Saturday, 28 September 2013

One telephone call may seal Obama's place in history

For many, the Obama presidency has been a disappointment. The 'Yes we Can' mantra has faded into a distant memory. But in many ways he was bound to disappoint. Voter expectation for change wasn't predicated on an agreement on what that change would be. Change meant different things to different people. 

But change there has been, and nothing reflects that change more than a simple act; a telephone call.

When Obama lifted the phone in the Oval Office to call Iranian President Rohani it represented a different way of thinking about world affairs. It said 'Yes we can' to solving issues in a way that doesn't require a resort to military intervention. 

Of course it required the biggest change of all. A change in the Iranian Presidency. But it takes two to tango and the first tentative steps have been taken in a fifteen minute telephone call. 

It is of course too early to say what a rapprochement with Iran will lead to. But if there is rapprochement it may make Obama's mark in the history books. If it creates a new atmosphere for resolving the problems of the Middle East the world will be a safer place. 

It is also too early to say  how the Syrian crisis will resolve, but Obama backed away from a military strike to 'give peace a chance'. At one point it looked as if a military strike had momentum. But popular will said a resounding 'no'. First it was rejected by the UK parliament; then Obama backed off to seek congressional approval.

Some saw this as weakness. But it takes strength to think again. As Obama has said in response to criticism that he was dithering 'I am much more concerned with getting the policy right'. 

How different history might have been if the Bush administration had taken time to think again about invading Iraq or at least thought through what the end point was likely to be.

If the Syrian regime gives up its chemical weapons it will be a major achievement. Russia will take great credit for brokering the way forward. But Obama has shown real courage in stepping back and supporting the process. It is surely better than military intervention in a messy civil war. 

There will be those who are sceptical. Perhaps they are right to be. But when I heard the news of the telephone call made by Obama I was full of hope and optimism. A great deal more now needs to be done. But it is the first bit of optimism I have felt in international affairs for a long time. A cloud has lifted and the sun might shine. 

Thursday, 26 September 2013

Is Ed Miliband right on freezing energy prices?

Is Ed Miliband right to challenge the energy industry on pricing? It is a populist move. At a stroke he has outflanked Cameron on an issue the prime minister once had a go at when he questioned the complexity of tariff choices. But is a price freeze a sustainable policy?

It hasn't taken five minutes before energy company bosses were parading in the media with doomsday scenarios. The lights would go out if a Labour government freezes energy prices for two years.

It is of course a load of piffle. The lights will not go out. Not, that is, if there is sufficient investment in energy production. The energy industry will argue that it is supply and demand operating in the market for energy that should and does determine prices.

The truth is that energy markets are complex. Supply depends on the capacities of power plants, their current technical state and planned refurbishment, or on supplies from abroad. On the demand side the weather  plays an important role. Temperature and cloud cover influence consumer behaviour directly. Severe winters add to demand.  It is also affected by changes in the state of the economy and industrial output. Instability in the Middle East is a major factor on world energy markets. Other factors include consumer behaviour.

Nevertheless, energy production and prices operate in a highly distorted market. Costs of production and prices in relation to supply and demand don't operate unfettered. Investment in 'green' energy is heavily subsidised. So much so that in June this year David Cameron was threatening to cut green energy subsidies.

Cameron blamed these subsidies for pushing up energy bills. So the market is distorted and some argue that it needs sorting out. The political wind is turning against green energy. In any event, around 100 Tory MPs are unhappy about wind farm proposals in their constituencies, and this will influence energy policy. We in the countryside don't like wind farms peppering our landscape. Politics plays a major role in determining future energy supply.  It isn't at all clear what the government strategy is.

In his 2011 autumn statement George Osborne effectively abandoned environmental targets saying "If we burden [businesses] with endless social and environmental goals – however worthy in their own right – then not only will we not achieve those goals, but the businesses will fail, jobs will be lost, and our country will be poorer."

The government is right in one sense and that is that the subsidies for renewable energy distort the supply side market. Turbine owners received £1.2 billion in support last year. My point here then is that government already interferes with the energy market through these subsidies. It is a bit rich for the energy industry chiefs to cry foul and threaten to turn the lights out when Labour promise to control prices to the consumer. The government claim that without the subsidies, householders would be paying an average of £60 more for their electricity bills. 

We need a sensible debate about how the UK can meet its energy needs. What consumers experience is that prices go up but rarely come down and whilst energy company profits rise.

But there are two problems with the Miliband populist approach. Once government interferes with prices it is difficult to see how it stops interfering.

What happens when the freeze ends? The most likely scenario is that prices will increase. The 'market' will readjust. This has always been the problem in the past with prices and incomes policies.  They store up problems.

I suppose it is possible that prices could be linked to a clearly understood index by a toughened regulator. But  what would  be that index? Unless Miliband has answers to this question Labour spokespersons will have difficulty making the case. The easy part is saying prices are too high; the hardest part is saying what they should be and why.

Miliband has a bold policy. But the devil may be in the detail. It needs to be fleshed out.

Postscript

Predictably, David Cameron has hit back at Labour's new policy on freezing energy prices. He knows, however, that the public are angry about rising energy bills. We remember his own fumbled attempt at taking on the energy companies last year when he insisted that energy companies would be 'forced' to offer customers the lowest tariff.

David Cameron declared ''I want to be on the side of hard pressed, hard working families who often struggle to pay energy bills.''  Ed Miliband has now outflanked him.

It makes it difficult now for Cameron to attack Labour's interventionist plans directly.

So what is Mr Cameron's strategy for lower energy prices? Not surprisingly his policy is to push 'new technologies like fracking'. We will recall that Lynton Crosby, Cameron's recently appointed election guru, controversially has links with the fracking industry.  But, hey, I'm sure they never discuss it...it never comes up in conversation...no lobbying scandal here then.

Post-postscript

There are already signs that the Tories have adjusted their position in response to Labour's plans to freeze energy prices.



Wednesday, 25 September 2013

GP income falls as costs rise

Have you ever wondered what your GP earns? The truth is of course that GPs compared to most of us earn a good whack. But that isn't the point. It is a high pressured, high skilled job and average GP income has been falling steadily for several years.

