Major approach is also too generous for Cameron.)

The fact that the NHS will get "increases" that make Thatcher/Major look generous means that the NHS is heading for a financial crisis.

Figures

Today the Parliamentary and Health Service Ombudsman released a report of care of the elderly in the NHS. It has got a lot of press, and the BBC on their normally sensible Radio 4 news bulletins report that these highlight the need for "a complete overhaul of NHS". So let's have a look at the figures.

The report says:

"The complaints were made about NHS Trusts across England, and two GP practices"

So it is not just hospitals, it is GPs too. Remember this when you read articles based on this report, this BBC report, for example, does not mention GPs at all.

"the results of investigations concluded by my Office in 2009 and 2010"

So it is over one year.

"Of nearly 9,000 properly made complaints to my Office about the NHS in the last year, 18 per cent were about the care of older people. We accepted 226 cases for investigation, more than twice as many as for all other age groups put together. In a further 51 cases we resolved complaints directly without the need for a full investigation."

So out of 9000 cases referred to the Ombudsman 1620 (18%) were about the elderly yet of these, only 14% (226) did they feel that they had to investigate. In any 3% of complaints the Ombudsman recognised that there was an issue, but resolved it without investigation. This means that the other 83% (1343) were rejected for some reason or other, why? Would this suggest that 83% of complaints escalated to the Ombudsman should not have been? The Ombudsman says that it performs the following tests and if they fail the complaint is "declined for investigation":

Preliminary assessment

• Is the complaint within the Ombudsman’s remit?
• Has the complaint been properly made to the Ombudsman in writing (as required by legislation)?
• Has the complainant completed the local complaints procedure?

Further assessment

• Is there some indication of maladministration or failure in service?
• Is there some evidence of injustice or hardship arising?
• Is there a likelihood of a worthwhile outcome to an investigation?

It appears that the 1383 complaints that were not investigates were declined for one of these reasons. The Ombudsman gives data from 2009/10 that suggests that 29% of complaints are "not properly made", 29% were "premature" (ie have not complained locally, or has not waited for the local response), 27% were "discretionary" (for example the Ombudsman thinks the NHS has acted correctly or that the complainant was offered reasonable redress) and 9% were "withdrawn by the complainant". The Ombudsman suggests that just 3.6% of the complaints were within their remit and suitable for investigation or intervention.

This raises the question of why the complainant decided to escalate the complaint to the Ombudsman.

The Hospital Episode Statistics online website says that in 2009/10 there were 14,537,712 Finished Admission Episodes. So out of 14m episodes, the Ombudsman gets 226 complaints upon which the BBC say that we must have a "complete overhaul of the NHS". Perspective?

OK, so the Ombudsman is the last chance of complaint. If there is an issue with NHS care and a complaint is not handled locally to the satisfaction of the person making the complaint, they can take the complaint to the Ombudsman. This would suggest that the 226 is a "tip of the iceberg" that there are more complaints, but they have been resolved locally. The NHS Information Centre collate figures about complaints. NHSIC says that in 2009/10 there were 101,077 written complaints from NHS Trusts (ie hospitals), there were 48,271 written complaints about General Practice (including Dental).

Of the NHS Trusts written complaints, 1,168 were about "Elderly (geriatric) services", (Table 3). However, 7,667 were for A&E Services and 31,046 were for Inpatient Services, and so a proportion of these will be from elderly people. Some complaints will be about administration, appointments, food, cleaning etc, these are not the sorts of complaints that the Ombudsman is referring to so we need to separate them. Table 5 lists the reason for the complaint about NHS Trusts and 42,727 were for "All aspects of clinical treatment". Similarly Table 9, for General Practice, lists that 16,300 complaints were Clinical complaints (a proportion of which will be about care of the elderly). The problem is that these are very wide criteria. We do not know the severity of the complaint. We do know (from Table 1) that in 2008/09, 1935 (out of 89,139, 2.1%) complaints were not resolved, this would suggest that in the vast majority of cases the complainant was satisfied with the result.

There is also the "mustn't grumble" argument, that is, most people in this country do not complain. It is very difficult to get estimates about the level of this. There are some suggestions from American customer satisfaction ("for large ticket items ... 5-10% of complainers escalating to local management or corporate" suggesting that, at worst, the NHS complaints figures twenty times less than they should be), but these are for consumer goods (eg cars) and not about life-and-death issues, which one would expect the complainant would consider much more important. The NHSIC does suggest that complaints are rising slowly: complaints in 2009/10 for "All aspects of clinical treatment" increased by 0.8% from the figures of 2008/09. Whether this is due to patients being more willing to complain, or to a change in the quality of care. The Ombudsman does say that

"In April 2009, a new integrated system for handling complaints within the NHS and adult social carewas launched."

that is, we cannot make comparisons with previous years because they used a different system.

