Tuesday, 29 January 2013

Will HS2 be redundant?

I suppose I can't resist saying something about HS2. At least it shows that, if the government wishes, it can find funds for infrastructure investment.  A plan B is possible. The public consultation about the proposed route was a farce. No environmental impact assessment had been carried out. So answering the questions was a stab in the dark.

HS2, we are told, will 'transform journeys'. HS2 is forecast to carry up to 5.4 million passengers every year who might otherwise have travelled by air, as well as potentially seeing up to 9.8 million passengers transfer from the national road network. Those are big numbers. It might help cut the carbon footprint.

I am not at all sure where they get these estimates from. Well I do really. They use an econometric model to project the numbers of air passengers, The Unrestricted Error Correction Model is one of them.  It has an equation that has a lot of Qs and Zs in it and a few bits of Greek alphabet. And it has been quite an accurate model. So I'll accept their projection, although with some doubts about whether it sufficiently accounts for changes in work and lifestyle; the way we live, where we live and work.

More freight trains using the space freed up on the existing rail network will reduce lorry traffic on the motorways and help improve air quality. And it will provide opportunities for development on under-used brownfield sites. It will provide jobs in its construction and maintenance. That is the argument. But do we need it? And is it the best way to generate growth?

I don't know the answers, but what I do think is that it will probably suck the economic life out of the Midlands and the North. Cutting journey times will extend the London commuter belt. Northern towns will become domiciliary for London workers. It will push up house prices just as it did in the South Eastern commuter belt. And it probably won't generate or regenerate the areas of greatest deprivation.

The fact that they anticipate it will 'free up space' on existing lines is worrying. It suggests they anticipate reduced service for passengers on the existing commuter routes. So I would expect reduced and poorer services; more crowded trains not less. Many towns will not be served by HS2 and the existing services are likely to be starved of funds for  essential upgrade.

And what of technology and changing work practices. Will it really be necessary for people to continue working in offices in London? Will more work and meetings be 'virtual'?

Much is made of the fact that it will be the first major infrastructural project since the Victorians built the railways. The railways made the canals redundant. By the time HS2 is finished, will it really be needed?

And meanwhile HS2 will carve through the countryside destroying precious woodland. I don't know. What do you think?

Monday, 28 January 2013

Patients at risk from increased administration overload on front line NHS staff

Cuts in NHS budgets are exacerbating the bureaucratic burden on front line staff. This is the warning given by the NHS Confederation in a report published last week. The NHS Confederation, a body representing all organisations that commission and provide NHS services, is worried that the current NHS reforms, by making the system more complicated, will increase still further the administrative burden on NHS front line staff.

Government ministers have argued that the £20 billion cut in the NHS budget would not affect front line services. Yet, between May 2010 and September 2012 whilst the number of managers was reduced by 18 per cent and the number of clerical and administrative staff declined by 10 per cent,  a consequence has been an increased administrative load on doctors and nurses. If the administrative burden does not also fall, the report warns, there is a risk that front line staff will be diverted to form filling.

Reorganisation has compounded the problem. Commissioning is becoming more complex; for example, child health services are now commissioned by eight different parts of the system, including local authorities. Providers and commissioners will need to coordinate and build working relationships with more organisations than previously, which inevitably takes time and increases the administrative load. The number of commissioning organisations is also increasing; 211 clinical commissioning groups (CCGs) are set to replace 152 primary care trusts. There will also be a greater number of local bodies involved in providing health care, with health and wellbeing boards, local Healthwatch and more CCGs than there were primary care trusts.

There is already evidence that cuts in spending have driven some hospitals to dangerously low levels of staff, putting patient lives at risk. The Royal College of Nursing  has identified 61,276 NHS posts which have either disappeared or are set to go as a result of cuts in spending and warn that the NHS is "sleep walking into a crisis." Nurses say that they "do not have enough staff to deliver good quality care. Demand for services is continuing to rise, however staffing levels are being slashed."

 Dr Peter Carter, Chief Executive & General Secretary of the RCN, welcoming the Confederation report, said that nurses  “have been telling us for several years that they are forced to spend too much time filling in forms, ticking boxes and duplicating information."  An RCN survey in 2012 found that 53% of nurses said that clinical information systems were duplicating paper records.

It is time the government abandoned the pretence that cuts in NHS budgets can be managed without impacting patient care. It is putting patients at risk. 


Sunday, 27 January 2013

Mr Osborne knows best!

I sometimes wonder when I listen to discussion about 'the unemployed' and 'getting tough', or about 'strivers' and 'shirkers'  whether we appreciate fully the seismic impact of the financial crisis on British businesses and jobs. In the space of 12 months in 2008/09 a staggering 220,000 companies went out of business with the loss of 1 million jobs.  What is needed is investment and the creation of new jobs. What is not needed is cuts in spending. Cuts in spending further contract the economy and increase the deficit in public finances through loss of tax revenue. The way out of recession is to get people back to work productively, spending in the high street and paying taxes.

It all seems obvious. It isn't the equivalent of economics rocket science. Many have been saying it. The tragedy is the coalition and the political consensus signed up to the idea that the deficit had to be cut. The deficit was not the problem. It was if anything a symptom. Now we have chief economists at the IMF saying what we knew all along. Not only should there have been a plan B, there shouldn't have been a plan A. Plan A, a slash and burn of  public spending and services, is doing dreadful damage not only to economic recovery but to the people most affected, the poorest. 

But what is Mr Osborne's response to the Chief economist at the IMF calling for change in approach? He rejects it. "I don't think it is right to abandon a credible deficit plan," he says. He is concerned about losing credibility should the government now change course. Credibility? With the economy likely to move into triple dip recession there is no credibility. The only credibility is that of saving face; of not admitting that the coalition have got it so terribly wrong. So we are set to continue with policies that are clearly not working.


Saturday, 26 January 2013

Labour need to answer key questions on its new approach to the long-term unemployed.

Labour's attempt this month to sound tough on benefits for the long-term unemployed is worrying. They are adopting a carrot and stick approach. Britain,  Ed Balls says, "needs real welfare reform that is tough, fair and that works." It is sadly familiar language.

Labour says it will offer a "job guarantee" to the long term unemployed. Government will "ensure" there is a job for each adult who is long-term unemployed, and people will be obliged to take this job or risk losing their benefits. It sounds fair, a guaranteed job. But where would this job come from?

There are currently around 130,000 adults over the age of 25 who have been out of work for 24 months or more. According to official figures unemployment now stands at 7.7% of the work force.  But unemployment is unevenly distributed across the UK. In the worst affected areas such as Ladywood and Hodge Hill in Birmingham it is as high as 10 - 11.7 %.  Unemployment in Birmingham is greatest in the inner city areas. In one ward it stands at almost 30%. Finding jobs in these areas is particularly difficult.

The West Midlands has one of the highest economic inactivity rates in England. In February last year West Midlands business leaders urged the Government to promote a “culture of entrepreneurism” and to encourage banks to lend to industry – and warned they could not create jobs without state support.

Last year Channel 4 News uncovered data showing that the 'welfare to work' company A4e had been able to secure sustainable employment for only 3.5% of job seekers under the government's work programme. This flag-ship programme clearly isn't working. In November, Jonty Olliff-Cooper, director of policy and strategy at A4E, blamed the coalition for the failure of the company to meet targets suggesting that there "isn't enough money to tackle long-term unemployment."

There are no easy or quick fixes to finding work for the long term jobless. It requires sustainable investment to create real jobs and it requires the development of skills to match them.  It needs jobs created in areas of need. 

