Integration

Its clear that the NHS needs reform since there is a lot that needs to be done, but little money to pay for it. The one thing that cannot happen is to fund healthcare by introducing user charges. That is always a threat when Conservatives have won a majority, but it was certainly my worry with Labour trying to improve public services with the funding straitjacket they created during the election campaign. User charges are an admission of failure. But reform can make the NHS more efficient. And the current buzzword when it comes to reform is integration. As a patient, as a user of healthcare across several providers I am very much in favour of integration, but from the patient's perspective.

Over the last few years, particularly in the last year, I have suffered quite serious healthcare issues and it's clear to me that I won't get better. I'll leave the details for the narrative over the next few weeks, but to whet your appetite, in 2023 I had five MRIs, two CTs, two lumbar punctures, two electrical nerve tests, a PET scan, and an ultrasound. Last year I have had numerous blood tests, some for blood chemistry, some for antibodies, some genetic tests and one weird blood test where the sample had to be kept exactly at blood temperature so the phlebotomist had an insulated box with a thermometer and a heater and would only draw the blood when the inside of the box was at blood temperature. Prior to 2023 I saw two hospital specialists on an annual basis. At the end of the year I was seeing three more eye specialists, a neurologist and a respiratory specialist. This year I am about to see another eye specialist (so that means, five eye specialists) because my eyes are getting more complex. I am seeing these specialists every other month, so the number of consultant appointments has gone from three a year to almost 20. I also had 19 days in hospital at the end of last summer.

These specialist appointments have been across four hospitals in two hospital trusts, and when you add in the number of General Practice appointments there are a lot of appointments, a lot of tests and a lot of notes. There is also a lot of duplication. Getting all of these organisations to work together is very hard, but even if that was possible, it is often harder to get specialists in a single organisation to work together. Integration is a long term project, but its clear to me that it is necessary.

What the Computer Says

This is not a Luddite attack on computers, in fact it is the opposite. This post is not telling you that computers are bad, but to tell you that they are just tools and that we have to avoid using them badly.

Last week there were floods. So I looked at the Environment Agency website to see if there were floods nearby. There were some 'red' areas and a lot of 'orange' areas. There was no key as to what red and orange meant, but there was a lot of orange areas. The reason is that there are several rivers nearby. Nothing more than nearby rivers and heavy rain. My wife travelled home through one of the red areas and she was not affected by flooding. That evening we had dinner with my son, and we had to drive through one of the red areas to his house in one of the orange areas. No sign of flooding, no sign of people evacuating from an orange area.

And yet there are flooded roads in the area. I was at a meeting on Thursday morning and most of the people were late because traffic was slow through flooded roads and some villages were cut off. My house is nowhere near a water course, but the end of my garden floods to 30 or 40 cm several times a year, and it was flooded last week. My garden is not marked on the Environment Agency as being at risk of flooding.

So what is happening?

It appears that the flood warning maps are based on what a computer has indicated using fairly basic information: the computer says flood! If the river level is higher than normal it is clear there is a danger of flooding and hence the lowest land near to the river is more likely to flood. The Environment Agency has contour maps and an algorithm has simply highlighted the land near the level of a water course. The maps come from satellite imagery and appear to be detailed - the red and orange areas appear to have jagged edges, as if being one side or other of the line is important. However, this is a very broad measure, and will not predict the most of the immediate flooding and will not necessarily give the extent of existing flooding.

The people who were late to the meeting on Thursday drove along the dual carriageway which is above the fields it goes through. The flooding was caused by poor drainage, a blocked culvert, and heavy rain had accumulated on the road. My garden floods partly because it is lower than the gardens of my two immediate neighbours. But also because local planning guidelines are that rainwater from roofs should be channelled into a 'soakaway' rather than the main drains, and as an area of heavy clay with a high water table in the winter, a soakaway turns into a pond that overflows and flows into my garden.

The Environment Agency maps highlight the catastrophic danger of flooding - if the river overflows then these are the areas most likely to be flooded. It does not reflect the blocked culverts on major roads or inadequate planning decisions. These are details you do not expect the Environment Agency to collate. Even so, it is not clear if the maps are accurate unless they also reflect the local flood avoidance actions being taken, including water management schemes like purposely flooding farmland. In other words these these maps appear to be detailed, but the actually lack the most important details.

The reason why I mention this here is because it does highlight an issue of big data. This is a problem that often happens with healthcare commissioning where commissioners focus on the broader trends and pay no attention to the fine details of the data. The problem is that the fine details are actual people, and it is no comfort to a patient to learn that the service is designed for the majority of people if they are the minority that has been masked by commissioners looking at the broad trends.

This Tiredness Is Exhausting

I wrote this title three years ago, but I didn't get any further than the first paragraph, for reasons that will become apparent as you read this blog.