Having gone through all these figures I conclude:

• There are roughly half as many complaints for GPs as for hospitals, whereas GPs have 51% of patient contacts and hospitals have 18% of patient contacts.
• 226 cases out of 14.5 million episodes every year is very small, it is statistically insignificant
• 98% of NHS complaints are resolved locally
• 96% of the complaints received by the Ombudsman should not have been escalated to them
• There is no accurate information about how many people do not complain when they should
• There is little information about the severity of complaints in the NHSIC reports

The danger of this Ombudsman report is that people will extrapolate, and the BBC has certainly done this painting a picture of the NHS that is far worse than it is in reality. The Ombudsman even suggests that people are complaining when they shouldn't by rejecting 96% of the complaints they received.

People read this report from the Ombudsman and think "this could be my mother" rather than the actual case which is that these are truly exceptional cases. Until we have real, accurate studies, we cannot use this report to make conclusions like the NHS needs a "complete overhaul".

Cameron's Big Society HIGNFY style

The following comes from David Cameron's defence of his increasingly lame duck Big Society policy:

Fill in the blank HIGNFY style.

There's a reason for Health and Safety laws. They protect the health and promote the safety of us, and in this case, our children. This was a fundamentally stupid thing for Cameron to say, and because he thought he had to say this shows how desperate he is.

Nick Clegg and the NHS

It is clear that the blue Liberal Nick Clegg is the big disappointment of last year's election. He fooled many people into thinking that he would stay Osborne's axe, but it is clear that him and his Orange Book colleagues were just as much small statists as Cameron, desperate to destroy our public services. There will always be a place for Clegg in the Conservative party.

However, it didn't fool me. His interview with the Independent in 2005 where he said that he wanted the NHS "broken up", that frightened me (I blogged about it before the election here). After the election I read the Liberal Democrat plans for the NHS and that frightened me too (as you can read here).

Nick Clegg does not believe in public services and so he is well suited in his partnership with David Cameron. As more policies are unveiled by the government, heralding the great sell-off of our services the public are starting to get very twitchy. In fact they are getting worried. Yesterday Nick Clegg attempted to calm the natives with his "Speech on the future of the public sector". In this, he talked about the NHS, but rather than quoting Bevan, he quoted Beveridge. This is an obvious choice because Beveridge was a Liberal and he did a lot of the foundation work that lead to the creation of the NHS. However, it is important to note that the NHS is not the service that Beveridge designed: it is Bevan's NHS, not Beveridge's. It is pointless of Clegg to quote him, unless, of course, Clegg wants to make a political point.

Beveridge’s report said the Department of Health should, and I quote, “supervise” the new health service, not run it.

See what he has done there? Because Beveridge said that the state should not have a responsibility to provide healthcare, Clegg is now saying that the state should not have a responsibility for healthcare provision. This harks back to Clegg's Orange Book inspired quote that he wants to break up the NHS.

He goes on:

And Liberals argued for local government to have a role in the NHS right from its founding, for fear that a fully centralised system would put too much power in the hands of central government instead of the professionals and the patients. The logic of Andrew Lansley’s reforms is precisely to reverse this imbalance: to put power within the NHS in the hands of those who understand patients, the GPs, in those who are accountable to patients, the local authority.

This is a complete misunderstanding of the Health Bill. The Health and Well Being boards proposed by the Bill are just a re-vamp of the local authority Health Scrutiny boards, they do not give more power into the hands of the local authority. (And anyway, why give that power to local councillors, why not give it to service users: patients?) And the so-called "GP-led consortia" don't even have to be led by a GP! They don't even have to have a GP on their board! I really do wonder if Clegg has read the Bill.

Certainly Clegg has been infected with the government's lack of rigour when it comes to statistics:

Health inequalities and the gap in achievement between poor children in different parts of the country actually worsened under Labour.

While it is true that the difference between the life expectancy of the richest and the poorest has increased in the last decade, what he fails to acknowledge is that this increase in health inequalities has been a trend since the 60s!

The term "health inequality" conjures up images of the poor suffering ill health. However, it is significant that over the last decade the life expectancy of the poorest has increased, that is a real achievement, the poor are getting healthier and living longer. The problem (if you can describe it as a problem) is that the life expectancy of the rich has also increased, but faster than the increase of the poor. So what should we do, introduce euthanasia for the rich? That will certainly have an effect on health inequalities! For those interested, I had a rant when Cameron made the same point. Basically the poor are more likely to smoke than the rich and the most significant public health policy of the last government (the smoking ban, which has led to large numbers of people giving up smoking) will only show outcomes in many years time. I am sure that in a decade's time there will be much smaller health inequality because of the effects of the smoking ban.