Joblessness is complex. There is no simple solution to matching job opportunities with required skills and to locate businesses in areas of high unemployment.  A family cannot move simply to regions of higher employment. Costs of housing and child care and moving away from family support are all barriers. Unemployment and poor job opportunities are economically structural rather than behavioural. Building real jobs needs investment, but banks are still failing to lend to start up businesses or to provide businesses with the funds they need to grow. 

Labour's guarantee of a job is great but it might be more difficult to achieve than the headline suggests. Building real jobs will take time and investment. And there is one nagging question Labour needs to answer about its new 'tough'  approach. What happens to those who fail to get a job? 

According to the new policy their benefits will be cut. But then what? Is Ed Balls willing to watch as they lose their homes and their children fall deeper into poverty? Labour's carrot and stick approach begs more questions than it answers.

Postscript

I sometimes wonder when I listen to discussion about 'the unemployed' and 'getting tough', or about 'strivers' and 'shirkers'  whether we appreciate fully the seismic impact of the financial crisis on British businesses and jobs. In the space of 12 months in 2008/09 a staggering 220,000 companies went out of business with the loss of 1 million jobs.  What is needed is investment and the creation of new jobs. What is not needed is cuts in spending that will further contract the economy and increase the deficit in public finances through loss of tax revenue. The way out of recession is to get people back to work productively, spending in the high street and paying taxes. 


Wednesday, 23 January 2013

The political convenience of blaming the poor


The government talks of 'fairness' in distribution of benefits.  But what is fair? During the boom years the poor got poorer, the middle class got richer. The biggest beneficiaries of government largesse have been the middle classes, not the poorest.

Over the last decade, the relief on income tax and National Insurance Contributions totalled a staggering £358.6 billion. The middle classes benefited from tax exemption through personal equity plans and ISAs in which they were able to accumulate savings with tax free interest. The huge expansion of higher education from the 1960s onwards created educational opportunities for their children on an unprecedented scale, whilst the opportunities for the poorest were restricted. University education remains to this day largely a middle class preserve.

The middle classes benefited from child allowances and expansion of nursery school provision. Until it was abolished by Gordon Brown in 2000, the middle classes benefited from mortgage tax relief. Gordon Brown referred to it as the 'middle class perk'. The largesse and opportunities distributed to the middle classes have been substantial.

So when we talk of fairness, let's have a reasonable assessment. Fairness doesn't mean pushing the poor deeper into poverty. The middle class have been the greater dependants on state handouts not the poor. It is unfair now to make the poorest suffer the most. Unfair, but politically expedient. The rhetoric of 'welfare dependency', of 'strivers' and 'shirkers' is aimed largely at the the C2s, the skilled manual workers who abandoned Labour and voted Conservative at the last election.

It is politically convenient to blame public spending and to blame those receiving welfare benefits. Savage cuts in welfare spending hit the poorest most, and middle Britain the least.  The political map requires it. The confluence of the maps of poverty and the political map is no coincidence (see figure). It is politics at its most cynical.

Distribution of poverty in England (left) and the distribution of seats won by conservatives (blue), Labour (red) and LidDems (yellow) at the  2010 general election  (right)
The economic policy of the coalition government is based on a lie, the premise that the financial crisis was due to profligate spending by the Labour government. Yet we know the truth.  Unsustainable consumption by the middle classes, fuelled by corrupt and inept practices by the banks, created the financial crisis. The failure of previous governments is that they did not see this; they failed to regulate the banks, they stoked up the politically convenient 'live now, pay later' approach of the middle classes.

The middle classes are to blame; and for that the poor are expected to pay a disproportionate price. The fallacy, the downright lie, that public spending is responsible is not only absurd, it also fails to address the real causes of the financial crisis; the fundamentals are not addressed, the poor, the sick and the disabled are made to suffer the most, and yet Osborne and company are seeking to restore the status quo, another unsustainable boom.

They grind away at an engine that is broken. Its cam belt snapped and all cylinders that drove the economy were irretrievably damaged, but Osborne insists on restoring it, and it trundles along on one cylinder, pop, pop, pop. And each spark and bang, each whistle and grunt, is hailed as a sign of economic recovery. The Bank of England pumps more money in; Osborne sucks it back out. He can't balance the books because revenue falls. It is the economics of hope rather than reality.

And so we see another absurdity. At best, the economy trundles along; at worst in a triple dip recession. Yet the government insists on taking more money out by swingeing cuts in spending. Benefits are cut, libraries close, the NHS collapses, local services are squeezed, more people are driven into poverty. It really is remarkably short sighted.

The government it seems is more worried about credit ratings; the ratings of organisations whose credibility must surely be in question. They are mesmerised by the very organisations who were responsible for creating the mess. If we don't do as they suggest, we will lose our credit rating, be downgraded, as if this was a terminal sickness. Most of us had never heard of these ratings organisations, now our government would rather follow their dictate rather than listen to the people they represent. Creating  a shibboleth out of credit rating is an absurd way to run the economy.

I am reminded of the futility of Wilson and Callaghan back in the early 1960s desperately propping up the value of sterling, only to ignominiously admit defeat.  It was all a matter of confidence they said. In the end, devaluation set us on the road to recovery.



Monday, 21 January 2013

Mr Duncan Smith is wrong on poverty

In 2011 the Secretary of State for Work and Pensions, Mr Ian Duncan Smith set out a 'new approach to child poverty'. At its heart he says are the principles of "work, fairness, responsibility and support for the most vulnerable". It is set to fail;  and the reason it is set to fail is because the underlying assumptions are wrong.

At its heart is the idea that the cause of poverty is that people don't work. It adopts a carrot and stick approach based on the notion of "welfare dependency". It sets out to "reward those who work". The flip side of the policy is to punish those who do not. It seeks to drive feckless people into work by cutting their benefits. The poor are to be blamed for their poverty.

It adopts a Victorian approach with the assumption that poverty is to do with behaviour. If only the poor would adopt different lifestyles, the idea runs, then they could 'help themselves out of poverty'. It raises the image of drug and alcohol abuse, poor parenting, and a host of other stereotypic assumptions about the poor.

It is politically convenient because it sets out to divide the poor into the virtuous and the sinful. But it is on the whole wrong. And because it is wrong it will drive more families into poverty. It will systematically withdraw benefits from those who need them including the majority of poor working families.

Mr Duncan Smith's policies are based he says on "the belief that work, not welfare, is the best route out of poverty for those who are able to work." To make his point he chooses to emphasise those families where 'no one works' which the Department of Work and Pensions (DWP) estimate is about 1/6. But this is a very simplistic assumption; at best it is only one part of the anatomy of UK poverty.  His approach to poverty is based on a stereotype; on a minority rather than on the substantive causes of poverty. As a result it stigmatises the poor as architects of their own condition.

The Universal Credit, he says, will support those who "do the right thing", who "take a full time job." The language is clear. It seeks to divide those who are 'virtuous' and 'do the right thing' and those who are 'sinful'. So why is this wrong?

The idea that poverty arises from fecklessness, drug or alcohol dependency, or is the fault of the poor themselves from poor lifestyle choices is cruel and unsustainable. According to statistics from the DWP there are 3.6 million children living in poverty in UK today. That is 27% of all children. This is now set to rise as a result of the government's policies by at least a further 300,000 in the next few years. But these are not the children of the work-shy. They are not the children of parents who have been 'doing the wrong thing'. At least 62% of these children are in working families. Mr Ian Duncan Smith's first assumption is wrong.

It is wrong because the root cause of poverty is low pay coupled with poor work opportunities. And much of this stems from the cycle of poverty; poverty increases morbidity which reduces productive capacity, educational attainment and opportunities for work. But geography also plays a major part. Poverty is multifaceted and cannot be simply solved by cutting benefits. Cutting benefits simply drives more people into poverty.