Figures released by the Health and Social Care Information Centre (HSCIC) show that average income before tax of contractor GPs was £103,000 in 2011/12, a drop of 1.1 per cent on the previous year, representing a continuation of the gradual fall in contractor GP incomes from their peak at £110,000 in 2005/06, the year after new contracting arrangements were introduced. Contractor GPs form the majority (around 80 per cent) of the GP workforce.

Today's report shows that average gross earnings for contractor GPs were £267,900, a 0.5 per cent increase on 2010/11. So how is it that GP income has fallen? The answer is increasing costs.

Contractor GPs pay for expenses such as premises and practice staff wages out of their gross earnings - and these costs increased more than earnings, rising by 1.6 per cent to £164,900. Almost 62% of Contractor GP earnings is taken by expenses of running the practice.  

But average statistics don't really tell the full story.

Around half of contractor GPs (50.3 per cent) had an income before tax of less than £100,000, roughly the same proportion as in 2010/11 when 48.9 per cent fell into this bracket. Just 2 in 100 contractor GPs (2.0 per cent or 670) had an income of more than £200,000 before tax.

Average incomes before tax were £106,100 in England, £93,300 in Wales, £92,800 in Northern Ireland and £88,700 in Scotland. Average income before tax for contractor GPs in 2004/05, when the current contracting arrangements were introduced, was £100,200 in cash terms and £119,300 in real terms.

HSCIC Chair Kingsley Manning said: "This report provides a detailed insight into the income of GPs and their practice expenses, showing that the average income before tax of a contractor GP is £103,000.

The data confirm a continued gradual decline in average GP incomes and will provide a useful contribution to discussions over the remuneration of the family doctors."



GPs "a demoralised workforce"

Responding to the new figures  which show a decline in average GP income, Dr Chaand Nagpaul, Chair of the BMA’s GP committee said:

“GPs are already demoralised by ever increasing and unmanageable workloads. This further pay cut for GPs while running costs increase, and the failure of the government to ensure that pay is frozen as it is with other NHS staff, will only add to this.

“Despite claims that pay is out of control there has been a 11 per cent drop in GP income since 2008, which along with increased bureaucracy has led to the current recruitment and retention crisis facing general practice.

“GPs are working harder than ever before to maintain high quality services and carry out 340 million consultations a year. However, ever increasing costs of care without adequate funding to match is unsustainable and means quality of patient care will inevitably be hit.

"The government needs to address the economic and bureaucratic straitjacket that many practices are now finding themselves in so GPs can be enabled to provide the best quality care to their patients.”

Tuesday, 24 September 2013

Hospitals fall short of standards on post mortem consent

Many hospital trusts in England and Wales are falling short of the recommended standards on obtaining consent for a post mortem, indicates a snapshot survey of practice published today online in the Journal of Clinical Pathology.

Active informed consent became a key tenet of post mortem exam procedures following the organ retention scandals at Bristol Royal Infirmary and The Royal Liverpool Children’s Hospital, which prompted the enactment of the 2004 Human Tissue Act.

At Bristol Royal Infirmary the hearts of children were taken without the knowledge of their  parents. Collections of hearts and other organs were held in hospitals across the UK without relatives knowing.  A public outcry resulted when it was revealed that Dutch pathologist Dick van Velzen had systematically ordered the "unethical and illegal stripping of every organ from every child who had had a postmortem" during his time at Alder Hey Hospital regardless of whether the parents had consented and also where parents had specifically stated that they did not want a full post-mortem.

The 2001 report on Alder Hey revealed that over 104,000 organs, body parts and entire bodies of fetuses and still-born babies were stored in 210 NHS facilities.

The presumption by clinicians at the time was utilitarian in nature; the greater potential benefit obtained from retention and research was considered to outweigh other considerations including the fundamental principle in modern medicine of informed consent. This fundamental principle has a high threshold and would require an equally valid but conflicting principle to justify its breach. In this case no such conflicting principle exists.

The argument that patients may benefit in the future from research and/or medical education is little more than an ethically invalid open cheque. A cheque that bounces on a number of grounds, not least of which is how such a balance can be made. Furthermore, were it to be justifiable on such grounds, it should not be clinicians and scientists who are the arbiters of such a balance. It should be the patients or their relatives who make such a choice. It should not be a decision made by clinicians alone. Informed consent is central to the 2004 Human Tissue Act and guidance is laid down on how it should be obtained in practice. One key element in practice is that informed consent in such cases should be obtained by staff appropriately trained.

The 2004 Act stipulates that consent must be actively sought from either the individual while alive, or when this is not possible, from a nominated representative or close family member. Such is the importance of this fundamental principle that breaches of the law attract a prison sentence and a fine. But how well are hospitals adhering to the principles of the Act?

In the current survey, the authors obtained staff policies on post mortem procedures from 26 hospital trusts in England and Wales. They compared the content with guidelines set out by the regulator in this area, the Human Tissue Authority (HTA).

They focused particularly on whether the policies explained: the law behind consent to post mortem; the consent process; which staff members should take consent; and training requirements for consent takers.

The HTA guidance states that every hospital should provide staff with a documented consent procedure, and have relevant experience and understanding of the procedures involved.

The guidance also says that staff should be trained in dealing with bereavement and have witnessed a post mortem themselves, and specifies that responsibility for obtaining consent “should not be delegated to untrained or inexperienced staff.”

Out of the 26 post mortem policies scrutinised, one failed to explain the legislation governing consent to a post mortem; more than one in 10 (12%) of policies did not outline a clear process for how consent for the procedure should be obtained.

Furthermore, 12% of policies did not specify which staff members should take consent for a post mortem, and almost one in four (23%) of policies failed to state the training requirements of those responsible.

One in three (35%) trusts did not stipulate any requirements for the consent taker to be sufficiently experienced; over half of trusts (58%) did not specify that consent takers needed to be trained in bereavement; and over two thirds (69%) did not recommend that consent takers should have witnessed a post mortem.

Some 12% of policies failed to outline the consent process in full, including failing to describe when families should first be approached, or which staff members should talk to families before they are presented with a consent form.