For five years, from the beginning of 2010 to the end of 2014 I suffered from Chronic Fatigue. The fatigue was debilitating and, for someone who always made sure he was reliable, it made me thoroughly unreliable. I could not work because my fatigue meant I could rarely manage a full working day and often I had whole days when I could do no more than lie on my bed.

For the record, I have had type 1 diabetes for 40 years. I was also diagnosed with an underactive thyroid more than a decade ago and have been taking thyroxine. The diagnosis of my thyroid condition came about when I mentioned to my diabetic specialist that I was feeling depressed and when he talked me through the symptoms he told me that it sounded like an underactive thyroid and ordered the tests that confirmed it. (Ironically, I have been told by other people with thyroid problems that their GP had misdiagnosed them as depressed and only received the thyroid tests when the antidepressants didn't alleviate the symptoms.) Both diabetes and thyroid problems can cause fatigue, but the fatigue is different to what I experienced during my five years of CF.

As far as I remember the CF came on slowly, there was no trigger event after which I started to feel fatigued. However, I do remember events when I was far more tired than I should have been. For example on the 10th April 2010 there was a march in London to support public services. It was not a long march, it started at the park on the Embankment, along the embankment, went past the Houses of Parliament, along Whitehall and ended in Trafalgar Square. A short walk, but halfway round I had to sit down. I could not proceed until I had rested for 20 minutes. This was not me. I am the fidgety purposeful sort of person that does not rest until a task is completed. Yet here was I stopping halfway and resting. I don't do that, or at least, I didn't until then.

Misdiagnosis

The fatigue got worse and so eventually I went to my GP. The first suspicion was that I was not taking the right thyroxine dose. This involved changing the dose and having blood tests six weeks later to see the effect of the medicine. An overdose of thyroxine (T4) is not good for your heart so one of the tests is for a hormone - thyroid stimulating hormone (TSH). If your T4 levels are low, you produce TSH, so high levels of TSH show that you need more thyroxine. Conversely, low levels of TSH indicate that you may be taking too much thyroxine. (Such a feedback loop appeals to my physicist training: you raise or lower the thyroxine does until you achieve 'normal' levels of TSH and T4. The problem, of course, is determining what 'normal' is.)

In my case my values of T4 and TSH showed that the existing dose was right, but the GP I saw at that time clearly wanted to pursue it further and suggested that I may need triiodothyonine (T3) therapy. He told me that although the medicine could be prescribed by the NHS, the endocrine consultant at the hospital (who was my diabetes consultant) was not convinced about its use and so if I wanted to use it I would have to see another consultant. Since this was after the 2010 election, and we were in the new world of Lansley's NHS, the GP suggested I could see the other consultant privately. I was a patient too fatigued to work, and earn, so I did not have the money to spend money on healthcare that I thought was not necessary. This, however, was the new NHS. I decided not to see that GP again: he thought he knew more about endocrinology than the endocrine consultant and wanted to promote private healthcare over the NHS.

I tried another GP at the same practice. This time my diabetes was the barrier to diagnosis. The GP looked at my notes, saw that I had type 1 diabetes, looked at my HbA1c and told me: "Your blood sugar is a bit high, did you know that high blood sugar can make you tired? Try to get it lower." When I tried to explain that the blood sugar was not high (want to see high? try taking bovine insulin for ten years with only a urine chemistry set to monitor the treatment) he would not listen to me. When I tried to explain that my blood sugar was high because I was not taking exercise, so it was the fatigue that was making my blood sugar high. I was not fatigued because of the blood sugar, the fatigue was making my blood sugar high: he just dismissed the idea. Another GP I will not see again.

My HvA1C at that time was in the mid-50s. The NICE recommendation for a Type 1 diabetic is to have a value less than 48 mmol/mol. My diabetes consultant was not worried with the figure, and just gently encouraged me to try and get it lower. The GP, however, did not understand Type 1 diabetes and thought that a few points over the NICE level was 'clearly' a source for my fatigue. I have a letter when I was 22 that the diabetes consultant I was seeing then wrote to my GP. I was going through what the consultant called "a holiday from diabetes", (he told me that it often happens to young people). At 186cm my weight dropped to 64Kg (BMI 18.5). The blood tests (in modern units) were: my spot blood sugar was 30 mmol/l (it should be about 6) and my HbA1C was 180 mmol/mol (it should be less than 50). Was I tired then? No. I was buzzing. I was studying for a PhD in semiconductor physics, doing long hours in the lab and library and travelling a lot. Clearly when I was first diagnosed (at 11) with T1D I had a much higher HbA1c, because I certainly felt fatigue then.

So a GP refusing to listen to me because my HbA1C was a few points over the 48 recommended says a lot about his ignorance of diabetes and his disdain for patients. Neither of these GPs looked at my notes, and neither saw that (at that point) I had had Type 1 diabetes for 35 years and hence must have had a period of high blood sugar and the fatigue, and then asked me if the fatigue I was suffering was like that? No. As far as they were concerned, there was only one diabetes 'expert' in the room and it wasn't me.