But it is wrong for another reason. It is based on the assumption that cutting benefits will drive those who are unemployed into work. But it can only do this if there is work available and they have appropriate skills.

The geography of poverty reveals a different story.  Poverty is unevenly distributed; it is clustered.  In the most deprived areas it is as high as 70% of the local population (see figure modified from The Guardian Data Blog).

Poverty clusters in England
click to enlarge
Analysis by the ONS demonstrates a clear mismatch between availability of jobs and the most deprived areas.  Private sector employment is clustered in a few key areas, such as the south east of England. The north of England, the Midlands and Wales, show low private sector job densities and poorer job prospects. Adopting policies blind to this mismatch is reckless.

The sobering fact is there are far fewer real jobs available in those areas most blighted by poverty. By emphasising 'welfare dependency' it makes a wrong assumption. Welfare dependency doesn't come from people not wanting to work, but from the absence of job opportunities and from low pay.

The real cause of poverty is low income. It is true that 42% of all families below the UK poverty line have no working member. Unemployment is clearly a factor. But there is no simple solution to matching job opportunities with skills and geography. Joblessness is complex. A family cannot move simply to regions of higher employment. Costs of housing and child care and moving away from family support are all barriers. Unemployment and poor job opportunities are economically structural rather than behavioural. Any policies that tackle poverty must also tackle the economic realities behind it.

Simply cutting benefits and 'driving people' into work to 'make them better people', to use Mr Duncan Smith's words, is not a recipe for success. We need real economic policies aimed at growth and renewal of the most deprived areas, the areas hit most by the recession, and we need strategic policies to tackle low pay and skills.



Sunday, 20 January 2013

The poor get poorer and the rich get richer but let's blame the poor.

There are some no doubt who won't really care about the poor in the UK until they are homeless in the streets with bloated starvation bellies. I guess it will wait for a 'live aid' concert by rich pop stars with crass lyrics to tell the world that the poor in the UK need feeding. Since writing my piece on the cuts in benefits driving 200,000 more children into poverty, at least a few have questioned me about 'what real poverty means'. It is the 'yes but' kind of argument. Poverty they say is 'relative'. No it is absolute. It is absolute because of its effects on inequality and opportunity.

Poverty, particularly in childhood, produces a cycle of poor health and lack of opportunities to break out of the chain. Poor health blights a generation through poor educational attainment and poor job prospects. Poverty, bad housing and undernourishment create a cycle of poverty handed on across generations. The cost of the coalition's policies is difficult to calculate, but over time with increasing burdens of poor productivity and of ill-health and the consequent impact on health and social services, the cost in terms of resources will be immense. It is a foolish and short-sighted approach. But it is also cruel. It blights the lives of a generation and more.

The truth is the politicians won't touch the middle class. That is where the votes really count. For decades now, politically the poorest have been ignored; an underclass economically, without effective political representation. If only we could distribute them to some key marginal constituencies then perhaps they might have a voice. Yet the real beneficiaries of 'welfare dependency' have been those of the middle classes. 

Those of the middle class have been the ones who through concession after concession have built up equity in their homes, benefited from the enormous expansion in higher education for their kids. The flip side of the cycle of poverty is the cycle of wealth. Wealth produces greater health and well being, better housing, better education and attainment, better job prospects and more wealth and greater political influence. And meanwhile the poor get poorer. And inequalities in health and well-being grow ever larger. 

It is no coincidence that the Liberal Democrats cynically promised not to raise university tuition fees.  There were votes in it. The greatest beneficiaries of low and no fees have been the middle classes. Yet we are told the poor are 'trapped in welfare dependency'! No, they are trapped in poverty and inequality. It is the middle class who are trapped in dependency. 

But what of the poor? What we tend to do with the poor is blame them, or at best to blame their 'lifestyle'. It is as if the poor are poor because of their behaviour. Rather than address the real issue of poverty, inadequate income and opportunities, we address their behaviour and lifestyle as if by exalting them to behave differently they can miraculously break free from the cycle of poverty and poor health; it is all extraordinarily Victorian in approach. 

Yet public health policies have been so directed without the slightest evidence that they are effective. The truth is, as a study set up by NICE concluded in 2007,  "interventions designed to change behaviour rarely alleviate inequalities in health, and in some cases may exacerbate them." And in the process they may stigmatise the poor for 'bad' lifestyle and perpetuate a myth that it is 'lifestyle' rather than inequality that keeps them in poor health.

Inequality kills, but it is the poor who get the blame. As if they had the means to solve their poverty; if only they would do this or that and 'help themselves'; the poorest who had no hand in the financial mess created by the greed of the middle class and the bankers for whom there was no tomorrow taking their fat bonuses. Yet, the poorest are asked to carry the greatest burden of cuts. We mortgaged our tomorrow and now it is the poorest who will suffer the most. It is cruel and unfair. It is unjust. It is a disgrace. 


Friday, 18 January 2013

An incredulously stupid approach to child poverty

The government now acknowledges that its squeeze on tax credits and child benefits will push 200,000 more children into poverty. Ministers argue that it is no longer a valid measure of the impact of their policies.

But child poverty matters; it matters a great deal because it represents a crucial link in the chain of poverty and ill-health. The impact of child poverty is transgenerational. The problems of poor health are likely to affect the next generation too. The health costs to the nation will far outweigh the relatively paltry savings made now by cutting benefits. Yet the impact of the cuts is immense.
Standardized Mortality Ratio
 data from bmj; 1993; 307;1519-24

A simple measure of the likely effect of child poverty is to consider the impact of undernourishment during development and early childhood on the risk of cardiovascular diseases in later life.

One such measure is represented in the standard mortality ratio of adults born small and undernourished compared to those born well nourished (see figure). Those born small (<5.5 pounds) and undernourished are twice as likely to suffer from diseases such as diabetes and to die early from cardiovascular disease. It debilitates and shortens productive life.

This is one of the reasons why tackling child poverty is such a critical strategy. It can break the cycle of poverty and disease. Poor health blights a generation through poor educational attainment and poor job prospects. Poverty, bad housing and undernourishment create a cycle of poverty handed on across generations. The cost of the governments policies is difficult to calculate but over time with increasing burdens of poor productivity and burdens of ill-health and its impact on NHS resources will be immense. It is a foolish policy. It blights more than a generation.

It is unfair that the poorest should once again be made to suffer for a financial crisis that was not of their making. It is incredulous that we should make children suffer for it. But that is what the government's polices are doing. It is foolishly short-sighted. It is also cruel.



Read Ray'a Novel: It wasn't always late summer 

Thursday, 17 January 2013

The merits of Prince Charles' approach to health and wellbeing

Prince Charles has been at it again. This time he has written an article published in the current Journal of the Royal Society of Medicine (JRSM) in which he advocates an "integrated approach to medicine and health."

Prince Charles defines an 'integrated approach' as being "an approach to care of the patient which includes mind, body and spirit and which maximizes the potential of conventional, lifestyle and complementary approaches in the process of healing."

Whilst I might disagree with him on some of the detail, and we certainly wouldn't agree on some alternative medicines such as homoeopathy, nevertheless I am in complete agreement with the core thrust of his argument.

A distinguishing feature of modern medicine is that it is 'evidence based'. This is as it should be. Patient trust requires that medical practise and treatments are based on knowledge and some kind of fundamental and tested principles. But for too long medical science has been driven by a reductionist approach.  It has tended to view the human body as an aggregate of mechanisms rather than an integrative process, and whilst this reductionism has sought answers and causality at the molecular level, medicine has tended to follow suit. Researchers working in the minutiae of their disciplines rarely cross boundaries, and increasingly they seek answers at the level of the gene.