“Given the sensitive nature of consent discussions, it is vital that the process is conducted in an appropriate manner,” write the authors. Adequate and clear guidance for this is therefore essential they add, highlighting “the significant shortcomings” their analysis revealed.

They point out that hospital post mortem rates have been falling steadily, despite the importance of the procedure in understanding disease and enhancing medical education. And a clumsy, poorly informed approach to families when a loved one has just died is unlikely to reverse that trend.

The authors acknowledge that policies do not necessarily reflect actual practice, and some of the trust policies may also have subsequently changed.

But they emphasise that in the current climate of financial cutbacks, “it would be feasible for trusts to see [post mortems] as an easy target to limit investment to the detriment of the medical profession. Hence it is vital for the HTA to uphold standards and continue to ensure that the consent process is always carried out in a satisfactory manner for all concerned.”

Friday, 20 September 2013

Bureaucracy and box ticking are compromising NHS primary care

A new BMA survey says that GPs need to be freed from increased bureaucracy, box ticking and administration so they can spend more time meeting the needs of their patients.With that I suspect most of us would agree. 

As I get older, and now suffering from age-related illness, I use my GP more than I ever did before. I have become one of the 'burdens' of 'an increasingly aging population'. When I visit my local GP clinic I am struck by how many of us in the waiting area or in the queue at the reception are over 60s. Until a year ago I rarely visited my GP. I certainly couldn't tell you the names of any of 'my' doctors. Now it is different. I am rooted in that cycle of being regularly poked and prodded. I have become a NHS statistic.

The survey of GP opinion is the largest since changes to the GP contract took effect in April 2013. In total, 3,629 GPs completed the survey, just over 10% of all GPs in England. I worry that only 10% of GPs responded. Perhaps 90% of GPs who didn't respond were too busy ticking other boxes. It does question the representative value of the survey.  But let's for the moment at least take the findings at face value. 

Key findings include: 

97% said that bureaucracy and box ticking had increased in the past year while 94% said their workload has increased.
82% felt that some of the new targets were actually reducing the number of appointments available to the majority of patients.
89% said that more targets will not improve patient care.
90% said their practice’s resources are likely to fall in the next year.
45% of GPs said they are less engaged with the new clinical commissioning groups (CCGs) because of increased workload.
86% of GPs reported a reduction in their morale in the past year.

These results are similar to those of the the seventh annual report into “GP Work life”, funded by the Department of Health, and published this week

The level of overall job satisfaction reported by GPs in 2012 was lower than in all surveys undertaken since 2001.

In the Department of Health Survey, GPs reported most stress due to ‘increasing workloads’ and ‘paperwork’ and least stress due to ‘finding a locum’ and ‘interruptions from emergency calls during surgery’. Reported levels of stress increased between 2010 and 2012 on all 14 stressors, generally by 0.2-0.4 points on a five-point scale. Reported levels of stress are now at their highest since the beginning of the National GP Worklife Survey series in 1998. 

Dr Chaand Nagpaul, Chair of the BMA’s GP committee said:

“GP practices are already struggling with declining funding and rising patient demand, especially from an ageing population. Recent changes to the GP contract have created additional and unnecessary workload that is diverting valuable time away from treating patients. Worryingly 8 in 10 GPs report a reduction in morale, and nearly half of GPs are less engaged with their Clinical Commissioning Groups due to workload."

The government promised to sweep away red-tape and targets. Yet the government recently introduced new targets which include encouraging GPs to carry out a large number of "lengthy and clinically dubious questionnaires" that ask how many hours patients spend on gardening, cooking and DIY.

Absurdly they also introduce a programme offering appointments to all healthy 35-40 year olds simply to check their blood pressure. GPs are very worried that the time taken for this programme and questionnaires is resulting in fewer appointments for other patients who are in need of care.

As Dr Nagpual says, despite this difficult environment, GPs are working harder than ever before. There is a wealth of experience and talent in general practice that could be harnessed positively for patient care. 

“The BMA wants to work with the government to deliver real benefits to patients and remove the administrative burden that is putting pressure on already overstretched GP services. We particularly need to see how we can free up more time to deliver the personalised care that patients deserve and meet the challenges from an increasing number of older patients who need coordinated and effective care.”

GPs should be able to concentrate on ensuring good patient notes and treatment, not filling in forms that are not directly related to patient care.

See also:

Patient safety put at risk by long hours for Junior Doctors
Broken pledges and the crisis in the NHS
Deepening crisis in the NHS

Wednesday, 18 September 2013

Homeopaths Without Borders: exploitation or humanitarian?

Today on bmj.com a senior researcher from the Institute for Biomedical Ethics criticises the campaigning group that wants to help the world’s most vulnerable people with homeopathy.

David Shaw says that although the movement Homeopaths without Borders has received a “great deal of criticism in recent years for unethical practices”, it has gone “entirely unmentioned” in medical literature. He says this is surprising given that the campaign is “engaged in activity even more dubious than that of most homeopaths”.

Research and modern medicine

It has often been said that medicine is an art as much as it is a science. It is certainly a craft that requires understanding of the needs and circumstances of the patients it treats. Modern medicine is 'evidence based', which means that it progresses through research and new treatments are soundly tested in randomised controlled trials (RCTs). The two approaches, medicine as a craft and evidence based medicine are complementary; ideally they work together. Whilst modern medicine isn't simply the application of science, it isn't hocus pocus either.

When modern medicine offers humanitarian assistance throughout the world, as it does through organisations like Medicin sans Frontieres,  it brings this evidence based knowledge, skill  and understanding to help those in need. Those being helped assume that what is being done is tried and tested and approved. They trust the skill of those who are treating them. Homeopathy offers little or none of this.

Homeopathy not evidence-based

Homeopathy is a 200-year old system of medicine that seeks to treat patients with highly diluted substances that are administered orally. Homeopathy is based on two principles: "like-cures-like" whereby a substance that causes a symptom is used in diluted form to treat the same symptom in illness and "ultra-dilution" whereby the more dilute a substance the more potent it is (this is aided by a specific method of shaking the solutions, termed "succussion"). It is claimed that homeopathy works by stimulating the body's self-healing mechanisms. There is a paucity of evidence that it works.