Indeed, during a following appointment with the diabetes specialist I described the fatigue and he said my blood sugar - while not desirable - was not high enough to cause the fatigue. The GPs were blinded by my existing conditions. Over several months the diabetes specialist ordered various tests - adrenal, testosterone and even a sleep study - but none came up with a conclusive explanation for the fatigue. Finally he told me that he thought it was Chronic Fatigue Syndrome, and then he retired. The locum specialist was not particularly interested in the fatigue, and so I never really did have any help for the condition.

The Fatigue

It's easiest to describe the fatigue with a typical 'good' day. I would wake, as normal, at 8 not feeling particularly tired (I usually felt that I had benefitted from the sleep). I would do light work in the morning, mostly reading. By lunchtime I would start to feel physically tired and so in the afternoon I could not do any reading and - trying to make sure I kept active - I would do something in the garden, potter in the greenhouse, or do some weeding. By four the physical tiredness would get unbearable. I would have a headache and all my muscles ached, and I would barely be able to stay stood up. My brain would have slowed so much that any decision making was impossible. So I would take some ibuprofen and go to bed for a couple of hours. This happened every day, for five years.

During the time I had Chronic Fatigue I found that I was cold. I took to wearing tracksuit trousers in bed because I was so cold, and I wore two pairs of socks (one over the other) every day, even in the summer. I had extra blankets over the duvet. I was just so cold. Now I am recovered I am no longer cold and I wear just one pair of socks at a time!

I found that the main problem was not the physical tiredness, it was the mental tiredness. This was why it was so different to the fatigue from high blood sugar or lack of thyroxine. The CF slowed down my brain considerably. It got so bad that my wife said she was worried that I was developing dementia (in my 40s). I could not hold a conversation with my (sharp witted and intelligent) adult children, I was typically minutes behind the discourse.

Before the fatigue I was a technical book writer and speaker. Over a period of 10 years I had written 6 books each over 500 pages, 150 articles (I had two monthly columns) and spoke at four or five conferences a year. I went from writing 500 page books to struggling to write 500 words. When you write a book - even a technical book - you have to tell a story, so each chapter has to lead the reader through that story. Although I would have an outline to write to, the chapter would be in my head until I had committed it to the computer. I would know where I was coming from and where I was going, and have a rough idea how I was going to get there. While writing the 'journey' would change and I would make adjustments to how I would get to the final point.

In my job I would read many books, and I used to review technical books for publishers. If needed, I sometimes would speed read technical books, and I could read a 500 page book in a couple of days (I only did this occasionally - I found that I took in the book sufficiently well to be able to know the content of the book and where to find passages, but I really didn't get an understanding of the subject which I would have done if I read the book thoroughly).

With Chronic Fatigue I lost that ability entirely. If I wrote more than a few hundred words I would lose sight of the purpose of what I was writing. I have many abandoned articles on my hard disk where I clearly had an idea, but after working on it for a few hours I had lost the impetus and the inspiration and often I just forgot what the article was about. Reading was no better. I could not read for more than a hour at a time at best. If I was reading a complex subject I would often have to read sections several times. If the article involved several concepts I would be completely lost, I could barely hold one concept in my mind at any one time.

Managing The Fatigue

One of the main problems with Chronic Fatigue is that if you do any exertion - mental or physical - then it makes you overwhelmingly tired for days after. You cannot avoid those situations, so you have to learn how to manage them. I would avoid anything more than a half day meeting if I could. If the meeting was in the morning I would rest the day before and then when I got home after the meeting I would go to bed for the entire afternoon. If the meeting was in the afternoon, I would rest the morning before and then when I got home after the meeting I would go to bed. If the meeting was for an entire day then I would rest the day before but I would know that the day after I would be incapable of doing anything other than lie down.

You may think that the "treatment" for Chronic Fatigue is sleep, and so all I needed to do was to sleep more: go to bed earlier, wake up later. Unfortunately, it's not that easy. Going to bed earlier just results in sleepless hours, and if anything it makes you more tired. The reason why I would do some light physical exercise when I started to feel tired is that if I tried to sleep, I would not be able to. Although the Chronic Fatigue makes you feel tired, your body has other criteria it uses to determine if you can sleep. I spent many hours just staring at the bedroom ceiling, unable to listen to the radio (because I was too fatigued to follow the programme) but unable to sleep. I can tell you that the tiredness from Chronic Fatigue is exhausting. I learned that taking some exercise is important, it helps you sleep.

Rather than taking exercise (or working) until I was tired, as I do now, I had to do as much exercise (mental or physical) as I knew I could do and half a day's mental activity was my limit. This takes discipline but you soon learn that you have to do this because if you don't, you will pay with days of excessive fatigue. Conversely, you also know that you have to do something otherwise you cannot sleep when you need to.