And the word 'level' is a problem too because it expresses an idea of layered causality. The top layers are 'caused' by activity in the layer below them; a layered hierarchy where the 'ultimate' cause of what happens at the 'top' layer is to be found at the bottom layer. It is a 'bottom up' approach; genes, cells, tissues, organs and organ systems, and the final layer, the body.

It expresses itself in medicine too. In medicine we tend to look for cause and effect in clearly layered terms. Many effects we regard as 'symptoms'. Better to treat the cause rather than the symptoms, although it is often symptoms which not only cause discomfort but can also be lethal. It is as if there is an 'ultimate' cause, a 'faulty gene'. If we find that then we can treat it with targeted drugs.  Indeed some suggest that this will be the ultimate revolution in developing new treatments. The human genome project is based on just this idea of layered, hierarchical and 'bottom up' gene-centred causality. But not only has the gene centred view influenced biology and biomedicine; it has also influenced social sciences, society and politics.

Modern politics tends to view society as, at best, an aggregate of self-motivated or self-interested individuals. It reached its peak in Mrs Thatcher as prime minister musing that there was 'no such thing as society'. It rather misses the point; and it misses the point precisely because it doesn't look for it. The gene-centred view rather sees humans, and any other organism, as vehicles at the behest of genes; a view advocated by Richard Dawkins in his The Selfish Gene.

This view has been beautifully turned on its head by the distinguished biomedical scientist Denis Noble in his book The Music of Life;  and the 'central dogma' has been challenged in a recent lecture, 'Rocking the foundations of biology',  which can be viewed on Voices from Oxford. Denis Noble is no off the rails scientist. He is president of the International Union of Physiological Sciences and distinguished in his field of modelling how the heart works.

What Prince Charles advocates is patient-centred healing. We have indeed often lost sight of the process of healing and the personal aspects that can enhance it. This is not to dismiss the pharmacology but to consider what process within and without the body  make such treatments work better. Prince Charles puts it thus:

"One senior professional said to me that what seems to go missing all too easily is the art of thoroughly understanding the patient's narrative. He said that we need to equip our health professionals with skills (and a desire) to listen and honour what is being said, and – importantly – what is not said to them."

I doubt many medical professionals would disagree. The problem is finding the resources and time. Modern medicine shouldn't be about simply finding magic bullets. We would be very disappointed. They are very rare.  We need a different set of research questions and new goals, and one that considers how our social and environmental being affects our body, heart and mind. We need each other and we need to understand why and how.

Developmental science is teaching us that many manifestations of disease in later life have origins in the nutritional environment particularly during development. Health, well-being and equality matter in determining the epidemiology of disease. Inequality is a broader cause of disease than any 'faulty gene'. 

Holistic, yes; but it isn't mad.


Wednesday, 16 January 2013

NHS and nursing staff under pressure as staff shortages impact on patient care and safety


There is growing concern that the NHS might be at a tipping point, with top down reorganisation and massive cuts to budgets. In a previous article  I argued why it is disingenuous for the government to claim that £20bn cut in the NHS budget could be made without affecting front line staff, doctors, nurses and vital technical support. The claim that 'streamlining' efficiency savings could be made without cuts in front line staff is wrong. The government knows this of course. But it doesn't stop them repeating the falsehood.

There is increasing evidence that cuts are affecting patient safety. According to rulings by the official safety watchdog, The Quality Care Commission, 17 hospital trusts have dangerously low numbers of nurses.

The Royal College of Nursing has identified 61,276 NHS posts which have either disappeared or are set to go as a result of cuts in spending and warn that the NHS is "sleep walking into a crisis." Nurses say that they "do not have enough staff to deliver good quality care. Demand for services is continuing to rise, however staffing levels are being slashed." But there are other worrying signs.

Last year, the Nursing and Midwifery Council (NMC), the governing body for over  670,000 registered nurses and midwives, reported that there has been an unprecedented  increase in the numbers of nurses referred for conduct and fitness to practise investigations. In 2011-2012 there were 4,407 referrals compared with just under 3,000 in 2009-2010. That is a whopping increase of 48%.  Something has changed and currently we can only speculate on what that change might be. But there is one big question, and that is whether this increase represents a change in the culture of referral or whether it reflects a change in the working conditions of nurses.

Also last year another report was published, the NHS staff survey for 2011 which revealed some equally startling figures. Whilst the majority (87%) of nursing staff feel satisfied with the quality of care they provide to patients, only 67% reported being able to do their job to a standard they are personally pleased with. Critically, only 30% said there are enough staff in their hospital for them to do their job properly. Essentially nursing staff are 'overworked' and are having to deal with greater stress caused by staff shortages. It is inevitable that this will impact on patient safety.

Tuesday, 15 January 2013

And the PIPs will squeak! Groundhog day for personal independence payments.

Here we go again. Groundhog day. From April  new rules are to be set for qualification for disability allowance or personal independence payments (PIPs) as they are to become in April. The new assessment according to the Department for Work and Pensions (DWP) "will focus on an individual’s ability to carry out a range of key activities necessary to everyday life." Information will be gathered from the individual, as well as healthcare and other professionals who work with and support them. Most people will also be asked to a face to face consultation with a trained independent assessor as part of the claim process.  From the experience of the Work Capability Assessment, it looks like another recipe for pain and suffering. 

I often wonder who it is that draws up disability or capacity criteria. What kind of person is it that decides if you can go up two steps without being in pain you are 'fit'? What about the third and fourth or subsequent steps? Of course I do like being optimistic; positive thinking is better than negative. "What can you do?" seems a reasonable question to most people. But it isn't; or at least it isn't in isolation. And here is the problem with the parametrics of disability.

 Disability isn't simply an aggregate of each individual parametric; they interact in often unpredictable ways. They have qualitative as well as quantitative features, and often whilst the latter are easier to 'measure' the former is sometimes what makes any problem disabling. It is how it affects the person.

The problem with what can be measured is that it tends to squeeze out the subjective. "We'll measure this because we can" becomes an underlying principle. Furthermore it appears to be objective.  It is they say 'fair' because it is objective, a yardstick applied to everyone, consistently. Everyone will be 'treated the same'. It sounds fair, but it isn't. Treating people 'the same' isn't at all fair. We are different. People are affected differently depending on circumstance and how any given parameter impacts on their lives. The subjective makes a difference.

The criteria for the 'descriptors' to be used were established after a period of consultation.  Yet, those criteria are already being changed. For example, it has now been decided that those unable to walk greater than 20m will qualify, which has shaved a full 30 m off the previous qualification. I guess that is in the Olympic spirit. We are all for breaking records. But 30 m difference suggest something fishy is going on. it will clearly have a major impact on the numbers qualifying.

Government ministers say it will target those who need it the most. Which is all very well but what about those who simply need it, not 'the most' but do really need it? Those for example who whilst they can walk 20 m would nonetheless be severely unwell if the walked say 30 m?

 Disability is not something that can be measured by a simple yardstick. It is usually multifaceted and affects people in different ways. Circumstances matter. The DWP specifically rules out using 'key factors' such as pain, nausea, breathlessness, motivation, in assessing the 'descriptors'. Most healthcare professionals would be appalled at such an egregious folly.

By including lists of symptoms the DWP says "we might unintentionally narrow the scope of the assessment."  Unintentionally? By leaving them out it intentionally narrows it. They are not only an essential ingredient,  but most often  they are also the critical factors that physically and mentally limit capability. They are of course difficult to measure; how much pain, what type of pain, where is the pain and how it affects function would need to be assessed. But, however difficult they should not be ignored. It would not be ethical to ignore them. Difficulty is not an excuse for poor judgement.