Homeopathy is not part of mainstream medicine because it is not evidence based.  The Royal Pharmaceutical Society of Great Britain has concluded that homeopathy is based on a false premise and that "no plausible scientific reason has yet been proposed as to why it should work". Put bluntly, the overwhelming body of evidence is that it doesn't work, and if it doesn't work it is unethical to suggest that it does.

As the UK House of Commons Select Committee on Science and Technology concluded from its long consideration of the evidence "there has been enough testing of homeopathy and plenty of evidence showing that it is not efficacious".

In response to this criticism, advocates of homeopathy argue that much of modern mainstream medicine isn't strictly based on evidence. That may be so; there is more to medicine than the appliance of science. But modern medical practice evolves in the light of ongoing audit of what does and does not work and it seeks to understand why through research. None of this underpins homeopathy.

For the most part through physiological and pharmacological research we can say how drugs work in the body. We may not always be correct but science is an ongoing process of challenging established ideas. None of this is part of homeopathy the basis of which is 'not understood' after 200 years of history.

Homeopaths without Borders

Homeopaths without Borders seeks to promote itself in countries where it does not already have a foothold. Shaw says the Kenyan example, which implies that homeopathy can save lives, is “shocking” and something which no mainstream organisation has claimed for several years.

The Homeopaths without Borders North American group sent several homeopaths to help the people affected by the Haiti earthquake but according to Shaw, “people affected by massive earthquakes cannot benefit from homeopathy any more than people living safely in London”. He adds that it might even harm patients by making them believe that they do not need to seek usual treatment for injuries or disease.

Shaw says that following the earthquake, more Haitians will believe in a “discredited system of ‘medicine’ making long term harm more likely than if the campaign had not got involved in the first place”.

He believes that Homeopaths without Borders North America “exploit developing countries” and is happy to suggest that homeopathic therapies can also help in pregnancy care and delivery.

Homeopaths without Borders also ask for monetary donations, which Shaw believes seems “somewhat pointless” given that there is no evidence for its efficacy and as such it may be diverting money away from “genuinely humanitarian organisations”.

Dr Shaw concludes that “homeopathy is neither helpful nor humanitarian” and is exploiting those “in need of genuine aid”.

In an update on their Haiti mission in 2011 Homeopaths without Borders reported on worsening conditions.

"The team reported that conditions in Haiti remain difficult; piles of rubble still sit in the streets, roads are filled with potholes and rebuilding is extremely slow. Potable water is scarce as is sufficient food, and fear of cholera is evident.

"Haitians continue to demonstrate symptoms of trauma and grief from an earthquake that took place a year and a half ago. Skin problems such as ringworm are prevalent as are gastrointestinal problems including severe diarrhea; some of the latter are related to poor nutrition. Vaginal infections persist. Sadly the group treated several very ill infants who were malnourished, dehydrated, underdeveloped, feverish and covered with rashes from head to toe.

Although a great variety of remedies were used, following were the most frequently administered: Arnica, Aconite, Ignatia, Causticum, Nat mur, Sepia, Phosphorus acid and Sulphur."

Significantly missing from the report was any account of the effectiveness of the 'treatments' given. Nor is it clear how the 'like cures like' principle was at work. Arnica cream has a record of use in treatment in  medicine, but a systematic review of clinical trials shows that homeopathic preparation of Arnica was no more effective than a placebo. Onions can certainly stimulate tears, but it is difficult to see how they can be a cure for the common cold or influenza, yet a homeopathically prepared 'onion solution' might be prescribed by a homeopath.

Homeopath claims

Homeopath organisations claim that research published in medical journals such as the Lancet and the British Medical Journal "have confirmed the effectiveness of homeopathy". This is disingenuous at best. I doubt whether the editors of these prestigious medical journals would agree. On the contrary, the Society of Homeopaths has been censured by the UK Advertising Standards Authority for making unsubstantiated claims that homeopathic remedies can cure depression, bronchitis, osteoarthritis, and vertigo. Most controlled clinical trials show no beneficial effect yet these unsubstantiated claims continue to be made.

Homeopathc preparation of Ignatia continues to be pushed as a remedy for bereavement, heartache and pain.  With little or no evidence it is also suggested as a remedy for headaches, sore throat, nervousness, insomnia, heart palpitations, gas, indigestion, mood swings, menstrual irregularities, irritable bowel syndrome, painful hemorrhoids, or a dry, tickling cough.

I am sure Dr Shaw's hard hitting opinion piece will spark considerable debate.  Many of the arguments have been well rehearsed. Much of the debate will be vituperative; sadly, it usually is. But the central question will be whether there is evidence that homeopathy works and if so why. If there is no such evidence, or the evidence is slim, then it is unethical to suggest otherwise.

There is much that is wrong with the pharmaceutical industry. I believe we need a more holistic approach to understanding disease and treatments.  Homeopathic practitioners have a belief in their approach. This I respect. But it stretches truth and is unethical for them to make claims that cannot be substantiated.

Postscript

The adjudication of the UK Advertising Standards Authority makes interesting reading. The body found the claims of the Society of Homeopaths to be misleading and not substantiated.

"The Society of Homeopaths provided three studies to substantiate the claim that there was sufficient research evidence to support the use of homeopathic treatment for allergies and upper respiratory tract infections. Our expert advised us that the first paper concentrated on effectiveness, safety and cost effectiveness rather than efficacy. The second paper concerned 24 studies, but those with the highest patient numbers showed only non-significant effects in favour of homeopathy or no effectiveness over placebo. The third paper concerned 27 trials and studies and some evidence suggested in some conditions, homeopathy showed some benefit. However, the authors noted that there were general weaknesses in the evidence due to the lack of independent confirmation of reported trials and the presence of conflicting results. Our expert considered that the evidence was not sufficient to support efficacy claims for homeopathy for the treatment of allergies and upper respiratory tract infections. We therefore concluded the claim was misleading and had not been substantiated."

You may also be interested in these articles:

Hilary and Steven Rose lift the lid on modern biomedical science.
Something isn't right in the world of pharmaceuticals. Alarm bells are ringng.