Since I could not work I decided that I would volunteer the time when I was not tired to the local NHS. I was already an elected FT governor and I volunteered to be part of the local CCG's patient group. This involved meetings, maybe, half a day a week. Although I tried hard to be reliable, volunteering means that there is some leeway in your expected reliability. It also helped me because I had regular commitments. The temptation with Chronic Fatigue is to simply 'take to your bed' and hope the condition goes away one day. Although the regular meetings tired me out, they made sure that I did do something.

Going Forward

My Chronic Fatigue stopped fairly suddenly: one day I found that I did not need the afternoon nap. The first day that it happened it was a bit of a surprise, but when I found I didn't need the nap the next day, it was clear that something had changed. Over the following year I had a few 'relapses', which I think was me being careful and reacting to normal over exertion by immediately going to bed. I no longer get the 'post exercise malaise' the exhaustion that could last for days after doing some exertion more than you are used to.  I have not had the flu-like symptoms of headache and muscle ache since then.

Now when I go to my FT or CCG meetings I cycle the 10 mile round trip: as I explained to one of my colleagues, 'if you can do it, you should'. And I am writing a technical book, its quite a grueling schedule: 400 pages, ten chapters, one chapter every two weeks. It is such a brilliant feeling to be able to think again, to be able to exercise again.

And my HbA1c. Its still in the mid 50s, my diabetes consultant is still gently encouraging me to get it lower, but is not worried about the figure.

Enough is Enough - Burnham's Speech on Social Care

This is worth reading, as well as Dan Poulter's useful intervention and Jeremy Hunts disgraceful attempt at political point scoring where he fell flat. Burnham spoke during the Opposition debate on Social Care on the 16 Nov and its likely this will be the most important speech he will do in the House, with the Mayoral vote in Manchester next year. He really should have been the Secretary of State for Health longer.

Andy Burnham (Leigh) (Lab) 

I congratulate my hon. Friend the Member for Worsley and Eccles South (Barbara Keeley)—my good friend—on an excellent speech. She ​has no equal in this House as a champion for older people and their carers. Her speech, unlike the speech by the Secretary of State, was firmly rooted in the real world.

This is the century of the ageing society. Caring for people as they live longer lives is the greatest public policy challenge of our times, but for years Parliament has shown itself to be unequal to that challenge. I want to speak today to tell the story of the efforts to reform social care over the last decade, because I want the facts to be on the record, so that people can understand what happened and vow to do better. The story explains the mess we are in today. To be honest, it is quite a shocking story of partisan point-scoring and, worse, political cowardice, which have seriously failed millions of older and disabled people.

The story started nine years ago at the spending review in 2007. I was Chief Secretary to the Treasury at the time, and at the insistence of the Treasury I gave the Department of Health the condition on its spending review settlement that it would conduct a root and branch review of the funding of social care. There was a recognition, even in the Treasury, that if we allowed the situation to continue, it could, in the end, damage the national health service. Quite clearly, the funding was not sustainable, and if social care was left to collapse, it would drag down the NHS with it.

The urgency of such action had been recognised almost a decade earlier, in 1999, when a report by a royal commission on the matter recommended free personal care, paid for by general taxation. It did so for the reason that if we pay for free preventive care in people’s homes, those people do not end up in hospital and costing us all more. Nothing was done, and by 2007 the need for reform was urgent. So between 2007 and 2009, a huge amount of detailed modelling work was done and options were looked at.

When I arrived in the post of Health Secretary in 2009, the work had come to a head. The analysis supported a clear conclusion that radical reform, rather than patching up, was needed. Department of Health officials supported the Treasury analysis that there would be risks to the NHS if social care was allowed to decline. A Green Paper was published in July 2009, and the idea of a national care service was first put forward. The thinking was that only by bringing the systems together, with a system of clear national entitlement, would we be able properly to move towards integration. The maintenance of two entirely differently funded systems—one free at the point of use and the other means-tested and charged for—would mean that they would never be able to speak the same language and there would always be barriers to integration.

I was ready to grasp the nettle, because it was clear to me that the NHS was facing a decade of lower funding from 2010 and 2020, and that one of the ways it could cope with that was with the efficiencies we could unlock through properly and fully integrating health and social care and by moving from a hospital-based medical model to a person-centred social model of care starting in the home.

This is where things went wrong. Picking up that I was ready to up the momentum for reform, the then shadow Health Secretary, Andrew Lansley, approached me in Portcullis House just before Christmas 2009 and asked me for cross-party talks. I thought about it, but I agreed. I thought, as my hon. Friend the Member for ​Barrow and Furness (John Woodcock) has suggested, that we should take the issue out of party politics, which would be better for everybody. We had a couple of meetings, in which we went round the issues. I favoured the more ambitious, comprehensive reform of paying for social care on the NHS principle—that everybody contributes, but everybody is covered for their care needs and has peace of mind in later life. Andrew Lansley wanted a more voluntary system, in which the insurance market would come up with solutions. That was where we left it.