The government are as usual being disingenuous with estimated uptake. The DWP says that 'broadly' the same number of people will receive the benefit. This is an odd calculation when they expect to save a staggering £2bn.  Either those receiving the help will get less or far fewer people will qualify.  Broadly takes a lot of defining. The government can't have it both ways.

Monday, 14 January 2013

In the footsteps of William Harvey


William Harvey 1578-1657
Often our ‘gut instinct’ is to take a particular course of action but our ‘rational mind says no’, and often in hindsight we wish we had followed our ‘gut instinct’.  The heart figures prominently in our cultural expression of emotions. It is in our poetry and our literature. But is there a physiological explanation for this? Can the heart once again be centre-stage of our feelings? Do we really have ‘gut’ instincts? In a three-part series of videos by Voices from Oxford, Professor David Paterson, Associate Head of Medical Sciences at Oxford University, explores with Denis Noble a paradigm shift in the way we think about our heart and brain and the intimate neural connections between the two.

 Appropriately the filming is at Merton College where, as a result of the 17th Century English Civil War, William Harvey was briefly Warden. Harvey revolutionised our understanding of how the body works by describing the role of the heart as a pump, a mechanical device for circulating the blood round the body. His seminal work contributed over centuries to a “decoupling” of brain and heart, and of the heart from our concept of mind.   But as David Paterson explains the heart is “physically hard-wired by the nervous system”. It has a nervous network involved in its excitability.  The heart and brain are not “isolated islands”.
 
Understanding what these connections between brain and heart do is one of the big challenges for the 21st Century. Reductionism has driven science historically. We have “been very good at breaking things down” into organs, cells, molecules, but “the challenge now is to bring those parts back together, to reassemble them.” The potential for interdisciplinary work is “one of Oxford’s greatest strengths” but it is still “poorly tapped”. It is a challenge, Professor Paterson says Oxford University is well placed to address with opportunities for multidisciplinary interaction between sciences and the humanities and also with international collaboration.

This article also appeared on Voices from Oxford

In the footsteps of William Harvey

Ray Noble is News Editor of Voices from Oxford

 

Are PFI hospitals value for money?

The news last summer that some hospitals were having difficulty meeting their financial obligations under their PFI arrangements led to speculation that hospital Trusts would fall into receivership like a row of dominoes. I have not been enthusiastic about the use of PFI in the NHS. I am, however, sceptical of some of the scary stories about how much they are costing and how big a problem they are. It is easy enough to take a few cases where there are problems, and there are some, and create a myth that they are inherent and endemic. Where there are problems, they are usually specific to those Trusts.

The left have always been sceptical about PFI if only because of the Private bit of the 'initiative'. It is regarded a bit like unsafe sex; unprotected, it could lead to unwanted consequences. A key question is not whether the scary stories are true but whether they are typical and what the  explanation for them might be.

Information collated by the National Audit Office indicates that most PFI contracts are performing either satisfactorily or better than satisfactory, and they have been meeting the expectations of the Trusts. Indeed, there is strong evidence that for the most part contracts have been delivering value for money, and  67% of Trusts have reported consistent and improved performance over time. Nevertheless, it is also clear that this is not true for all PFI arrangements. Nor have we seen the full impact of the cuts in NHS funding on the ability of Trusts to meet their PFI obligations. How you interpret this depends on whether you see the glass as half full or half empty.

The glass is certainly not half empty. Although 33% of Trusts have been dissatisfied with at least one service provided under their PFI contracts, this does not mean the PFI is not working well overall. Usually problems are corrected. Another key indicator is how they are working compared to non PFI hospitals, and here the NAO finds a mixed bag. Nevertheless, on the whole, costs and performance are similar to services in non-PFI hospitals. Cleaning, laundry and portering costs are about the same; catering is on average slightly cheaper in PFI hospitals.

I have no problem with the idea behind PFIs as long as service delivery can be assured and something can be done if expectations are not met.  PFI arrangements funded the build of 100 new hospitals  between 1997 and 2010. Many of the old hospitals they replaced, with shortage of space and built for a different age, were unable to develop services with state of the art technology,  and they were unable to adapt to the changing needs of patients. Furthermore the buildings were becoming expensive to maintain. Without the new hospitals the NHS would now have been in a very sorry state. New hospitals were needed. What was at issue was not whether they were needed but how they could be financed.

When considering the costs of PFI, rarely do the critics undertake a proper cost analysis.  They would need to demonstrate, not only that the hospitals could have been built and the services provided at a lower cost, but also how it would have been financed and what the cost of that financing would have been. Only then can we understand the relative costs of the PFI arrangements.

What we do know is that the capital value of the PFI  hospitals is estimated at £6bn and the annual spend on the contracts is £890m. PFI annual charge payments represent between 0.4 and 18.3 per cent of a Trust’s annual operating costs with a mean of 5.8 per cent.  For some Trusts that is a large fixed cost. Before the banking crisis, most PFI Trusts ran surpluses. The problem for those Trusts now in deficit is that these fixed costs cannot easily be reduced. With fixed contractual arrangements it is not easy to find savings in the services the PFI contract provides. The NHS is expected to find savings of £20bn by 2015 and this fixed cost is likely to be a reason why it is difficult for  some Trusts to find savings other than through cuts in front-line services. Again whether you blame the PFI arrangements or the cuts in funding depends on your perspective.

Nevertheless it is worth considering the costs of PFI hospitals in the light of other proposed capital projects. It is estimated that the cost of the full High Speed 2 rail link, linking the Channel Tunnel with Birmingham and the North, would be around £32.5bn. The cost of replacing Trident nuclear weapons capability has been estimated at £34bn. At the end of the day, it depends on political priorities and choices.




Sunday, 13 January 2013

That was the week

I started the week by considering how the wrong message had been taken from the Olympics and Paralympics. In 'If we invest in people we can win' I argued that medals had been won because support was given to the particular sports and to the individuals. If you invest in people you can produce winners. Hard work alone wasn't the key to success.

Contrary to the portrayal by Mr Cameron and his colleagues, the majority of those receiving welfare benefits are hard working and dedicated, day in and day out. But, for the poorest of them, he is cutting their support. They are winners and yet he is taking away from them the support they need to go on being winners; bread winners for their families. It really is a very cynical move by the government. They are making the poor pay the most for the mess the bankers got us into. I suspect  from their divisive rhetoric, Mr Duncan Smith offers a disingenuous and divisive comparison,  the assumption is that protecting middle income groups will win votes. They probably gave up long ago on attracting votes from the poorest. 

Privatisation in the National Health Service is gathering pace with fears of increasing fragmentation of service provision. More than 100 private firms will be commissioned by the NHS to provide basic services including physiotherapy, dermatology, hearing aids, MRI scanning, and psychological therapy. In 'Ideologically driven reform will undermine the NHS' I argued that this would make it easier to scale down provision by the NHS itself and would open the way for charging for these key services.

As with winter fuel allowances and bus passes for the elderly it will be argued that providing these services free for everyone regardless of wealth would be unfair, thus paving the way for the breech of the fundamental principle of the NHS that health care should be free at the point of delivery. A wedge will be driven deep into the heart of the NHS and the service will be cracked open. Consumer choice will become the principle guiding commissioning and delivery. It will all seem fair to those who can afford it. Once broken the NHS will be difficult to rebuild. It took decades of public funding and commitment to create; it might take just a few years to destroy. 

The impact of £20bn of cuts from the NHS budget was considered in two further articles challenging the assumption that cuts could be made without affecting front line services. In 'Don't believe it when they say front line services won't be cut' and 'NHS sleepwalking to a disaster' I questioned the assumption that the NHS and other services such as the police and social work had too many managers. All are affected by big cuts, and in all cases it is affecting the front line service. 