Thursday, 12 September 2013

UK employment figures all smoke and mirrors?

As the UK unemployment rate falls, Ed Miliband is right to point to the disparity in unemployment between the north and south. If there are signs of economic recovery, it clearly isn't uniform across the country.

The headline figure of falling unemployment masks the real problem for an economy that is still sluggish and for a patchy recovery.

The unemployment rate is highest in the North East (10.4%) and lowest in the South East (5.8%). The disparities are illustrated in an interactive map showing the distribution of people receiving job seekers allowance produced by the Office for National Statistics.

It is also a distinctive feature of this recession that increasing numbers are working part-time because they are unable to find full-time employment. In 2008, just 16.6% of the male workforce had part-time employment, now it is 32.6%. For women the percentage in part-time employment increased from 7.1% (2008) to 13.5% (2013).

Millions of hard-working but hard-pressed families have seen inflation outstrip any increase in earnings, a trend that is set to continue. A real feel-good factor may be hard to conjure.

The right wing think tank Centre for Policy Studies warns the Chancellor against complacency. It makes the points that the deficit is still 'extraordinarily high', unemployment is still 'way above its pre-crisis peak', productivity performance has been poor, and many underlying structural problems persist.

Postscript

A defining and continuing feature of this long recession is perhaps 'underemployment' rather than simply unemployment with a massive increase in those working part-time. There has been an unprecedented fall in earnings while inflation has increased. Many of those with part-time employment have been unable to increase their income by increasing hours worked.

The price of petrol has increased by 54% since 2008. Hard working families have seen the cost of living increase across the board. Changes in welfare funding means that the poorest and the disabled have born the brunt of the recession caused by the banking crisis.

See also:

The disgraceful falsehood of Mr Osborne's spending review
Failure to act on corporate tax avoidance is a disgrace.

Tuesday, 10 September 2013

French resolution at UN on Syria is mischievous.

The resolution proposed by France at the UN following the Russian proposition that Syria put its chemical weapons beyond use is unfortunate if not disingenuous.

France knows that by including a condemnation of the Syrian regime for the chemical attack of 21st August it would be unacceptable to Russia and thus courts rejection. Indeed, Russia has already called it 'unacceptable'. The French resolution promotes division in the security council at a time when it could be moving towards unanimity. It is inept at best; at worst it is mischievous. What is needed now is  for the UN to move forward on setting up a viable process for decommissioning Syria's chemical arsenal.

None of this will be easy in the middle of a civil war. It has been suggested it would require a cease-fire to ensure safety for the inspectors and to ensure the weapons did not get into the wrong hands or go missing. The Obama administration is also not short of mischief making. It calls for 'swift' action, when it knows this is not possible.

It will take time to prepare the ground, to broker a cease-fire, to install a decommissioning team. It is not at all sure the opposition in Syria will be willing to play ball and nor are the opposition forces united. Such a process will be far from 'swift'. And even supposing a team can be put on the ground in Syria, there will be setbacks. The process will stumble at some stage. That is par for the course in such matters. Nevertheless it is the best proposition on the table.

Meanwhile, Obama is rapidly losing credibility on his 'red line'. He has lost the initiative which passed to Russia via an inept remark by Secretary of State, John Kerry. It appears now that the idea was first mooted in discussions at the G20, and yet the Obama administration still appears to have been wrong-footed on it.

Nevertheless for Obama it is a way forward. All sides must now work hard for its adoption and implementation. Finally the UN may be able to play a worthwhile part in ensuring safety of the Syrian people and ensuring chemical stockpiles do not get into the hands of terrorists and a regime mindful to use them.

Postscript

Obama and Hollande rightly say that the threat of a military strike against the Syrian regime has played a major part in the positive response of the Assad regime to the Russian proposal. Equally, it has to be said, that Russia would not have been able to approach the Assad regime without retaining close relations. Political solutions to seemingly intractable problems most often require a willingness to engage with 'the enemy'. Setting unattainable conditions as laid out at the UN by France is unhelpful and obstructive to a diplomatic solution.

Post-postscript

We can only hope that the road map to eliminating the Syrian stock of chemical weapons is a success. It is a difficult task and some experts consider it to be an unrealistic time-table for the stocks to be destroyed by September next year. In a war-torn country this may not be possible, and so what then? The US and its allies, France and the UK, want a military strike to remain a possible response. With a military strike still on the table, it will not be in the interest of the opposition forces to cooperate in allowing chemical weapons decommissioning to progress. A lot will depend on how much security the Assad regime can provide and on the location of the stockpiles. There are a lot of 'ifs', although it is a step in the right direction. Russia and the USA are at last working together on the Syrian conflict. How much agreement can last will depend as much on domestic US politics than on the real situation in Syria.



Monday, 9 September 2013

Let's stop the gagging law

You might have heard about the “gagging law” currently being voted on by MPs. If you haven’t heard of it, it’s really bad news. If it goes through, it will have a chilling effect on British democracy and on our right to speak up on the issues that matter to us.

Basically, the law slashes the spending limits on campaigning for the year before any election. Campaigns that have impact don’t cost the earth, but they aren’t free.

Community groups, charities and campaigning organisations would all be hit. Election time is when ordinary people have the most influence on our politicians. On the big issues of the day – whether or not to go to war, the future of our NHS, the environment, welfare, immigration, etc. – we'd all be gagged.

The problem is that this law has come out of nowhere and not many people have heard what’s going on. If we’re going to defeat it, we need to get the word out further. If every single person who’s ever joined a local campaign group or taken action with their favourite charity knew that they could be stopped from doing that again, the outcry could explode.

How can we leave political lobbying in the run up to elections to big business? Charities represent millions of individuals whose voice would be lost. Let's stop this undemocratic bill.

Here’s a simple five minute video you can watch for more information. Can you take a look, and then help get the word out by passing it on to your friends and family?




Afterword

The Bill passed its second reading with 309 MPs voting in favour, 247 against. The Bill now moves to the committee stage where detailed examination takes place.