Another problem with the term is that people tend to think it means the same as equity of access. This is not correct: health inequality is not the same as access to healthcare (although the latter will have an effect on the former). In fact according to the Commonwealth Fund the NHS is the most equitable system: everyone has equal access.

The NHS of Bevan was about access to healthcare: the very poorest should have access to as high quality healthcare as the very richest. (However, as I outlined yesterday, this is not the case under the current government. Prisoners are being given cut-price, lower quality, primary care that the rest of us because the contract was awarded on price only and not on quality.) The Health Bill will devolve so much decision making that we will end up with a healthcare lottery. There will be "winners", but sadly, there will be "losers" and the "losers" are more likely to be in the poorer areas (the Inverse Care Law). In any healthcare system there should never be losers, if there are, then the system needs a re-design.

Clegg stumbles on:

The UK has one of the worst mortality rates amenable to healthcare among rich nations.

This had been comprehensively dismissed by Prof John Appleby, yet Clegg was still using this excuse, why? It shows deep level of desperation to use a statement when you know it is misleading.

Why can’t I register with any GP I want?

Well Mr Clegg, why don't you ask a GP why we have defined GP boundaries? Try this explanation from the excellent Jonathon Tomlinson. There is a reason for most things, Mr Clegg, and if you want to change a policy you have to address the reasons why that policy existed. Lansley's policy does not mitigate the dangers of being able to choose any GP.

There is no liberal reason why those who deliver public services must always work directly for the government - so long as we are absolutely clear about the principles under which those services operate.

This statement made me chuckle. The reason is that I have heard this before and I argued vociferously that NHS workers do not "work directly for the government". It is a nonsense statement of the utmost order. The previous time I heard this statement it omitted the word "liberal" for obvious reasons: it was spoken by Arvin, an American Tea Partier I know, who thinks that the United States is close to collapse and anarchy because of Obama's healthcare reforms. It's amazing that Arvin and Nick are so a like.

My philosophy is simple: unlike the Conservative governments of the past, I believe you have to fund public services well. But unlike the Labour governments of the past, I believe public sector monopolies almost never spend that money best.

So why don't you spell it our Mr Clegg? If "public sector monopolies" don't spend money well, the implication is that you take the services out of public ownership, right? What is that called Mr Clegg? I spy with my little eye, something beginning with P:

In our public services, we need diversity of provision. Because no one person and no one organisation has all the right answers. So, as we modernise public services in the years to come, I will take a hard line against monopolies because they stifle innovation. New and alternative providers - from the private, community and voluntary sectors - have a vital role to play in our public services.

I agree that no one person has all the right ideas (step forward Mr Lansley, and accept that you may be wrong...) but the whole point of a collaborative, rather than a competitive, system is that it is easy to apply best practice across the whole system. The problem with the system being created by Lansley is that when you introduce profits into the system there is no incentive to share innovations, because the innovations are where the profits come from.

Here's a clue or you Mr Clegg. Most of our fundamental science research is publicly funded, the reason is that private companies are not willing to take the risk inherent in the process of innovating.

My first job was as a post-doc in the Physics Department at Nottingham University (I started my post-doc the same year that Andre Geim also started a post-doc in the same department. I worked for a different group, my group had the big lasers.) Nottingham is well known for Prof Sir Peter Mansfield who was awarded the Nobel prize for his work on MRI (or as we physicists call it, Nuclear Magnetic Resonance). The point is that the important early work on MRI was publicly funded. It was only when it was clear that the technique worked and was useful, that manufacturers started to get interested. Without the public funding, and the work of publicly employed scientists, we would not have MRI. University professors are as much part of a government monopoly as NHS surgeons are.

When I started my PhD at Nottingham the department had just taken delivery of a second-hand Molecular Beam Epitaxy machine. They had bought the machine cheap from Phillips Research, who were closing down their semiconductor research facility in the UK. The reason was because the beancounters looked at the cost of the machine, looked at the annual running costs, and looked at the revenue from the machine and decided that they would get more if they sold the machine. The irony was that soon after the machine was up and running in our department UK regulators gave the green light for satellite TV. Satellite dishes used a special high frequency transistor called a HEMT that could only be made using an MBE machine, but Phillips had sold theirs to Nottingham! The private sector had clearly failed.

I will take a hard line, too, against any attempts to replicate the mistake of skewing the market against public sector providers, effectively bribing private companies by offering them more money to do exactly the same job as you. That was wrong.

::Cough:: Have a look at this will you? Lansley is creating a rigged system.

I categorically do not believe that private providers are inherently better than public sector providers

If that is the case, why use them at all? You said above: "providers - from the private, community and voluntary sectors - have a vital role to play in our public services". Are you deliberately trying to contradict yourself?