Saturday, 12 January 2013

Bias and spin in reporting trials of new drugs for breast cancer

A paper published this week in the Annals of Oncology has demonstrated bias in the reporting of  outcome and toxicity of phase 3 randomized controlled trials (RTCs) for breast cancer. These trials are the final stage of testing of the efficacy and toxicity of a new drug or treatment before approval by regulatory agencies.

Papers published in scientific and medical journals have an abstract, a summary of the findings, and it is in this that the results are often presented in a biased way. Of the reports of 164 trials they reviewed, 33% of them showed bias in the reporting of the primary end point (PE) and as many as 67% in reporting the toxicity. Bias in reporting of outcome is common for studies with negative PEs.  Reporting of toxicity is poor, especially for the studies with positive PEs. It isn't that the authors don't give the correct result in the body of the report. The problem is that they put a 'spin' on them.    It is shocking but perhaps the finding is not surprising.

It is often argued that science is 'ethically neutral'. I have never subscribed to such a view. There isn't an ideal position of neutrality;somewhere from which we can see things free from assumptions or even prejudice. There is always a view from somewhere; a perspective that influences the way in which we see or interpret apparently objective data. In short there isn't a view from nowhere.

Science tests ideas, usually by first framing them into clearly testable hypotheses. What this tells us is that science is a human activity, it isn't a body of knowledge existing in some rarefied library. As soon as we touch it we frame it. We bring it into our world view.  It is also the case that science rarely if ever produces definitive answers. For all studies there are caveats; it might be difficult to control or account for all possible variables. This always provides leeway in interpretation of results and it is here that bias and spin are often in play.

Emphasising the positive over the negative in results is a judgement. In the case of Phase 3 human trials such judgement can have significantly harmful consequences. Ethical science isn't simply a matter of 'getting the right result' or the 'result right'. Ethical science should always be alert to its vulnerabilities. It has motive, it involves perspective and decision. Where there are choices there must always be ethical consideration. Scientists should consider the consequences of any bias they may introduce into their reports.

Friday, 11 January 2013

NHS 'sleepwalking to a disaster'

In a previous article this week I argued why it is disingenuous for the government to claim that £20bn cut in the NHS budget could be made without affecting front line staff, doctors, nurses and vital technical support.  The claim  that 'streamlining' efficiency savings could be made without cuts in front line staff is wrong. The government knows this of course. But it doesn't stop them repeating the falsehood.

The Royal College of Nursing  has identified 61,276 NHS posts which have either disappeared or are set to go as a result of cuts in spending and warn that the NHS is "sleep walking into a crisis." Nurses say that they "do not have enough staff to deliver good quality care. Demand for services is continuing to rise, however staffing levels are being slashed."  

Looking around the country and the reality is revealed. At the Royal Bolton Hospital 500 jobs are to be cut with further savings being considered by changing the contracts of 1685 nursing, midwifery and support staff.  In April last year the University of Leicester Hospital announced cuts equivalent to the loss of 271 full time posts.  Up and down the breadth of the country hospitals are announcing savings leading to staff redundancies.  Cuts are being made to clerical workers and other support staff as well as front line staff. But this is not without its impact on patients and patient services. In one case in North London elderly patients are being asked to check themselves in for appointments.  

The NHS is a huge organisation that employs around 1,180,000 staff. During the previous Labour government NHS funding increased in real terms by around 7% each year, particularly since the prime minister Tony Blair had set the target of reaching the European average as a percentage of GDP. By 2010 many of the targets set by the Labour government had been met and significant progress was being made in others. Health inequality stubbornly refused to budge.

The numbers of doctors increased from 88,693 in 1999 to 132,683 by 2009 (an increase of 49.6%). The number of fully qualified nurses increased from 261,340 to 336,007  (+28.6%) over the same period; scientific, therapeutic and technical staff increased from 86,837 to 128,331 (47.8%). Clinical support staff increased by 32.9%. But managers and senior managers increased from 23,378 to 42,509 (82%).

This percentage increase in managerial staff  is large. Nonetheless the percentage of staff who are categorized as managerial  (3-4%) may not be inappropriate. Indeed even TheTaxpayers Alliance accept that this is lower than some private companies.  The requirement for management and support staff is not proportional if new services are being developed in new buildings. What you cannot do is streamline management by simply cutting the budget. Whilst efficiency savings might be made over time, the immediate impact of savage cuts is on the ability to deliver front-line services, and sometimes with the absurdity of elderly patients having to check themselves in for care. It is just as likely that units would have to close down for lack of resources.

It isn't easy to compare the structure of the NHS with any other type of corporation. The scale and diversity of services is a problem; the collection of information, its storage and accessibility about patients made daily creates a burden few companies would manage. The term manager covers a variety of grades including 'team leader'. A team leader may also be a member of front line staff in say portering. There is not always a clear distinction between front and back line staff. We could say that front line is doctors and nurses but this would ignore the support the front line requires. When a doctor takes a sample it is sent to a laboratory for analysis; when a doctor or nurse processes a patient's notes these then get processed, stored and retrieved.

Developments in modern medicine are founded on laboratories and advanced technical services.  Preimplantation genetic diagnosis and IVF, for example,  require scientific and technical staff in the running and the development of the services provided. The laboratories are housed in buildings that have to be managed, they require supplies of reagents and laboratory equipment that has to be ordered and processed. They have administrative work that needs support. All this requires some kind of management. It isn't easy to pick a figure of management that is appropriate. But services such as PGD were in their infancy just a decade ago. Now they form a key part of diagnostics and reproductive choices for patients.

Demographic change means that the NHS has to be continually changing to meet shifting needs. But the NHS had been doing well. Yes it has had its share of scandals and poor service. But on the whole it has been a remarkable success story. Now it is under threat as never before faced with fragmentation, creeping privatisation of services, and cuts. The Royal College of Nursing are right. We are sleep walking to a disaster.

Postscript

According to rulings by the official safety watchdog, The Quality Care Commission, 17 hospital trusts have dangerously low numbers of nurses.

Thursday, 10 January 2013

Unethical work capability assessment is not fit for purpose


“Do you have pets at home?” The client answered in the affirmative, so the records show that the client, “Feeds and cares for dog without difficulty”. The truth was their pets were cared for by their children.

This is from an account given by the Citizens Advice Bureaux (CAB) in their evidence to the third year review of the Work Capability Assessments. It is one of many statements from their clients experiences of WCA.  In yet another case it was reported a  "client sought advice as the HCP recorded no abnormality and no problem with hands, despite the client having visibly swollen and deformed hands, with a consultant rheumatologist report confirming this."

Anecdotal, yes. But anecdotal evidence can be powerful when the sum total creates a coherent and meaningful testament; when each voice like a thread weaves a tapestry that is compelling and authentic. When there are common features to each narrative. "They did not listen." "They moved on to the next question when I tried to explain." For how else can such evidence be? These are real lives, real people with real stories to tell. Each witness contributes their story of a system that isn't working; a system that is cruel, impersonal and ineffective. And it is cruel and ineffective precisely because it does not listen to their stories.

The CAB evidence should be heeded. Many of the clients they advise have their WCA decision reversed on appeal. It is usually reversed in the light of facts, knowledge and understanding that is not considered in the assessment. The experience of how their clients have been treated in the process is second to none. Their conclusion about the system is damning.


"Citizens Advice retains concerns about the descriptors that are used for assessment purposes. Evidence received from clients suggests that the descriptors that are currently used are not the best markers of a clients disability, or a fair assessment of what they could reasonably be considered ‘fit enough’ to do in a work-environment."