Certainly the Bill lacks clarity. This was indicated in the debate by Mr Lansley for the government:

"I had conversations yesterday with the National Council for Voluntary Organisations, which helpfully supplied us with a copy of its legal advice, which of course illustrates that, technically, the uncertainties that are being talked about could in large part be construed to relate to existing legislation rather than the Bill that we are bringing forward. In truth, it is the responsibility of the Charity Commission, where charities are concerned, and the Electoral Commission for all third parties, to work together to ensure the soundness of the definitions in the Bill." 

No clarity there then!

John Kerry should be careful how he uses history to justify a strike against Syria

We cannot solve the problems of today by belatedly acting on the problems of yesterday. Yet a key pillar of John Kerry's justification for a punitive strike against the Assad regime is that the world stood by in the past when other atrocities were committed in previous conflicts. 

"We need to hear an appropriate outcry as we think back on those moments of history when large numbers of people have been killed because the world was silent," he said today when meeting British foreign secretary William Hague. "The Holocaust, Rwanda, other moments, are lessons to all of us today."

I am afraid history is rarely a good argument for the USA, or for Britain and other former colonial powers. History reveals a very dirty business when it comes to support for nasty regimes. The USA at best looked the other way and at the worst supported the use of chemical weapons by Saddam Hussein in the war with Iran in the 1980s. I suppose this must have been one of the 'other moments' in history referred to by John Kerry.

Without further sanction by the UN security council a punitive strike would not be legal. Only a strike that could demonstratively protect civilians would be legal. As far as I understand it there is no legal sanction for punitive action. But I confess I am no expert in international law. What I can say, however, is that the ethics of punitive action is dubious.

John Kerry is right when he says that "the end of the conflict in Syria requires a political solution." It would be better if the Obama administration worked to that end. It is difficult to see how a punitive military strike against Assad facilitates a political solution. If it weakens the Assad regime, the opposition forces would be unlikely to want a negotiated settlement. No, it is a very contradictory position for the Obama administration to hold.

The USA has now given the Assad regime just one week to hand over all its chemical weapons. Why
just one week? It is an empty gesture as John Kerry himself says; Assad will not comply with such a demand.

Afterword

Russia today also called on Syria to put its arsenal of chemical weapons under international control for destruction. It is clear John Kerry's ultimatum was made with some degree of cynicism and the US administration has been caught on the hop by Russia's move. Nonetheless, should Syria comply with Russia's request then this clearly would be a way forward to avoid a military intervention.

Thursday, 5 September 2013

Est-il possible d'avoir une politique étrangère éthique?

The following is an article I wrote in August 2011 for my sister blog Chanteur de la Vie at Le Monde. In light of the current crisis in Syria I thought it might be of interest to readers:

En prenant son poste en 1997, M. Robin Cook, ancien secrétaire des Affaires étrangères au Royaume-Uni a déclaré que notre politique étrangère « doit avoir une dimension éthique et doit prendre en charge les demandes des autres peuples pour les droits démocratiques sur lesquels nous insistons pour nous-mêmes ». Treize ans plus tard en 2010 un autre secrétaire des affaires étrangère, William Hague a un but similaire pour une «politique étrangère avec une conscience». Mais est- il possible d'avoir une politique étrangère et éthique?

Je pense que dans l'équilibre global, la réponse est oui, mais vu de plus près la réponse est souvent non. Les affaires étrangères son des entreprises salissantes. Les affaires étrangères doivent équilibrer les intérêts nationaux, la promotion de la sécurité et du commerce international. Une partie de ce mélange est la promotion des droits humains, de la liberté et de la démocratie. Mais la paix et la stabilité mondiale est essentielle pour tous ces objectifs et ceux-ci viennent avec un prix. Le compromis est souvent essential pour assurer la sécurité d'une région, et le dialogue est souvent mieux que la confrontation.

Il est facile de critiquer les gouvernements pour leur inaction ou de traiter avec des dictateurs. Mais l’adoption des positions morales n'est pas toujours le meilleur moyen d'atteindre cet équilibre difficile, et parfois les nations doivent faire face à des dirigeants peu scrupuleux. Quand il s’agit de tension dans une partie du monde il serait prudent de ne pas moraliser sans avoir de moyens en place pour apporter des changements efficaces et durables. Celui-ci démontre un geste sans substance et peut bien causer plus de tort que de bien.

Apres 9/11, l’ancien président George Bush a déclaré dans la définition de sa politique étrangère, «notre première priorité doit toujours être la sécurité de notre nation». Cela peut conduire de traiter avec les régimes de mauvais goût. Décider qui est le plus grand ennemi et la meilleure façon avec quelle de les traiter fait partie du procès des affaires étrangères. Les régimes tels que celui de Musharraf, l’ancien président de Pakistan, sont devenus des alliés dans la «guerre contre le terrorisme» et en particulier l’Afghanistan. Pourtant, les dossiers des droits de ces États sont souvent effroyables.

Faire face à une petite nation telle que l’Afrique, par exemple, exige des niveaux de la diplomatie différente que de traiter avec la Chine. Il est assez facile d'imposer des sanctions contre un petit État que de prendre la même action contre la Chine. Mais la Chine a le pire bilan des droits humains et reste aussi un membre du Conseil de sécurité de l’ONU.

Après la seconde guerre mondiale, identifier l’ennemi était devenu facile. Churchill avait tracé une ligne avec son "rideau de fer" prononcé dans un discours aux Etats-Unis en 1946. Les anciens alliés de la guerre sont enfin devenus ennemis. Le communisme était désormais devenu une des plus grandes menaces pour le monde libre.

Mais le développement de deux grandes superpuissances nucléaires avait créé une impasse dans une guerre froide qui allait dominer et déterminer les affaires étrangères pour quarante ans. La crainte d'un effet domino avec les pays en Asie du Sud Est en particulier, tombent une à une aux communiste. Ceci a conduit les politiques des Etats-Unis dans les années 50 et 60. C’est cette même stratégie qui dirigera les Etats-Unis dans le bourbier de la guerre au Vietnam et qui se terminera par un échec. Dans les années 1980 une nouvelle approche sera adoptée.