Then a bombshell was dropped in February 2010: the poster saying, “Now Gordon wants £20,000 when you die.” I very vividly remember the day when it landed. I was told that Andy Coulson had put pressure on Andrew Lansley to do it, and that he did not really want to, but felt he could not say no. I do not know whether that is true, but I know that the Conservatives, who asked me for cross-party talks, betrayed the confidence that I gave, and they have never seen fit to apologise for that. The point is not about the personal political damage that that did, but about the chilling effect the poster had on the social care debate. It instantly killed any talk of radical reform, and it actually had a deadening effect for the rest of the following Parliament—the last Parliament—during which no real progress was made.

That brings me to what happened after the election, when, as shadow Health Secretary, I challenged the Government from the Opposition Front Bench about the poster that they had put out during the election saying that they would cut the deficit, not the NHS. I made the point that if they did so, they would in effect cut social care: if they prioritised NHS spending within the reduced envelope, that would have devastating consequences for social care and would in the end come back to affect the NHS.

From the Dispatch Box at every Prime Minister’s Question Time, the then Prime Minister used to quote me as claiming that it would be irresponsible to give the NHS real-terms increases, but he never commented on the second part of what I had said, which was that it was irresponsible to do so if we were cutting social care. I did say that, and it was irresponsible to social care in the way they did to pay for their commitment to the NHS. Social care was cut by 9% during the last Parliament, with 400,000 vulnerable people losing support in their homes. Those people ended up in A&E or trapped in hospital beds, piling pressure on the hospital system.

Dr Daniel Poulter (Central Suffolk and North Ipswich) (Con)

I pay tribute to the right hon. Gentleman—this may be my last chance to do so—for the work he has done as a Member and wish him well in his future career if he is successful in his election. Does he agree that the chilling effect of the outcome of those conversations before the election and perhaps the betrayal of his confidence, as he puts it, is that there could no longer be a rational conversation about properly funding the health and care system through any form of taxation? That is the problem that has emerged, and perhaps the best way to fix it is through general taxation.

Andy Burnham

I am very grateful to the hon. Gentleman for his intervention and the spirit in which he made it. He is absolutely right: that set everything back and ​meant that there was no possibility of a cross-party approach. There will have to be such an approach if we are to fix social care and, indeed, to give the NHS what it needs, because they will both need more funding during this Parliament. That is the real shame. I did not make my point about Andrew Lansley for political reasons; I just want people to understand what happened, so that the current generations of politicians might do something different.

The answers we have since had from the Government are wholly inadequate. We have heard today that the precept does not raise enough money, particularly for poorer councils. It is no answer; in fact, it just cynically devolves the responsibility for the whole issue to local government, even though councils did not create the problem. I still favour an all-in system. I will say it: I favour a system in which we ask older people to pay a set contribution, so that they have peace of mind in later life, with all their care costs covered.

Mr Jeremy Hunt

I am listening very carefully to the right hon. Gentleman. In the spirit of wanting to rise above party politics, will he agree that it was totally wrong of him to suggest at any stage in the last Parliament that the Government wanted to privatise the NHS, when we have never had the intention to do so? It was wholly irresponsible to scare the public about that.

Andy Burnham

In a week when Virgin Care is taking on a huge community care contract, I do not think the Secretary of State should be making that point—particularly the Secretary of State who privatised ambulance services in Greater Manchester. I honestly do not think we need to go there.

The point that I am making is about funding social care. The Conservatives claimed that we were introducing a new inheritance tax. Do people not understand that just 3.4% of estates in this country attract inheritance tax? Why is that? Because the vast majority of estates are whittled down by the costs of care—tens of thousands of pounds, or hundreds of thousands of pounds for some people. That is not fair and it is not sustainable. We must be able to do better.

I feel so strongly about this because I saw my grandmother go through the care system in England 20 years ago and, frankly, it was nowhere near good enough. I arrived here saying that I would do something about it. I tried to do something about it, but we have not got anywhere near a solution to the scale of the challenge. People will need to put party politics aside and find common ground. The point scoring and failure to grasp big issues have led to a situation where people have low regard for this place.

We are left with a malnourished, privatised care system in England that is sinking lower as we speak. A culture of slap-dash 15-minute visits is entrenched, in which staff do not get properly treated, trained or respected. Standards in care homes have slipped even further, and stories of neglect and abuse abound—we hear them all the time. Countless vulnerable people and their families still have to pay these cruel dementia taxes, which have risen under this Government, losing everything they have worked for and going into later life with everything on the roulette table: home, pension, savings—the lot. That is not the care system we should ​have in 2016 in this country. At what point are we going to say, “Enough is enough,” and actually do something about it?

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.

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.

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.

Postscript

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.

Privatisation

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.

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.

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.