WCA is not fit for purpose. It is based on no reasonable evidence that it works, and meanwhile it does harm.  The Work and Pensions Secretary, Mr Duncan-Smith says it will do good because it will help people back into work to lead productive lives; it will, he says, "make them better people". A utilitarian ethical consideration should consider the ratio of benefit to harm. The harm  cannot simply be ignored because politicians believe in the greater good. Driving people off benefits regardless of the consequences is at best reckless; but when that harm is already clear, it is immoral. And the harm to patients with mental health problems is already compelling.

In a survey of GPs commissioned last year by Rethink Mental Illness and carried out by ICM, 84% of GPs said they had patients who presented with mental health problems such as stress, anxiety or depression as a result of undergoing, or fear of undergoing, the Work Capability Assessment; 21% said they had patients with suicidal thoughts; 14% had patients who had self harmed; 6% had patients who had attempted or had committed suicide. They also thought that the system failed to consider their knowledge and understanding of the patient's history and condition.

How many tears must be shed before their stories are read? We cannot help people 'back to work'  simply by driving them off benefits regardless of their circumstances and regardless of the way their disability affects them in their daily lives.   A process that takes no account of this is a system that is not fit for purpose. It is a heartless and cruel system. In a civilised society we can do better.


If you are concerned about the WCA and how it is affecting people's lives there are two petitions you might consider signing:









Wednesday, 9 January 2013

Mr Duncan-Smith offers a disingenuous and divisive comparison

Some time ago, actually it was a long time ago when I was in my early teens, someone close to me bought a table. It was an early flat pack variety. It came with a top and four legs. He followed the instructions to the letter screwing the legs into the top. But when he had completed it the table wobbled. One leg he explained was shorter than the other three; so he sawed a bit from each of the other legs. The table wobbled. One leg, he explained, was longer than the other three. So, he sawed a bit off. The table wobbled. He went on cutting the legs, but the table continued to wobble. Cut, cut, cut! By this time he had convinced himself there was no alternative to it.  He ended up with a very low table indeed, supported by four very stumpy legs and a bit of cardboard placed under one of them to stop it wobbling on the uneven floor. 

Mr Duncan-Smith argues that we need a 1% cap on benefits to be 'fair to average earners'. Average  earners have seen their incomes rise by less than inflation whilst benefits have increased in line with inflation. That he says is unfair. One leg is too long, so he is going to cut a bit off. The table will of course continue to wobble. And it will wobble because the floor is uneven. The reason this time is that what he thinks is a separate leg isn't separate at all. It is a kind of category mistake.  It is a neat category, those on benefits, as if they are a different kind of human being.

Cutting benefits in this way will simply drive many hard working families deeper into poverty. Five million workers receive less than a subsistence wage. In the longer term, cutting benefits is counter productive. The cycle of poverty and disease, particularly child poverty, simply adds to the burden of health costs. It is less than fair because it makes the poorest pay disproportionately for the financial mess they had no hand in creating. They are paying through cuts in benefits and cuts in services upon which they rely the most. The government are missing the point about fairness, and the poorest are paying for the government's lack of policy to stimulate growth, get Britain working and cut the deficit. That is unfair.

Nearly 7 million working-age adults forming 3.6 million families in the UK are living in extreme financial stress. They have no savings, no equity in their homes and they struggle to feed their families. Furthermore the poorest 10% have seen their incomes fall in real terms for over a decade. This contrasts with the richest 10% who have seen their incomes rise in real terms. Now that is unfair. The gap between rich and poor is ever wider. Having given a break to the rich by cutting top rate tax, it is disingenuous for the government to now justify a cap on benefits by arguing for fairness. 

There is another problem with the argument about fairness. It just doesn't stack up. Mr Duncan-Smith gets his maths wrong again.  John Leech, the Liberal Democrat MP for Manchester Withington got it absolutely right in the parliamentary debate. It is unfair, he said, to equate a 1% limit on benefits worth less than £100 a week with a 1% pay rise for someone on a salary of £25,000 a year. Some Liberal Democrats, such as Charles Kennedy, have vowed to continue to fight this "divisive and unfair policy".  If they do so, they deserve credit and support for that. 

Most of those receiving benefits are in work, and most of them also  have received less than inflation increases in earnings. They too have been squeezed by the recession, and now the government wants to squeeze them further. 

Mr Duncan-Smith prefers a disingenuous and divisive comparison. It fits the 'shirker' and 'striver' categorisation, which Mr Vince Cable finds distasteful. It is wrong. it is unethical.  It is a bad policy and a bad argument. 

 

 

Tuesday, 8 January 2013

Don't believe it when they say front line services won't be cut.

There is an assumption often made in debate on the NHS. It is said there are too many managers. It is an assumption rarely supported with any kind of evidence. It is one of those ideas we just have to go along with. If you suggest otherwise people will think you are an idiot. So, we just go along with it. But is it true? The truth is I have no idea, but I suspect neither does anyone else, although there may be one or two 'experts' in the field of man management who do. But it is a very dangerous assumption.

It is important of course because the other idea we hear a lot is that 'cuts won't affect front line services'. The truth is, despite pledges given by the government, the NHS has already lost over 6000 nurses. But why would anyone take seriously the idea that cuts would not affect the 'front line'? The reason is the assumption, you see, that there is so much management and 'back office staff', that these could be shed instead. Now if you believe that, then you are...mistaken. We hear it for the police too; 'back-room staff'.  If only we could get rid of these useless cretins then all would be well. They don't really do anything, so getting rid of them would be painless. We hear it in relation to the 'bobby on the beat'. It is all a load of political twaddle, and it is said with such gravitas. And the reason they can get away with it is because, of course, we always go along with the 'too much management' idea. The truth is we have lost over 9600 front line police. In Greater Manchester they have lost a third of their traffic police. 

The other idea is 'form filling', as if this was totally unnecessary. But imagine if the police never filled in any forms, or the doctor never made any notes, or if a nurse never ticked a few boxes. I would be very concerned. "Can I see my notes?" "What notes?" Not a good scenario for effective clinical management. 

There are of course different kinds of manager. In one sense the person whose job it is to make the tea could be said to be a manager, if only because they manage. Anyone who organises anything is a manager. IT managers manage...IT. Clinical managers manage...clinics. Not difficult is it? And that brings me to my next assumption. All managers are overpaid. 

Now the assumption that all managers are overpaid stems largely from the assumption that they are not really necessary; in which case they shouldn't be being paid at all! It is easy to accept one assumption once you accept another. They tend to arrive in sets. A set of assumptions often underlies debate and unfortunately decisions. We tend to take the highest paid as our example of the public service gravy train. We rarely consider the lower paid or how many of them there might be. Here is a list of types of manager posts in the NHS: Porter team leader, Cook team leader, finance team leader, General office manager, business manager, catering manager, clinical team leader, finance team manager....Chaplain team leader....Perhaps I had better not list them all. There are about 87 of them with increasing degrees of seniority.  Now you might say "there you are then, 87, far too many!" But what would be a good number? 50? 60? And why? Also, not all of them are by any means highly paid. 

The truth is that if there weren't any managers then we would have to invent them. If you want to make a complaint anywhere the first thing you think of asking is 'who is in charge?'. Who is responsible for arranging the deck chairs? Who is responsible for things being in the right place at the right time and in working order? If the answer was 'nobody' then I expect you would call that ridiculous. And who would be processing your complaint? Someone in the 'back office'. 

Even when we are not talking about managers there is an assumption that back-office staff can be culled without real effect on services. But this is clearly ridiculous. Without the back-office staff the the front line staff would be more overloaded with paperwork than they are. In a recent survey 88% of social workers feared that vulnerable lives were being put at risk because of the cuts. Cuts had increased workload and social workers were not able to spend sufficient time with vulnerable children and parents.  Lives are put at risk by these silly and unsubstantiated assumptions made by politicians. But do we really believe the politicians believe these assumptions? 