Selon la « doctrine » du Président Reagan, les Etats-Unis avaient apporté une aide visible et invisible aux guérillas anti-communistes. Les mouvements de résistance pour «faire reculer» étaient soutenu par les Soviétiques des gouvernements communistes en Afrique, en Asie et au Sud de l’Amérique.

Cette approche a consisté à soutenir des dictateurs brutaux contre la volonté de leur peuple. Par exemple, l'administration de Président Reagan a donné son soutien aux « contras » au Nicaragua, mais aussi il les appela «l'équivalent moral de nos pères fondateurs ». Selon Reagan, la cause de la liberté et la démocratie contre la marée du communisme a justifié le soutien de ces alliés, même ceux qui voudraient nier ces droits à leur peuple.


"Opération Cyclone" était le mot de code pour le soutien Américain pour armer, entraîner et financer les talibans en Afghanistan dans leur lutte contre l'Union soviétique dans les années 80. En 1999, l'ancien Premier ministre britannique Margaret Thatcher a visité le général Pinochet, l'ancien dictateur du Chili qui était alors en résidence surveillée à Londres pour lui remercier «d’apporter la démocratie au Chili». En 1973, Pinochet a dirigé un coup d'Etat au Chile contre le président Salvador Allende, un marxiste qui a été démocratiquement élu. Pour Mme Thatcher et M. Reagan, les dictatures fascistes étaient préférables aux gouvernements élus marxiste.

La chute de l'Union soviétique a conduit l'établissement de démocraties dans les pays autrefois dans le bloc soviétique. L’avance des dictatures communistes a été immobilisée, et je suis dorénavant libre d'écrire mes opinions sans crainte d'entendre une frappe à la porte. Dans les années 60, j'ai démontré à Londres contre la guerre Américaine au Vietnam, mais au moins moi j'ai eu cette liberté. Je suis très conscient que ma liberté vient avec un prix lourd. Il a été gagné au détriment de la liberté d'autres personnes dans le monde dans les pays comme le Chile ou l’opposition a été brutalement détruite.

Après l'attaque terroriste sur les tours jumelles du World Trade Centre à New York, le président Bush a adopté une vue simplifiée du monde et a parlé d'une «guerre contre le terrorisme». Pour les USA cela était devenu la nouvelle orientation de la politique étrangère. Il a établi un nouveau pivot de l'équilibre pour des relations étrangères. Elle a remplacé la guerre contre le communisme, la guerre froide, comme le facteur essentiel de la définition de ceux qui sont devenu alliés et ceux qui sont devenu des ennemis. Cette menace à la paix et a notre sécurité mondiale a maintenant était témoin au terrorisme et les armes de destruction massive. Vu de ce point d'être poursuivi, l'ennemi a dû être identifié. Ce n'est pas facile lorsqu'il s'agit de terroristes. Ainsi l'ennemi a été défini entant des Etats qui soutiennent le terrorisme et qui a développée des armes de destruction massive ou soi-disant les Etats de l'«axis of evil».


Pour les néoconservateurs ceci est devenu une croisade de moralité, et en entrant dans la poursuite de cette croisade, ils ont cru pouvoir justifier les moyens au-delà de l'éthique. L’emprisonnement sans procès et la torture à l’ile de Guantanamo est devenu le cadre de la poursuite de moralité avec l'idée qu’ils avaient ce droit. Mais le fait d’être moral ne passe pas une politique étrangère éthique.


Jusqu'à 2003, la Libye avait été un État voyou. Kadhafi a eu un programme d'armes nucléaires et a soutenu le terrorisme. Le régime de Kadhafi a ouvertement soutenu les attaques terroristes sur ​un nombre de cibles occidentales. Kadhafi a indiqué qu'il allait continuer à soutenir le « Red Army Faction », le « Red Brigade », et l'Armée républicaine Irlandaise (IRA). En 1986, les forces Américaines ont bombardée des cibles libyennes en représailles à l'attentat contre une discothèque, « La Belle » de Berlin,

C'était parce que la Libye a abandonné son programme d'ADM que Bush et Blair ont décidé à traiter avec le régime libyen. Ils voulaient envoyer un message fort qu'il était possible d'engager dans un dialogue et si le soutien aux programmes de terrorisme et les WMD ont été abandonnés alors la relation pourrait changer.

En 2008, le fils de Kadhafi, Saïf al-Islam a annoncé qu'un accord avec les États-Unis selon lequel la Libye aurait effectué des paiements d'indemnisation aux victimes de l'attentat de Lockerbie et autres attentats contre l’Etats-Unis. En conséquence, le président George W. Bush a signé un ordre exécutif de restaurer l'immunité du gouvernement libyen des poursuites liée au les attentats et rejetant tous les cas d'indemnisation en instance aux États-Unis.

Nous sommes tous coupables d'hypocrisie dans les affaires étrangères et en particulier par rapport à la Libye et Kadhafi. Par exemple, au début de l'intervention militaire en Libye la prestigieuse université britannique, The London School of Economics (LSE) a abandonné rapidement ses liens avec Kadhafi. Le fils de Kadhafi, Saif, était un étudiant à la LSE. LSE avait accepté £ 1.5m de la Charité Kadhafi international, une organisation dirigée par Saif Kadhafi. Les journaux britanniques, par exemple The Daily Mail, ont attaqué le LSE pour sa décision d'accepter l'argent de Kadhafi. Le quotidien The Sun a décrit les liens avec Kadhafi comme une toile d'araignée. Pourtant, la LSE suivait tout simplement l'exemple donné par le gouvernement britannique dans le traitement de Libye.

Lors de sa retraite du pouvoir en 2007, l’ancien Premier ministre Britannique, Tony Blair a fait une "tournée d'adieu" aux pays africains y compris la Libye. En 2009, le journal The Sunday Times a rapporté que le Premier ministre britannique M. Blair a contribué à obtenir des contrats de défense dans le cadre de l'accord avec la Libye. Cela aurait permis à la personne trouvée coupable de l'attentat de Lockerbie d’être libéré de prison en Ecosse et de rentrer chez eux. En 2007, le gouvernement britannique a accepté un colis pour £ 5.000.000 avec la Libye qui comprenait des blindés et des canons à eau.