DevoManc: Huge Centralisation of NHS Commissioning

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.

Fill in the gaps

This is my response to Bill Morgan in a blog on the Spectator. Bear in mind that Morgan was a Special Advisor to Lansley so there is a whiff of the Mandy Rice-Davies about his post.

You rightly start by saying that the 2010 winter was affected by a flu outbreak. However, you then go on to say that 2011, 2012 and 2013 were uneventful. This is not true. There was more flu and norovirus at this point last year compared with now. Last year the NHS could cope (just) with the flu, this year the NHS cannot cope even without flu. It is this problem we have to address. The run up to Xmas was mild - just like it was the year before - so why wasn't 2014 like 2013?
It isn't a small dip in A&E performance. Every winter you will find that *some* trusts will fail to meet targets (the usual suspects), but what is characteristic about this winter is that *every* trust has been effected, even the best performers. Since the dip (you claim "small", well on the front line it isn't seen that way) is universal, so there must be a universal reason for it. You're right to say that Labour have jumped upon the Lansley "reforms" (well, fragmentation of the NHS) without explaining why it has affected A&E performance. The problem is that most trusts will say that they really don't know - the problem started in the summer when we had winter activity all year with no lull. As you rightly say, no trust, nor NHS England can explain why, but the facts are clear - there are large numbers of frail elderly people, who are sick with multiple conditions and these are the reason for the drop in performance. 
People from different parts of the health service and different political persuasions, will have their theories, but it is rather silly to blame it on the GP contract because the performance problems is not due to the people who would have otherwise gone to a GP. You dispute the cuts in social care, which I think is brave since many social services are close to collapse. (My theory, is that it is community health services, that has failed. I think we have got to the limit of treating people "in the community", at home or in nursing homes, certainly at the level of funding there is now. Nursing homes are a particular problem, there isn't enough NHS medical care in those homes (which is their right), so people are deteriorating unseen. You *can* blame GPs for that. Consequently people are being admitted from care homes in a poorly state. But I can be wrong, just like anyone else.)
You say "the reforms – largely focussed on making doctors responsible for long-term NHS planning", which is a statement from a politician, not from someone with any experience in how CCGs run. Most GPs will tell you that they have no more control or say in how local services are planned. GPs are inherently independent and most of them want to remain so. A few GPs have got involved in CCGs, but this happened with PCTs too. GPs joined the PCT and became managers and those few GPs who have joined CCGs have now become managers too. Analysis I have carried out on CCGs show that less than a third of CCG boards have a GP majority (and mostly, that is the limit of GP involvement). Plus ca change, plus c'est la meme chose.
In fact the fragmentation of commissioning has been a disaster, which is why things are changing now and with co-commissioning CCGs are starting to look just like PCTs. For my condition - type 1 diabetes - there was one commissioner of all the NHS services I use in 2010. Now there are three different commissioners, one for the GP services, one for the hospital services and (bizarrely) another one for the monitoring of my diabetic eyes. None of these commissioners talk to each other. Whenever I ask them why such-and-such service is not integrated with the other services (like it was in 2010) I am told "we don't commission that". It's a mess, and the mess was predicted when Lansley came up with his plans in 2010.
You talk of the timing "why would a set of reforms cause short-term problems in our A&Es two-and-a-half years after most of them were in place". This is a valid question (except your calendar is wrong, the reforms came into place in April 2013, 20 months ago, not 30 months ago). However, I think you are saying "look over there". We know that social care has been viciously cut in the last four years (NAO says a 7% cut in spite of a £1bn from the so-called ringfenced NHS budget every year), and four years of cuts are enough to put that service to the edge. Four years of a deteriorating service is more likely to have an effect than a 20 month old policy, however cracked-pot that police was.
Your Wales argument is a red herring. Wales is mostly rural, it has higher levels of deprivation than England and is arguably too small and too dispersed to be an effective health system. The problem in Wales is not Labour, it is Wales, and maybe we should accept that devolution of the NHS to Wales was a mistake.

Bear in mind that Morgan works for a public relations company and its a fair bet that they have a contract with someone or other connected to the Conservative party, so the piece is more PR than anything else. I thought I would fill in the gaps in the PR piece.

Private patients and the Efford Bill

The Efford Bill is a good start into reversing the damage that is the Health and Social Care Act (the Act that "senior Tories" who couldn't be bothered to listen to experts now describe as gobbledegook). However, as you would expect with such a short bill there are few details. In this post I will cover one issue: NHS trust providing private services.

Private Patients and Foundation Trusts

The 2006 NHS Act has a section to restrict the income from private patients that a Foundation Trust (FT) can generate s44:

(1) An authorisation may restrict the provision, for purposes other than those of the health service in England, of goods and services by an NHS foundation trust.
(2) The power must be exercised, in particular, with a view to securing that the proportion of the total income of an NHS foundation trust which was an NHS trust in any financial year derived from private charges is not greater than the proportion of the total income of the NHS trust derived from such charges in the base financial year.
(3) "Base financial year" means the first financial year throughout which the body corporate was an NHS trust or, if it was an NHS trust throughout the financial year ending with 31st March 2003, that year.