Now remember I am an agnostic about all this. I don't know if there are too many managers or too much form filling; but if you are going to use the assumption that there is then I would ask that you present more than odd snips of anecdotal evidence. And I would advise caution when politicians tell you that cuts won't affect front line services. They will. They will because of another assumption; that the front line can work without back-office support or management.

Postscript

The Royal College of Nursing  has identified 61,276 NHS posts which have either disappeared or are set to go as a result of cuts in spending and warn that the NHS is "sleep walking into a crisis." Nurses say that they "do not have enough staff to deliver good quality care. Demand for services is continuing to rise, however staffing levels are being slashed."  

Monday, 7 January 2013

Ideologically driven reform will undermine the NHS

Privatisation of the National Health Service is gathering pace with fears of increasing fragmentation of service provision. A new term has been coined for it: 'atomisation'. The fear is that it will lead to less strategic planning. Planning will be dominated by the market; what's good sells.  More than 100 private firms will be commissioned by the NHS to provide basic services including physiotherapy, dermatology, hearing aids, MRI scanning, and psychological therapy. Doesn't sound too bad does it? I already use a private company to get my hearing aids. After all, it is simply a technical service. What is more important is where it is all heading and why. I expect it will be easier to introduce charges at the point of delivery once such changes are bedded in. And it will be argued on fairness. The arguments will run as they do now on winter fuel payments, free bus passes and child benefit. It will be asked why the wealthy should benefit from these as well as the poor. Sometime down the line it will be like dentists; finding an NHS one will become like a needle in a hay stack.

And this is the biggest problem for the Tories in carrying out the kind of 'reform' of the NHS they would really like. It is the fundamental principle at its core: that treatment is free at the point of access and delivery. It has been a line in the sand since its foundation. But what if you then make access to services the same as prescriptions for medicines. A prescription for physiotherapy  for hearing aids or psychological counselling would be easier to charge. After all it is done already. And all the more readily if you could get the service faster if you paid.

We recall the Tory election manifesto promising no top down reform of the NHS. But let us put that aside. It is an old argument and in any case we didn't believe it. I have never known a Tory government that did not try to 'reform' the NHS; reform usually means some form of privatisation. The big idea in the previous Tory government was an 'internal market'. They believe 'competition' produces greater efficiency. What it often does, however, is to produce 'cost cutting', which isn't quite the same as efficiency. 

Privatisation they also believe will make service provision more responsive to the customer's needs. The patient is no longer a patient, passively accepting poor service delivery, but a 'customer' able to make wishes felt in a market place. But the way a customer does this is, of course, through pricing and choice. And so the argument will run. Wouldn't it be better to put the power of purchase in the hand of the patient? Let them choose what level of service they want. It is a simple step once you have already introduced NHS provision by companies already in the market place. 

There is no doubt that the NHS faces great challenges as it moves forward. It needs to be responsive to needs resulting from demographic change and changing lifestyles. But also it needs to reform as new technology alters medical practice. Population growth, life expectancy and age distribution most obviously produce changes in service needs. But then there are those not so obvious. Many of us will be living alone. By 2032 it is expected that about 40% of the population will be 'living alone' and 1.4 million of these will be 85 or older. It is a sobering statistic and it is clearly going to change not only the demands on health care but how these will need to be delivered. Not because this geriatric population will be necessarily unhealthy.  Far from it, it is likely they will be healthy; why else would they be living so long? But it will change service needs. It will certainly change needs for community services and how these will operate.

What really puzzles me is that the changes being made by the government really don't address these key fundamentals. They are tinkering with the system ideologically without viewing the bigger picture. They are obsessed with the mechanics of it all rather than with its purpose. The government's reforms start with changes in the way health services are commissioned, you then introduce new service providers, you then de-commission the service provided by the NHS (why duplicate) and then where will we be? It is time for honesty. It is time we said what 'atomisation' and 'fragmentation' of the NHS means. 

Sunday, 6 January 2013

If we invest in people we can win

It seems a bit late to talk about the Olympics. That was last year's news. But I was always concerned we would take the wrong message from the Olympics and Paralympics. It has been revealed that half a million soldiers, nurses and teachers will have their incomes slashed in the coalition's benefits crackdown. That is half a million 'strivers'; half a million winners. Mr Cameron clearly has learned very little from the Olympics. If you want winners then you have to support them. 

 Like many others I was enthralled by the wonderful success of British athletes. Each day I would clap with joy at each new medal added to the tally. I didn't expect to be so riveted by it all. "Isn't it fantastic?" friends and relatives would say. And I would say "Yes! Fantastic! Wonderful!" But even as I expressed my enthusiasm, I had nagging doubts. Not doubts that it was fantastic, or about the effort and achievement of the athletes. I shared their joy. I shared their emotion. Often tears came to my eyes as they lifted their medals for all to see on the podium.  No, my doubts were about the message. 

It was inevitable that the Olympics would mint political coinage. After all, as well as being a competition, it is a political event, a political circus. And politicians were there beaming away at medal ceremonies, if only to show what good blokes they are. Some for their pains got booed; oh the joy. Almost immediately  the Olympic spirit was turned into political rhetoric. The prime minister in his Party conference speech referred to the 'lesson'. Britain's Olympians and Paralympians he told us

"have taught us another lesson: graft equals success. You don’t get to the podium without making huge sacrifices and really wanting to win. That lesson can be applied to our country. It will be a hard road to success – but that’s the road we must take."

What he meant was the pain of cuts in spending and welfare will be the price worth paying for success. Hard work and dedication are certainly needed to achieve any ambition.  But the idea that this is all it needs is very wide of the mark. Furthermore, it offers a false prospectus. 

Olympic success did not come from hard work and dedication alone. It had a vital ingredient; funding, investment. Success in the velodrome wasn't due to the hard work and dedication of the athletes alone. It came at least in part because of investment of many years.  Hard work and dedication won't win gold without it. If talent is not spotted, nurtured, supported, then it will wither on the vine, no matter how much hard work and dedication a talented individual puts in. Going for gold is not itself sufficient. As UK Sport says it takes the provision of support services "without which the UK's top athletes would find it difficult to be competitive on the world stage." Olympic athletes have what most of us can't have, even those of us who are equally talented. They have a team dedicated to improving  performance. 

In the London Olympics British cyclists won 8 golds, 2 silver and 2 Bronze. This was achieved with funding between 2009 - 2012 of £26m. As Sir Chris Hoy says of his achievements in the sport, without the funding and support "there's no chance I would have achieved these goals."

Physiotherapists, sports masseuse, nutritionists, sports psychologists, strength and conditioning coaches, lifestyles advisers, biomechanicists, technical coaches, the list goes on.And then there are the researchers developing new sports gear just to give the team the edge; certainly true of cycling.  All working with the hope that the hard work of just one or two, or perhaps just a few individuals will win. Just a few, not the many. For every winner there are many more who don't win; for every athlete who gets to the games, there a many who do not. No the Olympics is not where we find the answers. It has very little to tell us about the real world. We can be 'inspired' by Olympic athletes, but they are exceptional, and no matter how inspired we might be, on the whole we won't have access to the kind of support they need. 

So, the real lesson is not the hard work and pain. That is a given. There are many hard working people doing that day in and day out to keep a roof over the heads and feed their families. Contrary to the portrayal by Mr Cameron and his colleagues, the majority of those receiving welfare benefits are hard working and dedicated, day in and day out. But, for the poorest of them, he is cutting their support. They are winners and yet he is taking away from them the support they need to go on being winners; bread winners for their families. 

They keep the engine of Britain going day in and day out. They are striving, working hard. They deserve to be supported.