This is yet another poor Clegg speech. It is full of platitudes, contradictions and assertions without evidence. And this man is the deputy Prime Minister.

Prisoners

While everyone is talking about prisoners it is pertinent to mention that prisoners need healthcare (and here's me being a bit controversial) probably more than they need votes. (Those of you arguing that voting is a human right should first acknowledge that healthcare is a more important human right.)

The following is from the Northern Echo:

[Care UK] has been awarded a £53m NHS prison health contract. The contract, awarded by the North-East Offender Health Commissioning Unit, has been awarded to Care UK rather than current NHS providers.

If the primary care in a PCT was replaced with a private provider* then there would be an outcry, but don't forget, these are prisoners here, so they don't count.

Actually, if there is a master plan to privatise the NHS, prisons would be the best place to try it out first, because few people pay any attention to how prisoners are treated.

* Yeah pedants like to say that GPs are "private contractors", but note that GPs have NHS pensions, NHS training and they have a single UK-wide (even though health is devolved) NHS contract. Private companies do not have those. GPs are part of the NHS.

GP Consortia sizes

Just for those interested, here is a plot of PCT sizes and GP "pathfinder" consortia sizes:

The data I have used here are from ONS and the Department of Health.

The 141 GP commissioning consortia are the first two waves of "pathfinder consortia" and cover half of the population of England. The 152 PCTs cover the entire population of England (two PCTs, Surrey and Hampshire, have been omitted since these are outliers with populations over 1 million).

The most noticeable feature of this graph is that the pathfinder consortia tend to be much smaller than PCTs. The median size for GP Consortia (light blue) is 157,000 whereas for PCTs (dark blue) the median is 282,000.


The government's Impact Assessments that accompany the Bill (section A64) states:

Overall, the future costs are dependent on a number of factors, particularly the number and size of GP Consortia, on which the Department is not being prescriptive. Ultimately, the extent to which GP Consortia can and will join together to perform functions will be the determinant of future costs. Preliminary analysis suggests that if GP Consortia are established with an average size of 100,000 population, in a similar form to PCTs and without any sharing of resources to deliver some functions, then some functions may incur additional costs. This could mean that the savings of £1.3bn a year from reduced administration costs may be partially offset by up to £475 million.

This suggests that size does matter, and the smaller consortia will not be able to commission services as efficiently as the larger consortia. The government is committed to an arbitrary cut by one third in commissioning costs and so this will put immense pressures upon GP commissioners.

In response to the NHS white paper the BMA held a half day event to consider the issues surrounding GP commissioning. The consensus from this event gave a figure on the minimum size for consortia:

The majority of delegates felt that anything smaller than a population of around 500,000 may face difficulties and carry too much risk, while it would not be able to take advantage of the necessary economies of scale to ensure that commissioning was efficient. There was also recognition that commissioning groups would need to be of sufficient size for credible interaction with acute trusts and local authorities. ... It was suggested that within commissioning groups covering 500,000 or more patients, locality arrangements could be put in place to facilitate local engagement and the development of locally relevant patient pathways. Where consortia are smaller than this, it is likely that they would need to collaborate with their neighbours and where appropriate form larger federations.

A study by Civitas says:

In 10 European countries analysed, seven have seen a consolidation of commissioning organisations over the past 15 to 20 years, two have seen no change. In only one country (Spain, due to devolution) has the number of commissioning organisations increased. In all countries apart from Switzerland the average population coverage of a commissioner is above 300,000 people.

None of these suggest that the median pathfinder size of 157,000 is optimal. The smaller consortia will have three options:

1. Merge with another consortium. In this case the consortia lose their original identity.
2. Cluster with other consortia and share the commissioning.
3. Purchase the commissioning from the private sector.

While it is true that no consortium will be forced to use private sector commissioners, the drive to save one third of commissioning costs (compared to PCTs) and the economies of scale means that the smaller consortia (from the graph above, that means most consortia) will need to either cluster or buy private sector commissioning.

Dishonest Cameron

During Prime Minister's Question Time today Valerie Vaz asked a rather weak partisan question:

Q11. [39071] Valerie Vaz (Walsall South) (Lab): The provisions of the Health and Social Care Bill were not costed before or after the election. Given the extension of commercial providers, is it the case that the NHS is not safe in the hands of the Government, but that the hands are in the safe of the NHS?

It is fun to taunt the government, but this is a very clumsy question, it would have been far better to ask Cameron about a detail of the Bill, like, say, why doesn't it mandate that there are GPs on the consortium boards? or why doesn't it mandate that midwives and nurses are involved in commissioning? or what are the mechanisms for a patient to challenge a commissioning decision? Any of these, worded correctly would highlight how dangerous the Bill is and how it is putting a lot of power in the hands of just a few, very rich people.