Une politique étrangère éthique est vouée à l'échec, il y a trop de mauvais régimes a qui je doute nous pourrions accepter de ne pas commercer avec eux. L'indignation morale dans la politique étrangère sera toujours sélective et hypocrite.

Dans les années 1980 de nombreux membres influents du Parti révolutionnaire des travailleurs s'est rendu en Libye pour faire des discours pour le soutien de Kadhafi, mais alors ils ont apporté leur soutien à Saddam en Irak. La vérité est que l'approche de l'Occident à Kadhafi a changé avant et en arrière. Reagan et Clinton lui ont bombardé, il a été en faveur de la gauche en raison de son «socialisme islamique» que l'on appelle, qui n'était ni musulman ni socialiste. Il a été courtisé par la gauche, vilipendé par la droite, puis courtisé par la droite et vilipendé par la gauche. Je pense qu'ils ont du bien rire entre eux.

Heureusement que le dernier mot va se donner au peuple Libyen.

Back of pack health warnings have little impact on teen smokers

The causal link between lung cancer and tobacco smoking has long been established. It was in the 1950s that the link was first clearly demonstrated. Since then the addictive nature of nicotine has also been shown and it is one reason why it is so difficult for smokers to stop.

Despite this knowledge it took a long time for health authorities and governments to act effectively on smoking as a killer. Today, smoking is recognised as the largest single factor in preventative illness. In the UK an estimated 102,000 people die each year from smoking-related diseases including cancers.

Most people start smoking as teenagers. I certainly recall my first tentative 'drags' on a cigarette when I was at school. In those days (oh dear such a long time ago!) we were able to buy single Woodbines at the local tobacconists. Fortunately I managed to stop smoking in my early twenties; others were not so fortunate.

Teenage smoking remains a problem. Official statistics suggest that at the age of 15 years, 11% of children in England report being regular smokers.  In recent years, girls have had consistently higher rates of smoking than boys. But clinical studies suggest the incidence of teenage smoking is much higher than suggested studies relying on self-reporting.

In 2008 the UK became the third European Union country to require pictorial health warnings to be carried on the back of cigarette packs. But does it work as a deterrent?

A new study published today online in Tobacco Control suggests that back of pack picture or text warnings depicting the dangers of smoking have little impact on teenage smokers, particularly those who smoke regularly.

Pictorial warnings work better than text alone, but if positioned on the back of the pack they are less visible and less effective, say the researchers.

In only five out of the 60 countries worldwide do these pictorial warnings cover more than 75% of the main surface areas of a pack. Furthermore, no European country including the UK has adopted the World Health Organization standard of warnings covering half the surface area. Article 11 of the Framework Convention on Tobacco Control (FCTC) provides that package health warnings must be at least 30% – and should be at least 50% – of the package’s front and back (on average). The use of pictures is optional.

The current study published today looked at the responses of more than a thousand 11 to 16 year olds in the UK, in two waves of the Youth Tobacco Policy Survey in 2008 (1401) and 2011 (1373).

The same text warnings appeared on the front and back of packs at both surveys, with the only difference being the display of images on the back of packs to support the text warnings in 2011.

The teens were quizzed about the visibility and impact of the warnings; how well they served as visual cues; how easy they were to understand and believe; and how persuasive they were. Their responses were scored on a sliding scale from 1 to 5.

Most of the respondents in both waves (68-75%) had never smoked; 17-22% had experimented with cigarettes; and around one in 10 were already regular smokers, defined as smoking at least one cigarette every week.

Half the respondents in both waves said they had ‘often’ or ‘very often’ noticed the warnings, and around one in five had very often read or looked closely at them. But the percentage of regular smokers who noticed them fell from 77% in 2008 to 66% in 2011.

Overall, only one in 10 teens said they thought about the warnings when the pack was not in sight, although those who had never smoked were significantly more likely to think about warnings ‘often’ or ‘very often.’

At both time points, most (85%+) teens found the warnings credible, but in 2011 those who had never smoked were less likely to find them easy to understand, while experimental smokers were more likely to find them truthful and believable.

And while the proportion of teens who thought the warnings were capable of putting them off smoking and make them less likely to smoke increased between 2008 and 2011, this only applied to those who had never smoked and to experimental smokers. There was no change among the regular smokers.

Recall of text warnings on the pack front fell between 2008 and 2011, from 58% to 47% (Smoking Kills) and from 41% to 25% (Smoking seriously harms you and others around you), while recall of three images on the back of packs, depicting diseased lungs, rotten teeth and neck cancer, all increased.

However, recall of the other back of pack images remained below 10%, and the three text warnings on the back of packs with no supporting images were recalled by less than 1% at either time point.

The proportion of teens who said they hid the cigarette pack from others increased significantly between 2008 and 2011, but there was no increase in other avoidant behaviours. And among regular smokers, the proportion who said that the warnings stopped them from having a cigarette fell from 32% to 23%.

“As warnings need to be salient to be effective, positioning pictorial warnings only on the less visible reverse panel limits their impact,” write the authors. “While recall was high at both waves for pack-front warnings, it was low (below 10%) for the pictorial warnings on the pack reverse, fear-appeal pictures aside,” they add.

The fact that the UK has used the same pictures since 2008 may also have increased the “wear out” factor, particularly for regular smokers, say the authors.

“Positioning pictorial warnings only on the back of packs may have had a deterrent effect on never and experimental smokers, but for most measures no significant differences were observed. The impact on regular smokers was negligible,” they conclude.

If warnings are ever to work then they have to be more prominent. Regular teenage smokers may be harder to crack. We need a better understanding of what drives them to smoking in the first instance and how best they can be persuaded to stop.

There is much to suggest that teenage smoking is imitative or seen to be 'cool'. Smoking is more prevalent amongst those whose parents also smoke.  Smoking can also be a form of rebellion and is heavily influenced by glamorous advertising. We need to address the socio-psychology of why teenagers smoke.

Cigarette manufacturers produce a product that ruins health and kills.  Smoking kills should be the only words appearing on any packaging.   But more important, governments should not bend to the will of powerful lobbyists for the tobacco industry. What happened to the call for plain packaging?