This says that the income from private patients as a proportion of the total income of a Foundation Trust must not be higher than the proportion in the financial year 2002/03. If an FT generates a higher proportion it will be in breach of its "terms of authorisation" and this may result in regulatory action (most likely a look of stern disapproval from Monitor).

The section also implies that an NHS Trust which intends to apply to become a Foundation Trust must make sure that its private income generation was proportionally the same as it was in 2002/03 financial year. Since the then government said that every NHS Trust had to become a Foundation Trust this section was more influential on aspirant NHS Trusts than on authorised FTs (GOSH authorisation as an FT was delayed by several years because of its rampant private business). However, the rule was easily circumvented since the section involves income and not numbers of patients, and trusts came up with clever dodges like joint ventures (The Christie) or moving the private work to a charity (GOSH) so that the income to the NHS Trust was the profit of the joint venture company (or the surplus of the charity, donated to the trust) rather than the revenue for private patient treatment. Although the regulator, Monitor, took action against such dodges, the action was closer to a stern look of disapproval than to actual action that would reduce private patient activity.

Although every NHS Trust "had" to become a Foundation Trust, there was no rigid timetable and no sanctions against NHS trusts that failed to become an FT, and so, in practice, NHS Trusts with large incomes from private patients just generated more private business. There were lots of criticism of section 44, particularly in the case of patents. If a trust creates a new device, drug or treatment and decided to create a worldwide patent, the income from licencing under this patient (even if it does not involve UK patients) was still considered part of the private patient income. Furthermore, the omission of the numbers of private patients in the law meant that a trust could treat lots of private patients but charge them small amounts and still meet the s44 criteria.

Health and Social Care Act

The Health and Social Care Act (HSCA) repealed section 44 and replaced it with a more lax restriction. The Tories hoped that repealing this section would result in Foundation Trusts creating private businesses, but this has not happened, certainly not at the rate that the Tories hoped for.

Section 164 of the HSCA replaced the old s44 with this section:

(2A) An NHS foundation trust does not fulfil its principal purpose unless, in each financial year, its total income from the provision of goods and services for the purposes of the health service in England is greater than its total income from the provision of goods and services for any other purposes.

This says that NHS income of a Foundation Trust (again, omitting NHS Trusts) must be more than the income from its non-NHS services. It is erroneously quoted as "49% private patients" for two reasons. First the non-NHS income can be more than 49%: it can be 50% less £1. (Does this matter? Yes it does. A small NHS trust will have an income of £200m so the 1% difference between 49% and 50% is £2m, and £2m is not a small amount of money.) The second reason this is not a "49% private patient income" rule is that the section does not mention private patients, it says "total income from the provision of goods and services for any other purposes". That is, any income other than income from Clinical Commissioning Groups (CCGs) or from NHS England. This "any other purposes" includes local authorities, charities and even car parking charges (paid by NHS patients). So a trust that has no private patients will have a non-NHS income under this section, potentially an income of many millions. Yet again, our law makers have made a bad law.

Neither s44 of the NHS Act, nor the new section created by s164 of the HSCA covered NHS Trusts. It is clear that about a third of NHS trusts will never become Foundation Trusts, which means that those third will know that the private patient income restriction does not apply to them in practice. Further, both sections have downsides, covering services other than private patients.

Efford Bill

The Efford Bill has two clauses that cover private patient income: clause 7 covers private patients in Foundation Trusts and clause 8 covers NHS Trusts. In effect, they say the same thing (and hence finally applies private patient income restrictions on NHS Trusts): The following is from clause 7:

(3) An NHS foundation trust shall ensure that its total income from the provision of goods and services for provision of services provided to individuals for or in connection with the prevention, diagnosis or treatment of illness otherwise than for the health services or for which charges are made by the trust is not greater than either—
(a) such percentage of its total income from the provision of goods and services in connection with the prevention, diagnosis or treatment of illness as the Secretary of State shall direct; or
(b) such higher percentage as shall be determined by the Secretary of State for an individual NHS foundation trust.

This says that there will be a private patient income cap, and it will either be a universal cap or it will be set on an individual trust basis. This does not say what that proportion will be, so a Tory Secretary of State can set the cap to 50% to get the same effect as the HSCA. Allowing the Secretary of State to set individual caps is a sop to the rampant privatisers in trusts like Royal Marsden or GOSH who have built up their private businesses to be significant proportions of the trusts' income.

The phrasing of the clauses "for which charges are made by the trust" implies private patients, however, it still covers income, not the actual services or numbers of private patients.

Two Tier NHS

The main reason for restricting private patients is to prevent the creation of a two tier NHS, where NHS patients in an NHS hospital will get second rate services compared to private patients. The Efford Bill clauses do not address this issue.