The question Vaz asked simply gave Cameron an open goal to spout some platitudes. He replied thus:

The Prime Minister: On the NHS, I can do no better than quote the shadow Secretary of State for Health. This is what he said about our plans:

“No-one in the House of Commons knows more about the NHS than Andrew Lansley… Andrew Lansley spent six years in Opposition as shadow health secretary. No-one has visited more of the NHS. No-one has talked to more people who work in the NHS than Andrew Lansley… these plans are consistent, coherent and comprehensive. I would expect nothing less from Andrew Lansley.”

That was said by Labour’s shadow Health Secretary. I could not have put it better myself.

Did Healey really say this? Well yes did, and when he said it it made me cringe. I wanted to say to Healey "Come with me to the West End and have a look at a few of the quotes painted outside the theatres. See what can be done with your words?" Amateur and naive. 

Cameron quoted Healey from a speech he gave at the King's Fund (21 January):

This is a Conservative plan for the NHS. This is Andrew Lansley’s plan. No-one in the House of Commons knows more about the NHS than Andrew Lansley – except perhaps Stephen Dorrell. But Andrew Lansley spent six years in Opposition as shadow health secretary. No-one has visited more of the NHS. No-one has talked to more people who work in the NHS than Andrew Lansley. The Health select committee concludes – in so many words – and as I believe, that these are the wrong reforms at the wrong time, “blunting the ability of the NHS to respond to the Nicholson challenge” to improve services to patients and make sound efficiencies on a scale the NHS has never achieved before. But these plans are consistent, coherent and comprehensive. I would expect nothing less from Andrew Lansley.

I have highlighted what Cameron quoted. But look at what Cameron missed out, in particular: "these are the wrong reforms at the wrong time". Read the rest of the speech and you will not get the impression that Healey has the same opinion of Lansley as Cameron has.

Cameron is clearly being dishonest and knows it.

Big Society (Privatisation) Bank

Today at Prime Ministers Questions Ed Miliband riled David Cameron about the failure of his big idea, the Big Society. Cameron replied:

And something I can tell him for the first time today is, because of our deals with the banks, the big society bank will be taking £200m from Britain's banks to put into the voluntary sector.

This is nothing to be proud of. The Big Society Bank will not provide cash for charities as we know them now. It is Cameron's rather sneaky privatisation fund.

In the following I will use "private sector" rather than the government's preferred term "voluntary, community and independent sector" because I am more honest than the government.

The Spending Review in October explains this:

1.87 The Government believes that while it should continue to fund important services, it does not have to be the default provider. This stifles competition and innovation and crowds out civil society.1.89 As well as new opportunities and rights, the Government will assist new providers by improving access to the resources they need. The Spending Review announces that:

• the Government will direct around £470 million over the Spending Review period to support capacity building in the voluntary and community sector... As part of this, the Government will ... establish a Transition Fund of £100 million to provide short term support for voluntary sector organisations providing public services. The Big Society Bank will bring in private sector funding in addition to receiving all funding available to England from dormant accounts;

The point is that the government does not want the state providing public services. Put that another way: they do not want central government, local government nor the NHS to provide public services. Francis Maude will even publish a paper mandating that a proportion of public services must be provided by non-public bodies. In the past Thatcher and Major were honest and said that they were privatising, Cameron is congenitally dishonest, and he will not use the "p" word because he knows how unpopular it is. So therefore he talks about "Big Society" and "voluntary, community and independent sector" providing public services. It just means privatisation.

The £200m Cameron announced is to fund the removal of public services from public sector providers and hand them to non-public (private) sector providers. This is just Cameron's privatisation fund. And note that £200m is less than half the £470m promised last October.

Update:  Urban Forum point out that the £200m will be provided to the Big Society Bank "on a commercial basis" by the big banks. That is, all the deal has done is to get the banks to agree to lend the money.

Broken manifesto promise number 97

OK, I have not been keeping count, but surely this is the Conservatives' number one pledge?

We understand the pressures the NHS faces, so we will increase health spending in real terms every year.

(p45, Conservative manifesto 2010)

We will guarantee that health spending increases in real terms in each year of the Parliament, while recognising the impact this decision will have on other departments.

(p24, Coalition Agreement 2010)

However, although we all know that this pledge was broken months ago when in the Spending Review Osborne gave such a small increase in funding that a slight raise in inflation has turned the small "real terms" increase into a small "real terms" decrease. And we also know that the "ring fenced" budget is no such thing because the Spending Review indicates that NHS funds should be used to fund social care that is normally funded by local authorities. We all know this, but until now the government have not admitted to this, they keep telling us that the NHS has a "real terms increase". Until now.

The sharp eyed editor of the Health Service Journal, Alastair McLellan, discovered the following response from Oliver Letwin to questioning during the Public Accounts Committee:

The Health Service will continue to be a Health Service that’s free at the point of care. It will continue to be a Health Service that’s universal in its scope, and we very strongly believe that the only way that we can enable the Health Service to meet the increasing demands year by year that are being placed upon it, against the background of what is a very special settlement, namely one which keeps its funding constant in real terms, but which nevertheless is much less large in its increases each year than it had been in the last few years.

Letwin has a habit of letting the cat out of the bag, but in the past this was in opposition. This time in government he has admitted that the Conservatives have no intention of honouring their election pledge.

The sale of our woods

Caroline Spelman has handled the policy of selling off the Forestry Commission land very badly and now her colleagues (including David Cameron) are trying to row back, unsuccessfully. Her department produced a consultation document and accompanying this is one titled "Selection Criteria: For the sale of Forestry Commission land in 2011" I think that is unequivocal don't you?

This sale document says:

On 2 December 2010, Ministers announced that approximately 40,000 hectares of land currently managed by Forestry Commission England would be sold over the four year period 2011/12 to 2014/15.

The consultation document says that the Forestry Commission owns 258,000 hectares, so the sale document is for about 16% of their land. It is important to point out that this document says that the government has already agreed that they would sell this 40,000 ha, there is no consultation on this 16% of the Forestry Commission estate. The sale document says that preference will be given to voluntary or community groups. There is ample evidence that at the moment woodland is valued at least at the price of bare agricultural land (currently ~£5,200 per acre or £12,800 per ha), however some woodland in 2010 sold for up to £15,000 per acre. 40,000 ha is about 100,000 acres, if we assume woodland fetches about £5,000 an acre this means that voluntary groups will have to find about £500m. (We have to assume market rates because the sale criteria document says "This will be an open market valuation carried out by the FC’s selling agents".) There will either have to be a lot of very rich volunteers, or maybe the government is expecting to go for their second preference: commercial timber companies.

Half a billion pounds is a lot of money, even spread over four years, however, note that the sale document says that the land will be sold at market value, so this £500m assumes that land will retain its value. Basic economics says that if you flood the market the price will plummet. According to chartered surveyors SmithsGore every year around 100,000 ha of agricultural land is sold. Woodland would make a tiny proportion of that figure, so (an average annual figure of) 25,000 ha of extra woodland on the market would depress the market considerably. But I must stress again, this is only for the 40,000 ha that the government has already agreed to sell.

The consultation on the remaining 84% (218,000 ha):

the Government is proposing a mixed-model approach with the following elements:

• Inviting new or existing charitable organisations, to take on ownership or management of the heritage forests to secure their public benefits for the long-term future;
• Creating opportunities for community and civil society groups to buy or lease forests that they wish to own or manage;
• Finding commercial operators to take on long-term leases for the large-scale commercially valuable forests. By leasing rather than selling, it will be possible to make sure that these forests continue to deliver public benefits through lease conditions.

In addition, the Forestry Commission is increasing its estate rationalisation through open market sales (and lease reversion).

(That term "lease reversion" is interesting, isn't it?)

The preference is for voluntary or community groups to buy the land. Let's do some calculations with those figures. This is for the remaining 218,000 ha (540,000 acres). Again, assuming a commercial value of £5,000 per acre, this would bring in a cool £6.75bn. I never thought that charities and "community groups" were so rich!


However, if the government is likely to sell (on average) 64,000 ha of woodland per year in a market that is usually a few hundreds per year, the value of woodland will plummet, and potentially it would be next to worthless. This may be good news for community and voluntary groups to whom the woodland would be sold at "market value", but it is also good news for the commercial companies who hope to get their hands on 150 year leases on the commercial plantations.

Whatever way you look at this, the policy seems totally ill-thought out and designed to fail. It is no wonder Cameron is making noises about stopping this silly sale.

Trees

It looks like the government's plans for the Forestry Commission is likely to be yet another u-turn. I will address their policy in my next post, but to set the scene let me make a declaration: I am a tree hugger.

Tree Hugger

I have to declare some interest here. When I got the first royalty cheque for my first book (in 1996) I put it into my woodland fund. For most of my life I have taken an amateur interest in woodlands and enjoyed walking in them. Not only do woodlands sustain a large amount of wildlife and some very interesting symbiotic relationships, they have also been important for our nation as a source of fuel and construction materials, and food sources for livestock. All of this interests me because it explains the roots of our nation. For about 10 years I was on the mailing lists of several land agents and I viewed several woods, but none were ion my limited price range, nor near enough to where I live. My woodland fund has since morphed into my rainy day fund and regularly gets raided to pay the bills (it always seems to rain here).