There are two basic principles that need to be met to prevent the creation of a two tier system:

1. The treatment of private patients do not adversely affect the treatment of NHS patients
2. Private services must not be subsidised by the trust from NHS income.

The first principle says that NHS patients should not see the quality of their treatment deteriorates when the trust treats private patients. "Quality" is a broad term, and it could cover things like private patients not having to wait their turn at an outpatients clinic, so the NHS patients have to wait longer, or the re-scheduling of NHS patients treatment because a private patient has chosen to be treated at that time. However, I think the best metric is waiting times, indeed, I think that waiting times are so important that this is effectively a subclause to principle 1:

1. a) A trust will not be allowed to treat private patients in a speciality where it is not meeting the 18 week referral to treatment target for NHS patients.

The 18 week referral to treatment target (RTT) is a guarantee to NHS patients. A common cause for patients to pay for private treatment is that they are waiting too long. A trust that wants to have private patients (and there are many reasons why they will want this, other than income) there is an incentive to have long waiting lists, so NHS patients have to suffer so that the trust can increase the numbers of private patients.

The second principle says that a trust's private income must be calculated in a business like way, and that there should be no overt or covert subsidies. An example of overt subsidies are diagnostics. If a private patient has a MRI scan that patient should be charged a commercial rate for the scan, they should not be charged the NHS tariff rate which is typically lower than commercial rates.

Covert subsidies are more nuanced. For example, every NHS trust treats emergency patients and so have intensive care units (ICU) able to treat the most ill of patients. Private hospitals typically do not have ICUs, or if they have a unit it is a low level unit. This means that if something untoward happens the private hospital calls 999 and the patient suddenly becomes an NHS patient. Private patients in an NHS hospital have the reassurance that the skills and equipment to handle emergency patients are on site, and indeed, this is often a marketing point for the trust's private patient unit. However an ICU is not cost free, the unit is paid by emergency tariffs and capital charges are paid from the trust's general income. The unit exists for every patient treated by the trust since potentially every patient may need it, and hence the payment for every patient will include a contribution to pay for the ICU. Similarly, private patients should contribute to the funding of the facility, if they don't then that is a covert subsidy.

Amending the Efford Bill

The Efford Bill should have sections to address the principles given above. On an annual basis, an NHS Trust or Foundation Trust must meet the two principles. In the case of NHS Trusts there should be an annual declaration from the trust board that the two principles have been met. In the case of a Foundation Trust the trust's Council of Governors should provide this declaration. In both cases, the declaration will typically come from the trust's auditors who will have a duty to inspect the trust's private patient business.

Meeting the RTT target is so important that on a quarterly basis achievement the RTT target should be evaluated and if the target is not met the trust should only be allowed to treat private patients in the failing speciality following quarter if the trust can give credible assurances that it will meet the target in that quarter.

There are two more changes that should be made to the Efford Bill as described in the next section.

Reasons for Private Income

The usual reason given by trusts for treating private patients is that it provides extra income for the trust (hence why principle 2, above, is important). However, the income from private patients is rarely large (not every trust has a thriving private patient business like GOSH). Using private patients to subsidise NHS treatments has several issues, not least because few private patients like to be treated like a cash cow to subsidise NHS treatments. If NHS tariff is too small to cover the cost of the treatment the solution is to increase tariff, not to subsidise NHS treatments by other activity.

To address this issue the Efford Bill should have a section that says that NHS patients must be taxpayers funded. At the beginning of the bill is a section that says that NHS treatment should be free at the point of use (a version of this section has appeared in NHS Acts since the 1946 Act):

(4) The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

The mention of charges here refers to the co-pay that exists in the NHS: dental charges, prescription charges, charges for devices like wigs etc. While such charges are abhorrent it is unlikely that they will be removed. There should be an additional clause that says that notwithstanding the income from the charges mentioned in section 1(4) NHS treatments should be funded wholly by the taxpayer. This will remove the excuse that many trust's give that they have to have a private business to subsidise NHS patients. It also puts an onus on Monitor and NHS England, who set the NHS tariff, to ensure that tariff covers the costs of treatment.

The main reason for private patients is HR. Consultants are currently able to do private work even though they are contracted to an NHS organisation. Private patient units in NHS hospitals mean that the consultants do not have to go offsite to run their private business. In all other sectors of the economy this would be called moonlighting and would be disallowed. So to remove this incentive there is a need to change the consultant contract so that they can only work for the NHS organisation that they are contracted to. I doubt if such a change will ever happen, so an alternative would be to say that all income from private patients treated in an NHS organisation should be treated as income of the trust. This will ensure that the consultant is still an NHS consultant regardless of whether the patient is private or NHS. The intention of this rule will be to persuade consultants to treat their private patients in a private hospital, and hence prevent the creation of a two tier NHS.