A while ago I went on a woodland management course and learned a lot about how to maintain a wood. Interestingly, I was the only person on that course who didn't own a wood, but afterwards, and my enthusiasm boosted, I decided that a wood was something worth saving for. Some of the people who are protesting about the government's policy on the Forestry Commission say that it will mean that the rich will own "our" woods. It is as if they think that when a tree grows on a piece of land that land suddenly becomes public, with an automatic public right of access. That is nonsense, of course, every square inch of land is owned by someone (and the state does own a lot), but ownership of land does not change any public rights of access.

In the days when I actually thought I would own a wood, whenever I saw someone drive a brand new £20k car I used to think "oh, that's half a wood". I drive a 12 year old car because I put my savings into my woodland fund and not into a "I buy a flash new car every year" fund. Priorities, you see. (For those interested, woodland costs between £5,000 and £15,000 per acre, depending on where it is.)

I am a tree hugger, but you may retort "so do conservation work and everyone can benefit?" Good point, and I have. But I would also like to do what I want. I own my own house and so it means that I can paint the front door whatever colour I like, similarly I want to own a small amount of woodland and I want to manage it the way I want. Since I am a tree hugger it means that I would not clear fell my wood. (Indeed, I would not be able to because I am sure the Forestry Commission would object.) But it would mean that I could try new techniques. Call me individualist, if you must.

If I own 10 acres of woodland (sadly, I don't) then that to me is my garden. If there is a public right of way through it, then that is fine by me, but I would not want people to roam off the footpath. Firstly for their safety (I may be felling or lopping trees) and secondly, for mine (can I be assured of the intentions of the guy skulking behind that tree?).

Trees

So, let's talk about trees. The first thing is that a forest does not have to have trees. Woods have trees. Forests can be moorland, fen, heathland or woodland. It's all about the forest laws of hunting deer: deer live in a forest, and although there may be trees in that forest, it may not have trees and yet it still will be a forest. My personal hero on the subject, Prof Oliver Rackham (the author of The History of the Countryside, a must read book), uses the term woodland rather than forest. He also uses the term forestry for managing plantations. I defer to his expert opinion.

The term "ancient woodland" (or "ancient forest") is thrown around rather carelessly. The fact is, many tree species live longer than humans so most woods are going to be older than any living human. Most of the trees in our woods are little more than 100 years old (I'll qualify this a little further down), and the reason is because most woods were clear felled during the First World War woods because of the great demand for wood. The age of a wood is not the age of the individual trees, instead, it is how long there has been a wood in that location. (You have to distinguish the wood from the trees!) There is evidence that man has managed woodland in the British Isles for 6500 years. There may well be woods which have had trees for this time, but there will not be trees of this age. When a wood is managed it means that it is no longer natural, it is being used as a crop (compare grassland - natural - to a field of barley - a cultivated grass, woods managed for a crop are like a field of barley). Natural unmanaged woodland is called wildwood. According to Rackham, there is no wildwood left in Britain, although there are fragments of comparable temperate wildwood in North America.

Deciduous trees are wondrous, truly amazing. The reason why I say this is because when you chop down a deciduous tree you do not kill it; it will sprout again. This is the basis of English woodland management, you chop down trees, they re-grow and 25 years later you've got more trees to chop down. This process is called coppicing and it means that the tree may well be much older than the trunk that you see above ground. So when the English woods were clear felled during the First World War it did not mean that the woods were being removed from the country side. It just mean that the current crop of trunks were harvested and the trees would simply regrow.

There are only 35 tree species that are native to the British Isles, but there are something like 700 different species that grow in this country. Some of these are grown as specimen plants in domestic gardens and arboretums and some are grown commercially. Native English woodland is mostly deciduous: ash, oak, willow, hazel (technically, a shrub), birch, beech, hawthorn, rowen, elm, lime, alder are the common species. Holly, yew, juniper and Scots Pine are the native evergreens, although as the name suggests, Scots Pine is native in Scotland. The native part is important because it means that not only is the tree suited to the climate but it also supports native wildlife and fungi.Non-native trees support less wildlife.

Woodland Harvests

For centuries every community in England would have a wood to provide the community with fuel, fodder and materials. These woods would be managed with a technique called coppice with standards. The standards are the tall, straight trees that provide the timber for construction; they also have the genes for good healthy offspring and so provide the seed for replacement trees. A standard may take 60 years to grow to its full height, so a woodsman manages the trees for a future generation to harvest. Such long term thinking is absent from modern policies: can you imagine a company making an investment that would only make a profit 50 or 60 years later?

Coppice is harvested at much shorter periods than standards: say 6 years or up to 25 years, depending on what the wood is used for. Before the large coal fields were exploited coppiced wood was the main fuel in Britain. For example, Cheshire was deforested to provide the wood to feed the salt industry where brine was boiled to produce crystalline salt. Even after coal became the main source of energy wood was still important because the coal mines needed pit props, which were mostly made of wood.

When you walk in a wood you are often awed by the height of the trees, but I urge you to look down. The width of the trunk rarely shows the age of the tree, instead, look at where the trunk grows from the ground. If the tree has been coppiced in the past there will be several trunks from the same roots (the term for where the trunks grow is the stool). Sometimes the stool is a metre or more across indicating a very old tree.


Trees also produce edible products, for example, some nuts can be eaten by humans. However, other tree seeds are a valuable food sources for animals, as are tree leaves (particularly the young leaves). Indeed, many established woods have a woodbank which marked the edge of the wood and was used to keep the livestock that is feeding in the wood, in; and to keep the livestock that is not supposed to be in the wood, out. Walking through an old wood you can often see these woodbanks.

Man has been practicing woodland management for something like 6,500 years and so this has encouraged specific flora and fauna suited to this style of woods. Tree branches block out light and this means that woods support flora that prefer a lot of shade. But when a tree is coppiced light floods in and it means that for several years the area will be bathed in light, yet largely uncultivated and this encourages flora that benefit from sunlight.Thus coppicing encourages a cycle of flora, some plants preferring sunlight, some preferring shade.

The Decline of Woods

It is widely known that Britain almost ran out of wood during the First World War and so the Forestry Commission (note, Forestry not Forest) was created to ensure that in the future the country would be supplied with wood. However, as those people who have watched Downton Abbey will recognise, there were huge social changes after the First World War. The community woods that I mentioned above had long since stopped being used by the communities for fuel, and they had mostly been taken over by large landowners who used them for game. After the carnage of the First World War these private woods were largely neglected, and no longer coppiced. Ninety years later, this has resulted in tree stools having fully grown trees. 

The following table is taken from the Forestry Commission and show the decline of coppiced woodland in Britain in the twentieth century. This table shows the estimated areas in thousands of hectares of simple coppice (C) and coppice with standards (S).

Year	England		Wales		Scotland		Britain		Total
	C	S	C	S	C	S	C	S
1905	215		6		9				230
1913	208		8		11				227
1924	31	163	7	8	2	2	40	173	213
1947	41	91	7	1	<1	<1	48	92	140
1965	18	10	<1	-	-	-	18	10	29
1980	26	11	2	<1	<1	<1	28	12	40
1997	11	10	<1	-	<1	<1	12	11	23

It is quite clear that over the last 100 years private woods have not been maintained. They really have little value commercially. In addition, the increasing demands on agriculture has lead to many woods being grubbed up (the roots removed) and the land used to grow food. However, in the last couple of decades woods have taken on new value for recreation for tree huggers like me.

Plantations

You cannot coppice conifers; if you chop down a conifer you kill it. However, a softwood conifer has a distinct advantage over a deciduous species: it is much faster growing. The construction industry needs timber with even grain and few knots, so modern conifer species are grown as tall, straight trees with few branches.

To supply Britain with the wood it needed, the Forestry Commission was given the task of rebuilding and maintaining a strategic timber reserve, and it did this through purchasing land and planting. Inevitably much of these woodlands were plantations of conifers, since their focus was on timber that could be used. By 1934 the Forestry Commission owned 370,000 hectares, and of these 130,000 were under plantation. During the Second World War some of this was felled: yet again the country needed wood (mostly for pit props) but this time the Forestry Commissioned delivered.

About 30% of the English Forestry Commission woods are broadleaf. To some extent this is due to their stewardship of the large woods of the Forest of Dean and the New Forest, but it is also due to efforts to plant more broadleaf woods. However, it does highlight that 70% of the Forest Commission's woods are conifers, and since conifers are not native in England we can deduce that about 70% of the Commission's woods are non-native plantation. The problem with plantations is that they are mostly monoculture, non-native, fast growing conifers: they are wildlife deserts, the trees are grown as a crop.

Walk through any plantation and you'll see that little grows in the pine needle leaf litter. This is because the trees are grown so close together that there is little light reaching the ground, and no coppicing is carried out. It is also because the trees are non-native. Walk through a broadleaf wood and you'll see undergrowth with many types of flora and shrubs, and if coppicing is carried out then you'll see many more undergrowth plants. Plants means animals, so broadleaf woods support much more wildlife and flora than plantations.

The Forestry Commission does a lot of good. They fund research, they maintain rights of access and pay for rangers in their woods. They supply grants and give advice for private land owners to grow woodland. All of this costs money. The Commission costs the taxpayer relatively little money because it has a separate source of income: plantations. So while plantations are non-native and mostly wildlife deserts, they are necessary to fund conservation work that the Forestry Commission performs.


In my next post I will describe the government's policy towards the Forestry Commission.